Reflection: OBGYN Rotation
Going into this rotation I wasn’t completely sure what to expect as far as the distinct sections of the rotation: labor & delivery, gyn-call, OB-call, and 2 weeks of clinic. I kicked things off with labor and delivery overnights, followed by two weeks of overnight gynecology and obstetric call shifts, and finally 2 weeks of OB GYN clinic. Over all, the experience was unique in it’s array of patients with each week offered different opportunities to be involved, but also to see how the various subdivisions of this specialty within the hospital interact with themselves as well as with the other departments within the hospital.
Labor and delivery was a great opportunity to put myself out there in order to be involved, whether that be by introducing myself to all of the patients so they are comfortable with my presence as a student, or by making sure the various providers knew I was interested in being involved and learning new skills. In that first week I was able to assist with several normal spontaneous vaginal deliveries, as well as scrub in for a cesarean section. There was plenty of opportunity to monitor and interpret tracings, participate in exams, and assist in deliveries.
In the two weeks of overnight call shifts I had my first view of how a physician assistant “on call” responds to consultations in the hospital setting. There were many consults to the emergency department involving patients with acute issues that required the expertise of an OBGYN provider, including many ectopic pregnancies and threatened abortions. I also enjoyed the follow ups with patients who were postoperative following cesareans or hysterectomies which included focused physical exams and gathering a history of their recovery following their procedures.
I’d have to say my favorite weeks of this rotation were the ones spent in clinic. Being able to spend an entire day with a single provider and see how they approach each patient was extremely educational. It was here that I was able to get the most experience with pelvic exams, breast exams, use of the speculum, and taking samples for culture. The providers were happy to teach and were very careful in making sure each patient was comfortable while progressively allowing me as a student to contribute more and more to their care during the visit.
Journal Article with Summary
Objective: To compare the treatment success and failure rates, as well as side effects and surgery
rates between methotrexate protocols.
Data Sources: PubMed, Embase and the Cochrane library searched up till July 2018.
Study eligibility criteria: RCTs that compared women with ectopic pregnancies receiving the single dose, two dose or multi-dose methotrexate protocols.
Study appraisal and synthesis methods: Odds of treatment success, treatment failure, side effects and surgery for tubal rupture as well as length of follow-up until treatment success compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in high hCG and large adnexal mass groups, as defined by individual studies. Cochrane’s collaboration tool used to assess risk of bias.
Results: The two dose protocol was associated with higher treatment success compared to single dose protocol (OR: 1.84, 95% CI: 1.13, 3.00). The two dose protocol was more successful in women with high hCG (OR: 3.23, 95% CI: 1.53, 6.84) and in women with a large adnexal mass
(OR: 2.93 95% CI: 1.23, 6.9). The odds of surgery for tubal rupture were lower in the two dose protocol (OR: 0.65, 95%CI: 0.26, 1.63), but not statistically significant. The length of follow up was 7.9 days shorter for the two dose protocol (95% CI: −12.2, −3.5). Odds of side effects were higher in the two dose protocol (OR: 1.53, 95% CI: 1.01, 2.30).
Compared to the single dose protocol the multi-dose protocol is associated with a nonsignificant reduction in treatment failure (OR: 0.56, 95% CI: 0.28, 1.13) and a higher chance of side effects (OR: 2.10, 95% CI: 1.24, 3.54). Odds of surgery for tubal rupture (OR: 1.62, 95% CI: 0.41, 6.49) and time to follow-up (−1.3, 95% CI: −5.4, 2.7) were similar.
Conclusion: The two dose methotrexate protocol is superior to the single dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and large adnexal mass.
My Summary:
This article that was chosen is a meta-analysis studying the population of women with ectopic pregnancy that was diagnosed by transvaginal ultrasound. The intervention was either single dose, two dose, or multi dose methotrexate protocols. The comparison were amongst these various protocols. The meta-analysis identified studies from searches of PubMed, Embase, and Cochrane library using various key words; methotrexate, ectopic pregnancy, tubal pregnancy, dose and protocol. Five hundred and twenty one duplicates were removed and after screening there were 7 articles left that were deemed appropriate for the analysis. All of the studies were randomized control trials ranging from 70 to 160 participants.
The 2-dose protocol was found to be superior to the single dose protocol, with even follow up length being shorter in those who had taken the 2 dose methotrexate protocol. There was also a reduction in the odds of tubal rupture surgery with the 2 dose protocol, although this finding was statistically insignificant. There were, however, more side effects associated with 2 dose protocol, although these were generally mild and did not interfere with continuation of treatment. The article recommends that the 2 dose treatment be considered the first-line option for ectopic pregnancy therapy. A strength of the study includes it’s discriminating inclusion criteria, as evident by the dramatic reduction of results to included studies, but is also clearly limited by this small number of randomized control trials deemed appropriate for inclusion. This article was chosen due to the number of cases of ectopic pregnancy I observed on this rotation that were treated with methotrexate, most often the single dose protocol.
Site Evaluation Summary
My site evaluations were a great combination of informal discussion, strict evaluation of the “pharm cards”, and education on how to best approach the patients I chose in my H&P assignments. The first evaluation began with quizzing on the 5 drugs I chose related to OB GYN; misoprostol, mifepristone, dinoprostone, methotrexate, and tranexamic acid. From there we moved on to my first H&P which addressed a patient with multiple complaints including vaginal discharge with scant blood, but an issue of incontinence was most important to the patient. They endorsed no history of STIs, but did relate their incontinence to the birth of their baby boy 9 months prior. By the description it was determined to be a stress incontinence and one that had persisted for quite some time and in recent weeks had been getting even worse. Ultimately a referral to urogynecology was made and the patient was educated on the use of kegel exercises for her incontinence. On speculum exam, there was no blood noted in the vaginal vault or from the cervical os, although a white-yellow discharge was noted from the os, and the patient was treated empirically with ceftriaxone and doxycycline while cultures were pending.
