OB-GYN-L Messages for April, 2008: Re: What's next-steroids after 34 w

Re: What's next-steroids after 34 w

From: JD Stewart,MD

jdstewartmfmob@sbcglobal.net

Wed Apr 30 12:55:09 2008

Are we working in an ideal world or do we deal with what is waiting on the ward?

I don't imagine you tell your patients "I'm sorry, there hasn't been sufficient clinical randomised trial data in peer review journals to support me doing ANYTHING for you..we have been looking at this for 40 years and still can't come up with THE proper answer. Too bad you aren't in an ivory tower halfway around the world so that a properly vetted, IRB approved and non-financially encumbered trial would be available, as the articles (published by the ivory towers) have taken as their new conclusion and recommendation mantra when they cannot show anything new, but wish to publish their meta-analyses.

Evidence re: IUGR and known risks for prematurity abound. I've said nothing that isn't in any OB text.

My point is the paralysis by analysis /committee/ insurance/lawyer medicine that allows us to be put into a corner in OB such as this where there IS no one right way out, as there is no risk free path in life...yet we are to produce perfect results every time, or someone is at fault.

AH life! No one here gets out alive...

At Wed, 30 Apr 2008, Dr Eberhard Lisse wrote: >
>Is anything you say encumbered by evidence?
>
>el
>
>on 4/29/08 7:35 PM JD Stewart,MD said the following:
> > 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?

-- JD. Stewart, MD MFM up too late all night, every night...still 10 years later

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