OB-GYN-L Messages for October, 2006: Re: Clinical scenario

Re: Clinical scenario
From: Terrence.Jones@kp.org
Mon Oct 9 19:46:12 2006

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Maybe in reply to: Elrod, Darryl G Maj 48 MDOS/SGOBO: "Clinical scenario"

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At some point in dilation, the membranes are now in contact with vaginal flora, as Joe had initially mentioned. From this perspective, the situation might be viewed akin to PT PROM. Recall from Lynn's posts last April (4/8/05) on gest age timing for delivery in this scenario (ROM) as was reflected in two surveys of MFM's in 2004 (Healy, AJOG 5/04; & Ramsey AJOG 10/04). And remember how delay may have cytokine mediated consequences to the CNS. Also, keep in mind that connective tissue changes within the cervical matrix, as within the membranes (Zaga-Clavellina, J Soc Gynecol Investig (5/06), 13:271-9), may indicate the presence of certain unwanted microbes. And, as Ef responded to Lenora, alveolar consolidation in the neonate's CXR does not discriminate between surfactant deficient RDS and bacterial pneumonia. (Tho cultures can be helpful; they are less likely to be positive after two doses of antepartum amoxicillin.) Finally, at this gestational age, RDS and/or pneumonia, when treated, will have long term outcomes that are not different than waiting one, or two weeks (however unlikely this might be). But cytokine mediated CNS effects, hmmmm? As Jane mentioned, the Patient is a great resource. If the last delivery (37 weeks) was associated with an ICN stay, then amnio(centesis) can reassure Her (and help exclude infection if waiting on an immature L/S). If the cramping She was having when -2 station (admission) is no longer present, check to see if the vtx is now floating. If amnio(tomy) is planned (instead of Pit, first), keep a foley nearby - Bernard will tell You how this can stabilize things in a pinch (prolapse). Just unclamp the foley when Your on the uterus... /tj
PS: Anyone using aromatase inhibitors (with COC's, or progestin) for endometriosis pain?
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"Elrod, Darryl G Maj 48 MDOS/SGOBO" <Darryl.elrod@LAKENHEATH.AF.MIL> Sent by: ob-gyn-l@obgyn.net 10/09/2006 04:25 Please respond to ob-gyn-l
To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> cc: Subject: RE: Clinical scenario
I will beg forgiveness and tell you that when she was 4-5cm MY instinct was to have her delivered. Unfortunately, I wasn't the back-up for the midwife at that point and others have different feelings.
Again, for sake of argument, what defines 'labor' in this case? The fact that she hasn't had regular contractions is what was used to keep her admitted, rather than deliver her. Others argued that amniotomy was a form of augmentation of labor and is against ACOG guidelines for electively inducing someone less than 39 weeks, thinking that if by being 8cm was truly 'active labor' that she would keep going on her own without an amniotomy.
D. Glen Elrod, Maj., USAF, MC
-------------------------------------------------------------------- =A0 --------------------------------------------------------------------
-------------------------------------------------------------------- 28 yo G2P1 shows up to our midwife at 36+2 wks for her GBS testing. Her last delivery was at 37 wks and she is feeling a bit of pressure. No regular contractions, just some irregular cramping. She happens to live about 30 minutes from the hospital. On exam the midwife finds that she is 4-5cm/75% and -2 station.
Hospital day 2 (now 36+4) she is checked again and is 6-7cm. The next morning at 36+5 she is 8cm but still no regular contractions, no bleeding, no leaking fluid.
We have a group discussion about her care and come up with several different options.
For sake of argument, who would

* call her in labor and deliver her now. * Wait for her to actually go into 'labor' since she is technically preterm * Amnio her and deliver if mature * Give her steroids and deliver in 48 hours * Deliver her at 39 weeks if she is still pregnant, but keep her admitted until then.
Glen
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         At some point in dilation, the membranes are now in contact with vaginal flora, as Joe had initially mentioned. From this perspective, the situation might be viewed akin to PT PROM. Recall from Lynn's posts last April (4/8/05) on gest age timing for delivery in this scenario (ROM) as was reflected in two surveys of MFM's in 2004 (Healy, AJOG 5/04; & Ramsey AJOG 10/04). And remember how delay may have cytokine mediated consequences to the CNS. Also, keep in mind that connective tissue changes within the cervical matrix, as within the membranes (Zaga-Clavellina, J Soc Gynecol Investig (5/06), 13:271-9), may indicate the presence of certain unwanted microbes. And, as Ef responded to Lenora, alveolar consolidation in the neonate's CXR does not discriminate between surfactant deficient RDS and bacterial pneumonia. (Tho cultures can be helpful; they are less likely to be positive after two doses of antepartum amoxicillin.) Finally, at this gestational age, RDS and/or pneumonia, when treated, will have long term outcomes that are not different than waiting one, or two weeks (however unlikely this might be). But cytokine mediated  CNS effects, hmmmm? As Jane mentioned,  the Patient is a great resource. If the last delivery (37 weeks) was associated with an ICN stay, then amnio(centesis) can reassure Her (and help exclude infection if waiting on an immature L/S). If the cramping She was having when -2 station (admission) is no longer present, check to see if the vtx is now floating. If amnio(tomy) is planned (instead of Pit, first), keep a foley nearby - Bernard will tell You how this can stabilize things in a pinch (prolapse). Just unclamp the foley when Your on the uterus...  /tj   PS: Anyone using aromatase inhibitors (with COC's, or progestin) for endometriosis pain? NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents.  If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them.  Thank you. <table width0%> <tr valign=top> <td> <td>"Elrod, Darryl G Maj 48 MDOS/SGOBO" <Darryl.elrod@LAKENHEATH.AF.MIL> Sent by: ob-gyn-l@obgyn.net 10/09/2006 04:25 Please respond to ob-gyn-l <td>                To:        Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>         cc:                 Subject:        RE: Clinical scenario</table> I will beg forgiveness and tell you that when she was 4-5cm MY instinct was to have her delivered.  Unfortunately, I wasn't the back-up for the midwife at that point and others have different feelings. Again, for sake of argument, what defines 'labor' in this case?  The fact that she hasn't had regular contractions is what was used to keep her admitted, rather than deliver her.  Others argued that amniotomy was a form of augmentation of labor and is against ACOG guidelines for electively inducing someone less than 39 weeks, thinking that if by being 8cm was truly 'active labor' that she would keep going on her own without an amniotomy. D. Glen Elrod, Maj., USAF, MC -------------------------------------------------------------------- =A0 -------------------------------------------------------------------- --------------------------------------------------------------------  28 yo G2P1 shows up to our midwife at 36+2 wks for her GBS testing. Her last delivery was at 37 wks and she is feeling a bit of pressure. No regular contractions, just some irregular cramping. She happens to live about 30 minutes from the hospital. On exam the midwife finds that she is 4-5cm/75% and -2 station.  Hospital day 2 (now 36+4) she is checked again and is 6-7cm. The next morning at 36+5 she is 8cm but still no regular contractions, no bleeding, no leaking fluid.  We have a group discussion about her care and come up with several different options. For sake of argument, who would  * call her in labor and deliver her now.  * Wait for her to actually go into 'labor' since she is technically preterm * Amnio her and deliver if mature * Give her steroids and deliver in 48 hours  * Deliver her at 39 weeks if she is still pregnant, but keep her admitted until then. Glen 

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Previous message: Betsy Hyde: "Re: Clinical scenario"
Maybe in reply to: Elrod, Darryl G Maj 48 MDOS/SGOBO: "Clinical scenario"

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