Ventral Septal Defect

  1. Ok, I will confess: I know 'nuthin 'bout birthin babies!!! (Gone With the Wind) So, here is my scenerio (oh, BTW, I am a ICU/ER RN):

    My daughter is about 36 weeks. Was dx with gestational diabetes, difficult sugar control (they don't know why; previously a diabetic???), boderline pre-ecclampsia (per MD), and 2 weeks ago, was told the baby (by the way, a boy: Julian Gabriel!!!) has a very large VSD. Aorta is 4mm (maybe a blockage, they said; I wonder coarctation???) and the doc brought up "Down's". Measurements last Friday showed fundal height 40, and weight between 7 lbs 7 oz and 8 lbs 2 oz. Her due date is April 13 (though the US said it is March 23, the doc did not change her due date). Cardiac surgery is a given, though when is up in the air, depending on how he does after birth. Doc said they could not tell now if he has pul HTN (said they would be able to tell after birth).

    They told her she could delivery naturally! I don't understand this. My thinking is: bad heart, huge baby, chances of complications high: should be scheduled C-section! I had her specifically ask the doc why (I am not there yet; she is in Seattle and I am leaving my travel assignment 1 week earlier to go there). His response: He is not in failure yet.

    So, if they can't tell if he has pul HTN, how can they tell he is NOT in failure???

    It has seemed that every time she goes to the doc, which now is 2x/week, also with NST's twice a week, nothing is good news! Oh, I forgot, she said she was GBS negative!!! LOL!!!

    Does anyone have any insight for me, the worrying grandma (at least until I get across the country - NH to Seattle - leaving tomorrow!!!)

    Thanks for any tidbits or questions I can ask the doc when I get there!!!
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  2. 9 Comments

  3. by   babynurselsa
    Hang in there Copper. Please please please just tell me she is seeing and Ob and not a family practitioner....
    Hopefully she will be delivering in a hospital with a NICU?
    baby is gonna be a good sized feller but not unreasonably so. I don't see a problem with letting her have a chance at a vag delivery.
    Sounds like the ob is throwing alot of info at her right now.
    Baby is measuing 40weeks cause he is a big guy that won't change her due date. I have seen a couple of 8lb 32 weekers, they were still 32 weekers though.
    Baby shouldn't be in PPHN yet as he is still giving minimal blood flow to the lungs due to fetal circulation, the blood shunts on across the PDA to by and large bypass the lungs and mommy is oxygenation him.
    Just hang in there Gramma.
  4. by   Godswill
    While I have no insight, i just wanted to say HUG, and keep the faith, My df is due two days before your dd and her baby is measuring 2 weeks bigger than normal too, do just said she will induce at 38 weeks point blank.

    Being a mother of a stillborn, i would suggest your dd get a second opinion for some one else. i know it may be hard to get a doc to see her so late in pregnancy, but maybe a high risk ob/gyn will, When in doubt keep searching till u get the answers u need to feel satisfied and at some peace. You and dd are in prayers
  5. by   Jolie
    Quote from rncopper
    Ok, I will confess: I know 'nuthin 'bout birthin babies!!! (Gone With the Wind) So, here is my scenerio (oh, BTW, I am a ICU/ER RN):

    My daughter is about 36 weeks. Was dx with gestational diabetes, difficult sugar control (they don't know why; previously a diabetic???), boderline pre-ecclampsia (per MD), and 2 weeks ago, was told the baby (by the way, a boy: Julian Gabriel!!!) has a very large VSD. Aorta is 4mm (maybe a blockage, they said; I wonder coarctation???) and the doc brought up "Down's". Measurements last Friday showed fundal height 40, and weight between 7 lbs 7 oz and 8 lbs 2 oz. Her due date is April 13 (though the US said it is March 23, the doc did not change her due date). Cardiac surgery is a given, though when is up in the air, depending on how he does after birth. Doc said they could not tell now if he has pul HTN (said they would be able to tell after birth).

    They told her she could delivery naturally! I don't understand this. My thinking is: bad heart, huge baby, chances of complications high: should be scheduled C-section! I had her specifically ask the doc why (I am not there yet; she is in Seattle and I am leaving my travel assignment 1 week earlier to go there). His response: He is not in failure yet.

    So, if they can't tell if he has pul HTN, how can they tell he is NOT in failure???

    It has seemed that every time she goes to the doc, which now is 2x/week, also with NST's twice a week, nothing is good news! Oh, I forgot, she said she was GBS negative!!! LOL!!!

    Does anyone have any insight for me, the worrying grandma (at least until I get across the country - NH to Seattle - leaving tomorrow!!!)

    Thanks for any tidbits or questions I can ask the doc when I get there!!!
    Blessings to your family! Julian Gabriel is lucky to have such a loving grandma! I'm sorry that your daughter is having such a rough time of things!

    First of all, the gestational diabetes: Diabetic mothers do have a greater risk of giving birth to babies with cardiac defects. Research differs as to whether this risk is increased by poor control of blood sugars, but frankly, that is water under the bridge now. Anything that can be done to keep her sugars under control from now on will benefit both mother and baby at the time of delivery. Measurements of fetal growth in infants of diabetic mothers (IDM) can sometimes be misleading. A due date based on ultrasound takes the baby's size into account. IDMs are typically large for gestational age, so that tends to throw off the accuracy of dating the pregnancy by ultrasound. Basing her due date on her last period is probably far more accurate, unless she had very irregular periods prior to conceiving. Even an ultrasound done early in pregnancy is likely to be more accurate in terms of dates, as embryonic and fetal growth is fairly predictable in the early weeks of pregnancy, before factors such as genetics and diabetes begin to affect the baby's size. So, that is a very long winded way of saying that her April due date is probably accurate.

    As for the heart defect: A ventricular septal defect is an opening in the wall that separates the right from the left ventricle, the pumping chambers of the heart. It is not uncommon, and not terribly difficult to repair, with a patch being sewn in place. The dilation of the aorta is more concerning to me, and I share your question that it may represent a possible coarctation. Those, too, can be repaired. It is unsettling and frustrating not to know just exactly what is wrong prior to delivery, but obtaining a good quality echocardiogram is not always possible prior to birth. Ideally, your daughter will deliver in a Level III hospital where the baby will have immediate access to cardiologists, cardiothoracic surgeons, and the testing necessary to sort out his problems (echocardiogram and cardiac cath). Pulmonary HTN is not diagnosed prior to birth. Because of the pattern of fetal circulation, ALL fetuses have pulmonary HTN. Most babies are able to transition their circulatory pattern without difficullty at birth. Those who do not develop persistent pulmonary hypertension (PPHN). Congestive heart failure can be seen on ultrasound, so if it has not been observed, that is a good thing. Congestive heart failure is not related to pulmonary hypertension in utero.

    Babies with Down's syndrome are at increased risk for heart defects and other birth anomolies. I don't know if this statistic alone is the reason that the doctor mentioned the possibility of Down's, or whether there is something else that makes him suspicious, such as associated gastrointestinal or kidney defects, family history, maternal age, etc.

    As far as delivery, a vaginal delivery is not necessarily inappropriate. Remember that all the baby's oxygen and nutrients are coming from mom, and despite the defects, the baby's heart appears to be pumping adequately, since there is no evidence of CHF. Babies born by C-section, ESPECIALLY infants of diabetic mothers, are at increased risk of breathing difficulties at birth because they don't get the benefit of having their chests squeezed to help expel fetal lung fluid. Retained fetal lung fluid can lead to tachypnea, increased work of breathing, and decreased oxygenation, none of which are desirable in light of the baby's cardiac problems. Also, your daughter will likely be monitored continuously during her labor, so at the first sign of fetal stress, a C- section could be performed. She may want to discuss the possibility of having an epidural in place early in labor in order to hasten things along should a section become necessary.

    Her frequent visits are undoubtedly tiring and overwhelming, but very necessary. IDMs are at greater risk of unexplained fetal demise in the last several weeks of pregnancy, and must be monitored closely. If she even thinks that she is feeling decreased movement, she should get to the hospital immediately.

    Please keep us posted and let us know how things are going! Best wishes to the family!
  6. by   bagladyrn
    (((RNCopper))) Lots of good info here already, so just wanted to add that I'll be keeping you and your daughter in my thoughts! Drop me a note when you have a chance and let me know how they (and you) are doing. Do you have things arranged to get to Seattle and someone to meet you there? If not, I may have some ideas - let me know!
  7. by   rncopper
    OH, THANK YOU GUYS VERY MUCH for the info, hugs, and good vibes!!!

    Jolie: Thank you for a very GOOD in-depth answer to my questions in my head! It is VERY difficult to have my daughter ask her doc MY questions (she is not medically oriented!!! LOL!!)

    Christie has now been transferred to a high-risk OB (she had been seeing him for the GD) and he will be doing the delivery. She also had to change hospitals to one that was associated with the cardiac echoneonatalogist (hey, that probably isn't what he is called!!!) and within close proximity to Children's in Seattle. The room will be JUST A TAD crowded with the all the people (docs) that said they will be there!!! ME, TOO! so I am glad you guys gave me a heads up on all the pathophys!!

    BagLady: I will email you right now!

    Again, thank you all, and I will let you know when HUGE Julian Gabriel is born!!
  8. by   BRANDY LPN
    Did your daughter have a AFP? (alphah-fetal-protein) this is done earlier in preg. and is a marker for downs and other disorders. Although it is not 100% accurate.

    My 6 year old was born at 35 weeks, she had a ventricular septal defect and a patent ductous arteriousis, and mild LPA stenosis. Her VSD was relatively small and did not require intervention, while it has not closed spont. as they believed it would, it is smaller and will require no surgery. She did have the PDA closed with coil embolization (via cath) at 20 months. She had some resp. involvement before this time and was admitted several times in resp failure and was bordering on CHF. Now however she is a normal healthy active child, she will always have to have ABT prior to dental work ect.

    The fact that your daughter is GBS negative is a good thing as this will lower the risk to the baby.

    I guess the reason that I am telling you this is that I want to reassure you that a child with a heart defect, may not have an easy start but can live a normal active childhood. It is also good, in my opinion, that your daughter has found this out early enough that she can prepare for the fact that baby may not be able to stay with her after the birth and it will be easier to deal with if they have to ship him to a larger facility.

    I will keep you and your family in my thoughts, Pleases let us know how he does.
  9. by   keeper
    I'm a little late in replying but I wanting to add myself to the list of people who have safely delivered a child with a VSD. My son was born with tetralogy of fallot, a condition which included a silver dollar sized hole. He was born vaginally, and at home, no less! lol. The defect wasn't discovered until he was four months old and was repaired at 13 months of age.

    He's a happy, healthy first grader now!

    Sarah
  10. by   Jolie
    I ran across a website that may be of interest to you. It is RnCeus.com and it has a module on VSDs. You can read thru the course without charge, and access other sites with further information and case studies.
  11. by   rncopper
    Well, I got here in Seattle to see my HUGE daughter. A little excitement last week (started labor WHILE I was at home in SD.....!!!) but then it stopped; now with just intermittent contractions, some periods are hours long. Lots of walking, they wanted to do a scheduled c-section because of the size (on Fri est wt - 10.5 lbs!!!!), so did the amnio but the lung maturity did not make their cut off (don't know the exact test, but they wanted the number to be above 50 and it was 32). So it looks like it will be the 6th of April, or sooner (by natural labor), if Christie has HER way!!!

    Again, thank you for all your support. Will let you all know when it happens and I become totally gray from this experience!!!

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