Re: What's next-steroids after 34 w
From: art fougner, md (evsono@pipeline.com)
Tue Apr 29 14:06:26 2008
So Ef ...
Any Follow-up?
Art
At Tue, 29 Apr 2008, JD Stewart,MD wrote:
>
>Logic can prevail, if we allow...big studies/ Meta analyses showing a
>smaller head circ and 5% less average body weight have a fatal flaw
>inherent in the study populations in that they do not account for
>factors we know have such an effect- namely smoking ( cited at an
>average 8 ozs less at birth at term), maternal weight gain, drug abuse,
>use, work patterns, history of preterm births ..etc. Some have even
>included twins and anomalous babies.
>
>No long term growth deficits or developmental aberrations in all these
>children of moms with asthma or allergies or CT disorders who have been
>on large repeated doses of steroids have been shown in the last 40
>years...
>
>Steroids work every day, just as they will continue to work until we are
>buried. The problem is a statistical matter (nearly impossible to
>gather enough data to show an p<.o5 improvement over a baseline 98-99%
>survival without problems..) not a biochemical or physiologic process
>that suddenly stops working on a magic date.
>
>Re: Should we dose/ redose at 34-35-even 36w? Ask yourself- What does it
>hurt? How sure can any of us be about gestational dating? If the baby
>does come "late preterm" and is that 1-2% with problems, who is going to
>defend your "not recognizing her risk for delivering early and and
>failing to offer steroids/progesterone/cerclage/smoking cessation/
>aromatherapy SOONER?"
>
>Why tocolyse at 34-35-36 if doing so will not improve the outcome
>(unless you give steroids...)?
>
>Questions for article below: Hospitalization/ off work/ tocolysis for
>weeks has no economic cost?
>
>At Sat, 26 Apr 2008, Efrain Ramirez wrote:
>>
>> Neonates born after
>>34 completed weeks of gestation rarely have mortality or major
>>morbidity, but the financial costs remain significant ($7000 per case),
>>and efforts to prevent delivery at this gestational age are probably
>>indicated. Economic costs associated with PTB include the cost of
>>initial hospitalisation, the cost of any chronic diseases resulting from
>>the prematurity and social costs including loss of gainful employment by
>>a family member taking care of the infant or child and loss of potential
>>future earnings of the affected child.
>
> Antenatal steroids, if given to
>>the mother at least 48 hours prior to a PTB, have shown significant
>>reductions in RDS, IVH and NEC. Efforts to prevent, or avoid, PTB
>>include the use of tocolytic agents which have been shown to prolong
>>gestation for a minimum of 48 hours, or longer in some cases. The range
>>of tocolytic agents used to delay or prevent PTB work through many
>>different pathways, with varying degrees of success. Which tocolytic
>>agent to use depends on many factors including underlying maternal
>>status, gestational age of the fetus and documented efficacy of agent
>>used.
>>
>>At Fri, 25 Apr 2008, Garry E. Siegel, M.D. wrote:
>>>
>>>Thanks for the input, Dan and Ef.
>>>
>>>Is there evidence to use steroids as you've suggested, or is it just
>>>based on experience/obstetric horse sense?
>>>
>>>Isn't there a bit of a thought that steroids may have long term growth
>>>consequences? In other words, there may be harm such that one shouldn't
>>>use them unless clearly indicated.
>>>
>>>Garry
>>>
>>>At Thu, 24 Apr 2008, Efrain Ramirez wrote:
>>>>
>>>>Agree!!!!
>>>>
>>>>Ef
>>>>
>>>>At Thu, 24 Apr 2008, R. Daniel Braun wrote:
>>>>>
>>>>>Steroids do more than prevent RDS. They also decrease incidence of IVH and
>>>>>NEC, which can still occur after 34 weeks. Risk of giving steroids is ??????
>>>>>
>>>>>Dan
>>>>>
>>>>>On Thu, Apr 24, 2008 at 9:05 AM, Andrew Folley <agfolley@hotmail.com> wrote:
>>>>>
>>>>>> I must have missed how the diagnosis of IUGR was made?agf
>>>>>>
>>>>>> > Date: Thu, 24 Apr 2008 06:11:49 -0500
>>>>>> > From: cdsb@bellsouth.net
>>>>>> > To: ob-gyn-l@mail.obgyn.net
>>>>>> > Subject: RE: What's next
>>>>>> >
>>>>>> > I don't give steroids after 34 weeks either. And Garry is right, the baby
>>>>>> > isn't thriving, it's small.
>>>>>> >
>>>>>> > But if the fetus were say 30 weeks with IUGR, but with Reactive NST and
>>>>>> 8/8
>>>>>> > BPP, then I think there wouldn't be such a rush to delivery.
>>>>>> >
>>>>>> > So the real question here I think is given an IUGR fetus with perfect
>>>>>> > testing, what is the EGA we would electively deliver?
>>>>>> >
>>>>>> > Everyone may have a different answer. Here is an example of there being
>>>>>> 10
>>>>>> > different ways to do something in medicine and nine of them not being
>>>>>> wrong.
>>>>>> >
>>>>>> > Charles
>>>>>> >
>>>>>> > -----Original Message-----
>>>>>> > From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Garry
>>>>>> E.
>>>>>> > Siegel, M.D.
>>>>>> > Sent: Wednesday, April 23, 2008 10:47 PM
>>>>>> > To: Multiple recipients of list OB-GYN-L
>>>>>> > Subject: Re: What's next
>>>>>> >
>>>>>> > Over 34 weeks--no steroids unless amnio done and lung maturity not
>>>>>> > proven.
>>>>>> >
>>>>>> > Yes, the late preterm baby alluded to in ACOG's Committe Bulletin has
>>>>>> > more morbidity, etc., but this baby is far from thriving inside.
>>>>>> >
>>>>>> > Reassuring testing is nice, but nicer is a baby in the nursery.
>>>>>> >
>>>>>> > Deliver her, my friend.
>>>>>> >
>>>>>> > Garry
>>>>>> >
>>>>>> > At Wed, 23 Apr 2008, Efrain Ramirez wrote:
>>>>>> > >
>>>>>> > >No fetal weight gain at all in the last 2 weeks.. umbilical artery
>>>>>> > >doppler normal.. MCA not done.. mother perceives fewer FM's.. just
>>>>>> > >like the other pregnancy.
>>>>>> > >Definitive asymmetric IUGR.
>>>>>> > >Level III NICU .. I had to deliver in the last year to babies at 26
>>>>>> > >weeks .. doing well..
>>>>>> > >Steroids? - it's a Democratic Primary..
>>>>>> > >Legally speaking an unexpected IUFD would be hard to defend... NICU
>>>>>> > >complications, IMHO, easier.
>>>>>> > >Thanks to all.. recommendations well taken.
>>>>>> > >
>>>>>> > >Ef
>>>>>> > >
>>>>>> > >At Wed, 23 Apr 2008, art fougner, md wrote:
>>>>>> > >>
>>>>>> > >>Middle cerebral artery doppler? Uterine artery doppler?
>>>>>> > >>If all normal, would suggest (unencumbered by data) twice weekly nst's
>>>>>> > >>with AFI's, weekly dopplers and elective delivery at term.
>>>>>> > >>
>>>>>> > >>Art
>>>>>> > >>
>>>>>> > >>Just my opinion. I could be wrong.
>>>>>> > >>
>>>>>> > >>At Wed, 23 Apr 2008, Efrain Ramirez wrote:
>>>>>> > >>>
>>>>>> > >>>30 some G2, P1 - previous C/S - IUGR - at 36 weeks - apparently no
>>>>>> > >>>reassuring FHR's.2 weeks at NICU.. at present 34 w and 5 d.. BPP
>>>>>> > >>>10/10, EFW - 1500-1600 below 5th.. normal umbilical Doppler .. what's
>>>>>> > >>>next?
>>>>>> > >>>
>>>>>> > >>>Ef
>>>>>> > >>>
>>>>>> > >>>--
>>>>>> > >>>"I can accept failure, but I can't accept not trying." - Michael
>>>>>> Jordan
>>>>>> > >>>
>>>>>> > >>--
>>>>>> > >>art fougner, md
>>>>>> > >>"May The Wings of Liberty Never Lose a Feather." - Jack Burton
>>>>>> > >>
>>>>>> > >--
>>>>>> > >"I can accept failure, but I can't accept not trying." - Michael Jordan
>>>>>> > >
>>>>>> >
>>>>>> > --
>>>>>> > Garry E. Siegel, M.D.
>>>>>> > Private Practice
>>>>>> > Roswell, GA
>>>>>> >
>>>>>>
>>>>>> ------------------------------
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>>>>>--
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>R. Daniel Braun, MD FACOG(L) ABMP CMTh
>>>>>> ------------------------------
>>>>>Professor Emeritus
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>> ------------------------------
>>>>>Dept. of Obstetrics and Gynecology
>>>>>> ------------------------------
>>>>>Indiana U. School of Medicine
>>>>>
>>>>>R. Daniel Braun
>>>>>
>>>>>"Science without Religion is LAME; Religion without Science is BLIND"
>>>>>Einstein 1941
>>>>>
>>>>--
>>>>"I can accept failure, but I can't accept not trying." - Michael Jordan
>>>>
>>>--
>>>Garry E. Siegel, M.D.
>>>Private Practice
>>>Roswell, GA
>>>
>>--
>>"I can accept failure, but I can't accept not trying." - Michael Jordan
>>
>--
>JD. Stewart, MD
>MFM up too late all night, every night...still 10 years later
>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
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