Re: new case
From: Luis Sanchez-Ramos (luis.sanchez@jax.ufl.edu)
Tue May 30 06:17:53 2000
You're too defensive. I was not only refering to your case, but all the
other cases published and unpublished which have come to light in recent
months. Just because a protocol states that misoprostol should not be
given to patients having regular uterine activity doesn't mean that it
is not given. I did not question whether or not oxytocin should have
been used: I posed the question that perhaps oxytocin may have caused
the uterine rupture and not misoprostol.
LSR
At Mon, 29 May 2000, Betsy Hyde wrote:
>
>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
>>would suffer a catastrophic uterine rupture with two separate 25 mcg
>>doses of misoprostol (adminestered to apatient who is not having regular
>>uterine activity).
>
>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
>>ruptures occurring spontaneously or after the administration of other
>>uterotonic drugs (PGE2, oxytocin)at their institutions?
>
>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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