February 8, 2012
In every mistake, there’s a lesson to be learned. Several times a year I have to review medical malpractice cases as it relates to obstetrics. Unfortunately, the same preventable mistakes occur over and over again. A recent case review brought home the importance of diagnosing and treating fevers aggressively as they relate to pregnant women, particularly if they’re in labor.
Any fever over 100°F needs to be investigated. Common colds don’t cause a fever. Bronchitis, Influenza (or the “flu”) and pneumonia do. A cold that is associated with body aches all over suggests the “flu” and needs immediate attention to prevent its progression to pneumonia. A cough associated with fever and backaches suggest pneumonia which requires aggressive antibiotic therapy. A cough associated with green or yellow phlegm suggests bronchitis, especially if there is a history of smoking. Right-sided lower back pain associated with a fever and frequency of urination suggests a kidney infection that needs antibiotic therapy. An untreated kidney infection can cause respiratory problems if not treated appropriately.
What happens if you break your water or “rupture” your membranes? The clock starts ticking. The amniotic sac that protects the baby is gone and it is now at risk for developing an infection. If the baby is premature, most clinicians will use a “wait and see” or conservative approach as long as the baby is not in jeopardy. The longer the baby remains inside the uterus, the better its chances of breathing once it’s born because its lungs will have an opportunity to develop. A woman could also be close to her due date, break her water but not have contractions. In both cases the patients should be admitted to the hospital to protect both mother and baby. There are two schools of thought regarding ruptured membranes. The pediatricians recommend starting the mother on antibiotic therapy if she has ruptured membranes for 18 hours or more. Some obstetricians prefer to wait until the patient actually develops a fever. At present, medical studies do not prescribed a hard fast rule favoring one method over the other. However, in the case that I reviewed, the baby unfortunately died because of significant infection and antibiotics had not been started until the mother developed a fever.
All fevers in pregnant women need to be aggressively treated with antibiotics in order to safeguard the baby. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
November 30, 2011
On a recent Sunday in the bathroom of the Baltimore-Washington International Thurgood Marshall Airport, a baby boy made his entrance to life. His mother was approximately 28 weeks and delivered prematurely, however both baby and mother were healthy according to the media. Although the details of the delivery are sketchy, anyone involved in obstetrics can predict what occurred.
The mother might have had a previous history of a urinary tract infection, or complained of back pain. Did her ultrasound reveal a short cervix? Or perhaps she had a history of a previous early delivery. If it was her first pregnancy, did she complain of mild abdominal pressure? Premature labor is one of the most common reasons for birth defects and has a price tag of approximately 26 billion dollars per year. The signs and symptoms of preterm labor often go unnoticed or diagnosed because healthcare providers aren’t paying attention. A urine analysis report showing bacteria in the urine will not be addressed. No inquiry will be made as to whether the patient made frequent trips to the bathroom or whether she drank soda. Soda predisposes patients to urinary tract infections because of the carbonation or bubbly component of the drink irritates the bladder. Untreated urinary tract infections can cause premature labor. A complaint of lower abdominal pressure will be attributed it to “round ligament pain” even though the patient is well beyond 20 weeks when it is most likely to occur. A complaint of back pain will be blamed on the changing shape of the uterus rather than sending the patient to the hospital for further evaluation. In essence, some healthcare professionals keep missing the diagnosis or intervening too late.
According to the American College of Obstetrician/Gynecologists (ACOG) pregnant women can travel up to 32 weeks by air provided they don’t have any complications or high risk conditions. The change in altitude can sometimes cause the “water to break” or the placenta to separate too soon. All pregnant women who plan to travel (especially by air) should consult with the OB provider for advice and instructions. For pregnant women who plan to travel, here are some suggestions:
- Obtain a copy of your prenatal record prior to traveling in the event of an emergency
- Find out the name of the nearest Level 3 hospital where you will be staying
- Do not sit for more than 2 hours without standing for a few minutes to stretch your legs to prevent blood clots.
- If you are complaining of back or abdominal pain before traveling, contact your provider immediately
Fortunately the baby born in the airport bathroom appears to be fine. However not all unexpected births have a happy ending. Pregnant moms, if you have to travel, please don’t push the envelope.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.