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Case Study  2 - Umbilical Cord Entanglement Followed with Home Fetal Heart Rate
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MS a 22 y/o Gravida 2 Para 0 Ab 1 was evaluated for pregnancy from 8 weeks onward. By 28 weeks a placenta previa was determined and followed with ultrasound every two weeks. Betamethasone was administered once for the possibility of premature delivery. By 34 weeks the placenta was noted to have migrated away from the cervical os and also noted was a fetus with cord entanglement. On closer inspection the fetus had a loop of umbilical cord around the neck, nuchal cord (NC), an arm loop (AL), and body loop (BL) Fig: (1,2.) Due to changes in fetal behavior and fetal heart rate (FHR) a fetal heart rate monitor was placed at the home for closer observation. Once a night for 30 minutes FHR was studied with the use of Corometrics 150 fetal monitor and 410 modem.

 

Figure 1 (click for enlarged view)

 

Figure 2 (click for enlarged view)

 

 

Because of persistent FHR changes indicative of umbilical cord compression the patient was transferred to Labor and Delivery for continuous monitoring. An observation at home the night before transfer around 2:30 a.m. suggested a FHR deceleration to 60 BPM for several minutes with a change in characteristics. This observation was made during a similar episode. Due to previous experiences with this combination of factors an Oxytocin Stress Test was performed the following day. After several hours of no reassuring FHR patterns, consistent changes emerged requiring delivery of the infant. A viable female infant with NCx1, BLx1 and A1x1 was delivered and did well at 36-37 weeks gestational age. FIG (3a,3b).

 

Figure 3a & Figure 3b
(click for enlarged view)

 

 

The ability to identify the fetus at risk of cord entanglement complications is determined by the use of ultrasonography and fetal heart rate monitoring. In addition to this, knowledge of changes in fetal behavior is helpful in alerting the Obstetrician to a potential problem. Recently it has come to our attention that maternal sleep patterns may play a role in fetal behavior. We have documented 30 cases where the time of fetal demise was during the period of midnight to morning (6am). The explanation may be that the maternal blood pressure is dropping in a stepwise fashion during REM sleep and as a result a "stressed fetus" cannot adapt to this change. In this case during maternal sleep, on two separate occasions, low B/P of 90/50 appeared to play a role in FHR decelerations. Fig: (4).

 

Figure 4

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