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Re: new caseFrom: Betsy Hyde (elishyde@connix.com)Mon May 29 18:18:17 2000
At 10:17 AM 5/29/00, Luis Sanchez-Ramos, MD wrote:
>It is hard for me to believe that a patient with an unscarred uterus these are the facts. The woman received 2 25 mcg doses of misoprostil, 4-6 hours apart. Our institutional protocols state that doses will not be repeated if contractions are more frequent q 3-4 minutes. The second dose was given only because she was *not* contracting. After the second dose she had a brief period of very painful contractions, and developed tachycardia. The contractions then stopped. Not detectable on the monitor and not reported by the woman. At the time of the next dose, the cervix was 4cm, so the miso was not given. She was transferred to the labor floor. At this point it is about 7 hours after the last miso dose, she was not contracting, cervix was 4cm. I do not think pitocin was an unreasonable plan....remember, this was a dead fetus. Would like to know what other list members would have done.
>I can understand one's eagerness to make public these occurrences. actually, making <<public these occurrences>> was not the point of my original post. The purpose of my post was to elicit the opinions of list members in nailing down a reason for tachycardia, SOB and abdominal pain in a woman who had delivered a stillborn fetus. At the time of my post, neither I nor my OB attending, cardiologist, MFM consult, or general surgeon knew she'd sustained a uterine rupture. The diagnosis was made at surgery, well after I posted this case. Although uterine rupture was include in my list of differentials (along w/ PE and AFE), there was no way to confirm the diagnosis.
>However, I wonder if they have the same interest informing us of I can only speak for the experience of my practice. Have no idea what the institutional experience is. I have worked in this collaborative practice for 16 years, and we've averaged 600+ births/year during that time. So, let's round it off to 10,000 births for which I have personal knowledge. This was the only rupture in an "unscarred" uterus. In the past 6 months I have had 2 uterine ruptures in VBAC attempts....both were induced with pitocin for fetal indications. Also during my tenure with this group we have had 1 spontaneous rupture, at home, in a woman with prior C/S during early labor. No other ruptures. I posted this case because it was a puzzle. I don't think I deserved the comments that we shouldn't ever use miso because we don't know how to use it, that we are "eager to make public these occurrences", and that I am, in some way attempting to hide other examples of uterine rupture in my practice. I am not. It is certainly disappointing that a straight-forward posting of an interesting (to me) clinical case is met by such hostile replies by someone with such a wealth of experience in the area of misoprostil use.
-- Betsy Hyde CNM Assistant Clinical Professor, Yale University Director, Midwifery Services Obstetrics-Gynecology-Infertility Group, PC New Haven, CT
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