--
________________________________
Charlie Chambers
Sent: Friday, June 08, 2007 4:12 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: 17 oh progesterone
I think that I would be reluctant to treat in the first two. The 34 week
with PROM seems much more reasonable.
On Jun 8, 2007, at 7:47 AM, Andrew Folley wrote:
I have 3 ladies I am considering starting on 17 OH P at 20 weeks. #1
had an incompetent cervix in first pregnacy with rescue cerclage at 24
weeks and preterm deliviery at 29 weeks. #2 developed severe
preeclampsia and and was induced and delivered early at 28 weeks.
Finally #3 more delivered second baby at 34 weeks following PROM. Do
you think it is inappropriate to manage them with weekly 17 OH-P at 18
weeks etc??
From: garrys@mindspring.com (Garry E. Siegel, M.D.)
Reply-To: ob-gyn-l@obgyn.net
To: Multiple recipients of list OB-GYN-L
<ob-gyn-l@dns.obgyn.net>
Subject: Re: Ob: PP hemorrhage in a VBAC--why do we VBAC,
anyway :)?
Date: Thu, 7 Jun 2007 22:51:27 -0500
Good question and comment, and I was raised to do so, also, and
still
do. However, I explore every uterus after delivery if possible
(i.e. if
hurts/no epidural, I likely don't do it--if they are comfy, I
do).
I am certain that the CNM did NOT explore it.
Garry
At Thu, 7 Jun 2007, Marie Harkins wrote:
>
>When I first started to work in obstetrics (mid 80's) the
hospital
>policy for VBAC included manual exploration of the uterus after
>delivery. Some of the older docs did it then, no one does it
now.
>Do any of you still do this, or did you do it at one time? Do
you
>think it would have made a difference in this case?
>
>--
>Marie Harkins, CNM
>Ithaca, NY
>
>On Jun 7, 2007, at 4:24 PM, Garry E. Siegel, M.D. wrote:
>
>> The case was straightforward; I just posted it this way to
generate
>> discussion.
>>
>> She is thin, and I reopened her low transverse skin incision
in a
>> Maylard/semi-Maylard fashion (that's how I do sections) and
didn't
>> take
>> the inferior epigastrics and had tons of room. I also did
the case in
>> Allen stirrups, in case I needed vaginal access (i.e. to see
if the
>> bleeding had stopped).
>>
>> Upon opening the perioteum, I expected a hemoperitoneum, yet
she
>> didn't
>> have it. However, you could see clot underneath her bladder
flap, and
>> the clot--easily 500 to 1000 ml.--was concealed under the
bladder flap
>> and kept coming out vaginally (the vagina was full of clots,
as was
>> the
>> firm uterus). The clot was from a low transverse rupture,
>> obviously of
>> the old incision, easily palpable and then visualized. The
clot had
>> nicely dissected the bladder way off the incision, and I
could easily
>> access the pelvic planes necessary to safely access the
uterus and see
>> the ureters easily. The left half on the incision was mush,
this was
>> her fourth (and they planned no more), so it was an easy
decision
>> to do
>> a TAH. As is often the case, the lower uterine segment and
vagina
>> were
>> ballooned and distorted, but I could define the cervix and
actually
>> grasp the vaginal portion of the cervix through the rupture
so that I
>> could preserve the upper vagina easily.
>>
>> She got 8 units in total, and looked great this AM.
>>
>> Garry
>>
>> At Thu, 07 Jun 2007, rmodugno@aol.com wrote:
>>>
>>> Hmm... Why is he asking this?
>>>
>>> Did a laparotomy - found the uterine incision intact with a
posterior
>>> blowout through the uterine vessels?
>>>
>>> Robert Modugno MD MBA FACOG
>>> Sylva, NC
>>>
>>> -----Original Message-----
>>> From: Garry E. Siegel, M.D. <garrys@mindspring.com>
>>> To: Multiple recipients of list OB-GYN-L
<ob-gyn-l@dns.obgyn.net>
>>> Sent: Wed, 6 Jun 2007 7:21 pm
>>> Subject: Ob: PP hemorrhage in a VBAC--why do we VBAC,
anyway :)?
>>>
>>> 37 YO P 4004 at term
>>> #1 Term LTC/S, breech, document
>>> #2 and #3--VBACs, uneventful, our CNMs, 9 to 10 pound babies
>>>
>>> This deliver--SROM, irreg ctx., augmented. While the CNM
was
>>> caring for
>>> her, I stopped in a followed her a bit. Clincal EFW 4200 g
>>>
>>> Dilatation was protracted for a multip., and she had a
couple of
>>> runs of
>>> hyperstimulation (meaning tachysystole with bradycardia)
that
>>> resolved
>>> with the old Pit on/Pit off/flip sides.
>>>
>>> She progressed to complete dilation, and started with big
variables.
>>> After pushing around 5 to 10 minutes, heart tones were
jumbled
>>> (FSE) and
>>> unreadable, and I watched the CNM with the head crowning,
and simply
>>> whispered to her (she is a newby but a goody) to make an
>>> episiotomy, and
>>> have her push even between contractions and "get the baby
out."
>>> The baby
>>> came out, all well.
>>>
>>> PP she hemorrhaged, and it was assumed by the CNMs/L and D
nurses
>>> to be
>>> atonic--methergine, more pit, hemabate.
>>>
>>> When she got hypotensive, I got the call.
>>>
>>> Room exam--firm fundus 2 fingers below, no lacerations, lots
of BRB.
>>> Belly soft, no complaint of shoulder pain, FWIW.
>>>
>>> Hct. 23 (was 37), quick CT showed fluid in upper abdomen,
clot in
>>> pelvis, ?hematoma of uterus--we went from the CT scanner
across
>>> the hall
>>> to the theater.
>>>
>>> What did I do and what did I find?
>>>
>>> Garry
>>>
>>> --
>>> Garry E. Siegel, M.D.
>>> Private Practice
>>> Roswell, GA
>>>
>>>
>>>
>> --
>> Garry E. Siegel, M.D.
>> Private Practice
>> Roswell, GA
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
Microsoft Office Live
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************************************************************************
****
Charlie Chambers
Hood River, OR
cchamber@alumni.rice.edu
"Almost anything you do will seem insignificant but it is very important
that you do it....You must be the change you wish to see in the world"
-- Mahatma Ghandi.
************************************************************************
*******
