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. 

Food Friday: Vitamin D

Vitamin D is in the spotlight. Is this celebrity justified ? 

Vitamin D is a fat soluble compound that is necessary to human health.Interestingly, it is not widely available in our diet. It is however, manufactured in our skin when the skin is exposed to UV rays from sunshine. It is of course available in supplements, supplemented foods, and a few foods naturally. 

You might wonder how we developed to need something that seems so hard for modern people to obtain naturally. I think it is a good bet that pre-agricultural people especially those along the coast got more sun and UV exposure than we do today. I suspect that plus their intake of vitamin D rich fish supplied their needs. Then as people began to move inland, wear more clothes, eat less fish and live long enough to have to protect against skin cancer, their vitamin D requirements became harder to meet. 

 Vitamin D is historically most “ famous” for its role in enhancing Calcium absorption. Calcium is critical for bone mineralization. Deficiency of Vitamin D leads to rickets and osteomalacia, which are failures of the bones to properly form. 

Those at risk for vitamin D deficiency are breastfed infants who aren't supplemented, dark skinned people, people who wear occlusive clothing, the home bound, the elderly, the obese, vegans, and those whose gastrointestinal tracts are inflamed or cannot absorb properly. 

It seems odd to me that breastfeeding does not supply all the necessary vitamin D a newborn needs. This is simply because the Vitamin D content of human milk is related to the mother’s vitamin D status. The infant cannot get vitamin D though UV exposure since it is not appropriate to expose infants to direct sunlight. There has been a big recent campaign to educate breastfeeding mothers about the need to supplement with vitamin D. 

Vitamin D also affects the general functions of cell growth, neuromuscular function, immune function, and the control of inflammation. These features are why there is more than the average amount of buzz around this mild mannered vitamin. Two hundred and fifty studies on vitamin D and various health parameters were done between 2009 and 2013. These were systematically reviewed by the Agency for Healthcare Research and Quality, and to date, it concluded that it is still not possible to specify a relationship between vitamin D and specific health outcomes other than bone health. As the number of studies indicates, there is widespread interest, or even hope that vitamin D therapy will prove useful for a wide variety of conditions, especially those involving autoimmunity. 

Adults need between 600 and 800 IU of vitamin D per day. It is best not to take more than about 4000 IU per day from all sources, unless specifically instructed to do so by your physician. Vitamin D is fat soluble, can be stored in the body and can, in excess, lead to toxicity. 

It is best to get your vitamin D from a combination of foods, fortified foods, and supplements. The best dietary sources of food are fatty cold water fish such as salmon, cod, tuna and swordfish. (As a side note, pregnant women should restrict their intake to salmon and cod, since tuna and swordfish may theoretically have increased levels of heavy metals. ) Besides these, egg yolks, fortified orange juice and fortified dairy products are the best sources. 

If you are concerned your vitamin D levels are low, ask your doctor about testing your levels. We have been screening patients more proactively lately, and have found some astounding deficiencies. The good news is, they are quite easy to fix. 

Here’s my favorite go-to recipe for a great blast of vitamin D and protein: 

Salmon Salad

Simply mix one drained can of coho salmon with 1-2 tablespoons of olive oil based mayonnaise ( My favorite is called “Lemonnaise”.), Add a table spoon of dill relish, a couple Tablespoons of sliced olives, some capers, finely chopped celery, chopped sun dried tomatoes, and whatever else suits your taste. Mix. Do not feel compelled to put it on anything. Enjoy. 

Refererence: 

National Institute of Health Office of Dietary Supplements 

Wellness Wednesday: Menstrual Wellness

At first I thought the #freethetampon movement was a bunch of hooey. However, now I am giving it a second look. What got me thinking was a Tedx talk given by Nancy Kramer featured here on this website:

http://freethetampons.org

This site has some hard numbers about how many girls and women have to interrupt their school or work day to improvise a solution to an unanticipated period (86 % of us !) This is because restrooms the world over are stocked with toilet tissue, soap and something to dry hands, but there are scarcely ever any tampons or pads.

Granted there is an additional cost to providing these supplies, but in terms of school or professional environments, there are also benefits: less time away, less workplace stress, etc. Supporters of the #freethetampon movement advocate that tampons and pads should become freely available in every public bathroom, much like toilet tissue or soap. They view it as a public good and standard of decency in consideration for the everyday realities of normal body functions in women. Most women prepare as best they can and carry adequate menstrual supplies most of the time. But, as a Gynecologist I can assure you that irregular cycles and uncontrolled menstrual flow happen once in a while to most women. Even the best prepared among us has most likely struggled with an out of control period at one time or another.

Back to the cost of menstrual supplies. Did you know that in most places there is sales tax on tampons and other menstrual hygiene materials ? Sales tax criteria vary by state. Montana, Alaska, Oregon and New Hampshire have no sales tax on anything. Beyond that, Minnesota, Pennsylvania and Maine tax the customary items of “ tangible personal property” excluding necessities like food and medicine. Most notably these states also exclude menstrual hygiene products from sales taxation! In these states menstrual hygiene products are classified as necessities rather than “ luxury” or “ tangible personal property” items. Every other state taxes menstrual hygiene products. Every other state has what is being called the “ tampon tax.” Critics of the tampon tax say that it unfairly discriminates against women. They point out that it is a tax that women have to pay solely by virtue of being women, which is sex discrimination.

The tampon tax issue together with the #freethetampon movement has catapulted the menstrual cycle into the public limelight. For most of history however, the subject has been totally taboo. Most generally menstruation has been looked upon as an “unclean" state. In many cases menstruating women have been set apart from their family during this time. Even until recently it has been considered a topic not fit for polite conversation. And for reasons which are still not clear to me, menstruation has been a source of embarrassment or shame.

Many contemporary women are interested in removing the stigma of shame associated with this normal body function. To do so, they have taken several tacts. If you search the web on such matters, you will find all kinds of art from posters, pins and jewelry which flaunt these taboos, and demonstrate menstrual pride. There are references to “shark week”, “riding the cotton pony” and visits from “Aunt Flo”, normalizing and humorizing the subject. In one instance at one American high school

(https://en.wikipedia.org/wiki/Tri-Valley_Central_School,)

a security guard’s public search of a girl’s purse also included questions about whether she was on her period. The incident was considered intrusive. The next day, boys at the school came to class with sanitary pads taped to their shirts in a show of solidarity for the girl. Girls wore tampon necklaces. Finally, most of you have heard by now how Kiran Gandi, a Harvard business school student, ran the 26 mile London Marathon on her period, without a tampon and with visible bleeding, to “ transcend oppression” and to publicize the plight of those women who lack adequate menstrual products.

You get to decide how you feel about your period. But you should know a few things about it. No period is comfortable or convenient, but some get downright bad. If you meet certain objective criteria, you should call your doctor and get checked. Abnormal periods are not healthy, and should be treated.

Here is a section from our page on on adolescent and childhood Gynecology which describes the beginnings of periods :

The mean age of menarche (first menses) is approximately 12 1/2 years of age, with a range of about 11 to 14. Menarche typically occurs 2 to 3 years after thelarche after the breasts are fully developed. Ninety eight percent of females will have had menarche by age 15. Any adolescent girl who has not reached menarche by 15, or within 3 years of thelarche should be evaluated. Additionally, any vaginal bleeding before the age of 8 is a concern and should be evaluated by a a gynecologist.

- See more at: http://drginanelson.com/childhood-gyn-concerns#sthash.ykiQ4Hoh.dpuf

More menstrual facts you need to know:

Periods should not last longer than a week.

Period intervals ( time from day 1 of one period to day 1 of the next period ) should not be less than 21 days or greater than 35 days.

Total flow should not exceed 80 cc (1/3 cup) in one cycle.

Period flow should not make you lightheaded or anemic.

Period pain should not keep you from school, work or exercise.

You can get pregnant on your period.

If you experience any of these things, you should call your doctor. Depending on your age and medical history, an evaluation may be done. Depending on the results, a treatment can be planned.

Tips for menstrual management:

You may pick from either pads, tampons or both. You may use menstrual cups as long as you wash them as instructions indicate. None of the internal methods should be left in longer than needed, or they can foster infection. Apparently there are now unisex tampon necklaces you can wear, to use yourself or to “help a sister". There is even an app, developed by a Harvard freshman, Olenka Polak, called “ Code Red” which alerts sympathetic users in your area that you are caught in a “ periodic emergency”.

Menstrual health is a physical and psychological challenge. Don’t feel like you have to meet this challenge alone. 

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

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

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

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

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

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

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

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

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

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

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 ". 

Wellness Wednesday: Following up on Serious Injury: the Role of Physical Therapy

When you are injured badly, you are in pain and you are shaken up, sometimes literally. You lose perspective. You may have temporary alteration of your memory mood and judgment. You need guidance on how to recover, and your instincts aren’t a good guide. That is why in good medical care environments, you have a team of people, from family and friends, to doctors and nurses who help you get better.

In the very best of medical care environments, you have those, plus the group of therapists: physical therapists, cognitive therapists, occupational therapists, and family therapists. These are the people who take you from healing and back into high functioning. We underutilize them. I write today to make you aware of all this by sharing what our experience has been thus far with my son Vale and his physical therapy.

As those of you who have been reading this blog know, our son Vale had a serious ski injury on Saturday February 6th. He sustained a comminuted (broken to pieces) fractured femur, a mild concussion, a broken rib and a mild pulmonary contusion. That evening he had a long emergency surgery requiring a great deal of internal fixation. The next day he was discharged home as per is customary. He required pain meds, and still had memory deficits, though he was basically himself. Appetite was slow to come and he was quite discouraged. 

Much to our surprise, they requested his first physical therapy visit the very next day, or post operative day two, Monday the 8th. I couldn’t imagine what they would be doing with him at that early stage, despite my familiarity with surgical recovery in general.

When we arrived, they informed us they had spoken with his surgeon and were appraised of his hospital course. They proceeded to perform consultation much like we doctors do, beginning with a history and then proceeding with a physical exam. However, this exam was precise, detailed and recorded, covering all neurological aspects, range of motion, and strength. 

I expected all this. What I didn’t expect was the best part. The facility was beautiful and open, and all the staff were fit and upbeat. There was even a freshly shampooed dog randomly going from area to area to cheer people up. The whole encounter brightened our son’s spirits, and renewed his hope. They told him all about the typical post op course with injuries like this. This showed him a light at the end of the tunnel. It gave him some tasks to do and milestones for progress, thereby dispelling feelings of powerlessness.

There were so many more things to do to help his recovery than we had anticipated. I often recommend that patients enter physical therapy. Not uncommonly they ask me, “ What could they possibly do that would help ? “ The answer is, go and see. Since Vale has entered PT, he has gotten serial cognitive testing, passive range of motion exercises, strength exercises, electrical stimulation and deep oil massage of the muscles near the fracture. Soon, when the incision is better healed, he will have water therapy. 

His sessions are not necessarily comfortable. Nonetheless he looks forward to them. He can see his own progress because it is actually measured. Thus he is consistently encouraged. They tell me this is typical. Today is post op day ten and it was his first day back to his University classes. He felt himself, and did not notice any problems in following the material or using his crutches. I credit his ongoing PT for his speedy recovery.

I encourage all of you to look into physical therapy if you have chronic pain, injury, or problems getting around. There are many other conditions which can benefit from physical therapy. Discuss this with your doctor at your next appointment to see if you might stand to benefit. 

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

Zika virus again begins the headlines. It has now been well established that Zika virus can be sexually transmitted. The CDC ( Centers for Disease Control) has recommended that men returning from Zika affected countries take special precautions if their partners are pregnant or apt to become pregnant. They are advised to abstain or use protection through the duration of the entire pregnancy. The primary method of transmission is still believed to be through mosquitos, however, Zika has recently been isolated from both saliva and urine. 

Zika’s devastating effects on the unborn are similar to effects caused by the more well known viruses Rubella and Cytomegalovirus (CMV). Zika virus is associated with microcephaly (small underdeveloped brain and skull, with attendant developmental disabilities) and eye defects, and so are CMV and Rubella.  Researchers are turning attention back to these better understood viruses to get clues about how the ZIka virus functions. 

Additional recommendations from the CDC and ACOG ( American College of Obstetricians and Gynecologists) include testing all women living in or returning from ZIka infected countries. The US Olympic Committee has reiterated the CDC cautions, but has not issued any prohibitions against anyone going to or participating in the games. 

In the interesting and promising department, Columbia has recorded over 3000 cases of Zika infected pregnant women. To date, no cases of microcephaly have been reported there. The reasons for this are uncertain. Post Zika Guillaine Barre syndrome has been studied in Columbia as well. Guillaine Barre is a reaction to certain viral infections which produces a usually temporary paralysis. It can be life threatening since it can paralyze the respiratory muscles. Columbian officials have noticed a 66 % increase in Guillaine Barre reactions compared to baseline. 

President Obama has asked Congress for 1.8 billion dollars in funding to combat the Zika Virus. As of Friday, there are 79 cases of Zika in the United States. 

Influenza is another viral danger which continues to deserve our attention. The good news there is that we have an effective vaccine. Flu vaccine is very important to pregnant women, since pregnant women are much more vulnerable to serious disease if they contract the flu. New research indicates flu vaccine in pregnancy is most effective if given in the first trimester. 

There are other situations which can cause serious birth defects. One is exceedingly common: alcohol. Last week the CDC made news by recommending that pregnant women abstain from all alcohol. They also advised health professionals to advise women to stop using it even if they are just trying to become pregnant or, more interestingly, are simply having unprotected sex. 

Frankly, these do not see like radical recommendations to me.  They certainly do not seem mysogynist or anti-women. However, that is how some women are reacting. The blogosphere has been ablaze with what is, in my opinion, inflammatory rhetoric, saying that the government is trying to "take over women’s bodies", and other such nonsense. I wonder what these commentators think of the draconian measures recommended by South American governments to keep pregnant women from getting Zika ? Authorities have advocated that women not get pregnant for two years, and if they already are, to cover themselves and stay inside. 

Here is an issue that may have a feminist component. Consider that only women must buy feminine hygiene products. They buy them in profusion, regularly, and all throughout their reproductive life. Some people believe that women should not have to pay sales tax on such products. President Obama is in favor of ending the so called “ tampon tax”. 

Viruses and alcohol can cause serious birth defects. While smoking does not, it is strongly associated with growth restriction, low fluid, abruption, and preterm birth. CDC data indicate 8.4 percent of pregnant women smoke. 

There us no doubt that our collective concern over the exotic and seemingly uncontrollable threat of Zika virus is justified. However this threat to pregnant women and others should be blended with renewed and commensurate concern for equally serious threats which we can address: smoking and alcohol. 

Food Friday: Food for Healing

As most of you know, we spent the better part of the week nursing our 22 year old son after his ski accident. He sustained a badly fractured femur requiring a long surgery which entailed significant blood loss. He also had a mild concussion, pulmonary contusion, and a broken rib. He is stable and improving. But his course has illustrated several important things about nourishing those who are recovering from illness or injury. I thought we might take a moment and discuss them here, especially since it has been on my mind. 

When people come home from the hospital, most of time, their IV is removed. They will come home adequately hydrated. However, that can quickly change, since their capability to hold down food and drink is often limited. Your job as caregiver is to help minimize nausea which may be interfering with hydration, and to provide appropriate enticing liquids for them to sip. If your “ patient” did not come home with anti-nausea medication, and needs it, do not hesitate to call their doctor. Most of the time this can be prescribed over the phone, but sometimes, nausea heralds a concern, and the patient will be asked to come in for an evaluation. 

Another way to minimize nausea and maximize intake is to avoid overuse of narcotic pain pills. The most common are lortab and percocet, aka hydrocodone and oxycodone. These are necessary with early post ops, but they can cause nausea and constipation. Ask your doctor how they should be used if you are not sure. 

Sick or injured people do not always know what they need. It is up to the caregiver to encourage them in the right direction. In this regard, many patients will not want to drink as much as they ought. So you have to be clever. 

Hydration of the unwell is best accomplished gradually and continually. This way they are more apt to tolerate it. It is also best accomplished by fluids which contain some sugar and some electrolyte (like IV fluid!) . 

For starters, let’s do water. Some who cannot drink water can drink soda water, aka plain club soda. Even more can drink this with a splash of fruit juice or a wedge of lemon or lime. Some do well with dilute fruit juice. Decaf instant iced tea works well. Oftentimes having it quite cold will help, but this is suboptimal if your patient is chilled. Some do better with frozen cubes of the aforementioned drinks. 

On the other hand, many patients prefer hot drinks. Herbal tea is the go-to here. You can make it more appealing by adding honey or agave, and a little lemon. Decaf coffee is not a bad choice, but lots of caffeinated coffee is dehydrating. 

Some patients prefer savory or salty drinks. This is an advantage since it will better expand their intravascular volume. Here broth is the best solution, unless they can take something like Bloody Mary mix, or salted tomato juice. The best of all is a brothy chicken soup, just like tradition teaches us. Nowadays organic broth mix is widely available commercially in chicken, beef, and vegetable flavors. 

You can also hydrate your patient with watermelon if they like it. Most fruits will help, and a smoothie of fruit, ice, water, juice, and even plain yogurt can be very agreeable, even to one who is sick. 

When patients are doing well enough to take solid food, there are a few key nutritional points to bear in mind. Healing from illness and injury takes more resources than ordinary life - lots more resources. A man needing 70 g of protein a day will come to need over a hundred. He will need more nutrients too, though he may not necessarily need more calories. Therefore, everything a recovering person eats should be nutrient rich. Leave the top ramen, Pepsi, and white bread for another day - like NEVER. Present choices such as chicken, salmon and red meat, but prepare them in a way that is easy to eat. For the meat and chicken, cook it well, ground or in small pieces. For salmon, consider getting canned salmon and making it up like tuna fish salad with mayonnaise, relish and olives. But beware, if your patients are picking at their food or dairy containing drinks, the dishes cannot stay out too long, or they will spoil. The last thing you need is a recovering patient with food poisoning. With the same goal in mind, don’t put too much on a serving plate. Start with a small serving and get seconds if you need to. And, for best results, offer small quantities of food quite often. 

Caregiving is hard work. With a little forethought and a few tricks of the trade, your well hydrated, well nourished patient will have the best chance at an optimal recovery. 

Wellness Wednesday: Recovering from a Serious Injury

This last weekend my son Vale had a major skiing accident. He broke his femur, had a pulmonary contusion, a broken rib, and a mild concussion.  He had to have emergency surgery. We quickly travelled to attend him, and since then we have been making arrangements for his recovery care. 

Though he will be off school for a time he will stay at college and we will return home. Therefore, I have been working with a team of friends and relatives to accomplish his care. This will, of course, consist of a series of wound checks, physical therapy appointments and post op appointments. It will also consist of a calendar of people doing shopping, making meals and doing laundry. When he returns to school in two or three weeks, it will mean getting driven to campus and wheelchairing around. It will mean seeing how it goes.

It has also meant getting correspondence passed back and forth between the doctors, physical therapists and the university faculty. To coordinate all this, I have had to send no end of contact information. I have had to create shared calendars and documents in the cloud, and distribute them to all his friends and family who have stepped forward to help.

Vale has had to deal with pain, disappointment and disruption. It is taking all of us together to shore him up during this trying time. It is taking everything from favorite foods to ice packs, but it is worth it. Even though it has been only four days, we can see distinct and major improvements every day.

 I am in awe of his caregivers. The surgeon and anesthesiologist spent significant time on the phone with me both before and after the case. It was easy to tell they were top notch, but they were also genuinely invested in my son, and empathized with me having to be so far away during the surgery.  I will be forever grateful for the time and energy they spent. I later leaned that that they spent this kind of energy during the entire weekend, since Vale's hip fracture was one of five such cases. The winds in the mountains had been high, and had swept the ski slopes to a hard shiny gloss. It took its toll.

Vale's physical therapist was a ray of hope. She came from both academic and clinical practice backgrounds, and was deeply invested in her field. She was immediately able to put us at ease and to identify all kinds of helpful strategies. Vale felt 100 percent better after one appointment, from a combination of the physical treatments, but also the encouragement of knowing his prognosis.

All this touched me as a mother and as a physician. It sheds renewed light on what I do.

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

The Zika virus continues to spread. There is increasing evidence that Zika infection causes microcephaly in the unborn as well as post viral paralysis Guillaine Barre syndrome. Every day there is new information about the outbreak, and the CDC ( Centers for Disease Control) is the best place to learn about it.

Unfortunately, there is yet no hint about treatment, and a vaccine is 1-2 years the making at best. The WHO ( World Health Organization )has warned that ZIka is likely to spread to every country in the Americas except Canada and continental Chile. As of this last Friday, January 29th,  the World Health Organization has reported 31 cases in 11 United States states and 1.5 million cases in Brazil alone. The WHO estimates that the virus could affect 4 million people by the end of 2016. About half of those will be women and an unknown percentage of those women will be pregnant.

In other news ACOG, the American College of Obstetricians and Gynecologists, has updated a “ Committee Opinion” which it distributes to all of its physician members. According to lead author, Dr. Allison Stuabe, "the goal is for OB/GYN's to own breast-feeding as a part of reproductive physiology”. The paper advocates that breast-feeding support should begin during prenatal care when breast-feeding can be discussed in clinic. Breast-feeding is still underutilized in this country and the world over. 

The American Heart Assoication has issued a report saying that “heart disease remains undertreated and under diagnosed in women”. It goes on to explain that "The causes and symptoms of heart attacks can differ markedly different between the sexes". Compounding problems is that “ women are under represented in clinical trials for heart disease ", occupying only about 1/5 of the slots. Moreover the report indicates,"even when women are included in trials, researchers do not often parse out the gender specific data that could deepen scientists understanding of how the disease affects women”

Last year the Gynecology community was startled by the revelation that ovarian cancer is now thought to originate in the Fallopian tubes. Accordingly, ACOG made a recommendation that they be removed in the course of surgery for other benign indications. However, a new study through Yale indicates that only slightly more than 5% of eligible surgeries utilize this recommendation. In all fairness, this is relatively new information and the efforts to disseminate it were fairly modest. Additionally taking the tubes out takes extra time at surgery and entails a certain amount of extra surgical risk. I was once told by an old professor of mine that it was not good to be either the first one on the block or the last one on the block to adopt a certain new surgical technique. 

This time the USPSTF (The US Preventive Services Task Force) has done something right. They have come out with a strongly worded recommendation to screen all adults for depression. They have gone on to particularly mention the need to screen all pregnant women and new mothers. They are basing this recommendation on new data indicating that maternal mental illness is more common than previously thought. New research indicates what has been called postpartum depression may actually begin during pregnancy and that left untreated these mood disorders can be "detrimental to the well-being of children". It is interesting that in the past the USPSTF has required proof of benefit to recommend any given intervention. Maybe today's announcement is a sign they will also begin using common sense.

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, 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. 

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

Good Monday. We start out with good news, noting findings reported at the World Diabetic Congress that those who breastfeed have a substantially lower risk of developing type two diabetes later in life. 

Northern hemisphere readers will note that the CDC ( Centers for Disease Control) has reported that this year's flu activity, so far, is relatively low. They also note that slow starts aren't unusual and those that haven’t yet gotten a flu shot should get one, especially since this year’s vaccine is good match. 

USPTF (The United States Preventive Services Task Force) has once again released it’s version of guidelines for breast cancer screening. They are, predictably, lax, and recommend individualization for women of average risk before age of 50, and every other year between 50 and 74. They have chosen this age range of screening since they state their data show this is the age range “ of greatest benefit” from mammograms. This is no doubt true since this is when most cancers are diagnosed. However, what they cannot seem to understand is that women want ALL the benefit that mammograms can confer. Think about it. Their recommendations would condemn any woman below 50 of average risk to having her cancer detected only when it became palpable. Of course mammograms detect them far earlier, when they are more curable. 

Women want ALL the benefits mammograms can confer, and yes, they understand all such diagnostic tests must be weighed against their risks. But in this case, the risks are so small. They are the risks of biopsies for concerning findings which come back negative for cancer. They are also, according to the USPTF, the risks of fear and discomfort of the procedure. I have seen two and a half decades of patients and I have never heard one patient cite these risks as even coming close to outweighing the benefit of screening for cancer. Where does the USPTF get the idea that these particular risks are so important or that women even care that much about them ?

The good news is that the controversy has hit the airwaves and the blogosphere. NBC, the Washington Post, the NY Times, and Newsweek, among others, all covered it. ACOG (The American College of Obstetricians and Gynecologists) maintains a recommendation of annual mammograms after 40, and the American Cancer Society recommends annual mammograms from 45 on. ACOG plans to convene a conference to sort out the issue once and for all. 

Group B strep is an important pathogen for moms and newborns. A new vaccine against it is under development. 

Big news: Ovarian cancer actually seems to arise in the tubes. The data for this is sufficiently compelling that ACOG is recommending removal of the tubes with preservation of the ovaries when applicable. 

The CDC reports that the average age of first time mom’s is at an all time high, being 26 years and 4 months. This can be attributed, at least in part, to fewer teen pregnancies. 

In sobering news, a new virus called Zika is causing birth defects in the Caribbean and South America. It is spread through mosquitos. The CDC may warn pregnant women not to travel in that region. I’m sure we’ll hear more about efforts to deal with this in the near future. 

The effort to develop personalized vaccines to treat ovarian cancer is in the early stages. This work is on the desk of the FDA as we speak. 

Wow, so much happening ! 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 Ob/Gyn

2016 brings in some good news for women’s health. Physicians are starting to weigh in on the new over the counter contraceptives available in Oregon and California, and they are overwhelmingly applauding it. 

A recent article in the Los Angeles Times also indicates physicians are also weighing in on the controversy on mammogram frequency recommendations, and many support annual screening from the age of 40. This view is supported by the American College of Obstetricians and Gynecologists, the American College of Radiology and the National Comprehensive Cancer Care Network. 

The National Public Radio Health Blog Shots has indication that 2015 was the year “ menstruation came out of the closet. They cite the care of Kiran Gandhi who finished the New York Marathon on her period,without pads, drawing publicity to the idea that #PeriodsAreNotAnInsult. They cite other instances where menstruation entered polite public conversation, thereby beginning to erode long held taboos. 

The FDA now classifies mesh for prolapse as a "high risk device". Given the complication rates, I think this is a good thing. Also good is that the FDA excluded mesh for incontinence which is a different device entirely and works rather well, without the same high complication rate. 

You may hear of a retrospective observational study has picked up an association between the use of oral fluconazole (Diflucan) in the first 6 months of pregnancy with a 50% increased risk of miscarriage. From this data, it is not at all possible to say whether the diflucan is causing these miscarriages. Think about it…. maybe it is the yeast itself, or a diet high in sugar. More study is needed to figure this out. 

A new blood test may help physicians sort out those at risk for preeclampsia. This is most welcome since it is sometimes difficult to discern preeclampsia from chronic hypertension. 

Finally, in some really fantastic news, the Journal of the American Medical Association (JAMA) has published research indicating that even “ older women” i.e. 69 or older, who get regular mammograms have a lower likelihood of dying from breast cancer during the ages of 75-84 compared to their counterparts who did not get regular mammograms. Currently we are permitted to stop screening around 70 and the US Preventive Services Task Force says mammograms should not be done after 75. This has to do with supposedly having an expectation of living less that another ten years. You know, something tells me this whole line of thinking is going to evolve as women live longer and more vital lives. I wonder what Betty White, Angela Lansbury, Sandra O’Connor, Ruth Bader Ginsburg or Dame Maggie Smith would have to say about all this. 

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

Good Monday and Happy New Year. ACOG (The American College of Obstetricians and Gynecologists) has once again reiterated the newer recommendations regarding cervical cancer screening. They have stated that “ Women ages 30 to 65 at "average risk" for cervical cancer should receive co-testing with cytology and HPV testing every five years or screening with cytology every three years”. ( Cytology just means sending cells with a pap and co-testing means DNA testing for HPV, Human Papilloma Virus via the same sample.) I would like to emphasize a couple of aspects of this statement: the phrase “ average risk”, and the idea that they are talking about sending specimens to the lab. 

Average risk is not precisely defined, and this is ok, since it gives clinicians room for applying clinical judgement to individual patient cases. Average risk does not certainly include those patients, who are by virtue of disease or medication, immunocompromised. It does not include those who have recently had precancerous cells in the cervix, vagina or vulva. In my opinion it does not include those who have a significant smoking habit, since smoking is tightly associated with accelerating the progress of HPV disease. I do not believe average risk includes those with alcohol or drug problems since these patients can have poor immune function and struggle with satisfying recommended follow up protocols. In my opinion, average risk also should not include those with high risk sexual habits, such as having unprotected sex or large numbers of partners. But does the media ever highlight any of these things ? I have not seen it. 

These ACOG recommendations are about the recommended sampling frequency for cells on the cervix. They are not a statement about the frequency of annual exams or even pelvic exams. Those proceed on their own schedules for their own separate indications. The media has not done a good job at highlighting this important distinction. After all, a woman is more than just her cervix. 

The Journal of the American Medical Association (JAMA) has received a request from a group of researchers to retract their own study from the Journal on the grounds that they have discovered that the lead researcher has falsified data about the usefulness of nitroglycerin for improving bone density.  Kudos to those whistleblower researchers. 

South Carolina Department of Health and Environmental Control (DHEC) will revise its regulations concerning the practices of licensed midwives, what we call lay midwives, meaning those who are not Certified Nurse Midwives. The DHEC was picketed by about 50 midwives. ACOG has said that while women deserve the right to chose where they deliver, they should be informed of the risks and benefits of the choices, including the two to threefold risk of neonatal death while delivering outside the hospital. (This data came from a study reported in the New England Journal of Medicine (NEJM) and involved a study of 80,000 pregnancies in Oregon.)

Let’s think a little more about that statistic on neonatal death. Neonatal death is defined as the baby dying in labor or in the first month after birth. Why would such a terrible thing happen in the hospital ? High risk pregnant patients come to the hospital. High risk mothers may have very early labor, ruptured membranes, or severe preeclampsia, all resulting in deliveries so early that babies are far more apt to die or have serious morbidities. This is the source of neonatal death in the hospital, not the average pregnant women who comes in for labor or induction.  On the other hand, most licensed lay midwives restrict their practice to low risk patients, with none of these aforementioned problems. And yet many more of their patients end up with dead babies, despite the fact that hospital caregivers are dealing with these sometimes insurmountable obstacles. Problems which are solved by a simple medication in the IV, or the use of forceps, or even a C Section in the hospital, result in death when the same problems occur outside the hospital.

Speaking of neonatal death being two to three times more prevalent among those who birth at home, did you ever consider that this is a group average ? What happens when you unpack that group ? It turns out that first timers delivering at home have a 14 fold increase risk of first apgar score of ZERO, which is tantamount to neonatal death. And while the multiparous patients (women with multiple prior births) may do better with labor, they are much more prone to hemorrhages and other maternal complications, which are not even addressed in this statistic. 

So beware of the medical reporting in the popular media. Don’t take those statistics at face value. Remember the actual human realities behind them. 

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

Medical Headlines took a bit of holiday break just like us, so today’s report will be brief. 

The Journal of Pediatrics recently presented research that has shown that many new parents use car seats incorrectly. The most common mistakes are straps too lose and chest clips placed too low. Anyone with doubts can just stop by any labor and delivery or pediatric clinic for an on the spot demonstration of the correct technique. 

In the good idea department, the American Journal of Public Health reports that young pregnant women  might get significant benefits with group prenatal care. The study groups ranged in age between 14-21 and received either traditional prenatal care or group prenatal care. Those receiving care in the group setting were 33 % less likely to have a small for gestational age baby. Personally I think it would be fun to instruct young women in a group setting. 

In the frustrating and dangerous section, Reuters has reported on Canadian study retrospectively comparing 11,000 low risk women who had home birth with 11,000 low risk women with hospital birth. Their endpoints were still birth or death. For these endpoints, there was no significant difference in outcomes, with the incidence at home being 1.5/1000 versus 0.94/1000 in the hospital. There are two glaring problems with drawing a conclusion from this: 

1. The incidence of stillbirth and neonatal death is small in both cases, so comparisons of even large numbers cases are relatively unrevealing.

2. We care about many more outcomes than still birth or neonatal death. For example, we care about near death of the baby or the mother, brain damage, post partum hemorrhage, retained placenta, postpartum infection, and so many more grave life altering things. The truth of the matter is that neonatal and perinatal medicine is so good now that no matter how badly a case is managed, modern medicine can almost always salvage it enough so that it does not qualify as a stillbirth or a neonatal death. Badly managed cases requiring intensive perinatal and or neonatal care that do not result in stillbirth or death are definitely things I should think everyone would want to avoid, but nonetheless are NOT on the radar of this study. For that matter badly managed cases that require intensive perinatal and or neonatal care that do not result in stillbirth or death but that DO result in bad outcomes like brain damage are not also reflected in this study’s conclusions. How helpful is that ? And yet, what is the Reuter’s headline ? “ Home Births May Be Safe For Low Risk Pregnancies “ Really ?

From the “ clues on the trail” department, we have the following two tantalizing tidbits. One, it turns out that there is some sort of association between gum disease and breast cancer. Those with gum disease have a 14% increased risk of the disease. Add smoking and it jumps to 20-30 % and that means smoking ANYTIME in the last 20 years. Yikes ! information like this could ultimately help us understand how breast cancer arises or persists. 

Two, Metformin, a common medication to help with ovulatory dysfunction, polycystic ovary syndrome, carbohydrate intolerance, and diabetes, “can block the release of toxins from the placenta when preeclampsia is present." Wow cool. Now someone smart needs to figure out why.

Ending with heartwarming news, the journal Pediatrics has presented research showing that “ kangaroo care” benefits premature and underweight babies in several measurable ways. Kangaroo care is prolonged skin to skin contact, and it is associated with half the risk of serious infection, 78% lower risk of low core temperature, and 88% lower risk of dangerously low blood sugar. 

So go hug your kid and have a happy new year. 

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

This weeks news is all about the facts and figures. Statistics is like pie. It is all about how you cut it. That is to say, the real meaning of raw data is challenging to correctly interpret. A great deal of the message from a study depends on how the data is presented. Be wary about drawing conclusions from studies where none can be drawn. 

The CDC report indicates that the number of abortions in the United States has hit a record low compared to 1990. This is true for all ethnic groups.

A new study has hit the press indicating that use of SSRIs, common antidepressants, in the first trimester is NOT associated with increased risk of autism spectrum disorders. Nonetheless the study also showed babies whose mother’s took SSRIs were 75% more likely to get autism than than their peers. Whether this is related to the mom’s condition, the medication or something else is totally unknown and cannot be known from this study. 

In the strange, counterintuitive and questionable department, a new observational study published in the Journal of the American Medical Association shows more complications among those with a planned C section compared to those with an emergency C section done after labor. This is against what has been show before, and against common sense. Authors at the NYT Blog Well speculate that somehow the labor is “ good” for babies. You just as well might speculate that people who chose elective C sections are less healthy to begin with. No conclusions can be drawn, although many will be. 

New findings in the Journal Cancer Epidemiology show that while cancer rates are declining in developed countries, they are increasing in the developing parts of the world. With development comes smoking, and more obesity, which increase the risk for certain cancers. 

The now ancient Women’s Health Initiative, which gathered data on a great many things, has been mined once again. This time it has revealed an association between smoking and infertility. No surprises there. 

I guess I am not the only one who doubts the work of the USPTSF on the issue of breast cancer screening and mammograms. Over 60 lawmakers, headed by Representative Debbie Schultz of Florida, have included a provision in the new budget requiring that the US government officially recommends breast cancer screenings at age 40 rather than 50 as the UPTSF does. Looks like they feel American women are willing to undergo some increased anxiety and discomfort in exchange for earlier detection, longer life, and less mortality. 

A new study out of Britain once again raises the question as to whether the use of the Ca 125 blood test can help detect ovary cancer and save lives. The results are by no means conclusive, but they will provide an impetus for much needed additional study. 

Back to pie. This week I hope you have several kinds, pumpkin, cherry and whatever is your favorite. Merry Christmas week ! 

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

Until recently, the only treatment for preeclampsia is delivery. However, a new study is underway to test Recombinant Human Antithrombin to manage early onset ( 23-30 weeks) preeclampsia. As the same suggests, this medication acts by inhibiting abnormal blood clotting and inflammation, two components of preeclampsia. If this helps, this will be the first medication to directly address this common and serious disease. 

In the unbelievable department, The Government Accountability Department (GAO) has discovered something concerning at the National Institute of Health (NIH) . They have discovered that the NIH does not, in their research, always keep data on sex, thereby making it impossible to determine whether or not an intervention or exposure affects men and women differently. Those of us from the world of Ob/Gyn can tell you that rather often, the same factor will affect men quite differently than it will affect women. 

Here’s your reference http://www.gao.gov/products/GAO-16-13

The Radiologic Society of North America heard research results indicating that the recent Medicaid Expansion has boosted rates of breast cancer screening in low income women. Assuming these and other women do not pay too much attention to the USPSTF ( US Preventive Services Task Force) recommendations of later and less frequent mammograms, we may soon see increased rates of early detection and eventually, longer survival. 

ACOG (The American College of Obstetricians and Gynecologists) has made its strongest statement yet on pregnancy, stating not only that it is safe, but that it is recommended on a daily basis and should be the norm. 

OB/GYNS all over the world are nodding on this one. The Journal of the American Medical association has indicated the WHO's (World Health Organization) optimal rate of C section at 10% is too low. As C section rates rise to 15%, the study shows maternal and infant deaths decrease. In fact, maternal and infant deaths continue to decline through about 19%. This is the sweet spot, meaning where maternal and infant well being are at their highest. In the US about 33% of births happen by C section. This probably has to do with many things, including our culture, patient preference, doctor’s risk tolerance, the medico-legal climate, and the obesity epidemic. We can improve. 

Sobering : False positive mammograms may be linked to a higher risk of breast cancer later in life. The group in question is those whose mammograms indicate the need for a biopsy but then whose biopsies are negative. These women, despite negative biopsies, have a 39 % higher risk of breast cancer in their future that women who didn’t require a biopsy. I wonder how this finding will factor in to the recommended frequency of mammograms. So many authorities are weighing in on how frequently they should be done. ACOG still says every 1-2 years after 40. 

It turns out that giving flu vaccine to pregnant women in the second and third trimester benefits not only the mom but at least have of the unborn babies as well. Bonus ! 

Stay tuned next week for more breaking news from the world of Ob/Gyn ! 

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

California and Oregon will soon allow pharmacists to screen patients and prescribed birth control pills. While the American College of Obstetricians and Gynecologists considers this a step in right direction, they believe they should be available over-the-counter, plain and simple. While it is true that low dose combination birth control pills can have medical complications in a very small percent of people, by and large their health benefits far outweigh their risks.

As most of you probably are already aware, hepatitis C has a new medical treatment which provides a cure in a very high percentage of people. However, hepatitis B has remained a challenge, and in particular, we have had to deal with the problem of vertical passage of the virus from mother to baby during pregnancy, labor and delivery. However recently at the meetings of the American Association for the Study of Liver Diseases, new research was presented. In the course of a randomized controlled trial, a drug called Tenofovir was shown to be able to reduce vertical transmission. 

Yet another encouraging recommendation about exercise in pregnancy has been released. According to the American College of Obstetricians and Gynecologists, nearly half of US women gain too much weight while they're pregnant. We all know that women who gain too much weight in pregnancy are very uncomfortable. However they also have higher rates of miscarriage, premature birth, stillbirth, and babies with birth defects. They’re also more likely to have heart problems, sleep apnea, gestational or pregnancy associated diabetes, preeclampsia also known as toxemia, and abnormal blood clots. They are at higher risk for cesarean section. So there are ample reasons to find ways to control this weight gain. 

The new memo released by ACOG advises pregnant women to exercise regularly and more often than they currently do. The memo states that while walking is the best exercise, jogging, Pilates, yoga, cycling, swimming, and other forms of exercise are perfectly acceptable. ACOG cautions against contact sports such as skiing, and other specialized sports such as scuba diving.

More good news: it appears that breast-feeding for two months or more reduces a gestational diabetic’s risk of developing type II diabetes later in life by 50 %. Moreover, the risk of diabetes lessens as the patients breast-fed longer.

Finally, here is some good news that initially sounds a lot like bad news. Since 2010, there has been a significant increase in the number of women under age 26 who have received a diagnosis of early-stage cervical cancer. In the next age group, 26-34, the numbers were unchanged. What changed for the younger age group? The answer is the availability of insurance. One of the features of the ACA, The affordable care act, was to allow children to stay on their parents insurance plans through the age of 26. Most likely the increase in diagnoses came from increased compliance with recommended screening, i.e. pap smears. Once again, we are reminded that appropriate screening leads to early diagnosis, which leads to less invasive treatments, fewer complications, and higher rates of cure. 

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

Happy Monday on this short week ! This week in honor of Thanksgiving I plan to apply the filter of gratitude to the news that I feature. Let’s see how this works out. 

The LA Times recently reported on the actual C Section rate in the US ( 33%)  as compared to the theoretical ideal of 15 %. An ACOG (American College of Obstetricians and Gynecologists) spokesman indicated that this discrepancy was largely about risk tolerance of the involved parties. Gratefulness filter: Le’t be glad we live in a place where C sections are readily available to those who need them. 

Findings coming out of the African American Cancer Epidemiology Study indicate that black women with the healthiest diets were 34 % less likely to develop ovarian cancer that their counterparts who ate the most unhealthy diet. Gratefulness filter: Diet is an easy factor to modify !

Findings presented at the American College of Rheumatology indicate that Denosumab was superior to Zoledronic Acid ( Zometa) at restoring low bone density due to osteoporosis. Gratefulness filter: This is great news for all with low bone density ! 

The Supreme Court rejects the case against Planned Parenthood. Justices Scalia and Thomas dissent. Gratefulness filter: Let is be glad we live in a country that respects free speech of differing parties, that observes due process and the rule of law. 

About 10 % of all new mothers suffer from post partum depression. New York is rolling out a ambitious program which will require that all expectant and new mothers will be screened for depression. Gratefulness filter: Thank goodness awareness is increasing about this important and treatable problem. 

Rhode Island has a new state mandate requiring HPV vaccine for youngsters. Nearly three quarters of seventh graders received it by the start of the school year. Gratefulness filter: Thank goodness we have a way to prevent cervical cancer. 

Count your blessings this week and stay tuned for more news from the world of OB/Gyn next week on Medical Monday ! 

Medical Monday: Weekly News Update in Obstetrics and Gynecology

Good Monday.

A new study presented at the annual meeting of the American Society of Anesthesiologists suggested light meals during labor may be safe for most women. Ordinarily we would like to restrict intake to clear liquids nothing at all depending on the risk level of the woman. The main concern here is the risk of aspiration which means inhaling food particles from the stomach into the respiratory tract. Pregnant women are at increased risk for aspiration compared to non-pregnant women due to  the pressure from the baby and the relaxation of the esophageal muscles. Moreover, women are often nauseous during labor, increasing risk. The highest concern comes if the patient needs to go to cesarean section. In this instance she needs to be on her back with only a slight tilt, and this increases the risk of aspiration even further. It is unfortunate that the lay reporting makes it sound like we fear that women might aspirate during normal labor. Our concern is mostly having to do with the chance that they will go to cesarean section on a full stomach. 

Shots Blog on NPR covered this interesting tidbit: Babies and mothers exchange cells each others circulation during pregnancy labor and delivery, And they are maintained in circulation thereafter. These are believed to have implications for cancer and auto immune diseases that affect women. It is unclear whether these are beneficial, harmful, or both, depending on the circumstances. 

We know that when people have more testosterone in their system that they are more assertive or aggressive. But we are now finding is that the converse is also true. According to a study published in the Proceedings of the National Academy of Sciences, our testosterone levels rise in response to assertive behavior such as the use of power in a work situation. Study noted that this is especially true in women.

Did you know that tobacco use before pregnancy and in pregnancy is associated with cleft palette and congenital heart defects? The CDC's National Center on Birth Defects and Developmental Disabilities performed a meta-analysis which indicated that 6% of oral clefts and 1.4% of non-syndromic heart defects are attributable to maternal smoking in the first trimester. 

Yet another study underscores the fact that drinking alcohol increases a woman's risk of breast cancer.

Got cold sores? Don’t feel bad. The World Health Organization estimates that half of the world’s population under 50 does too. 

Stay tuned for more news from the world of obstetrics and gynecology, Next week on Medical Monday.