Hospital Cuttings

June 28, 2011

Welcome to this, my first column for OBGYN.net. My hope is that my monthly articles will entertain, question and stimulate you in all areas of OBGYN. I am a general obstetrician and gynecologist working in North London, United Kingdom with particular interests in endoscopic surgery and urogynaecology. I am also an award winning medical journalist. Over the coming months I hope to share my experiences and thoughts with you, challenge our beliefs and contribute to the ongoing debate that shapes improvements in clinical care. I welcome your feedback.

Welcome to this, my first column for OBGYN.net. My hope is that my monthly articles will entertain, question and stimulate you in all areas of OBGYN. I am a general obstetrician and gynecologist working in North London, United Kingdom with particular interests in endoscopic surgery and urogynaecology. I am also an award winning medical journalist. Over the coming months I hope to share my experiences and thoughts with you, challenge our beliefs and contribute to the ongoing debate that shapes improvements in clinical care. I welcome your feedback.

I am always late leaving my antenatal clinics, the reason is simple: counseling patients. Out of all areas of our specialty, antenatal patients do, I think, take the most time. This problem is getting worse as more screening tests become available. The poor obstetrician has to spend even longer with the pregnant woman advising her on the indications, risks and benefits of each test, although thankfully in the United Kingdom not yet the cost of them, but that's another story…

We've just started offering our pregnant patients HIV tests and have been surprised at the uptake levels - over 60% accept. The clinical problem, which takes most counseling, is, I believe, screening for chromosomal disease, especially Downs Syndrome. The couples are naturally anxious and we usually have a good discussion about the available options: doing nothing, nuchal pad translucency, serum screening, karyotyping or anomaly scanning.

Despite trying to be as open and non-directive as possible, I find the whole counseling procedure challenging. Invariably after a long discussion examining each option at length, the patient will turn to you and say "well doctor, what would you do?" which slightly defeats the aim of the counseling. I've often found it an interesting paradox in that, sometimes when faced with a difficult clinical situation we ask the patient what they want. Is this truly giving patients a choice or passing the buck on a difficult decision which we, as highly trained individuals are uncomfortable with?

Menorrhagia is one of the most common problems that we deal with. You'd think therefore that we'd have got the question of how to investigate it sorted by now wouldn't you? I held a straw poll among colleagues at a conference last week as to what investigations they do in women with menorrhagia, the diversity of views indicated that either we're all doing it wrong, or we just don't know what to do. Since this is such a big clinical problem, and our insurance companies are spending vast fortunes treating it, this simply won't do.

Not surprisingly hysteroscopists insist hysteroscopy is necessary for all women with menorrhagia, those with ultrasound expertise repudiate this claiming a pelvic ultra-sound with an outpatient endometrial biopsy is all that is needed. I don't think there has ever been a randomized trial between hysteroscopy and pelvic ultra-sound as investigational methods in menorrhagia largely due, I imagine, to methodological difficulties in organizing it.

A gynecologist recently mentioned to me that he had stopped investigating patients who have experienced a single episode of post-menopausal bleeding. He personally examines the patients and performs a cervical smear. If there are no abnormal findings he discharges them instructing them to return promptly if they have any more bleeding. If there is more than one episode of bleeding or abnormal findings he performs hysteroscopy and an ultra-sound scan.

Using this approach, he claims he gives an efficient service and says he has never missed a malignancy. Is he a dangerous maverick or a caring gynecologist who uses his clinical experience to minimize patient discomfort and expense ?

Congenital toxoplasmosis is a condition I know very little about and is not a big problem in the United Kingdom. Recently I had a patient who had a detailed anomaly scan at 18 weeks gestation. The radiographers diagnosed microcephaly and sent the concerned parents to see me.

I was generally reassuring, arranged a repeat scan for 3 weeks time and also checked a toxoplasmosis and other infection screen, more to be seen to be doing a test by the parents than expecting to find a positive result. Not surprisingly the repeat scan was normal, but the toxoplasmosis result was equivocal for infection in pregnancy. This was where the fun started.

Our fetal medicine expert advised us, that, while waiting for confirmation we should commence the woman on powerful antibiotics in case of congenital infection. These drugs with potentially serious haematological side effects were then started pending the reference lab results after further tests.

Two weeks later it reported that it could not report definitively and sent the sample to a well respected Professor of Toxoplasmology for further examination. Subsequently, after tracking him down for over two hours in various hospitals, he advised there was no evidence of acute infection in pregnancy and the antibiotics could be stopped reducing the risk of side-effects.

On contacting the patient to give her this good news that she could stop the tablets, her husband replied " She's never been any good with tablets and doesn't like taking them in pregnancy so we never bothered with your prescription!" What more can I say?