Octave

Recently, the media has been enchanted by a 33 year old who delivered via C-section a full set of octuplets at a hospital in Bellflower, California. Such multiple gestations have only become a reality with assisted reproductive technology. But they are extremely dangerous for mother and children. This is not a desirable outcome. It may even be unethical on part of the health care provider. If this was done through in vitro fertilization, that many embryos should not have been transferred. The risks of multiple gestations include stillbirth, prematurity (as was the case here at 30 1/2 weeks), low birth weight (here, the smallest was 1 lb, 8 ounces = 680 g where an average birth weight is 3500 g), cerebral palsy, and need for neonatal intensive care. For mother, there is a much higher risk of C-section. But even beyond that, there are so many social factors to consider. This mother already has 6 children. How is this going to impact her family? How will it impact the future of the children? Though it is impressive that 46 well-orchestrated medical personnel accomplished such a feat successfully, it really isn't ideal at all.

Pregnancy Options

In one of our classes, we were asked to consider our own preconceptions and opinions regarding pregnancy, abortion, and adoption. For example, how do we feel about an undesired pregnancy that is carried to term? An undesired pregnancy that is aborted? A pregnancy that a family cannot financially support carried to term? Or an abortion undertaken solely because of financial reasons? Are there any circumstances in which a woman should not carry a pregnancy to term? What if it was a result of rape? Or if the woman is a drug addict? Or even if the parents are simply divorced? Are there any circumstances in which a woman should not be able to choose abortion? What if the baby is just poor timing; she wants to have one, but not for another year? What if she is coerced by her partner?

Ethically of course, the woman can decide to carry a pregnancy to term or elect an abortion. But how we feel as providers can easily change the tone of a conversation or sway a patient's opinion. Like psychiatry, we have to watch our internal emotions regarding these personal and charged topics. Countertransference can be a powerful subconscious presence in these situations.

I was personally most struck by questions of adoption. How do I feel about women carrying a pregnancy to term intending to put their infant up for adoption? Is it permissible if the woman cannot financially support the baby? What if she only wants to do it for career reasons? What if she wants to do it because the pregnancy was unintended and she does not want an abortion? What if she wants to do it because the baby has a congenital defect? For me, putting up a baby for adoption has a lot more impact because such a decision imposes a further burden on another person or society in general. I'm not sure how the value of autonomy in a pregnancy should be weighed against beneficence to the infant or justice with respect to societal resources.

Operating Room Gynecology

I spent this week with the benign gynecology team. It felt very surgical. There is a small inpatient service at Mount Zion (one of UCSF's satellite campuses) and most of our day is occupied by operations. Over the week, we've had a few operative hysteroscopies, using a scope to look inside the uterus to assess for things like fibroids, retained products of conception, and arterio-venous malformations. We've had a laparoscopic ovarian cystectomy and an open ovarian cystectomy, a laparoscopic hysterectomy and an open one, and an abdominal myomectomy. It's always fascinating seeing the same procedures done in different fashions for various reasons (for example, we were worried that one rapidly growing fibroid was a leiomyosarcoma so we did it open instead of laparoscopic). I've also seen a few D&C's (dilatation of the cervix and curettage of the uterus).

It's fun being in the operating room. It reminds me strongly of surgery. I like the setting and the satisfaction of dissecting out the pathology. It's nice to have familiarity with the tools, approaches, thought process, and techniques of surgery. I also realize that an ob/gyn's surgical repertoire is fairly limited. Even though they do laparoscopic, open abdominal, and transcervical procedures, the bulk of diseases I saw involved fibroids, ovarian cysts, uterine bleeding, and pelvic pain (there's also the field of female incontinence).

30 Years of Medicine

We had a lecture today from a very entertaining professor, Dr. Nachtigall.

"I'm impressed by you guys. Medical students these days have to learn so much. They say medical knowledge doubles every ten years. Since I went to medical school, there's 8-fold more knowledge. In fact, back in my day, we learned the head with one mnemonic: TEON."

We looked at him with earnest ears.

Dr. Nachtigall gestured at his facial accouterments. "TEON: Two eyes, one nose." He then pointed at his legs. "The other one that we learned was LEG which stands for: lower extremity, ground."

Clearly, the mnemonic to differentiate between arms and legs.

Poem: Inauguration

Inauguration

It’s like coming home, this georgic grace
that sweeps the cornfields, causes stalks to twitter,
telling us that unfortunate truth: those we love
are never the ones who love us.
I yearn to regale you with virtues,
my ambitions, my glorious and refined,
but hesitation holds me trigger-fingered
for history runs rampant today, and I
would be remiss if I did not tip my hat to those coffers
and say my sin is one of pride,
just or unjust, shining and shameful
a funeral cloak to send smoldering
on the coals of time’s descent.
You could not know
You could not know because you are popular,
you are popular as the sun, popular
as the ruddy tinged cheeks, popular
as a Cadillac shimmying up the driveway.
You never had a moment of want,
suitors fell at your doorstep,
a suite of tutors, a tower of books
a host of dreams and a Greek play too,
you’ve had everything but this
so I linger, phantom between apology and arrogance
because this could have been anything
ten dozen cranes, an origami fleet sailing
to another time, perhaps
when you would have forgiven me.

Stop the Bleeding

My friend and fellow blogger Stephanie gave me sage advice about this rotation from her dad, an ob/gyn. "Stop the bleeding," he says. Unfortunately, I learned this well on my last call night when one patient's peripartum plight became more and more worrisome.

This woman had a prior C-section and was attempting a vaginal birth after C-section ("VBAC" or TOLAC = trial of labor after cesarean). Attempting a normal vaginal delivery with a previous surgery on the uterus carries a risk of uterine rupture, a life-threatening condition for mother and fetus when the womb tears open from the forces of contractions. Some institutions including UCSF support women choosing VBAC by offering in house anesthesia, close monitoring, and experienced staff. Our patient had a constellation of poor risk factors. She was post-term (41 weeks+6 days). Although she had broken her bag of water, she was not in labor (premature rupture of membranes), and as a result, was at risk for infection (chorioamnionitis). After reviewing risks with her, we decided to augment her labor with pitocin. While benign and standard for a regular laboring patient, pitocin for her carried further risk of uterine rupture (1-2% rather than 0.8%).

Even with gentle pitocin augmentation, she wasn't progressing; the cervix was minimally dilated and effaced, the baby was at a high station. But we kept going until about 9 at night when a nurse called for a doctor. The patient had a large episode of painless vaginal bleeding, about 500mL (the same volume as a bottle of water). We were worried; the whole team rushed in, two attendings and the anesthesiologist were at the bedside, and we were evaluating for fetal distress and uterine rupture. But the baby was doing fine and the patient's vitals were stable. A cervical exam by the resident was "weird"; the cervix did not feel normal, and the baby's head could not be palpated. A bedside ultrasound confirmed the diagnosis; this was a previously unknown placenta previa (the patient's care had been transferred from an outside hospital and they did not know this).

We then decided to C-section the patient; she and her husband agreed to the plan. She lost another liter of blood during the spinal anesthesia. We had two IVs but one stopped working. Her blood pressure dropped to 60/30mmHg before we managed to transfuse two units. When we crash sectioned her, she lost another liter of blood. Baby was out and doing fine. But the placenta took a lot of negotiation; part of it may have been overlying the previous C-section scar and grown into the tissue of the uterus (previously unknown placenta accreta). We worked hard to stop the bleeding, managing to evacuate all placental tissue. We typed and crossed her for a few more units.

A few hours later, a nurse called us from the recovery room where the patient passed two "baseball sized clots" per vagina. She was still bleeding. The resident and the attending did several attempts at manual evacuation of clot. The uterus was pretty "boggy", the word we use when it doesn't clamp down to prevent bleeding. While the rest of our body clots to stop bleeding, the uterus, a muscle, needs to contract. If stuff is in the uterine cavity, whether placenta or clot, the uterus cannot contract effectively. So the resident and attending manually scraped out clots. We gave some methergine and hemabate but she bled liter after liter of blood.

Normally after every surgery and delivery we estimate blood loss. A normal blood loss in a vaginal delivery might be 350mL; in a C-section, maybe 800mL. Above 500mL in a regular delivery and 1L in a C-section, we consider a hemorrhage. The proverbial 70kg man has 5L of blood. Here, our patient lost 500mL before reaching the OR, another 2L in the OR, and now 2L post operatively.

The resident initiated a massive transfusion protocol, treating this patient as if she were a victim of a car crash or had a heavy gastrointestinal bleed. We called the blood bank to get more blood and fresh frozen plasma (containing coagulation factors). We were afraid she would go into DIC - dissminated intravascular coagulation - due to depletion of coagulation factors. The anesthesiologist toyed with the idea of inserting an arterial line and transferring to ICU. We finally stopped the bleeding with a Bakri tamponade balloon, exerting intrauterine pressure.

In the end, the patient remained stable, and the baby was healthy. After transfusion of five units of blood, we normalized her lab values. But throughout the night, her course was tenuous and prompted us to think of many critical care issues that we normally do not deal with on labor and delivery. Always stop the bleeding.

The Bird and the Baby

The title of this post refers to The Eagle and Child, a pub in Oxford, England which boasted patrons such as JRR Tolkien and CS Lewis. Now of course, it makes me think of the proverbial stork delivering babies to expectant mothers (how much easier that would be, I realize).

My three weeks on labor and delivery have been awesome. I've delivered seven babies, and it's really fun. I've gained a lot of confidence in delivering healthy newborns and learned a lot about the process and experience of the laboring patient. The first moment that new parents realize they are such is truly amazing; the cry of relief, the tears, the thrill and happiness - it's pure magic. I've seen the spectrum of deliveries: a multiparous woman going from 2cm to delivery in several hours, the patient whose induction takes 4 days, the stoic who needs no pain relief, the passionate who fights through the pressure, the hysteric who needs every skill, tool, and word of encouragement we can muster. I've seen single moms, lesbian couples, first kids, fifth kids, fifteen-year-olds, forty-year-olds, extended family, terrified husbands, resolute boyfriends. Though normal pregnancy, labor, and delivery can be routine, there's a lot of fun and joy in getting to know everyone involved and seeing them triumph over these challenges of mother nature.

In addition, I've participated in a few C-sections and a tubal ligation, reminding me how much I like the operating room setting and dissection. I've assessed patients in triage for preterm labor, mastitis from breastfeeding, and bogus chief complaints (a fifteen year old came in with her friends because they wanted to see the fetus on ultrasound). But the most interesting patients are often transferred from outside hospitals or fetal treatment patients. We've had a twin gestation where one twin has a life-threatening arrhythmia; how do you selectively control one twin's heart rate? Can you convert someone in utero? We have people with peripartum cardiomyopathy, twin-twin transfusion syndrome, and unstoppable preterm labor. Some transfers are unbelievable: a 23 weeker who was delivered by crash C-section at an outside hospital for an unclear indication (very sad case, the baby is going to die and the mother is a 17 year old). Some transfers are fascinating: a repeat C-section for a patient with achondroplasia. The fetal treatment center here takes patients whose fetuses have complex cardiac defects; I've seen several pregnancies complicated by hypoplastic left heart syndrome, double outlet ventricles, transposition of the great vessels, and coarctation of the aorta. Those deliveries are particularly high energy, with pediatrics and cardiologists standing by to resuscitate if needed.

So as a whole, my time here has been lots of fun. I've learned a lot and realized the intersection between solid medical complexity and pregnancy - maternal-fetal medicine - is really thought-provoking and intricate.

Image is a Victorian postcard, in the public domain, taken from Wikipedia.

Longitudinal Clinical Experience II

I wrote a previous post on the patient population at my longitudinal continuity clinic. My LCE is in hematology and oncology. It's a very different experience than standard clinical rotations. Though it is outpatient clinic like family medicine, heme/onc is so much more specialized and management-based. We see a lot of breast, colon, and prostate cancers along with a few leukemias and lymphomas. The hematology side varies a lot, from increased clotting tendency to leukopenia to thrombocytosis. Patients range in age, but most are older than 50. Our patients are all referred to us from other providers.

Cancer diagnoses are usually made by primary care physicians who send patients to us for chemotherapy. My preceptor knows in depth the various chemotherapy regimens and the evidence regarding new cocktails and combinations. There is very little diagnosis involved. A lot of it is finessing side effects, education, coordination with surgery and radiation oncology, and specific therapies. Hematology patients vary a lot more. Consults range from benign "reassure the patient" to acute myelogenous leukemia. There's a lot more diagnosis, analyzing lab values, and problem solving.

In terms of content, I've realized outpatient oncology does not thrill me. I'm not hugely interested in learning the nuances of chemotherapy regimens. But it is fascinating to see the wide range of cancer presentations, from breast cancer in a 30 year old to a metastatic prostate cancer in a 90 year old. I really enjoy the hematology; the diseases there are so weird and interesting.

I am learning an incredible amount about how to relate difficult diagnoses and end-of-life considerations. My preceptor is incredible when talking to patients, building a solid foundation of rapport and trust. He approaches difficult topics directly, easily, and deftly; even when giving a young patient a terminal diagnosis, he frames the conversation in practicality and hope. He explains statistics and prognosis in a surprisingly clear, straightforward, and accurate way. He is able to sympathize with patients yet avoid being consumed by the intense emotions and serious topics. These skills are the hardest to learn and sometimes, the most useful.

Inauguration

Image is from Wikipedia, in the public domain.

Evidence Based Medicine and Ob/Gyn

Unfortunately, some routine things in ob/gyn have little evidence. For example, fetal heart monitoring is standard of care today because of medicolegal precedent. Intuitively, monitoring the fetus' heart rate seems like a good idea; it's one of the few noninvasive ways we have of seeing how the fetus is doing. But there's no evidence suggesting that monitoring leads to better outcomes for mother or child. Indeed, the evidence suggests monitoring increases only one thing significantly: rates of c-sections (which we would like to avoid).

Indeed, how much medical intervention is appropriate in the process of childbirth? For thousands of years, women have been giving birth without the help of doctors. And they were doing well. Now is our medical meddling worthwhile? Is it beneficial for the mother and baby? Is it cost-effective? Certainly we would like to think we do no harm. But a hospital is an instutition, sterile and unwelcoming. Would women feel more comfortable delivering at home? Would babies do better in that environment?

To give credit where it is due though, Pap smears have the best evidence in my opinion of reducing cancer-related mortality. While there's never been a randomized controlled trial, the epidemiology, both in the U.S. and worldwide, is compelling.