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Re: Efrain's question From: Braun, R. Daniel (rbraun@iupui.edu) Thu Feb 10 12:53:21 2000 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Geffrey Klein, MD: "Re: Efraim's question" Previous message: Braun, R. Daniel: "Re: Efraim's question" I apologise for the mistake on your name. I thoght I had seen it with an "m". I have inserted my comments in your reply. BTW, I would not criticise some one else who did an amniocentesis on this patient and I would testify in a court of law that an amniocentesis was consistent with good care. If asked how I would manage the patient, I wouldn't do an amniocentesis and that also is consistent with the standard of care. There frequently is more than one way to do things correctly. It took me about 10 years out of my residency to learn that. Dan R. Daniel Braun, MD FACOG Clinical Professor Department of Obstetrics and Gynecology Indiana U. School of Medicine Indianapolis, IN 46202 OBGYN.net International Representative for United States Certified AllExperts Expert Check out my bio/ratings page! http://www.allexperts.com/displayExpert.asp?Expert=1236 -----Original Message----- From: eramirez@icepr.com [mailto:eramirez@icepr.com] Sent: Wednesday, February 09, 2000 9:27 PM To: Multiple recipients of list OB-GYN-L Subject: Re: Efraim's question First I am also a firm believer in the Maxim: "When all else fails, examine the patient." No question about it. But -- you don't know if she is either 32 or 36 right? You couldn't contact her prior physician --it has happened to me many times --- so you must assume she has a classical C/S but are not sure -- right ?-- you are not sure if she has GDM - ( I use now 135) -right? And you also can't predict if she is going into labor --right? So can not do anything except wait -- and during that period of time she is at risk for uterine rupture - -you would not give MgSO4 ---although she has BV and probably UTI-- risk factors for preterm labor right?-- and corticosteroids are out of the question in your scenario. I would give her corticosteroids. Then she develops regular mild, uterine contractions but there is no change in the cervix -- you keep waiting? -- but you were the one who examined the lady and you believe that a repeat C/S is warranted (gut feeling she was 35-36 with IUGR)-- baby dies of severe RDS -- When was the last time you saw a 32 weeker die of RDS in your NICU? maybe she was 32 with a bit more than a GDM...maybe. You did a rewind and did wait -- --went home--- nurse calls you 2 AM-- the lady had a rupture -- residents are taking care of her-- Under the direction and supervision of one of my colleagues who is here in the hospital all night, the same as I was all night last night. Suppose--Just suppose you did an amnio at 2 PM results at 8 PM Irreducible minimum time to do an L/S ratio is 4-6 hours unless you take shortcuts and then the results are of questionable validity. Our laboratory only does them at 8 AM unless you can talk the pathologist into doing it as an emergency. At 2:30 PM FHT's drop to 60 and emergency c/s done discover bloody amniotic fluid and needle hole in umbilical vein. Deliver 32 week baby with Hgb of 4 , dies in nursery. Suppose -- just suppose you did an amnio results at 4PM -- negative PG/immature L/S -- your next step? Depends, If she is in labor, I would section her, If not, I would watch her. Positive PG/Mature L/S - your next step? Depends, If she is in labor, I would section her, If not, I would watch her. At Wed, 9 Feb 2000, Braun, R. Daniel wrote: > >First, I would put her in our observation unit to continue monitoring to >find out if the contractions are increasing or not. i.e. is she trying to go >into labor? At teh same time since it is 2 PM, I would try to contact her >prior physcian and get him/her to fax a copy of the records to me. I would >also try to get documentation from the hospital as to the type of cesarean >that she had. Sometimes, you can perform miracles with telephone and fax. >She is either 32 weeks with an AGA or 36 weeks(due to her history) with an >SGA fetus. Since the NST is reactive and the BPP is 10, the chances of her >having an IUFD secondary to Uteroplacental insufficiency in the next 4 days >is in the range of 1 in 1000 even if she is SGA. The fact that the fetus is >symmetrical makes one think that either she is 32 weeks AGA or if she is 36 >weeks and is SGA, there would be little that one could do now to help that >situation. IOW it would probably be some serious infection or chromosomal >anomaly or other serious problem not amenable to treatment at this time. So >the only acute problem is the diagnosis of labor or not. If she goes into >labor and it is felt that she did have a classical, then repeat C/S. If she >is not in labor then further observation and management as indicated. > >I don't think that I would do an amnio at this time. If it was mature and >she was 32 weeks the fetus is still at risk for other problems related to >prematurity if I deliver her. If it is 36 weeks and false negative, it might >make me delay doing a delivery fo a term baby that is SGA and probably won't >develop RDS. > >I might have an entirely different opinion if I were to put my hands on her >abdomen and my ultrasonic eyes on the baby. One of the things I have >learned, in years of teaching residents, is that when presented a case >verbally, one can get one opinion, but when examining the patient, one can >get a completely different feeling about what is going on. I strongly >believe in the Maxim: "When all else fails, examine the patient." > >ps: I almost forgot to address the one hour glucola. Is 140 considered >normal in the institution where it was done?? The arguments about what >should be the cutoff level are rampant. Some places use 130 and some use >145. The lower the cutoff the greater teh sensitivity but the lower the >positive predictive value. The higher the cutoff the lower the sensitivity >and the higher the PPV. I would not say that 140 necessarily rules out GDM. > >Dan > >R. Daniel Braun, MD FACOG >Clinical Professor >Department of Obstetrics and Gynecology >Indiana U. School of Medicine >Indianapolis, IN 46202 > >OBGYN.net >International Representative for United States > >Certified AllExperts Expert >Check out my bio/ratings page! >http://www.allexperts.com/displayExpert.asp?Expert36 > >-----Original Message----- >From: eramirez@icepr.com [mailto:eramirez@icepr.com] >Sent: Wednesday, February 09, 2000 7:36 PM >To: Multiple recipients of list OB-GYN-L >Subject: Re: Fetal Lung Maturity Question (was: Fetal Lung Maturity >Questi > >Dan -- let's throw aside all discussion -- I would like your honest >opinion on this hypothetical case. I respect your opinions - I don't >always agree with you, but I listen. >38 y/o G2 P1 stillbirth, previous classical C/S by history 9 years ago. >She says her unborn child (female) died in utero because "she was small >-- undernourished" --she can't recall BW. She divorced, now lives with >a friend. The reason for her C/S, she says was, "placenta previa". She >was 8 months pregnant. Lab tests results are available including a 1 >-hour GCT of 140. Hgb of 9.9.(done around --according to her EDD around >30 weeks) She has had only 3 prenatal visits and was told by her doctors >that her due date was on 3/8/00 based on her LMP and the U/S done >approximately 5 weeks ago but you do not have the results or the >films.(you won't mind some calc. :-) . She has irregular menses.She >has moved to your town recently and she has been told (rightly so) that >you are a very fine obstetrician. >VS are WNL, 5'6" 195, weight gain about 40 pounds, fundal height of 33 >cms. You do a comprehensive U/S. EFW 4 pounds, male, ratios WNL, AFI >of 8 placenta posterior, low lying. NST reactive --3 mild contractions >in 30 minutes- BPP 10/10. >She has no complaints except for some , mild burning sensation when >voiding. Pelvic exam Cx 30%, mid position, closed. Has BV (sniff test) >It's 2PM -- what would be your next step? > >-- >"The things you learn after you know everything are the important ones" > -- "The things you learn after you know everything are the important ones" Next message: Geffrey Klein, MD: "Re: Efraim's question" Previous message: Braun, R. Daniel: "Re: Efraim's question"

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