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Posted in Clinician Information

Misoprostol Only Protocol for Management of Early Pregnancy Loss

This protocol was useful when stationed in Sasebo, Japan, for managing missed abortions. The Japanese clinics did not have access to these medications and could only offer mechanical evacuation. Our clinic only had access to misoprostol (not mifepristone). Before you start this, it’s critical to know your backup plan in case of serious bleeding.

Credit

Adapted verbatim January 2019 from www.reproductiveaccess.org

Eligibility

Patients with a nonviable pregnancy up to 12 weeks gestational age are eligible for medical management.

Non-viable pregnancy is diagnosed by ultrasound and/or falling quantitative hCG levels. Gestational age is based on ultrasound findings rather than last menstrual period (LMP). Ectopic pregnancy must be excluded, as medical treatment for ectopic pregnancy differs from that of nonviable intrauterine pregnancy.

Exclusionary criteria include severe anemia, allergy to mifepristone or misoprostol, bleeding disorders, and liver disease.

Procedure

1. Labs:Necessary labs include Rh screen, hematocrit, and quantitative serum hCG level. If prior knowledge of Rh status is available, Rh typing need not be repeated. Serum hCG level may be deferred in patients who can follow-up with ultrasound, if the initial diagnosis was made by ultrasound. Consider gonorrhea and chlamydia screening for those at risk.

2. Counseling:Clinically stable patients should be counseled on all options for managing early pregnancy loss including expectant, medical management, and uterine aspiration. Patients who choose medical management with misoprostol alone should understand that mifepristone/misoprostol is more effective for treatment of nonviable intrauterine pregnancy.

3. Misoprostol:Prescribe or dispense four tablets of 200 mcg misoprostol (800 mcg total) for the patient to use vaginally. The patient places 800 mcg of misoprostol in the vagina at home at a convenient time. The patient should be given a second dose of 800 mcg of misoprostol in case passage of tissue does not occur with the first dose.

4. Pain medications:A prescription for ibuprofen 600 mg should be offered to the patient. Instruct the patient to take ibuprofen prior to misoprostol insertion, and then every 6 hours as needed for pain. A small supply of low-dose narcotic may also be prescribed for severe breakthrough pain.

5. Patient Instructions(see RHAP take home instructions to give to patient):

The patient should be given contact information for how to reach their provider and be provided with guidelines regarding when to call. Patients should be instructed to call for:

  • Heavy bleeding, defined as soaking through two thick maxi pads per hour for 2 hours in a row;
  • Fever or purulent vaginal discharge; or
  • Uncontrolled pelvic cramps or pain not improved with medication.
  • The patient does not need to bring products of conception back to the provider and should not be instructed to do so.

6. Follow up:Patients should schedule follow-up to ensure a complete passage of tissue in one of two ways: 1) repeat quantitative serum hCG level following passage of tissue (a drop of 80% by 7 days) or 2) a transvaginal ultrasound with absence of sac. Note: if one of these criteria has been met, no further follow-up of serum hCGs is warranted.

If no passage of tissue occurs (the patient has not bled as much as a period) within 12-24 hours of taking the misoprostol, the patient may use a second vaginal dose of 800 mcg misoprostol. If no passage of tissue occurs by 48 hours, the patient may resume expectant management or be referred for uterine aspiration.

7. Documentation:A chart note must be completed, to document the above and ensure a follow-up plan.

References

Chung TKH et al. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertility and Sterility, 1999, 71(6)1054-1059. Prine LW, MacNaughton H. Office Management of Early Pregnancy Loss. American Family Physician. 2011 July 1; 84(1):75-82.

Wood SL, Brain PH. Medical management of missed abortion: A randomized clinical trial. Obstetrics and Gynecology, 2002, 99(4)563-566.

Posted in Reposted Articles

‘New era in digital biology’: AI reveals structures of nearly all known proteins | Science | AAAS

What just a few years ago was being talked about as an interesting possibility nows seems to have come true. “AI” doesn’t mean computer can think exactly, but it sure means they can solve some cool difficult problems!

‘New era in digital biology’: AI reveals structures of nearly all known proteins | Science | AAAS

‘New era in digital biology’: AI reveals structures of nearly all known proteins | Science | AAAS
Posted in Reposted Articles

VA Weighs Limiting Access to Outside Doctors to Curb Rising Costs | Military.com

Unsurprisingly, purchasing care from a system designed to maximize profits turns out to be more expensive. In 5 years we can expect to have similar headlines regarding about the military healthcare system’s push to offload dependent and retiree care. Hopefully in 10 years the laws will be changed to re-grow military healthcare. And in 20 years we can undo the damage that is about to occur. Time to hang on for a rough ride!

VA Weighs Limiting Access to Outside Doctors to Curb Rising Costs | Military.com

VA Weighs Limiting Access to Outside Doctors to Curb Rising Costs | Military.com
Posted in Reposted Articles

Article: Michael Grinston’s Quiet War to Help Make the Army More Lethal, Wokeness Hysterics Be Damned | Military.com

I appreciate hearing about current military leaders who are pragmatic and smart. Too often, we are swept away when discussing the pitfalls of our organization. It’s easier to blame the system than to blame people because we understand our personal limitations too well. Instead, let’s remember that people matter, and effective people are the cornerstone of an effective DoD.

Michael Grinston’s Quiet War to Help Make the Army More Lethal, Wokeness Hysterics Be Damned | Military.com

Michael Grinston’s Quiet War to Help Make the Army More Lethal, Wokeness Hysterics Be Damned | Military.com

Considering the loss of abortion protection for our sailors, marines, and their spouses

Background reading

Although the SECDEF has vowed to maintain access to reproductive rights, we have already entered a time of uncertainty. Although many states that rushed to overturn Roe v. Wade laws are not fleet concentrations, there are likely over 15,000 active duty Navy personnel in states whose trigger laws were enacted in July 2022.

Update 17-Aug-2022: DoD Q&A about post-Dobbs care

Number of active duty Navy and Marines in States that are moving to ban pregnancy termination:

  • Texas (6,164 active duty Navy personnel / 2,282 active duty Marines)
  • Mississippi (4,742 / 447)
  • Oklahoma (1,647 / 558)
  • Tennessee (1,634 / 150)
  • Missouri (233 / 1,440)
  • Louisiana (398 / 761)
  • Utah (50 / 92)
  • Kentucky (53 / 89)
  • Arkansas (10 / 109)
  • Idaho (33 / 41)
  • South Dakota (4 / 14)
  • North Dakota (2 / 14)
  • Wyoming (2 / 8)

How can Navy physicians help?

Talk to your sailors, marines, and their family about this issue! Young servicemembers may be wary of starting this discussion. So create a safe space in the exam room or clinic to discuss their concerns. Train corpsmen on women’s health. Educated HMs act as your agent, sharing insight with patients (in the clinic) and other junior servicemembers (in casual settings).

Consider how you will react to challenging logistic and potentially ethically tough situations. If you are operational, find out what kind of support the CO gives to requests for travel for abortion services so that you can better counsel your patients as to their options.

Navy Pregnancy Instructions

Know the governing instructions. Current instructions do not provide guidance on the nuances of the recent legal changes, but they are essential background. My Navy HR’s AD pregnancy page has links to the relevant documents:

Emergency Contraception Options

When possible, educate servicemembers and patients on their emergency contraceptive options BEFORE they need them!

  • Levongesterol, 1.5 mg (Plan B One Step) – Available over the counter at any military pharmacy in any state, 1 dose.  2.5% pregnancy rate if taken within 120 hours, about half that if taken within 72 hours.
  • Ulipristal, 30 mg (Ella) – Requires prescription, 1 dose.  1.3% pregnancy rate if taken within 120 hours.
  • Copper IUD – 0.1% pregnancy rate if placed within 120 hours.
  • Mirena IUD – One large NEJM study suggests similar effectiveness to copper IUD, insufficient data for CDC to recommend yet.

Connecting Patients to Resources

Several organizations can connect patients to information and funding.

Medical Termination of Pregnancy

To be clear, military physicians working in an MTF may only offer treatment to terminate a pregnancy in cases of a nonviable pregnancy, rape, or to save the mother’s life. But it is helpful to understand the most likely treatment options in early pregnancy that may be offered at outside facilities (or online).

Mifepristone and Misoprostol for Undesired Pregnancy of Unknown Location

Preventing Future Pregnancies

Posted in Clinician Information

Clomiphene (Clomid) to Induce Ovulation

Adapted (partially verbatim) from LexiComp.

How to take it:

50 mg once daily for 5 days. Begin on or about the fifth day of cycle if progestin-induced bleeding is scheduled or spontaneous uterine bleeding occurs prior to therapy. Therapy may be initiated at anytime in patients with no recent uterine bleeding.

Contraindications

Hypersensitivity to clomiphene citrate or any of its components; liver disease or history of liver disease; abnormal uterine bleeding; enlargement or development of ovarian cyst (not due to polycystic ovarian syndrome); uncontrolled thyroid or adrenal dysfunction; presence of an organic intracranial lesion such as pituitary tumor; pregnancy

Canadian labeling: Additional contraindications (not in the US labeling): Hormone-dependent tumors, thrombophlebitis, uterine fibroids, mental depression.

Warnings/Precautions

Concerns related to adverse effects:

  • Ovarian enlargement: May be accompanied by abdominal distention or abdominal pain and generally regresses without treatment within a few days or weeks after therapy discontinuation. If ovaries are abnormally enlarged, withhold therapy until ovaries return to pretreatment size; reduce clomiphene dose and duration of future cycles.
  • Ovarian hyperstimulation syndrome (OHSS): OHSS is a rare exaggerated response to ovulation induction therapy (Corbett 2014; Fiedler 2012). This syndrome may begin within 24 hours of treatment but may become most severe 7 to 10 days after therapy (Corbett 2014). Symptoms of mild/moderate OHSS may include abdominal distention/discomfort, diarrhea, nausea, and/or vomiting. Severe OHSS symptoms may include severe abdominal pain, anuria/oliguria, ascites, severe dyspnea, hypotension, or nausea/vomiting (intractable). Decreased creatinine clearance, hemoconcentration, hypoproteinemia, elevated liver enzymes, elevated WBC, and electrolyte imbalances may also be present (ASRM 2016; Corbett 2014; Fiedler 2012). Treatment is primarily symptomatic and includes fluid and electrolyte management, analgesics, and prevention of thromboembolic complications (ASRM 2016; SOGC-CFAS 2011).
  • Visual disturbances: Blurring or other visual symptoms can occur; symptoms may increase with higher doses or duration of therapy and in some cases may be irreversible. Patients with visual disturbances should discontinue therapy and receive prompt ophthalmic evaluation.

Disease-related concerns:

  • Ovarian cancer: Prolonged use may increase the risk of borderline or invasive ovarian cancer.
  • Polycystic ovarian syndrome (PCOS): Use with caution in patients unusually sensitive to pituitary gonadotropins (eg, PCOS); a lower dose may be necessary.
  • Uterine fibroids: Use caution in patients with uterine fibroids, may cause further enlargement.

Other warnings/precautions:

  • Appropriate use: To minimize risks, use only at the lowest effective dose for the shortest duration of therapy (especially for the first course of therapy). Women with PCOS, amenorrhea-galactorrhea syndrome, psychogenic amenorrhea, post oral contraceptive amenorrhea, and some cases of secondary amenorrhea of undetermined cause may most likely benefit from clomiphene therapy.
  • Experienced physician: Use should be supervised by physicians who are thoroughly familiar with infertility problems and their management.
  • Multiple births: May result from the use of this medication; advise patient of the potential risk of multiple births before starting the treatment.
Posted in Patient Information

Picky Eating

Adapted (partially verbatim) from Am Fam Physician. 2015 Aug 15;92(4):274-278.

Kids don’t need as much food as you think!

One way children start to show their independence is by choosing what they want to eat. You should make meal times as pleasant as possible. The amount of calories and nutrition a child needs is less than many parents realize. You can find out how much your child needs by going to choose my plate.

Parents often describe their toddlers and preschoolers as picky eaters. The reluctance to eat or try new foods (food neophobia) is a normal developmental stage that the child usually outgrows. However, there are picky or fussy eaters who restrict their intake to only a few food items, regardless of whether they are new or familiar.

Some ways to reduce picky eating include:

  • Avoid offering many sweetened foods or foods with high carbohydrate content (breads, sweetened cereal, rice).
  • Don’t let your child drink too much milk or juice. The calories in liquids can take away appetite. A child should have no more than 16 to 24 oz of milk and 4 to 6 oz of juice per day.
  • Follow the rule of 10s: children should try a food at least 10 times before deciding they don’t like it.
  • Offer foods that are similar to ones your child likes. (For example, if your child likes canned peas, offer cooked carrots instead of raw carrots. The softness of the food may make a difference.)
  • Use an older sibling as a role model to help children try things they think they don’t like.
  • Mix foods, even if the mixture doesn’t make sense to you. (For example, a child may eat “ants on a log” because it is a fun way to present celery, peanut butter, and raisins.)

Mealtime Roles for Parents and Children:

The main approaches to picky eating include social modeling of normal eating behaviors, repeated exposures to new foods, and positive mealtime experiences. There is a strong correlation between parent and child nutritional behaviors. Parental efforts to control the child’s intake of food using pressure to eat a certain food or quantity of food, restriction of certain foods, or promise of a reward have negative effects on food acceptance and are discouraged. In the Satters’ Division of Responsibility Model, the parents’ role is to provide mealtime structure, positive social modeling, and a variety of healthy foods, whereas the child decides how much and which foods to eat.

Satters’ Division of Responsibility Model

Parents:

  • Provide mealtime structure: time and place.
  • Create a positive environment: pleasant interaction.
  • Allow the child to feed himself or herself.
  • Provide a variety of healthy foods.

Children:

  • Eat if he or she wants to.
  • Choose what to eat out of the offered foods.
  • Stop eating when full.
Posted in Uncategorized

How to update Outlook Address Information

The steps below allow you to update the contact information shown when people find you in the Global Address List (GAL) in Outlook.

Go to https://idco.dmdc.osd.mil/idco/. Select your PIV (Authentication) cert to get into ID Card Office Online. Select “My Profile.”

Choose “My Profile”

Log in (again) using your CAC.

Choose “CAC”, then “Login”

Update your “My Profile,” first to verify your personal email, and family member contact information.

Update your personal email and family member contact information first.

Now update your work information.

Select “MIL” and verify your work information.

The last tab, “MIL” should be reflected in your address in Outlook. The Navy email system is undergoing yet another update. This is a good thing, as the current iteration is badly outdated. However as a result some or all of this post may not apply to you any longer. Historically changing this information could take up to 72 hours before it populated in Outlook, and this may still be true.

Posted in Patient Information

Thumb Sucking Parent Information

Adapted (partially verbatim) from Am Fam Physician. 2009Jul15;80(2):139-142.

About Thumb Sucking and Pacifiers

Thumb sucking is an innate reflex and one of the most common security and self-soothing mechanisms. In infants, thumb sucking and pacifier use are often classified together as nonnutritive sucking methods. Pacifier use has been linked to decreased breastfeeding duration, but the same effect of thumb sucking on breastfeeding has not been reported. In some studies, combinations of the use of pacifiers and thumb sucking have been reported to lead to decreased breastfeeding. Pacifier use has been documented to be protective against sudden infant death syndrome (SIDS) in children younger than six months and was included in the 2005 American Academy of Pediatrics SIDS guideline update; however, there have been few studies advocating thumb sucking as an equally preventive measure against SIDS.

The incidence of thumb sucking among children decreases with age, and most children spontaneously stop thumb sucking between two and four years of age.

When Should Children Stop Thumb Sucking?

School-aged children with persistent thumb sucking should be referred to a pediatric dentist. At this age, when the permanent teeth erupt, thumb sucking can affect a child’s teeth alignment and mouth shape. The greatest risk of developing malocclusive problems, such as overbite and crossbite, occurs in children who have persistent thumb sucking problems beyond four years of age.

American Dental Association Recommendations to Stop Thumb Sucking:

  • Praise children when they don’t suck their thumb (e.g., verbal praise, stickers).
  • Reward your child for not sucking his or her thumb (example: for every day children do not suck their thumb, they get to mark an “X” on a calendar. After a certain number of “X’s,” they can receive a reward).
  • Find alternative ways of comforting and soothing for children (e.g., stuffed toy or special blanket).
  • Provide reminders or negative reinforcement for thumb sucking (e.g., placing topical bitter liquids on the thumb, putting a bandage around the thumb to remind the child not to suck on it).
  • Involve older children in ways in which they can stop sucking (e.g., have children help create their own reward system).

Featured Image: Topical bitter liquids marketed to help discourage thumb sucking: Mavala Stop, Thum