Medical Monday: Breaking News from the World of Obstetrics andGynecology

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Regular readers of this column know that for many months we have started with news pertaining to the Zika virus epidemic. This is of special interest to those in the field of Obstetrics and Gynecology, since it is both perinatally and sexually transmitted. This means that once a person acquires Zika virus from a mosquito, she may pass it to her unborn child, and anyone may pass it to a sexual partner. Zika has been widespread in South and Central America and has come as far north as the southern part of the United States. During the warm spring and  summer months, officials were frantic to control it, employing measures of all kinds, but without anything truly effective. Many thousands were infected, and many of those were pregnant. This column has not only served to educate readers about Zika; it has also documented in realtime the painstaking progress of work that has been done, bit by bit, to understand and control the disease. 

As a physician of 27 years, I have read about many disease processes. I have never, however, witnessed the observation, diagnosis and gradual clarification of a new disease quite like this. I was in college when HIV/AIDs came to the fore (1979-1983), but by the time my third year of medical school (1987) had come along, we had wards of patients with HIV/AIDS related complications like Kaposi’s sarcoma, pneumocystis  pneumonia, and disseminated herpes. We understood only a bit at that point, and we felt rather helpless. I am by no means a caregiver on the front lines of the Zika Virus battle. However, I can imagine how they must feel, based on my limited experience with HIV. 

Zika is different in that in can affect the next generation. HIV can also be passed perinatally and also by sex. However, when it affects a baby, it leaves that baby neurologically and developmentally alone. Not so with Zika. For some reason, Zika targets the baby’s brain and sets some process into motion which disturbs and potentially stops the brain's growth, while the rest of the baby continues to grow. As with other perinatal viral infections, contracting Zika early in pregnancy makes matters worse, and interferes with development at an earlier stage. This makes sense. However, the latest revelations about Zika are even more troubling. A new study by the CDC (Centers for Disease Control) indicates that a Zika affected mother may produce a term baby who appears entirely normal at birth. However, that baby may well go on to develop microcephaly, the hallmark of the Zika's affect on the central nervous system. This seems to indicate that we do not know how long the effects of Zika virus infection can last. It raises questions about newborns, toddlers, or growing children getting their own Zika infections. This has far reaching implications for how all families in Zika affected areas live their lives. It clearly has implications for the medical community and society at large. 

Meanwhile, the WHO (World Health Organization) has declared that Zika is no longer a public health emergency. Well, of course it is. However this designation simply means that the crisis should no longer tap emergency funds, but rather should have it’s own proper ongoing budget. Nonetheless, some authorities feel this is premature, and have urged the WHO to reevaluate the decision come warmer weather. The CDC, by contrast, will retain Zika at the highest emergency level. Brazil, the epicenter of the outbreak, will continue to consider it an emergency. The hope is that these deliberations and administrative designations will not get in the way of efforts at infection control, basic research and of course, the much hoped for VACCINE. 

In other news, a new study has emphasized the importance of thyroid function in pregnancy. The immune system changes in pregnancy and so does thyroid function. Not uncommonly pregnancy is the time when low thyroid is diagnosed. This new study has highlighted the very important fact that optimizing thyroid function in pregnancy improves birth outcomes in measurable ways. We know that seriously low thyroid functioning pregnancy is associated with mental deficits in children, a condition called Cretinism. However, optimizing thyroid replacement also prevents still birth, and low birth weight infants. 

 A majority of the news otherwise on this short week had to do with the new administration’s plans to dismantle or alter the ACA (affordable Care Act). As time goes by, we hear different things about this. I get the feeling that reality will set in and that pragmatism will have it’s way with lawmakers and their promises. Perhaps the new administration will be satisfied if they can shuffle and rename a few things, then take credit for the good ideas. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The news this week is dominated by virus science.

The first United States baby with Zika related microcephaly has been born in New York City. While this is not surprising, the fact that many women are ignoring Zika related travel warnings is. This summer, over 2000 pregnant women traveled to Zika affected areas and have com back requesting testing. In many cases, they are traveling to the Dominican Republic. AS f the present, cases from the Dominican Republic account for more than a fifth of all US cases. The CDC(Centers fro Disesase Control) and the American Academy of Pediatrics are grappling with how to develop protocols to care for infants who will be born with microcephaly. These infants have serious mental and physical disabilities since the higher portions of the brain are underdeveloped. 

Florida is one of the most vulnerable states in the Union to the Zika virus. Authorities estimates over a quarter of a million women are at risk in Florida. Various research indicates that a Medicaid expansion there would help reduce the risk of pregnancy women to Zika. There is also a push to require employers to take measures to limit their pregnant employees exposure to mosquitos. 

As of mid July the CDC is tracking around 1300 cases of pregnant women with Zika. Fourteen were sexually transmitted, and the rest acquired through travel. 

There is also a Utah case on record this week of a man who acquired Zika through close family contact. He was taking care of an elderly man who had acquired Zika due to travel. 

Hepatitis C is on the rise, both in women of reproductive age, and not surprisingly, in their children under 2. There is no vaccine yet for Hepatitis C, but very recently, a very good treatment has been released. 

In other viral news, work has been done showing that certain vaginal flora (Prevotella BIVIA) make it easier to transmit HIV. However, a silicone ring imbued with antiviral drug may help reduce the risk of transmission. Pregnant women with HIV have now been shown to do better if their therapy is continued postpartum. 

Finally, in some other good news pertaining to viruses, the American Cancer Society has endorse the vaccination of all preteens, boys and girls against HPV (Human papilloma virus.). 

Say tuned for more riveting news from the word of Ob/Gyn next week on Medical Monday. 

Medical Monday: Breaking News form the World of Obstetrics and Gynecology

Good Monday ! We will start our news this morning with a revelation that a once deadly virus is now under firm control via the three pronged approach of surveillance, treatment and vaccination ! I speak, of course of the Human Papilloma Virus,(HPV), responsible for causing cervical dysplasia and cervical cancer.

A new CDC study published in The Journal of pediatrics reports states that" thanks to a vaccination program that began decade ago fewer US women are entering adulthood infected with” HPV. Apparently this study is the first to show falling levels of dangerous strains of the virus in women in their 20s. Human papilloma virus vaccine also known as Gardisil, has been available for use for children ages 9 through 26 for many years now. It was initially only available for girls because the studies were done first on girls but subsequently it was released also to boys. 

Zika is our newest viral threat. It has ravaged South and Central America and proceeds northward into areas where the Aedes aegypti mosquito can live. Zika is blood borne and spread by this mosquito. Male to female sexual transmission of ZIka is now also confirmed. It is also vertically transmitted, meaning from mother to unborn child, and is strongly linked to the development of microcephaly in the the growing fetus, which produces severe brain damage. Conclusive proof of the connection is likely to come in June when a large cohort of nearly 5000 women mostly in Columbia will give birth.

Zika infection is also a threat to the nonpregnant in that it is strongly associated with a much higher risk of developing post viral paralysis, Known as a Guillain-Barré syndrome. World Health Organization researchers note that there is been a spike of Guillain-Barre "everywhere that we are seeing to seek a virus".

In the good news department, breast cancer survivors are now believed to be able to safely use vaginal estrogen therapy. Vaginal estrogen therapy is used to treat vaginal atrophy, often see in menopause or after breast cancer treatments which stop a woman from producing estrogen. Vaginal atrophy is a painful condition which causes various problems and prohibits intercourse. We do not give systemic estrogen to breast cancer survivors since we are concerned it could encourage a cancer recurrence. Vaginal treatments are not believed to produce a systemic dose. 

In more good news, a cheap easy to use vaginal ring is helping to curb HIV transmission rates in Africa. The rings slowly releases an antiviral drug to combat HIV and it needs to be changed every 4 weeks. It reduces transmission by 30 %. 

In concerning news, preeclampsia in pregnancy seems to be associated with a measurable risk of cardiovascular disease later in life. The effect is so pronounced, that left ventricular functional abnormalities can be seen on imaging family soon after delivery. 

Also concerning is new research indicating that breast cancer risk may be increased in those with hyperthyroidism. 

Finally, in the news-that-sounds-like-science-fiction department, the first uterus transplant in America has been performed. The recipient is 26 years old. She will have to wait year before attempting In vitro fertilization. If she succeeds, she will be permitted to keep her uterus for one of two children and then it will be removed.