Friday, December 17, 2021

Hand Presentation

     I had two interesting placenta's this week, which is saying a lot, because I rarely get one a year. They are junk surgicals. Back in residency I cut my hand on a placenta. Unfortunately the histo director Marty saw me and made me initiate the reporting of it to workman's comp and HR. About thirty minutes into that process I could tell it was going to take a long time so I was like fuck this and went back to gross. Took a deep dive into the charts and Mom didn't seem high risk. When I was planning my first pregnancy I told my OB Cindy to check for all the things, AIDS, whatnot. I can handle putting myself in harm's way but not a kid. It was all negative, thank goodness.

    Anyway, the first one had chorioamnionitis. This is the most common placental problem but the requisition was what piqued my interest. It said hand presentation. I normally don't open Epic for a placenta but I did. Mom was of the young age that the prerequisite effort for her current predicament was possibly criminal and not recreational. She had no idea she was pregnant and called 911 bc there was a hand protruding from her vagina. I think I would have had a coronary before I was able to call 911. But she did, and delivered a viable 25 week old female infant in the ED. What a way to enter the world, I marveled. Maybe this chick will be president someday.

    The second one was today. We document the amount of placental villous infarct - it is estimated grossly - and they are usually under 5% which is normal. This one was 85% infarcted, which I've never seen. Mom had asymptomatic Covid, she was in town from a small town bc hubs was on ECMO with Covid. A closer examination of the req showed the baby was IUFD - intrauterine fetal demise. 33 weeks. I learned there are case reports out there that show that having Covid can cause massive fetal malperfusion and placental infarct. So it can bypass Mom and be terminal to fetus. Melody and I marveled - I printed out a case report for us to read.

    Mandee Novack did a Covid update for us last night and I watched the video today. The Omicron variant, which is plaguing South Africa and Europe, is just hitting the US and Mandee thinks it will cause massive problems in January (after my Christmas Eve party thank goodness). It's more transmissible than Delta and OG Covid but less virulent. Meaning vax boosted people will probably be ok. She showed lots of charts and graphs and where the other two VOC - variants of concern - were like a steady climb Omicron is like a straight up peak. 

    We had a plateau in April but there was no plateau after Delta there was just a nadir and we are on the rise again. Omicron is definitely here, if not yet detected. She got all sciency and nerdy in a good way but the gist is that Omicron has never before been seen molecular variants on it's spike protein. It has S dropout, and we have Thermofisher which is the only machine in the state to record S dropout so she's been charting it since Thanksgiving. No big spikes it that yet, but it's coming. BioFire and Thermofisher have the ability to identify the Omicron variant in the pipeline - it's coming soon. 

    Mandee predicts that while it may not be as virulent or cause as much problems as Delta it will be a crisis, if a more abbreviated one. It will wreak havoc on staffing - those L&D nurses who throw baby showers and have breakfast after a night shift could catch it and wipe out 40% of a department for 10 days. Whereas Delta and OG have a transmission rate of one it has a transmission rate of 5 so that might cause, and already is in Europe, exponential disaster. If one person infects 5 and they go onto infect five more it's a real problem.

    There will be testing issues and shortages. At the peak of Delta we were testing 500 a day in the drive through and this is worse. We have shortages on monoclonal antibodies and that's bad too. Our ICU's have remained full through Delta's waning and if there are asymptomatic people transmitting it to already sick patients they won't do well. Child care will be a big issue - Omicron doesn't care if you are vaccinated, although you will probably be ok you will still be a problem and there will be lots of shut downs of day care units. She illustrated the transmissibility with an article about a person from South Africa staying on the same floor as a person from Canada. Camera footage showed they never even passed in the hallway but the person from Canada got it anyway. So it can go through walls and HVAC units. Delta and OG could not do that.

    Cecelia came home today - I got two tubs of pimento to celebrate and she is happily diving into one with Ruffles. Jack excitedly texted that he got all A's this semester - I'm proud of his hard work. I've had a rough week physically but I'm excited to be off for a whole week. Got lots of boring doc appointments and OT but that's ok. Boring is better than exciting sometimes. Hope you are well, much love, Elizabeth

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