Re: Polyhydramnios, induction
From: art fougner, md (evsono@pipeline.com)
Tue Jan 8 20:05:03 2002
if mom would agree to therapeutic amnio - why not FISH? possibly, you
may at least rule out trisomy 21, 13, 0r 18. also, to be devil's
advocate, the harm in waiting for labor is?
art
At Tue, 08 Jan 2002, jafar6 wrote:
>
>Could use advice and consensus.
>
>We have a 29 year g2p1 now 36+6 weeks who was found to have serious fetal
>CNS abnormalities on ultrasound, including, asymmetric cystic dilitation of
>the lateral ventricles with an intrahemispheric cyst, agenesis of the corpus
>callosum and severe polyhydramnios (AFI = 35 cm). The patient did not want a
>diagnostic amniocentesis. She presented too late for a quad screen. Echo,
>MRI do not show any other abnormalities. The provisional diagnosis is
>porencephaly with developmental CNS defects. The fetus is AGA size and tests
>well with NST's and BPP's. Her previous delivery was a term spontaneous
>vaginal birth of a 7 lb fetus. She is not a gestational diabetic.
>
>The patient complains of discomfort (especially lower rib pain), lack of
>sleep, and edema of her legs. Supine hypotension and difficulty in standing
>without feeling faint are also a problem. Her protein and albumen are
>borderline but not bad. Her BP is normal. She wants to be delivered.
>
>I asked the private physician, if he would consider induction if the cervix
>was ripe. He booked her at 38 weeks (we thought that with maternal
>discomfort, poly and 38 weeks, amniocentesis for maturity would not be
>necessary. The cervix is about 1cm , 50% effaced, and soft with a very high
>floating vertex.
>
>The physician was concerned that labor would be hard to induce with severe
>uterine distention and could increase risks such as prolapsed cord,abruption
>and postpartum hemorrhage.
>
>I remember reading in older editions of Williams Obstetrics, that labor
>induction could be easier with a therapeutic amniocentesis and reduction of
>fluid down to normal. The text commented that this would decrease the risk
>of cord prolapse with transcervical amniotomy. So. I agreed that the
>procedure is reasonable. The tentative plan then became: therapeutic
>amniocentesis, cytotec that evening and planned delivery at 38 weeks with
>neonatologists awaiting the compromised fetus during waking (and
>fully-staffed hours).
>
>I will be away next week (covering elsewhere during planned induction). My
>associates heard about my plan, and they didn't seem interested in carrying
>it out. They said that needling the membranes (trans-cervically) would be
>the best way to rupture them. And that severe poly should not hamper
>induction. They didn't seem to mind the planned induction.
>
>I thought that the less distended uterus would be more amenable to induction
>and the gradual(transabdominal) reduction of fluid might decrease the risk
>of cord prolapse and abruption. Besides, I would feel safer using cytotec
>(sorry, Parker and Waichman) if the uterus was less distended. A medline
>search and the new texts I have don't address this issue.
>
>Any opinions regarding induction with polyhydramnios, floating head, and
>borderline ripe cervix?
>
>Thanks in advance
>
>Gary Kleinman, MD
>
>Bridgeport, CT
>MFM, Genetics
--
art fougner, md
ich bin ein New Yorker
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