Re: Deliver now or Special Delivery later
From: R. Daniel Braun (rd.braun@gmail.com)
Mon Jun 29 07:25:51 2009
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Ef,What did you mean by "not at home"?
IMHO, the Attending should not go home until this lady is delivered. For me
this would probably be about 24 hours, because I might give her that long
for the steroids to "work".
Dan
On Sun, Jun 28, 2009 at 11:25 PM, Efrain Ramirez <eramirezt@coqui.net>wrote:
> Yes you are right - not at home -- problem with this case is that we (at
> least I don't)do not have enough information.. if chemistry is Ok and
> patient responds to antihypertensives ..I would give her a course of
> corticosteroids .. IMHO
>
> Ef
>
> At Sun, 28 Jun 2009, JD Stewart,MD wrote:
> >
> >Pardon the tone,......but this has set me off.
> >
> >At Sat, 27 Jun 2009, Andrew Folley wrote:
> >>
> >>Definitely wait and watch careflully in house would like to get to 28
> weeks for improved neonatal outcome. Degree of proteinuria???
> >>
> >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:
> >>
> >>Definitely wait and watch careflully in house would like to get to 28
> weeks for improved neonatal outcome. Degree of proteinuria???
> >>
> >>Date: Sat, 27 Jun 2009 15:48:57 -0500
> >>From: 4obgyn@gmail.com
> >>To: ob-gyn-l@mail.obgyn.net
> >>Subject: Deliver now or later
> >>
> >>33 yo G1 P0 presented @ 25 4/7 weeks EGA after a witness seizure at work.
> Brought in by ambulance and seized again in ER. BP 220/160. No
> significant past medical history. Husband did say she had headaches for one
> week and swelling for two weeks. Also was hit by a dodge ball on her
> forehead three days before presentation. She was last seen by her ob two
> weeks ago when it was uneventful. She had a negative CT of the head prior
> to being released from the ER to L&D. Baby's heart beat now in normal
> range. Cervix closed, firm, uneffaced. Cephalic presentation by
> ultrasound. MgSO4 given in ER, BP gradually responding to Hydralazine and
> Labetolol. No coagulation abnormalities. I am wondering how many of you
> folks will deliver her right away, or how many will give her steroids and
> wait? Thanks in advance for you input.
> >>
> >>Allan
> >
> >--
> >JD Stewart, MD
> >MFM up all night, every night
> >10 years later..
> >
>
> --
> "Life is what happens to you while you're busy making other plans."- John
> Lennon
>
--
--
R. Daniel Braun, MD FACOG(L) ABMP CMTh #20900069
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
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Ef,<div>What did you mean by "not at home"?</div><div>IMHO, the Attending should not go home until this lady is delivered. For me this would probably be about 24 hours, because I might give her that long for the steroids to "work".</div>
<div><br></div><div>Dan<br><br><div class="gmail_quote">On Sun, Jun 28, 2009 at 11:25 PM, Efrain Ramirez <span dir="ltr"><<a href="mailto:eramirezt@coqui.net">eramirezt@coqui.net</a>></span> wrote:<br><blockquote class="gmail_quote" style="margin:0 0 0 .8ex;border-left:1px #ccc solid;padding-left:1ex;">
Yes you are right - not at home -- problem with this case is that we (at<br>
least I don't)do not have enough information.. if chemistry is Ok and<br>
patient responds to antihypertensives ..I would give her a course of<br>
corticosteroids .. IMHO<br>
<br>
Ef<br>
<div><div></div><div class="h5"><br>
At Sun, 28 Jun 2009, JD Stewart,MD wrote:<br>
><br>
>Pardon the tone,......but this has set me off.<br>
><br>
>At Sat, 27 Jun 2009, Andrew Folley wrote:<br>
>><br>
>>Definitely wait and watch careflully in house would like to get to 28 weeks for improved neonatal outcome. Degree of proteinuria???<br>
>><br>
>Wait and Watch carefully for what? A transfer to the Path in the<br>
>basement on the fuzzy blanket gurney?<br>
><br>
>What other disease process did you have in mind that will be fine with<br>
>vital signs , office exam (no/low proteinuria), labs and baby exam 2<br>
>weeks earlier, and then present with increasing headache,swelling, BP's<br>
>in this range and seizures? Lupus plus dodgeball?<br>
><br>
>She is eclamptic and already on MagSo4, and her critical level of<br>
>hypertension is "responding" only to 2 IV meds....What's the plan? What<br>
>is your "definite" next therapy for the next 3 weeks when this is no<br>
>longer enough? Cochrane deep water immersion or abdominal decompression?<br>
><br>
>When did a month of bedrest, nitroprusside, diuretics, phenytoin and<br>
>"careful watching" ever begin to work for eclampsia?<br>
><br>
>The question of gaining 24-48 hours for steroids is a reasonable<br>
>question...not a lot of definite evidence this helps in light of the<br>
>increased risks of abruption/ seizure/ mortality in this setting...the<br>
>steroid studies were derived from large populations of "normal" early<br>
>deliveries, and the findings transported to all clinical situations,<br>
>just because...well, we think ( and opine...)it should work.<br>
><br>
>Caveat- Even on Dr Sibai's service with all the papers he has published<br>
>on this, he managed to squeak out these few weeks for quite a few<br>
>patients, and proved it could be done in his particular setting with an<br>
>army of students, residents and fellows, but really failed to show a lot<br>
>of benefit to neonatal outcomes for the effort, or any further<br>
>improvement over the outcomes of the delivered 25-28 weekers in the<br>
>NICU....so if you are doing this "for the baby", think twice before<br>
>blindly applying the "28 weeks in utero just has to be better" principle<br>
>for this baby...<br>
><br>
>The added phrase "definitely" would merit repeating the OB rotation in<br>
>med school..or a guest appearance at law school...<br>
><br>
>At Sat, 27 Jun 2009, Andrew Folley wrote:<br>
>><br>
>>Definitely wait and watch careflully in house would like to get to 28 weeks for improved neonatal outcome. Degree of proteinuria???<br>
>><br>
>>Date: Sat, 27 Jun 2009 15:48:57 -0500<br>
>>From: <a href="mailto:4obgyn@gmail.com">4obgyn@gmail.com</a><br>
>>To: <a href="mailto:ob-gyn-l@mail.obgyn.net">ob-gyn-l@mail.obgyn.net</a><br>
>>Subject: Deliver now or later<br>
>><br>
>>33 yo G1 P0 presented @ 25 4/7 weeks EGA after a witness seizure at work. Brought in by ambulance and seized again in ER. BP 220/160. No significant past medical history. Husband did say she had headaches for one week and swelling for two weeks. Also was hit by a dodge ball on her forehead three days before presentation. She was last seen by her ob two weeks ago when it was uneventful. She had a negative CT of the head prior to being released from the ER to L&D. Baby's heart beat now in normal range. Cervix closed, firm, uneffaced. Cephalic presentation by ultrasound. MgSO4 given in ER, BP gradually responding to Hydralazine and Labetolol. No coagulation abnormalities. I am wondering how many of you folks will deliver her right away, or how many will give her steroids and wait? Thanks in advance for you input.<br>
>><br>
>>Allan<br>
><br>
>--<br>
>JD Stewart, MD<br>
>MFM up all night, every night<br>
>10 years later..<br>
><br>
<br>
--<br>
</div></div>"Life is what happens to you while you're busy making other plans."- John Lennon<br>
</blockquote></div><br>
FACOG(L) ABMP CMTh #20900069<br>Professor Emeritus<br>Dept. of Obstetrics and Gynecology<br>Indiana U. School of Medicine<br><br><br>R. Daniel Braun<br>
<br> “Science without Religion is LAME; Religion without Science is BLIND"<br> Einstein 1941<br>
</div>
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