20 wk fetus, prom

Mimi2RN, ASN, RN · May 9, 2005

I don't deal with the moms, but we have had babies delivered several weeks after PROM. I remember one whose mom came in ruptured at 20 weeks, delivered at 34 wks. She was kept in the hospital on bedrest at first, was given betamethasone at 23 weeks, as well as abx. Baby was in the NICU for a couple of weeks, but he's done very well, considering that some docs wouldn't have given him a chance.

ldnurse7581 · May 9, 2005

i dont really have an answer to your question, but your post made me think of a case we had a month or two ago....

pt is G1p0 20something, pregnant w/twins between 14-17wks gestation (cant remember exactly). comes in per ems, c/o bleeding. and she sure was bleeding, not just one of those who c/o bleeding and have a 'pink spot on underwear'. when the nurse checked her, all she said she felt was "either a bunch of clots or placenta." well, i assume it ended up being clots b/c this was at shift change on a saturday and when i came back to work the next wk they said the pt's membranes had ruptured and she was on ob hall on abx. well, later in the wk, (maybe friday??) she was getting septic, so md decides to induce. well,most of the day shift nurses and anesthesia were all against it b/c babies still had pulse. i am against abortion, but when it comes to saving mom (and she can try and conceive again in the future) i can see where the doc is coming from. but crna on call said they werent going to do an epidural b/c that was abortion. (pt delivered before she starting hurting too severly)... what is your opinion on this and which side would you have been on??

RNLaborNurse4U · May 9, 2005

Sounds like she needs transferred to a higher level facility with a level 3 nicu. We get pts transferred in to us all the time (via helicopter/ambulace) from other small hospitals sometimes hours away. We take the patients that other hospitals with NICU's refuse to take. We take em all.

She needs to be seen by a maternal fetal medicine specialist, where they would most likely put her on strict bedrest, repeat the U/S (and probably follow with some serial U/S), put on magnesium sulfate to keep the uterus calm, antibiotics, IV fluids, with a nicu consult. Our MFM would most likely add in some indomethacin too. As long as you have a heartbeating fetus, and mom is afebrile, and mom has no life-threatening illnesses or complications, our MFM docs would try and keep this baby as long as possible. Oh yeah - and add in some betamethasone at the appropriate time too.

In fact, we have a 22 weeker and a 19 weeker on our floor right now. Things look more dismal for the 19 weeker because she is a complete previa, but she's still pregnant with a heartbeating fetus.

We also just delivered a 24 weeker whom labor progress could not be stopped, and baby is in the NICU.

We also have 2 long term, stable, antenatal units where we keep our pretermers after we on L&D get them stabilized. Our NICU is 32 beds, but sometimes expands higher to accomadate our large preterm population. Our L&D unit runs quite a bit like an OB ICU at times, due to the instability of our patients. Of course, we get the "regular" old low risk deliveries too!

Jen

L&D RN

SmilingBluEyes · May 9, 2005

20 weeks? Depending on how stable mom is, we would do all we could to get her transported to a higher-level facility (we are level 2 only) and let them handle it. It's a case-by-case thing. A person presenting grossly ruptured, in advanced state of dilation and infected is quite a different case than one who presents "leaking" and closed/thick and stable at the time. You have to take into consideration the whole clinical picture and treat accordingly.

Minou · May 9, 2005

Hi all,

Thank you for the great replies. I am still torn about this " hypothesis " of mine. ok, Now what if I were to say that this hypothetical mom had been told in er that once on ob, she would be getting an abortion, because she has had a normal pregnancy up to now but is possibly rom now ?( I really am not judging er, only that headless person that might hypothetically say such a horrible thing )....I mean that is a strong term...so she might come up to ob and tell the rn " so when the baby comes out, you're going to kill it ? " Does that not give you the chills ?...Yeah, that's right, we've got snuff bags on standby !!! which brings me to this...we make an initial attempt to transfer, no beds, ok sorry your baby's gonna die !!! I know I'm emotional about this and hopefully am not blowing this out of proportion, but this is the 21st century right ? I understand health care costs, but if this were a rich/influental/well known person, do you not think her little butt would have immediately been flown to a higher level (3) facility ?( hypothetically speaking of course )... I'm talking normal developing, normal weight for gestational age, happy up to now fetus, so his pool's empty, lets attempt to fill it back up. mom afebrile, not responding to 2 days of pit, HELLO ? maybe repeat U.S. ? or here's a good one : maybe do speculum exam ?

I am getting carried away ( hypothetically ) .

In reply to ID about those 14-17 wk twins, I agree with you that if the mom's life is threatened, yeah, induce because these babies already have a slim chance and should they be born anyways at say 21-24 wks, they might well have big lifetime health challenges ...

I hope I don't sound like I'm too much of a rambling fool, but some things ( yes even hypothetical ) hit you straight in the gut,

Thanks,

Minou

BittyBabyGrower, MSN, RN · May 9, 2005

She should have been transported out. We have had many moms rupture way before due day, even as early as 16-17 weeks and the kids come out fine.

Jolie, BSN · May 9, 2005

I don't understand why the OB would insist on pitting this patient. If she desires to continue the pregnancy and shows no s/s of infection or other complications that could potentially threaten her health, then it seems to me that she deserves the chance to try. Of course the baby is not viable at 20 weeks, but it is possible that the pregnancy may be continued to the point of viability.

My daughter was not viable at 16 weeks when I began to contract and dilate. Thank God my OB thought she was worth saving.

JaneyW · May 9, 2005

Hi all,
Thank you for the great replies. I am still torn about this " hypothesis " of mine. ok, Now what if I were to say that this hypothetical mom had been told in er that once on ob, she would be getting an abortion, because she has had a normal pregnancy up to now but is possibly rom now ?( I really am not judging er, only that headless person that might hypothetically say such a horrible thing )....I mean that is a strong term...so she might come up to ob and tell the rn " so when the baby comes out, you're going to kill it ? " Does that not give you the chills ?...Yeah, that's right, we've got snuff bags on standby !!! which brings me to this...we make an initial attempt to transfer, no beds, ok sorry your baby's gonna die !!! I know I'm emotional about this and hopefully am not blowing this out of proportion, but this is the 21st century right ? I understand health care costs, but if this were a rich/influental/well known person, do you not think her little butt would have immediately been flown to a higher level (3) facility ?( hypothetically speaking of course )... I'm talking normal developing, normal weight for gestational age, happy up to now fetus, so his pool's empty, lets attempt to fill it back up. mom afebrile, not responding to 2 days of pit, HELLO ? maybe repeat U.S. ? or here's a good one : maybe do speculum exam ?
I am getting carried away ( hypothetically ) .
In reply to ID about those 14-17 wk twins, I agree with you that if the mom's life is threatened, yeah, induce because these babies already have a slim chance and should they be born anyways at say 21-24 wks, they might well have big lifetime health challenges ...
I hope I don't sound like I'm too much of a rambling fool, but some things ( yes even hypothetical ) hit you straight in the gut,
Thanks,
Minou

Minou--I believe you might hypothetically work where I do! It is kind of sad to me that these hypothetical things happen at other places as well. I have found a new job at a large teaching hospital where maybe these things won't hypothetically occur as often. I'm positive there will be other hypothetical problems, but it's nice to know that more will be at least attempted (hypothetically!). Whew, my fingers are tired.

Minou · May 9, 2005

Thanks for the validation,

of course i'm hypothetically not quite in your area which means that this goes on in more than one hypothetical place ( i need to start cut & paste ). I've talked to almost everyone concerned about this hypothetical pt and it's like I'm the only one awake....I've actually never laid eyes on this pt, as she is in her room and I've been working nursery lately so every time i tell that pt's rn : Hey why are we pitting her, are we sure she's srom, are we sure about the amniotic fluid,no atb ?, what about a transfer, are you comfortable with this situation ? have you asked her obgyn ? they all look puzzled and then go : " Yeah, I'm uncomfortable, but what can we do ? I've tried to talk to that obgyn but he basically sarcastically blew me off , I've called my unit manager, who thought I had a good point but that it was the doc's call...." make sure you document well " I've been in touch with a neonatologist at a nearby NICU who will gladly stand by in case but in the meantime we're not doing anything, it's like this fetus just has to come out, regardless....Geez...if surgeons can go in and repair heart defects on 20-24 wk fetuses ( so they already have a malformation, right ) why can't we accomodate a perfectly formed one ? I'm confused and the more I write the angrier I get.... If this were the OBGYN's own baby/wife, you think he'd make a little effort to protect his unborn child ? And another thing...if this OBGYN were the most caring doc around, I might consider that he has valid reasons for not doing anything ( reasons that obviously escape me ) but NO !

Whewww....I feel a little better,

Minou :angryfire

babyktchr, BSN, RN · May 9, 2005

20 weeks? Depending on how stable mom is, we would do all we could to get her transported to a higher-level facility (we are level 2 only) and let them handle it. It's a case-by-case thing. A person presenting grossly ruptured, in advanced state of dilation and infected is quite a different case than one who presents "leaking" and closed/thick and stable at the time. You have to take into consideration the whole clinical picture and treat accordingly.

Our tertiary center will not accept a 20 week transfer. Depending on situation, we will keep the person pregnant, on antibiotics, and keep her stable until viable.

SmilingBluEyes · May 10, 2005

Depending on situation ours may. Esp when history is sketchy (e.g. dates could be later) etc. It goes by situation really.