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

Zika is still in the news this new year, but this is definitely the off season. In good news, the CDC (Centers for Disease Control) has released $184 million dollars to the states and territories to fight to Zika virus. The funds will be used to improve testing and to enable the states to track pregnancies and births affected by Zika. In other good news, two studies published in the New England Journal of Medicine and the Journal of the American Medical Association reported that the risk of Zika associated microcephaly maybe less than previously estimated. Microcephaly is one of the more severe side effects of perinatal infection with the Zika virus. However it is not the only side effect as Zika affects many other organs and many other aspects of the central nervous system, many of which are yet be fully quantified. It may be that while microcephaly is less prevalent than previously estimated, serious less well defined or obvious side effects are more common than previously estimated.

New research published in the Journal Gynecologic Oncology indicate that there is a new up-and-coming ovarian cancer drug. In this small study, progression free survival was increased from 6.8 months to 15.4 months. This may not sound like much but it's a step in the right direction which, ultimately, may be combined with other such steps.

Republican Representative from Georgia Tom Price has been nominated for Health and Human Services Secretary. This has been a controversial nomination. Dr. Price is an orthopedic surgeon, and as such has been endorsed by the American Medical Association. At the same time, many in the medical field voiced their opposition to this nomination. Several thousand physicians have signed a  petition indicating their displeasure and stated that the American Medical Association does not speak for them. Meanwhile, the President of the American Congress of Obstetricians and Gynecologists, Dr. Thomas Gellhaus, has expressed concerns that some of the bills supported by Dr. Price would “…not serve women's health well”.

In other political news the GOP is divided on the issue of the ACA (Affordable Care Act). Basically, the two camps are as follows: repeal and do not replace versus revise and rebrand. GOP leaders have tried to assuage concerns about the repeal or revision of the ACA promising that "no one is worse off". There is concern however that ensuring that "no one is worse off" will be difficult to accomplish, given that the GOP intends to repeal certain taxes which have been used to fund the ACA.

In sobering news, alcohol consumption, bingeing and alcohol related deaths are up sharply among American women. This is the case as reported by the Washington Post on analysis of Federal health data. Analyzing the data has revealed that this is particularly true among American white women. At the same time, findings published in the current issue of the Journal Drug and Alcohol Dependence show that between 2005 and 2013 binge alcohol use and alcohol use disorders are increasing among older adults.

The Journal of the American Medical Association has produced new research which has broken down how we spend on healthcare. Not terribly surprising are the first two diseases that cost us the most as of 2013: coming in at number one for $101 billion dollars is diabetes, number two at $88 billion is heart disease and a surprising tie for number two is back and neck pain at $88 billion. These are nontrivial numbers which are generally spent in the hospital setting. Therefore it comes as no surprise that hospitals have been voicing their warnings to the incoming  administration about the possible repeal of the ACA. They have calculated that they stand to lose $165 billion if the estimated 20 million people lose their insurance they gained under the ACA. They warned of “an unprecedented public health crisis" and possible collapse of the whole healthcare sector.

In perhaps the most interesting news of the week the American College of Obstetricians and Gynecologists is going head-to-head with the FDA over the issue of anesthesia for pregnant women. The FDA recently issued a warning against the extended or repeated use of "general anesthetic and sedation drugs in infants and toddlers and pregnant women in their third trimester”, indicating these "might damage children's developing brains”.  Their recommendation is based on observational studies on animals. ACOG has issued a statement indicating that they are unaware of data on pregnant women that support the FDA's claims. They go on further to state that these warnings may cause patients and providers to inappropriately reject the use of these medically indicated drugs.” As a practicing Obstetrician, I can imagine the difficulties this warning is going to cause with pregnant women who need surgery for trauma, gallbladder removal, appendectomy, or even C section where spinal blocks or epidurals do not work or are contraindicated. 

Back in the good news department, Texas, of all places, has produced seven lawmakers that have filed bills for the upcoming legislative sessions seeking to "eliminate the sales tax on feminine hygiene products". The state of Texas has a 6.25% sales tax on all retail sales. Additionally certain local entities can impose an additional 2% tax. Currently certain hygiene products such as pads, tampons and menstrual cups are designated as luxury items and as such are subject to the retail tax. Changing this law would repeal this so-called"Tampon tax" which is considered unjust because it targets only women. Besides, everybody knows these items are not luxuries, they are necessities.

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

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

Two weeks worth of news will be covered this week !

Nearly two third of infected Zika patients are women. This has been determined recently in Puerto Rico, but also widely across South and Central America. Experts are not sure about the origins of this number, stating this might be because women are more likely to seek care and be diagnosed. 

In the good news department, an experimental vaccine has been shown to protect mice against Zika. This is a promising step, but still many steps from a human vaccine. And in the reminds-me-of-science-fiction department, antibodies from the blood of recently recovered Zika infected mice can be injected into other Zika infected pregnant mice. This causes the levels of Zika virus to drop in the unrecovered mice.  This novel treatment is to be tested next on non-human primates. 

A Zika “ syndrome” is coming into definition. It has five cardinal features: 

  1. severe microcephaly
  2. decreased brain tissue with  specific pattern of calcium deposits indicating brain damage
  3. damage to the back of the eyewash a specific pattern of scarring and increased pigment. 
  4. joints with limited range of motion
  5. too much muscle tone. 

The very first baby born in Puerto Rico remains hospitalized. This baby and all other Zika affected babies will be followed until age 3 in a registry called the "Zika Active Pregnancy Surveillance System”. 

In non-Zika news, a recent study indicated those who give birth in winter may need extra vitamin D supplementation. Our recent experience substantiates this. We have yet to quantify this, but in our obstetric population, it is not uncommon for us to uncover vitamin D deficiency. Good news: prescription supplementation is easy and works well. 

Did you know that long acting reversible contraceptives such as IUDs can be placed immediately post partum ? This is a breastfeeding compatible way of providing women with reliable contraception especially if they are unlikely to follow up at later visits. 

Preliminary reports on a herpes vaccine in humans are encouraging. This new vaccines reduces lesions and viral shedding for several months. It consists of three shots three weeks apart. 

Rates of preterm birth are increasing in the US. This is especially true among black and native women. 

Antenatal steroids for lung maturity were, until recently used only until 34 weeks. Now, they have found to have been useful for late preterm births between 34 and 36 weeks, and even for women undergoing planned C section 37 weeks and later. Steroids reduce the rate of neonatal distress syndrome these babies. 

In the we-already-knew-this-department, researcher have now shown that low carb meals reduce insulin resistance. Insulin resistance is bad; it means your cells don’t respond normally to insulin and do not transport sugar from the bloodstream into the cells well a they should. Eating low carb restores the cells responsiveness to insulin. 

The World Health Organization (WHO) has issued revised recommendations for antenatal care. This includes double the number of recommended prenatal visits compared to before. (Surprise ! Prenatal visits help ! )

There is yet more good news. When Kenyan women are provided with HIV self test kits, partner and couple testing increases to more than 90%. As they say, knowledge is power. 

Stay tuned for next week, when we will cover more news from the world of Obstetrics and Gynecology, and doubtless, reactions to the election from those in health care. 

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

Zika infections in the US have taken sharp uptick of late, presumably due to the weather and mosquito activity. Zika infections in American pregnant women now number around 300, the largest number of which are located in Puerto Rico. Numbers are also up since the initially reported numbers did not reflect asymptomatic infections, which can affect fetuses as well. The CDC ( Centers for Disease Control) estimate about 80% of Zika virus infections are asymptomatic. 

The Zika virus is transmitted by mosquito bite and by sexual contact. Consumer Reports has studied the so called natural mosquito repellants and, sadly, found that they last no more than an hour. DEET is much more effective, and has been found to be safe in pregnancy. 

The CDC and Harvard Public Health have analyzed preliminary data. Women who get Zika in section in the first trimester have about a 13% chance of having a baby with microcephaly. The background incidence of microcephaly is on the order of .02 to .12% in the US. So far, it appears that infection in the second or third trimesters is not as consequential.

I wonder if Zika related brain damage is either present or not present, versus a spectrum of damage. If it is spectrum, what do the other 87% of babies have that we should know about ? 

The CDC director has made an impassioned plea to Congress. The House and Senate each have separate Zika funding plans, but they cannot agree. Meanwhile days could make the difference as summer approaches. 

A new study out of U Penn indicates that pregnant women who use marijuana increase their risk of preterm labor by five times. I am more interested in what it may be doing to the brain of both the mothers and the babies, and would be glad to see more research done on this important topic. 

The whole pelvic mesh situation is seemingly going from bad to worse. Mesh sheets are used in surgery to reinforce tissue. Various types of mesh in sheets or ribbons are used for hernias and for urinary incontinence. Johnson and Johnson developed mesh for use in pelvic prolapse patients. However, complications started arising including migration or erosion of the mesh. People were indeed injured, and lawsuits arose.  Washington and California are filing lawsuits against Johnson and Johnson, alleging that the company misrepresented the risks of its use. 

Now some of those same pelvic surgeons who installed mesh are removing it. Is is fitting and customary for a surgeon to handle any of her or his post op complications However in this instance, American Medical Systems has recently alleged that some physicians and lawyers are “ persuading” women to remove their mesh implants in order to make money and inflate damage claims. They also explain that there are now lending companies who work with physicians to fund these mesh removal cases. For shame !!! I will be following this story closely.

I have used Monarc “ ribbon” to suspend the bladder to help incontinence. It has an acceptable complication rate. However, years ago, when a fellow doctor friend of mine and I went to get trained on Monarc insertion, we were also asked if we wanted to train on mesh. I distinctly remember that moment when she and I looked at each other and made bad faces. It gave us both the creeps. We said no because our gut impression told us it seemed prone to complications. Lucky guess. Or maybe it was that the idea of having a piece of screen door sewn just under your vagina skin did not sound OK to us. 

The Republican Governor of Oklahoma Mary Fallin has ignored the party line, and vetoed the recent bill making abortion a felony. This brave politician described herself as “ the most pro-life governor in the nation” but vetoed the bill on the basis that it was “ambiguous and vague" and “ would not survive a constitutional challenge” , i.e. it would be illegal. The Governor was under great pressure from the Christian right to pass the bill. She also received information and pressure from the Oklahoma State Medical Board, the American College of Obstetricians and Gynecologists (ACOG), and the Center for Reproductive Rights.

Acting this presidential could get you a nomination. Similar bills are being put forth in South Carolina and Louisiana. 

Many of you have read my rants about various and sundry public health generated guidelines about women’s health screening tests. These would include mammograms, paps, annual exams and the like. My rants have generally been about the more lax approach seen by generalist governing bodies like the American College of Physicians, and the American Academy of Family Physicians. ACOG guidelines are more stringent, and I believe this is because we rely on more rigorous data produced by specialists in the field. Even so, generalist guidelines hit the press just the same as ACOGs, and it is difficult for a layperson let alone a community physician to understand why the recommendations are so different. 

As an example, ACOG believes the evidence supports mammograms in the 40s for women of average risk, whereas the American Preventive Services Task Force does not advise them until the 50s. In a nutshell, this is because the APSTF did not choose their study endpoints in the most meaningful way. Their harms included trivial things like fear of mammograms, and their endpoint was death rather than years of life. The public and many providers were thrown into confusion. 

Fast forward to the present for some good news.. ACOG will now be partnering with these same organizations to develop what will hopefully be an evidence based rigorous set of Women’s Preventive Services Guidelines. 


Stay tuned for more news 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, Gynecology and Women’s Health

Good Monday.

Zika virus takes front and center this week as the CDC (Centers for Disease Control) has issued a travel alert "urging pregnant women not visit Brazil and about a dozen other countries in the region where mosquitoes have spread the Zika virus.” As of Friday the list of countries includes “ Brazil and 13 other countries and territories in Latin America and the Caribbean: Colombia, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Suriname, Venezuela, and Puerto Rico. This is especially unfortunate since Brazil will be the site of the summer Olympics this August.

Zika virus is spread by mosquitos. Women who are infected by it have symptoms such as fever, rash, muscle aches and pink eye. If they are pregnant, their unborn babies are at high risk to be infected and born with microcephaly, a condition where they are born with abnormally small heads, small brains, and often a short lifespan. Women who have been infected by Zika virus cannot spread it to other women since it is spread by mosquitoes. 

Concern has been raised about an association between Zika infection and post viral Guillaine Barre Syndrome. This is a post viral paralysis that is usually self limited. Researchers in Brazil have noticed a significant uptick in the incidence of this syndrome and estimate that the Zika infection raises the odds of getting Guillaine Barre about 20 fold. 

El Salvador has been hard hit with this virus, documenting nearly 5400 cases so far in 2015. Pregnant women have been advised to remain fully covered to avoid getting bitten. Imagine the apprehension that is going to develop over this. Salvadoran authorities have also advised women to refrain from getting pregnant for the next two years.

So far pregnancy, travel and clothing restrictions are some of the only measures I have heard of to prevent spread. Additionally, genetically modified mosquitos are being produced to reduce the mosquito population in affected areas. 

Aside from the sheer gravity of the situation and these recommendations, it is interesting to consider the societal consequences of a span of time with NO BIRTHS for 2 years. 

All of the other news pales in comparison to this, and so I am going to leave you with the thought that Big Pharma all over the world is doubtless burning the midnight oil trying to cook up a drug or a vaccine. Let us pray they succeed.