Re: Incompentent Cervix?
From: Efrain Ramirez (eramirezt@coqui.net)
Sun Jun 26 12:50:49 2005
I agree -- yes - read EBM and discuss it with the patient - but also
trust your experience and feelings - for example - there is a new
article stating that in cases of severe preeclamspsia you can
discontinue Mag sulfate if there is an urine output >100 mL/hr for 2
consecutive hours - I know that I am not going to do that unless it has
been proven ad nauseam - I won't go home at 12 midnight after D/C Mag
S04 - with hight BP and elevated enzymes just because one aricle says so
-- these "findings" come a go ... good luck!
> At Sun, 26 Jun 2005, Garry E. Siegel, M.D. wrote:
>
>Richard:
>
>Agree with others, as there clearly is no right answer. Of course,
>involve the patient in discussion (after all, you must have a great
>relationship through a tough 1st pregnancy and then the others) and see
>what her "worry level" is. My guess is that the ease of a 13 week
>cerclage, with such minimum downside, and her success--whether related
>to the prophlyactic cerclages or not--will lean her dramatically towards
>another.
>
>My gut say cerclage here, although I BET she would be fine either way.
>
>Garry
>
>At Sun, 26 Jun 2005, Robert J. Carpenter, Jr. MD wrote:
>>
>>To me there is no truth. Given the first circumstance and placement of cerclage
>>which modern (last 7 yrs) randomized US/Dutch studies clearly indicate that
>>outcomes are the same but one suggests that preterm delivery may be later in
>>sutured than in control provides no real answer to today. The suggestion for f/u is
>>okay and so is placement of cerclage now. Given no truth I would choose the latter
>>since several patients like this where later -"if the cervix" changed - demonstrated
>>substantial change - I would go for cerclage now. Discuss the pros/cons and
>>document well.
>>
>>On 24 Jun 2005 at 21:24, DoctorJoe@aol.com wrote:
>>
>>> In a message dated 6/24/05 4:23:06 PM, rkaplan@triad.rr.com writes:
>>>
>>> > I have a patient who has had 4 full term deliveries. In her 1st
>>> > pregnancy she had some mild cramping at 25 weeks and an exam
>>> > revealed a 2cm dilated cervix, 90%effaced with membranes firmly
>>> > against the os. I performed a rescue cerclage, put her on oral
>>> > terbutalene (for whatever good that does) and she delivered at 38
>>> > weeks, one week after I removed the cerclage.
>>> > In her subsequent pregancies I placed prophylactic cerclages
>>> > early in
>>> > the 2nd trimester and she carried all these pregnancies to term and
>>> > usually several weeks after the cerclages were removed.
>>> > She is pregnant again and asked me if I really felt that
>>> > cerclage was
>>> > necessary. I gave her my opinion but told her I would ask my
>>> > colleges on the internet. Thanks in advance for your imput.
>>> >
>>>
>>> Interesting question. It raises a few questions:
>>>
>>> 1) Do you think the "rescue cerclage" done in the first pregnancy
>>> "worked?" In other words, if you had NOT done the cerclage, but merely
>>> put her at bedrest with the terbutaline, would she still have made it
>>> to 38 weeks?
>>>
>>> 2) After one cerclage, is there a place for the theory that cervical
>>> scarring may act in lieu of a second cerclage? In other words, after
>>> all the cerclages you've done, do you think her cervix has scarred
>>> down to be "competent" now?
>>>
>>> 3) Considering the history you've had with cerclages generally, and
>>> also your experience specifically with this patient, what do you
>>> consider the risk and travail and cost of a cerclage which might be
>>> worthless (although, maybe not)?
>>>
>>> Joe P.
>>>
>>--
>>Robert J. Carpenter, Jr. MD
>>6624 Fannin, #2720
>>St. Luke's Medical Tower
>>Houston,TX 77030-2339
>>713-795-4600
>>
>--
>Garry E. Siegel, M.D.
>Private Practice
>Roswell, GA
>
--
I think I will do nothing for a long time but listen,
And accrue what I hear into myself...and let sounds
contribute toward me.
~walt whitman~
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