Re: Deliver now or Special Delivery later
From: Efrain Ramirez (eramirezt@coqui.net)
Mon Jun 29 20:04:50 2009
APGAR 8/9 in a 25 weeker -- I don't get that kind of kindness from my
neonatologists :)
Ef
At Mon, 29 Jun 2009, Allan wrote:
>
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>Thanks for weighing in everyone. It is interesting to see that there may a
>paradigm shift in progress. The dictum I knew for treatment of eclampsia
>was termination of pregnancy. A quick check with UptoDate pointed to
>"Eclampsia is usually considered an absolute contraindication to expectant
>management'. But there seems to be a camp of folks who feel strongly about
>giving steroids and wait a day of two. The scientific basis for this I do
>not know. The way I see it is that there is a time bomb inside the mother,
>and the baby can't be very happy inside that diseased environment. Wouldn't
>the baby have enough natural steroids from being stressed inside already?
>
>Anyway, here is more information. Turns out her BP was 130/90 at 9.5 weeks
>during her first visit. Her BP got better during subsequent visits. On
>presentation the labs that were out of range were AST, LDH, BUN and uric
>acid. She received one dose of steriods. Amniotic fluid was low. She had
>a c/s. A live 650g baby girl was deliverd. Apgars were 8/9! Mother is
>stable. Baby now intubated.
>
>--
>Allan
>On Mon, Jun 29, 2009 at 8:26 AM, R. Daniel Braun <rd.braun@gmail.com> wrote:
>
>> 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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><div>Thanks for weighing in everyone. It is interesting to see that there may a paradigm shift in progress. The dictum I knew for treatment of eclampsia was termination of pregnancy. A quick check with UptoDate pointed to "Eclampsia is usually considered an absolute contraindication to expectant management'. But there seems to be a camp of folks who feel strongly about giving steroids and wait a day of two. The scientific basis for this I do not know. The way I see it is that there is a time bomb inside the mother, and the baby can't be very happy inside that diseased environment. Wouldn't the baby have enough natural steroids from being stressed inside already?</div>
>
><div> </div>
><div>Anyway, here is more information. Turns out her BP was 130/90 at 9.5 weeks during her first visit. Her BP got better during subsequent visits. On presentation the labs that were out of range were AST, LDH, BUN and uric acid. She received one dose of steriods. Amniotic fluid was low. She had a c/s. A live 650g baby girl was deliverd. Apgars were 8/9! Mother is stable. Baby now intubated. </div>
>
><div> </div>
><div>Allan<br></div>
><div class="gmail_quote">On Mon, Jun 29, 2009 at 8:26 AM, R. Daniel Braun <span dir="ltr"><<a href="mailto:rd.braun@gmail.com">rd.braun@gmail.com</a>></span> wrote:<br>
><blockquote class="gmail_quote" style="PADDING-LEFT: 1ex; MARGIN: 0px 0px 0px 0.8ex; BORDER-LEFT: #ccc 1px solid">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">
><div class="im">On Sun, Jun 28, 2009 at 11:25 PM, Efrain Ramirez <span dir="ltr"><<a href="mailto:eramirezt@coqui.net" target="_blank">eramirezt@coqui.net</a>></span> wrote:<br></div>
><blockquote class="gmail_quote" style="PADDING-LEFT: 1ex; MARGIN: 0px 0px 0px 0.8ex; BORDER-LEFT: #ccc 1px solid">
><div class="im">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>
><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" target="_blank">4obgyn@gmail.com</a><br>>>To: <a href="mailto:ob-gyn-l@mail.obgyn.net" target="_blank">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></div></div>--<br></div></div>
><div class="im">"Life is what happens to you while you're busy making other plans."- John Lennon<br></div></blockquote></div><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></blockquote></div><br>
>
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>
--
"Life is what happens to you while you're busy making other plans."- John Lennon
