Case Archive
Maternal-Fetal Medicine
Ref. # 199001

A 37 year old woman, gravida 3, para 1-0-1-1, had a pregnancy achieved with in vitro fertilization because of premature ovarian failure. Her medical history included a spontaneous miscarriage nine years prior and a delivery by cesarean section at term seven years prior. She declined genetic testing for advanced maternal age because it was a premium pregnancy. At 35 weeks and 2 days of gestation, she developed spontaneous rupture of membranes. There was further leaking and the woman presented to a major medical center. A group B strep test was performed. Ultrasound suggested an estimated fetal weight of 2383 grams. Records indicated consideration of induction the next morning. The woman opted to transfer to the medical center of her obstetrical care providers. Another group B strep test was performed. An ultrasound showed an amniotic fluid index of 12 cm. The woman had conservative management for the next five days, when her strep culture returned "abundant GBS." She was started on ampicillin. That night she started a fever and was diagnosed with chorioamnionitis. Induction of labor followed. At 0130 a note described decelerations; she was 1 to 2 cm in cervical dilation. At 0420 and at 0600 she was still at 2 cm. Rapid progress ensued and the woman had a forceps delivery of a 6-pound infant with Apgars of 3 and 6. A medQuest maternal-fetal specialist opined the care rendered was negligent in two areas. First, the conservative management at the woman's advanced gestational age was inappropriate. For women who have preterm (less than 37 weeks) premature rupture of membranes, management depends on the gestational age. At 34 or more weeks, standard of care is to induce labor, because the chance of the baby having complications on the inside is greater than on the outside. Secondly, the group B strep prophylaxis was mismanaged. There was a failure to contact the major medical center for results of its culture reports, as well as a failure to check the regional center's own reports on a daily basis. Antibiotics should have been given much earlier. The negligence directly resulted in the baby's severe injuries.

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