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

Policy News

The “Global Gag Rule” is a rule which prohibits international health care organizations from counseling about abortion lest they lose their aid money from the USA. More recently Title X funds are being withheld from groups in the US who perform abortion or mention it as a choice. Many feel this amounts to a domestic gag rule. However, the Trump administration is back peddling, saying it only relieves Title X recipient caregivers of the requirement to mention abortion as an option. These are two very different things. I wonder which is really the case. I wonder too, if this means the Title X grant givers will requests the medical records documenting patients' visits to see what caregivers and patients are discussing. ACOG (American College of Obstetricians and Gynecologists) has called this an “egregious intrusion” in the doctor patient relationship.  Analysts point out that, additionally, these new rules will give those “health clinics" which oppose abortion and birth control easier access to Title X funds.

Medical News 

The Chair of ACOG New York has produced a guide to the Gyn annual exam for the New York Times. In it, she has explained what to expect, including the holistic nature of the visit. Many people think of the annual Gyn exam as just a pap. However, it is wellness and preventive check that addresses the overall health of the patient. Pelvic exams are performed as indicated according to protocol. Patients are also reminded about what should not take place, such as more touching than is necessary. Patients are reassured that they are entitled to an explanation for everything that is done. 

Texas is starting to take the bull by the horns. Maternal mortality and morbidity in Texas has been egregious. Authorities are now honing in on the contributing factors, and devising strategies to address it. The Texas Medical association has drawn up a list of recommendations including statewide legislation to improve health care coverage for pregnancy women, to increase access to long acting reversible contraceptives (LARCS), and to increase the quality of record keeping on maternal complications. 

Tobacco smoke from a pregnant women damages the unborn baby’s lungs (among other things). New research indicates that vitamin C may mitigate this risk. The changes from smoking do not simply harm the baby in that time frame. In utero exposure to those chemicals induce changes in the baby's genes (epigenetic change) which may persist throughout life. 

SIDS (Sudden Infant Death Syndrome) has been a worry for some time. I remember when it was first defined. At that time, we had no clue about its cause. It remains incompletely understood. However we now understand that the odds of it are greatly reduced when the parents do not smoke, and also when the baby sleeps on their back. This knowledge has given rise to the “Back to Sleep” movement which promotes putting babies to sleep on their back. We have also since learn that avoidance of loose bedding and avoidance of co-sleeping is protective. This means newborns must not sleep in the same bed with parents, despite what may seem like convenience. Nonetheless, NPR has recently reported on the disconcerting trend of increasing co-sleeping. AAP the American Academy of Pediatrics has come out again against co-sleeping which iss highly the associated with an increased risk of sleep related deaths in babies under 4 months of age. 

The Institute of Clinical and Relational Science at UCSF (University of California San Francisco) has produced research indicating yoga may help incontinence and anxiety in older women. Findings were presented at the American Urological Association in San Francisco. 

Marijuana in pregnancy is again in the news, with yet more reports coming out about its disruption of fetal brain development. It is also linked to smaller birth weights and irritable behavior in infants. It is also linked to higher likelihood of still birth. And yet, 70% of Colorado dispensaries are recommending marijuana to pregnant women for nausea in pregnancy. Conflict of interest and flagrant irresponsibility, much ? 

Lung cancer in young women has now surpassed that in men. Lung cancer in men and women has decreased over the last two decades, however it is decreasing more rapidly in men. 

There is now good data that air pollution is related to infertility and preterm birth. A new study on the subject shows that the closure of oil and coal plants boosts fertility in nearby communities. 

There’s an app for that. Maybe. There are many apps pertaining to birth control. There may even be one that can help predict the risk of preeclampsia. However, before you go relying on one of these, Please check with your doctor about the validity of such an app. Quality varies, so buyer beware. 

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

The American Civil Liberties Union (ACLU) and the HHS ORR ( Department of Health and Human Services Office of Refugee Resettlement) are battling out a constitutional question. The are debating whether or not unaccompanied undocumented immigrant minors in shelters have any rights to abortion under the Constitution. I am no constitutional scholar, and I am ignorant as to the extent that our Constitution applies to undocumented immigrants. Whether or not they are in shelters, or unaccompanied, seems immaterial. Their age could be germane, but again, perhaps could be handled under the terms of our own age laws. Any insights would be appreciated. For any women or girl, undocumented or otherwise, to give birth or to have an abortion is  a momentous and expensive event. Either one is also a medical event and that is the most important point. We already have medical policies in this country about such things, and I cannot understand why immigration status would alter the medical algorithm such an undocumented minor would follow. We need to remember that these questions are primarily medical, not political. 

New Hampshire has proposed a bill further reducing barriers to contraception. Currently, contraceptives may only be prescribed three months at a time. However, the state is considering a bill to increase this to a whole year. This seems logical to me as a Gynecologist since, at least with a patient who is established on the pill, I only need to see her once per year. If I am observing her on a new pill, or working to decrease side effects, special arrangements can made to see her sooner. The New Hampshire bill also specifies that insurers must continue to cover it entirely without copays. 

The very red State of Idaho is espousing contraception. Idaho House legislators are advocating a bill which would obtain a “waiver” ie. federal permission, to expand family planning services to women aged 19-44 who do not qualify for Medicaid, Medicare or other programs. 

Unlikely bedfellows in Connecticut are trying to secure prenatal care for the newly pregnant. Republican legislators are working with Planned Parenthood to offer health insurance to pregnancy women if they sign up within 30 days of finding out they are pregnant. 

The red state of Nebraska, on the other hand, is draining funds from Planned Parenthood in a move that will decrease family planning services in an already medically impoverished state. The may com through restriction of Title X grants. 

Dr. Haywood Brown the President of American College of Obstetricians and Gynecologists, has flatly called out the Trump administration and their “ continued move away from scientific evidence based policies and toward unscientific ideologies”. The particular context this time was the announcement of preferential Title X grant giving to organizations that teach “natural family planning” and abstinence for birth control. Where is the pussy grabbing now ?  This administration has such an on again off again relationship with sex I just cannot keep track. 

In medical news, culture seems to be playing a big role in smoking. Witness the great discrepancy in smoking rates among pregnant women by state. Worst is West Virginia, at 25%, whereas in California it is a little over 1%. The average across the US is about 7%. But, I am a splitter, not a lumper, and it seems our efforts to curtail smoking in pregnancy should vary state by state, perhaps even county by county, to be the most effective. 

You may have heard about all the problems and lawsuits having to do with vaginal mesh used in prolapse surgery. You may also have heard of more of a tape or ribbon procedure to fix stress urinary incontinence (SUI). They are different. Vaginal mesh is a large sheet of mesh, whereas the tape/ribbon is narrow like the name suggests. They are not in the same category for complications. A new study has shown what we all have expected and hoped, that the tension free vaginal tape is safe and effective for women with SUI. 

Probiotics are all the rage, and I mean in the hallowed halls of medicine, not the local vitamin store. A new study of very high quality (a meta-analysis) has found that probiotic and fish oil supplementation in pregnancy may reduce the risk of eczema and egg allergy in the offspring. That’s great, you say, no eczema or egg allergy. Actually, I am going speculate intelligently, and suggest to you that eczema and egg allergy are what I would call marker conditions, meaning conditions which are part of a greater category of tendencies that we call atopy, or the tendency to react to things. Atopic patients are those with troubles like asthma, rashiness, and lots of allergies. Their immune system is likely a little dysfunctional in vaguely defined ways. If simple nutritional interventions during pregnancy can help curtail such tendencies in children, that’s interesting and beneficial. 

A new document of WHO (World Health Organization) pregnancy recommendations for woman in childbirth strikes me as unwieldy. It seems to address such a wide range of women in a wide range of conditions that it becomes unusable. Yes, it highlights recent findings and recommendations about giving natural unaugmented labor longer to progress. Yes, it advocates for movement and positioning during labor, and the presence of a supportive environment and support people. It mentions delayed cord clamping. But these are already standards of care in the US. However the document gets an identity crisis when it states continuous monitoring is not recommended, and yet allows food in labor, does not mandate an IV, and yet allows pain relief like epidurals. (One cannot have an epidural without an IV). It is a document for caregivers of patients who in many cases have had little or no prenatal care, and so in a modern care environment they would be considered high risk until proven otherwise. In no state of this union would a high risk patient be permitted to go without IV or monitoring. Neither would they be permitted to eat if an epidural was under consideration. In any labor, C section is a real possibility, and to have food in the stomach ahead of that is a real risk. On the other hand, if there were no facilities for C section then perhaps it is fine to allow patients to eat and go without an IV. But one’s ability to allow these things would not, under those circumstance, be because they are safe. It would be because they would not matter. 

I am afraid this document will entirely confuse practitioners in a modern care environment. The WHO document recommends things which, in our environment, would be indefensible. The document almost needs to be cleaved into two documents, one for those in poorly equipped areas, and one for those unwell equipped area. This document appears to be written by people who would like to think that the rules should be the same for all women in the world, and that all laboring women in the world would have the same standard of care. I am one of those people. However, the authors of this WHO document are trying to torque this equality into being by sanctioning the labor care methods of minimally equipped facilities; in short, they achieve a unified standard of labor care by writing a  document recommending a much lower standard or care for all. We in the US already have enough trouble with our maternal morbidity and mortality without these recommendations. 

A new headline in “Health Day” covering an article  published in the Journal of Nursing has concluded that "food and drink in labor appear to be safe". ACOG currently sanctions only clear liquids in labor, and this is to avoid the risk of aspiration of solid food particles, something to which pregnant women are vulnerable, especially if they go to C section. When an apparent discrepancy in recommendations like this comes up, it is always good to unpack the details. Did I mention I was a splitter ? It turns out the study was case-control design, done at a smaller Port Jefferson, New York hospital over 4 years. The study was actually comparing just ice chips versus clear liquids like jello and italian ices, the so-called "food". We have known for some time that clear liquids, which is what jello and italian ices are, are safe. The “food”is not solid, the study's conclusion is not news, and the recommendations have not changed. However, I worry that laboring women around the country will be asking to see a menu to order food as they enter labor. 

Stay tuned for more news from the amazing world of Obstetrics and Gynecology, right here, next week, in Medical Monday. 

Medical Monday: Belated Bullet Version

Policy News 

In the name of choice, the Trump administration is proposing new rules to allow small businesses to circumvent the stipulations of the ACA and create cheap/incomplete heath insurance plans exempt from covering various "essential benefits” like: 

• mental health care 
• emergency services 
• maternity care 
• newborn care 
• prescription drugs

How is this even classifiable as insurance ? How many will be duped into buying this ? It will be just like the old days and those that cannot afford to pay for what their insurance does not cover will leave the rest of us and the medical system to foot the bill. Their cheap incomplete insurance will put little into the collective pot, cover little, and leave much unpaid. 

Deja vu: 

To repair or replace the ACA ( Affordable Care Act), that is the question. That is the question the GOP is asking itself. And it was the same exact question this time last year. GOP moderates say repair, GOP conservatives say replace. Nobody can say what to replace it with.  

Forget about the ACA ? Here's FAQs:

• Requires every consumer to hold health insurance of some kind or face penalty fee. (The Individual mandate) 
• The Fed supplies subsidies to insurance companies to enable them to charge consumers lower premiums and to provide comprehensive coverage. 
• There are no lifetime limits on health insurance benefits. 
• Essential health benefits ( see above) must be covered by all new plans. 
• Contraception should be covered through the “ contraceptive mandate”. 
• A consumer cannot be dropped by health insurance except through committing fraud. 
• Covers preventive services and immunizations. 
• Covers dependents until 26. 
• Creates a cap on insurance company administrative expenditures. 

The law had many more provisions but these are arguably the main ones of consumer interest. 

Since the Trump administration came to power, the following have been rescinded, weakened, or questioned : 

• The individual mandate
• Federal subsidies 
• The contraceptive mandate 
• Essential services 

Now that the holidays are over, Congress must find a way to save CHIP, the Children’s Health Insurance Program. Prior to Christmas, Republicans stole from Peter ( preventive health care under the ACA) to pay Paul (CHIP). That stopgap fund will run out in another couple months. 

Medical News 

First in the no-surprises department: 

• Smoking during pregnancy is associated with increased rates of ADHD. 
• Puerto Rico is facing an ongoing public health crisis without power, water and food. 
• Influenza is widespread in the US, especially the South. 
• Pregnant women in polluted areas have higher risks of birth defects. 
• Pregnancy weight continue to rise in the US, and with them pregnancy complications. 
• Maternal mortality is increased yet again in Texas. 

Good News Department: 

• A brand new programs on reducing Maternal Mortality, the Alliance for Innovation in Maternal Health, has already reduced maternal death rates in four states by 20%. 
• Estrogen cream may go generic soon, thereby reducing the very high cost of comfort. 
• Prescription of multivitamins and/or folic acid during prenatal care is associated with lower risk of autism in offspring. This was a 12 year study on over 40,000 children .
• The cancer death rate in the US has declined 1.7% just since 2015. Could this be related to the affordability of cancer screening covered through Obamacare ? 

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

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

As expected, the Trump administration is planning to roll back the contraceptive mandate. The contraceptive mandate requires that insurers cover costs for contraception without copay. The proposed change in regulation would allow employers to refuse to cover contraception because of religious or moral objections. This change will not go unchallenged, Numerous lawsuits will likely be initiated if this change takes place. 

Those objecting to the contraceptive mandate often cite their objection to certain birth control methods which prevent implantation. However, mainstream authorities focus on the fact that increased contraceptive availability is associated with plummeting incidence of abortion and unplanned pregnacy. 

In other policy news Texas plans to continue funding their task force to determine the causes of their alarming rate of maternal mortality. It is really a shame that Texan’s don’t just save their money and acknowledge the obvious: that increased maternal mortality is directly related to their gutting of health care services to women. At this time, one quarter of Texas women lack health insurance. Data from many quarters tells us that this is a sure fire way to ensure poverty and high maternal mortality for many generations to come. 

Arkansas is racing to the bottom as well. A Federal Appellate court in St. Louis has ruled that Arkansas can block Medicaid funding to Planned Parenthood. 

Winning the race to the bottom, is of course the the Trump administration, who has resolved to cut Teen Pregnancy Prevention program funding. The American College of Obstetricians and Gynecologists (ACOG) came out with a swift condemnation of this plan. The current administration supports abstinence only programs, and yet asserts they favor “ evidence based” programs. Sling that medical jargon. 

Lawmakers have prevailed upon the Trump administration to make the Federal Government insurance subsidy payment for August. In fact, it is Republican members of Congress together with Democrats who have convinced the administration to continue payments, fearing a collapse of insurance markets. They believe this will buy time for a bipartisan solution to stabilize the markets. The CBO (Congressional Budget Office ) continues to warn that ending subsidies with cause premiums to rise by 20% by 2018. 

In encouraging news, Oregon has passed law budgeting half a million dollars to expand comprehensive reproductive health care coverage for all its citizens. The law also requires insurers to cover such services with no out of pocket cost. Available evidence tells us that, as a direct result, they should expect decreased rates of unplanned pregnancy and abortion, with increased levels of educational attainment among women, decreasing unemployment statewide, and increased standards of living. 

https://www.cdc.gov/obesity/data/prevalence-maps.html

On to the medical news. 

It is time for us to start thinking about obesity in more sophisticated ways. Obesity is a devastating and widespread medical problem. It is also very personal and for that reason it is challenging to discuss and treat. We are now beginning to understand that the causes of obesity include but are not limited to individual habits. For example, poverty and its many causes factor in strongly. We can graph the incidence of obesity on maps and thus understand obesity is part of culture as culture spreads across geography. New research out of the National Institute of Health has revealed that the “ origins of obesity lie as much in early childhood - even prenatally and intergenerational- as it does in an individual’s current behavior. “ Obesity is closely tied to many forms of human suffering and disease, from heart disease and diabetes, hypertension and cancer, to poor self esteem and depression. Further research is necessary, by all means. However to effectively address this serious problem, both patients and physicians are going to have to do better at mustering their courage and talk about obesity in frank and accurate terms. 

You might have noticed my mention of obesity as having a role in increasing cancer risk. Maybe you were not aware of this, since there is not an obvious connection. However, we have always know that obesity is associated with many types of cancers. However, new research from the Journal of the Academy of Nutrition and Dietetics sheds more light on the subject. It turns out that “ women who eat a lot of high calorie foods may face a slightly higher risk of obesity related cancers - even if they remain thin” The study went on to elaborate that “ women who favored low nutrient high calorie foods had a 10% higher risk of cancer linked to obesity. “ Cancers related to obesity include cancer of breast, colon, ovary, kidney, and endometrium (uterine lining). 

A new study from the Canadian Medical Association has shown that oral cancers related to the HPV are on the rise. Between 2000 and 2012 it is believed that the incidence of such cancers has risen by 50 %. 

Smoking in pregnancy is still a big problem. It turns out that depression in pregnancy makes smoking more likely. This tendency of smoking during depression in pregnancy is on the rise, according to new research published online in the October issue of Drug and Alcohol Dependence. 

HPV and smoking are a bad combination. Did you know smoking greatly accelerates the progress of HPV related disease ? 

HPV has an effective vaccine against it. However, new research indicates that less than half of girls and a quarter of boys are vaccinated. HPV ( Human papilloma virus ) has a vaccine. Humans papilloma virus causes genital warts, precancerous and cancerous lesions of the genitalia and mouth. Vaccines are available for young people from the ages of 9-26 years of age. They have little in the way of known side effects. 

In other virus news, there have been no locally transmitted cases of Zika viruses in Florida yet this year. The same encouraging trend has also been seen in Latin America and the Caribbean. Authorities now believe that those infected develop immunity to reinfection. However, authorities are also concerned that Zika may now be getting transmitted sexually. Work on a Zika vaccine is underway. 

Again, I encourage you all to contact your elected officials about your views on women’s health. Tell them the American people are willing to shoulder their collective responsibility for people's health care and the good of the future. 

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

In policy news, it is no secret that Senate Republican bill to repeal the Affordable Care Act was a failure. Their proposals included many measures that would curtail health care for women in the form of either provision of contraception, for health screening for condition such as sexually transmitted diseases, breast cancer or cervical cancer and access to prenatal and maternity care. The failure of this bill led many of us who care for women to breathe a sigh of relief. 

However there is a new threat to women's healthcare. The House Appropriations Committee is responsible for setting the federal governments spending priorities for the upcoming year. These budgetary items come in the form of bills. Most of the bills concern essential services such as the military but included with these budgetary plans are several add on provisions or riders which contain potential law related to women's healthcare and it's funding. For example, the bland and harmless sounding "Financial Services and General Government Bill" would prevent people from purchasing insurance through the Affordable Care Act exchange which includes comprehensive reproductive coverage. As another example, the "labor, health, and education" bill would eliminate funding for Title 10 family planning clinics which provide a low income women and men with cancer screenings birth control tests for sexy transmitted diseases. The Republican plan for this care is to reroute it to community health centers. However many question the ability of community health centers to meet this increased demand.

MATERNAL MORTALITY BY COUNTRY FROM THE CIA WORLD FACTBOOK VIA indexmundi.com

Representative Nita Lowey (Democrat from New York) is the top ranking Democrat on the House Appropriations Committee. She and several colleagues have offered alternative amendments to guarantee that women have access to these health services. They include provisions for birth control without co-pay, Title X family-planning funding, rescinding the Global Gag Rule, and re-instituting funding for the United Nations Population Fund. Without control of Congress these are likely doomed, but at least drafts are in place and the issues are on the table.

Last week, Senate leaders passed some bills that stand to help patients. The first is a bill that will help fund the FDA review of prescription drugs and medical devices.  The second bill, called the”Right to Try” Act, it will help the FDA to “…speed review generic drug applications”.

Even those of us who applauded the Affordable Care Act realize that it needs some more robust Federal funding for the the upcoming years. Republican Senator from Tennessee Lamar Alexander has “...organized bipartisan hearings next month" to help fund ACA a insurance marketplaces next year. Governors from both parties have urged the Trump administration to act continue to making ACA subsidy payments. President Trump has tried to characterize these federal contributions to defray the cost of healthcare as an insurance company "bailout". 

The expanded health care that the Affordable Care Act provided was beneficial in human and longer-term economic terms. However instituted immediately in the then insurance marketplace, it would have been financially unaffordable without federal subsidies. That is the reason why the federal government subsidies were designed in the first place. Consumers would contribute, States would contribute, and the federal government would contribute through the taxpayers, in what amounted to an elaborate cost sharing plan. The implicit and explicit philosophy was that the healthcare of the American people was a shared responsibility and a worthwhile financial investment for the future. 

As has been previously reported, Texas has a maternal mortality crisis. The maternal mortality rate is 35.8 deaths per 100,000 live births as of 2014 where is the rest of the nation sits at 23.8 deaths per 100,000 live births. Texas's rate is characteristic of a third world country Robinson United States of America which has state-of-the-art medical care. This issue has been on the table for several months now in a large study is underway to fully understand the reasons why. Meanwhile editorials in Texas newspapers abound to the effect that the crisis is no mystery. Various pieces of legislation large and small, State and federal, over the last decade have resulted in curtailment of access to women's healthcare, including reproductive health care, general women's healthcare, and prenatal care. Could there be a connection?

In the medical news, we begin with the opioid crisis. According to new research publishing the animals of internal medicine, approximately 2,000,000 Americans self report that they are addicted to opioids. There are likely many more. 11 million admit to misusing opioids. Opioid addiction is surprisingly dangerous and hard to treat as it becomes enmeshed with behavior and Biology. There are specialists who treat opioid addiction but they are few and far between even in sophisticated medical communities. Doctors who will treat pregnant women with opioid addiction correctly are even more scarce.

Do you think cultural factors matter in health? Do you think behavior is ”catchy” ? I just learned that pregnant women in Florida smoke at double the rate of women in the rest of the country. I think such outliers are very interesting and provide potentially informative subjects for study.

I am the sort of person who is very interested in maps and infographics. The idea of regional variations in health behaviors is fascinating to me and can be portrayed in maps. See todays' illustration lifter from indexmundi.com who lifted it from the CIA World Factbook   The case of Florida and smoking, the case of Texas and maternal mortality, and indeed the case of the entire south and rates of obesity should constitute low hanging fruit for any interested researcher. 

The FDA is taking a powerful step in the battle against smoking. We have had warning labels. We have had higher taxes on cigarettes. We have had educational campaigns. However now, the FDA will lower the amount of nicotine in tobacco products. There is good reason to believe that lower nicotine in cigarettes will lead to smokers quitting and enable them to quit more easily.

In the odd and frightening department we see the new research published in the Journal Cancer Epidemiology, which suggests that postmenopausal women with gum infections are more likely to get many common cancers than their peers. Ladies, use those electric toothbrushes, that thick floss, and those peroxide and fluoride mouthwashes. Check in with your dentist. More research is clearly necessary.

Mothers across the world are missing a great opportunity. This is breast-feeding. According to the World Health Organization and UNICEF, only 40% of babies were exclusively breast fed for six months, which is the undisputed recommendation. Rates in the United States are considerably lower with  25% of mothers exclusively breast-feeding for six months. The report included research on the key reason why mother stop breast-feeding. It is the need to return to work. Solving this problem would be a matter of addressing culture, policy pertaining to postpartum leave, paid postpartum leave, and breast-feeding in the workplace.

Breast-feeding has numerous benefits for babies, mothers, families, and society at large. A new study documents that breast feeding may be linked to a lower risk of breast cancer. This study was a meta-analysis of 18 prior studies. 13 of which showed that breast cancer risk dropped 2% for every five months a women breast-fed.

News continues to filter in regarding the use of CRISPR to edit genes in human embryos. At present CRISPR has been used to edit out the single gene mutation that causes hypertrophic cardiomyopathy. The most logical next candidates are other single gene mutations which cause disease. Examples of single gene diseases are cystic fibrosis, sickle cell disease, fragile X syndrome, muscular dystrophy, also known as Huntington's disease. Hope is on the horizon ! 

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

Medical Monday: Part Two

Medical Monday: Medical News Section 

Pregnancy related death continues to rise in at a fairly steady rate in the US. As of 2013, we sit at 17.3 women per 100,000 live births with a rage of about 12 per 100,000 for whites and 40 per 100,000 for blacks. Cardiovascular diseases of various kinds accounts for about 40% if these deaths. About 9% are due to pulmonary embolism, and 7% are related to high blood pressure and preeclampsia. The rest pertain to infection, hemorrhage and rare disorders like amniotic fluid embolism. 

Teen births are statistically high risk. It turns out that high teen birth rates cluster in certain cities. Analysis of the data shows these clusterings are not random and are not related to poverty to education. Most generally, the clusters are in the southern states, but they also exist in Denver, Fresno, and Yakima. San Antonio has the distinction of being the number one urban center with a teen pregnancy cluster. These findings my begin to help shed light on what is no doubt at least partly a cultural phenomenon. 

Breastfeeding has been touted has having numerous benefits, including health benefits to the mother. It turns out that prevention of uterus (endometrial) cancer is one of those benefits. Breastfeeding EVER confers an 11% reduction of risk. The longer the breastfeeding the more the risk was reduced, until risk reduction peaked at somewhere around 6-9 months of breastfeeding. 

Polycystic Ovary Syndrome (See PCO section HERE) is a complex of problems which include problems with ovulation (producing an egg), as well as obesity, excess male hormone, and difficulty metabolizing carbohydrate. A given patient may have one, all, or just a selection of the features of this varied disease. Generally, doctors have assumed that obesity and carbohydrate intolerance goes together. However new research has shown that even normal weight patients with PCO have have significant insulin resistance. This points for the need to counsel normal weight patients to eat a very high quality diet rich in protein, vegetables and fruit, and healthy fats. 

The overall incidence of depression in teens in higher than once previously believed, coming in at about 14% for those between 12-17. Of note, by 17, girls had a three fold higher incidence than boys. 

In the vice department, the news is sobering. New research from the Journal of Drug and Alcohol Dependence has shown that children born to women who smoke as few as 10 cigarettes per day have problems later in life. In particular, they have increased problems “learning and thinking”. 

The British Medical Journal has published research showing that even small amounts of alcohol produces changes in brain function which play out as poorer performance on language related tests. This data comes from research on 550 men and women over a 30 year period of time. 

Hard data is in from last year’s mosquito season in America (including Puerto Rico). Zika virus, which is transmitted by mosquito, produced birth defects in about 5% of babies who’s mothers became infected in pregnancy. This number was higher for those infected early, and lower for those infected late. We should learn even more this  year, and hopefully get one season closer to a vaccine for this dreaded disease. 

For those in Zika- vulnerable states: Remember, DEET is safe in pregnancy. Zika is not. 

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 has finally given some time bound recommendations to prevent the spread of Zika virus. In particular, they are advising women to wait 8 weeks after Zika infection to attempt pregnancy. Men are advised to wait 6 months before having unprotected sex. Imagine, there is nearly an entire continent of people who are being asked to strictly observe these rules. 

Knowledge about Zika is diffusing northward. Nonetheless, about 1 in 3 people in the US think Zika is spread like a cold. Furthermore, 42% do not realize it is sexually transmitted, and 29% do not realize it can be spread through blood transfusions. Seventy five precent do not know of its association with Guillaine Barre syndrome, post viral paralysis. They have obviously not been reading this blog. You know that it can be acquired through a bite from the Aedes Aegyptae mosquito, from sexual contact with an infected person, vertically from mother to child, and also in any manner that is blood borne. 

The CDC is working hard to get sources of contraception to Puerto Rico, which is under dire threat from the Zika virus. The CDC has recently ramped up their presence on the island and estimates that 138,000 women there do NOT wish to become pregnant but do NOT have access to birth control. 

Democrats in the Colorado House have moved to take away copays for birth control in their state. It still has to pass the House where the GOP holds a one seat majority. 

The Governor of Virginia Terry McAuliffe has vetoed a bill which would have blocked Planned Parenthood Funding in his state. Apparently the bill as written would not affect the ability to provide abortions but would have blocked small state grants for health services like cancer screening and sexually transmitted infections. 

The FDA is altering the labelling for the use of “ Mifeprex” the so called abortion pill. It can now be used for up to 70 days after a missed period rather than 49. The new criteria have been approved by the WHO ( World Health Organization), the AMA ( American Medical Association) and ACOG ( American College of Obstetricians and Gynecologists.) These governing bodies have all cited the need to bring legislative practice into line with available scientific evidence, and this meets this requirement.

I can not help but wonder if this change was hastened by the Zika crisis plaguing the Americas. Because of the specter of the complication of microcephaly in babies born to Zika infected mothers, abortion is under more consideration there than ever before. 

Smoking is has been a scourge to all, but it is arguably harder on women than it is on men. Many people do not realize it’s role in fostering cervical cancer. The reason for this is that HPV ( human papilloma Virus) causes cervical cancer by inserting its DNA into the DNA of our cervical cells. Chemicals from smoking makes DNA fragile so that it breaks ( and admits the virus) easily and makes more errors in replication. That is one of the main ways it causes disease including cancer all over the body. A shocking new report has found that smoking while pregnant produces the same DNA mutations in babies as it does in adult smokers. This study was large and considered very authoritative. 

New research published in the Journal Circulation has indicated an association between endometriosis and cardiovascular disease. This was an observational study with large numbers, so it does not speak to causality or mechanism. It is nonetheless useful information in that it may prompt more investigation, and even at this early junction, prompt more targeted screening of possibly at risk patients. 

Wow this week’s news is rather sobering and somehow all connected. Here’s hoping the week will bring some good news to the world of Women’s Health.