Dropped by OB at 34.5 weeks

What is the name of your state? AL
My wife has a fairly rare prregnancy related condition called cholestasis. We have been working with a doctor that dropped us after 34.5 weeks because we argued with the nurse. The nurse tries to act as a go-between but she does not know anything about the condition. Our frustration with her lack of knowledge casused the blow-up. With all the potential complications is it legal to drop a patient this late?
She was scheduled to be induced on Nov 30.

The Dr. gave no indicaton that the issue with the nurse was that serious and stated that she would have been the same if it were her child at risk. She is part of a larger group and the "decided" to let us go.

ICP is a serious complication, annoying to the mom who must suffer the itching but more serious for your child and induction 11-30 may be too late.

The doctor should not drop your wife's case without a referal, she should be getting frequent monitoring, amnio to see if the lungs are mature for the earliest possible delivery. Tomorrow, call first thing and see if you can get this resolved, also contact a university hospital near you and ask for referal and or possible treatment there or go to this site for information and referal to ob familiar with ICP http://www.itchymoms.com please update us with your progress.

brassua93
38 weeks gestation is the recommended stage of delivery of the baby unless the mother is jaundiced, then delivery should be at 36 weeks. November 30th appears to be the appropriate anticipated date of delivery.

You and your wife created this problem and finding a legal solution to the problem may be impaired by your actions. You should contact an attorney at once and discuss your options with the attorney. It is possible that the attorney can mediate a resolution to this situation and keep your wife in the care of the same OB practice. The attorney should be able to get the OB practice to understand the liabilities the practice is accepting by discharging your wife as a patient without securing a suitable alternate OB and neonatal recovery team.

If insurance is paying for your wife's care, contact your insurance company at once and ask for assistance in gaining a new provider or resolving the problem with the treating OB.

Best wishes,
EC

ellencee said:

brassua93
38 weeks gestation is the recommended stage of delivery of the baby unless the mother is jaundiced, then delivery should be at 36 weeks. November 30th appears to be the appropriate anticipated date of delivery.

You and your wife created this problem and finding a legal solution to the problem may be impaired by your actions. You should contact an attorney at once and discuss your options with the attorney. It is possible that the attorney can mediate a resolution to this situation and keep your wife in the care of the same OB practice. The attorney should be able to get the OB practice to understand the liabilities the practice is accepting by discharging your wife as a patient without securing a suitable alternate OB and neonatal recovery team.

If insurance is paying for your wife's care, contact your insurance company at once and ask for assistance in gaining a new provider or resolving the problem with the treating OB.

Best wishes,
EC

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Ellen,
I beg to differ, your response is one of the reasons OP is having problems with the nurse in the first place. Your response is NOT congruent with the treatment guidlines for ICP which is a high risk pregnancy and the decision to delivery early is based on the maturity of the lungs, not whether or not the mother has jaundice or not. The problem with the nurse and the practice's abandonment of a high risk pregnancy is NOT OP's fault for the ignornace of the nurse or the practice's failure to provide care, unfortunately these responses are common because ICP is rare in the US <4% whereas it is more common in Chile approximately 14%.

OP and his wife are lucky that ICP was even diagnosed, sometimes it is confused with PUPPS, but having been diagnosed, this pregnancy needs to be monitored appropriately, now, not blame OP and his wife for seeking apropriate treatment. Deliveries are suggested at 34 weeks if the lungs are mature, which means the mother and child must be monitored, that was why I mentioned amnio, without which most OB's won't deliver until 36 weeks. If needed the lungs may be matured with Prednisone which may also be given to the mother to resolve the itching. If ICP is diagnosed early enough or there is a history of ICP with prior pregnancies, treatment with ursodeoxycholic acid (UDCA) is reccommended and by most studies, the most effective treatment but at 34 weeks may be too little too late. OP didn't indicate what if any treatment or monitoring was given, which may be the issue. UDCA is preferred as opposed to cholestyramine which may help the itching but not reduce the buildup of bile acids which is what causes fetal mortality. If the mom is treated with UDCA for an appropriate amount of time, then delivery at 36 weeks without amnio may be OK.

That is why I gave the referal I did, for them to get to a university hospital for treatment and worry about the legal consequencies after they have secured appropriate care and a safe delivery.

Intrahepatic cholestasis of pregnancy increases the risk to the baby of meconium staining during delivery, preterm delivery, and intrauterine death. Women with ICP should be monitored closely, and serious consideration should be given to inducing labor as soon as fetal lung maturity is confirmed.

My daughter-in-law had ICP with both deliveries, the first was mis Dx as PUPPS and we nearly lost the first grand daughter who was born by C/S at 40 weeks, but is a healthy 4 yo now, my other grand daughter was delivered by C/S @34 weeks and weighed 9 lbs (no doubt on gestational age) she is also healthy now, in either case the outcome could have been different in a matter of hours or minutes. Problem is by the time lack of fetal movement is noticed in otherwise normal pregnancies, it is often too late.

rmet4nzkx
In the next post, there is list of experts (at the end of the article) with whom you can argue your medical expertise on the subject; they are afterall, only specialized MDs and I'm sure your input is sadly missing from their data.

I beg to differ, your response is one of the reasons OP is having problems with the nurse in the first place.

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I wasn't there when their difference of opinion occurred; I was not aware that you were.

This isn't about your opinion or my opinion; this is about an infant that doesn't stand much of a chance of surviving its birth if these parents don't do what it takes to remain under the care of the treating physician who has been following this pregnancy all along. The treating physician scheduled the delivery for November 30th and I'm betting on his, or her, professional decision's being 100% correct. It is not your place or mine to disagree with the scheduled date of delivery. The fact that it matches the reference materials that I have (all of them!) makes me feel comfortable with the MDs decision and with 38 weeks unless the mother is jaundiced, then at 36 weeks. You can provide treatment to your OB patients in any manner that suits you (and still meets the minimum standards of care); but, you have no knowledge of this pregnancy's progression (as far as I know). You can not apply your daughter's pregnancies with this patient's unless you have been the treating physician for each. I swear, your family has had every illness, every legal situation, every everything; I'm glad I'm not related to you. I don't think I could withstand one crisis after another.

I stand by my advice--get an attorney NOW to resolve this issue or get the insurance company NOW to resolve this issue. All I am concerned about is an infant in need of protection and how that infant can get here safely.
EC

INTRAHEPATIC CHOLESTASIS OF PREGNANCY
J. Reichen M.D.
Prevalence USA: 0.01 %
Switzerland: 0.35 %
Sweden: 2.8 %
Chile: 15.1 % in Caucasians to 27.6 % in Araucanians (28)

Etiology Genetic predisposition: HLA association in Chile (20, 27), autosomal dominant inheritance in Scandinavia (14)
Environmental factors
Central role of estrogens/gestagens (prevalence higher in twin pregnancies (12), women often suffer from pruritus when taking oral contraceptives). It has been speculated that there is a combination of a defect in sulfation of estrogens/gestagens together with a defect in canalicular excretion of these metabolites (39).
The primary defect may be a change in the reductive metabolism of progesterone (21, 23). Indeed, exogeneous progesterone can trigger pruritus (1). 3a,5a-isomers are particularly increased and an abnormal ratio of 3a- and 3b-isomers is typical (40).
Decreased sulfation of estrogens and monohydroxy bile acids (6) has been refuted in a later study (21).
Low serum selenium and decreased glutathione peroxidase activity have been invoked (16). An incrase in selenium plasma levels was associated with a decrease in incidence in Chile (38).
Heterozygosity for molecular defects in MDR3 (36, 37). A recent Finnish study in 57 patients found no mutations in MDR3 or estrogen a receptor (43).

Presentation Typically in third trimester (week 20 - 35). Onset during the first trimester occurs in 10 %, in the second in 25 % (17, 40).
Pruritus, jaundice
Elevated serum bile acids precede abnormalities of other liver tests (19); however, pruritus might precede any abnormalities in liver tests including serum bile acids (42)

Maternal outcome Pruritus disappears immediately after delivery in most patients
risk of recurrence high
Prolonged pruritus after delivery has been described (4, 24)
One kindred with a progressive course leading to cirrhosis and death has been described (18).

Fetal outcome Preterm delivery 20 % (31)
Meconium staining 25 % (31)
There is no fetal distress if serum bile acid levels remain < 40 mmol/l; it increases 1 - 2 % for each mmol increase above that level (42).

Incidence of fetal distress and death high if early delivery is not induced (5). If early delivery is induced, slightly but not statistically significant lower APGAR score and higher mortalitiy (31)

Treatment Transaminases, serum bilirubin and serum bile acids should be frequently monitored
Ursodeoxycholate decreases pruritus and ameliorates liver enzymes (25, 26) and may even improve fetal outcome (25). A high dose (20 - 25 mg/kg/d) regime is effective and safe for mother and fetus (41).
Dexamethasone has the same effects (15)
Deliver at week 38, at week 36 in case of jaundice
Epomediol (11) and S-adenosyl-methionine (10) have also been used with some success. UDCA is clearly superior to SAMe (8). The latter compound was ineffective in a randomized clinical trial (30).
Phenobarbital and cholestyramine are useless (13, 33).

Next post for references (too lengthy for this post)

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Brites D, Rodrigues CM, Oliveira N, Cardoso MD, and Graça LM. Correction of maternal serum bile acid profile during ursodeoxycholic acid therapy in cholestasis of pregnancy. J.Hepatol. 1998; 28:91-98.
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Davies MH, Da Silva RCMA, Jones SR, Weaver JB, and Elias E. Fetal mortality associated with cholestasis of pregnancy and the potential benefit of therapy with ursodeoxycholic acid. Gut 1995; 37:580-584.
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Gonzalez MC, Iglesias J, Tiribelli C, Ribalta J, Reyes H, Hernandez I, Bianchi M, Andrighetti F, and Molina C. Epomediol ameliorates pruritus in patients with intrahepatic cholestasis of pregnancy. J.Hepatol. 1992; 16:241-250.
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Hirvioja ML and Kivinen S. Inheritance of intrahepatic cholestasis of pregnancy in one kindred. Clin.Genet. 1993; 43:315-317.
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Mella JG, Roschmann E, Glasinovic JC, Alvarado A, Scrivanti M, and Volk BA. Exploring the genetic role of the HLA-DPB1 locus in Chileans with intrahepatic cholestasis of pregnancy. J.Hepatol. 1996; 24:320-323.
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Ribalta J, Reyes H, Gonzalez MC, Iglesias J, Arrese M, Poniachik J, Molina C, and Segovia N. S-Adenosyl-L-Methionine in the treatment of patients with intrahepatic cholestasis of pregnancy: a randomized- double-blind- placebo-controlled study with negative results. Hepatology 1991; 13:1084-1089.
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ellencee said:

brassua93
38 weeks gestation is the recommended stage of delivery of the baby unless the mother is jaundiced, then delivery should be at 36 weeks.
Maternal jaundice may be an additional reason to deliver @36 weeks but it is not the Standard of Care, maturity of the lungs is SOC for the child, that's determined by amnio etc. I brought the date into question, I didn't say it was necessiarly wrong but lung maturity is the deciding factor.
November 30th appears to be the appropriate anticipated date of delivery.
We cannot make that judgement based on the information given, that's why I called it into question. I pointed towards to the SOC for this type of high risk pregnancy, which includes monitoring, testing and early delivery, all of which are included in the article you referenced. Since none of this was mentioned by OP, such thngs normally are mentioned when/if they occur and OP's complaint was that the nurse wasn't familiar with ICP that most likely the lack of appropriate care was the issue, which is a common problem with ICP in this country since it is so rare.

You and your wife created this problem and finding a legal solution to the problem may be impaired by your actions.
This is where YOU became very judgemental, possibly exhibiting the same attitude as the nurse in question. How can you condon such behavior and then blame the patient?

There was a question of receiving appropriate care for a high risk pregnancy in a time limited situation, while they can try to resolve the situation with the OB who would or should have known better than to ABANDON a high risk OB patient @ week 34.5, a suggestion I did make, however, given the critical nature of this situation, the best interest of the child is served by seeking appropriate medical care, NOW, and then looking at the legal recourse after that is obtained.

While the usual course is to remain with the treating OB for the entire course of the pregnancy, this is a HIGH RISK pregnancy which includes the referral for specialized care as the SOC NOT abandonment or blaming the patient and spouse.

You should contact an attorney at once and discuss your options with the attorney. It is possible that the attorney can mediate a resolution to this situation and keep your wife in the care of the same OB practice. The attorney should be able to get the OB practice to understand the liabilities the practice is accepting by discharging your wife as a patient without securing a suitable alternate OB and neonatal recovery team.

Would you want to stay with an OB who abandonded your high risk pregnancy and increased the risk to your child? Actually a part of their legal recourse in time, is to make complaints to the appropriate boards for the nurse and OB, something for the future, not now, so I didn't even mention it.

If insurance is paying for your wife's care, contact your insurance company at once and ask for assistance in gaining a new provider or resolving the problem with the treating OB.
Most have an appeals process that can be expidited, but having contacted a university hospital re care first will speed up this process and will most likely be where they will be sent.

Best wishes,
EC

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ellencee said:

rmet4nzkx
In the next post, there is list of experts (at the end of the article) with whom you can argue your medical expertise on the subject; they are afterall, only specialized MDs and I'm sure your input is sadly missing from their data.

If you read any of the articles you would have seen they said the same thing as I, except for the addition of a maternal cause to deliver early @36 weeks for jaundice by the author of that article.

I wasn't there when their difference of opinion occurred; I was not aware that you were.
You are correct, neither of us were there, however, nothing was mentioned re any care beyond diagnosis, thus advice based upon the worst case scenerio with a high risk patient abandoned.

This isn't about your opinion or my opinion; this is about an infant that doesn't stand much of a chance of surviving its birth if these parents don't do what it takes to remain under the care of the treating physician who has been following this pregnancy all along.
You are partially correct, the child is at serious risk also if the mother is prevented from receiving appropriate care, NOT continued treatment by an OB that abandonded a high risk parient without referral.
The treating physician scheduled the delivery for November 30th and I'm betting on his, or her, professional decision's being 100% correct. It is not your place or mine to disagree with the scheduled date of delivery.
The OB's opinion is a moot point because they abandoned the patient, a new delivery date will be determined by the new OB, which hopefully will be based on appropriate monitoring and testing. SOC for ICP is information OP is entitled to have as they search for appropriate care even if they continue with the former OB.

The fact that it matches the reference materials that I have (all of them!) makes me feel comfortable with the MDs decision and with 38 weeks unless the mother is jaundiced, then at 36 weeks. Actually your reference was only made by the 1 author not all of them and specifically when jaundice is present in the mother, if you had read the other portions of the abstract you cited you would have noticed the same references to monitoring bile acids and lung maturity.

You can provide treatment to your OB patients in any manner that suits you (and still meets the minimum standards of care); but, you have no knowledge of this pregnancy's progression (as far as I know). Nor do you, but how can you assume the SOC has been met with a high risk patient abandonded?

You can not apply your daughter's pregnancies with this patient's unless you have been the treating physician for each.
Daughter-in-law, of course I did research on the issue and the SOC can be applied to this patient which is the essence of OP's quesiton.

I swear, your family has had every illness, every legal situation, every everything; I'm glad I'm not related to you. I don't think I could withstand one crisis after another.
What? Every??? I guess I have been blessed in many ways! I usually try to take the negative things that happen to me and try to find, apply the positive learnings to life and in helping others. I'm sorry that you see the world in such a negative manner. I have seen you attack some members because you disagree on a personal level but apply it to their medical/legal questions with obvious bias, yet other times you give very good advice.

I stand by my advice--get an attorney NOW to resolve this issue or get the insurance company NOW to resolve this issue.
Get appropriate care NOW, worry about the rest after.

All I am concerned about is an infant in need of protection and how that infant can get here safely.
EC

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I agree with your last statement, but an attorney can't deliver that child unless they are also an OB.

ellencee said:

INTRAHEPATIC CHOLESTASIS OF PREGNANCY
<sniped>
Presentation Typically in third trimester (week 20 - 35). Onset during the first trimester occurs in 10 %, in the second in 25 % .
Pruritus, jaundice
Elevated serum bile acids precede abnormalities of other liver tests ; however, pruritus might precede any abnormalities in liver tests including serum bile acids
Maternal outcome Pruritus disappears immediately after delivery in most patients
risk of recurrence high
Fetal outcome Preterm delivery 20 %
Meconium staining 25 %
There is no fetal distress if serum bile acid levels remain < 40 mmol/l; it increases 1 - 2 % for each mmol increase above that level.
Incidence of fetal distress and death high if early delivery is not induced (5). If early delivery is induced, slightly but not statistically significant lower APGAR score and higher mortalitiy

Treatment Transaminases, serum bilirubin and serum bile acids should be frequently monitored
Ursodeoxycholate decreases pruritus and ameliorates liver enzymes and may even improve fetal outcome . A high dose (20 - 25 mg/kg/d) regime is effective and safe for mother and fetus .
Dexamethasone has the same effects
Deliver at week 38, at week 36 in case of jaundice (Please note, the only reference to this is from this author, this is in addition to the general recommendation to deliver as soon as lungs are mature and checking bile acids)
Epomediol and S-adenosyl-methionine have also been used with some success. UDCA is clearly superior to SAMe. The latter compound was ineffective in a randomized clinical trial.
Phenobarbital and cholestyramine are useless.

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Hopefully OP will give us an update.

updating the events

We called the morning after and found an excellent Dr. in the same hospital. Much more informed about the condition. We were well aware of many of the things that were posted. Thanks for the additional info. My wife's Bile Acid Levels reached 97 and all information that we have read indicated that delivery of the baby should come before 36 weeks. Our new Dr. has scheduled us for delivery on the 22nd. The baby had received the steriod shot for lung development at 33 weeks and he is measuring in the neighborhood of 6 pounds. His heart rate has remaind strong with no irregularities. My Wife's discomfort has increased even with the Actigall (Urs Acid). Her mother had a stillbirth at 38 weeks. This was prior to knowledge of Cholestasis but her mom had all the symptoms and the baby appeared to have no abnormalities,

brassua93 said:

We called the morning after and found an excellent Dr. in the same hospital. Much more informed about the condition. We were well aware of many of the things that were posted. Thanks for the additional info. My wife's Bile Acid Levels reached 97 and all information that we have read indicated that delivery of the baby should come before 36 weeks. Our new Dr. has scheduled us for delivery on the 22nd. The baby had received the steriod shot for lung development at 33 weeks and he is measuring in the neighborhood of 6 pounds. His heart rate has remaind strong with no irregularities. My Wife's discomfort has increased even with the Actigall (Urs Acid). Her mother had a stillbirth at 38 weeks. This was prior to knowledge of Cholestasis but her mom had all the symptoms and the baby appeared to have no abnormalities,

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I'm glad you found an new OB with whom you are more comfortable and glad to hear that even though the original OB was looking at a later delivery, had at least taken measures to ripen the lungs and that the baby is good sized for the early delivery. I'm also glad to hear that your wife is already taking Acigall (UDCA) which is the most effective Rx so at least the reccommended treatment was being taken. I can understand your concern based on family history of ICP and stillbirth and now just a few days until the birth of your child. I'm glad you got a new OB the next morning without unnecessary frustration and that you are well informed on this rare condition which means you must advocate for yourselves as you have learned. I'm sorry your wife is still uncomfortable and sure you have tried all the usual means to counteract the itching. Please keep us updated, have your wife relax as much as possible, listen to soothing music. When this is over and your child safely delivered, then you can look at possible legal options and/or administrative complaints. Your wife should not have been abandoned at this stage in a high risk pregnancy without referal or addressing your concerns. Also understand that if her labor is induced and she fails to progress, there may be a need for a C section.
Best wishes!