Re: Deliver now or Special Delivery later
From: Efrain Ramirez (eramirezt@coqui.net)
Sun Jun 28 22:23:38 2009
Yes you are right - not at home -- problem with this case is that we (at
least I don't)do not have enough information.. if chemistry is Ok and
patient responds to antihypertensives ..I would give her a course of
corticosteroids .. IMHO
Ef
At Sun, 28 Jun 2009, JD Stewart,MD wrote:
>
>Pardon the tone,......but this has set me off.
>
>At Sat, 27 Jun 2009, Andrew Folley wrote:
>>
>>Definitely wait and watch careflully in house would like to get to 28 weeks for improved neonatal outcome. Degree of proteinuria???
>>
>Wait and Watch carefully for what? A transfer to the Path in the
>basement on the fuzzy blanket gurney?
>
>What other disease process did you have in mind that will be fine with
>vital signs , office exam (no/low proteinuria), labs and baby exam 2
>weeks earlier, and then present with increasing headache,swelling, BP's
>in this range and seizures? Lupus plus dodgeball?
>
>She is eclamptic and already on MagSo4, and her critical level of
>hypertension is "responding" only to 2 IV meds....What's the plan? What
>is your "definite" next therapy for the next 3 weeks when this is no
>longer enough? Cochrane deep water immersion or abdominal decompression?
>
>When did a month of bedrest, nitroprusside, diuretics, phenytoin and
>"careful watching" ever begin to work for eclampsia?
>
>The question of gaining 24-48 hours for steroids is a reasonable
>question...not a lot of definite evidence this helps in light of the
>increased risks of abruption/ seizure/ mortality in this setting...the
>steroid studies were derived from large populations of "normal" early
>deliveries, and the findings transported to all clinical situations,
>just because...well, we think ( and opine...)it should work.
>
>Caveat- Even on Dr Sibai's service with all the papers he has published
>on this, he managed to squeak out these few weeks for quite a few
>patients, and proved it could be done in his particular setting with an
>army of students, residents and fellows, but really failed to show a lot
>of benefit to neonatal outcomes for the effort, or any further
>improvement over the outcomes of the delivered 25-28 weekers in the
>NICU....so if you are doing this "for the baby", think twice before
>blindly applying the "28 weeks in utero just has to be better" principle
>for this baby...
>
>The added phrase "definitely" would merit repeating the OB rotation in
>med school..or a guest appearance at law school...
>
>At Sat, 27 Jun 2009, Andrew Folley wrote:
>>
>>Definitely wait and watch careflully in house would like to get to 28 weeks for improved neonatal outcome. Degree of proteinuria???
>>
>>Date: Sat, 27 Jun 2009 15:48:57 -0500
>>From: 4obgyn@gmail.com
>>To: ob-gyn-l@mail.obgyn.net
>>Subject: Deliver now or later
>>
>>33 yo G1 P0 presented @ 25 4/7 weeks EGA after a witness seizure at work. Brought in by ambulance and seized again in ER. BP 220/160. No significant past medical history. Husband did say she had headaches for one week and swelling for two weeks. Also was hit by a dodge ball on her forehead three days before presentation. She was last seen by her ob two weeks ago when it was uneventful. She had a negative CT of the head prior to being released from the ER to L&D. Baby's heart beat now in normal range. Cervix closed, firm, uneffaced. Cephalic presentation by ultrasound. MgSO4 given in ER, BP gradually responding to Hydralazine and Labetolol. No coagulation abnormalities. I am wondering how many of you folks will deliver her right away, or how many will give her steroids and wait? Thanks in advance for you input.
>>
>>Allan
>
>--
>JD Stewart, MD
>MFM up all night, every night
>10 years later..
>
--
"Life is what happens to you while you're busy making other plans."- John Lennon
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