Zika virus

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

Policy News 

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Yet another Federal Judge has put a stop to the defunding of a regional Teen Pregnancy Prevention program. This time .a district court judge in Washington, DC has ruled that that HHS (Department of Health and Human Services) must process the grant for $3 million dollars which provides for 20 health educator jobs and provides for teen pregnancy prevention education.

Many voices have come out in opposition to proposed changes to Title X funding. Title X funding is meant to ensure access to reproductive health care. However, funds are due to be cut from any provider who mentions abortion even as an option. Proponents of the measure say parenting and adoption will also be promoted. Opponents say this is being sought to placate anti-abortion elements of the electorate as well as to close programs and clinics, thus decreasing federal health care spending for those on the lower end of the socioeconomic spectrum. 

Thirteen governors have signed a “ sharply worded letter” sent to HHS secretary Alex Azar opposing the proposed Title X changes. The letter cites “reckless policy” which “upends decades of bipartisan cooperation”. 

Texas which has struggled mightily with appalling maternal morbidity and mortality, has voiced particular concern that changes to Title X could undermine efforts to combat impact rampant maternal complications in the State. 

Medical News 

Newer gene testing is allowing doctors to better target therapies to individual patients. In particular, we are now gaining insight, through genetic analysis, about which tumors in which patients are likely to respond to chemotherapy, and conversely, which are not. Gene testing is allowing some patients to skip chemotherapy and the complications that that entails. 

Also in breast cancer news, immunotherapy is being brought to bear in the fight against breast cancer. In one case study a 49 year old woman who had failed all other therapies received immunotherapy with a large clone of her own best cancer killing immune cells. These were produced by identifying and removing theses cells, and then amplifying them to 100 billion then using them as a treatment. This patient, who had no further treatment options, is now three years with NED- No evidence of disease !!! 

In similarly encouraging news a pairing of new ovarian cancer drugs have shown themselves to be effective against heretofore drug resistant ovarian cancer. 

Zika virus is again upon us in the South and authorities in Florida are taking precautions. Thus far there have been cases noted, but none have been of local origin. Zika Virus is transmitted by certain mosquitoes and is prevalent in tropical and subtropical climates such as in Florida, Central and South America. Zika virus contracted in pregnancy can make serious birth defects in the central nervous system of the unborn. 

Many women are identified as having pregnancy associated diabetes. They may require medication or dietary modification in pregnancy. New research now indicates that such patients may benefit from a postnatal lifestyle intervention program. Such women with a history of gestational diabetes are at increased risk for diabetes later in life. 

In concerning news, a new meta-analysis has indicated that hypertensive disorders of pregnancy such as chronic hypertension and preeclampsia may be associated with a higher risk of autism spectrum disorders and ADHD (attention deficit hyperactivity disorder). Women with untreated chronic hypertension, over weight women, and others have a higher risk of having hypertensive disorders of pregnancy. Maintaining normal weight and fitness before pregnancy can decrease the incidence of hypertensive disorders during pregnancy. 

A new and encouraging study has shown that resistance training helps stave off depression. Most of the exercise literature now supports the combination of light resistance training women for women, especially older women as it preserves muscle and burns fat. The combination of cardio and light resistance is often called HIIT or high intensity interval training. Low hanging fruit ! 

Stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday. 

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

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Vice President Biden has called for the Congress to separate the issue of funding Planned Parenthood from the issue of funding the war against Zika. He has addressed the Republic led Congress in the strongest possible terms. He went so far as to point out the irony of the the fact that the people ostensibly most concerned about the unborn, anti-abortion Republicans, being the least willing to take measure to protect the unborn. Earlier this week, the Senate rejected a 1.1 billion dollar funding bill. Sixty two percent of Americans feel that Congress should approve additional funds to fight Zika, rather than pull them from other programs. 

The CDC (Centers for Disease Control) has reported that Brazil has already noted a doubling of their rate of nervous system defects, including but not limited to, microcephaly. The rate of Guillane-Barre or post viral paralysis has tripled. 

In the mice model, there is some evidence that Zika resides in the eyes. There is speculation, therefore, that it can be spread by tears. 

The WHO ( World Health Organization) has modified their advice for those in or returning from a Zika affected area. Men were to practice safe or no sex for 8 weeks. Now, that recommendation has extended to the same time frame for women: 6 months. This recommendation stands whether or not the couple is trying to conceive. Only 58% of people in the United States know Zika can be spread by sex. 

Not all South American Countries show cases of microcephaly after Zika infection in pregnancy. Not all mosquitos can transmit Zika. For example, Columbia, has had fewer than three dozen cases of microcephaly whereas Brazil has had 2000. Culex mosquitos, which are  20 times more common than Aedes mosquitos, cannot transmit Zika. The sooner basic research is done to find out the reasons behind these observations, the sooner we may get some control over Zika. 

There is other big news. The FDA, Food and Drug Administration, has banned 19 chemicals commonly found in antibacterial soaps, saying not only do they not do any good, but that they actually may do harm. There is concern especially over triclosan and triclocarbon in that they are now felt to promote antibiotic resistance. There is also concern that they may be endocrine disruptors, meaning they may interfere with sex hormones like estrogen and testosterone. Soap and water are the best ways to get clean. While I advise the frequent soaping of hands at work, and routinely upon arriving at home, I prefer my patients avoid soap on the face or any delicate tissues. 

In the good news department, we have several items. First, MRI without contrast appears to be safe in pregnancy. MRI is useful for taking care of pregnant women with many important conditions. 

HPV vaccine provided in the middle school setting met with an 86% adoption rate. This is much better than “ in the wild”. Research of this kind may provide insights into improving vaccine utilization. Maybe some of it boils down to convenience. 

Recent research indicates that use of hormones, in both oral contraceptive and postmenopausal hormone replacement forms, may be responsible for decreasingly mortality rates from ovarian cancer.  Hormone use is known to suppress the ovaries which also seems to suppress the development of this type of cancer. Ovarian cancer is one of the most dreaded Gyn cancers. This is for two reasons:  It usually presents at an advanced stage, and the screening tests for it are not very good.

Help for ovary cancer treatment is coming from an unusual source. IBM’s supercomputer Watson is utilized in a program called Watson for Genomics wherein the genes of known cancer patients are sequenced and uploaded to a database. Personalized treatment plans can be developed for each patient. In the future, this data might be used for better early risk assessment and detection as well. 

Stay tuned next for more breaking news from the world of Obstetrics and Gynecology. Next week should prove very exciting since I will be at Stanford MedX - an amazing conference on innovation in health care. Check it out here : 


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

Florida has an ongoing Zika outbreak in a Miami neighborhood of Wynwood. The CDC (Centers for Disease Control) has confirmed local transmission there for several days. In response, Florida Governor Scott has pledged that Zika tests will be free for all pregnant women. Apparently there is a Zika test kit shortage and physicians' offices have waiting lists for their use. Pregnant residents in Florida are beginning to curtain their activities and travel in their home towns. Other women are delaying pregnancies, freezing eggs for later, or leaving the area when pregnant.

California has the seen the first births of Zika infected babies. These cases have been from mothers who travelled to Zika affected areas. 

Texas Medicaid has decided to cover the cost of mosquito repellant to women of reproductive age. 

President Obama has asked Congress to reconvene early to work on Zika. Meanwhile the CDC has itself provided an additional  $16,000,000 to 40 states to combat Zika. They had already given $25,000,000 in July. This comes out to and additional $400,000 per state on average and does not sound like much in the scheme of things. The money is meant for developing programs to collect and track data on both the mothers and the babies affected by Zika. I have to say that when money is short, as it is, that making the choice to fight the virus with information seems like the wisest first step. When more money comes in, which hopefully it will, it can go to bigger ticket items like better mosquito control and vaccines. Current mosquito control techniques are poor against the mosquito since it can live indoors or outdoors, can hatch in a tiny amount of water, can bite multiple people, and has eggs which can last for months. 

The CDC has clarified that all pregnant women need to be assessed for risk of Zika. They do not necessarily need to be tested, but their travel history and the travel history of their partner or partners should be assessed. 

The CDC has reviewed data which show that the use of Long Acting Reversible Contraceptives (LARCS) is low in Zika affected States. LARCS are among the most effective means of contraception and considered safe for most all women. 

Finally in encouraging Zika news, The Journal Science has reported that three different Zika vaccines have worked “to perfection” in rhesus monkeys. Each of these vaccines works by a different mechanism to stimulate the immune system to combat the virus. One vaccine uses dead virus, but the other two use two different viral DNA subunits to stimulate an effective immune response. 

In other news, the CDC has reported that adults across the board are about 15 pounds heavier than they were 20 years ago. Boys and girls weigh more as well, though boys' heights have gone up. Girls' hights have stayed the same. The average 5’4 woman weighs 168.5 pounds, which qualifies as a BMI (Body Mass Index)  of 29, nearly going from overweight to obese at a BMI of 30. Normal BMI is somewhere between 19 and 25. See the NIH (National Institute of Health) BMI calculator HERE: 


Vitamin D is in the news again. Apparently Vitamin D levels decrease by 20 % after cessation of oral contraceptives (OCs). This has potential consequences not only for women but for any pregnancies that ensue. Because of his new finding, it might be appropriate to check Vitamin D levels after OCs are stopped or before pregnancy is considered. 

In the close-to-science-fiction department, we turn our attention to telomeres. What is a telomere ? Tasciences.com quotes Blackburn and Epel from the Journal Nature, saying that

“ Telomeres are the end caps at the end of each DNA strand that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damages, and our cells can’t do their job.”.

Telomere length is therefore a marker of cell aging. Cell lifespan shortens as telomeres shorten. We are born with a certain telomere length. The majority of telomere shortening occurs in the first 4 years of life. Little is known about why telomeres shorten. It turns out that early exclusive breastfeeding for just 4-6 weeks is associated with longer telomere length at age 4-5 years. This may have consequences for long term health and overall longevity. The CDC has reported that just about half of all postpartum women are breastfeeding at 6 months. Less than a third were still breastfeeding at a year. The American Academy of Pediatrics has recommended that women breastfeed for at least 6-12 months. 

The Journal Pediatrics reports that “ Breast milk give a boost to premature babies mental and physical development.” Those who received breast milk during the first 28 days of life had measurably better IQ, math, memory and motor skills at age 7 compared to those who received less breast milk. I will comment that to pump breast milk for 28 days while your premature baby is in the NICU (newborn ICU) requires a high level of dedication. Perhaps it is difficult to factor out this maternal dedication as a factor in the better outcomes of the breastfed babies in their study.  These breastfeeding mom’s of preemies either are or become some of the most dedicated and resourceful moms out there, due, at least in part, to what they have to deal with. Maybe the better outcomes are born of the mother’s overall dedication. Hat’s off to you…. dedicated NICU moms. 


Stay tuned for more breaking news from the world of Obstetrics and Gynecology next week on Medical Mondays.  

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

About 1.6 million pregnant women are at risk for Zika virus infection in South and Central  America. Now, health officials are concerned that local transmission of Zika virus has begun in southern Florida. This means the virus was acquired in Florida, instead of being acquired elsewhere while a person was traveling. This means that some of the mosquitos in Florida carry the virus.

In related news, the blood supply in South Florida is now considered to be potentially contaminated with Zika virus. The FDA ( Food and Drug Administration) has asked that all blood donations from South Florida halt until all donations can be screened for Zika virus.

In even more striking news, the CDC ( Centers for Disease Control)  is recommending that all pregnant women be screening for the Zika virus. 

As most of you know, Congress left for its seven week vacation without coming to an agreement on Zika funding. The President of the American College of Obstetricians and Gynecologists has written a strongly worded letter to Congress on this matter. 


Proceedings from the National Academy of Sciences include research that indicates that women who enter menopause early age faster than other women. They were able to quantify this, saying that menopause speeds up cellular again about 6 %. They also indicated that poor sleep can trigger similar aging type changes. 

In related news, women who start menstruation late and who have menopause late compared to average are more likely to achieve 90 years of age. Information like this is useful in that it helps identify factors tied to longevity. 

Research from the Journal Circulation has indicate that only 2.5 hours of moderate exercise per week has measurable effects on heart disease risk in women. Let’s see, taking one day off per week leave six days for exercise. Divide that into 2.5 hours to get the time per day needed for exercise. Only 25 minutes per day needed to reduce cardiac risk ! 

Stay tuned next week for more breaking news from the world of Ob/Gyn and women’s health.

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 from the World of Obstetrics and Gynecology 

Women in Latin American are more likely to get Zika than men. We presume they are exposed equally to Zika carrying mosquitos. This difference appears once girls become sexually active. How do you put it together ? Here is what doctors and researchers think. They believe sex may spread Zika more than was previously believed. Furthermore, getting Zika though sex is easier for a woman than for a man. Other sexually transmitted infections follow this pattern and in their case, it is because sex in women causes undetected micro abrasions which allow greater access to the bloodstream. 

President Obama has come out and said that Congress should not recess for summer until Zika funding is secured. With this funding, a vaccine will be produced sooner. Some speculate that the issue of Zika calls to mind issues of contraception and abortion, and that is why Congress is unable to deal effectively with it. Zika is bringing reproductive rights into focus. ACOG ( American College of Obstetricians and Gynecologists) representatives have noted that the southern states likely to have the most Zika are the same ones which have high unintended pregnancy rates and poor access to family planning resources. But Texas is taking a different angle anyway. They are trying to scratch up enough funds on its own to provide mosquito repellant to it’s poor women, budgeting 2 bottles per month per women.  

In other news, US maternal mortality rates have doubled in the last 25 years. Black women fare the worst, with mortality rates quadruple that of white women. 

The president of ACOG has come out stating that we should have a much more critical attitude toward chemicals in the environment which may cause birth defects. Project TENDR has been created from a variety of expert disciplines to advocate for greater government oversight on the chemicals. TENDR stands for Targeting Environmental Neurodevelopmental Risks. 

Newborns get about two months of flu protections from a shot given to mom during pregnancy. 

Despite the demonstrates efficacy of the HPV vaccine, it is still woefully underutilized. Moreover, HPV related cancers are on the rise. Between 2008 and 2012, they have increased about  17 %. HPV cancers are not just cervical cancer in women. They also include head and neck cancers in both men and women. 

Finally, in the good news department, an eight study meta-analysis out of Europe has shown that obese infertile women who have trouble ovulating do better with lifestyle intervention than fertility drugs. Six months of interventions resulting in weight loss were four times more likely to conceive than their counterparts who used fertility drugs alone.  

Wellness Wednesday: Summer Safety Kit

Here is a convenient comprehensive kit to keep you safe this summer. It recaps some posts from the recent and more distant past, all in one convenient place and on the theme of having a safe and happy summer. 

Reclaim your Summer

This deals with the importance of time off and the concept of summer vacation for adults. 

Weathering the Heat

Contains some amazing facts and figures about heat stroke.

Five Steps to Mosquito Protection

This is especially important to review in this season of the Zika Virus.

Wellness While Gardening

Tells of the little known perils of playing in the dirt. 

Hydration 101

This critical post has concrete information to help you stay out of trouble this summer. 


Stay tuned for next week on Wellness Wednesday, when we will talk about the Summer of the Mind.  

Medical MondayL Breaking News from the World of Obstetrics and Gynecology


In Zika news, it has become clear that we do not yet know the length of time that Zika stays in the reproductive tract of a man. Thus, we do not now how long he may be able to transmit it sexually. 

In a recent poll, 73% of Americans feel Congress should pass the funding to fight the Zika virus as recommended by the Obama administration. However, reflecting a poor grasp of the situation, only 46% feel they need to pass it immediately. 

In the we already knew this department, ACOG ( American College of Obstetricians and Gynecologists) has issued new evidence based guidelines to help prevent perineal lacerations. These include using episiotomy selectively, and well as using warm compresses before birth. 

SCOTUS ( Supreme Court of the United States) has struck down a restrictive Texas abortion law. This law would have required that abortions be provided at an ambulatory surgical center by a physician with hospital privileges. There is no scientific data saying that either of these elements is necessary for safety of the procedure, which is normally done in an office by a midlevel provider such as a nurse practitioner. Many abortion clinics would have had to close had this law stayed o the books. The Court ruled by a 5-3 vote largely along gender lines that these laws placed an undue burden to women seeking legal forms of health care. 

In other SCOTUS news, the Court has refused to hear a legal challenge to the Washington State rule that pharmacies must deliver all prescribed medications, even emergency contraception. This ends a nine year legal battle in which some pharmacists and a pharmacy refused to stock or fill the morning after pills. The Court voted 5 to 3 not to accept the case. Four Justices must agree to accept a case if it is to be heard. 

In the pendulum swings department, there are two items. First, Obs are giving serious consideration to the optimal time for delivery. In the past, 42 weeks was considered a reasonable time for induction. In my tenure, this has become 41 weeks. Now 39 weeks is under consideration. 

Secondly, women with a statistical risk of ovary cancer of 4% or more who is over 40 may be better off with her ovaries and tubes removed. When I finished residency in 1994, we encouraged women facing a hysterectomy to have the ovaries out as well if they were over 45. In recent years, this has become more of a patient choice. Now, we are refining this judgment to include family history and other risk factors in a statistical model to determine the best course, and it may favor removal of the ovaries earlier than previously recommended. 

Once again the USPTF (US Preventive Services Task Force) has cited the lack of evidence supporting the annual pelvic exam, and how it should be done only when symptoms are present. And yet, when examining their published statements, one sees that they do not highlight the fact that there has been nothing done to prove or disprove the utility of the exam either way. This is because doctors the world over have taken it as common sense to do the exam, thus no study has been done. The public should know that saying that there is no proof that something is not useful is NOT the same as saying that something has been proven TO BE not useful. Personally I find important things every week if not every day I do a pelvic exam, and that includes both speculum and bimanual exams. Furthermore, nobody is traumatized by their exam. Children and those with disabilities who need exams and who might be traumatized are examined with the aid of anesthesia supervision. 


Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology.  

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

The CDC( Centers for Disease Control has revealed that there are 6 cases of Zika related birth defects in the mainland US. These  are those that have delivered so far. Overall, there are 234 cases of confirmed Zika in pregnancy women in the US. All of these Zika infections were acquired elsewhere and brought here. Accordingly, New York has the most cases of Zikaa in the US, being a port of entry. So far there have been no cases of Zika infections transmitted by mosquitos in the US, though Aedes mosquitos are due to being bitting in the Southern states this week. 

Another preliminary study has come out suggesting that contracting Zika later in pregnancy confers less risk of perinatal malformations. This study was done in Columbia where there are over 12000 pregnant women who have the virus. It is interesting to note that about 80% of Zika infections are asymptomatic. These asymptomatic cases cause microcephaly all the same. 

The WHO (World Health Organization) has come out stating that there is little risk that the Olympics will case Zika to spread around the world. I personally question this, but hope they are correct. 

In other news, California Governor Jerry Brown has signed a bill potentially allowing illegal immigrants to buy insurance coverage on the state’s exchange. This seemingly radical idea is interesting to consider, since these people do come in for care. Without this coverage this care goes unreimbursed but still costs the taxpayer money. With the coverage, these people would presumably come in for preventive care or at least for earlier treatment which would mean a savings in both money and human suffering. 

A study released this last week predicts that if the next president repeals the ACA (Affordable Care Act) the  24 million Americans will lose health insurance coverage. Most doctors feel this would cost us more than the insurance in the long run. Speaking of the ACA, premiums may rise as much as 10% next year. 

CMS(Center for Medicaid Services) has adopted a policy encouraging the use of LARCs (Long Acting Reversible Contraceptives). They have concluding that this is good way to reduce the incidence and cost of unintended pregnancy. An article this week in the Atlantic has highlighted how many communities in the south the so-called “ Bible Belt” discourage discussion of contraceptives, especially IUDs, preferring instead “ abstinence curriculums” .

New research published in Obstetrics and Gynecology has indicated that most websites and apps for fertility are inaccurate in predicting fertility window. Really ? This is not rocket science. 

In the good news department, there may finally be some help to prevent vertical ( mother to child) transmission of Hepatitis B. When Tenofevir is used before birth, infant’s viral load and 7 month infections rates are lower than those who did not get the treatment. 

Stay tuned next week for more news from the world of Obstetrics and Gynecology. And don’t forget…. DEET is safe in pregnancy !! 



Medical Monday: Breaking news From the World of Obstetrics, Gynecology, and Women’s Health 

To follow recent tradition, I will give the Zika update first. The WHO (World Health Organization) has reported that the spectrum of neurological damage to babies with Zika is greater than previously appreciated. Microcephaly is certainly the most obvious problem, but others such as spasticity, seizures, and vision problems are possible. 

This week a new method of acquiring the virus was confirmed. An American lab worker working with the Zika virus has contracted it though a needle stick. 

In the US, funding is still not present to fund the fight against the virus. Nonetheless, scientists at the National Institute of Allergy and Infectious Disease (NIAID) are “aggressively pursuing" a vaccine. 

Research is also taking place regarding how to alter the genes of the Zika carrying mosquitos so that they are sterile. Wiping out an entire species through genetic engineering may have unintended consequences. Researchers are examining this important issue. 

Over thirteen hundred cases of Zika are confirmed in Puerto Rico, but there are probably many more including those who are asymptomatic. ACOG (American College of Obstetricians and Gynecologists) is leading the effort to train physicians on the island to place IUDs for contraception. The WHO this week has finally issued a recommendation to women in affected areas to delay pregnancy. 

Both ovary and breast cancer therapies are in the news this week, and the messages are promising. For starters, research presented a the annual meeting of the American Society of Clinical Oncology has highlighted 11 additional genetic mutations associated with increased risk of ovarian cancer. This may ultimately give us expanded opportunities for screening and treatment of this disease. 

On the treatment side, it turns out that a combination of IV and intraperitoneal chemotherapy is more life extending than either therapy alone, for the treatment of ovarian cancer. Also on the treatment side, it turns out that extending anti-cancer hormone therapy such as Tamoxifen for 10 instead of 5 years reduces risk of recurrence or second primary in older women with early stage breast cancer. 

Syphylis cases have more than tripled in the last decade. At the same time, the majority of sexually active women between 15-25 have NOT been screened EVER for any sexually transmitted infections since they do not believe themselves to be at risk.

The CDC ( Centers for Disease Control) has reported the “ the US obesity epidemic continues to worsen”. Fully 40% of US women are obese. Obese is defined as a body mass index (BMI) at or greater than 30. Do you know your BMI ? 

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

Zika Virus was front and center at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG) this last week. Hospital protocols are being developed to handle Zika affected births. Additionally, research continues into the the way that the virus affects babies, some utilizing the placenta. 

The annual ACOG meeting also presented a medical legal panel which presented evidence that latest cluster of TRAP (targeted regulation of abortion providers) laws were not based on medical indications. Many such laws are introduced under the auspices of medical necessity, where the available medical literature does not indicate such. It seems to me that abortion opponents should be truthful about promoting pieces of legislation based on their moral and religious views, and not medical science, for which there is none. 

In Brazil, where Zika virus is rampant, abortion is illegal, even for anomalies. Recently, evangelical politicians there have introduced stricter penalties there for those who illegally are found to have aborted a baby with microcephaly. There are nearly one million illegal abortions in Brazil each year. The number of women who are hospitalized for complications from these illegal abortions is ten times the number of women who are not. 

Oklahoma just passed a law making it illegal to have an abortion. It is a felony there, punishable by up to three years in prison. Physicians performing abortions would have their medical license revoked. 

And no matter where you stand on the issue of abortion, it comes as good news that abortions in the US and other developed countries have significantly declined since the 1990s. In my experience, abortion is a tough decision for people and is fairly hard on women. 

Also in the good news department, new research in JAMA (Journal of the American Medical Association) indicated that exercise wards of a variety of different types of cancer, even in those who smoke or are obese. There is a 20 % risk reduction for about 13 different types of cancers including esophagus, lung, kidney, stomach, endometrium and others. 

And in some news which I consider to be outstandingly good news, a panel at ACOG has generated a strong statement of consensus that 39 weeks is the optimal time to delivery a baby.  They have stated that there is little to gain and considerable to lose thereafter. We Ob/Gyns are committed to practicing evidence based medicine, and so I have managed patients according to the existing algorithms of the day supported by the best available evidence at the time. But, as my 22 years of practice have ticked by, I have had a stronger and stronger hunch about this 39 week point. Now there is finally a high level consensus about it. The presentation was so strong the the 63% opposed to the consensus before the talk turned into a 81% for the consensus by the end of the meeting. Inductions at 39 weeks had a lower complication rate than previously appreciated, and the C section rate did not increase. 

The vaccine rate for HPV (Human papilloma virus) has been low in this country. However, it is more than it has been in last years, and the rates of high risk HPV disease are decreasing. To really stamp out cervical cancer, we need to achieve the so-called “herd immunity” conferred by near universal vaccination. 

More good news…. In 2010, 16 % of Americans were uninsured. In 2015 this dropped to 9.1 % of Americans. Of course this is related to the ACA, the Affordable Care Act. Of course this has a cost. But, as a physician, I would like to remind the non-medical public that it is much cheaper for the taxpayer to pay for early prevention of illness and pregnancy than to pay for delayed treatment of illness and unintended pregnancy. 

Stay tuned for more breaking news from the work of Obstetrics and Gynecology next week on Medical Monday. 


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

A new inexpensive paper based rapid test for Zika has been introduced. This represents progress, but it’s accuracy remains to be determined. More recently, it has been discovered that testing urine for Zika is even more sensitive than blood. Good news for low cost testing ! 

Researchers are endeavoring to discover how the Zika virus does its damage. As in the case of many disease processes, the immune system seems to be mediating. Zika first affects the placenta by limiting the growth of placental blood vessels. It then moves to the fetal brain where, the immune response to the virus turns off a gene needed for fetal brain cells to specialize. 

Also of interest: there are pairs of twins who are unequally affected by Zika. In some cases, one twin develops microcephaly and one twin does not. Findings like this might lead to clues about how to test for, prevent or treat the condition. 

The United Nations has set up their own fund to combat Zika. Sixty -one countries are now affected by the virus. The National Governors Association in the United States has calling on Congress to strike a deal on emergency funding for Zika. It has been 2 months since President Obama initially requested the $1.9 billion though to be necessary to fight the virus. 

The safety of the widely used anti-nausea drug Zofran was questioned last year after a piece of research was released. A newer study from the Journal Reproductive Toxicology has found no connection to birth defects. In fact, it has also found that women who used Zofran were less likely to have a miscarriage or stillbirth. 

Outspoken Ob/Gyn and former clinical instructor at Harvard, Dr. Amy Tuteur has pointed out how the natural birth industry has fostered guilt and shame among those who have required or who chose medical interventions for labor and delivery. These interventions include pain relief, hospital birth and C sections. Most of these interventions are done in the service of the health and well being of the mother and baby. Dr. Tuteur points out that some may have lost sight of these fundamental goals. Anyone wishing to hear more of her opinions (which are as sharp as her scalpel) should go to http://www.skepticalob.com

The chair of Illinois ACOG Dr. Maura Quinlin is trying to address the rise in home birth by bringing parties together to craft regulations to guide the practice. Chief among them is the need to restrict the practice to “ low risk women”. My position on this is that this is a first step; but that many women with complications start as low risk, and that they go from complicated to uncomplicated in the blink of an eye.

Most home birth midwives in the US are not Certified Nurse Midwives, who have years of graduate level education and hospital training. Most home birth midwives in other developed countries are. This is one reason behind the disparities in safety data between the US and other countries. The president of the American College of Nurse-Midwives and the president of the American College of Obstetricians and Gynecologists are working to establish educational competencies for midwives practicing in the US in order to bring them up to the standards in the rest of the world. 

Findings recently presented at the annual meeting of the American College of Obstetricians and Gynecologists have shown some alarming facts associated with home birth. Women with prior C section who opted for home birth, even those attended by Certified Nurse Midwives, had a greatly increased risk (10X) of infants with serious medial conditions including seizures and neurological dysfunction (brain damage). Additionally, home birth VBACS ( vaginal births after C sections)  attended by midwives have a much higher risk of Apgar scores of 0—5. Earlier data referenced on my site has shown a greatly increased incidence of first Apgar of 0 for first deliveries at home. 

Maryland is moving forward with the “ Contraceptive Equity Act” , prohibiting copays and preauthorization requirements for contraceptives. Insurers have until 1-1-18 to comply. Hopefully more states and countries will follow suit. 

The chair of the Michigan section of the American College of Obstetricians and Gynecologists has noted that numerous pieces of legislation have been introduced in recent years that aim to govern the practice of medicine for women. These have had to do with everything from reproductive and contraceptive care, to breast surveillance and even ultrasounds. She is encouraging the public to be wary about this. I would say it like this: Be wary of politicians who want to practice medicine without a license, especially if they only seem to want to do so on women’s bodies. 

The Missouri house last week debated a bill that would assign the fetus full personhood. Further south of Missouri, past the Mason Dixon line, mosquitos capable of carrying the Zika virus are plentiful. This is where the virus will have its greatest effect in the US. However, it is also the part of the US where reproductive services are harder to procure. The southern states, especially Florida and Texas have had some of the largest funding cuts to contraceptive services of any states in the union. They also have some of the higher rates of unintended pregnancy. In what should be a source of statewide embarrassment,  Florida cut Planned Parenthood clinics out of Medicaid funding, but now is crying for more Federal Aid (your tax dollars) to combat Zika. That’s some nerve.  

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

A startling report by the Pan American Health Organization has reported that Zika can be carried by the Mosquito Aedes Albopictus, also known as the Asian Tiger mosquito. This is important since before this, we only thought it could be carried by Aedes Aegyptae, which has a much more restricted range. The potential northern reach of Zika pay be much farther than previously believed. (See map.) 

Testing for a Zika virus vaccine is slated to begin in September of this year.  

In other good news, there may be another strategy toward curbing the spread of Zika by mosquitos. Apparently, infecting a mosquito with a bacteria called Wolbachia makes it less likely to get Zika. It is hoped that Wolbachia colonized mosquitos will infect the entire population of mosquitos, displacing Zika.  

Hypertensive disorders of pregnancy such as preeclampsia, also known as toxemia, appear to have some modifiable risk factors. These would include diabetes, obesity, cholesterol levels, pre-pregnancy blood pressure levels, and the incidence of binge drinking. These factors should be targeted and improved before pregnancy to minimize the chance of preeclampsia. 

A retrospective study published in the journal Pediatrics has revealed that women who get flu vaccine in pregnancy protect their babies as well. Those babies whose mother received flu vaccine turned out to be 70% less likely to get the flu. Among those babies whose mothers had received the flu vaccine who did get the flu, they were 80% less likely to require hospitalization. 

An English study from the Journal of Adolescent Health has revealed that 3/4 of girls from ages 11-18 have listed breast related concerns as reasons for dropping out of sports. Other data has showed that 72 % of women have experienced exercise related breast pain. And yet only 10% of girls in the survey were wearing a sports bra prevent this. The study also queried girls about their knowledge about breast heath and development. 90% said they wanted to know more.The survey showed that the favored solution was a females only health class with a female teacher sometime around age 11. 

New research presented at the annual meeting go the Pediatric Academic Societies shows that HPV is associated with a twofold increased risk of self destructive escape behaviors such as cigarette smoking, marijuana, and use of alcohol. I wonder if this means we should begin pap and HPV screening on young women with these behaviors sooner than the recommended 21 years of age ? 

Normal weight people who ate 25 % less than they wanted were studied for two years. Research published in Journal of the American Medical Association Internal Medicine has shown that after two years, they were happier, less stressed, slept better, and had better sex drives that their counterparts who ate all they wanted. My guess is that this habit generated a sense of mastery, which transferred over to other areas of the test subject's lives. The study also showed that test subjects lost weight, from what had to be the high range of normal to about 22.6, the lower side of normal in Body Mass Index (BMI) 

Ever hear the term “ reproductive coercion “? Neither had I. However, I have heard of a phenomenon where men pressure women to get pregnant against their wishes. It can involve the sabotage of birth control and is highly associated with physical abuse. A recent study among sexually active high school girls in New York has shown that gives as young as 14 report reproductive coercion.  This problem is just coming to light. 

In related news, women serving in the military have been noted to have trouble obtaining their prescribed birth control. Perhaps related to this is the higher rate of unplanned pregnancy in the military compared to the general population. Is this reproductive coercion? Not exactly. 

In the “ I had no idea “ department, it appears that 1 in 6 hospital beds in the US are in Catholic affiliated hospitals. This percentage has increased in recent years. In these hospitals, there are, of course, no abortions performed. However, health care staff are also advised not to promote contraception, and not to perform sterilizations. Is this reproductive coercion ? 


Stay tuned for more breaking news from the world of Ob/Gyn, here, next week, on Medical Monday. 




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

Good Monday. The administrative wheels are beginning to turn in response to the Zika virus. In particular, the CDC(Centers for Disease Control) and OSHA( Occupational Health and Safety Administration) have issues interim guidelines for employers and workers who are in settings which increase their risk for contracting Zika virus. This includes workers in outdoor settings, travel or health care settings. Guidelines deal primarily with protective clothing and the correct use of EPA approved insect repellent. Additionally the CDC has activate the Emergency Operations Center to Level 1. This means the CDC assigns the largest number of staff possible to work 24/7 on the response. To date so far, there have only been three other Level 1 responses, to Ebola, H1N1, and Hurricane Katrina. Experts in Brazil have come to understand that the perinatal consequences ot Zika go beyond microcephaly. It has been found to " erode the fetal brain"...destroying the lobes which control vision and thought an other basic functions. Moreover, Zika appears to prevent formation of areas of the brain "not yet formed". 

Meanwhile the House and the Senate continue to debate about what is the “ right number” for money to fund the efforts to handle the Zika crisis. 

At the same time researchers at NASA and NCAR ( National Center for Atmospheric Research) have made themselves exceptionally useful and, lacking an adequately absorbing space mission, have created a month to month map model which plots risk of Zika in US cities. The map does this by taking into consideration climate and population factors and how they affect the prevalence of the carrier of Zika, the Aedes Aegyptae mosquito. These maps really brings the situation into focus. Have a look HERE

Beast cancer risk prediction may be about to improve. New research presented at the American Cancer Society annual research meeting suggests that adding  “ genetic risk score” together with mammography density and hormone levels to current models will improve predictions. Improved predictions are help us devise tailored screening regimens for individual patients of varying risk. Hormones will be assessed only in postmenopausal women not taking andy hormone therapy. In these women, they plan to sample estrogen, testosterone and prolactin. Adding these markers improved risk prediction somewhere between 6 and 10 fold. 

The FDA (Food and Drug Administration) has recommended that there is a possible new link between flucaonazole (Diflucan) and miscarriage. This possible link is restricted to high dose or extended therapy regimens, not the 150 mg single dose most commonly prescribed. However, in response to this warning, the CDC is recommending the use of topical products only in pregnant woman. 

All you moms know it , I know it, and now science knows it. Mom brain notwithstanding, healthy new mothers are smarter, faster and more resilient than their pre-pregnancy selves. Older research has demonstrated this. Now the journal Behavioral Neuroscience has published research using sequential MRI studies of new mothers’ brains. They have found increases in grey matter in the prefrontal cortex and the parietal lobes and others between about 2 weeks postpartum and 3 months postpartum. These are areas which have to do with emotional regulation, survival instincts and hormones. 


Stay tuned for more breaking news from the world of Obstetrics, Gynecology and Women’s Heath.  

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

As per recent precedent, we will be starting with Zika virus news.

NIAID ( National Institute of Allergy and Infectious Disease) chair Dr. Anthony Fauci has reported that Zika virus has yet another disease manifestation in non pregnant adults. Besides producing microcephaly in the unborn, and Guillaine Barre partial paralysis in a certain number of adults, it also produces significant neurological damage to what appears to be a small percentage of adults. More information will doubtless be forthcoming. 

Many have wondered why the virus, which was identified many years ago, had not caused problems on this scale, before. The answer is most likely lies in the fact that it has mutated since it was a harmless strain in Africa. It is interesting to note that this information comes to us through a collaboration between UCLA and the Chinese Academy of Medical Sciences and Peking Union Medical College. 

CDC ( Centers for Disease Control) had recommended that men with symptoms who have been in a Zika infected area abstain or use condoms for 1 least 6 months. Men without symptoms must take these precautions for 2 months. That said, it is also true that 4 out of 5 people with Zika do NOT show symptoms. Hmmmm….

It is becoming more appreciated that Zika related changes in the fetal brain may require sophisticated imaging like antenatal MRI to diagnose. In other words, a woman may not find out until late in pregnancy that her baby is affected. It is important to keep in mind the big picture that most pregnant women with Zika give birth to what now appear to be normal babies. However, there has not been enough time to determine what percent are born normal, or how long or intensively one needs to observe the child before the child is declared normal. 

In other, but ultimately related news,CMS, the Centers for Medicare and Medicaid Services, has warned officials in all 50 states that ending Medicaid funding of Planned Parenthood may be out of compliance with federal law. Ten states, Alabama, Arizona, Louisiana, Kansas, Missouri, Oklahoma, Texas, and Wisconsin have already cut off funding or have passed legislation to do so. CMS has sent letters to each state to “ ensure they have a clear understanding of their obligation to follow longstanding Medicaid law guaranteeing that beneficiaries have the right to receive covered services, including family planning services…” Failure to comply with result in another warning, then penalties ($). 

With weather experts predicating a hotter than average spring and summer, Zika carrying mosquitos are expected to expand their territory in the southern states. Legislators and activists in these states had better think hard about taking away family planning clinics which are principal access points for contraceptives. Ready access to contraceptives may become very important if Zika outbreaks develop in these southern states, which doubtless they will.  To put it very plainly, less access to contraception means more unplanned pregnancy, and in the setting of a Zika outbreak, more potential for Zika affected pregnancy, and thus more potential for seriously affected fetuses, and more demand for abortion. 

As many states are developing legislations to make abortion procedures more restrictive, other groups are promoting the use of abortion medication, which in many cases of early pregnancy, would make abortion procedures unnecessary. At the same time others are promoting “ Perinatal Hospice Care” as another way to avoid abortion, even of babies with fatal anomalies. These facilities would provide end of life care for babies born with conditions not compatible with long term survival. This would include babies with severe chromosome anomalies, severe brain defects, and other abnormalities like the congenital absence of kidneys. The appearance of these facilites coincides with the appearance of legislation in 6 states which requires physicians to counsel expectant parents with an unborn baby with a fatal condition about Perinatal Hospice as an alternative to abortion. In other words, they are advising the parents that they MAY continue to carry the pregnancy, give birth and then place their child in a hospice until it dies. I speculate that facilites of this type are bound to arise in South America where abortion is neither widely accepted nor available, and where there will soon be thousands of severely brain damaged babies due to the Zika virus. 

Now for more virus related news. Polio vaccine has been revised. There have only been 12 cases worldwide, and this latest step should eradicate it once and for all. It is important to note that the world once feared polio as we now fear Zika. 

Gardisil,  the quadrivalent vaccine against HPV (Human Papilloma Virus) has been extremely helpful to curtail HPV disease. It reduces the onset of cervical cancer by 63% and death by 43 %. However, Gardisil 9, which covers 9 HPV subtypes rather than 4, would decrease the same by 73% and 49%, respectively. This vaccine upgrade is estimated to be worth $27 billion in health care savings over the next 35 years, not to speak of the reduction in human suffering. 

Finally, in the awesome news department, women who work out while pregnant seem to confer significant lasting benefits to the cardiovascular and brain function of their unborn children. ACOG (American College of Obstetricians and Gynecologists) continues to recommend that women with uncomplicated pregnancies do MODERATE exercise before, during and after pregnancy to benefit themselves and their children. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, next week, on Medical Monday. 

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

The first US  “Zika Summit” happened a week ago Friday. Much of what was discussed was how to fund the crisis. While it is expected that there will be a few cases of Zika clustered around the country, it is not believed that Zika will affect the United States the same way it has affected Brazil. Special attention was paid to Puerto Rico where hundreds of thousands of Zika cases are expected and therefore thousands of pregnant women anticipated to acquire the infection. 

Congress has not approved the current administration's request for $1.9 billion in funding to fight the ZIka virus. For this reason NIAID (National Institute of Allergy and Infectious Diseases) director Dr. Anthony Fauci has decided to divert funds from the study of Ebola for preventing and fighting the ZIka virus. Transfer of funds from other sources is being contemplated.

It is now accepted that Zika is the cause of post Zika fetal microcephaly. However there seems to be more to the story. This which was hinted at earlier has now been confirmed: Zika virus has spread throughout South America and Latin America. However according to the World Health Organization,“… a surge in microcephaly has been reported only in Brazil.” This remains to be explained, but when it is, it will doubtless provide clues to how the virus causes microcephaly.

Generally it is believed that infections of all kinds are most threatening to pregnancy when they are incurred in the first and second semester. However in the case of Zika, it appears that this is not necessarily true. A recent study published in the New England Journal of Medicine indicates that complications connected with the virus carry over into the third trimester. They note that it is unclear whether “...there is a point in pregnancy where contracting the illness isn't potentially serious”. 

During this period, while public health officials have been recommending mosquito control precautions in countries vulnerable to Zika, I have been wondering about the safety of DEET. Most experts agree it is safe for use by pregnant women as long as they use it as intended. There is one study of 900 women in Thailand published some years ago in 2001 which provides reasonable evidence that daily use of DEET causes no discernible problems.

An interesting law in Tennessee makes it a criminal offense to give birth while addicted to drugs. These women face jail. Naturally this law was designed to deter pregnant women from using. However physicians in the state have declared that the experiment backfired, noting that women who are pregnant and using simply avoid obtaining prenatal care.

In the "practicing medicine without a license" department, Arizona's Republican Governor Doug Ducey signed a billto require abortion clinics to utilize Mifeprex according to an outdated FDA protocol and not the current evidence-based protocol. The new protocol provides that the medication can be used for a significantly longer time in pregnancy then the old protocol. The change in protocol was approved by the American College of Obstetricians and Gynecologist who noted that it aligned with "current available scientific evidence and best practices”. 

New research indicates that pregnant women who use marijuana are 77% more likely to give birth to a low birth weight baby. These babies are also more likely to end up in newborn ICU. Authors of this study note that it is important that we determine the effects of marijuana in pregnancy since so many states have legalized its use.

It would seem a threatening world out there. However, I can see a faint silver lining in all this. It seems the world is finally focusing on the reproductive health of women and children as a foundation for a healthy society and the future for us all.  

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

Research on Zika continues at an accelerated pace. This last week Zika news includes the release of a new three-in-one test to test for Zika, Chickengunya and Dengue. Researchers say this cannot keep up though without an emergency spending bill from Congress. 

Puerto Rico has become a strong cause for concern. The director of the CDC has visited recently and expects “ hundreds of thousands” to be infected by Zika, among whom are thousands of pregnant women. Puerto Rico is believed to be an important route of infection to the United States. 

In Brazil, newest numbers show 29 % of Ultrasounds on babies born to Zika infected mothers show fetal anomalies with “ grave outcomes”. The newest research shows the prevalence much publicized defect called misrocephaly, but it is also becoming clear that other kinds of problems are likely Zika-related. These would include: lack of amniotic fluid, other forms of fetal brain damage, blindness,and stillbirth. 

There are 273 cases of Zika in the US States and 282 cases in the US territories including Puerto Rico. 

A small randomized controlled trial published in March of this year studied 78 first time mothers and their second stage of labor. The second stage is the time from becoming completely dilated to pushing the baby out. The old guidelines allow first timers pushing well to take 2 hours without epidural or three hours with epidural. Study subjects were allowed to push for one hour greater than current guidelines. In this study, when they did, C sections rates were cut in half without any other adverse effects noted  in either mother or baby. The authors remarked that the study was underpowered to detect small but clinically important differences. It does however, suggest that first timers were being “cut” as we say, too soon. 

As an Obstetrician, I would note that I have seen this study reported in the press. Many assumed that this meant that caregivers should now let patients push longer. Finally I got at look at the study itself. Nowhere in the press did it mention that all of the women in this study have epidurals. This makes it more difficult for many people to push effectively. Now it makes sense to me that more time made for more safe vaginal births. Certainly in many cases,  second stages with low quality epidural-influenced pushing should not be expected to make as much progress as second stages in women with strong epidural-free pushing. More time should be given for these patients. Normally, in a real labor population, some people have epidurals and some do not. Labor length averages are going to be influenced by his. However, If every single patient in a small study has an epidural, result swill skew toward the effect of the epidural-ized labor. Obviously. 

The old labor guidelines were made in the days before epidurals. In those cases, the women were probably unmedicated and thus pushing for all they were worth. In such cases, the old time allowances were probably appropriate. The idea is that, if your patient was going to deliver vaginally  safely, she should be able to do so within the old time allotments. Furthermore, if you persist in pushing her longer, you set yourself up for a variety of bad situations like stuck shoulders, a traumatized baby, or a traumatized mother, or a very late and thus risky C section. Hard coordinated pushing should result in continued progress of some degree. If it does not, the safety of vaginal birth should be questioned.

There are various signs we watch for during labor to tell if the baby can safely be delivered vaginally. It is so much more than the time duration of pushing. We watch the fetal heart tones, the evolving shape of the baby's head, the movement of the baby in response to the mother’s particular push in whatever particular position she is in. We factor all this in. I may know someone is stuck after only one hour, and I may let someone else safely go for four. It is a matter of not only knowing the labor guidelines, but but knowing the reasons behind them and knowing your particular patient very well. 

In the way cool department, researchers are using an iPhone app to begin a study of postpartum depression. They will be looking at a possible genetic predisposition for PPD. Using the iPhone will allow them to more easily get the enormous numbers (100K) they need to produce quality conclusions. 

In the good news department, Vox report that several more states, Missouri, Hawaii, Washington, South Carolina and Tennessee are considering bills to allow pharmacists to prescribe birth control pills. Ob/gyns support these bills because of the well established safety of these medications. 

The Supreme Court is hearing arguments about the ACA’s (Affordable Care Act) contraception mandate. A religious group called “ Little Sisters of the Poor”, one of the plaintiffs, are nuns, and they argue “ the birth control provision violates the laws of God.”

Governor Mike Pence of Indiana has signed a bill prohibiting abortions even for birth defects. He did this despite opposition from several of his female pro-life Republican colleagues in the House. Has he heard of the Zika virus ?


Stay tuned for more breaking news from the world of Ob/Gyn next week on Medical Monday. 



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

The CDC (Centers for Disease Control) predicts Zika will spread along the Gulf States of the US this Summer. The CDC has also said that since mosquito control in Florida is good, the risk there should be relatively low. As with regard to South America, and in particular Mexico, the CDC has noted that the Aedes mosquito, vector for the virus, is rarely seen above 6500 feet. 

Researchers studying a Zika outbreak in French Polynesia have identified a 1% risk of microcephaly among children born to mothers infected in the first trimester. Observers of the Brasil outbreak think the figure is too low given what they are seeing. It will take several more months to draw any conclusions.

As of Friday, there are 450 people in the United States who are infected by Zika. This does include Puerto Rico, where the Puerto Rican section of ACOG ( American College of Obstetricians and Gynecologists) are providing IUDS free of charge. (So proud of my brothers and sisters in ACOG ! )

In other news, concerns have been raised in an opinion piece in the journal Obstetrics and Gynecology that media coverage of controversial medical technologies may prevent certain women from getting the best treatment for their particular needs. They site the recent reluctance of doctors to use mesh implants, morcellators, or Essure sterilization even in patients for whom they are well suited. 

In the no-good-reason department, new research shows that sexually active teens with LARCs ( Long acting reversible contraceptives such as IUDs) are 60 percent less likely to use condoms that similar girls taking the pill. Birth control use in teens is distributed as follows: 2% use LARCs, 6% use Depo Provera injection, patch or ring. 22% use the pill. 

Also in the no-good-reason department, new research indicated 50% of pregnant women who quit smoking start again after childbirth. What percent of smokers quit during pregnancy ? 13 %. 

What about smoking pot in pregnancy ? One thing’s for sure, Ob care givers are not consistently counseling patients about it. These are the findings of new research published in the journal Obstetrics and Gynecology. I will say that as a caregiver, It is challenging to counsel against something that is so widely used, and for which people will rally. Neither the popular media and the research community  give us much in the way of support here. In fact, the facts on MJ use in pregnancy are not encouraging. If you are interested you can read the definitive information HERE, which is a summary document from the American College of Obstetricians and Gynecologists to its members. This is an area needing further attention. That is, if we value the brain power of the next generation. 

Steroids are given to mothers at high risk for preterm delivery. At this time, we give them from 24-34 weeks of gestation. However, new evidence indicates they may be helpful given even as early as 22 weeks. Hopefully the demand for this will be small. 

A new study published in JAMA ( Journal of the American Medical Association) reveals that vaccine aversion may be beginning to manifest in increasingly rates s measles and pertussis (whooping cough) in the United States.  No surprise here. 

Also In the vaccine department, there is good news. Chicken pox, also called Varicella, is now nearly 100% preventable. Think that’s no big deal ? Try telling that to someone like me who got it at the age of 24 ( and got seriously ill) or someone with a terrible case of shingles, which is reactivated chicken pox. New data says getting two shots instead one, one at age one, and the second around 4-6 years of age, confers near 100% protection. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, here, (or hopefully in your inbox) next week, on Medical Mondays. 



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

Good Monday.

The CDC continues to study the relationship of the Zika virus to a severe brain anomaly called microcephaly. No one really doubts the association; The goal in documenting the association scientifically it to understand the mechanism of how the virus dose the damage and therefore how, ultimately to prevent or interrupt it. Similarly, new research this week provides stronger links between Zika infection and Guillaine Barre syndrome, or post viral partial paralysis. 

Zika virus has been seen as far north as Washington DC. Aedes Egyptae mosquitos have been identified there as well, and it is speculated that they survive the winter by staying indoors or in subways. Apparently the mosquito maps in the US are “not complete”. 

Preterm labor and delivery has vexed Obstetricians for decades. We have little to prevent it. We did feel were making inroads into predicting it using two specific tests: ultrasound measurement of the cervical length and a swab for a chemical called fetal fibronectin. However, according to new research these may not be as useful as previously thought. Risk factors for preterm birth are young age, low pre pregnancy maternal birthweight, smoking, short inter conceptual interval, urinary tract infections, and periodontal (gum) disease. 12% of all births in the US are preterm. Preterm delivery is the leading cause of neonatal mortality in the US. For more information, see our section HERE on preterm labor. 

A study reported in the Journal of Adolescent Health has shown that only about 42% of men have heard of emergency contraception, aka the morning after pill. This is a safe effective solution to prevent unplanned pregnancy. It is available over the counter. 

Essure is a device placed in the fallopian tubes for sterilization. It turns out to have a far higher complication rate than was previously believed or advertised. A powerful social media campaign brought this to the attention of the FDA who has now studied the matter and given its recommendations. Essure will not be pulled off the market. Instead, Bayer AG will be required to perform new studies on the implant. The FDA will also require a boxed warning and supply a checklist for physicians to review with patients. The FDA is currently seeking public input on the packaging. 

From the chickens and eggs department, a recently released study in the Journals of Gerontology showed that “ higher education, positive wellbeing, overall good health, and higher physical functioning all contribute to women maintaining good memory health after age 80.”  This data comes from a study initiated in 1991 and is a subset of the huge Women’s Health Initiative Study famous for its revelations about postmenopausal hormone replacement therapy. 

A recent study in older first time pregnant women shows that induction at or after 39 weeks is NOT associated with a bad birth experience or a higher risk of C section. This is contrary to the prevailing wisdom. 

This last week, the US Supreme Court has heard arguments over the matter of abortion facilities. At issue is whether they must meet hospital grade surgical standards. Proponents state this will make the facilities safer. Opponents say that this is a ruse, cost prohibitive and simply a legal way to close down all but a few facilities (75% of them according to ACOG, the American College of Obstetricians and Gynecologists. Medical experts say this level of facility is not medically necessary for these procedures.

Meanwhile statistics in the US now indicate an 18 % drop in unplanned pregnancies between 2008 and 2011. One third of these pregnancies were averted though legal abortion. Further south, the staunchly Catholic South American countries grapple with the devastation of Zika induced microcephaly and the question of abortion should it be identified. 


Stay tuned next week for more breaking news from the world of Obstetrics, Gynecology and Women’s Health. 




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

Pope Francis has done something unprecedented. On Thursday the pontiff has suggested that women threatened with the Zika Virus may use contraception. This historic and, dare I say inspired move has given me great hope. The Roman Catholic church has had a longstanding ban on contraception. However, the Zika virus scourge traveling though south and central America, with its devastating effects on the unborn, has caused him to announce this exception. Pope Francis has made it clear that the exemption is “ rare and specific”. This announcement is likely to have a profound and widespread impact particularly on poor Latin American countries where the dictates of the church are absolute and where Zika virus is the most prevalent.

It is becoming better and better established that Zika, virus infection, especially early in pregnancy, is associated with the development of microcephaly. Microcephaly refers to small head, but it also entails a small dysfunctional brain. Researchers are now becoming concerned that normal appearing, non- microcephalic babies of mothers who had Zika during their pregnancies may have more cognitive and mental heath problems as they age. The potential social effects of this are enormous. 

Links between Zika infection and post infection paralysis, aka Guillaine Barre, are becoming stronger. Of course this will potentially affect men as well as women. The exact incidence of Guillane Barre after Zika infection is as yet, unknown. 

In other news, new research indicated that babies should get vitamin D supplementation whether or not they are breastfeeding and are eating solid foods. Breastfed children need 400 IU Vitamin D daily, even if they are also receiving formula. 

ACOG (American College of Obstetricians and Gynecologists) continues to push for contraception as a quality measure. This means it is a feature of medical care and insurance coverage that is routinely assessed. The ACA ( Affordable Care Act) requires all insurance plans to cover all FDA approved contraception, but this has not yet been fully implemented. 

For about 25 years “steroids” have been used in mothers under 34 weeks to accelerate the lung maturity of their growing unborn baby. This is done if an early delivery is suspected to occur. However new research in the New England Journal of Medicine indicates there may be benefit to giving steroids through 36 weeks. 

The CDC just released a report indicating that 1/3 of adults are getting insufficient sleep. Less than 7 hours of sleep is associated with increased chance of diabetes, heart disease, stroke and all- cause mortality and “ frequent mental distress”. 

So to prevent these things, I should go to sleep soon. However, I will leave you with this: My patients often bring me things from far flung places since they know I do not get out much. Tomorrow, when I sit down at my desk, I will see one gift that is more special now than it was before: a souvenir photo of Pope Francis and a miniature rosary from Rome, where one of my Catholic patients heard him speak. To this Jewish girl, Pope Francis is a hero, a real “mensch ".