Re: Urgent MFM OB question

[Guest guest]

Contact these people - they have the most expertise.Pro-life MFM'sl This organization exists for just this type of situation.http://www.prolifemfm.org/--- Subject: Urgent MFM OB questionTo: nfpprofessionals Date: Monday, March 23, 2009, 7:00 PM

The basics:

39 y.o. G4 P0303 17 4/7 wks presents to ED with worsening SOB x 7 days

& increasing leg swelling. h/o TII DM, cHTN, Asthma, dx'd with CHF

last November '08 - was placed on digoxin, lasix, ACE-I with

resolution of sx; found out she was pregnant in Jan, promptly stopped

ALL meds. Didnt' see a doc yet b/c of insurance issues. Today BNP

800, Left ventricular EF 16%. Last pregnancy ended with c-section at

32 weeks due to superimposed Pre-E, intubated in ICU for several days

after section. all the articles i can find advise termination. Please

help! Of course we'll do the usual, digoxin and lasix as needed,

control blood pressure, but people are already talking termination and

this lady is already headed downhill. Any advice or experience is

appreciated.

thanks.

[Guest guest]

Maybe this thought can buy you time to think:

Delivery (termination) usually causes congestive heart failure to worsen. Most cardiac problems worsen with delivery (termination).

It sounds like she's much too sick for termination.

Paddy Jim Baggot MD

To: nfpprofessionals From: mdavmd@...Date: Mon, 23 Mar 2009 19:53:04 -0700Subject: Re: Urgent MFM OB question

Contact these people - they have the most expertise.Pro-life MFM'sl This organization exists for just this type of situation.http://www.prolifemfm.org/--- On Mon, 3/23/09, medschoolrunner <kwins002umaryland (DOT) edu> wrote:

From: medschoolrunner <kwins002umaryland (DOT) edu>Subject: Urgent MFM OB questionTo: nfpprofessionals Date: Monday, March 23, 2009, 7:00 PM

The basics:39 y.o. G4 P0303 17 4/7 wks presents to ED with worsening SOB x 7 days & increasing leg swelling. h/o TII DM, cHTN, Asthma, dx'd with CHFlast November '08 - was placed on digoxin, lasix, ACE-I withresolution of sx; found out she was pregnant in Jan, promptly stoppedALL meds. Didnt' see a doc yet b/c of insurance issues. Today BNP800, Left ventricular EF 16%. Last pregnancy ended with c-section at32 weeks due to superimposed Pre-E, intubated in ICU for several daysafter section. all the articles i can find advise termination. Pleasehelp! Of course we'll do the usual, digoxin and lasix as needed,control blood pressure, but people are already talking termination andthis lady is already headed downhill. Any advice or experience is appreciated.thanks.

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[Guest guest]

agreed!!

Sincerely yours,

Dominic M Pedulla MD, FACC, CNFPMC, ABVM, ACPh

Cardiologist and Varicose Vein Specialist (varicoseveins1@...)

President, The Oklahoma Vein and Endovascular Center

Associate Clinical Professor of Medicine, OUHSC

Specialist in Non-contraceptive (Natural) Family Planning

(office)

(cell)

PedullaD@...

Urgent MFM OB question

To: nfpprofessionals

Date: Monday, March 23, 2009, 7:00 PM

The basics:

39 y.o. G4 P0303 17 4/7 wks presents to ED with worsening SOB x 7 days

& increasing leg swelling. h/o TII DM, cHTN, Asthma, dx'd with CHF

last November '08 - was placed on digoxin, lasix, ACE-I with

resolution of sx; found out she was pregnant in Jan, promptly stopped

ALL meds. Didnt' see a doc yet b/c of insurance issues. Today BNP

800, Left ventricular EF 16%. Last pregnancy ended with c-section at

32 weeks due to superimposed Pre-E, intubated in ICU for several days

after section. all the articles i can find advise termination. Please

help! Of course we'll do the usual, digoxin and lasix as needed,

control blood pressure, but people are already talking termination and

this lady is already headed downhill. Any advice or experience is

appreciated.

thanks.

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[Guest guest]

ACE inhibitors worked well in this patient although they are asociated with significant fetal complications including stillbirth when used during pregnancy. This is the sticking point, I think, in this case. Hydralazine is a vasodilator which may be used in place of an ACE inhibitor, which would not be considered dangerous to the fetus. Next one could consider ACE inhibitors in this patient. It must be considered from both pro-choice and pro-life perspectives. From the prochoice perspective, the fetus is often considered dismissable or of no consequence from the prochoice perspective, when the mother's life is at stake. If the fetus is considered to be of no importance when the mother's life is at stake, these options could be considered: From the pro-choice perspective:1.) Termination-worsens maternal cardiac condition and is potentially the most dangerous option from maternal perspective.2.) ACE INHIbitor-improves maternal condition. Could cause complications for fetus but fetus is of no import anyway.

Paddy Jim Baggot MD

To: nfpprofessionals From: pedullad@...Date: Tue, 24 Mar 2009 12:30:37 -0400Subject: Re: Urgent MFM OB question

agreed!!

Sincerely yours,Dominic M Pedulla MD, FACC, CNFPMC, ABVM, ACPhCardiologist and Varicose Vein Specialist (varicoseveins1)President, The Oklahoma Vein and Endovascular CenterAssociate Clinical Professor of Medicine, OUHSCSpecialist in Non-contraceptive (Natural) Family Planning (office) (cell)PedullaDaol Urgent MFM OB questionTo: nfpprofessionals Date: Monday, March 23, 2009, 7:00 PM

The basics:39 y.o. G4 P0303 17 4/7 wks presents to ED with worsening SOB x 7 days & increasing leg swelling. h/o TII DM, cHTN, Asthma, dx'd with CHFlast November '08 - was placed on digoxin, lasix, ACE-I withresolution of sx; found out she was pregnant in Jan, promptly stoppedALL meds. Didnt' see a doc yet b/c of insurance issues. Today BNP800, Left ventricular EF 16%. Last pregnancy ended with c-section at32 weeks due to superimposed Pre-E, intubated in ICU for several daysafter section. all the articles i can find advise termination. Pleasehelp! Of course we'll do the usual, digoxin and lasix as needed,control blood pressure, but people are already talking termination andthis lady is already headed downhill. Any advice or experience is appreciated.thanks.

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[Guest guest]

The most important thing to the baby's health is the mother's health. If the mother is in congestive heart failure, the baby will suffer the most. From the baby's perspective alone, if ACE inhibitor is necessary, it should be done. PJB.

To: nfpprofessionals From: pedullad@...Date: Wed, 25 Mar 2009 09:43:29 -0400Subject: Re: Urgent MFM OB question

I think the CHF is too severe, and offsets I think, the risks to the child from the ACEi. The ACEi is too essential and I don't think could be replaced by hydralazine in this case. The risk to the child would have to be accepted I think, purely on medical grounds and without any ideology.

Sincerely yours,Dominic M Pedulla MD, FACC, CNFPMC, ABVM, ACPhCardiologist and Varicose Vein Specialist (varicoseveins1)President, The Oklahoma Vein and Endovascular CenterAssociate Clinical Professor of Medicine, OUHSCSpecialist in Non-contraceptive (Natural) Family Planning (office) (cell)PedullaDaol Urgent MFM OB questionTo: nfpprofessionals Date: Monday, March 23, 2009, 7:00 PM

The basics:39 y.o. G4 P0303 17 4/7 wks presents to ED with worsening SOB x 7 days & increasing leg swelling. h/o TII DM, cHTN, Asthma, dx'd with CHFlast November '08 - was placed on digoxin, lasix, ACE-I withresolution of sx; found out she was pregnant in Jan, promptly stoppedALL meds. Didnt' see a doc yet b/c of insurance issues. Today BNP800, Left ventricular EF 16%. Last pregnancy ended with c-section at32 weeks due to superimposed Pre-E, intubated in ICU for several daysafter section. all the articles i can find advise termination. Pleasehelp! Of course we'll do the usual, digoxin and lasix as needed,control blood pressure, but people are already talking termination andthis lady is already headed downhill. Any advice or experience is appreciated.thanks.

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[Guest guest]

You could but if it's insufficient you'd have to be more aggressive. Moreover, the best argument in a secular or values-hostile environment would be mom responding very well to treatment, so here the aggressive treatment is a sort of "defense" (in more ways than 1 obviously) against the decision to "terminate".

Sincerely yours,

Dominic M Pedulla MD, FACC, CNFPMC, ABVM, ACPh

Cardiologist and Varicose Vein Specialist (varicoseveins1@...)

President, The Oklahoma Vein and Endovascular Center

Associate Clinical Professor of Medicine, OUHSC

Specialist in Non-contraceptive (Natural) Family Planning

(office)

(cell)

PedullaD@...

Re: Urgent MFM OB question

Couldn't you use cautious Lasix and some gentle fluid restriction? Consider labetalol for the beta-blocker? I have seen BNP's in the 5000's (although not in pregnant women), so 800 does not seem so bad.

AH MD

On Mon, Mar 23, 2009 at 9:00 PM, medschoolrunner <kwins002umaryland (DOT) edu> wrote:

The basics:

39 y.o. G4 P0303 17 4/7 wks presents to ED with worsening SOB x 7 days

& increasing leg swelling. h/o TII DM, cHTN, Asthma, dx'd with CHF

last November '08 - was placed on digoxin, lasix, ACE-I with

resolution of sx; found out she was pregnant in Jan, promptly stopped

ALL meds. Didnt' see a doc yet b/c of insurance issues. Today BNP

800, Left ventricular EF 16%. Last pregnancy ended with c-section at

32 weeks due to superimposed Pre-E, intubated in ICU for several days

after section. all the articles i can find advise termination. Please

help! Of course we'll do the usual, digoxin and lasix as needed,

control blood pressure, but people are already talking termination and

this lady is already headed downhill. Any advice or experience is

appreciated.

thanks.

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