219. Pancakes

At 34 weeks Rosie was hospitalized with “intrauterine growth retardation” and poorly controlled diabetes. Are the two complications related? One causing the other? Both caused by an unknown factor? Coincidental?  

Anyway, I walk in for morning rounds and find her eating pancakes.  I go ballistic!  Who allowed that? Then I found out that pancakes are indeed on the hospital’s diabetic diet because the venerable American Diabetes Association wants to make sure that diabetic patients get enough carbs so that they don’t crash from hypoglycemia (low sugar).  That’s fine and good for type 1 diabetics whose blood glucose levels vary widely.

But for type 2 diabetes, carbs are the problem, not the solution.  Many type 2 diabetes will resolve with low carb diets.  So no white bread, no white rice, no potatoes, no pasta, NEVER; and rarely whole grain breads and pasta, brown rice.  As for pancakes?  Give me a break.

218. Heroin part two

A month later, with negative urine screens for any opioids--not even the narcotics (Percocet) that I thought she took regularly, Carolyn returns to preop.  With no unexpected confessions, and a more flexible anesthesiologist, her hysterectomy proceeds without complications. At the eyesight level, the uterus, fallopian tubes, and ovaries appear normal, including no evidence of endometriosis (I wouldn't expect to see adenomyosis).

The pathology report not only confirms the presence of adenomyosis but also notes the presence of small fibroids, which can also cause pain. 

Carolyn went home the morning after as planned.  She did not need more than the usual postop pain medications.  I provided a prescription for 40 Percocet instead of my usual 30 since her history suggests narcotic tolerance--more will be needed for the same pain control.  

It's now been almost a week--I expected a call requesting a refill (at 2 Percocet three times a day, she would have run out by now), but have heard anything.  No news is good news.

217. Heroin part one

Hardly a day goes by without a news headline about the nation's opioid epidemic.  So no surprise when a patient's history reveals a history of substance abuse, including heroin. 

47 year old Carolyn was referred to me by a partner who didn't have time on her schedule for a hysterectomy.  Carolyn experiences chronic pain, especially with menses, which some providers attribute to endometriosis, others to adenomyosis. 

Adenomyosis occurs when the active cells of the inner uterine lining expand into the more sedate muscle fibers that comprise the uterine wall (which they are not supposed to do), Hysterectomy is the only effective treatment.  Remove the uterus--remove the adenomyosis.

Hysterectomy for pain can create more problems than it solves, but I reviewed the chart and said okay. 

The morning of surgery, Carolyn tells the admitting nurse that she used heroin the day before (just a little bit she said; "I didn't really feel anything").  The anesthesiologist promptly cancelled the surgery, saying he wouldn't do it unless he could confirm that she had been off heroin for six months.

But taken at face value, she does have a reason for pain; she takes narcotics for pain; trying to take her off of all narcotics and similar drugs for six months, is not realistic.

So we're going to try again, monitor her urine for a couple of weeks and try again after labor day.

216. Natural Birth

Sounds patronizing but when I have a laboring patient who I think is trying too hard to have a "natural birth" I make the observation that a woman wanting a really natural birth would forego the hospital and even the comforts of a king size Sealy mattress and find some wilder place for the delivery (and then eat the placenta afterwards--though I usually don't add that). The point I'm trying to make, probably not very successfully with the image I have chosen, is that "natural" is an imprecise concept, not helpful for labor decisions

Pain can cause muscles to contract (tighten), which in turn increases blood pressure, which decreases blood flow to the uterus (when muscles encircling blood vessels contract, the vessels are smaller, meaning less blood flow to the uterus and other organs).  There may be evolutionary explanations for this sequence, but none are helpful in modern childbirth.

That was my approach with Nelli, having her first baby at age 24.  To which her mother-in-law promptly proclaimed that she had delivered three babies all natural.  Thanks, mom.

After about 10 hours of labor (4 hours of hard labor), she requested an epidural and went on to deliver vaginally about 6 hours after that.

215. Saturday Morning, 3 AM

me:  ob on call, up with a patient in active labor--she will deliver about an hour later

CNM:  recently graduated midwife, new in our practice, not afraid to ask questions.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

CNM: my patient has been on Pitocin [intravenous medicine which initiates or increases labor contractions] for 12 hours now, and she is unchanged at 3cm.  What should I do?

me: did she get Cytotec [misoprosto--another medicine to induce contractions]? Or the Cook catheter [a plastic balloon inflated inside cervical canal to promote cervical dilating]?

CNM:  three doses, each 25 mcg; I tried to place a Cook catheter, but couldn't do it; never failed before and I've done a lot

me: that's a small Cytotec dose, why not [the usual] 50?

CNM: That's what Kris did [the previous CNM]; I don't know--I'm new here.

me: Well, Kris is wimpy, if she didn't come in contracting, start with 50.  If she were to present with irregular contractions, you might want start with 25 and then increase to 50 with second dose. But here, I'd have given her 50 from the beginning.  Have you considered another attempt to place the Cook catheter?.

CNM: maybe stop everything, let her sleep and start all over in the morning?

me: what difference is a few hours going to make?  Why not just sent her home?

CNM: we're inducing her for gestational hypertension

me:  what's her blood pressure now and what was her blood pressure at her first clinic visit?

[pause while records are being searched]

CNM, 126/84 now, 124/82 at first visit

me: doesn't sound like gestational hypertension to me; that was just stuck in to justify an induction for a patient that you didn't want to send home.  I'd try the Cook catheter again, while continuing increasing the pitocin.

[Cook catheter not attempted; pitocin continued: vaginal delivery around noon]

214. Clueless

I can usually come up with a presumptive diagnosis, or at least some testing (imaging or blood work) that would work towards either a diagnosis or a tentative treatment plan.

But with Caroline, I am clueless:

This 29 year old describes severe pelvic cramps lasting for about 45 minutes upon awakening, usually from a "sexual dream." Happened rarely until last year when they started occurring every few weeks; not associated with mens. She states they do not feel like orgasms which anyway are not painful to her. The symptoms are relieved within 10 minutes of having a bowel movement although she does not necessary feel like she needs to have a BM. She denies any problems with her bowel--in general is very regular. Her only significant history is migraine HA.

213. Deadly Combination

At 24 Melissa found herself in a dangerous situation.  She has experienced a life-long near absence of platelets--those blood components that help blood clot, important since small vascular tears are common and without some self-clotting mechanism, we'd bleed to death from a simple bump, bruise or scratch.

The normal platelet count ranges in the low hundred-thousands; mine was measured in January: 218,000--just right.  Melissa platelets hover between 2 and 5 thousand.

Second, she has experienced deep vein thrombosis, where a clot somehow did form (who knows how that happened) then broke off and obstructed some pulmonary vessels (pulmonary embolism).  These traveling blood clots ("DVTs") can also cause heart attacks and strokes. 

And finally, her menses started and just wouldn't stop (the low platelet thing).  Many of the medicines used for heavy menses can't be used because they increase the risk of stroke (having had one DVT means a rest-of-your-life risk for having another). 

In the hospital, she received fluids, and both whole blood and platelet transfusions, and my group was consulted, resulting in recommendation for progesterone pills--a hormone that can stop bleeding without--in theory at least--increasing the risk of.  The initial dose wasn't helping, so when I was on call I recommended doubling the dose.  A few days later one of my partners doubled it again, which is what I would have done.  That seemed to help--the bleeding almost completely stopped

A few days after that, still in the hospital, she coded and could not be resuscitated, a presumed fatal pulmonary embolism.

212: Second Opinion

Think of the schoolyard tetherball--an object at the end of of a rope twisting as it moves. That's not exactly what happens with ovarian torsion, but you get the ideal.  The ovary is suspended by one "rope" (ligament) attached it to the uterus, and at the other end, a ligament headed in the direction of the abdominal sidewall.  Blood vessels and nerves course through these ligaments. An enlarged (i.e., heavy) ovary is more likely to twist. Twisting causes pain and kinks off blood vessels supplying the ovary; the ovary could be lost.

Note the twisted ligament below the ovary

An athletic, 32 yr old emergency room physician, Beth just didn't feel right, so went for a run. When that just worsened the pain, she went to her own ER. A CT (xray) scan, an ultrasound, some blood tests and several hours later, I was called because the only abnormal finding was the ultrasound's failure to confirm blood flow into the ovary--a sign of torsion. Well, not the only abnormal finding, the CT suggested a "large fecal mass," i.e., constipation even though she felt her recent bowel movements regular.

In my ER told me she was feeling better--not uncommon as twisting can come and go, but still encouraging. That plus the normal size of the ovary led me to recommend waiting a few hours and repeating the ultrasound instead of immediately proceeding with surgery. Sometimes surgery can untwist the ovary, sometimes the ovary just has to be removed.

She agreed with me (if she had agreed, I would have been okay with the laparoscopic look-first-then-decide approach).  The second ultrasound, done by different technician and interpreted by a different radiologist, showed normal blood flow to both ovaries.  So she went home with some advice about laxatives.

211. Second Guessing

A normal pregnancy develops in the uterus not in the quarter-inch diameter fallopian tube. But that appeared to be happening for 32 year old Maria, her sixth pregnancy. 

She first experienced a week of spotting, then cramping. In the ER, the pregnancy hormone HCG was low, so all evidence pointed towards miscarriage. But an ultrasound seemed to show blood accumulating in the abdominal cavity, so maybe a tubal pregnancy after all. A tubal pregnancy can rupture the tube causing life-threatening bleeding as well as severe pain.  Her initial blood level was normal and when measured six hours later remained unchanged.  Also, no pain with an abdominal exam.

Decision point: Proceed immediately with laparoscopy to remove a resumed ectopic pregnancy, or wait, repeating the blood test after several more hours, resorting to surgery only if the blood level drops.  We decided on the latter. The blood level did drop a little, not conclusive but enough to proceed.  She did in fact have an ectopic pregnancy, and the damaged-beyond-repair tube was easily removed.  But there was no active bleeding and not much old blood either, the body's own protective mechanisms having stopped the bleeding and in the process of reabsorbing the loss.  

So, was this a needless, costly, and perhaps dangerous surgical intervention, or a wise precautionary move to prevent equally dangerous internal bleeding?

210. Zika

First pregnant patient today with questions about the Zika virus (what took so long?). Seems that she's going to DisneyWorld in Orlando. 

There have been 87 reported cases of Zika infection in Florida, most from overseas travelers, but with one sexually-transmitted infection. So Anna should be safe, though at some point local mosquito populations may become part of the problem when they bite one of these travelers and then transmit the virus to the local population

States where Aedes aegypti (the mosquito species most likely to transmit Zika) have been found.
With climate change, the blue wave will progress northward

We talked about insect repellents generally and specifically those containing DEET, which are the most effect repellents.  An urban myth makes DEET sounds like a poison, but aside from a predictable risk of local irritation (maybe 6% of users), which can happen with skin care products, from Ivory soap to any scented product, DEET appears safe.

209. Pelvic Pain

I am rarely comfortable with my diagnoses of pelvic pain.  Any age, any body type, any psych profile.  Pelvic pain can be constant, intermittent, sharply defined, or a vague ache. Ovaries, fallopian tubes, bowels, bladder, may share common nerve pathways, and to a lesser extent, muscles, ligaments and tendons. So a patient may be convinced that her ovary is the problem when it may be the bowels.  Sometimes an ultrasound or CT X-ray will point to the source: a tubal pregnancy, say, or a large, twisted ovarian cyst.  But sometimes, no test helps. So I may suggest a tentative diagnosis, but doubt often remains.

Consider Rachael, a 29 year old who presented with severe pelvic cramping, lasting for 45 minutes after awakening, usually from a sexual dram.  During past year, frequency has increased to once every few weeks.  She states that they do not feel like orgasms, which are not painful.  The symptoms are relieved within 10 minutes of having a bowel movement, though she does not feel the urge to relieve her bowels.  Otherwise, no problems with her gastrointestinal system.  Her only significant history are migraine headaches. 

I suggest to the family practice doctor who consulted me, to manage her as a patient with irritable bowel, and if this proved unhelpful to refer her to gynecology.  I've not heard back

208. A Migraine with Aura

The risk of ischemic stroke for women from 15 to 45 is about 5 per 100,000 women per year. Ischemic strikes are caused by an obstruction in a blood vessel in the brain that deprives adjacent neurons of oxygen (so they die and don't grow back, though with time other parts of the brain may take over the lost function).

Add birth control pills (OCPs for oral contraceptive pills) and that number doubles to 9, presumably due to the estrogen component of OCPs.  Add migraines with aura, and now we're talking 50 to 60 strokes per 100,000 women per year. Add cigarette smoking and age over 35 and the number skyrockets.


Migraines are severe, disabling, usually but not always one-side headaches, usually associated with other neurologic symptoms. An aura is the presence of these symptoms (usually visual disturbances) just before the onset of the headache.

35 year old Bonnie has migraines, often (but not always) with aura.  Her headaches increase just before and during menses, but decrease when she takes OCPs every day (not pausing for a week as most OCPs are taken in order to trigger a reassuring ("my period started--I'm not pregnant") menstrual flow. I provided a very low estrogen dose OCP to minimize stroke risk.  But she developed acne.  She asked for a pill which may reduce not increase acne.  Such a pill exists but appears to increase strokes more than other OCPs.

So, fewer migraines on continuous OCPs, but great risk of stroke because of her aura migraines. But some experts say never ever OCPs for women with migraines with aura, but shouldn't the patient be the one making that decision, assuming she has been presented with and understands the risk data presented above?

207. Wear Red Friday

Friday was Wear Red Friday.  A couple of days before I met a patient whose story tells us why there is a Wear Red Friday.  She is a PE teacher, and for many years has participated in several runs a year, from 5 to 20K. Ten years ago she dropped out of a half marathon because of a nose bleed. The nose bleed turned out inconsequential, but in the course of an interview with the race's volunteer doc, she explained how she had become slower in the past few years, even to the point of dropping out of one race because of fatigue. 

She attributed this to age (47 at the time) but remembers him telling her that she should be getting faster with more races, or at least be holding her own. So re recommended follow-up with her primary care doctor.  She did and was scheduled for a treadmill test (in which one undergoes continuous monitoring of the heart's electrical activity while running).  A heart not receiving enough oxygen during exertion will show abnormal electrical activity. She "failed" the treadmill test and a week later underwent double coronary artery bypass.

Her weight is normal, she has never smoked, is not diabetic, and has no family history of cardiac disease.  Were it not for a doctor's perceptive questioning, she might have had a fatal heart attack during one of her runs.

The theme for Wear Red Friday:  Coronary Artery Disease is the #1 cause of death among women.

206. Socially-Acceptable Addiction

If I could buy stock in caffeine, I'd do it; caffeine's PR on such a rise lately:

1. increased athletic performance with increased adrenaline and access to body fat (= energy)

2. increased memory and general cognitive function

3. decreased risk of neurodegenerative diseases such as Alzheimer's and Parkinson's

4. decreased risk of some types of cancer, diabetes, some liver disease, kidney stones, strokes

These findings are based on association studies, as in let's study people with higher intake of caffeine (read coffee drinkers) and look at their health and athletic/academic performance.  But is it the caffeine, or the coffee, or some other yet to be identified factor?

All I know is that when I am driving long distance or need to be alert for a long afternoon clinic or night call, I pop a 200mg caffeine pill.  One of my partners apparently favors the 188mg caffeine Java Monster, about the same as coffee, which can range from 100 to 300 for a 12 oz cup, compared with 25-50 for tea or 40 for a Diet Pepper or Diet Coke (from caffeineinformer.com).

Spoiler alert: those who find that caffeine has lingering effects (say more than 4-6 hours), may be "slow metabolizers," due to a variant of the CYP1A2 gene, which increases risk of heart attack and/or hpertension with more than two cups of coffee daily. 

205. At A Shower?

I met Melinda for an IUD removal, which appeared to have migrated and penetrated the uterine wall, causing pain.  Though usually simple--just a gentle tug, this malpositioned IUD could be a problem. It seemed to come out easy enough but she experienced moderate discomfort. But it was out.

Then the retrospectively questionable decision to insert a new one at the same visit--she did need contraception, after all.  This insertion was painful and a week of persistent pain led to the IUD removal.

Unexpectedly the pain continued.  Blood tests did not show any infection, nor did an ultrasound reveal any abnormality. The patient requested increasing amounts of narcotics, as many as 70 tablets in one month.  With no explanation for the pain and with a history of opioid addiction, we decided to limit narcotics, first to 40 per month, then 30, and so on.

That's when she came and said her purse, with all the pills in it, had been stolen while at a friend's baby shower.  We've heard stories of pills being lost when a patient stood over a toilet while shaking a few out of the vial, and of pills stolen from a locked car or from a high alcohol density weekend party. But at a shower?

Whatever, during these tapering down or in some cases steady state prescriptions, we make it very clear that no early refills will be made no matter what.  We call that a pain contract.