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.