Re: 17 oh progesterone
From: Charlie Chambers (ricechaz@earthlink.net)
Fri Jun 8 10:08:53 2007
I think that I would be reluctant to treat in the first two. The 34
week with PROM seems much more reasonable.
On Jun 8, 2007, at 7:47 AM, Andrew Folley wrote:
> 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
>> >>>
>> _____________________________________________________________________
>> >>> ___
>> _____________________________________________________________________
>> >>>
>> _____________________________________________________________________
>> >>> AOL now offers free email to everyone. Find out more about =20
>> _____________________________________________________________________
>> what's
>> >>> free
>> >>>
>> _____________________________________________________________________
>> >>> ___
>> _____________________________________________________________________
>> >>>
>> _____________________________________________________________________
>> >>> from AOL at AOL.com.
>> _____________________________________________________________________
>> >>>
>> >> --
>> >> Garry E. Siegel, M.D.
>> >> Private Practice
>> >> Roswell, GA
>> >
>>
>> --
>> Garry E. Siegel, M.D.
>> Private Practice
>> Roswell, GA
>
> _________________________________________________________________
> Don=92t miss your chance to WIN $10,000 and other great prizes from =20=
> _________________________________________________________________
> Microsoft Office Live http://clk.atdmt.com/MRT/go/aub0540003042mrt/
> direct/01/
>
************************************************************************
****
Charlie Chambers
Hood River, OR
cchamber@alumni.rice.edu
"Almost anything you do will seem insignificant but it is very important
that you do it....You must be the change you wish to see in the world"
-- Mahatma Ghandi.
************************************************************************
*******
