Re: Deliver now or Special Delivery later
From: JD Stewart,MD (jdstewartmfmob@hotmail.com)
Sun Jun 28 22:46:48 2009
2 questions really- steroids and / or waiting.
Yes steroids... Maybe waiting 24-48 hrs if lucky...have in mind and
look for your next signal it's not working and time to deliver...hope it
is a quieter but not stillborn baby, slowly worsening renal function or
lab changes and not abruption, stroke or blindness.
Assuming this will work for another month is assuming a different
diagnosis of new sudden onset critical malignant hypertension and
unveiled underlying seizure disorder in a 25 week pregnancy that was
fine 2 weeks ago...How does one get there other than pre-eclampsia/
eclampsia, drugs and/or remotely possibly autoimmune disorders?...
At Sun, 28 Jun 2009, Efrain Ramirez wrote:
>
>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
>
--
JD Stewart, MD
MFM up all night, every night
10 years later..
