Manic Monday

Wow, if I didn't know any better, I would have thought that yesterday was a *Friday* the 13th rather than a *Monday* the 13th. The morning started with the blast of the pager in the wee hours of the morning. It was the mother of a young teenage girl, under my care for an enlarged ovarian cyst. Earlier in the month we had completed her work up for malignancy (it was negative), she had a significant amount of discomfort, and she was to follow up in the office this week to plan for surgery. Her mother's voice was strained as she explained that she had been up all night with severe pain, nausea, vomiting, and a low grade temperature. I was immediately wide awake, differentials running through my head. Topping the list? Ovarian torsion.

I bolted out of bed and told the mother that I would meet her at the hospital. I notified the OR about the possible surgery and headed in. While I was waiting for the patient to arrive, I checked on my admitted patients. One patient had been admitted the day prior for pre-term contractions at 32 weeks. I had placed her on magnesium sulfate for tocolysis and initiated betamethasone therapy for the fetal lungs. Upon admission she was 2 cm dilated. Overnight she had contracted irregularly on the magnesium, but the contractions had appeared to slow down. She had started complaining of increased pelvic pressure about 15 minutes before I arrived, so I re-checked her cervix and found her to be 4 cm dilated with bulging membranes. I made a few phone calls and arranged her transfer to UniversityHospital, about 30 miles north. Our nursery is not equipped for infant care less than 36 weeks, so off she went. Last I heard, she's still pregnant.

Next was my labor induction for post-dates. Her previous labor had lasted for over 24 hours, and she was convinced that she would labor all day long. About 7 am she was 3 cm and 90 percent effaced, and the head was at 0 station. I broke her water, told her she would have a baby before noon, and told her if she wanted an epidural, she'd better ask for one sooner than later. She laughed it off, as did the nurse. While I was admitting my ovarian torsion patient, the nurse paged me and told me that the patient had just gotten her epidural and was feeling pressure to push. I ran upstairs while they prepped the torsion patient for surgery and caught a baby; less than 2 hours from the time I had first checked her cervix.

Then it was back to the OR for the surgery. All of the imaging studies had suggested that the ovarian cyst was originating on the right ovary, so imagine my surprise when the patient's torsion was actually in her left adnexa! The right tube and ovary were perfectly normal. The adnexa was not twisted once or twice; it was twisted on the pedicle no less than 4 times. The Fallopian tube was a hematosalpinx and it was irreparably damaged and filled with clot. It measured 12 cm by 10 cm. The ovary appeared dusky, but I made an attempt to salvage the tissue. There was bleeding in the uterine cornu that was difficult to control, but it was all hemostatic by the end of the case. The real kicker is that there was no ovarian cyst at all! The ovary, while edematous from lack of venous drainage, had no cystic lesion. So where was the pelvic cyst? I'm not certain. I am awaiting pathology, but I guess it is possible that the cystic lesion in the pelvis was arising from the Fallopian tube, perhaps in the form of a hydrosalpinx. That is pretty rare in young patients, and even more rare in a women that is not sexually active, but until I have the pathology, I guess I'll just have to speculate. Today, the young girl, even after major abdominal surgery, says that she feels a million times better! I feel badly that she has lost her tube, but hopefully the ovary can regain some function.

Needless to say, I never made it to the office on Monday. This means more double-booked clinic appointments and hellish clinic days for me. Bleargh. It also means that I got a late evening phone call by a patient I have yet to see (her appointment was cancelled because I was dealing with emergencies). She was really very nasty, demanding that I order her another h.cg level, since she hadn't had one in 2 whole weeks and she was having some cramping. She was having no bleeding or spotting. I tried to explain that another single level would not tell me anything about the status of her pregnancy, and if she was concerned about the pain to go to the ER. Otherwise, I told her I would order an ultrasound in the morning (US department goes home around 9 pm, and suffice it to say her call was later than this.) She was still supremely pissed off when she hung up the phone because I had the unmitigated gall to cancel her first OB appointment due to other people's emergencies. Frigging shame on me. One day, I shall manage to be in all areas simultaneously, so as not to upset such delicate sensibilities.

(Before I get flamed, yes, I know she is worried. I understand this. Cramping can be scary, but it is also a normal early pregnancy symptom. She has already had 4 normally doubling betas and an ultrasound that shows a viable intrauterine gestation. I am not without compassion, but I recognize obsession when I see it. She is only 7 weeks, and it is going to be a looooonnnggg pregnancy at this rate. Maybe I'll transfer her to high risk? Tempting.)

As for Body for Life? This is day two. I'm doing pretty well with staying with the eating plan...except for getting all of those meals into a day. (Seriously, I barely have time to pee, much less eat every 2 hours). Right now I am procrastinating my upper body workout in favor of writing this blog, and dreaming about what I am going to eat on my "free day." Somehow, I don't think that this is the way it is supposed to go. Ah well. Enough rambling for the day, I've got surgery charts to dictate for tomorrow.