March 14, 2008

Reproductive Issues

Today was a day of reproductive problems.

I went to the Maternal/Fetal Medicine department at Queens and I shadowed a physician there for a few hours. She was a "problem-pregnancy specialist."

The first patient that we saw was a young woman with suspected preeclampsia. It's basically a condition of high blood pressure, protein loss in the urine and sometimes accompanied by edema. It can lead to further complications like seizures, preterm delivery and stillbirth, so it can be pretty serious. She had chloasma and linea nigra, darkened pigmentation of the cheeks and a dark line down from the belly button. It was the first time I'd ever seen (or heard) of it. It's also called the "mask of pregnancy."

I had a good time chatting with her and her husband about school and their physician and such during their non-stress test (fetal heart rate monitoring) that I missed the beginning of the Dr. B's next patient encounter.

It was with a young diabetic woman who recently found out that she was pregnant. Unfortunately, she is a "RFN", meaning that she has retinopathy (can't see), ne'f'ropathy (kidney problems) and neuropathy (sensation loss in her lower legs.) These are long term complications of poorly managed diabetes and from the looks of it, she had a lot of support problems in her family that prevented her from getting quality care. It was really sad, because it meant that she had to make a difficult choice -- continue the pregnancy and risk early preeclampsia, possible miscarriage and progression of her blindness and kidney failure that would put her on dialysis... or terminate the fetus.

I... I don't know what to say about this. There were some other emotional issues that complicated her decision-making process that really surprised Dr. B. and I. I wish that Dr. B. followed up on it, because it was quite striking. Perhaps at a later visit she will. It's a tough position to put anyone in, deciding which life will suffer to ensure the welfare of the other.

Perhaps it could be a blessing for her if she decides to continue... I said hopefully. Dr. B. expressed her doubts and I can see why. She has difficulty maintaining a stable life for herself; adding a child would just be an additional stressor. The child will likely have a lot of complications due to vascular insufficiency in utero... diabetes is one of those silent systemic diseases that wreaks havoc on all parts of your body but doesn't let you know what it's doing until it's too late.

I left that obstetrics session with a lot of things to think about. How will I handle these issues with my own patients? What level of autonomy vs paternalism do they want? After all, it takes an expert's opinion in order to figure out what to do... and then the choice is left up to an overwhelmed patient. On the other hand, being harsh or judgmental affects the relationship with the patient who relies on the doctor to be their advocate... it would undermine everything to pull in biases and overrule what is in the patient's best interests.

I guess it all comes down to that. Interests. Values. Discovering what matters most to the people you see in the clinic and seeing how that affects their decisions. Helping them to understand the significance of the issues at hand and the role that they play.

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Later on tonight, I went to the homeless shelter near school to help out at our free clinic.

One of the fourth year students gave a short talk entitled "Reproductive Issues in the Homeless." He shared some statistics with us, basically saying that physicians often avoid the issue of sexual matters with homeless and that limits their contraceptive use. Ironically, being monogamous and not engaging in sex trade is actually associated with lower contraceptive use since "commercial sex workers" are the types who seek out these methods of protection.

Some of my classmates, so inspired, decided to take a bag of condoms and distribute them to residents of the shelter. Later on, he told me that a lot of the women there would initially refuse to take any condoms, but when pressed, they would glance around, see if anyone is looking.... and then they'd take the entire cup of condoms being offered.

Truly there is more we can do to help these women in the area of reproductive health than just offering them a dozen condoms on a particular night. A lot of them have health insurance and just educating them about some of the options (IUDs, rod implants, Depo-Provera) can go a long way.

All in all, it's been quite a day for me.

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