Fetal Demise

During my sojourn at Ft Bliss/William Beaumont, I had the opportunity to see how an intrauterine fetal demise is managed-from US to second opinion, to induction (On several different patients, not the same one). It was interesting watching different providers interact with the different moms/partners as well as seeing different parts of the process.

The first case was that of a 32 y/o AA mom, G2P1, at 15wks GA. Informing mom of a likely demise on US was handled tactfully, with another provider consulted and a second opinion offered. The mom in this case was upset, but not shocked--she was in office that day because she was worried about her baby--"something isn't right".
I saw her again with the provider offering a second look--confirming still no fetal movement/cardiac activity, no signs of life. The second provider offered options. Both parents were present. It took them some time to digest the information given regarding the 3 options--watchful waiting, induction, or D&E. The provider gave them a lot to think about, then advised them they had time to talk it over before deciding. They left the room with the information they needed to consider and verbalized what they needed to do to complete the process. Both were calm, all questions they had at the time answered.

The next couple illustrated what an induction would be like. This involved a 35 y/o G3P2 at about 28 wks. They were admitted to L&D at around 0800. A plan was in place--mom was to be induced using 600 mg cytotec and infant delivered. Mom did not want any pain meds delivered as she wanted to be lucid and not "drugged up". Her statement was that this was the only time she was going to have with her baby girl, and she "wanted to make the most of it."
She actually delivered around 5 hours later. We had been worried that little one was presenting breech and that this was going to be a difficult passage. Luckily it worked out well. Little one was was tiny and fragile--650 some grams. Dad had a much harder time of it than mom afterwards. It was interesting to observe the family dynamics. Both sons, 2 1/2, and 4 were introduced to baby "J". The older one was more cognizent of what was going on but thought his sister was asleep. The littlest one responded to the emotion in the room and was cranky. Grandma was weeping, while grandpa was quieter and tried to help manage the older children. Mom in fact seemed to be at the most peace.

Also interesting was provider interaction. The nurse was very hands-on, very actively involved, where the nurse midwife had so many calls on her time that she was unable to be there much for the pt. There was a grief counselor involved, and her interaction was fairly close after the fact. It seemed as if the hospital processes were intrusive, though necessary, and made it difficult for the different professionals involved to utilize their training to the fullest. In fact the parents were contacted by mistake by the lab the next day regarding a genetic test that had been ordered. This upset the parents no end--and was a simple error due to processing the sample that had already been collected.

So what I learned--developing rapport is key. Each of the providers had a different style. Some more empathetic, some more direct--each effective in these cases. Managing the relationship helped the pt/family deal with the decisions to be made and manage their emotional reaction to the content of the information they were given.
I also learned managing my own reactions was more difficult than I expected. I did get a bit teary-eyed. I did get a lump in my throat. When I was talking to the mom while she was holding her infant I did have to work at it a little bit. Dad was a bit easier, but mostly that was because I kept expecting him to pass out and I was ready to help keep him from falling and hurting himself.

The managing my inner self bit has been a theme this semester at least--keeping an open mind, giving pts the opening without leaping to conclusions... People don't always react the way you'd expect.

Torn between Molluscum contagiosum and Gardasil vs. HPV

I was going to talk here about the 18yo female who had her Gardasil 3-shot series, before she had any sexual activity (per her report), and still ended up with an ASCUS PAP with HPV-having to discuss with her how there are over 100 HPV strains and the Gardasil only protects against 4 types and she still needed to use condoms or abstinence to decrease possible transmission of other HPV types.

However, a more interesting time with my preceptor was identifying and treating 2 patients with Molluscum Contagiosum. Each pt had c/o'd "bumps down there" that occasionally itched. Both pt's were worried they had genital warts. When examined, both pt's were "topiary" shavers and at first look by me, could have had folliculitis (barbae) pubis-from shaving genital hair off that then grew back and curled into the skin, or it could have been acne, or heat rash from my first glance. My preceptor quickly showed me the waxy, pinkish-flesh colored looking flat papules with a small central pit (umbilicated) that identified the "bumps" as molluscum contagiosum. In either case, the patients were told to stop shaving their genital area-to continue would increase spread of the molluscum.

Typically, the lesion of molluscum begins as a small, painless papule that may become raised up to a pearly, flesh-colored nodule. The papule often has a dimple in the center. These papules may occur in lines, where the person has scratched. Scratching or other irritation causes the virus to spread in a line or in groups, called crops.

The papules are about 2 - 5 millimeters wide. There is usually no inflammation and subsequently no redness unless you have been digging or scratching at the lesions. The skin lesion commonly has a central core or plug of white, cheesy or waxy material. In adults, the lesions are commonly seen on the genitals, abdomen, and inner thigh.

Molluscum contagiosum is a harmless virus but it may persist for months or occasionally for a couple of years. It frequently induces a type of dermatitis in the affected areas, which are dry, pink and itchy. Molluscum contagiosum may rarely leave tiny pit-like scars.

Non-medicine treatment- the infection can be cleared without medicine if there are only a few lesions as there were in our 2 patients at the clinic (each had less than 10 total). First, the affected skin area was cleaned with an alcohol swab. Next, a sterile angiocath needle was used to cut across the head of the lesion, through the central dimple. The contents of the papule (the central cheesy core) was removed with another alcohol swab. This procedure was repeated for each lesion (and is therefore unreasonable for a larger infections). With this method, the lesions would heal in two to three days. There was minimal pain with each molluscum core removed.

Lesions may resolve spontaneously without any treatment and without scarring within 6 to 12 months but may take as long as 4 years to completely disappear. Other treatment options include use of caustic chemicals (podophyllin, trichloroacetic acid, silver nitrate), lasers, and/or cryotherapy (liquid nitrogen). These options require a trained health care provider, may require local anesthesia, and can result in pain, irritation, and scarring. If every lesion is not removed, the condition may recur. Infected persons should return for reexamination one month after treatment so any new lesions can be removed. Sex partners should be examined for signs of infection as well.

Molluscum Contagiosum at a Glance

• Very common, contagious, benign skin disorder

• Caused by poxvirus

• Often seen in otherwise healthy people

• Commonly affects children and sexually active adults

• Typically on the trunk arms, and legs

• Looks like scattered, small, smooth tan or pink bumps

• Easily curable in most cases

• Sometimes clears on its own without treatment

• May require multiple treatments and ongoing maintenance therapy

• Often treated with freezing with liquid nitrogen

Prevented by good skin hygiene

http://lagunaskincenter.com/molluscum.aspx

There is a reason this is forbidden

A couple consisting of a 21 year -old who who was 20 weeks pregnant and her 45 year old active duty husband came in for a routine OB visit. As I would soon find out, this visit was anything but routine. At first glance I noticed the age discrepenancy between husband and wife; I didnt give this much thought, I just thought to myself, "lucky guy". However, my preceptor soon informed that they were second cousins to eachother. They hailed from Spain, if that makes any difference. Anyway, the woman spoke no English and we needed a translater to help get us through the interview and exam. She smoked a 1/2 pack of cigarettes a day and suffered from anxiety. We had to ask the husband to leave the room as we inquired about her emotional health. During the actual physical exam and assessment, I found that her fundus was at least 2 fingerbreadths below the umbilicus; keep in mind, she was 20 weeks at the time of the visit. I did capture fetal heart tones, around 185, -high, but my preceptor did not seem too concerned. We did an ultrasound and everything seemed to be o.k. The couple were eagerly awaiting to learn the sex of their baby, which they hoped would be revealed during the 20 week ultrasound the next day. What a difference a day makes, when their only concern one day was whether their baby was a boy or a girl. Unfortunately, we found out around noon the following day that the ultrasound showed that the fetus had polycystic kidneys, which was inevitably causing a low amniotic fluid index and growth restriction. We knew that this baby and the parents had a really tough road ahead of them. They were immediately referred to maternal-fetal medicine. I did not have the opportunity to follow-up with this case, for my rotation ended. My preceptor confirmed my suspicion that this defect could very well have been caused by such an incestous relationship, for polycystic kidneys are a recessive condition. How sad, you wonder if this could have been prevented, given all of the information we have about the potential dangers of such relationships. I wish them the best.

greg

"He just gets pushy"

Say what!!! This was the response of 24yo AD Army E-3 L.Z. G1P0 NOB at 11wks gestation when asked (behind closed doors after her initial intake and her "boyfriend/father of baby" departed the room for the "girly part of the exam" )about her boyfriend's behavior towards her during the interview.
We can all appreciate the depth and breadth of inquiry during an initial OB visit...which, should be answered as best as possible by the WOMAN....well, during the interview with this particular visit, L.Z. for some reason, allowed her boyfriend/father of baby of 6 months to answer most of the questions because, as he put it, " [she] was taking too long to answer the simple questions."
He was so blatantly verbally aggressive in the exam room, that I feared how he might behave towards her when not in public or if there was actually a "real" dispute between the them. So when he volunteered his excuse from the room to allow her physical exam to be conducted, I brought it down...tactfully and professionally as possible my concerns about her safety, the safety of her unborn baby as the pregnancy ensues and the overall safety and welfare of her and the baby after delivery. Though she became teary eyed, she insisted that he had never been physically, emotionally, sexually, or otherwise abused by him nor felt threatened for her life or safety. She simply stated, "He just gets pushy." I expressed to her, again, my concerns for her during the pregnancy and discussed the recency of their relationship and pregnancy state and potential for the verbal aggression to escalate to physical violence. I provided her with multiple numbers for support and counseling that we hand wrote on a sticky pad so as not to raise alarm to her boyfriend if he saw pamphlets or handouts specifically addressing the concerns. We thoroughly documented the encounter and instructed her to schedule a visit, ALONE, within the next week and if she didn't mind, to keep the provided informed if she was seeking counseling or assistance she sought so as to ensure her optimal safety throughout the pregnancy. We did not contact her command as there was no evidence of physical abuse on exam and she vehemently denied being abused. Her boyfriend was not AD and thus this would otherwise be purely domestic requiring involvement of local law enforcement if things escalated. Moral of the story, never be afraid to ask, never be afraid to offer, never ignore your gut instinct that something is wrong. She expressed sincere gratitude for recognizing his behavior as she admitted feeling "stressed" by it...ding, ding, ding!!! and that she would follow through with scheduling her follow-up.

Waterbirthing

While at FT Benning I did some side research for one of the CNM's to present to their ESC (excecutive steering committee) the process of waterbirthing. Benning was undergoing renovation of L&D and build a dedicated hydrotherapy tub for the waterbirthing process in a suite. The CNM group there have been champions for this process and successfully seemed to be moving forward. Unfortuneately, infection control (change in leadershp)for the facility was not included during the construction process or was not adequately paying attention so tub was installed but its clinical use held up. Now as centering patients learn about its existence and possible benefits it has created a great deal of disatifaction.

More research needs to be completed but up until now preliminary evidence supports shortening of the first stage of labor, better pain control (decreased analgesia), decreased interventions by healthcare providers, provides a gentler transition for infant to extra uterine life, and empowers mom to be more in control of the birthing process

Some concerns are related to infection control; exposure to blood, feces, and meconium, increased staffing required to safely monitor patients and equity for non-waterbirthing moms, Airway safety/aspiration risks. Finally stategies related to training, protocols, and CPG's.

This is an old and ongoing debate as this is not new, yet I found interesting the facility did not have prior to the actual installation of unit.

Check out www.waterbirthing .org , jump in the water is fine!

Centering

I recently had the opportunity to attend, participate in a Centering Group facilitated by the CNM’s and WHNPs at March Army Community Hospital (MACH). Enrollment in these groups is limited to 8-10 participants of similar gestational progress. This model for group prenatal care is intended to provide assessment, support and education throughout the course of pregnancy. Women are encouraged to participate more in their own care while the group as a whole shares past and present experiences of pregnancy. The class is organized into 10 planned sessions each of which has its own educational focus appropriate to the specific phase of pregnancy.
Centering is copyrighted program and the individual institution is required to pay for the privilege of incorporating Centering as a program offered by their clinic. Facilitators must participate in a 2 day work shop prior to leading a centering group.
In addition to the group interaction, and education each woman is assessed by the OB provider, and appropriate checks in cluding fundal height, fetal heart tones are performed at each class, with additional assessments cervical checks, and ultra sounds perfomed indiiually as required and or necessary.
The program incorporates self evaluations from participants who provide feedback. MACH is not currently conducting additional surveys or research to evaluate the programs effectiveness as compared to traditional prenatal care or to other prenatal classes.
The class of seven women which I observed seemed to be very effective in that all of the participants appeared to share information and advice openly but not so much as to be overbearing. The facilitator, a CNM, presented appropriate educational materials encouraged comments from the participants about what was being discussed, while allowing and encouraging participants to be fully involved in the class. Private time for assessment was provided in a way which was discrete and which did not detract from the overall flow and development of the day’s class.
Overall I found that I was impressed by the process and the individual participants seemed to be well satisfied. The advantage of this program for military personnel is that it excellent forum for discussion and sharing of pregnancy related issues along with personal support for women who are often remote to their natural family support systems

An expert opinion doesn't replace human kindness

Towards the end of my women's health rotation I learned a lesson that I hope to never forget. My preceptor and I were seeing a patient that was a 33 y/o G3P3 that was complaining of amenorrhea, a positive home pregnancy test and mild abdominal cramping. She stated that she had recently returned from out of town attending to a parent that is dying from cancer and been under a great deal of stress. She has a history of irregular menses and stating dates of last last menstrual that would place her at 10-11 wks gestation. The WHNP performed an initial ultrasound in the office but we were not able to see any sign of a viable intrauterine pregnancy. In fact the only thing of note was a thickened endometrium lining but not much else. The pt had a positive hcg with ok values but we weren't sure what to do. We consulted the on-call OB doctor handling complicated OB patients and he instructed us to ask the pt "how much she really cared about this pregnancy?", and to offer her the opportunity to terminate it now. This advice did not sit well with either of us. We instead ordered serial hcg's and scheduled her for a more detailed ultrasound later that week. Although this pregnancy was unexpected for her, we felt that unplanned doesn't always equal unwanted. In hind sight we felt the worse that would happen is finding out a few days later that it may not be viable.
When the pt returned, her values had improved accordingly and the more detailed ultrasound showed a viable fetus around 6wks. I shudder to think of what harm we could have caused by just following the expert, some life situations require us to pause and take a breath not forgetting to impart some human kindness.