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  #1  
Old 10-06-2011
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ObGyn Tocolytic drug question

A 19 yo primigravid woman at 42 weeks gestation comes to the labor and delivery ward for induction of labor. her prenatal course was uncomplicated. her cervix is long, thick, closed and posterior. the fetal heart rate is 140 and reactive. the fetus is vertex on ultrasound. PGE2 gel is placed intra-vaginally, one hour later, the patient begins having contractions lasting longer than 2 mins. the fetal heart rate falls to the 70s. which of the following is the most appropriate next step in management?

a. administer geneal anesthesia
b. administer terbutaline
c. perform aminionfusion
d. start oxytocin
e. perform c-section
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Old 10-06-2011
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perform c/s, not sure
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Old 10-06-2011
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I think answer is e. perform c-section...She is already post term since >42 is post term so induction of labour is done but fhr falls to 70 do shows fetal hypoxia or distress so i think e is answer....whats the answer seetal??
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Old 10-06-2011
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I go with E.
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Old 10-06-2011
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e. perform c-section
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Old 10-07-2011
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b. administer terbutaline
i would first go with tocolytics, then do a C- section.
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Old 10-07-2011
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Default actually step1an is right

terbutaline is a fast acting tocolytic agent tht is used off label in obstretrics to prevent preterm labor. it is also used as in this case to avoid fetal stress before the preparation of c-sec is done. so step1an is right.

except, i put this case up just as a discussion n perhaps a warning against answer choices. MgSO4 can also be used and its efficacy is the same as terbutaline. so say later u are given a case such as this one but had both those options, pls choose MgSO4. because as of 2011, the FDA has warned against the use of terbutaline as a tocolytic as it cause maternal death thereafter. since the usmle always wants to know if we are up to date with new advancements, i think all of us should put up cases like this where these options are no longer right.

here's a cutting from the FDA warning:
Terbutaline is sometimes used off-label for acute obstetric uses, including treating preterm labor and treating uterine hyper-stimulation. It has also been used off-label over longer periods of time to prevent recurrent preterm labor. There are multiple generic versions of terbutaline oral tablets and injectable formulations available. On February 17, 2011, the FDA warned the public that injectable terbutaline should not be used in pregnant women for prevention or prolonged treatment (beyond 48 to 72 hours) of preterm labor in either the hospital or outpatient setting because of the potential for serious maternal heart problems and death. The agency is requiring the addition of a Boxed Warning and Contraindication to the terbutaline injection label to warn against this use. In addition, oral terbutaline should not be used for prevention or any treatment of preterm labor because it has not been shown to be effective and has similar safety concerns. The agency is requiring the addition of a boxed warning and contraindication to the terbutaline tablet label to warn against this use.

but say a case was given like this and no choice of MgSO4 is given, ill choose c-sec. but i doubt they wont give an MgSO4 choice because, u must de-stress the fetus immediately first before performing a c-sec. if not the child's apgar score will be low and that sequelae is detrimental as we all know it.
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Old 10-07-2011
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Default try this

try this link guys.

http://www.fda.gov/Drugs/DrugSafety/ucm243539.htm

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Old 10-08-2011
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If we take this warning against the use of terbutaline, we still need to use it as in your Q?
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Old 10-09-2011
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Default

Quote:
Originally Posted by ag2011n View Post
If we take this warning against the use of terbutaline, we still need to use it as in your Q?
yeah thats just the thing. i think the new kaplan 2011 or 2012 would have changed that bit of information. but this question was taken from offline kaplan 2005. so at that time, terbutaline was the choice. but for when u take the step 2ck later, i think we wont have these options. or we mite have MgSO4 and terbutaline just to test if we know the FDA's new warning.

this can be very tricky and im not really sure how we will be tested here, but if im not mistaken, the usmle always wants us to be on top of latest information.
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