Hospice, Palliative Care Medicine, Pain Management, and OB/GYN

On today’s episode, Nick is flying solo to interview Nathan Riley, MD. Nathan is a practicing OB/GYN, but also a hospice and palliative care medicine fellow at the University of California San Diego. Nathan also is a podcaster in the #FOAMOb movement — check out his podcast, the OB GYNO WINO, where he pairs a reading alongside a bottle of wine. He also posts comprehensive show notes for each episode!

Nathan starts and shares with us his path to hospice/palliative care medicine, and what every OB/GYN should know about the specialty. The WHO definition of palliative care encompasses a lot of the essentials: “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.

Nathan shares with us some pearls on end-of-life and goals of care discussions, code status discussion, and pain management, where we spend the majority of the podcast. We start with the WHO analgesic ladder as a good starting point for a framework.

We then go into some pharmacology:

  • Cmax: the amount of time it takes a medication to go from administration to peak effect. This often is tied to route of administration: IV meds in 6-10 mins, SC/IM in 20-40 mins, and orally can be as long as 45-60 mins for max effect time!

  • Half life: the amount of time it takes for a drug to reach half of its original concentration in serum . For many opioids, this is in the 2-4 hour range. It takes 4-5 half lives to reach steady state, or when there’s equilibrium between intake and excretion.

  • Potency: describes a relationship between the amount of a medication and the effect produced. Higher or lower potency do not necessarily imply more/less side effects; just the dose to produce the response is different. As an example, fentanyl is much higher potency than morphine in its analgesic effect.

Finally, we review multimodal pain control for different common procedures in OB-GYN, including vaginal birth, cesarean section, and hysterectomy.

For vaginal birth and cesarean delivery, ACOG CO 742 is an excellent resource.

For all patients with vaginal birth, ibuprofen and acetaminophen should be enough, in addition to supportive measures and local topical anesthetics. Preparation prior to delivery regarding expected pain/discomfort is also important. If pain after vaginal birth is so severe that these patients require an opioid, Nathan’s pearl is to examine that patient! Many providers are still prescribing opioids, which may contribute to the opioid use epidemic in the USA currently.

After cesarean birth or after hysterectomy or abdominal surgery, preparation and expectation-setting are also key preoperative steps. For cesarean in particular, intrathecal morphine can reduce pain postoperatively.

Enhanced Recovery After Surgery (ERAS) pathways (check out ACOG CO 750), involve scheduled NSAIDs and tylenol, in addition to other steps that get patients eating and moving immediately post-operatively, can reduce opioid use. Opioids are usually necessary in the immediate post-op period; hydrocodone or oxycodone are preferable to hydromorphone (Dilaudid) in terms of opioid choices, due to their relatively lower potency. Local blocks and wound infusions or injections with local anesthetic may also be helpful. To manage constipaton, senna is preferred; docusate sodium may even increase ileus in the post period!

Check out the OBGProject for further reading:
- Cesarean Section Best Practices & Guidelines – The ERAS Committee Recommendations
- Managing Pain in the Postpartum Period: Recommendations Using the Multimodal Approach
- Preemptive Analgesia to Control Postop Hysterectomy Pain: The SGS Clinical Guidelines
- Can Pain Following Gyn Oncology Surgery Be Managed with a Very Restrictive Opioid Protocol?
- How Well Does IV Acetaminophen Control Post-Op Cesarean Pain?
- Fixed-Interval or On-Demand Treatment Better for C-Section Pain?
- Does Preop IV Acetaminophen Reduce Pain following Pelvic Organ Prolapse Surgery?

Vision Changes in Pregnancy

Today we are joined by Dr. Ben Young. Ben is an ophthalmology resident at Yale New Haven Hospital in Connecticut, and is sharing with us a common complaint that we know very little about - the eye in pregnancy!

Ben also hosts Eyes For Ears, an educational podcast and flashcard reference for ophthalmology residents. If you happen to know any vision sciences students or residents, let them know about it!

We start out talking about the “ocular vital signs,” which are:
- Visual Acuity
- Pupils (“swinging light test”)
- Intraocular pressure
- Visual Fields
- Extra-ocular movements

Image copyright of FOAMCast

The most common reasons for ophthalmology issues in pregnancy relate to either 1) vision changes requiring a new prescription, or 2) dry eye. However, don’t forget some key pearls:

- Monocular (single eye) double vision — dry eye. Binocular (both eye) double vision — badness!
- A Snellen chart and a flashlight are the best tools you have to help out a consultant.
- Check out this video on how to perform a swinging flashlight test.

Further reading from the OBG Project:
Get updates on this and more content, as well as other awesome features for FREE if you’re a PGY-4 — sign up for OBG First!
Is Cataract Surgery in Women Associated with Decreased Mortality?

Special SMFM Interview: Dr. George Saade

Our first special interview from SMFM is with Dr. George Saade. Dr. Saade is the Jennie Sealy Smith Distinguished Chair, Chief of Obstetrics and Maternal Fetal Medicine, and Professor of Obstetrics and Gynecology and Cell Biology at the University of Texas Medical Branch in Galveston, TX. His official bio can be found at this link.

Dr. Saade shared with us a number of great pearls, including his philosophy on pregnancy as a window to future health. We hope you enjoy and look forward to our next interview coming next Wednesday!

SMFM Interviews: Teaser Trailer

Hi all! We have a special release today after our exciting time at the Society for Maternal-Fetal Medicine’s 39th annual meeting. We were lucky enough to interview a bunch of exciting people in the field, and will be releasing interviews over the next several weeks.

If you want exclusive access to all of our interviews immediately, become a $5 / month member on our Patreon. Otherwise, we’ll be releasing a new interview every Wednesday for the foreseeable future!

Our fabulous interviews included:
- Dr. George Saade (UTMB)
- Dr. Sean Blackwell (UT Houston)
- Dr. Alison Steube (UNC)
- Dr. Mary D’Alton (Columbia)
- Dr. Cynthia Gyamfi (Columbia)
- Dr. Aaron Caughey (Oregon)
- Dr. Stephanie Ros (USF)
- Dr. Jeffrey Sperling (UCSF)
- Dr. Desmond Sutton (Columbia)
- Dr. Vincenzo Berghella (Thomas Jefferson)
- Dr. William Grobman (Northwestern)

Breastfeeding Part I

Today we start a two part series on breastfeeding with Dr. Erin Cleary, Assistant Professor of Obstetrics and Gynecology and Clinician Educator at the Warren Alpert Brown School of Medicine. She’s also the incoming MFM fellow at the Ohio State University — so look out for her in July, Buckeye listeners!

Also, thank you Dr. Daniel Ginn, our first Patreon sponsor — and apologies for the dad joke with your name!

We start today with a discussion of the anatomy of the breast, and in particular with lactation. At the bottom of this post is a corresponding Netter image to guide your listening.

The physiology of lactation is somewhat confusing, but in bulleted summary:
Lactogenesis I Early in pregnancy, human placental lactogen, prolactin, and chorionic gonadotropin contribute to maturation of the breast tissue to prepare for lactogenesis.

  • In the second trimester, secretory material which resembles colostrum appears in the glands.  A woman who delivers after 16 weeks gestation can be expected to produce colostrum.

  • Differentiated secretory alveolar cells develop at the ends of the mammary ducts under the influence of prolactin.  Progesterone acts to inhibit milk production during pregnancy. This makes sense from a viewpoint of energy expenditure- grow your baby first in utero, then switch to focus on growing it with milk.

Lactogenesis II is the onset of copious milk production at delivery.  In all mammals, it is associated with a drop in progesterone levels; in humans, this occurs during the 1st 4 days postpartum, with “milk coming in” by day 5

  • During the next 10 days, the milk composition changes to mature milk.  Establishing this supply is Lactogenesis III, and is NOT a hormonally-driven process like Lactogenesis I or II. Rather, this is supply/demand-driven with expression of milk

  • When the milk is not removed, the increased pressure lessens capillary blood flow and inhibits the lactation process.  Lack of sucking stimulation means lack of prolactin release from the pituitary.

Next week, we’ll be back again with Dr. Cleary discussing breastfeeding myths and contraindications, so stay tuned!

Netter’s Anatomy. Copyright Elsevier texts.