MDcooper
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18.A 19-year-old primigravid woman at 42 weeks' gestation comes the labor and delivery ward for induction of labor. Her prenatal course was uncomplicated. Examination shows her cervix to be long, thick, closed, and posterior. The fetal heart rate is in the 140s and reactive. The fetus is vertex on ultrasound. Prostaglandin (PGE2) gel is placed intravaginally. One hour later, the patient begins having contractions lasting longer than 2 minutes. The fetal heart rate falls to the 70s. Which of the following is the most appropriate next step in management?
A. Administer general anesthesia
B. Administer terbutaline
C. Perform amnioinfusion
D. Start oxytocin
E. Perform cesarean delivery
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| CocaCola
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E - Cesearen
fetus is in distress... contractions are longer than normal (normal is about 1 minute)
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| Aashi
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B-------> Administer terbutaline (this is the treatment for hyperstimulation caused by Prostaglandins), this will abort the hyperstimulation and fetal heart rate will return to normal..
GL
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| MHP
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E. Perform Cesarean delivery, because the fetus is in distress, you can´t wait until the terbutaline do his job
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| anjushree
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s.c terbutaline work fast----should be given in process of prep of C.S
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| drashishmahajan
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aashgi but ptn is already in labour room...also its a postdatd preg..n fetal distress is contraindication 4 the use of tocolytics--- i ll go wid c - section
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| sarika
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you terbutaline to stop that painful contraction...after which you will proceed to c section...so first B than E
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| drashishmahajan
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sarika even whn the contraction r hypertonic ...sedatives r used . not tocolytics
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| sarika
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no ashish...go all the way down to teh complications of PGE2. You will see the management of hyperstimulation.
http://www.fpnotebook.com/OB115.htm
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| drashishmahajan
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thanks 4 the page sarika ... but i m sticking to wht kaplan says n wht i ve STUDIED during the MBBS course... HE USE OF TOCOLYTICS IS LIMITED TO 1 .TO TRANSPORT THE PATIENT TO HOSPITAL 2.. TO ATTAIN FOETAL MATURITY... n wht about the fact tht the tocolytics r contraindicated in the foetal distress... n also if u see in the above link ,,thts the managemnt of the tachysystole---increase in the no of contraction nt the duration of contraction
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| Aashi
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The correct answer is ---> B( terbutaline)..This q was submitted in another forum,since MDcooper dint submit the answer,thought i would do that to avoid the unneccessary confusion..
Once patients reach 42 completed weeks of gestation, many physicians will induce labor for post-term pregnancy. This is done to avoid the uncommon but catastrophic outcome of fetal demise and the higher rates of placental insufficiency that develop as patients get further post-term. Prostaglandin (PGE2) gel is an effective agent to use for labor induction. It has been shown to improve the Bishop's score, to shorten the length of labor and delivery, to decrease the amount of oxytocin needed, and to decrease the cesarean delivery rate. The main complication from its use is uterine hyperstimulation. This hyperstimulation is defined as an increased frequency of contractions (greater than 5 every 10 minutes) or an increased length of each contraction (greater than 2 minutes) with evidence of fetal distress. When this hyperstimulation occurs, the patient may be treated with IV or subcutaneous terbutaline. This medication usually has a rapid onset of action in resolving hyperstimulation. IV magnesium sulfate can also be used.
GL
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| ram3
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The correct answer is cesarean section the fetus is in distress and
there is no reason to gice a drug here insteag go to cesarean section
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| Justice
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I also do not see a reason for medical management...
(E) CS
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| jamdoc
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there is a similar q in UW. answer is B
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| azygous
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Read the question again. it asks for..Which of the following is the most appropriate next step in management?
even if u take the patient for CS..whats the 1st thing u would do..
B..
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| hanwin
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Has to be B.
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| virgola82
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I don't agree because the cause of this condition is that too much PGE2 has been given so the best way to reverse this temporarly, ie for the time to move the pt in the section room, is to be to give tocolysis. So I'd pick terbutaline.
I have a question too, is it possible to operate, I mean to do c section, while the uterus is contracting?
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| MAGY17
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terbutaline...................yes
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| cirus
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Decrease Fetal Hr is not a condition where u can give a medical ttt & wait for response, the ans is CS
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| dr_arc
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yes the best step is csection.
but
the next best step is terbutaline.
cirus i agree, you do not wait to see if the terbutaline will act before making the decision for surgey. you give it to prevent further fetal distres by the contracting uterus while you are already moving the pt to surgery cos a fetus with a heart rate of 70 with such a hyper uterus is not going to make it by the time pt is administered anesthesia and csection done. giving terbutaline is a way of giving the fetus a better chance .terbutaline acts pretty fast but by itself is not the management in fetal distress as most of us agree. it is to buy time till you do the cs
virgola yes you can operate on a contracted uterus, infact a hypertonic uterus with fetal distress goes to csection.
anyway the anesthesia might have a relaxant affect on the uterus. it is after all smooth muscle.
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| drdt
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I appreciate the points u guys highlighted but anyonce can tell me that what about the potential teratogenic effects of terbutaline? It has been proven that terbutaline caries the risk of brain damage, developmental delay, speech damage, cognitive defect in the new born baby.
Terb. is approved by FDA to treat asthma. Its use for the preterm labor or to redu. ut. contractions is all "off label"
In 1997, the FDA issued its first warning about the use of Terbutaline Sulfate for the treatment and prevention of preterm labor, pointing out that the approved labeling stated that “the drug should not be used for the management of preterm labor.”
The most recent study conducted at Duke University and published in the Journal of Pharmacology and Experimental Therapeutics, showed that the use of Terbutaline might leave the brains of children susceptible to other chemicals present in the environment, such as pesticides. The study suggests that certain early drug or chemical exposures can predispose people to particular ailments. Recently, the National Asthma Education and Prevention Program has recommended that Terbutaline no longer be given to women with mild intermittent asthma while they are pregnant.
So, think twice before coming to the final answer.
I still want to see what is ur final answer now.
Thanks
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| dr_arc
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hey drdt this is indeed very very interesting and very worrisome given that not many know of this.
it would indeed be inappropriate to use terbutaline for pretem management given the risks, however for this case per se i would still think sc terbutaline cos one single dose and the baby is on its way out anyway very soon, so unlikely to cause harm.
further the benefit to the baby from stopping the hyper contractions with terbut as against the risk of almost certain mortality with continued contraction and distress pushes me to opt for terbutaline as the answer but only for this case. given this new information however i think it is out of question to use it for long term preterm prophylaxis.
thanks drdt this is indeed an eyeopener.
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| Shaina
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isn't tocolysis contraindicated when contratcions have begun
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| bioguy
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Wanna continue the debate?
This is the first time I see a large group of people (instead of one-on-one) so divided in their opinions.
Interesting question, though!
This tocolysis thing is so vague. Nobody has consensus on its use and contraindications.
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| wasedf
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In this question, the FHR is really low (fetal distress). I would go with C-section
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