Over Stimulated

Life begins in secret. 

The ovaries develop an "egg" or follicle is released and will travel quietly down the fallopian tube until it is fertilized.  It will implant into the wall of the uterus and eventually, the existence of new life will be discovered. 

It sounds easy enough.

But what happens when the ovaries are over-achievers?  Instead of producing one follicle or "egg," they produce 5, 10, 20 or more?  People actually pay for this service - called hyper-stimulation.  When one egg won't do - maybe a history of infertility or difficulty achieving pregnancy - patients take medicines to stack the deck in their favor.  And sometimes they succeed with one baby...two...or six.   Think Octo-Mom and John & Kate Plus Eight. 

Leave it to humans to take something that is already miraculous and try to super size it, right?

But ovarian hyperstimulation can also occur in the absence of infertility medications, albeit less commonly.  Called Spontaneous Ovarian HyperStimulation, it has been seen in young patients (<21 years), twin pregnancies or abnormal pregnancies (chromosomal abnormalities, molar gestations).  And when I say, "it's been seen" - I mean, most of us have read about it in a medical journal.

CM was an 18 yo G2P0010 at 9 weeks pregnant who came to casualty complaining of abdominal distention, nausea & vomitting and abdominal pain for 4 days.  I was called to evaluate when an ultrasound revealed bilateral ovarian "masses."

I reviewed the patient with "an intent to refer elsewhere."  She was pregnant, but there was a perfect 9 week fetus captured in the ultrasound photos.  Her abdominal distention was tympanic and very tender in the RUQ.  Her labs were off: Na 122/ K 5.4/ Hb 17/ WBC 14.5.  She was tachypneic and a CXR showed a right sided pleural effusion.   I easily ruled out ectopic and was ready to call "not it." 

But then there was this query of ovarian masses.  And I had to admit, she was a classic presention of Ovarian Hyperstimulation.  So I re-took the history.  Any history of any herbal medications?  Any medications?  Anything to help her get pregnant?  History of thyroid problems? PCOS?

No. No. No.  Accidental, unexpected pregnancy. No. No.

Spontaneous Ovarian Hyperstimulation?  I had heard of it.  It occurs so rarely that when trying to find the incidence of occurence - all I could find was: it occurs rarely.  So, unbelieving - I did my own ultrasound.

Her ovaries were so enlarged they were touching her diaphagm. Not even joking.  Sponataneous. Ovarian. Hyperstimulation.

Follicles measuring up to 4.5 to 5 cm.  Done hospital day 4 after abdomen was
less tender.

Viable fetus: 9 wks 6 days

 We admitted the patient to the ICU and started her on IVFs and Lovenox.  She eventually required a thorocentesis for the pleural effusion but otherwise did well.   We are trying to follow her closely during the pregnancy as she may be at risk for complications like fetal growth restriction and preeclampsia.  At her last visit, the fetus was 12 weeks and doing well.  Her ovaries had decreased to roughly 12 cm from 36 cm (!) on the original admission. 

Meanwhile, I am excited to meet the life that has perplexed me, demanding an early discovery of the "rare" type.  Who knows?  Maybe I'll be in the journals.....

Signs You May Be A Kenyan Ex-Pat

You find yourself drinking orange Fanta in the operating room.

You had to google SOPA. 

You watched Madonna's SuperBowl performance Live....on YouTube....on Tuesday.

You patch your scrubs when they get worn.

You are consistently 15-20 minutes late for everything.  Except lunch. 
Yet when you are on time, you are early...

It's February and you are still receiving Christmas cards and presents.

Any others?

Under Obstruction

January 30, 10pm:

The phone rings.  I fumble for the phone, just having fallen asleep.
"Hello?"
"Hello.  Now, we have a 15 year old G1 at term who has been pushing since yesterday.  Her vulva is edematous.  The cervix is complete and there is caput ++.  There are no fetal heart tones."
I sigh.  No anger.  No pity.  Just a sigh. 
"Prepare her.  I am coming."


January 29, 8 am:

A 15 year old G1 at term arrives at a health dispensary.  She is examined and found to be complete and zero station.  The baby is doing well.  The plan is to observe for an anticipated vaginal delivery.



January 28, In the night hours:

A 15 year girl wakes.  Pain grips her.  Water trickles down her leg.  She is in labor.



When I first started treating women with obstructed labor, my reaction to their vast array of complications was sadness.  Pity, even.   As I became more familiar with these women, I began to feel irritation and anger.  Why weren't they coming to the hospital sooner?  Kenya has plenty of medical clinics.  Transportation is eventually available.  Why, why, why? 

In January, I admitted 7 cases of obstructed labor, resulting 4 hysterectomies and 5 fetal deaths. 

I find myself falling into a routine in the care of these patients.  But the sharp edge of anger and pity is not completely gone, not completely replaced by the comfort of my medical check-list: Fast delivery, Triple antibiotics, copious irrigation, delayed foley removal.....yada yada.   Instead, with each case, even with the best outcome...live baby, patient maintains her uterus...there is this itching under my skin that doesn't go away. 
I know it's going to happen again...and I can plead with them to come sooner next time but its very rarely up to the patient.  I keep talking to patients and their families- telling them that: "God has blessed you by saving this mom and baby," or "Please, warn others, so that this does not happen to them..."  I cannot stop the lecture from erupting forth.....I am waiting for the one somewhere that will listen.

I've read that there are 3 hinderances to care for OB patients in third world countries (in addition to the physicial issues):
    1. Obstruction of Transportation - Does the patient have funds, access to transportation to reach a health care provider?
    2. Obstruction of Facilities - Are there health care facilities within walking/driving/traveling distance?
    3. Social Obstruction - This involves the peer pressure that mother-in-laws/husbands and other families may place on young women to deliver at home: Everyone else has delivered in our village.  They will automatically do a hysterectomy.  Social obstruction may cause some of the risk factors for obstructed labor: early childbearing, child brides and female circumcision.

So, where do we go from here?  What is the answer?  Is it community education?  More thorough antenatal care?  Social reform?  Probably all of the above. 

In the meantime, I will continue to operate.  I will save what can be saved and continue teaching my patients and their families.... honestly, anyone under the sound of my voice!

A few weeks ago, I was checking out the website of my residency program - just seeing who was there, who had left and how the place had grown. On each physician page, there was a blurb about what each doctor like to do or what they specialized in. "Dr. Jones is interested in general gynecology, infertily and laproscopic surgery."

It made me think about what my blurb would say.

Dr. Huber is interested in obstructed labor, emergency hysterectomies and hemorrhagic shock.

Eek. That's a little scary. And it's really not true....

I am Dr. Huber.  I am interested in a Kenya where women do not labor until their babies die and their uterus ruptures.  I specialize in hoping for this even when I cannot see the way to achieve it. 

Better.

CME

Continuing my medical education....with the help of Teddy.....

No, Teddy, You are NOT in the way.

Hmmm....I thought only medical students learned this way....

Who needs a fancy book stand?

The End.

A Hobby For Teddy

Once again, I have been requested to give an update on my furry companion.

Teddy has been doing very well.  And with the exception of once when we ran out of cat food and he had to eat leftover meat loaf for 2 days, I don't think he has any complaints.  In fact, over the past few months, he has found a hobby!

He has become an outdoors-kitty.  It began with me putting him out on the front porch tied with a makeshift leash.  But he was generally well behaved and he kept getting tangled in all the bushes, so we advanced to "un-restrained" outings.  He is very good.  He comes inside when called, he doesn't wander and he is mostly frightened of any stranger.

Here's what he enjoys:

He pic-nics on assorted salad greens....and sometimes he keeps them down.

He still spies on the neigbors....and the neighbors DOG!

He sunbathes.

He rolls around like a dog.

Sometimes he stalks prey....here he is stalking two large birds.  See them on the concrete wall?

He just stalked these two.....they were bigger than him!

I am glad they didn't carry him off.

And he practices hiding...for the day he can pounce on a small bird....I'll
keep you posted.....