fandarast
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A 22-year-old gravida 1, para 0 at 33 weeks of gestation presents to labor and delivery and reports cramping and lower back pain. She denies leaking of fluid from the vagina. You perform a speculum examination that shows no pooling, and Nitrazine paper stays yellow after contact with the secretions in the posterior fomix. Cervical cultures are taken. She is placed on fetal heart rate and uterine contraction monitoring, which shows a baseline heart rate of 155 bpm and three uterine contractions per a 10-minute period. Her cervix is dilated to 2 to 3 cm and 80% effaced. She also tells you that she has diabetes mellitus that has not been well controlled throughout pregnancy. The next best step in management of this patient is
A. Antibiotics
B. MgS04
C. Terbutaline
D. Corticosteroids
E. Ultrasound
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| shiny2k8
Forum Newbie
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A
Because terbutaline & MgS04 are tocolytics nd they r contraindicated if there is advanced cervical dilatation.
corticosteroids are indicated only if GA<32wks...
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| multani001
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but with diabetes in mother...surfactant production is decreased in the baby...so i think steroids should be given
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| dr.wad
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B...
2-3 cm is not considered as advanced dilatation.
terbutaline should may induce hyperglycemia.
steroid cod be given < 34 weaks but u have to fix the conception before.
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| inkspot
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i think D.
The lungs are not mature ( less than 35 weeks ) there is 80% efacement meaning the baby can undergo premature anytime. She is DM and in DM, the insulin is high which retards surfactant growth.
Whats the correct answer fandarast?
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| ricardoricardo
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i think that administration of corticosteroids is a later procrdure cuz any way it will not work immediatly,,
i thought that 4 cm is considered advanced cervical dilatation so we might give tocolytics but yes terbutalin cause hyperglycemia so Mgsulphate would be more approprpiate but more dangerous and need frequent monitoring
corticosteroids i think would not be helpfull after 32 weeks gestation , and it will antaginize her insulin and lead to more poor control
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| grechita12
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E i think the first step is be sure about the fetal condition (BP+Position+amniotic fluid) then asses lung maturation and decide mgm
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| HKM07
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I think its E ,As fetal condition should be assesd before any intervention
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| inkspot
Forum Guru
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how can ultrasound tell you about the fetal condition? the fetus heart rate is already given in stem and its reassuring.
the patient is in latent phase of labor. tololytics ( terbutaline and Mgso4 ) are contraindicated and are of no use.
antibiotics should be given but there is no hx of GBS also culture results not available.
with DM and prematurity the main concern is immature lungs and for that matter while the patient will be in labor for the next 10-12 hours dexamethasone should be given.
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| arlete
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What's the right answer?
Good question! 
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| nyimalay
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I would go for E.
USG to rule out fatal anomalies before giving tocolytics to maintain pregnancy and steroids for lung maturity.
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| lq2006
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Ultrasound
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| HKM07
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As mother in labour and the presence of cervical diltation 2-3 cm which is not advance ,the use of tocolysis is suitable with cervical dilattion less than 4cm in the absence of maternal and fetal contraindication but here Diabetes is a maternal contraindication at the same time in cerain cercumstances Magnessium sulfate can be use with diabetes and cardiovascular disease (Toronto Notes 2007) but here in our question theres a diabtes which is not under control through out pregnancy so raising possibility of fetal abnormality for this reason I am saing again E Ultrasound first and then Mgso4 to buy time
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| arlete
Intern in 2009!!!!!
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Discovering fetal abnormality changes the next decision in which way? I mean, even if there is a fetal abnormality, at this stage of pregnancy, isn't it the doctor's primary and immediate duty to avoid a premature labor?
(Cardiologist asking here, no ofense intended)
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| nyimalay
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What I understand is that it is not recommended to prolong/ maintain the pregnancy if there is fatal fetal anomaly.
Kaplan stated that fatal anomaly is a contraindication for tocolysis.
More input please.
Where are you fandrast?
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| nyimalay
Forum Elite
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What I understand is that it is not recommended to prolong/ maintain the pregnancy if there is fatal fetal anomaly.
Kaplan stated that fatal anomaly is a contraindication for tocolysis.
More inputs please.
Where are you fandrast?
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| arlete
Intern in 2009!!!!!
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nyimalay:
I see...
Well, it would be good to know the right answer at this point!
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| fandarast
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The answer is E. The patient is in preterm labor. Antibiotics and corticosteroids are given after initiation of tocolytic therapy, since tocolysis buys time (at least 48 hours) for the steroid to take effect on the fetal lung tissue and the antibiotics to treat an occult infection. Terbutaline is contraindicated in uncontrolled diabetes mellitus because it causes hyperglycemia. An ultrasound is indicated prior to inception of tocolytic therapy because a lethal fetal anomaly, in utero fetal compromise, and significant fetal growth restriction are all contraindications to tocolytic therapy. This is especially important in someone with diabetes mellitus who has not been under strict control.
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