|
|
 |
 |
 |
|
|
|||
|
||||
|
||||
Re: OB: Fun with preeclampsia--very long!From: Joe Cutchin (forcep@intercom.net)Fri Jul 27 20:13:46 2001
Garry Siegel wrote: > > Steve: > > In a pleasant and collegial way, you are wrong! > > Garry > > Explanation: > > 1. Her platelets hovered at 90 to 100K throughout. > 2. NST always good throughout. > 3. Severe pre-eclampsia at term mandates delivery. The elevated BP, > elevated creatinine of 1.1, and thrombocytopenia point to this diagnosis > without the need for proteinuria or an elevation of uric acid. What > more do you need? Had she been significantly pre-term, then steroids and > careful expectant management may have been warranted. > 4. When one hears hooves beating, think horses, not zebras! > > Do the listers want to vote: > > Diagnosis: > 1. Severe pre-eclampsia (or PIH) > 2. Other > > Garry > > > > >Amazing as it may be, I sympathise with Bob here. His point is well made that you > >have made a diagnosis on the flimsiest of evidence. I try to get it into the > >heads of my residents that the decision to induce is a decision to deliver and you > >don't decide to induce until you have decided that the baby is better out than > >in. I don't think that either condition was met here. The thrombocytopenia, > >while real, is not in itself anything more than a marker of the first part of > >HELLP syndrome. You didn't say what the NST showed, and you didn't tell us what > >her uric acid was. If these were normal I think I would have waited on a second > >platelet count after 24 hours bed rest. > > > >Ripening with misoprostol requires patience and persistence sometimes and this > >sort of scenario is not uncommon. That's why I think it pays to be certain about > >your need to deliver. She bloody nearly ended up with a C/S for failed induction > >for a very poor indication. > > > >Oh, and about Foley catheters. I use them for tubal chromotubation in infertility > >and put them in the nonpregnant cervix, so, no, there is no problem getting them > >into the pregnant cervix. Just don't try to insert a 20 gauge, stick to 16 or > >14. And no, you don't need an epidural fo that. > >stray > > > >Garry Siegel wrote: > > > >> >> > >> >>Well, we've got a problem already. You're diagnosing her with "severe > >> >>preeclampsia" when you've found that she has no proteinuria. Please explain. > >> >>What diagnostic criteria do you use? > >> > > >> >Bob, severe pre-eclampsia can certainly occur in the absence of > >> >proteinuria. Been there, done that. Variant of HELLP basically. > >> >Having said that, I am interested to see that someone diagnosed with > >> >"severe" preeclampsia was managed over a 3 day period. My goal is to > >> >get those patients delivered within 24 hours of diagnosis. I > >> >understand that this was somewhat of a "soft" call, but once the > >> >diagnosis is on the chart.... > >> > > >> >Was a foley bulb considered? I have found that an excellent adjunct > >> >to cytotec, when there are too many contractions to give a 2nd dose. > >> > >> > > >> Paul, you are my knight in shining armor to reply to Bob. I did not > >> make the distinction between Pre-eclampsia and Gestational Hypertension > >> and Pregnancy Induced hypertension, since I never can get them straight, > >> and, most important in this case, *it didn't matter*. Bob, sorry to be > >> argumentative and not scientific, but in this case, you gotta be > >> practicing Ob--I think that all of us would agree that delivery was > >> warranted. > >> > >> With respect to using a foley, I didn't grow up using them, and thus, it > >> didn't hit my radar scope. I will think about it next time, but I'm not > >> sure that this woman would have tolerated it. Can you put it in a > >> closed cervix? Would you ever place an epidural first? > >> > >> Paul, I am not aware of there being an arbitrary time limit in severe > >> pre-eclampsia. A staged ripening/induction like this isn't so common > >> anymore, but still OK, I think. Obviously, had her pressures been bad, > >> requiring apressoline (they didn't), her output diminshed, or her labs > >> getting worse, then I would have been more anxious to section her. As > >> it was, I was ready to section her just to put us all out of our misery! > >> > >> I bet that her SGOT will go up post partum! > >> > >> Garry > >> > >> -- > >> Garry E. Siegel, M.D., F.A.C.O.G. > >> Roswell, GA > >> Private Practice > > > >-- > > > >Dr.S.H. Raymond > >Head of Department of O & G > >Empangeni Hospital > >South Africa 3880 > >Phone: (+27) 35-7721111 > >Fax: (+27) 35-7922596 > > > > -- > Garry E. Siegel, M.D., F.A.C.O.G. > Roswell, GA > Private Practice "1"
--
Joseph H. Cutchin MD FACOG 4105463125
314 West Carroll Street 4105463128 Fax
Salisbury,Maryland 21801
|
|
Return to
|
Mail a New Message to the Forum: ob-gyn-l@obgyn.net Forum Administrator: geffrey.klein@obgyn.net Report Technical Problems: webmaster@obgyn.net Last Updated: Mon Nov 2 04:49:24 2009 |
The American Medical Association is no longer designating CME hours for AMA Category II CME credit. However, physicians themselves may self designate learning activities as Category II CME credit hours if they feel it is of sufficient educational merit and meets the formal definitions of continuing medical education. OBGYN.net believes these interaction in this forum meets these criteria. For further information see the AMA web site.