OB-GYN-L Messages for November, 2005: Re: 28 week PROM

Re: 28 week PROM
From: Terrence.Jones@kp.org
Sat Nov 12 14:20:29 2005

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Andrew, think almost everyone is going to sit on this one (28 wks), for now. Fever and tachy are late in the course. Contractions OTOH are likely to be just around the corner (nullip at 3 cm/90%? - either relative cervical incompetence and membranes degraded locally by vag flora; or infected decidua with secondary uterine activity promoting SROM with subsequent reduction in volume and concentration inflammatory cytokines/PG's with temporary cessation of uterine activity), given the WBC, and most WOULD NOT tocolyse without a negative amnio. (Which is no easy task with an RAFI of 3, and if the amnio came back normal in this Patient - I'd have some serious concerns about the reliability of the lab!)
Robert is echoing the sentiment from Lynn (4/8/05) WRT cytokine mediated CNS damage in PTPROM (and recent SMFM meetings presentations regarding timing of delivery (34 weeks, or in some centers 32 weeks)). Rick Sweet was here in October and we asked Him to discuss this further. Again, as Lynn pointed out per Roberto Romero's work, there are extensive numbers of cytokines and as yet indeterminate elements that play a role. Until there is more investigation, we won't know what organisms and host susceptibility markers can be predictive of outcome. But for now, Dr. Sweet DID point out (can't remember the study) that - 'once chorio is dx'd and efforts to deliver were initiated, there was no difference in outcome based on duration of labor/time to delivery' . Needless to say, that is a big leap of policy-making faith. Think most would manage like Robert - tho we all want to avoid an unnecessary incision into an infected uterus - if they're not responding... Fortunately, most will fly thru labor, once initiated. For those that do not -there's hemabate and cytotec (and B-Lynch?).
One thing that appears to be changing, is the perception of steroids and their role in this setting. The host inflammatory response may play more of a role than the infecting organisms, in mediating CNS damage. The former perspective of steroids and immune suppression as a problem is evolving (suggesting an "alternative strategy - let the wookie win?"). Wonder if any of You are working in "cool cap" center (for prevention of HIE in at risk infants)? If so - wonder if there's any interest in its role in chorio - as temperature appears to augment the pathogenic processes. Now, any comments on the Nov 10th NEJM? /tj
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---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Robert J. Carpenter, Jr. MD: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Given gestational age, I have never been an inducer without good reson. Having seen many such babies go days and weeks post rupture, I sit.
That means thrice daily EFM assessment for surveillance. If even a hint of Chorio pops up, then delivery. If it occurs, I also do not go 12-24 hrs to achieve vag delivery. Given FIRS delivery should be expeditious. By that I do not mena an immediate C/S.
--------------------------------------------------------------------------------------------- On 11 Nov 2005 at 20:39, Andrew Folley wrote: ---------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------- G1P0 28 week PROM wed am. Received steroids and on antibiotics. Cx 3 cm 90% no ctxs. Echo vertex AFI 3 2#7oz Inital WBC 17000 and CRP elevated at 2.1 No maternal fever or tachycardia. FHTs reassuring. In level III hospital.What to do? Sit tight and wait for obvious chorio? Induce 24 to 48 after Prom? andrew
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         Andrew, think almost everyone is going to sit on this one (28 wks), for now. Fever and tachy are late in the course. Contractions OTOH are likely to be just around the corner (nullip at 3 cm/90%? - either relative cervical incompetence and membranes degraded locally by vag flora; or infected decidua with secondary uterine activity promoting SROM with subsequent reduction in volume and concentration inflammatory cytokines/PG's with temporary cessation of uterine activity), given the WBC, and most WOULD NOT tocolyse without a negative amnio. (Which is no easy task with an RAFI of 3, and if the amnio came back normal in this Patient - I'd have some serious concerns about the reliability of the lab!)         Robert is echoing the sentiment from Lynn (4/8/05) WRT cytokine mediated CNS damage in PTPROM (and recent SMFM meetings presentations regarding timing of delivery (34 weeks, or in some centers 32 weeks)). Rick Sweet was here in October and we asked Him to discuss this further. Again, as Lynn pointed out per Roberto Romero's work, there are extensive numbers of cytokines and as yet indeterminate elements that play a role. Until there is more investigation, we won't know what organisms and host susceptibility markers can be predictive of outcome. But for now, Dr. Sweet DID point out (can't remember the study) that - 'once chorio is dx'd and efforts to deliver were initiated, there was no difference in outcome based on duration of labor/time to delivery' . Needless to say, that is a big leap of policy-making faith. Think most would manage like Robert  - tho we all want to avoid an unnecessary incision in! to an infected uterus - if they're not responding... Fortunately, most will fly thru labor, once initiated. For those that do not -there's hemabate and cytotec (and B-Lynch?).         One thing that appears to be changing, is the perception of steroids and their role in this setting. The host inflammatory response may play more of a role than the infecting organisms, in mediating CNS damage. The former perspective of steroids and  immune suppression as a problem is evolving (suggesting  an "alternative strategy - let the wookie win?"). Wonder if any of You are working in "cool cap" center (for prevention of HIE in at risk infants)? If so - wonder if there's any interest in its role in chorio - as temperature appears to augment the pathogenic processes. Now, any comments on the Nov 10th NEJM?   /tj ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Robert J. Carpenter, Jr. MD: Given gestational age, I have never been an inducer without good reson. Having seen many such babies go days and weeks post rupture, I sit. That means thrice daily EFM assessment for surveillance. If even a hint of Chorio pops up, then delivery. If it occurs, I also do not go 12-24 hrs to achieve vag delivery. Given FIRS delivery should be expeditious. By that I do not mena an immediate C/S. --------------------------------------------------------------------------------------------- On 11 Nov 2005 at 20:39, Andrew Folley wrote: --------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- G1P0 28 week PROM wed am.  Received steroids and on antibiotics.  Cx 3 cm 90% no ctxs. Echo vertex AFI 3      2#7oz     Inital WBC 17000 and CRP elevated at 2.1 No maternal fever or tachycardia.  FHTs reassuring.  In level III hospital.What to do?  Sit tight and wait for obvious chorio? Induce 24 to 48 after Prom?  andrew 

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