Re: ?hysterotomy at 22 weeks
From: Efrain Ramirez (eramirez@icepr.com)
Sat Apr 14 18:10:52 2001
Take a day off! - well done -- Our cut-off is 24-25 weeks.
At Sat, 14 Apr 2001, CarynRybs@aol.com wrote:
>
>Dear Listers,
>
>Came in for call this am and there is a 29 yo g7p2 tab x3 missed ab x1 at 22 4/7 weeks by a 7 wk crl and 18 wk sono confirming those dates who was admitted 5 days prior with PTL. Her 1st carried pregnancy was a classical c/section at 28 wks followed by an elective repeat c-section -low transverse- at term.
>
>This am she was starting to contract more and just 5 min before I came on was examined with a speculum and the cervix appeared 4-5 cm dilated with bulging membranes, footling breech with a probable high leak as pool,fern,nitrazine were +. They had been trying to gently "tocolyze" her with nifedipine and she was getting antibx. She was afeb, nontender uterus but wbc had increased to 14k though no L shift.
>
>Plan was for a hysterotomy as mode of delivery regardless of gestational age given her prior classical c-section and concern about uterine rupture/desire to preserve fertility, life etc...
>
>Do you
>1) Agree that the risk of uterine rupture is high enough to proceed with hysterotomy for maternal indications? regardless of gestational age/fetal viability
>
>2)Disagree and would let her vbac cautiously at this gestational age as previable fetus? What if she was infected grossly and warranted more immediate delivery- would you give her oxytocin with a prior vertical uterine scar?
>
>3)Try to do a D and E- too far along for my comfort and also with the multiple tabs and c-sections am a bit more reluctant as possible invasive placentation...
>
>It was an easy decision for me in some ways as someone else- our perinate- had already told her that she should not labor. So while I wasn't looking forward to the surgery for such a poor outcome, she had already been counseled and I didn't really want to come in and change the plan 5 min after meeting her.
>
>It took a little time to get her in the OR- pt and husband were quite angry and distraught and wanted to try to let the pregnancy continue. They talked to neonate again as they wanted a resusc which I did not recommend and talked with their family etc and then it took a while to get the spinal in since she couldn't sit still b/c of contractions... So I checked her after the spinal(had checked maybe an hour before and she was 4 cm and no palpable presenting part really) and could palpate 2 feet/legs coming though the cervix which was 4-5 cm and essentially did a breech extraction. The head was a bit entrapped but came with some pushing and gentle teasing of the cervix around the head. 22 week nonviable male,no resusc. Then did a careful manual extraction of the placenta followed by a very gentle curettage with sono guidance as the placenta was a bit ratty looking. Mininal blood loss...Was very glad that I checked her and that I did not put her through an unnecessary surgery an!
>d she is medically stable... Som
>eone was looking out for me today...
>
>One other question,how many have neonates and perinates pushing for resusc at 23 weeks?
>
>Just curious,
>Caryn Rybczynski MD
>Oakland, CA
--
"Life is neither the notes nor the silence between the notes, but the music that
arises out of sound and silence felt as a living whole. Stop choosing...between
chaos and order, and live at the boundary between them, where rest and action
move together..." David Whyte
