Medical Monday: Breaking News from the World of Obstetrics andGynecology

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

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

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

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

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

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

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

Zika funding. It comes down to this. Even as Congress has reached its planned seven week summer break, there is still no Zika budget, the United States faces its first couple deaths from Zika virus, one in Utah, and the other in Puerto Rico. The AP ( Associated Press) reports that the main hang up was Democratic objections to GOP language which would block Planned Parenthood clinics in Puerto Rico from receiving money to fight the virus. Shame on them all. 

The Imperial College in London has presented a bad news/good news scenario. Their modeling has indicated that Zika will likely last in Latin America for another two to three years. At that stage, herd immunity will hopefully develop. 

The CDC (Centers for Disease Control) is working on preparing a protocol for the first locally transmitted cases of Zika. One of the biggest challenges is that 80 percent of Zika infections area symptomatic. Almost all stars of the Union are at risk including the northernmost United States of Michigan, New Hampshire, Washington state and Minnesota. There are currently 346 pregnant women with Zika in the United States. 

Half a million people are excepted to travel to Brasil this year for the Olympics. However experts at the CDC are projecting that this will not spread Zika internationally. They have explained their position by saying that this half million represents only about 1% of all international travel to Brasil. 

HERE is the link to the excellent CDC pages on Zika.

Happily much of the other news this week is good, though a fair amount of it falls in the "we already knew this" category. 

One thing we did not even suspect was that a mouse could have a menstrual cycle. The spiny mouse has a tiny nine day menstrual cycle. Researcher hope the mouse will provide a model to study the reproductive cycle in women. 

Moderate exercise in pregnancy has been shown to benefit both mother and baby. In particular, mothers who do moderate regular exercise in pregnancy have lower rates of hypertension, gestational diabetes, and C section. 

Both mothers and fathers weight during  pregnancy affect the weight of children later in life. This is believed to be true not only by virtue of lifestyle but by genetics. It appears that both mothers and fathers weight influence gene expression in the unborn, which postnatally can affect weight. This knowledge may help us counsel prospective parents and spare their children unnecessary risk and struggle from obesity. 

The Journal of Pediatrics has published research indicating that breastfeeding reduces the incidence of diarrhea and otitis media (ear infections) in infants. At the same time, the USPSTF (US Preventive Services Task Force) used US taxpayer dollars to create recommendations which support but no longer promote breastfeeding. ACOG (The American College of Obstetricians and Gynecologists) has sent their objections in writing regarding this important change. The breastfeeding discussion needs to be continued, and very publicly, since we all have a stake in the outcomes. 

Stay cool this week, and take precautions from mosquitos. Remember, DEET is safe, and safe in pregnancy. 

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.  

Wellness Wednesday: Common Illnesses in Pregnancy

I was inspired to write this post in light of the significant spring cold season we are now finishing. It is common knowledge on the medical hill that this spring's common cold was a bad one.  For most people, the cough lasted several weeks, even though the illness itself was over. It was not pertussis, it was not flu. It was just a garden variety virus that hit hard. 


So I am going to take a moment and talk about prevention. Prevention takes three forms: 

1. Vaccinate for what you can: Pertussis, and Influenza

2. Hand washing and avoiding the sick. 

3. Keeping up on self care with exercise, sleep and nutrition. 

They really are immensely effective. 

Outside of pregnancy, when we get a cold or stomach flu, we doctor it ourselves. But in pregnancy it is different. In pregnancy, it is a good idea to touch base with your doctor about your symptoms if they are anything more than slight. She can give you a few guidelines and recommendations, even if no antibiotics are prescribed. On that note, just as a reminder, most of these common infections are viral, and as such, do not respond to antibiotics. That said, some viral infections can be followed by a bacterial infection. This may be the case if one gets better, and then worse again. Additionally, some viral upper respiratory infections can set off asthma and we can help with this too. 

I set up a page for common illnesses in pregnancy HERE and I couldn't help but notice that in all cases, treatment included, lots of liquids, like tea, soup, and water. Self care included tylenol, since ibuprofen is not recommended in pregnancy, rest and lots of baths and steamy showers.

Perhaps we shouldn't wait for an illness to take good care of ourselves. 

Wellness Wednesday: The Postpartum Period

So much attention goes into preparing for labor and delivery. I'd like to take a minute and focus on the next important period: the postpartum period. With forethought, preparation and help, the postpartum period can be made enjoyable and smooth. 

First you needs to know what to expect in the postpartum period. Next, you needs to know how to prepare for it. Finally you need to know when to reach out about concerns and questions. 

Learn more HERE.  

Medical Monday: Preeclampsia and blood pressure issues in pregnancy

Blood Pressure. We all know it can be a concern. But what is it really? Why is it such a concern in and out of pregnancy ?

Our entire body is fed by a system of pipes from large to tiny, which is pressurized by the pumping of the heart. Plumbing is a good analogy until you realize these aren't ordinary pipes. Most of these pipes are capable of changing their diameter, and thus their pressure within, in response to fine chemical signals. And they are pipes, which like ordinary plumbing, can build up sediment and develop blockages. They can even weaken and leak. Blood pressure is the pressure of the blood flowing in these pipes. 

Fluid balance, hormone, and immunologic changes of pregnancy have great sway of the blood pressure of a pregnant woman. If she happens to have the type of body which has tense stiff vessels even outside of pregnancy, that is, if she has chronic underlying hypertension, so much the worse. She will be prone to conditions like preeclampsia, also called toxemia. 

Click HERE to learn more about this fascinating and important area of Obstetrics .

Wellness Wednesday: Knowledge is Power. Get some.

I recently finished and published the website's pages on Infections in Pregnancy. At the bottom of those pages, I have added that much again in a new section called "Other infections of Perinatal Significance". Now this may sound way too scientific and unrelated to daily life, but nothing could be further from the truth. These are the big time everyday infections we hear of each week: Pertussis (whooping cough), Bacterial Vaginosis, Toxoplasmosis, Influenza, Herpes, Chicken Pox, and more. Learn more about these common infections and how they pose special risks to pregnant women. Learn what you can do to protect yourself and those around you. 

And, also coming tomorrow, will be a special section on Preterm Labor. Learn the facts and figures as we know them, and how we handle Preterm Labor today. Hint: It is not how we handled it even 5 years ago. 

Medical Monday: Discomforts of Pregnancy

Mother Nature considers pregnancy the height of her achievement. Because of this, she will throw all your bodily resources toward the cause. It's no wonder we feel like pregnancy takes over our bodies and, by full term, uses up most, if not all, of our strength. The rapid growth and development of not only the baby but of our own bodies is not without its dramatic and sometimes uncomfortable sensations. To learn more about these and how to deal with them. Click HERE.