Summary

Overall, I had a positive experience on my OBGYN rotation.  It was nice that a lot of my experience confirmed my interest in OBGYN and passion for woman’s health.  I loved having the chance to be involved in all different facets of women’s health, including clinic visits and counseling patients on safe sex practices and contraceptives to prenatal visits, as well has having time in Labor and Delivery and in the OR.  It was the first rotation where I felt like I liked every aspect of the work and definitely felt it was a natural fit.  Additionally, I had a lot of opportunities to do pelvic exams which were definitely intimidating to me earlier in rotations but it felt rewarding to be able to do them confidently and competently at this point.

One challenging part of this rotation was the fact that I never worked with the same provider twice.  This was especially challenging because each provider had different expectations and had different preferences on how much they wanted to involve the students. This definitely required me to be more assertive, however I think I would have gained more from the experience if I spent more time with fewer providers.

I definitely feel that I made the most out of the rotation given the challenges presented and I hope I have more opportunities to work in OBGYN.

Here is a log of all the patients I saw Case log8

Site Evaluation

Reflection

I enjoyed my meeting with my site elevator.  I definitely think that over the course of my rotations I have improved in my ability to present, including pertinent information and knowing which information is extraneous.  Additionally, I feel more confident in my ability to discuss these case with my evaluators.

Here is the history and physical I presented HP Rotation 8

Journal Article

Summary

Nausea and Vomiting ion Pregnancy

Background

• 50% of women have nausea and vomiting, additional 25% experience just nausea. Clinically significant in 35% of women causing missed work time and negatively affecting women’s personal life.
• Around 0.3 to 1% experience hyperemesis gravidarum which is characterized by persistent vomiting, weight loss of more than 5%, ketonuria, electrolyte abnormalities and dehydration.
• Onset of nausea is usually 4 weeks after last menstrual period, peaks at 9 weeks and usually resolves by second trimester, nausea and vomiting resolves by 20 weeks in 91% of women.
• There are a number of theories as to the pathophysiology of nausea and vomiting in pregnancy. These include:
  • Stimulus produced by placenta causes nausea and vomiting. Nausea and vomiting was less common in multiparous women, smokers and older women- all of which have smaller placenta volume.
  • Nausea vomiting is associated with bHCG levels. bHCG possibly stimulates estrogen production which increases nausea and vomiting.  Women with twins and hydatidiform moles have higher bHCG levels and higher incidence of nausea and vomiting.
  • May be due to vitamin B deficiency, women who take multivitamins with vitamin B have lower incidence of nausea and vomiting.
• Complications include; neuropathies due to B6 and B12 deficiencies as well as low birth weights in babies born to mothers who lost a lot of weight in first trimester.

Strategies and Evidence

Evaluation

• When evaluating a patient for hyperemesis gravidarum it is important to rule out GI causes of vomiting. Note that it is rare that vomiting and nausea starting more that 8 weeks after last period is less likely to be associate with HE.  Headache, fever and abdominal pain is suggestive of another cause.
• Lab work including urinary ketones, BUN, creatinine, ALT, AST, electrolytes, amylases, T4 and TSH should be measured to evaluate any other possible causes.
• bHCG cross reacts with thyrotropin stimulating the thyroid gland and thyrotopin is suppressed. This causes hyperthyroidism in pregnant patients which is treated with PTU.  Labs may appear similar to graves however, there will not the other characteristic findings.  These patients should be reevaluated at 20 weeks since levels usually normalize by then.  U/s should be used to rule out multiple gestation or hydatidiform mole.

Management

• Behavior modifications that reduce nausea and vomiting include:
  • Avoiding odors, environments and foods that trigger nausea.
  • Eating frequent small meals throughout the day and eating something first thing in the morning.
  • Small study showed foods high and protein and low in fat reduced vomiting and nausea.
• Patients with persistent nausea vomiting and high levels of ketones- IVF, thiamine, multivitamins and antiemetics.

Pharmacologic Therapies

• Studies showed significant decrease in levels of nausea with treatment with vitamin B6 compared to placebo. One study showed no correlation.
• Vitamin B6 and doxylamine combination removed from US market in 1983 because of possible teratogenicity, now claims are unfounded and 6000 subjects studied with no evidence of teratogenicity and 70% reduction of nausea and vomiting. Available OTC in US and recommended by American College of Obstetricians and Gynecologists.
• Metoclopramide (used when antihistamines fail) dopamine antagonist. Has been associated with tardive dyskinesia, should not be used for more than 12 weeks. Compared to IV promethazine less drowsiness and dizziness.
• Zofran compared to promethazine- less sedating. Case serious involving 169 women in first trimester, 3.6% of babies had major malformations.
• Droperidol risks of prolonged QT interval, torasades de pointes and fatal arrythmia.
• Methylprednisilone- mixed results. Small study showed it was superior to promethazine, larger study showed no difference in incidence of rehospitalization when compared to placebo.
• Use of glucorticoids at 10 weeks associated with increased risk of cleft lift (+/- cleft palette) by a factor of 3 to 4.

Alternative and Complimentary Therapies

• Acupuncture- small studies and results are mixed.
• Acupressure wrist bands- inconsistent result. In largest study no benefit found.  In study comparing ReliefBand to sham device there was a significant decrease in nausea and vomiting.
• Randomized, double-blind trials show benefit of ginger in reducing vomiting and nausea. It is considered a food supplement rather than a drug.

Managing Refractory Cases

• Total parenteral nutrition has significant risks; line sepsis (25%) and steatohepatitis. Should only be employed for patients not responding to antiemetics with >5% of body weight loss.

Conclusions/Recommendations

• Important to investigate other causes of hyperemesis, especially in presence of headaches and GI disorders.
• Recommended regiment: vitamin b6 10-25 mg q8hr, doxylamine 25 mg at bedtime and 12.5 mg in morning and afternoon.
  • If ineffective, phenothiazine, metoclopramide and ondansetron can be tried in succession.
  • Refractory cases- methylprednisolone after 10 weeks gestation

Hyperemesis gravidarium