Re: 34 week prom
From: Lynn D. Montgomery, M.D. (apgar10@montanadsl.net)
Mon Apr 11 12:00:03 2005
Dan,
Totally agree with the paucity of data. However, when you look at the
animal data regarding neurotoxicity of the various inflammatory mediators,
combined with the fact that there is no question regarding the increase in
neurodevelopmental issues in products of PPROM pregnancies compared to
matched simple prematurity, it certainly causes one to pause - seeing the
micros of the rat brains exposed to these various mediators is impressive.
Further Romero, et al presented data this year where they did
chromatographic analysis of amniotic fluid in these situations and found
over 160 different elements, some which remain unidentified. Now what
exactly does this mean - only time will tell. At the meeting, I asked why
nobody had looked at amniotic fluid and maternal blood in this manner
before. I got one answer that was pretty good, "cause CSI wasn't on TV
before this to give them the idea".
The lack of data is the very reason I have not chosen to lower my timing for
elective delivery in PPROM to 32 weeks. In the past two years however, I
have lowered from 36 to 34, given that the ultimate outcome from 34 weeks on
is the same.
Lynn
--
Lynn D. Montgomery, M.D.
Maternal-Fetal Medicine, OB/GYN
Rocky Mountain Women's Health
2835 Fort Missoula Rd., Suite 304
Missoula, Montana, 59804
406-549-0978
fax 406-549-0987
e-mail: apgar10@montanadsl.net
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of R. Daniel
Braun
Sent: Saturday, April 09, 2005 9:56 AM
To: Multiple recipients of list OB-GYN-L
Subject: Re: 34 week prom
Lynn,
Is the science for this really there? Or is it like so many other things
that we do, HUAM & Tocolytics for examle, that we do because even though the
science isn't there, we think it makes sense and it ought to work. IOW, is
there an RCT? I don't see any way to blind it, certainly an RCT, could be
done to answer the question. From your discussion, I got the idea that the
only studies were observational and some of them were in animals.
Dan
On Apr 8, 2005 9:55 PM, Garry E. Siegel, M.D. <garrys@mindspring.com> wrote:
> ROM at 34 or more--expectant management or deliver.
>
> No steroids over 34 weeks.
>
> Garry
>
> At Fri, 08 Apr 2005, Andrew Folley wrote:
> >
> >Lynn thanks for such a clear anc concise response. Over the past yar
> >I have been pushing for giving steroids antibiotics and tocolysis for
> >PPROM at
> >32-34 weeks and cytokine release etc and role in causing cerebral
> >palsy. Do you think that is too aggressive at this point??? andy
> >
> >>From: "Lynn D. Montgomery, M.D." <apgar10@montanadsl.net>
> >>Reply-To: ob-gyn-l@obgyn.net
> >>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
> >>Subject: RE: 34 week prom Date: Fri, 8 Apr 2005 14:04:10 -0500
> >>
> >>This issue has been addressed with several abstracts over the past
> >>two years at the Society meeting. Because of the increased
> >>incidence of neurodevelopmental issues associated with children who
> >>are products of PPROM over controls with just prematurity, the
> >>effects of various inflammatory markers (i.e. cytokines,
> >>metalloproteinase's, interlukins)have been looked at. Granted, some
> >>of these studies are animal models, but exposure of brain tissue to
> >>these substances has impressive effects. Because these factors are
> >>produced prior to clinical evidence of infection, and thus the
> >>potential untoward effects on the fetus, it has been suggested to
> >>move the point at which you electively deliver, with PPROM, earlier
> >>that what I was taught at
> >>36 weeks. Data is pretty conclusive that 34 weeks is the more
> >>prudent timing - issues regarding prematurity are outweighed by the
> >>risk of neurodevelopmental issues - and the fact that the ultimate
> >>outcome of pregnancies beyond 34 weeks is the same. One paper
> >>actually goes as far as suggesting that 32 weeks is the more prudent
> >>"end-point" in PPROM. I haven't yet been convinced to go that far.
> >>
> >>A year ago at the Society meeting, because of what these various
> >>papers suggested, I polled several programs represented, asking them
> >>what their policy was with regard to timing of delivery with PPROM
> >>and the predominate answer was 34 weeks.
> >>Lynn
> >>
> >>Lynn D. Montgomery, M.D.
> >>Maternal-Fetal Medicine, OB/GYN
> >>Rocky Mountain Women's Health
> >>2835 Fort Missoula Rd., Suite 304
> >>Missoula, Montana, 59804
> >>406-549-0978
> >>fax 406-549-0987
> >>e-mail: apgar10@montanadsl.net
> >>
> >>-----Original Message-----
> >>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
> >>Andrew Folley
> >>Sent: Thursday, April 07, 2005 10:16 AM
> >>To: Multiple recipients of list OB-GYN-L
> >>Subject: RE: 34 week prom
> >>
> >>Question: Had a patient show up last night G3P2 ruptured membranes
> >>34 weeks
> >>1 day. 2 prior c-sections. Not in Labor. What to do? She is
> >>vertex fluid in vault sent for f-pole showed not mature. My plan
> >>was steroids, tocolysis for 48 hours if necessary and repeat
> >>c-section in 48 hours.
> >>Along with GBS prophylaxis. Some of our MFMs were not so happy with
> >>the management plan. What ywoud you do???? andy
> >>
> >> >
> >>
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>
> --
> Garry E. Siegel, M.D.
> Private Practice
> Roswell, GA
>
--
R. Daniel Braun
Kinky for Governor
