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  Debendox was withdrawn from the market, even though the data used to discredit it was shown to be manipulated, and Dr McBride was struck off the medical register for a few years.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.