A Plethora of Problem Pregnancies

All I can say today is that it was both interesting and frustrating.  Interesting because we had an abundance of case studies in obstetrical medicine.  Frustrating because I wasn't allowed to do much about any of them.

I love the time I spent in surgery, but at times I wish I didn't have the experience because I sometimes long to be back in the O.R.  We had a number of cases today that I have done in the past, but now, I can only watch from the sidelines, and at times it gets so that I wish I was back in surgery, taking the patients to the O.R.  Not being stopped from seeing my patients all the way through because of my current position.  I hate being on the sidelines.

This is how I greeted the morning:


It made me think of San Francisco - of course if SF suddenly flattened out, lost about 3/4 of its inhabitants, and dropped 20 degrees below it's norm for this time of year.  Still.
But, let's focus on the positive... there really were a lot of interesting cases.  I can't explain all of the different medical conditions so I added a hyperlink to a website explaining them:

Hydrops fetalis in an Amish woman who was on her 9th pregnancy.  She has Rh negative blood and had 4 previous Rh positive pregnancies.  She is only in her 28th week, so tomorrow they plan to try an intra-uterine blood transfusion to see if she can at least carry the baby a little longer and to give it the best chance for survival. (http://www.healthsystem.virginia.edu/uvahealth/peds_hrnewborn/hydrops.cfm)

Gastroschisis in a 37 weeker who ended up getting a C-section when the baby started having problems.  Surgery was there to replace the bowel contents.  I had a couple of these during my peds surgery rotation, and I help put a silo in one of them.  They usually do better once everything is back inside.
(http://www.chw.org/display/PPF/DocID/34307/Nav/1/router.asp )

Psuedocyesis in a patient that has been to the L&D ward multiple times.  I talked about this while I was working in the ED at ECMC ( http://journals.aol.com/vbonalesmd/emresident/entries/2007/10/11/three-nights-three-tales/858 ).  Apparently this patient is bipolar, and when she doesn't take her medication she has bizarre delusions.  She got a laugh out of the other intern who, unknowingly, placed an ultrasound on the patient and found an empty uterus.  Although convincing oneself that they are pregnant to the extent of gaining weight, producing milk and even "going through labor" is a documented psychiatric condition, there's another called Munchausen's where a patient fakes a condition for some gain, mostly attention.  My patient at ECMC gained attention during her "pregnancy" including all the extra perks that pregnant women get.  Also, once she told everyone that she had lost her baby, she gained the sympathy from everyone for her "dead baby."  I am still not convinced that her first pregnancy wasn't a lie as well.

PPROM (Preterm Premature Rupture of Membranes) in a woman with twins.  The twins are 31 wks old so they are "preterm."  PROM happens when one's water breaks long before labor starts.  Usually labor will eventually follow, however the risk of infection is very high in these women because their uterus is now essentially exposed to the open.  The treatment is usually antibiotics and to watch for signs of labor.  In this case, the mother was transported from a Canadian hospital to Fort Erie by helicopter and then met by an ambulance that brought her across the border.  Supposedly, helicopters can't cross international borders with patients.  She's being watched and hopefully will give the twins a couple more days.  (http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnant/prm.cfm)

There was also a whole host of high risk patients, several sets of twins including the mother having a boy and a girl after IVF.  She was interesting because they had tried to fertilize 12 eggs.  Of the 12, only two developed, and one was considered "small and weak."  She was told that of the two to be placed in her uterus, more than likely only one would "stick."  So, she tells everyone "what was meant to be happened."

I had a teen pregnancy where the mother was found to have active herpes and had to be taken back for a C-section which I, of course, don't get to have anything to do with even though we diagnosed the lesions and I worked up the patient.

I had two other women that came in to rule out labor.  One I sent home just before the end of my shift, and the other was going to be re-evaluated by the overnight resident.

We had a mom with a baby with a bad congenital heart defect.  When I left, they were planning to induce her, and if the infant survived, they would stabilize it and transfer it to Rochester for either pediatric cardiac surgery or to await a transplant that might be its only hope.

Also, I complain a lot about having to do pelvics.  I think I've mentioned how there are certain parts of the body I really don't want to have anything to do with.  However, being on this service, I've now set myself a goal of being able to accurately measure cervical width.  Today, I finally was able to feel a cervix or two and confidently say whether it was a 2 or a 4.  Now I just need to add effacement, and I'll be golden.  Setting the challenge distracts me from what I am doing... and at times, we could all use a little distraction, n'est pas?

"Ski Rounds" tomorrow.  I will explain then.  Back to L&D for 24 hour call on Thursday.

Tags: gastroschisis, hydrops fetalis, pseudocyesis, Trisomy 18, PPROM