OBGYN CMS question

[Doc2b82]

I got a question today and I think the answer they are showing as the right is actually wrong but maybe someone can shed some light on it.

The question is about a patient who has PPROM at 28 wks. Everything else is normal. AFI is 5. Steroids and antibiotics are given....next step?

A) give steroids again in 24 hrs
B) Oyxtocin
C)Ext cephalic version
D) Amnio
E) Immdt c section

I picked E because the fetus was in breech position. Correct- A....I dont understand why. I even looked it up on Dynamed...just says single dose of steroids. Why is another needed?

Thanks for input guys.

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[Flash Forward]

Due to the high risk of premature birth, give steroids to help with lung maturation.

 

[Doc2b82]

Due to the high risk of premature birth, give steroids to help with lung maturation.

yes but steroids were already given....the answer/question was to REPEAT steroids again in 24 hours. I cant find a source to support this. Everywhere I have see it says a single dose is sufficient.

 

[Flash Forward]

This is from AAFP:

"Corticosteroids decrease perinatal morbidity and mortality after preterm PROM. A recent meta-analysis found that corticosteroid administration after preterm PROM, versus no administration, reduced the risk of respiratory distress syndrome (20 versus 35.4 percent), intraventricular hemorrhage (7.5 versus 15.9 percent), and necrotizing enterocolitis (0.8 versus 4.6 percent) without an increase in the risk of maternal or neonatal infection. Because corticosteroids are effective at decreasing perinatal morbidity and mortality, all physicians caring for pregnant women should understand the dosing and indications for corticosteroid administration during pregnancy. The most widely used and recommended regimens include intramuscular betamethasone (Celestone) 12 mg every 24 hours for two days, or intramuscular dexamethasone (Decadron) 6 mg every 12 hours for two days. The National Institutes of Health recommends administration of corticosteroids before 30 to 32 weeks’ gestation, assuming fetal viability and no evidence of intra-amniotic infection. Use of corticosteroids between 32 and 34 weeks is controversial. Administration of corticosteroids after 34 weeks’ gestation is not recommended unless there is evidence of fetal lung immaturity by amniocentesis. Multiple courses are not recommended because studies have shown that two or more courses can result in decreased infant birth weight, head circumference, and body length"

 

[TTPpentad]

Standard of care is two doses of dex/betamethasone a day apart. I had a real patient recently with basically the same description as the practice question. Got one dose betamethasone when I saw her and the OB was insistent she follow up in clinic the next day for dose #2.

ETA: In regards to your DynaMed findings, are you sure they didn’t say one course of steroids, not one dose? The single course of steroids is the two doses. Also, for your answer E, she’s only 28wks so the baby still has time to move out of breech position, thus you wouldn’t do an immediate C-section right now.

 

[Doc2b82]

This is from AAFP:

"Corticosteroids decrease perinatal morbidity and mortality after preterm PROM. A recent meta-analysis found that corticosteroid administration after preterm PROM, versus no administration, reduced the risk of respiratory distress syndrome (20 versus 35.4 percent), intraventricular hemorrhage (7.5 versus 15.9 percent), and necrotizing enterocolitis (0.8 versus 4.6 percent) without an increase in the risk of maternal or neonatal infection. Because corticosteroids are effective at decreasing perinatal morbidity and mortality, all physicians caring for pregnant women should understand the dosing and indications for corticosteroid administration during pregnancy. The most widely used and recommended regimens include intramuscular betamethasone (Celestone) 12 mg every 24 hours for two days, or intramuscular dexamethasone (Decadron) 6 mg every 12 hours for two days. The National Institutes of Health recommends administration of corticosteroids before 30 to 32 weeks’ gestation, assuming fetal viability and no evidence of intra-amniotic infection. Use of corticosteroids between 32 and 34 weeks is controversial. Administration of corticosteroids after 34 weeks’ gestation is not recommended unless there is evidence of fetal lung immaturity by amniocentesis. Multiple courses are not recommended because studies have shown that two or more courses can result in decreased infant birth weight, head circumference, and body length"

Thank you so much I did not see this! That puts my brain at ease lol

 

[Doc2b82]

Standard of care is two doses of dex/betamethasone a day apart. I had a real patient recently with basically the same description as the practice question. Got one dose betamethasone when I saw her and the OB was insistent she follow up in clinic the next day for dose #2.

ETA: In regards to your DynaMed findings, are you sure they didn’t say one course of steroids, not one dose? The single course of steroids is the two doses. Also, for your answer E, she’s only 28wks so the baby still has time to move out of breech position, thus you wouldn’t do an immediate C-section right now.

Thanks a lot I will look at it and see....its possible I misread....brain is on the verge of being fried so words are getting jumbled lol

 

[bluemagik5]

I got a question today and I think the answer they are showing as the right is actually wrong but maybe someone can shed some light on it.

The question is about a patient who has PPROM at 28 wks. Everything else is normal. AFI is 5. Steroids and antibiotics are given....next step?

A) give steroids again in 24 hrs
B) Oyxtocin
C)Ext cephalic version
D) Amnio
E) Immdt c section

I picked E because the fetus was in breech position. Correct- A....I dont understand why. I even looked it up on Dynamed...just says single dose of steroids. Why is another needed?

Thanks for input guys.

Answer is: D) Amnio (reasoning is because baby is doing well according to info you gave, not to mention she already received IM corticosteroids and antibiotics. Next step would be to rupture sac and give cervical ripening drugs (PGA1 or PGA2) followed by oxytocin if the contractions are not adequate). Hope that helps.

 

[Doc2b82]

Answer is: D) Amnio (reasoning is because baby is doing well according to info you gave, not to mention she already received IM corticosteroids and antibiotics. Next step would be to rupture sac and give cervical ripening drugs (PGA1 or PGA2) followed by oxytocin if the contractions are not adequate). Hope that helps.

unfortunately the answer was A for all the reasons discussed above.

 

[bluemagik5]

unfortunately the answer was A for all the reasons discussed above.

What??? That is nuts. I remember doing a uworld question EXACTLY like that and the next best step was to do amnio for expectant management. I really hate doing CMS questions

 

[Doc2b82]

What??? That is nuts. I remember doing a uworld question EXACTLY like that and the next best step was to do amnio for expectant management. I really hate doing CMS questions

I know its very frustrating. For some answers I have to dig REALLY deep on the www to get any sort of information on why "their" answer choice is right.