Patient Stories

Uncontrolled Diabetes and Pregnancy: Doubly Important 

This Women’s Telehealth patient case story emphasizes the importance of patient compliance to obtain a healthy baby outcome in one of the most common pregnancy complications – insulin controlled diabetes.

This Pregnancy’s Challenge:

An 18 year old patient presented in a rural area to the local OB physician when she was 16 weeks pregnant.  Her OB history showed she had been diagnosed with Type I Diabetes at age 5. She had been seeing a local endocrinologist but was told he would not follow her and manage her insulin during pregnancy.

The close diabetic monitoring required throughout the pregnancy would need to be provided by a Maternal-Fetal Specialist. Because the closest one was approximately  1 ½ hours from the patient’s home, she was referred to Women’s Telehealth by her local OB physician for co-management.  Women’s Telehealth provided MFM care through telemedicine visits.

Of additional concern was that the patient was noted to be non-compliant in her insulin regime and diabetic care.

The Team’s Actions:                                                        

• Initially, the patient was taking both long-acting insulin daily and at bedtime, and rapid-   acting insulin with meals.  She had an implanted blood glucose monitor and was to                         follow an ADA diet.
• During her initial MFM consult, Women’s Telehealth counseled the patient to monitor and bring her blood sugar logs and insulin regime to every visit.
• For four weekly visits, the patient did not follow instructions. Women’s Telehealth continued to counsel her as to the potentially poor outcomes for the baby if her blood sugar was not controlled, as well as the importance of complying with the monitoring, diet and insulin regime. During this time, her baby slipped from the 55^th percentile to the 29^th  Not a positive trend. 
• Women’s Telehealth provided on-going insulin management, ultrasound fetal monitoring and counseling regarding non-compliance. With positive reinforcement, SOMETHING CHANGED!
• Her 18-20 week anatomy scan was normal.
• From 23 through 33 weeks, the patient started bringing in her blood sugar logs and her insulin levels became controlled. In fact, she reported they were, “the best they’ve ever been.”  The baby grew from the 29^th percentile to the 52^nd  Dopplers and antenatal testing showed GREAT improvement.  

The Results:

• The story has not ended as the baby has not delivered. But, the baby is healthy and within a few weeks of a safe delivery. The patient was moved to an “all as needed” status with her insulin regime and blood sugars under control.
• Through telemedicine, the patient was able to stay local and receive the needed medical care, as she could not have traveled outside of her area.
• The tele-MFM option greatly improved patient compliance and results.
• The patient realized travel savings of 1,980 miles and over 35 hours. 

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The prevalence of diabetes in pregnancy in the U.S. is increasing. Pre-existing, Type I diabetes confers an increased and more significant risk to both mom and baby than gestational diabetes. Tight blood sugar control is critically important at all stages of pregnancy. Uncontrolled diabetes in pregnancy can lead to such complications as fetal anomalies, pre-eclampsia, fetal demise, macrosomia, neonatal hypoglycemia and spontaneous abortion.

 To learn more, visit: https://www.cdc.gov/pregnancy/diabetes-types.html

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Baby’s Gastroschisis: Early Diagnosis and Preparedness Made the Difference!

How to successfully manage the complexities of gastroschisis in pregnancy is the focus of this Women’s Telehealth patient story.

This Pregnancy’s Challenge:

At the anatomy ultrasound scan at 17 weeks, the OB physician found that his 24 year old Caucasian patient had a suspected gastroschisis.

Gastroschisis is a birth defect in which the fetus’ intestines and/or stomach protrude outside the abdominal wall.  A baby with this condition requires immediate surgery after birth to place the organs in the proper place in the abdominal cavity and close the hole in the abdominal wall.  Hospitalization is also needed for an extended period of time to ensure that the baby’s feeding and digestive tract are functioning well. Most babies with appropriate care and surgery at birth will grow up to have normal lives.  Successful outcomes often depend on early identification of this birth defect and preparing for surgery upon birth.

In addition to the suspected gastroschisis, other complicating factors included mom’s obesity, pregnancy-induced hypertension, low amniotic fluid, abnormal cervix and active kidney disease. The mom-to-be also needed an extra dose of oversight and compassion due to the loss of a baby during a previous pregnancy, caused by open neural tube defect.

The mom-to-be was referred by the OB physician to Women’s Telehealth maternal-fetal medicine (MFM) physicians for diagnosis and collaborative pregnancy management. Women’s Telehealth was asked to manage BOTH infant and maternal pregnancy complications.

The Team’s Actions:

Because there were no MFM Specialists in the patient’s community and it was over an hour drive to the closest one in Atlanta, GA, the patient opted for MFM care via telemedicine through Women’s Telehealth’s connection in her local OB office. 

• The patient was seen multiple times by Women’s Telehealth to assess her baby’s and her own well-being. The severity of the baby’s birth defect was moderate.
• Advanced, serial “live” ultrasound imaging for fetal growth and well-being was performed including: targeted ultrasound scan, fetal echo, BPP, Dopplers, cervical length and AFI measurements.
• Mom was admitted to the hospital for low amniotic fluid once during her pregnancy.
• Mom was counseled for what to do in the event of pre-term labor.
• Women’s Telehealth arranged for a pre-delivery consult with a pediatric surgeon at CHOA in Atlanta, as the baby would be transferred to the pediatric hospital as soon as it was born.               
• Women’s Telehealth arranged for a local Atlanta OB GYN group to deliver the baby via C-Section due to the birth defect.

  The Results:   

• Weekly monitoring by the Women’s Telehealth MFM doctor showed a worsening of the mom’s kidney disease.
• The decision was made to deliver the baby via C-section at 35 weeks at a hospital close to the children’s hospital where the baby would have its surgery and remain for some time.
• A baby girl weighing 6 lbs. 3 oz., with Apgar scores of 8/8, was delivered without incident.
• The baby was promptly transferred to the children’s hospital where successful closure surgery was performed.

Women’s Telehealth’s progressive telemedicine capability, providing the right treatment at the right time, supported the patient and the baby. In this case, the Women’s Telehealth team as able to help manage a complex pregnancy, make the appropriate arrangements to prepare mom and baby for upcoming surgical repair and help celebrate a positive outcome!

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The CDC estimates that Gastroschisis affects 1 in every 1,900 babies born in the U.S. each year. The cause of this birth defect is currently unknown but researchers have speculated that potential causes may be adaptations in genes and/or the lifestyle or environment of the mother.  Young, Caucasian women are the most common population to be at risk. For more information about this condition visit:  https://www.cdc.gov/ncbddd/birthdefects/gastroschisis.html

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Mom’s Rare Birth Defect – An Unchartered Pregnancy Story

This Women’s Telehealth patient story is a twist on a birth defect – the mother’s rare birth defect, a diaphragmatic hernia at birth, now posed a pregnancy management challenge to mom and potentially baby.

The Pregnancy Challenge: A mom-to-be from middle Georgia was 26 weeks pregnant when she visited her local OB physician for the first time.  When her initial OB assessment revealed that she had been treated for a Bochdelek Hernia at birth, her doctor promptly referred her to Women’s Telehealth for high-risk MFM Specialist care.

A Bochdelek Hernia is a rare, life-threatening congenital birth defect in which an opening in the diaphragm allows the baby’s abdominal organs to shift into the chest.  The patient required surgery at birth to place the organs in the proper position and repair the opening in the diaphragm, and, a tissue graft was placed surgically during childhood.  Rarely does a woman who has had this condition become pregnant herself later in life.                          

Of primary concern was:  Would the growing baby in utero cause the graft to stretch or possibly break? How would the growing baby affect the patient’s health? Would she be able to push during delivery or would a C-section be required? These were the serious questions facing the patient and her obstetric team.

The Team’s Actions:                                    

• The initial, advanced MFM ultrasound via telemedicine revealed that the tissue graft was intact and functioning well.
• The fetus was found to have a two vessel umbilical cord with low blood flow and was in the 9^th percentile for its gestational age, indicating Intrauterine Growth Retardation (IUGR).
• An extensive literature search revealed no documented, similar cases. 
• WT collaborated with other MFM’s and a graft surgeon in San Francisco who places grafts in children, to discuss the situation and graft function with a pregnancy stress.
• The patient was educated about immediate reasons to present to the ER.               
• Diagnostic genetic lab tests revealed the baby did not have any genetic or neural tube defects.
• WT is now in the process of writing this case study for publication in a professional peer reviewed journal, with the family’s cooperation, so there will be a future resource for others.        

The Results:

A healthy, > 5-pound baby girl was successfully delivered via C-Section at 35 weeks gestation!  WT is happy to report that the mom’s diaphragmatic graft functioned well throughout the pregnancy and required no medical or surgical intervention. 

Women’s Telehealth was pleased to be called on to help solve this rare pregnancy dilemma. It’s another example of how the advanced MFM technological services can be provided via telemedicine to treat complicated, high-risk prenatal cases often saving time and money as well.

Twin to Twin Transfusion Syndrome: A Life-Saving Story

A twin pregnancy comes with risks for mother and babies and this Women’s Telehealth patient story presents one such serious complication.

This Pregnancy’s Challenge: The ultrasound conducted by the patient’s local OB physician revealed that one twin was growing and the other was not. Preliminary tests indicated a suspected “Twin to Twin Transfusion Syndrome,” caused by a blood vessel defect. Left untreated, the survival rate for both twins would be less than 15%.  The mom-to-be needed immediate high-risk OB care and intervention. Because the closest MFM Specialist was two hours away and the patient would require consistent monitoring, she was referred to the OB/GYN’s MFM telemedicine partner in Atlanta, GA, Women’s Telehealth.

The Team’s Actions:                                

• The initial MFM telemed consult and specialized ultrasound confirmed the “Twin to Twin Transfusion Syndrome” and identified the problematic blood vessels causing it.
• The MFM physician forwarded all images and notes immediately to the closest fetal surgeon to see if he would take the case as there was a critical time window.
• The surgery was performed in FL and the patient stayed in the hospital for a few days to monitor mom and babies before they were released to home.
• WT continued to remotely monitor growth of both twins regularly until the OB and MFM doctors decided to deliver a little early via C-Section, to prevent loss and trauma.

The Results:

• Two healthy baby girls were delivered slightly early by C-Section with no residual health problems.   
• Cost savings were estimated to be > $12,000 in expenses.                             
• Travel savings of 2700 miles and 40 commuting hours were realized.                              

Early identification and treatment of this often-fatal condition in a rural area, where there is no MFM specialist, led to the successful birth of these babies. Women’s Telehealth is pleased to have played a key role in arranging life-saving surgery through their network of high risk OB specialists and the use of continued monitoring via telemedicine!

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Multiple births are much more common today than in the past. According to the U.S. Dept. of Health and Human Services, the twin birth rate has increased by over 75% since 1980, and triplet, quadruplet and high-order multiple births have increased at an even higher rate.  To learn more, visit:

https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/multiple-pregnancy-and-birth-twins-triplets-and-high-order-multiples-booklet/

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High Trisomy 18 Risk: Concerns Relieved Story

Unborn baby’s high birth defect risk is the focus of this Women’s Telehealth patient story.

This Pregnancy’s Challenge: In a prior pregnancy, prenatal tests indicated positive results for Downs Syndrome for this mom-to-be. Fortunately, this proved not to be the case and her baby was indeed born healthy.  However, with the next/current pregnancy, the patient was extremely worried when “Quad Test” results [deleted: during her current pregnancy] reflected a 1:56 risk for Trisomy 18 and the ultrasound conducted at the local hospital was inconclusive.

Trisomy 18, also known as Edwards Syndrome, is similar to Downs Syndrome, as they are both caused by a chromosome abnormality. Unlike Downs Syndrome however, Edwards Syndrome is potentially more life-threatening during the neonatal period and early life. It was very important that the mother and unborn child receive high-risk OB Specialist care. 

The Team’s Actions: Because there were no MFM Specialists in the patient’s community and it was over an hour drive to the closest one in Albany, GA, the patient opted for MFM care via telemedicine through Women’s Telehealth based in Atlanta.  WT was able to offer the patient in-depth evaluation and consultations via telemedicine directly from her local OB physician’s office.

• The patient declined amniocentesis, a procedure whereby amniotic fluid is collected for detailed diagnostic testing and at the time, free cell DNA testing via maternal blood was not available. 
• Advanced, serial “live” ultrasound imaging for fetal growth and well-being was performed.
• WT conducted regular MFM physician consultations to monitor the baby’s development.
• A co-management plan was developed between the WT MFM specialist and local OB/GYN.

The Results:

WT’s progressive telemedicine capability, providing the right specialist at the right time, supported the patient safely through an uncertain, emotional journey. In this case, the WT team was able to allay the patient’s concerns and celebrate a positive outcome!

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Birth defects are a common, critical and costly condition affecting 1 in every 33 babies born in the U.S. each year.* For more information about birth defect stats, prevention, diagnosis and aftercare, visit: https://www.cdc.gov/ncbddd/birthdefects/facts.html

*Centers for Disease Control and Prevention. Update on Overall Prevalence of Major Birth Defects–Atlanta, Georgia, 1978-2005. MMWR Morb Mortal Wkly Rep. 2008;57(1):1-5.

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