Antenatal steroids at 37 weeks

When the diagnosis of IUGR has been established, it is helpful to determine a specific etiology. Therapy may be nonspecific but should try to address the underlying cause. Many infants thought to be growth-retarded are, in retrospect, found to be constitutionally small. The key management issues are the gestational age of the pregnancy at the time of diagnosis and the urgency to expedite delivery. Most fetal deaths involving IUGR occur after 36 weeks of gestation and before labor begins. 1 The clinician must balance the risk of delivering a premature infant against the potential for intrauterine demise.

Delicate physiologic mechanisms allow for circulatory transition after birth with a resultant decrease in pulmonary vascular resistance. Failure of these mechanisms causes increased pulmonary pressures and right-to-left shunting, resulting in hypoxemia. This failure can be caused by meconium aspiration syndrome, pneumonia or sepsis, severe RDS, diaphragmatic hernia, and pulmonary hypoplasia. Severe persistent pulmonary hypertension of the newborn (PPHN) occurs in two out of 1,000 live births. 50 Risk factors include maternal diabetes, cesarean delivery, maternal obesity, and black race. Maternal use of a selective serotonin reuptake inhibitor is associated with the condition. Data show only a small absolute risk. 51

REFERENCES:
1. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. American Journal of Obstetrics and Gynecology. 1997;177(1):210–214.
2. Placenta accreta. Committee Opinion No. 529. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:207–11. PMID: 22914422 http:///Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Placenta_Accreta
3. Bowman ZS, et. al., Risk Factors for Placenta Accreta: A Large Prospective Cohort. Am J Perinatol. 2014 Oct;31(9):799-804. Epub 2013 Dec 12. PMID: 24338130
4. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985 Jul;66(1):89-92
5 Ballas J, et . al., Identifying sonographic markers for placenta accreta in the first trimester. J Ultrasound Med. 2012 Nov;31(11):1835-41. PMID: 23091257
6 Hung TH, et. al., Risk factors for placenta accreta. Obstet Gynecol. 1999 Apr;93(4):545-50. PMID: 10214831
7. Royal College of Obstetricians and Gynaecologists . Green-top Guideline No. 27. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management.
London. January 2011 https:///globalassets/documents/guidelines/.
8. Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10. PMID:23635709
9 Bowman ZS, et al., Risk factors for unscheduled delivery in patients with placenta J Obstet Gynecol. 2014 Mar;210(3):-6. doi: /. Epub 2013 Oct 2. PMID: 24096181
10. Chantraine F, et. al., Individual decisions in placenta increta and percreta: a case Perinat Med. 2012 Jan 23;40(3):265-70. doi: /jpm-2011-:22505505
11. Fitzpatrick KE, et. al., The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study. BJOG. 2014 Jan;121(1):62-70; discussion 70-1. PMID:23924326
12. Placenta accreta. Publications Committee, Society for Maternal-Fetal Medicine, Belfort MA. Am J Obstet Gynecol. 2010 Nov;203(5):430-9. PMID: 21055510
13. El-Messidi A, et. al. A multidisciplinary checklist for management of suspected placenta accreta. J Obstet Gynaecol Can. 2012 Apr;34(4):320-4. PMID: 22472330
14. Hull AD and Resnick R. Placenta Previa, Placenta Accreta, Abruptio Placenta, and Vasa Previa. In: Creasy RK, Resnik R, Iams JD, eds. Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice. 7th ed. Philadelphia, Pa.: Saunders/Elsevier; 2014:736
15. Royal College of Obstetricians and Gynaecologists. Green–top Guideline : Antenatal corticosteroids to reduce neonatal morbidity and mortality. London: RCOG; 2010

Prevention of contrast-induced acute kidney injury consists mainly of withholding contrast whenever possible and maximizing hydration with IV crystalline solution. 10,23,36,37 Among patients undergoing cardiac catheterization, left ventricular end-diastolic pressure-guided fluid administration was useful in preventing renal injury. 38 Controversy exists with regard to the usefulness of other medications to prevent acute kidney injury, such as sodium bicarbonate, N-acetylcysteine, fenoldopam, and theophylline. 23 Studies show N-acetylcysteine decreases serum creatinine; however, there is no protection against renal failure. 11,39,40

Antenatal steroids at 37 weeks

antenatal steroids at 37 weeks

Prevention of contrast-induced acute kidney injury consists mainly of withholding contrast whenever possible and maximizing hydration with IV crystalline solution. 10,23,36,37 Among patients undergoing cardiac catheterization, left ventricular end-diastolic pressure-guided fluid administration was useful in preventing renal injury. 38 Controversy exists with regard to the usefulness of other medications to prevent acute kidney injury, such as sodium bicarbonate, N-acetylcysteine, fenoldopam, and theophylline. 23 Studies show N-acetylcysteine decreases serum creatinine; however, there is no protection against renal failure. 11,39,40

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