Reflection on the Rotation

 I enjoyed each week at my OBGYN rotation from clinic weeks to overnight gynecological/labor and delivery shifts. During clinic weeks, I was often with a physician assistant who saw patients for annual gynecological check-ups, gynecological health concerns. I also had the opportunity to be a aprt of obstetrical appointments when with a midwife or physician at clinic. I learned how to do a do a pelvic exam with pap smear or cultures, bimanual exam and breast exam on women of different ages, body habitus and parity. I was very happy that I got so many opportunities practice these exams as I was not confident in my ability, however each exam helped me become more confident in my ability to do a proper exam. While with a midwife or physician I learned how to measure fundal height, find a fetal heart rate, and palpate the uterus to determine fetal positioning. While on labor and delivery, I assisted in vaginal and c-section deliveries and was also able to see patients in the labor and delivery triage floor for various complaints. During gynecological day/night shifts, I learned which medications are used and which for certain gynecological emergencies and the follow-up needed for post-partum patients. I enjoyed reading on the patients before going to see them but also enjoyed being the first person to get a history and physical, both served me well in my learning. My learning is always cemented when I see the diagnosis, treatment, guideline, recommendation in person in the clinical setting rather than only reading or writing about the topic. However, it is important for me to continue reading evidence-based recommendations and pathophysiology of conditions as I was often asked questions and at times had to say I will look that up and get back to you. Overall, this was another enjoyable rotation, and I am excited to continue my journey of clinical year to hopefully continue to build my skills and knowledge to help patients in my future as a physician assistant.

Site visit Summary

OBGYN was a wonderful rotation and one I was looking forward to ever since I had Professor Melendez class so I was thrilled when I found out I would be rotating at his hospital. My site visits went well and I was reminded of how quickly my preceptor Melendez could read an exert from a patient story and already know what questions needed to be asked, what follow up was needed and medications were indicated. I am once again reminded of why I enjoyed his class and looking forward to being in a specialty one day where this knowledge can become second nature. It was interesting to discuss certain medications indications, according to uptodate, and discuss whether Woodhull uses them for that indication such ad terbutaline and methotrexate. I intentionally chose a patient who was upset with her treatment and had to be educated about options for treatment as I wanted to research the options for treatment myself to learn.

Article summary:

Article chosen: Alur-Gupta S, Cooney LG, Senapati S, Sammel MD, Barnhart KT. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol. 2019;221(2):95-108.e2. doi:10.1016/j.ajog.2019.01.002

I chose this article based on the patients request for a second dose of methotrexate at her day 4 visit due to her HCG increasing. I wanted to see if there was an guidelines or literature that included patients with similar previous ectopic pregnancy/outcome and subsequent ruptured ectopic pregnancy outcome. This article was a meta-analysis review published in 2019 that studied odds of treatment success, treatment failure, side effects and surgery for tubal rupture as well as length of follow-up until treatment success with single dose, double dose and multidose treatment compared using random and fixed effects meta-analysis. 

Single dose vs. double dose

The two dose method was associated with higher treatment success compared to single dose protocol. The two dose protocol was more successful in women with high hCG and in women with a large adnexal mass. The odds of surgery for tubal rupture were lower in the two dose protocol , but not statistically significant. The length of follow up was 7.9 days shorter for the two dose protocol. Odds of side effects were higher in the two dose protocol

Single dose vs. Multiple dose

When compared to the single dose protocol the multi-dose protocol is associated with a nonsignificant reduction in treatment failure and a higher chance of side effects. 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. However due to its frequency of administration, the multidose protocol requires the addition of folinic acid rescue, alternating with methotrexate doses, to decrease side effects. The single dose was introduced to reduce the number of visits, but often requires additional treatment and follow-up.

Success rates

The success rates of medical management of ectopic pregnancies have varied with a range of 70–90% for the single dose, 80–90%for the two dose and 89–96% for the multi dose protocols.

What is a high HCG

In this study “high HCG” was defined as a range of greater than 3000–5500 mIU/mL for two dose versus single dose and greater than 800 IU/L for multi-dose versus single dose.

Patient application

This patients highest HCG was 2737 which met the criteria for the “high HCG” when looking at multi-dose vs. single dose but did not quite met the criteria for single dose vs. double dose of 3000-5000.

Take away

This reasoning is also echoed by the Academy of Obstetrics and Gynecology (ACOG) that states:

 There is no clear consensus in the literature regarding the optimal methotrexate regimen for the management of ectopic pregnancy. The choice of methotrexate protocol should be guided by the initial hCG level and discussion with the patient regarding the benefits and risks of each approach.

The choice of methotrexate protocol should be guided by the initial hCG level and discussion with the patient regarding the benefits and risks of each approach. In general, the single-dose protocol may be most appropriate for patients with a relatively low initial hCG level or a plateau in hCG values, and the two-dose regimen may be considered as an alternative to the single-dose regimen, particularly in women with an initial high hCG value.

However these guidelines did state if there if the decrease is less than 15% to readminister MTX but it does not clarify if that measurement is from day 1 to day 4 or day 4 to day 7.

ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy, Obstetrics & Gynecology: February 2018 – Volume 131 – Issue 2 – p e65-e77 doi: 10.1097/AOG.0000000000002464