Archive
Academic OB/GYN Cases: Abdominal Cerclage How-To
I had the opportunity to do an abdominal cerclage with one of my MFM colleagues this week, which was fantastic. This is a procedure that is rarely done, and for me is something pretty new. I had the opportunity to do a few of these in residency, but hadn’t done one for over 5 years and never in a pregnant woman, so that was a great envelope-pushing experience for me.
For my colleagues that haven’t had the opportunity to do one of these procedures, I want to lay out how its done. In short, the goal is to place a cerclage between the ascending and descending branches of the uterine arteries, at the connection of the lower uterine segment and internal cervical os. When you’re done it should look something like this –
Grey Journal: New Protocol for Medical Treatment of Ectopics
This month’s Grey Journal feels a little light on substance, but one article I liked was an article looking at a new protocol for use of methotrexate for treatment of ectopics(1). This protocol looked at giving a second dose of MTX if the day 7 HCG is not 50% lower than the Day 1 HCG, without checking a day 4. This is opposed to a typical single dose protocol, checking a day 4 and repeating MTX if the day 7 is not 15% lower than the day 4.
This study was based on data abstraction from 187 patients who were treated with single dose MTX for ectopic pregnancies, with demographics and HCG levels recorded over time. Based on these data, a comparison was made between a Day 1,4,7 strategy and a Day 1,7 strategy. Here’s what they found.
A Day 1,7 strategy has a very high sensitivity for picking up women who need another dose of MTX to successfully end an ectopic pregnancy, but a much lower specificity. This means that with a Day 1,7 strategy many more women will get treated with a second dose of MTX than with a Day 1,4,7 strategy. However, in tradeoff they will not need to get a day 4 blood draw. Depending on Beta HCG levels, anywhere from 2 to 10 additional women will get a second MTX dose per Day 4 blood draw avoided with this strategy.
So here’s a few thoughts on this:
1) This strategy leads to a lot more methotrexate use, in order to avoid a blood draw. From a cost point of view this could be a problem. Dr Thurman points out that MTX is inexpensive, but in many hospitals it is delivered as a chemotherapy agent. Even if it is regular injection, it usually isn’t available in the MD office and hospital nursing charges are high. Actual cost of drug is low, but delivery of drug can be expensive.
2) Some people think we should be doing 2 dose MTX for everybody anyway. Failure rates for single dose MTX are around 10% in a mixed population (2), though a mandatory 2-dose regimen hasn’t done much better in trials(3). This regimen would be a middle ground between a 1 dose and mandatory 2 dose regimen.
As this is just pilot data, it will be interesting to see this against a 1,4,7 regimen in a randomized trial. I know several of the investigators, and suspect that they will be doing this in the future. I look forward to those results. For now I will still use a 1,4,7 regiment, as to me a day 4 lab draw is not as big a deal as a second dose of MTX. But that being said, if a patient really hated getting blood drawn, this might be a better option for them. Then again if they hate blood draws much, maybe a laparoscopy would be better!
Source:
Thurman AR, Cornelius M, Korte J, Fylstra D. An alternative monitoring protocol for single-dose methotrexate therapy in ectopic pregnancy. Am J Obset Gynecol 2010; 202:139.e-16
Lipscomb GH, Bran D, McCord ML, Portera C, Ling FW. An analysis of 315 ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol 1998;178:1354-1358
Barnhart K, Hummel AC, Sammel MD, Menon S, Jain J, Chakhtoura N
Use of “2-dose” regimen of methotrexate to treat ectopic pregnancy.
Fertil Steril. 2007 Feb;87(2):250-6. Epub 2006 Nov 13.
Surgery, Calculus, and Why The Attending is Always Doing the Surgery
When I was a high school math nerd I looked forward to the AP calculus class I would take my senior year, because once I had done that I really would have achieved the tops that mathematics had to offer. Once I finished that class, I remember thinking “now I really understand math.” When I studied mathematics and computer science in college I realized how wrong I had been. I realized then that calculus was not the end of the mathematics – it actually was just the beginning. In fact, it was the first thing I ever learned that could even be called mathematics at all. The rest was just arithmetic.
As an academic gynecologic surgeon, I often get asked a question that reminds of me of my calculus realization, and that question is “Who will be doing my surgery?”
High Tech Mosquito Destruction
This is so cool its worth sharing. Sometimes people think so outside the box that it blows your mind. These inventors have created a very economical laser system that finds, tracks, and kills mosquitos at a rate of 100 per second, all with parts that were purchased on eBay. This was presented at TED in 2009 and 2010 as a potential aid in preventing malaria in developing nations. Each of these units would only cost a few hundred dollars, and powered by batteries could eliminate mosquitoes from a large area automatically, thus preventing malaria transmission. The system even figures out what sex each mosquito is based on wingbeat frequency, and kills only females.
Beyond use in the third world, this has potential application in developed nations as well, possibly replacing mosquito zappers forever!
Lancet: Ulipristal vs Levonorgestrel for Emergency Contraception
by Sharon Phillips, MD and Nicholas Fogelson, MD
Lots of people have been talking about Ulipristal acetate (Ellaone), a new emergency contraception option now available in the UK. The buzz is that it is effective for 5 days instead of 3.
Currently in the US we have only one option for EC (Emergency Contraception): levonogestrel (Plan B), which is FDA labeled for use up to 72 hours after unprotected intercourse. However, we now know that it is effective for up to 5 days after unprotected sex(1), though the efficacy seems to decrease the further out from the episode of intercourse you are.
It’s great to have a new EC option. Having 2 options might help bring the price down (Plan B can range from $30 to $60 for one dose). However, it may not be any better than what we already have.
Academic OB/GYN Cases – Cervical Ectopic Pregnancy
Academic OB/GYN Podcast Episode 15 – Green and Grey Journals January 2010
In this episode I discuss several articles from the January Issue of the Green an Grey journals, and a few articles from the Lancet to boot! We discuss the prospective outcomes in thrombophilia, Metformin and Glyburide in GDM, Miso vs Pit for PPH, interstitial pregnancy, and SFlt-1 and PLGF for detection of pre-eclampsia. Thanks for listening!
Academic OB/GYN Episode 15 – Green and Grey Journal January 2010
HIPAA, Medical Case Reports, and Unbalanced Benefit in News Reporting
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.
Academic OB/GYN 