Journal: Case Studies

Assessment for this topic consists of an exam (50%), two case studies (each 20%) and a personal portfolio (10%).

I think the work required is mainly reading and writing.

• Reading the subject notes, text and the e-readings, which are papers published in professional journals, or parts of other books
• Writing reflections about the issues raised in the provided material, as well as the portfolio, and case studies.  I don't know what the exam will look like - multiple choice, short answer, or essay. 

Today I had intended to get started on preparing the first case study, which is due for submission in a few weeks.  Another student has kindly posted a university 'guide' to answering case study assignments on the group facebook site.  It's not rocket science: there's nothing surprising in the guide, but I appreciate having it so that I approach the work systematically.

The case study question is about a 25 year old woman who is 7 weeks pregnant and suffering with nausea. 

It's an interesting scenario.  The assignment will require discussion about investigations and advice, possible treatments (over the counter, 'alternative', and on prescription), and follow-up.  The issue of teratogenic drugs is very pertinent.

My mind immediately returned to a Saturday afternoon some years ago (in the early 1990s I think) when I listened to the ABC Science program that exposed Dr William McBride for his scientific fraud relating to the anti-nausea medication, Debendox.  McBride was the highly respected obstetrician who had 'discovered' thalidomide as the cause of dreadful limb abnormalities in children in the 1960s. 

Debendox contained vitamin B6 (pyridoxine) and doxylamine.  My understanding is that pyridoxine has anti-nausea properties, and is excreted in urine.  There are no concerns about drug toxicity in the mother or the baby.  I don't know about doxylamine.  I will plan to follow up on that as part of my case study.  Debendox was withdrawn from the market, even though the data used to discredit it was shown to be manipulated, and Dr McBride was struck off the medical register for a few years.  I remember in the early 1980s, comments by colleagues that without Debendox many women with hyperemesis have no reasonable treatment.  I used vitamin B6 in my pregnancies to manage morning sickness, and in late pregnancy as a mild diuretic.

Some women experience mild nausea in the first trimester without vomiting - the sort of nausea that feels better if you have something to eat.  Others vomit almost every day of their pregnancy, without experiencing dehydration, and without any medical intervention.  Others have had multiple admissions to hospital emergency rooms for rehydration.

I have worked with women who have experienced a high level of nausea and vomiting, and managed to avoid medication.  Even in labour they have managed to keep enough fluid down, and avoided needing IV fluids or an injection of Maxolon (Metoclopramide).  Within minutes of the birth of the placenta these mothers have announced that they are no longer nauseated!

I'll leave it there for now.  The case study raises interesting professional and ethical questions.  I have some reading to do, some thinking, and then some writing.

Your comments are welcome.

ps - Another student posted a paper by Nulman et al (2009), Long-term Neurodevelopment of Children Exposed to Maternal Nausea and Vomiting of Pregnancy and Diclectin, published in the Journal of Pediatrics. 
The study showed that nausea and vomiting of pregnancy (NVP) has "an enhancing effect on later child outcome" and that "Diclectin® does not appear to adversely affect fetal brain development and can be used to control NVP when clinically indicated." (J Pediatr 2009;155:45-50)
My next question was, What is Diclectin, and is it available in Australia??
Answer: http://diclectin.com/ 

Diclectin®, the only pharmacological solution specifically indicated, prescribed and labelled for the management of NVP. Diclectin® consists of a combination of 10 mg of doxylamine succinate and 10 mg of pyridoxine hydrochloride (vitamin B₆) in a delayed-released formulation. This combination has been prescribed for over 50 years to more than 33 million pregnant women. 

It appears that Diclectin® is very similar to Debendox.

I am pleased with this piece of information.  I don't have the opportunity to get medicines from Canada, but pyridoxine is readily available, and as I wrote earlier, I have always found it a useful treatment for NVP.

journal: week 3

It's more than a week since my last entry into this little e-journal.

Today I have spent 4+ hours of focused time on the pharma topic, reading published papers and text, and working on Activity 1 of Module 2.


It's a cold day, and although the heater is on, and I am warmly dressed, my hands and feet are cold.  I thought about going for a walk.  I went outside to check my leafless Bonsai trees, and put a little water on a few of them, and some ferns that were looking dry.  Then it started raining, so I didn't go for that walk.

I feel pleased with myself for having got on with the study.  The course information tells me that it requires 18 hours study per week, which is 3X6 or 2X9, and that's just not going to happen.  So I tell myself I just have to work smarter, not longer.

I do enjoy getting my mind around a subject.  It's often difficult to find blocks of time in my world.  The phone rings, a woman thinks she might be in early labour, so we talk for a while.  Then I need to think ahead - do I need to be ready to re-schedule any consultations?  Is my equipment ready?  ...  Perhaps it's time for a cup of coffee.  The phone rings again.  Emails come in.  Let's not even think about FB!  [and, you might wonder how I have time to write a blog?] 


Activity 1 of Module 2, Pharmacology and Pharmacokinetics, is an exercise in which we look in some depth at the pharmacokinetics and pharmacodynamics of two medications. I have chosen Metoclopramide (Maxolon, an anti-emetic) and Enoxaparin (Clexane, a form of Heparin). 

Maxolon is a medicine that I might use if a woman is vomiting in labour.
Clexane is sometimes prescribed for pregnant women who have clotting disorders, or who have had recurrent early fetal loss.  One of my current clients is on Clexane, so it's a good opportunity for me to learn more about it.

Having put down the good side, here's a bit of the other side of the coin.

I am feeling very isolated and unsure as I work in this virtual classroom. I haven’t done online university study previously. I am wondering when we will have the opportunity for tutorials, and how that works. I am finding the discussion channels via the university's system and facebook inadequate and frustrating. There are 95 students enrolled, and it seems that the course was set up for a much smaller group. Many of the students seem to be in current employment, with a hope/plan for private practice in the future.

I am particularly concerned that I get it right, because other colleagues look to me for guidance.  It could easily be a case of the blind leading the blind.

Thankyou for your comments