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Archive for the ‘Gynecology’ Category

One for the medical students – on presenting

I have the pleasure of working with our resident GYN team for several weeks every few months, rounding on their patients and teaching each morning.  One of the best parts of this is hearing our medical students present their cases.

Presenting patients is a skill that takes a great deal of time to master.  Each student is taught the basic form of a medical presentation at an early ‘age’ – Subjective, Objective, Assessment, and Plan.  Each of these bits can be broken down into many subareas, such a Past Medical History or Social History (part of the subjective usually), Chest Exam or Labs (parts of the objective), or individually listed problems (each parts of the assessment and plan.)

This sort of structure is both an aid to great presenting and a hinderance.  It helps because it gives the presentation a structure that is easy to follow, and over the years of hearing such presentations the listener has created little boxes in their mind, and had developed the expectation that these boxes will be filled in a specific order.  By following this structure, the student fills those boxes and thus creates a structured narrative that fits the listener’s expectations.  This can be very functional and efficient.  The downside is that if the student follows that structure too tightly, the presentation sounds stilted, like a person reading a spreadsheet.  This creates a presentation that is technically correct, but lacks grace.

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The Downside of Understanding

December 13, 2010 25 comments

As I look back over my 10 year career in obstetrics and gynecology, I am sometimes struck at how many things have been discovered in this time period.  When I started the origin of pre-eclampsia was unknown, and now we know that it likely originates in an overabundance of a molecule called Soluble FMS-Like Tyrosine Kinase, a competitive inhibitor to natural angiogenesis in the placenta.  Ten years ago the origins of cervical dysplasia were still being developed, and now we know that the majority if not the entirety of cervical dysplasia and cancer is due to an infection of Human Papillomavirus,  and for all intents and purposes cervical cancer is actually a sexually transmitted disease.  We have developed this idea even further, allowing us to use HPV virus detection as part of a screening program for cervical dysplasia and cancer, and even to immunize for HPV infection in young women yet to be exposed.

All of these things amaze me.  But to be honest, they also make the practice of obstetrics and gynecology more difficult.   We have advanced our understanding to level that is impossible to explain to patients who lack a strong background in science, forcing us to accept simplistic explanations over explanations of how it really works. Let’s use HPV as an example.

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Categories: Gynecology

Academic OB/GYN Cases: Another Day, Another Dermoid

December 10, 2010 1 comment

First blonde one for me.   Gotta catch ’em all!

5 Things I Learned From Netter

November 7, 2010 18 comments

I recently had the opportunity to go to the anatomy lab and help the first years go through the pelvic anatomy.  What a blast!  There is nothing like dissecting a cadaver to tune up one’s surgical anatomy skills, and helping young eager medical students through it is a great experience.

Prior to going into the lab, I spent many hours going through Netter’s atlas to brush up on the anatomy so I could accurately help the medical students.  Its amazing what one can learn reviewing what one used to know.  Here’s a few examples:

1. The small vessels we like to cut at cesarean have names, and we can avoid them.

Everybody that does cesarean deliveries knows that there are small vessels in the path of entry that sometimes get cut, but not everyone knows what they are called.  So for the record, the small vessels in the subcutaneous fat that get cut are superficial epigastrics (most people know this one) and the vessels that sometimes go during the lateral extension of the fascial incision are ascending branches of the deep circumflex iliac artery.  One can see that these ascending branches lie between above the transversalis muscle but beneath the obliques, which explains why sometimes taking the fascial layers separately allows one to miss them.  I’ve always felt that the routine sacrificing of these vessels was a surgical faux pas, and knowing this anatomy helps one to avoid it.

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Categories: Education, Gynecology

Green Journal – Vertical vs Transverse Skin Incisions for Emergent Cesarean

Junes’s Green Journal had an interesting article on vertical versus transverse skin incisions for emergent cesarean deliveries that seemed worth some comment.

The point of the article was to look at a large retrospective cohort of emergent cesarean deliveries, stratify them by vertical or transverse skin incision, and then look at operative times and patient and fetal outcomes.  This dataset was drawn from recorded data from many different centers, as part of the MFMU Network system of studies.

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Getting stuff for the OR, and five things we can all do to make surgery less expensive

For the last 12 months, I have worked for a federally funded hospital.  When I came to this hospital, I immediately noticed that the GYN surgical equipment was very outdated, most likely because the primary focus of the hospital until fairly recently had been the care of men. Wanting to bring hospital up to snuff, I requested about $100,000 worth of new equipment, including a hysteroresectoscope, new hysterectomy clamps,  uterine ablation equipment, a laparoscopic morcellator, and a modern laparoscopic power source.  When I put in the order for these things I was assured that we could get these things in short order, as the hospital had upgrading GYN surgery on its priority list.

As time went on, the equipment never arrived.  It was held up in committee.  It needed further approval.  We needed more competitive bids.   After further investigation, it seemed that the hospital just didn’t have enough money to do anything non-critical.

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Surgical Video – Ovarian Torsion with Dense Adhesive Disease

27 year old woman with 2 years of intermittent left lower quadrant pain, presenting with sudden increase of pain and nausea.  Ultrasound showed a 7 cm cystic lesion in the left adnexal area.

Academic OB/GYN Cases: Abdominal Cerclage How-To

February 27, 2010 74 comments

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 –

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Grey Journal: New Protocol for Medical Treatment of Ectopics

February 22, 2010 1 comment

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.

Academic OB/GYN Cases – Cervical Ectopic Pregnancy

February 9, 2010 14 comments

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