Re: 17 oh progesterone
From: Andrew Folley (agfolley@hotmail.com)
Fri Jun 8 09:45:28 2007
I have 3 ladies I am considering starting on 17 OH P at 20 weeks. #1 had an
incompetent cervix in first pregnacy with rescue cerclage at 24 weeks and
preterm deliviery at 29 weeks. #2 developed severe preeclampsia and and was
induced and delivered early at 28 weeks. Finally #3 more delivered second
baby at 34 weeks following PROM. Do you think it is inappropriate to manage
them with weekly 17 OH-P at 18 weeks etc??
>From: garrys@mindspring.com (Garry E. Siegel, M.D.)
>Reply-To: ob-gyn-l@obgyn.net
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: Re: Ob: PP hemorrhage in a VBAC--why do we VBAC, anyway :)?
>Date: Thu, 7 Jun 2007 22:51:27 -0500
>
>Good question and comment, and I was raised to do so, also, and still
>do. However, I explore every uterus after delivery if possible (i.e. if
>hurts/no epidural, I likely don't do it--if they are comfy, I do).
>
>I am certain that the CNM did NOT explore it.
>
>Garry
>
>At Thu, 7 Jun 2007, Marie Harkins wrote:
> >
> >When I first started to work in obstetrics (mid 80's) the hospital
> >policy for VBAC included manual exploration of the uterus after
> >delivery. Some of the older docs did it then, no one does it now.
> >Do any of you still do this, or did you do it at one time? Do you
> >think it would have made a difference in this case?
> >
> >--
> >Marie Harkins, CNM
> >Ithaca, NY
> >
> >On Jun 7, 2007, at 4:24 PM, Garry E. Siegel, M.D. wrote:
> >
> >> The case was straightforward; I just posted it this way to generate
> >> discussion.
> >>
> >> She is thin, and I reopened her low transverse skin incision in a
> >> Maylard/semi-Maylard fashion (that's how I do sections) and didn't
> >> take
> >> the inferior epigastrics and had tons of room. I also did the case in
> >> Allen stirrups, in case I needed vaginal access (i.e. to see if the
> >> bleeding had stopped).
> >>
> >> Upon opening the perioteum, I expected a hemoperitoneum, yet she
> >> didn't
> >> have it. However, you could see clot underneath her bladder flap, and
> >> the clot--easily 500 to 1000 ml.--was concealed under the bladder flap
> >> and kept coming out vaginally (the vagina was full of clots, as was
> >> the
> >> firm uterus). The clot was from a low transverse rupture,
> >> obviously of
> >> the old incision, easily palpable and then visualized. The clot had
> >> nicely dissected the bladder way off the incision, and I could easily
> >> access the pelvic planes necessary to safely access the uterus and see
> >> the ureters easily. The left half on the incision was mush, this was
> >> her fourth (and they planned no more), so it was an easy decision
> >> to do
> >> a TAH. As is often the case, the lower uterine segment and vagina
> >> were
> >> ballooned and distorted, but I could define the cervix and actually
> >> grasp the vaginal portion of the cervix through the rupture so that I
> >> could preserve the upper vagina easily.
> >>
> >> She got 8 units in total, and looked great this AM.
> >>
> >> Garry
> >>
> >> At Thu, 07 Jun 2007, rmodugno@aol.com wrote:
> >>>
> >>> Hmm... Why is he asking this?
> >>>
> >>> Did a laparotomy - found the uterine incision intact with a posterior
> >>> blowout through the uterine vessels?
> >>>
> >>> Robert Modugno MD MBA FACOG
> >>> Sylva, NC
> >>>
> >>> -----Original Message-----
> >>> From: Garry E. Siegel, M.D. <garrys@mindspring.com>
> >>> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
> >>> Sent: Wed, 6 Jun 2007 7:21 pm
> >>> Subject: Ob: PP hemorrhage in a VBAC--why do we VBAC, anyway :)?
> >>>
> >>> 37 YO P 4004 at term
> >>> #1 Term LTC/S, breech, document
> >>> #2 and #3--VBACs, uneventful, our CNMs, 9 to 10 pound babies
> >>>
> >>> This deliver--SROM, irreg ctx., augmented. While the CNM was
> >>> caring for
> >>> her, I stopped in a followed her a bit. Clincal EFW 4200 g
> >>>
> >>> Dilatation was protracted for a multip., and she had a couple of
> >>> runs of
> >>> hyperstimulation (meaning tachysystole with bradycardia) that
> >>> resolved
> >>> with the old Pit on/Pit off/flip sides.
> >>>
> >>> She progressed to complete dilation, and started with big variables.
> >>> After pushing around 5 to 10 minutes, heart tones were jumbled
> >>> (FSE) and
> >>> unreadable, and I watched the CNM with the head crowning, and simply
> >>> whispered to her (she is a newby but a goody) to make an
> >>> episiotomy, and
> >>> have her push even between contractions and "get the baby out."
> >>> The baby
> >>> came out, all well.
> >>>
> >>> PP she hemorrhaged, and it was assumed by the CNMs/L and D nurses
> >>> to be
> >>> atonic--methergine, more pit, hemabate.
> >>>
> >>> When she got hypotensive, I got the call.
> >>>
> >>> Room exam--firm fundus 2 fingers below, no lacerations, lots of BRB.
> >>> Belly soft, no complaint of shoulder pain, FWIW.
> >>>
> >>> Hct. 23 (was 37), quick CT showed fluid in upper abdomen, clot in
> >>> pelvis, ?hematoma of uterus--we went from the CT scanner across
> >>> the hall
> >>> to the theater.
> >>>
> >>> What did I do and what did I find?
> >>>
> >>> Garry
> >>>
> >>> --
> >>> Garry E. Siegel, M.D.
> >>> Private Practice
> >>> Roswell, GA
> >>>
> >>> _____________________________________________________________________
> >>> ___
> >>> _____________________________________________________________________
> >>> _____________________________________________________________________
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> >>> _____________________________________________________________________
> >>> ___
> >>> _____________________________________________________________________
> >>> _____________________________________________________________________
> >>> from AOL at AOL.com.
> >>>
> >> --
> >> Garry E. Siegel, M.D.
> >> Private Practice
> >> Roswell, GA
> >
>
>--
>Garry E. Siegel, M.D.
>Private Practice
>Roswell, GA
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