OB - Needed more info and treatment

Ms. P is 19 weeks pregnant. Her VS are 105/67, 89, 99.1. She has a history of gonorrhea in February of this year when she went for her PAP. She was treated with “a shot and some pills.” On May 8 at 14 weeks, she began to bleed heavily, saturating through four large pads during the day and passing a clot the size of a golf ball. She also had some cramping. She went to the Emergency Room where she was diagnosed via ultrasound with complete placenta previa and was told to follow up with her OB. She went to her OB but by that time, the bleeding and cramping had stopped. She continued on full duty, doing PT and road marches because she was not given a temporary profile.

Today, Ms. P presents with severe cramping that feel like spasms; pain level 8/10; no spotting or bleeding. She has not eaten for 36 hours (taking a little water only) and feels lightheaded. A vaginal ultrasound indicates that the placenta is no longer sitting on the cervix. My preceptor explained that as the uterus grew, the placenta moved up and away from the cervix. The cervix was intact with no dilation or thinning. FHR was 150 and there was a lot of fetal movement. The patient was told that the baby was developing normally, the placenta previa had “resolved,” and she had no restrictions.

I would like to have seen Ms. P given an explanation for the pain and spasms. I asked my preceptor if it could be round ligament pain; he stated it probably was, but this was not explained to the patient. She was also not treated for her nausea and lightheadedness. It was very hot in North Carolina during this period of time; dehydration was an issue. I also thought that because Ms. P had a problem with placenta previa earlier in the pregnancy and she is now having nausea, she should have been given a temporary profile not to run or do road marches for the remainder of her pregnancy.

My preceptor surprised me with this case. He is a fertility doctor and is very compassionate with his patients. He is very generous with con leave and profiles. I expected more aggressive treatment.

OB ISSUE-Susan Frisbie-posted 13 June 2010

Twenty-eight year old, G1P1001, Caucasian female presents for six week postpartum appointment. She is active duty and part of a dual military couple. She is also active in basketball, running and enjoys most physical fitness activities. One day while playing basketball (prior to knowing she was pregnant) she fell and hit her head and suffered a brief loss of consciousness. She was taken to the emergency room and an MRI was done. The MRI revealed lesions consistent with Multiple Sclerosis. Her and her husband had been trying to conceive and she found out she was pregnant two weeks after the MRI. Her brother has Duchenne Muscular Dystrophy and she is also a carrier. Husband has no familial genetic history and is not a carrier for Muscular Dystrophy. Her prenatal course was unremarkable and she had an uneventful SVD. She was currently breastfeeding at the postpartum appointment but stated she has to stop now and start back on Interferon. While off the Interferon during pregnancy she remained symptom free. Her depression scale was an 8 but she was very open about her disease and does her best to not let her disease bring her down. She was very proud to share she took her Navy PRT 7 days after delivery. I ask about hindsight regarding the signs of Multiple Sclerosis and she said many but the most obvious sign is that she has been clumsy her whole life. She reports no muscle, bowel, bladder, eye, or neurological symptoms. Her postpartum physical assessment unremarkable. She states she will be able to remain on active duty as long as her disease allows. It’s amazing that a person with a debilitating disease can get pregnant, have an uncomplicated pregnancy and unremarkable delivery.

Post Partum or Pregnant?

OB Case:

I had a 34-year old African American woman presented to the OB clinic for her post partum/new OB appt. The patient was a 6-week post-partum visit from a D & C she received during her 4th month of pregnancy as a result of a massive fibroid. At that time the patient was informed and scheduled for surgery to have the fibroid removed. The patient resumed intercourse in hopes of having a baby in which she became pregnant again. The problem/issue is that this patient needs to have the fibroid removed prior to being able to maintain this pregnancy. The patient was counseled on the seriousness of this massive fibroid and the implications of future pregnancies and yet the patient is now pregnant again. The patient, in denial does not fully understand nor does she show any interest in what the effects of this fibroid can do to her and her upcoming pregnancy. She does not want to face reality even when shown with Ultrasound the size of the fibroid. I am personally amazed that she even became pregnant again. I know that sometimes women with fibroids have a hard time getting pregnant and yet she managed to get pregnant before her 6-week post-partum visit. I am just astonished by it. Education was enforced along with signs and symptoms as well as the risks explained to the patient. The patient was also informed of the possibility of a Myomectomy (although rare) to be performed during her pregnancy and she was referred to Maternal Fetal Health for High Risk Pregnancy.

I am so excited I am finally Pregnant!!!!

I had a 25yo G4P1 11wk gestation New OB Visit patient who responded to my question, "How are you feeling today?" with "I am so excited I am finally pregnant!" In short, she had her first child when she was 19, she had a missed abortion in 2009 at 9 weeks gestation, a missed abortion in February this year only to learn approximately two weeks after her D&C she was pregnant again. She didn't know she was pregnant with the the previous two so finding out "while" she was pregnant that she was pregnant was exciting! Unfortunately, when we went to check for fetal heart tones, none were to be found. We did a transabdominal US only to find no fetal movement or fetal cardiac movement...so we tried the transvaginal US, measured the fetus to be at approx. 8 weeks gestation, no movement, no heart movement....she was again...with a demise. Although my preceptor could have asked the doctor sharing her office with her to verify the US, she decided she did not want to trouble him for "this because it is routine and doesn't warrant me bothering him about it." He was standing right there in the hallway...completely available (well, in my opinion he was). The Acute MD was not available so my preceptor opted to have the client go to radiology to have a confirmation US performed and she would "get back with" the patient when the results were "available." She did have the patient return later that evening to review the results but, again, no MD was available to discuss her tx options. The patient had to wait two days before a doctor finally saw her to discuss her treatment options. I just found this to be unacceptable. I can't imagine making a woman sit there for two days knowing she had a three week demised fetus in her womb and no present control on how to deal with it. I think I would have asked the doctor sharing my office if he wouldn't mind spending some time with my client to review the findings and discuss tx options while I took on one or two of his clients. A long paragraph but I thought the details were important.