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Re: Deliver now or Special Delivery laterFrom: JD Stewart,MD (jdstewartmfmob@hotmail.com)Sun Jun 28 19:58:36 2009
Pardon the tone,......but this has set me off.
At Sat, 27 Jun 2009, Andrew Folley wrote:
> Wait and Watch carefully for what? A transfer to the Path in the basement on the fuzzy blanket gurney? What other disease process did you have in mind that will be fine with vital signs , office exam (no/low proteinuria), labs and baby exam 2 weeks earlier, and then present with increasing headache,swelling, BP's in this range and seizures? Lupus plus dodgeball? She is eclamptic and already on MagSo4, and her critical level of hypertension is "responding" only to 2 IV meds....What's the plan? What is your "definite" next therapy for the next 3 weeks when this is no longer enough? Cochrane deep water immersion or abdominal decompression? When did a month of bedrest, nitroprusside, diuretics, phenytoin and "careful watching" ever begin to work for eclampsia? The question of gaining 24-48 hours for steroids is a reasonable question...not a lot of definite evidence this helps in light of the increased risks of abruption/ seizure/ mortality in this setting...the steroid studies were derived from large populations of "normal" early deliveries, and the findings transported to all clinical situations, just because...well, we think ( and opine...)it should work. Caveat- Even on Dr Sibai's service with all the papers he has published on this, he managed to squeak out these few weeks for quite a few patients, and proved it could be done in his particular setting with an army of students, residents and fellows, but really failed to show a lot of benefit to neonatal outcomes for the effort, or any further improvement over the outcomes of the delivered 25-28 weekers in the NICU....so if you are doing this "for the baby", think twice before blindly applying the "28 weeks in utero just has to be better" principle for this baby... The added phrase "definitely" would merit repeating the OB rotation in med school..or a guest appearance at law school...
At Sat, 27 Jun 2009, Andrew Folley wrote:
>
-- JD Stewart, MD MFM up all night, every night 10 years later..
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