During the CRICO/RMF symposium on clinical challenges in obstetrics in September
2007, Dr. Ruth Fretts described three short cases. Dr. Fretts is an obstetrician/gynecologist
for a large multi-group practice in Boston; She is an Assistant Professor at Harvard
Medical School and the Chair of the Stillbirth Review Committee at Brigham and Women’s
Hospital in Boston.
Dr. Fretts is collaborating on a CRICO/RMF - funded study into decreased fetal movement,
and the potential to anticipate and even decrease adverse events. Using a prospective
tool to follow outcomes of patients with decreased fetal movement, Dr. Fretts’ team
is learning about links between patient risk factors, decreased movement and stillbirths.
“I am going to run a few cases because I think it does demonstrate how we kind of
can fall into traps, and we are all subject to these. In this case, the patient
was a 33-year-old otherwise low-risk woman who had her second pregnancy and the
first she had a miscarriage. She was noted to be growth restricted or she was measuring
size less than dates.”
“So throughout the medical record there were no complaints. But at 35 weeks she
had relatively low spinal height. So they decided to plan for an ultrasound, and
well documented in the chart was kick counting. And an NST was done because the
baseline was a little low and that is her test. Estimated fetal weight reported
in the chart was between 10 and the 25th percentile.”
“Then she presents again with decreased fetal movement for about four days, and
she has embarked on actually twice weekly visits now because of the story of the
measuring lower and the decreased fetal movement. She continues really twice weekly
and when I did the study, I searched on Apgar 0 and 0, so as she came in labor,
the baby had a stat C-section, the baby at Apgar 0, 0 and 3, and ended up severely
impaired, and she was on the third percentile.”
“So the moral of this story was that we, although she was having great vigilance,
missed the fact that she was falling off the growth curve. And we relied on our
testing to say, ‘oh, everything is okay,’ and she had yet persistent decreased fetal
movement. So the testing was falsely reassuring on a woman who was falling off the
growth curve at term. So again: poor outcome related to decreasing placental function,
and she had lots of diligence, but the combination of somebody falling off the grade
growth curve with decreased fetal movement at term. So here the testing was falsely
reassuring.”
“We have a second case, a 29-year-old woman from India. She had a positive AFP screen
for trisomia 18 and went on to have an amnio, which was fine. She did call on a
couple of occasions for decreased fetal movement, once at 35 weeks, and kick counting
was reviewed. She had normal appointments.”
“Then actually at 41 weeks and 1/7th days, she is on her way to ultrasound, and
she said, ‘I haven’t felt my baby move for two days.’ So the provider says keep
going, you know, go get your biophysical profile. So gets an 8/8 on her biophysical
profile, and she comes back to the appointment and they forget to talk about the
fact that the baby is not moving. Everyone is now focused on the biophysical profile,
and she is sent off for expectant management.”
“She later comes and she says the baby still hadn’t moved for two days. And the
baby had a demise. This was actually an appropriately growing baby, and this is
sort of the second case where you have at term in a post dates pregnancy that the
baby was maybe trying to tell you something with decreased fetal movement, and the
testing was falsely reassuring.”
“In both of those settings—and we had many women who had been evaluated, and they
didn’t have stillbirths—but what I think you have to keep in your mind is that if
they have additional risk factors that you have to think that as your risk goes
up for a stillbirth, your falsely negative tests go up too.”
“A third case is a woman who had also falsely reassuring testing at 25 weeks. She
reported anxiety, and she had had a previous stillbirth. She had a normal ultrasound
at 27 weeks, and at 28 weeks she went to the Brigham triage and said ‘I’m worried;
my baby is not moving.’ She had a non-stress test that was apparently appropriate
for gestational age and had a demise two days later.”
“This one I think it is difficult because it is a preterm pregnancy. It is hard
to know how the outcome would be different.”
“In summary, there were obvious opportunities that we could have done better. Usually,
the error is in the prolonged interval between the time the patient said she had
decreased fetal movement to the time she called. So educating our patients would
be a good first step.”
“We failed to diagnose growth restriction, and also a failure to adequately assess
fetal well-being in the setting where there were high-risk pregnancies.”
