Swollen Painful Pregnant Hands

Ever taken a close look at those old-school pics of Mickey Mouse? If you have, you’ll notice he’s wearing gloves. I can’t explain that, really, since he’s a mouse and generally in the entertainment business. Furthermore, his hands are, proportionally, HUGE. They’re almost as big as his whole head. It looks like ‘ol Walt drew this mouse, then put rubber exam gloves on it and inflated them to about 3 times normal size and said, “Yes! That’s it exactly. Just what I wanted. Now I’ll make his feet huge, too.”

Not to speak for her, but I think one of my pregnant patients now nearing the end of her 3rd trimester feels a little bit like Mickey right now. She recently emailed me to say that she thinks, maybe, she’s going crazy. “And don’t tell me ‘you’re just pregnant’ like you’ve been doing now for 6 months!” She says her hands have swollen up so much she can’t wear her wedding ring. Her fingers tingle and sometimes pain shoots through them, to the point of waking her up.

Incidentally, in my field, we make a distinction between people with symptoms that awaken them from sleep. There is a slight possibility that I put a bit too much emphasis on this clinical factoid as a result of my life-long love affair with the activity, but even docs who voluntarily wake up before 11am interpret the disruption of sleep as generally clinically-significant. So, my patient can’t sleep because of her hand pain/numbness. Must be serious.

Well, actually, it probably isn’t. Medically, at least. First, of course, I have to make sure she doesn’t have pre-eclampsia, which is very serious. In pre-eclampsia, the patient swells significantly, but also starts losing large amounts of protein in their urine and their blood pressure elevates dramatically as well. The risk of placental abruption (where the placenta tears away from the uterine wall) is extremely high and the threat to the live of the baby is very real. The WORST fetal heart strip I ever saw occurred as a result of an abruption after a night of preeclampsia. Worst, or, say, dramatic. TLC coulda gone miles with it.

But my current patient doesn’t have the other risk factors for preeclampsia. Absent this sketchy diagnosis, things look pretty “good”, actually. That is, she may be hating life, but odds are still heavily in her favor that she will come in for a nice, soft prego landing sometime in the next 3 weeks. Additionally, the cherubic baby is likely to emerge unscathed, look quizzically at the new mom still huffing and puffing and glowering, then turn to me with a look that says, “What’s her problem?”

So, it’s probably not serious, but the patient is miserable. Any idea what she has? Any idea how to help her? It would be good if I could avoid merely telling her she’s pregnant…and that her hands are similar to those of a cartoon mouse.

**A little perspective note: Have you ever contemplated how incredibly HUGE a toddler’s head is? We don’t realize it because we’re used to the way babies look. But if you watch a toddler raise their arms, the disproportion to adults is striking. The top of a kid’s head reaches past their elbows. Raise your own arm and think about how your head would look if it reached up to your forearm. So, there you have it, visual PROOF that our heads shrink with age. Now I know why I’m so much stupider than I used to be.

Gestational Diabetes – What We Did

A while ago I wrote a ‘You Be The Doc’ regarding a patient with borderline gestational diabetes. That patient had her baby recently, and it was something of a white-knuckle affair. Here’s what happened:

The initial test for GDM is a 1 hour glucose tolerance test, and the patient was VERY positive with a score in the 190’s. In the medical world, it’s considered bad form to designate someone as ‘very’ positive, or ‘borderline’ positive. These numbers are cut-offs. If you are past the cut-off, you’re positive. That’s it. No rounding, no data massage. The cut-off for GDM is 140. So the test is positive.

There are lots of reasons why the 1-hour GTT is lame. You can eat virtually anything on the McDonald’s menu, then come to the clinic and take the test and have a pumped up test result. So, because you can’t really trust a 1-hour GTT, we follow it with a similar test that is at least a bit more rigorous (still lame, though). The 3-hr takes 4 blood glucose tests – a fasting, then 1, 2 and 3 hours after drinking a sugar-rich solution. Our patient had normal values for all but the 4th test, and it was only off by about 3 points. 3 points! Everything else was normal. In my last post, I pondered whether or not to bestow the diagnosis of GDM on this patient with this glucose profile.

We did not. We told her she was fine. No intervention.

Hey, we’re family doctors. We’re mellow. A coupla out of range values. So what? No big deal right? Actually, you might ask, what is the big deal? Well, the whole point is to determine if your body can metabolize (that is, put away) glucose correctly. Glucose – sugar – in your blood stream is a BAD thing. It doesn’t belong there, it belongs in your body’s cells. Think of it as energy. Like little burning, flaming, sparking packets of sun-beam radiation (that, incidentally, also taste really, really good). As this stuff flies around your blood stream, it’s like an average 2 year old boy left alone in a glass-blower’s museum (well, at least my 2 year old boy). This is, metabolically speaking, why eating high-sugar foods isn’t healthy…or at least risky. At any point, your body may look at all that glucose tearing apart your capillaries in your eyes and kidneys and brain, start wringing its metaphorical hands and just curl up into an useless whimpering pancreatic fetal ball and give up. If, for some reason, your body can’t vanquish the insane levels of glucose the average American pours into their arteries in a given meal, you have diabetes. High blood glucose levels cause all kinds of problems. The most important of which, in pregnancy, is HUGE kids. We call ’em “macrosomic”.

My patient – who we did not treat for GDM – went into labor around 8pm. Very little cervical change occurred through the first 10 hours. By noon the next day – we’re talking about 16 hours of labor here – she was finally ready to push. After pushing for 5 hours, the baby still wasn’t out, in fact, she hadn’t really moved at all. Imagine, after five hours of the hardest work you’ve ever done in your life…you get to hear your doctor say something oblique and vaguely encouraging like, “You’re doing GREAT! I’m sure things will progress if we keep working.” There’s a thing called the “labor curve” to mention here. Typically, if there isn’t continual cervical change, and steady descent of the baby once the patient starts pushing, the patient is said to be “falling off the labor curve.” When this happens, docs need to start looking for a problem. In general we look for one of 3 P’s: Power – mom just can’t push hard enough or uterine contractions not strong enough, Pelvis – is the “chute” too small?, and Passenger – is the kid too big? In this case, the patient was off the curve, and we couldn’t be sure that any of the P’s were adequate.

We were able to see the baby’s head well enough to allow us to use a vacuum, which did help bring the baby into the base of the pelvis. At that point, we had an OB in the room to evaluate for C-section. She was particularly concerned with our decision to not treat for GDM based on this patient’s glucose profile. Almost certainly, she said, this baby was macrosomic because she, by definition, had GDM (remember, our 4th value was out of range by 3). She also said that she would have treated the patient for GDM based on her very high 1-hour test, forgoing the 3 hr. entirely, since it had been “very” positive.

You can imagine my handwringing concern at this point. I let this patient sit around for MONTHS, cooking up a huge baby that was not going to get stuck in her pelvis. Bad things happen when babies can’t fit through pelvises. To think I could have prevented it by just being more aggressive early gave me the opportunity to experience some new emotion – as yet unnamed – that combines stark fear with wistful, sharp regret and a sticky sort of guilt all mashed together with insecurity and self-castigation. We’ll call this feeling FRGIS. Mid way through this experience, I felt extremely “Frgis-y”. That is, quite terrible. I’d, perhaps singlehandedly, resigned this mother to surgery (best case), or perhaps something more terrible due to shoulders, head or neck getting stuck in the birth canal.

In the end, the vacuum (which only adds about 10% more power than the uterus and mother already provide) created just enough extra oomph to get the baby’s head through. The shoulders were a tight squeeze, but there was no distocia (shoulders caught on the pubic bone…can be REAL bad). The mother hemorrhaged and required 3 different medications to get it stopped, and she had a pretty good-sized laceration that took about a hour to repair. But the baby did fine. Actually, rather cute. I usually think they look like aliens.

The upshot was that the baby weighed around 8 lbs. This IS NOT MACROSOMIA! This is a big baby, but not medically large. In the end, we had nothing more than a difficult delivery, which probably had more to do with the mother being new at pushing and not really knowing how to do it than anything else. More stringent glucose management may have helped keep the baby a bit smaller, but she wasn’t especially large even without management. And the patient got no shots, no medications and no extra worry about having a metabolic disease while she worried about just getting through her pregnancy.

In the end, the patient ended up with a beautiful, normal-sized baby. Yes, there was a pretty big laceration, but these are relatively common irrespective of the size of the baby. But in general, our management was within the standard of care, although there is room to debate whether or not we should have been more aggressive. True, the doctors lost hair and years from their lives (or, my life, anyway), and experienced the wonderful emotion called FRGIS, but hey, this is medicine, right?

You Be The Doc – Gestational Diabetes

One of the more difficult things to deal with in medicine – I think – is borderline lab values. A huge component of most medical decisions relies on the patient’s latest labs; often the decision is almost perfunctory. But what about times when lab values are just barely positive? For example, a normal blood pressure is 120/80. What if a guy has 122/80? Is that hypertension? Should I put this disease on his problem list…there for insurance companies to see and thus charge him more for life or health coverage?

gdm6.jpgMost lab values can be manipulated to some degree. The entire field of biofeedback starts from this premise. In biofeedback models, the lab values can be changed by effectively willing your body to change it’s own parameters. If effect, you can think yourself to a lower blood pressure, lower cholesterol, more hair…maybe even bigger sexual organs I suppose. Go for it. Imagine big, big gonads if you want. See what happens.

Anyway, some people consider this mere quackery – I think it will be considered a fad in a few years – but some swear by it. And yeah, I’m sure there is some bridge across the Cartesian mind-body quagmire we’ve been wallowing in since Modernism awoke, but I’m not sure biofeedback is that bridge. Aside from whatever volitional input we may have on our bodies, there is the fact that all lab tests have margins of error associated with them. You hear about “sampling” error in all these perpetual polls in the presidential primaries. Obama leads Clinton 47 to 42 percent…but the margin of error is plus or minus 8 points. So Obama doesn’t lead anybody. He and Clinton are tied. Many of the good polling companies actually do some real statistics to come up with these numbers, brainball.jpgbut it doesn’t really matter much because none of us voters really care. All we care about is who’s gonna win the stupid thing? Who’s the prez gonna be? And, (for me) WHO’S FINALLY GOING TO PUT AN END TO DYNASTIC, BOURGEOIS RULE IN AMERICA?

Sorry, this is a blog, so I can digress and feel only a little bad. The points are that lab values are manipulatable both physiologically and statistically. The statistical manipulation – the margin of error, for example – exists because determining something like the amount of glucose molecules in a sample of blood isn’t exactly easy. There’s 2 major ways to do it, and a 3rd less-popular way as well. Each way is different from each other, so if you determine glucose values using Type 1, and then use Type 2, you have to convert one to the other’s value to even determine if they’re equivalent. The conversion is a math equation, not observational science.

Why does an average doc like me care about all these details? Well, these facts play out in my mind when I get a lab value that is juuuussst barely out of range. A positive value means the patient has a new disease that can affect their ability to get health insurance (a quaint little reality of this American health system I admire so much), but also can affect their care. One little lab value can determine if a person suddenly needs to take expensive medicines – brand-name cholesterol-lowering meds are a couple hundred bucks a month, for example. Or it may mean that they now qualify for surgical exploration to find a possible tumor. Some people have had things cut off of them – like breasts – only to find that they didn’t have cancer at all. This is called the false-positive rate and is one of the biggest reasons why I try very hard NOT to do even little tests on patients unless it really looks like they need it. Breast self-exams are a classic example of dangerous false-positive tests that lead to sometimes catastrophic interventions occasionally for no reason. **Disclaimer on this one: major controversy exists about whether or not breast self-exam are good or bad. This was just an example. Keep doin’ em if you do ’em.**

When pregnant, one of the things we screen for is gestational diabetes (we call it GDM). This disease only shows up during pregnancy, and often vaporizes just after the baby is born. It more resembles Type 2 DM than Type 1 in that it won’t really kill you in the short-term, but deranged glucose values give the patient headaches and lots of nausea and makes them feel pretty much miserable. The problem is that high glucose in the mom can lead to huge problems with the baby. First of them being that the baby can be, in fact, HUGE. But they can also end up obese in life. They usually end up with REAL diabetes. Being so big, there are risks for the delivery that aren’t pretty too.

gdm4.jpgSo, we need to avoid GDM. We screen for it by giving the mother an oral glucose test at 28 weeks. She drinks this sugary solution – absolutely disgusting…I’ve tried it – and then testing her blood sugar levels an hour later. This is a classic screening test: It has lots of false-positives, but fewer false-negatives. It’s reasonably good for catching GDM. But because of the fasle-negatives, we do a second test to try to filter some of them out, which is basically the same test with more sugar solution and blood tests every hour for 3 hours. People who have out of range glucose values for both tests, probably have GDM and need treatment which can include testing glucose values 3-5 times a day (rather painful, a bit bloody, and not cheap). The might also get insulin shots, based on the glucose values. They are usually sent for nutrition counseling to teach them how to eat basically no-carb foods. They also get regular ultrasounds every month or less to determine if the baby is getting too big, which may lead to C-section. And while we’re on the topic of false-positives, ultrasound becomes less and less accurate for determining weight as the pregnancy progresses. By the end of the 3rd trimester, the US could be off by as much as 2 lbs! An alarming US can easily lead to surgery when in fact the baby is of normal weight.gdm3.jpg

So, my patient had a 1-hour glucose test of 199. The cut-off is 150. That’s obviously positive – she qualified for the 3-hour test easily. The first test of the 3hr is a fasting glucose test (arguably the most important) and she was well under the limit. Her second test, at one hour, was also well below the threshold for GDM. Third test – at 2 hours – also negative. Then, at 3 hours, her test was 164. The cut-off was 160. She has a positive value. She may very well have GDM.

You be the doc. What would you do?

Here’s some possibilities:

A.) Bring her back for another 3h test, since they can be falsely positive (and, actually falsely negative). In other words, they aren’t always accurate.

B.) Give her the full-monty: regular US, daily glucose monitoring, insulin, diet counseling, weekly visits, evaluation for c-section

C.) One or two elements of option B – a partial intervention, so to speak

D.) Tell her the test is “fine” and leave it at that. Effectively, regard the test as negative, and tell her this.

E.) Bring her in and just test her glucose twice a week. Treat her if one of those values is out of range.

**I’ll describe what I did in a week or so.**

Pregnant with Hepatitis C…A Problem?

I have a pt. who is about 15 weeks pregnant. She has Hepatitis C. She’s one of my favorite patients, although I suppose I’d like her more if she knew less about medicine. It’s always a bit unsettling to try to help a patient who basically knows more than you about her medical conditions. Actually, I’m kidding. Patients who educate themselves (she lives on the internet…she’ll probably read this within the first 10 minutes of posting) are the best to work with because they often partner with their doc in taking care of themselves.

So the two of us are working on taking care of her Hep C problem at the same time as her pregnancy. The question is whether or not Hep C while pregnant is a problem.

The answer – from what I’ve gathered after reading and talking with GI specialists – is that Hep C is a problem in general, but pregnancy doesn’t have much bearing on it. The only big issue is trying to prevent the new baby from getting it. And like most things with Hep C, we humans don’t have too much control over that outcome.

blood-virus_hcv.jpgHep C is a virus (see funky-cool pic), so we can’t kill it. There is hep A, B, C, D, E and probably F,G, and who knows how many others, each quite different from the others. Hepatitis infects the liver, as the name suggests. It causes an acute infection, which isn’t usually a big deal and is over in a few weeks. But it also causes a chronic infection that isn’t a big deal either…for about 20 years. Then it’s a real drag. Imagine being told that – as of today – you just swallowed a time-bomb that might or might not explode sometime in the distant future. Bummer for you, dude. Have a nice day.

That’s Hep C.

El Problemo is that the acute infection usually leads to a chronic one, which over time causes cirrhosis (basically, a rotting liver). Hep C is the most common reason for liver transplantation in the the U.S. And in case you’re wondering, the liver is important. If you want me to talk about how your liver does positive things for your life, I’m happy to do that. Suffice it to say that the liver is not like a fibula, or funny bone, or navel or second testicle. It’s called the liver ’cause you can’t live without it. And when a person goes into liver failure, the experience is disfiguring, painful and often very bloody.

“Hmmmm.” You think, “So, what’s the bad news, Dr. A?”

The bad news is that the baby can get it too. There isn’t good information on how the infection happens (called vertical transmission), or what causes it to happen to some kids and not others. Currently, smart researcher types believe the biggest risk for vertical transmission is when the mom is also infected with HIV. Another problem is if the mom’s viral load is high (it usually isn’t if the mom is chronic). If neither of these things are present, the limited studies done on this topic suggest a relatively low transmission rate…something like 4-8%. On one hand, this is nice, because you can flip that number around and say that there is a greater than 90% chance that the baby won’t get Hep C from mom. On the other hand, it’s still close to 1 in 10 babies who get it. It’s a half-empty/half-full perspective kind of thing.

The virus has been found in colostrum (part of the breast milk), but there’s no evidence that babies become infected by breastfeeding, e.g. if you swallow a gnat, it doesn’t mean you’re now infected with gnats. “What about C-section?” You might ask. “Can’t you just zap the kid right out of there and keep it from all that birthing mucky-muck?” There has only been one small study comparing C-section to vaginal delivery and, statistically-speaking, there was no difference. It makes sense to keep the baby away from mom’s infected blood as much as possible. But if you’ve been in on both vaginal deliveries and C-sections, you know that until the day when we can just reach up there and put the kid in a zip-lock bag and pull ’em out, birth is just going to be a bloody affair no matter what route you choose.

So, after all that, what I can say is that we aren’t going to do anything for my patient. We’ll test her new baby for Hep C during the first year of life. But that’s about it. It makes for an intellectual but otherwise normal pregnancy.

After talking up the bad, here’s some cool stuff: The few studies on this subject show that infection doesn’t affect pregnancy. One small study suggested, actually, that pregnancy was beneficial to the long-term odds of mom progressing to liver failure. Also, it appears that even kids who do manage to pick up the virus from their moms tend to do pretty well. Some clear the virus entirely. Those who don’t usually aren’t affected at all during childhood.

There’s lots more that can be said here about Hep C, about pregnancy…about how smart my patient is (she’ll probably write in correcting me on something in this post). But those are the basics. Hep C is the social security of medicine…we worry about it blowing up in the future, but we have this sneaking suspicion that if we take care of things now, things will turn out ok.