OB-GYN-L Messages for November, 2003: Re: Amazing case!

Re: Amazing case!

From:

Terrence.Jones@kp.org

Mon Nov 10 19:51:39 2003

Not much time for secondary processing, so - 'off the top'. The term 'protrusion' reduces concers of specificity with the imaging study. Given there's a window, the amniotic fluid volume and fetal size, that cause it to open wider, will accelerate their contribution in the third trimester. So the dilemma would be to observe (there's an ostrich in the Sahara, secretly winking, soon to perish from thirst) with the intent (hope?) of intervention prior to catastrophic rupture, while gaining time for the fetus (a bit early for steroids - which in turn might provoke uterine ctxs) versus closing the window and risk precipitating need for earlier delivery (labor, infection, bleeding, SROM). Closing windows after 'iatrogenically' opening them, and including breach of membranes (for fetal surgical intervention) is not unheard of - and assoc with defined risks. Tho in such cases the myometrium has not been attenuated. I'd guess there are insufficient numbers of hypothetical patients in this scenario to give a denominator. Pain seems a motivating symptom, suggesting a process has started, with and end point predictably less than would be meaningful, WRT 'time gained'. Also, as a confounder unique to Your local Patient population - Those surviving the natural selection process, as it evolves in the climes of Montana, have within their hypothetical protoplasm, a greater concentration of adamantium than your typical 'X-man'. Since it's less than 28 wks, might see if Indocin would stop the pain. If so, continue 48 hrs to help reduce AFI and facilitate decompression and closure. If not, You can always decompress with needle and syringe. So, hypothetically, what would happen in a case such as You described? :) tj

PS Why 'two' prior classicals? Had She three low transverse, then developed lower segment obstructive myomatous change (+/- malpres) prompting an alternative incision(s)? If so, the pain might be a red(-degeneration) herring.

apgar10@montanadsl.net (Lynn Montgomery, M.D.) Sent by: ob-gyn-l@obgyn.net 11/10/2003 04:55 PM Please respond to ob-gyn-l

To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> cc: Subject: Amazing case!

Listers, Lets just say that this is a hypothetical:

Patient at 26 weeks gestation with five previous cesarean sections - two of them classical. Presents with low abdominal pain. MRI shows what is interpreted as "thinning of the lower uterine segment with apparent protrusion of the amniotic membranes through the segment". No contractions, ongoing pain, no fetal issues.

What would you do? You can't offend me cause it is only a hypothetical and not my hypothetical... Lynn

-- Lynn D. Montgomery, M.D. Rocky Mountain Women's Health Missoula, Montana

The information provided here is only an opinion and does not constitute the establishment of a patient-physician relationship. As with any medical problem, should you feel that you have a significant problem it is incumbent upon you to seek the appropriate medical care. I hope that you will understand that I cannot respond to individual e-mails directed to me.

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Not much time for secondary processing, so - 'off the top'. The term 'protrusion' reduces concers of specificity  with the imaging study. Given there's a window, the amniotic fluid volume and fetal size, that cause it to open wider, will accelerate their contribution in the third trimester. So the dilemma would be to observe (there's an ostrich in the Sahara, secretly winking, soon to perish from thirst) with the intent (hope?) of intervention prior to catastrophic rupture, while gaining time for the fetus (a bit early for steroids - which in turn might provoke uterine ctxs) versus closing the window and risk precipitating need for earlier delivery (labor, infection, bleeding, SROM). Closing windows after 'iatrogenically' opening them, and including breach of membranes (for fetal surgical intervention) is not unheard of - and assoc with defined risks. Tho in such cases the myometrium has not been attenuated. I'd guess there are insuffi! cient numbers of hypothetical patients in this scenario to give a denominator. Pain seems a motivating symptom, suggesting a process has started, with and end point predictably less than would be meaningful, WRT 'time gained'. Also, as a confounder unique to Your local Patient population - Those surviving the natural selection process, as it evolves in the climes of Montana, have within their hypothetical protoplasm, a greater concentration of adamantium than your typical 'X-man'. Since it's less than 28 wks, might see if Indocin would stop the pain. If so, continue 48 hrs to help reduce AFI and facilitate decompression and closure. If not, You can always decompress with needle and syringe. So, hypothetically, what would happen in a case such as You described?  :) tj         PS Why 'two' prior classicals? Had She three low transverse, then developed lower segment obstructive myomatous change (+/-  malpres) prompting an alternative incision(s)? If so, the pain might be a red(-degeneration) herring. <table width0%> <tr valign=top> <td> <td>apgar10@montanadsl.net (Lynn Montgomery, M.D.) Sent by: ob-gyn-l@obgyn.net 11/10/2003 04:55 PM Please respond to ob-gyn-l <td>                To:        Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>         cc:                 Subject:        Amazing case!</table> Listers, Lets just say that this is a hypothetical: Patient at 26 weeks gestation with five previous cesarean sections - two of them classical.  Presents with low abdominal pain.  MRI shows what is interpreted as "thinning of the lower uterine segment with apparent protrusion of the amniotic membranes through the segment".  No contractions, ongoing pain, no fetal issues. What would you do? You can't offend me cause it is only a hypothetical and not my hypothetical... Lynn -- Lynn D. Montgomery, M.D. Rocky Mountain Women's Health Missoula, Montana The information provided here is only an opinion and does not constitute the establishment of a patient-physician relationship.  As with any medical problem, should you feel that you have a significant problem it is incumbent upon you to seek the appropriate medical care.  I hope that you will understand that I cannot respond to individual e-mails directed to me.

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