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!