Academic OB/GYN

One of the interesting things about running a semi-popular blog is that from time to time the blog community decides to take up a topic and run with it, completely without any stimulation from me.  This happened recently on the Academic OB/GYN Facebook page, where a group of concerned individuals carried on a serious and passionate discussion about the merits of circumcision.   As such discussions tend to be, this one was dominated by the anti-circumcision activists, with occasional interjections by those that were less concerned about the issue, including myself.

Circumcision is an interesting issue because it crosses multiple boundaries.  It is a social tradition in many cultures, and in some cases considered a religious mandate.  It is also an ethical issue for many, with some feeling that it is an assault on an infant with long term negative impact on their psychosocial health.  For some it is just cosmetic.

As a young person, I always thought that my penis looked like penises were supposed to look. It looked like my father’s and my brother’s, and anyone else’s I had ever seen.  For the most part, I was blissfully unaware that a penis could look any other way, until one day in high school when my world completely changed.  I happened to see a friend’s penis we were showering after wrestling practice, and in that flash of a moment all kinds of things went through my mind.  Did he have some kind of growth on his penis?  Could he pee out of that thing?  A few other choice thoughts.  I can still remember the shock to this day.  All I had ever seen looked like mine, and in that moment what I saw was foreign, revolting even.  You see, from my frame of reference he looked like an alien.  It took me a few minutes and SNAP! it came to me like a ton of bricks – he has a foreskin.  He probably doesn’t have an alien death ray then.   I can relax about that one.

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Academic OB/GYN was featured on the web’s Medical Grand Rounds for January 4 2011.  Lots of good stuff worth checking out.

Well folks – I’m in San Francisco at ACOG.   In addition to the dinner monday, we will be doing a fair amount of ACOG content.   Check back for daily summaries of what’s going on at ACOG, including podcasts with interviews with poster presenters and industry folks.

If anyone wants to come to the dinner monday night, please RSVP soon!  We’ve got about 16 coming so far.  Sage Healthcare is sponsoring, so come on out and enjoy some great food and drink and meet other fans of Academic OB/GYN!

On January 12, 2010, a magnitude 7.0 earthquake rocked the island country of Haiti, destroying much of the capital Port Au Prince and leading to the deaths of as many as 200,000 people.  Since this time, thousands of images of the resulting carnage have been published in both traditional media and on internet sites.

Recently there has been some discussion about the appropriateness of some of these images, particularly those that depict individual humans in despair or even in death.  Some have argued that such images should not be published without the express consent of the person depicted, or with the consent of the next-of-kin in cases of the dead.  Media, for the most part, has held that in cases of extreme human events the benefit of publicizing the truth outweighs whatever emotional harm might come to an individual through publication of their plight.  They argue that the many outweigh the few, in this case.

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Academic OB/GYN isn’t just about me blathering on about current literature and interviewing folks – its about YOU too!   If there is any way I can help you, I want to know.    Send research questions, and I’ll try to answer them.  Need a video of some kind of surgery, I’ll try to make it.   Want a place to publish your ideas about our field, the blog’s all yours.  Wanna get some ideas from your colleagues that read the blog?   We can do it.

This thing is growing folks, and you can help.

Every time an Academic OB/GYN viewer asks a question, a blog post gets its wings…..

email@academicobgyn.com

tweet @academicobgyn

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The Academic OB/GYN podcast continues to go on strong despite the lack of new content.  We’re now over 3,000 downloads, which is great!   I want to assure listeners that I’m still working on new content but have been held back by my real job, and my upcoming move to Charleston, SC.   Once I’m settled in my new location I plan to move the blog to a private server and start creating more podcasts.  So stay tuned…

Ok – here’s a bit of rant inspired by something on call last night.

A multiparous patient labors for about 8 hours during a pitocin induction and develops a postpartum hemmorhage. Pit, methergine, and eventually hemabate are given with minimal response. The resident decides to place rectal misoprostol, and the uterus gains tone about a minute later. The resident remarks how well the miso worked and how we should us it more in the future.

This drives me crazy.

1) There are no venous channels that run from the rectum to the uterus. People act like they are doing something special by putting it in the rectum or even in the vagina, when in reality they are just using either as a mucous membrane to absorb the drug. The pharmacokinetics of miso are well studied, and it takes at least 1/2 hour to reach high levels of miso in the blood, and therefore in the uterus. There is no way that in one minute a lot of misoprostol got to the uterus. In fact, if one wanted the fastest effect, one should give it to the patient orally, as that causes the fastest rise in blood levels

2) Many studies have shown pitocin to be superior to misoprostol in treating and/or preventing postpartum hemmorhage. Why? Because of the above point – the IV pit gets to the uterus very fast. The miso takes 1/2 hour or more.

3) These thought open up a related irritation, which is the “novel” application of miso by placing it in the uterine cavity to cure uterine atony. The endometrium isn’t even a mucous membrane. Though the pharmacokinetics of this application have not been studied, I don’t think absorption will be so great, especially with all the blood rushing into the uterine cavity (the problem we’re trying to treat).  Blood comes out of the uterus.  It doesn’t go in.

So what happened in this case?

First the patient had atony. Then she got pit, which didn’t work well because pitocin receptors were very downregulated after the long induction. Then she got two effective uterotonics in fairly rapid succession – both of which were effective. Coincidentally, a bunch of misoprostol was placed rectally right around the time the IM methergine and hemabate reached the uterus, which despite its parental nature, still takes at least a few minutes. So residents, keep using that miso if you want, but I think its benefit is in preventing delayed atony 20 minutes later, not in the acute setting.

Of course, miso is great for third world nations where there are no IVs or refrigerators to keep parenteral uterotonics around. Or for causing first and second trimester abortions. Or for ripening the cervix in induction. Or for priming the cervix before a tough EMB. Or for dilating the cervix before a D and E procedure. Its just not that useful for postpartum hemmorhage, IMHO.

A related irritation – people who put patients on powerful antibiotics after they spike a 101.8 fever eight hours in at 400 mcg q6h second trimester miso induction, unruptured.  What makes you think they are infected?  They are unruptured, and happen to be on a powerful prostaglandin that reliably causes fever and chills at high doses.  Please, just reassure the patient and give them some tylenol.  Don’t use NSAIDs to break the fever, as the misoprostol is causing a fever downstream of the cyclooxygenase enzyme the the NSAID is blocking.  Not that the NSAIDs will antagonize the miso (which somebody tried to convince me of once), just that they don’t work that well a miso inspired fever.

What do you think?

Nicholas Fogelson, MD

Academic OB/GYN.com

I got an abstract rejected from 2008 SMFM this week. What the hell? It was a paper looking at outcomes in second trimester abortion stratified by different anesthesia type. It was properly done and everything, with stats, regression analysis, and snappy writing. I didn’t really want to go to Dallas anyway – though I may go to report for the blog.

How did ya’ll do? If you got something accepted or rejected, let us know! And stay tuned for more podcasts coming soon.

Nicholas Fogelson MD

Academicobgyn.com