POSITIVE LIVING

New ACOG guidelines on dysmenorrhea and endometriosis in adolescents

The American College of Obstetricians and Gynecologists (ACOG) has published a new committee opinion on dysmenorrhea and endometriosis in adolescents.
 

Dysmenorrhea, or menstrual pain, is the most common menstrual symptom among adolescent girls and young women. Prevalence rates vary but range from 50% to 90 %. Most adolescents experiencing dysmenorrhea have primary dysmenorrhea, defined as painful menstruation in the absence of pelvic pathology. Secondary dysmenorrhea refers to painful menses due to pelvic pathology or a recognized medical condition. Endometriosis is the leading cause of secondary dysmenorrhea in adolescents.

Following are the Major Recommendations:

• Most adolescents experiencing dysmenorrhea have primary dysmenorrhea, defined as painful menstruation in the absence of pelvic pathology. Primary dysmenorrhea characteristically begins when adolescents attain ovulatory cycles, usually within 6–12 months of menarche.
• Secondary dysmenorrhea refers to painful menses due to pelvic pathology or a recognized medical condition.
• The most common cause of secondary dysmenorrhea is endometriosis.
• Most adolescents who present with dysmenorrhea have primary dysmenorrhea and will respond well to empiric treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) or hormonal suppression, or both. However, some patients either present initially with symptoms suggesting secondary dysmenorrhea or they fail empiric treatment for primary dysmenorrhea and require further evaluation.
• Pelvic imaging with ultrasonography, regardless of findings on pelvic examination, also should be considered during evaluation for secondary dysmenorrhea.
• Any obstructive anomaly of the reproductive tract, whether hymenal, vaginal, or müllerian, can cause secondary dysmenorrhea.
• Although the true prevalence of endometriosis in adolescents is unknown, at least two-thirds of adolescent girls with chronic pelvic pain or dysmenorrhea unresponsive to hormonal therapies and NSAIDs will be diagnosed with endometriosis at the time of diagnostic laparoscopy.
• The appearance of endometriosis may be different in an adolescent than in an adult woman. In adolescents, endometriotic lesions are typically clear or red and can be difficult to identify for gynecologists unfamiliar with endometriosis in adolescents.
• If a patient is undergoing a diagnostic laparoscopy for dysmenorrhea or chronic pain, or both, consideration should be given to placing a levonorgestrel-releasing intrauterine system (LNG-IUS) at the time of laparoscopy to minimize the pain of insertion.
• The recommended treatment for endometriosis in adolescents is conservative surgical therapy for diagnosis and treatment combined with ongoing suppressive medical therapies to prevent endometrial proliferation.
• Patients with endometriosis who have pain refractory to conservative surgical therapy and suppressive hormonal therapy often benefit from at least 6 months of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back medicine.
• Nonsteroidal anti-inflammatory drugs should be the mainstay of pain relief for adolescents with endometriosis.
• Adolescents should not be prescribed narcotics long-term to manage endometriosis outside of a specialized pain management team. 

Risk factors for Preterm Birth (PTB)

Preterm Birth Risk Factors.

Updated guideline for Physical Activity throughout Pregnancy

Often, questions are asked about the exercises women should perform during pregnancy for the well-being of both mother and child.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) and Canadian Society for Exercise Physiology (CSEP) have jointly released Canadian Guideline for Physical Activity throughout Pregnancy with an objective to provide guidance for pregnant women, and obstetric care and exercise professionals, on prenatal physical activity.

The guideline is published in the British Journal of Sports Medicine and Journal of Obstetrics and Gynaecology Canada. 

Key Recommendations:

• All women without contraindication should be physically active throughout pregnancy.
• Pregnant women should accumulate at least 150 min of moderate-intensity physical activity each week to achieve clinically meaningful reductions in pregnancy complications.
• Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged.
• Pregnant women should incorporate a variety of aerobic exercise and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial.
• Pelvic floor muscle training (PFMT) (eg, Kegel exercises) may be performed on a daily basis to reduce the odds of urinary incontinence. Instruction on the proper technique is recommended to obtain optimal benefits.
• Pregnant women who experience light-headedness, nausea or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position.

Contraindications

All pregnant women can participate in physical activity throughout pregnancy with the exception of those who have contraindications (listed below). Women with absolute contraindications may continue their usual activities of daily living but should not participate in more strenuous activities. Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider prior to participation.

The following are absolute contraindications to exercise:

• Ruptured membranes
• Premature labor
• Unexplained persistent vaginal bleeding
• Placenta praevia after 28 weeks’ gestation
• Pre-eclampsia
• Incompetent cervix
• Intrauterine growth restriction
• High-order multiple pregnancies (eg, triplets)
• Uncontrolled type I diabetes
• Uncontrolled hypertension
• Uncontrolled thyroid disease
• Other serious cardiovascular, respiratory or systemic disorder

The following are relative contraindications to exercise:

• Recurrent pregnancy loss
• Gestational hypertension
• A history of spontaneous preterm birth
• Mild/moderate cardiovascular or respiratory disease
• Symptomatic anemia
• Malnutrition
• Eating disorder
• Twin pregnancy after the 28th week
• Other significant medical conditions

Safety precautions for prenatal physical activity

• Avoid physical activity in excessive heat, especially with high humidity.
• Avoid activities which involve physical contact or danger of falling.
• Avoid scuba diving
• Lowlander women (ie, living below 2500 m) should avoid physical activity at high altitude (>2500 m). Those considering physical activity above those altitudes should seek supervision from an obstetric care provider with knowledge of the impact of high altitude on maternal and fetal outcomes.
• Those considering athletic competition or exercising significantly above the recommended guidelines should seek supervision from an obstetric care provider with knowledge of the impact of a high-intensity physical activity on maternal and fetal outcomes.
• Maintain adequate nutrition and hydration—drink water before, during and after physical activity.
• Know the reasons to stop physical activity and consult a qualified health care provider immediately if they occur.

Reasons to stop physical activity and consult a healthcare provider

• Persistent excessive shortness of breath that does not resolve on rest
• Severe chest pain
• Regular and painful uterine contractions
• Vaginal bleeding
• Persistent loss of fluid from the vagina indicating rupture of the membranes
• Persistent dizziness or faintness that does not resolve on rest

How to start being active during pregnancy?

Previously inactive women are encouraged to start physical activity in pregnancy but may need to begin gradually, at a lower intensity and increase the duration and intensity as their pregnancy progresses.

It may be difficult for some women to follow these Guidelines without additional support or advice. Obstetric care professionals and exercise professionals must carefully consider the potential costs and perceived barriers to prenatal physical activity to facilitate participation. These Guidelines may be appropriate for women with a disability or medical condition; however, an obstetric care professional should be consulted for additional guidance. Although the majority of the evidence base for these recommendations used supervised exercise, physical activity during pregnancy does not need to be done in a supervised setting or with any specific equipment. For those with financial or other barriers to participating in organized exercise, activities as simple as walking can have positive benefits.

Mood Stabilizers Associated With Increased Risk for Stroke in Bipolar Disorder

The use of mood stabilizers may be associated with an increased stroke risk in patients with bipolar disorder, according to study results published in The British Journal of Psychiatry.
Researchers retrospectively analyzed data from a cohort (n=19,433) of patients with bipolar disorder using the Taiwan National Health Insurance Research Database. In the cohort, 609 cases of stroke were recognized between 1999 and 2012.  To examine the association between acute exposure to mood stabilizers and stroke onset, the investigators used a 14-day case-crossover study design. Over 14 days, potential factors were compared in patients and controls to link specific mood stabilizers with different forms of stroke, including hemorrhagic, ischemic, and others.
After regression analysis, investigators found that mood stabilizers were collectively associated with a significantly increased risk for stroke in participants with bipolar disorder (adjusted risk ratio (aRR), 1.26; 95% CI, 1.01-1.58; P =.041). With respect to specific agents, exposure to carbamazepine was associated with the highest risk for stroke (aRR, 1.68; 95% CI, 1.09-2.59; P =.018), particularly ischemic stroke. Furthermore, they reported that exposure to valproic acid was associated with an increased risk for hemorrhagic stroke (aRR, 1.76; 95% CI, 1.09-2.87; P =.022).
Lamotrigine and lithium exposure were not associated with an increased risk for stroke. 

"These findings may offer a guide for the choice of mood stabilizers in patients with bipolar disorder who require acute therapy for affective symptoms and who already have the risk factors for stroke," the researchers wrote.
Further studies are needed to fully investigate the links between mood stabilizers and stroke.
Reference
Chen PH, Tsai SY, Pan CH, et al. Mood stabilisers and risk of stroke in bipolar disorder [published online October 8, 2018]. Br J Psychiatry. doi:10.1192/bjp.2018.203

WORTH READING "Why doctors can’t take sick days"

Why doctors can’t take sick days

Lisa Sieczkowski, MD | Physician | September 21, 2018

 

I learn all manner of interesting things from the information sheets posted on the walls of the employee bathrooms at my hospital. I learn, for example, about upcoming CME offerings for advance practice providers, how many seconds one has to scrub the hub of a central line, and what the new process is when nurses need to call in sick. They call a specific phone number and state that they cannot come to work. Done. Someone else’s problem now.
This is amazing to me, because there is no such construct in place for physicians when we are sick.
Every few months, my cell phone dings at a sickeningly early hour. My “hospitalist MD” group text is the culprit.
“I’m so sorry but I have been up all night vomiting and don’t think I could possibly round today. Can anyone take my shift and I’ll pay you back as soon as I can? Sorry!”

Sometimes the text includes the green-faced vomiting emoji or maybe the pile of poop one depending on the victim’s exact symptomatically.
Our group has become large enough that usually someone who is not on the schedule that day eventually comes forward. But sometimes we have to run with one less doc or make due while the replacement dispositions his or her kids. For smaller groups or sub specialists, this may not even be possible.
Yet we are still more flexible by virtue of our shift work than are our counterparts in the clinics. They may have dozens of patients lined up, some of whom had carefully planned their child’s or their own appointment months in advance to coincide with days off of work or school. It certainly makes one think long and hard about the inconvenience that would be imposed on all of those patients and their families if one were to call in sick.
In the hospital setting, we do not have patients who have made appointments with us specifically. Most of the patients, in the unlikely event that they were counting on the same attending to return the next day, would not be too disappointed if someone else showed up instead. But instead of worrying about massively inconveniencing a panel of patients, we worry about massively inconveniencing our partners. The same number of patients will be on our service regardless of how many attendings work that day. We cannot ask the patients to reschedule for a future date. We can all do the simple arithmetic in our heads and realize that 36 divided by three is doable but 36 divided by two is quite a hardship for the two. This is very, very stressful. No one wants to be the slacker, the weak link. As stressful as it is to be overworked, it is more stressful to realize that it is your fault that your partners are being overworked.
So we always “pay it back.” There is no such thing as an actual sick day. At my previous hospitalist job, I called around one weekend as I was having a miscarriage in the bathroom on the Peds unit and found a replacement for myself. As soon as my next weekend off rolled around, though, I worked Peter’s shifts to pay him back.
The end result is that physicians work when they are not physically and mentally at their best in order to avoid the inconvenience to others and the inevitable need to pay someone back later. Potentially exposing co-workers and patients to communicable diseases. Ignoring the very same advice we give our patients.

Doctors fighting !!