"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.

What is that???

A 32 y/o G2P2L2 white female, 4 weeks postpartum s/p uncomplicated SVD with epidural presented to the acute care clinic with chief complaint of “blood clot inside labia”. States she noticed a dark red lesion inside her labia that morning. Denied pain, but c/o itching. Denied drainage from lesion, dysuria, hematuria, urinary difficulties, or vaginal discharge. Denied shaving, intercourse, or other trauma. Currently breastfeeding. On inspection and palpation, there was a 1cm x 1cm round, swollen, red, inflamed protrusion in the between the labia minora, covering the urethra and extending to the inferior border of the clitoris. The mass was firm, immobile, and nontender with palpation.


This image above is similar to what I saw.

I wasn’t exactly sure what the lesion was, but the provider immediately recognized it and diagnosed her with urethral prolapse. Urethral prolapse is not a common condition and is often misdiagnosed. Most cases occur in pre-menarchal and post-menopausal women and is thought to be caused as a result of trauma or lack of estrogen causing laxity of the pelvic floor. Our patient probably had multiple factors that contributed to her development of urethral prolapse. Trauma s/p foley catheterization and vaginal delivery and lack of estrogen induced by breastfeeding in the post partal period probably all played a part. Because the condition is uncommon, there is not a clear consensus about treatment, but options include manually replacing the prolapse, estrogen creams, kegels, physical therapy, and surgery. As our patient had a mild prolapse without signs of urinary obstruction, we opted for less aggressive treatment and prescribed estrogen cream and recommended kegels. So if you happen to see a post partum patient with an odd vulvar lesion, keep urethral prolapse in your differentials.

I'm in the Brig!

So...it never occurred to me that military women's health care also includes the inmate population! I know women commit crimes; it's not as if active duty women are exempt from bad behavior...but still, as an an active duty provider- am I really going to treat women in jail? Yes, particularly you Navy folk. The brig over at Miramar Marine Corps Air Corps Station is the military's only long term institution of confinement for active duty women prisoners. They can be held there for up to 10 years. If the sentence exceeds 10 years, then they are transferred to a federal prison. Most are there for murder as a result of IPV (Intimate Partner Violence). So, there I was on Friday morning...doing speculum exams...on a prisoner...in the brig. My preceptor shared with me that this experience is actually very similar to providing care for women in the deployed setting. A lot of abnormal menses [change in diet/exercise/stress; close proximity of many women living closely together (syncing of cycles)]; along with BV and candidiasis d/t changes in hygiene patterns and hygiene products. I had to do paper charting, we had to bring our own supplies- including speculums, and there is no microscopy. If it smells like BV, you treat for BV. If it looks red and inflamed w/itching to the vulva and inguinal intertriginous folds, you treat for candidiasis- you get the picture. As a military FNP, there is such a wide range of what care in austere environments means.

The OB/Gyn floor at Dewitt community hospital at Ft. Belvoir was an eye opening experience for me as it was the first unit I have been on that had more advanced practice nurses than physicians. I was apprehensive at first as I already have one strike against me for being male (sorry, but I have had lots of interesting past experiences). However, I have never felt more like a team member amongst the OB/Gyn staff in both the clinic and on the L&D deck. While paired up with different preceptors I was encouraged to be a provider (under close supervision) and thus I performed: NST's, AFI's, well-woman visits (paps, bimanuals), placement of intrauterine pressure catheters, and performed an artificial rupture of membranes. All of this was in the first week and I still have one more to go. Hopefully the learning curve will continue to be steep and challenging. This is certainly the right environment to be sending us to.

I thought this was women's health!

I arrived at my clinical rotation prepared to do women’s health. Imagine my surprise when finding myself discussing pediatric issues and testicular pain during a colposcopy visit. The patient came to her appt with her new baby and her husband. I am not quite sure how the topics came up, but I could not ignore questions about the baby’s growth/feeding or the husband’s complaint about ongoing severe testicular pain. It might be the first time that I recognized that the breadth of knowledge of the FNP is an asset and not a burden. I was able to answer questions and make appropriate recommendations for follow-up for all of the members of the family. Now if I can just figure out how to do all this in the 20 mins allotted.

36 yo AA G2P2A0 WWE

I saw this woman for a routine wwe but while taking her history, she revealed that she had recently been experiencing dysuria and urinary frequency. During the pelvic exam she had no unusual discharge or odor but did have some suprapubic tenderness duringt the bimanual exam. Both me and the WHNP were inclined to write this off as a run of the mill UTI and had the woman provide a urine specimen. As we discussed the case, we both came to the realization that perhaps we should also a wet mount in case she had another infection. When we did the wet mount, the diagnosis (if not the treatment) became obvious: bacterial vaginosis. The clue cells were easily seen. The primary difference in arriving at this diagnosis was the type and timeliness of follow up. The patient was asked to return after completing antibiotic treatment for another full exam. It made me realize the importance of sometimes looking deeper (no pun intended) than the assumed diagnosis.

Interesting Issue_Delgado

34yo G1P0 presents for NOB visit. She is originally from Thailand and does not speak English very well. Her husband is due to deploy to Afghanistan in November. When he leaves she will have no support system within the United States. During this visit we had to handle the psychosocial problems and family health concerns. You could tell the patient and spouse were very distraught on what the future may hold. This was her first pregnancy and she would have the child in a foreign country without her husband and she already had problems communicating her concerns. The couple believes that the best course of action was to have the patient stay in Thailand with her family once he had left for his deployment; however, they mentioned that Tricare was giving them a hard time because “she had to stay within the region he was assigned or they wouldn’t pay for medical expenses”. The couple wanted to ask our opinion on how to handle the situation. We told them that we could not tell them what to do; however, if she was to move in November she would be leaving around 28 wks gestation. So, a majority of her OB management would still be able to be performed at Bethesda.

Can anyone say TBI???

22yo female G1 P1 seen in OB clinic for 6-wk PP visit and questions about contraception, spec. Mirena. During the initial introduction, my preceptor noticed a bump on the pt's left forehead and inquired about it. Pt explained that in 2008 she had injured herself playing soccer when she and another player headbutted each other. She stated that it had never truly resolved, although it was much better. During the course of my interview, I found out that she and another player (300lb with glasses) had run full steam toward a soccer ball both with the intent of head-butting it to wherever. Instead, they collided in midair and were each thrown about 5 feet back. The other player broke his glasses and had a few minor cuts to his face, where my pt had lost consciousness for 2-3 mins, regaining it when she was being driven to the hospital. She had difficulty recalling name, place, date, etc. in the ER, but finally regained her memory. Fast forward to post-delivery 2010...pt now complains that she feels like her "center of gravity" is off and has tripped and fallen down her stairs x2 since delivery. She denies any vision changes (doesn't wear glasses/contacts), denies hearing difficulties or any hx of BP issues. She was negative for PIH, GDM or any other complications (except PUPP) during/post pregnancy. After discussing risks/benefits of contraceptive types (incl. Mirena) and performing necessary cultures prior to IUD insertion, pt was instructed on when to return for IUD placement and a NEURO CONSULT was initiated immediately. I thought this case was particularly interesting b/c of what we have learned about TBI in school/SIM center and that TBI can affect anyone at anytime...including 22 yo post-partum females.

Sometimes you don't want to know the answer

Pt is a 52 year old female in a monogamous relationship foe 33 years. They had not done anything for birth control and figured they would get pregnant if and when it happened. Needless to say she never got pregnant. They went to see their friendly neighborhood FNP who referred them for fertility counseling. Short while later she is pregnant with a donated egg. She has the sequential screen down and it comes back with a high risk positive screening for Down Syndrome. She thinks long and hard about it, talks to her pastor. Her and her husband decide there is no way they will terminate this baby and deny the amniocentesis. They say that they wish they never would have had the testing done as it anguished them for a decision they were never going to make anyway. Now they have a cloud hanging over the pregnancy instead of being truly able to enjoy it. She says she wish it would have been explained a little better, she just remembers being told it is one of those tests we do on all pregnant women. She was very clear that they never would have done it if they had truly understood what the test was. This goes back to the discussion Dr. Seibert had about should someone who would not terminate in anyway have the tests done. Sometimes you don't want to know the answer and would rather be in the happy dark.

Rash during pregnancy

31y/o Caucasian female ADAF G1P0 30.5 weeks. Was seen by WHNP for ROB. Patient had rash on abdomen/back diagnosis tinea and pt given fungal topical and dermatology referral. Patient had no improvement with fungal cream and lesions progressed to vesicles when derm provider assessed her. When patient presented to dermatology her rash had also spread to soles of feet, feet, arms, hands and all sections of her chest, abdomen and back. Patient was started on topical steroid by derm provider and lesion biopsies obtained. Differential diagnosis included Pemphigoid gestationis (he was pretty sure this would be confirmed by biopsies as patient was classic presentation per his reference text). I saw patient with OB MD. Preliminary biopsy results were available and they were not consistent with diagnosis of pemphigoid gestationis; “had eosinophilic characteristics”. Patient diagnosis dermatitis; current biopsies to be sent to AFIP for second opinion, Vistaril 100mg po q6h for sleep and continue topical steroid for lesions. Topical steroid seemed to be working—size of lesions was decreasing and fewer vesicular lesions observed. She had previously tried OTC Benadryl but it did not provide pain relief or help her sleep. Patient to start NSTs twice a week. OB provider to consult with dermatology to ensure biopsies were correctly collected (couldn’t be placed in formalin for this diagnosis). Patient was still having a hard time sleeping and even walking because of the lesions on her feet or those rubbing on her uniform. She was the last patient I saw during my rotation and I do not know her definitive diagnosis.

Pemphigoid gestationis (Medscape, 2010)

Pemphigoid gestationis (PG) is a rare autoimmune bullous dermatosis of pregnancy. The disease was originally named herpes gestationis on the basis of the morphological herpetiform feature of the blisters, but this term is a misnomer because pemphigoid gestationis is not related to or associated with any active or prior herpes virus infection.

Pathophysiology

Pemphigoid gestationisis a pregnancy-associated autoimmune disease. Most patients develop antibodies against 2 hemidesmosomal proteins, BP180 (BPAG2, collagen XVII) and less frequently BP230. Historically known as herpes gestationis factor, these circulating antibodies belong to the heat-stable immunoglobulin G1 subclass. The binding of immunoglobulin G to the basement membrane triggers an immune response, leading to the formation of subepidermal vesicles and blisters. The trigger for the development of autoantibodies in persons with pemphigoid gestationis remains elusive. Cross-reactivity between placental tissue and skin has been proposed to play a role. Pemphigoid gestationis has a strong association with HLA-DR3 (61-80%) and HLA-DR4 (52%), or both (43-50%), and virtually all patients with a history of pemphigoid gestationis have demonstrable anti-HLA antibodies. The placenta is known to be the main source of disparate (paternal) antibodies and can thus present an immunologic target during gestation.

Frequency

United States

In the United States, pemphigoid gestationis has an estimated prevalence of 1 case in 50,000-60,000 pregnancies.

International

Findings from European studies suggest that pemphigoid gestationis has an overall incidence of 0.5 cases per million people per year. In 1999, Jenkins et al² described the largest cohort of 87 patients in the United Kingdom with a total of 278 pregnancies, of which 142 were complicated by pemphigoid gestationis.

Mortality/Morbidity

No increase in fetal or maternal mortality has been demonstrated. A greater prevalence of premature and small-for-gestational-age (SGA) babies is associated with pemphigoid gestationis. Of infants, 5-10% born to affected mothers may present with transient cutaneous involvement that resolves as maternal autoantibodies are cleared. Patients with pemphigoid gestationis have a higher relative prevalence of other autoimmune diseases, including Hashimoto thyroiditis, Graves disease, and pernicious anemia, which are also associated with HLA-DR3 and DR-4 haplotypes

Race

Pemphigoid gestationis is less common among blacks than whites, which might reflect its association with specific HLA haplotypes.

Sex

This condition only affects females.

Age

Pemphigoid gestationis occurs in women of childbearing age.

Clinical

History

Pemphigoid gestationis typically manifests during late pregnancy, with an abrupt onset of extremely pruritic urticarial papules and blisters on the abdomen and trunk. Unrelenting pruritus often interferes with daily activities. Lesions may appear any time during pregnancy, but they most commonly develop during the second and third trimesters.Symptoms may abate at the end of pregnancy; however, dramatic flares can occur at or immediately after delivery. Pemphigoid gestationis usually resolves spontaneously within weeks to months after delivery and possibly quicker with breastfeeding. The persistence of disease activity for years postpartum has been reported. Pemphigoid gestationis may recur with the resumption of menses, use of oral contraception, and subsequent pregnancies. The 1999 cohort study by Jenkins et al² showed no association between change in partner and development of pemphigoid gestationis in subsequent pregnancies.

Physical

The initial clinical manifestations are erythematous urticarial patches and plaques, which are typically periumbilical. These lesions progress to tense vesicles and blisters. Some patients may present with urticarial plaques and may never develop blisters (see the images below). These hive-like plaques differ from true urticaria because of their relatively fixed nature. The rash spreads peripherally, often sparing the face, palms, and soles. Mucosal lesions occur in less than 20% of cases. Patients may have secondary infections at blister sites.

Differential Diagnoses

Bullous Pemphigoid
Cicatricial Pemphigoid
Linear IgA Dermatosis
Pruritic Urticarial Papules and Plaques of Pregnancy
Urticaria, Acute

Other Problems to Be Considered

Allergic contact dermatitis
Dermatitis herpetiformis
Drug-induced bullous disorders
Erythema multiforme
Papular dermatitis of pregnancy
Prurigo gestationis of Besnier
Pruritic folliculitis of pregnancy

Workup

Laboratory Studies

Routine laboratory studies are not helpful in diagnosing pemphigoid gestationis. The results with most hematologic studies are within normal limits, although peripheral eosinophilia is not uncommon and may correlate with disease severity. Laboratory values that may be elevated include immunoglobulin levels, erythrocyte sedimentation rates, acute phase reactant levels, and antithyroid antibodies.

The criteria for the diagnosis of pemphigoid gestationis include an appropriate clinical presentation, histologic findings of a subepidermal blistering process (as described below), and direct immunofluorescence (DIF) results that show a linear band of C3 deposition with or without immunoglobulin G (present in 20-25% of patients) along the basement membrane. The DIF test is the key assay to differentiate pemphigoid gestationis (positive DIF findings) from pruritic urticarial papules and plaques of pregnancy (negative DIF findings). However, a similar pattern of DIF results is observed in patients with pemphigoid gestationis, BP, and epidermolysis bullosa acquisita (EBA). DIF should be performed using samples from noninvolved perilesional skin.

http://emedicine.medscape.com/article/1063499-overview (for pictures and more detail)

Contraception Issues

I had a couple of interesting contraception cases during my clinical rotation. The first was a 21 year old G2P2 who came in to the gyn clinic because she wanted to be fitted for a diaphragm. The only thing she used with her husband in the past for contraception was condoms and spermacide. She had no previous experience with diaphragms but had found out about them on the internet. She was interested in using it because she was very adamant about not using any type of hormonal contraception. So basically, I had to start from scratch and tell her everything about diaphragms. It was interesting to me that someone so young would want a diaphragm, because you usually think of older women using them. But I think with the younger generation being more disinclined to use medications, we may see more diaphragms come into play.

Another case was a 24 year old G1P1 female who came in because she was interested in starting new contraception. She reported that she had tried an oral contraceptive in the past with good results and she had only come off to have her child. During the interview, the patient revealed that she has very heavy menstrual cycles every month and the oral contraceptives never seemed to help that much. After talking with the patient, I thought that she would benefit from the Mirena IUD. So, I started discussing the risks and benefits with her and she was on board until I mentioned that the Mirena could help decrease her menstrual flow and in time may even stop her period. She then commented that it is "not natural" for a woman to not have a period and that she would rather have heavy cycles than not have a period. No amount of education from us could change her mind, so we prescribed the oral contraceptives. It was just interesting to see these two patients with such strong viewpoints on contraception.