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Re: 2 cases, need inputFrom: fuf@gulf.netTue Nov 25 16:45:41 1997
> >Input please with the following: > >P1, 350#s, chronic HTN, .... Tell me your preferences, and >why: Aldomet? Clonidine? Other? > >Also, her SMAC returned with glucose of 137 > >2. So now what? Am I >obligated to recheck her AFI? How often? What's your 'protocol' for this >situation? > >Thanks, > >Deborah Wage FNP,CNM > P1: No proven advantage of prophylactic antihypertensives for mild chronic hypertension, or in this case, normal pressures. If pressures rise significantly (repetitive pressures of „160 systolic or „ 100 diastolic) and continuation of pregnancy is necessary or desirable, I would treat with a cardioselective beta blocker such as Atenolol (start at 50mg/daily). An alternative is labetolol (start 200mg b.i.d.). Both of these medicines do not seem to be associated with IUGR. Another safe alternative is a calcium channel blocker such as nifedipine which can be given as 10m q6h or more conveniently in the XL form as one tablet daily (60 - 90XL). I rarely use Aldomet becuase it is a weak antihypertensive with side effects (postural, headache). It's safety profile in pregnancy is good, so it is an alternative. I fear clonidine's "rebound" phenomena when it is stopped, but that too may be overblown. If pressures rise, carefully evaluate for superimposed preeclampsia. I would watch fetal growth carefully, IUGR may be a problem (as may be macrosomia) in this patient. Considering her weight, serial 3rd trimester sonography may be necessary. Arent you glad you have that early ultrasound for dates? Antepartpum testing is recommended for the last 8 weeks of gestation. Testing may be necessary earlier if problems arise. I would recommend delivery when patient is mature and inducible. I would not want this patient pregnant after 40 weeks. The 1hr post glucola test, preformed early in pregnancy and repeated @ 28 weeks if normal should be sensitive enough to detect gestational or type II diabetes. P2: An AFI of 9 is on the low side of normal in a 33 weeker. About 70% of patients with suspected leaks will actually be found to have one. Leaks may be slow and seal off, and I believe these patients (sealed off, AFI normal) are not high risk. Still most patients with a slow leak will progress to increased leakage and oligohydramnios, with all the associated risks. Some leaks are hard to tell. Fern and nitrazene tests are about 90-95% sensitive. I usually like to see 2 negative exams and 2 normal AFI's without a history of further leakage before I consider a patient to be "sealed off" or "never have leaked". If convenient, I would perform these exams several days to a week apart.2nd trimester leaks are small in volume and often test negative on vaginal exam. A 33 week leak has probably already declared itself. If the history persists or if the exam is not conclusive, fetal fibronectin (ffn) is very sensitive for SROM (but not too specific). Hope that helps. Gary Kleinman Perinatologist/Geneticist Packed and ready
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