OB/GYN may have been one of my favorite rotations thus far. I was excited to be in a field where I would be learning to improve healthcare outcomes specifically for female patients and enhance my understanding of the unique-gender specific health issues. This 5 week rotation was split between three areas: clinic, labor and delivery, and gynecological surgeries. I started out in the clinic, which was a great introduction as I learned how to deliver routine care to patients there for their gynecological annual exams or for their prenatal visits. The next two weeks I was in labor and deliver, which was unlike any experience I have had before. I had some exposure to it during my pediatrics rotation in the NICU, but to be on the floor for 12 hours was eye-opening and thrilling. It made the overnight shifts and 24 hour shift worth it. For my last week I was part of the gynecology surgical team. There were not many surgeries scheduled for that week, which was a bit disappointing, but I was grateful to be able to scrub into a myomectomy. 

I am thankful for the PAs that I followed during clinic because they gave me the opportunity to really participate in the care of the patient. I became comfortable in performing breast exams, speculum exams with Pap smears and STI tests, and bimanual exams. I remember when I was first given the chance to use the ultrasound and the memorable excitement of finding the fetus and seeing all the small parts. The providers let me measure the fundal height and use the Doppler to measure the fetal heart rate for almost all the patients that came in. High risk clinic was on certain days of the week and I got to see how management would change if the patient had gestational diabetes, history of placenta previa, history of preeclampsia etc. While I was on the labor and delivery floor, I had the chance to participate in the vaginal deliveries (delivering the placenta, taking placental ABG) and scrub into the C-sections. 

In addition to the procedural skills I performed, while I was on L&D, I was responsible for taking the history and presenting to the resident if a patient presented in labor and delivery triage or if there was an ED consult. I not only learned how to take a focused H&P, but how they like it to presented to them. One part of the history that I may not have thought of asking if not otherwise told so was a history of asthma. 45% of patients with a history of asthma have an asthma exacerbation during pregnancy, which can significantly decrease the amount of oxygen in the blood and the amount of oxygen that reaches the fetus. This can increase the risk of pre-eclampsia, preterm birth, low birth weight, and cesarean delivery. Another responsibility I had was updating the floor board, which had information on the patients currently admitted to labor and delivery, including gestational age, if they were induced or not and at what time, dilation and effacement, lab values, and medical conditions that may complicate the delivery. I felt that I was learning a new language, which I had to become familiar with very quickly. 

One memorable moment during the rotation was when I was in a C-section of a baby that was thought to be complete breeched with the head in the upper right abdomen but was actually in the transverse position. The cut was made too high, so parts of the baby was below and above the incision site. It felt like it took forever for the providers to pull the baby out, with the fear, which I later found out, that the baby was going to have at least one broken limb. They were trying to quickly get the baby out as possible but also staying aware of the mother, the amount that she was bleeding, and other potential complications. OB/GYN providers have the profound responsibility in balancing between maternal and fetal health, making it truly a multifaceted role. 

After completing the rotation, I think that I got a good sense of what it is like to work in OB/GYN. It was one of my favorite classes I took during didactic year and I liked the rotation just as much. It felt like a privilege to take care of potentially two lives. Two areas that I had hoped to have more exposure to was patients seeking abortion or patients dealing with infertility. I think there is a potential emotional component that may accompany such situations that I don’t feel particular prepared for or equipped to educate on. 

Optimal delivery method in the presence of low-lying placenta

Placenta Previa is a pregnancy complication where the placenta partially or completely covers the cervix. It typically is characterized by painless vaginal bleeding that starts in the second or third trimester and is a major risk factor for postpartum hemorrhage. Mothers are at a higher risk if they are older than 35 years old, are multiparity, a smoker or cocaine user, or have a prior history of curettage, cesarean sections, or placenta previa. The definitive diagnosis is made through transvaginal ultrasound. Depending on the symptom severity, patients may need to be hospitalized to managed for bleeding; however, approximately 90% of placenta previa cases diagnosed early in pregnancy resolve by the third trimester. When the placenta is completely covering the cervix, it prevents the mother from having a safe vaginal delivery, resulting in majority of individuals being scheduled for elective cesarean sections at 36-37 weeks. However, a vaginal delivery is not an absolute contraindication in cases of low-lying placenta. 

In a 2019 systematic review, researchers sought out to determine the probability of a successful vaginal delivery in women with low-lying placentas as the preferred method of delivery remains unclear. The researchers used OVID EMBASE, OVID MEDLINE, and clinicaltrials.gov to find studies published from inception to February 2017 with a primary outcome of successful vaginal deliveries in women with low-lying placenta and a secondary outcome of antepartum, intrapartum, and postpartum hemorrhage. Of the 10 articles identified, results showed that vaginal delivery was most successful if the placenta was lying at 11-20mm or more from the internal os with a significant lower emergency cesarean rate due to hemorrhage. No statistically difference was seen when the distance from the internal os was 0-10mm. The results are summarized below. 

Internal os distance (IOD) (mm)	Successful vaginal deliveries	Emergent Cesarean rate due to hemorrhage
0-10	43% (95% CI 28-59)	45% (95% CI 22-29)
11-20	85% (95% CI 70-96)	14% (95% CI 4.2-29)
>20 mm	82% (95% CI 58-97)	10% (95% CI 2.2-22.3)

Results of the secondary outcome showed a minimal difference between IOD and antepartum and postpartum hemorrhage. Interestingly the researchers found that women with larger IOD and women who delivered cesarean delivery required more blood transfusions due to increased intrapartum hemorrhage among caesarean deliveries compared to vaginal delivery. 

This study has demonstrated that a trial of labor is possible in women with a low-lying placenta within 20mm of the internal os in the third semester, with a significantly higher chance of vaginal success rate if the placenta lays more than 11 mm away and a smaller emergent cesarean rate due to hemorrhage if the placenta is more than 20mm away. Ultimately extensive education and counseling should be given to the patient and a shared decision should be made before labor. 

Limitations of the study include majority of the studies being retrospective studies, increasing the risk of selection bias with a possibility of overestimation and/or underestimation of the association between low-lying placenta and delivery outcome. Further results should focus on prospective studies that focus on reducing the time between the last ultrasound and delivery to determine the optimal delivery method. Other factors such as in the presence of posterior or anterior placenta or marginal sinus placenta previa or speed to which the placenta migrates per week should be assessed in whether there is an association between higher rates of successful vaginal deliveries or a need for emergent cesarean deliveries. 

MiniCAT Question: In women who need vaginal swabs to diagnose sexually transmitted infections (P), are self-collected swabs (I) as accurate (O) as clinician-collected endocervical or vaginal swabs (C) for STI detection, including chlamydia, gonorrhea, trichomonas vaginalis, and HPV?

MiniCAT Question: Among adults who present with cognitive deficits such as memory loss, confusion, and difficulty speaking (P), is the Montreal Cognitive Assessment test (I) more accurate at detecting dementia and its subtypes (O) compared to the Mini Mental Status Exam (C)?

Site Evaluator: Manual Saint Martin, MD 

For my first visit, I presented an H&P on a 22 year old male presenting in CPEP triage for depressed and suicidal thoughts. Despite being on Lexapro 10mg tablets, the patient reported feelings of sadness, homelessness, unintentional weight loss, decreased sleep, and disinterest in doing anything. Upon psychiatric examination, the patient exhibited fair judgment but with impaired impulsivity.  My differential diagnoses included major depressive disorder, borderline personality disorder, persistent depressive disorder, and medication/substance-induced depressive disorder. Based on the patient’s history and psychiatric evaluation, the patient most likely had Major Depressive Disorder. Given the patient’s suicidal thoughts and history of suicidal attempts, the team decided that the patient warranted overnight observation in CPEP for further observations and stabilization. I chose this case because it was the first patient that I did a mental status on and created a safety plan with. When I presented the case to Dr. Saint Martin, we discussed possible treatment options and appropriate medication dosing as the patient was likely on too low of a Lexapro dose. He agreed with my differential diagnoses. 

For my final site visit, I presented a case of a 19 year old male presenting in CPEP triage for agitation and erratic behavior. NYPD was called after he was found to be hitting the neighbor’s door with a metal hammer looking for his “fiancé”. He was found to have a history of substance-induced psychosis (daily use of marijuana and weekly use of alcohol), delusions, auditory hallucinations, and physical aggressiveness. Upon psychotic examination, the patient presented with poor judgment and poor insight, with illogical thought processes and delusional and paranoid content. My differential diagnosis included substance-induced psychosis, delusion disorder, schizophrenia, antisocial disorder, and bipolar I disorder. He has previously been prescribed Risperidone, but is noncompliant as he believes he is “perfectly fine, I just smoke weed.” Due to his current presentation and his history of substance use and physical aggression, the patient likely is presenting with substance-induced psychotic disorder. As the patient is noncompliant with his medications, he poses a possible danger to others, warranting overnight admission in CPEP for further stabilization and overnight observation. I chose this case because of the impact speaking to the mother in person had on me and the feeling of helplessness, as she couldn’t force her son to follow up in outpatient care because he is an adult and he doesn’t qualify to be admitted inpatient. Dr. Saint Martin really challenged me and made a good point on whether the patient was actually under the influence of a substance during the times he was physically aggressive or delusional about his neighbor, whereas I just assumed he was because he reported daily use of marijuana. I expressed that I didn’t specifically ask the patient those questions, but believe it is notable that his mother said his behavior worsened after he started smoking marijuana and drinking alcohol. When discussing differential diagnoses, I made sure to point out that none of the diagnoses can fully be determined while the patient was still using substances. The one differential that Dr. Saint Martin questioned was whether the patient had antisocial disorder or was just exhibiting antisocial behavior, which I had actually not thought about, but I clarified that because the patient had not shown any symptoms of conduct disorder at the age of 15 it was lower on my differential list.

Schizophrenia vs Schizoaffective disorder

Schizophrenia is a complex chronic mental disorder that affects a person’s thoughts, emotions, and behavior. It typically is characterized by symptoms such as hallucinations, delusions, disorganized thinking, and social withdrawal. Schizoaffective disorder was introduced in 1933 as it combines features of schizophrenia and mood disorders, such as depression or bipolar disorder. It is characterized by having depressive, manic, or hypomanic episodes with delusions and hallucinations that occur simultaneously or within a few days of each other. 

In a cross-sectional study, researchers sought out to compare the patterns of basic and social cognitive function between schizophrenia and schizoaffective through various tasks. Basic cognitive measures included verbal and nonverbal memory tasks (ex. Logical Memory I and II, Figural Memory subtest from Wechsler Memory Scale), digit span test, verbal learning test, Wisconsin Card Sorting Test, and Digit Symbol Substitution subtest. For measuring social cognition, the Hinting Task and the Bell Lysaker Emotion Recognition Task were used.   

From 1988-2003, participants were recruited from a VA outpatient clinic and a Connecticut Mental Health Center outpatient clinic. The study excluded participants that had a history of traumatic brain injury or other known neurological diseases were excluded. A total of 272 participants with a confirmed DSM-5 diagnoses of schizophrenia or schizoaffective disorder met the inclusion criteria. Prior to the study starting, the participants completed a neuropsychological test to establish a baseline. Multivariant analysis of variance was used for the basic cognitive and social cognitive variables. 

Overall, results showed that there was no statistically significant difference between the two conditions on basic cognitive measures however, individuals with schizoaffective disorder performed significantly better on one of the Hinting Task, which measures the ability to infer the real intentions behind indirect speech. When univariate analysis was used, individuals with schizoaffective disorder showed less impairment in figure recall task. It is interesting to note that though may not be statistically significant, in all the areas where the two conditions differed, individuals with schizoaffective disorder had less impaired performance. When looking at demographic differences, individuals with schizoaffective disorder were significantly more likely to be female, married, and Caucasian. 

The researchers concluded that since the results of the Hinting Task was the only task that was statistically significant, they speculate that schizoaffective patients have more intact Theory of Mind performance, meaning they are better able understand themselves and others as mental beings, based on beliefs, desires, emotions, and intentions, but have similar emotional perception as schizophrenic patients. 

In a more recent 2019 study, researchers at York University sought out to determine to what degree do schizophrenia and schizoaffective disorder differ on cognitive performance tests and if cortical thickness in areas of the social brain network on brain show sensitivity towards distinguishing between the two disorders. A total of 73 participants, recruited from various outpatient clinics, diagnosed with either schizophrenia or schizoaffective disorder without developmental or learning disability, other neurological or endocrine disorders, or concurrent diagnoses of substance use disorder were included. 11 cognitive/social tasks were given to assess for cognitive performance. Results showed that schizophrenia and schizoaffective disorder are in fact, largely indistinguishable when assessing cognitive performance, including analysis of brain network structures. The only difference was noted among individuals with schizoaffective disorder as they were found to have more proficient emotional regulation compared to the individuals with schizophrenia and close scores to the control values. The researchers concluded that the mood disorder portion of schizoaffective disorder, may enhance emotional processing making the affect more noticeable and able to detect. Additionally, depressive symptoms were found to be more common in schizoaffective individuals, suggesting that mood disturbance should be specifically assessed upon clinical evaluation. Among the brain MRIs analyzed, similar results of reduced thickness in the temporal and medial regions associated with social processing seen in schizophrenia was also seen in schizoaffective individuals. 

Sources:

• Fiszdon, Joanna M et al. “A comparison of basic and social cognition between schizophrenia and schizoaffective disorder.” Schizophrenia research vol. 91,1-3 (2007): 117-21. doi:10.1016/j.schres.2006.12.012 https://pubmed.ncbi.nlm.nih.gov/17258431/
• Hartman, Leah I et al. “The continuing story of schizophrenia and schizoaffective disorder: One condition or two?.” Schizophrenia research. Cognitionvol. 16 36-42. 10 Feb. 2019, doi:10.1016/j.scog.2019.01.001 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370594/