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Re: 20 weeks with PPROM + previaFrom: Malcolm Griffiths (Malcolm@mgriff22.demon.co.uk)Tue Jul 2 19:13:10 1996
In message <dahmd.910.00130356@gate.net>, dahmd@gate.net writes >In article "R. Daniel Braun" <rBraun@IUNET.IUPUI.EDU> writes: > >>I doubt that she has a complete previa or that she has ruptured >>membranes. They don't go together. If she has a total previa, how does >>the fluid get out without severe hemorrhage ??? > >I see your point, but disagree. There are a number of possibilities. There >could be a "high leak" above the previa, or more likely there could be a leak >at the os with leakage around the placenta. Water, or amniotic fluid, has >amazing abilities to sneak around barriers. For brevity, I did not mention >that she had an amniocentesis with instillation of indigo carmine that leaked >into the vagina (amnio negative for infection). She is not my patient, but >I'm sure the physician managing her can diagnose leaking indigo carmine! > >>If she opted for induction, I would utilize prostaglandin. IF SHE STARTED >>TO BLEED HEAVILY PRIOR TO ANY DILATATION ONE WOULD BE >>FORCED TO DELIVER ABDOMINALLY. (sorry, I hit the caps lock) If she >>dilated and then bled, one could use any of a number of maneuvers to >>apply pressure to the placenta and stop the hemorrhage. > >I think this is pretty reasonable. A type and cross for a few units would be >prudent beforehand. This may be the way they proceed with her care. > >>Ultrasound at 20 weeks is not very good at diagnosing previa. Rupture of >>BOW and loss of fluid makes it even worse. The lower uterine segment >>(read upper cervix) has an ultrasound appearance that is very similar to >>placenta. > >Agreed, but high-resolution sonography performed with multiple, experienced >physicians in attendance, and color-flow doppler have both documented placenta >wrapped around the os. They even performed a bried vaginal probe which >showed the same thing. You'll have to trust me on this one: she has a previa. > A few points. 1) The prognosis here if far from being total gloom. There is no certainty that this babe will either be lost or suffer major handicap. Generally speaking women in this postion will continue the pregnancy if they are told there is any chance at all for the baby. Does she really want to give up on her child and have an abortion ? 2) I too have been involved in case where their is a total contradiction between placenta praevia and PROM, though mostly at later gestations. I did a CS ten days ago for a 25 weeker with bad obstetric history, transverse lie, PP, cervical suture in since 14 weeks, PROM at 25 weeks with labour ~12 hours later. At operation I found a placenta covering the internal os, but only just. This baby is currently doing well ( off ventilator at ~72 hours ). 3) No-one seems to have considered a dilatation & extraction/evacuation here. If I *HAD* to terminate this pregnancy that's what I'd use. I've no experience of doing it in this situation. But as I don't routinely scan for placental location prior to D&Es, I sometimes encounter placenta before fetus - presumably placenta praevia - it's never caused me any problems. What do others think ?
--
Malcolm Griffiths MD,MRCOG,MFFP,Cert.Mgmnt
Obstetrician & Gynaecologist Luton & Dunstable Hosp.,UK.
Tel: 01582-497459 (office)
01525-222849 (home)
Fax: 01582-497424
email: Malcolm@mgriff22.demon.co.uk
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