GBS, cerclage, steroids: conflicting info

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• Reply: Harvey S. Marchbein, M.D.: "Re: GBS, cerclage, steroids: conflicting info"

I'm at 28w1d with triplets, on Brethine 5 mg po q4 after hospitalization last week x4d on mag, then Brethine. Hospitalization was prompted by exceeding threshhold on home uterine monitoring. Treated for presumptive UTI ("contaminated specimen" but symptomatic). Cervical length is 30mm on TVUS, no change from two weeks ago. One OB called it 25% effaced in hospital, but it's closed. Growth and development are maybe OK, but we're monitoring Doppler flows biweekly with peri because a few of our weekly u/s showed >20% discordance between Baby C and her siblings (who are size = dates). BP good, passed 1 hr glucose at 14 and 28 weeks. HUAM generally 0-2 CTX/hour since on Brethine.

My first questions are regarding the GBS culture done in the hospital. It came back "contaminated." What factors would lead to this result? In order to know how to rescedule, is it inappropriate to take the culture after KY's been added to the vagina (I usually get TVUS, then see OB)?

Also, I'm getting confused because of mixed messages from the various OBs in my group and my perinatologists. I thought I'd try to get some opinions here, since I know that most of you rely on evidence over tradition.

1) Some are telling me to minimize digital exams, and others are insistent on doing vigorous ones weekly. The exams do appear to increase contractions when the OB palpates the top of cervix rather than just checking for softening and external dilation. If the TVUS is showing no funnelling nor shortening, what's the benefit of palpating at the internal os? (And how might it change the plan of care?)

2) I asked the OB I saw today how our plan of care would change if he detected funnelling, and he indicated a cerclage would be in order. I was shocked, as it seems late for this procedure; in addition, his partners and my peris indicated that the risk far outweighed the benefit. Is a cerclage really a reasonable option this late?

3) Today's OB was very insistent on weekly steroid shots from now on, although this plan differed from that of his partners and my peris. On questioning about this difference, he said (I'm *sure* I heard this right) that the shots may be associated with an increased incidence of IVH. I thought the very opposite was true; has something changed?

Sorry for the length and number of questions. The setup takes so long that I thought it might be easiest to ask all at once.

With warm regards,

--
Patti Tessler

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