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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stay tuned for more news next week on Medical Monday. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Food Friday:Spring's First Fruits and Shopper’s Lists

This week the morels came out. Morels are the spirit of the forest rising up after spring mist and sun in close succession. They are hidden in plain sight. They are jewels amidst dung, a mushroom, not to be cultivated, and bringing the highest prices of anything in a northern hemisphere vendor’s stand. 

We gathered them as a seasonal rite, and to celebrate the birthday of a friend which comes at this time. They require a bit of esoteric knowledge, lest they be confused with inedible or poisonous varieties. They are not to be eaten raw. They are best cooked in butter and allowed to hold their own next to something simple like steak. 

To enjoy them, we must be sure we must of their origin and provenance. The effort we spend is in proportion to our enjoyment. By contrast, how is it that we give so little care to our everyday food ? 

Today’s post is a cautionary note about food safety. More than that, it is an invitation to experience our daily food more fully. You have probably all seen the bumper stickers “ Who’s your farmer?”. This is a valid question. It is both important and fascinating to learn about the origins of food. Once you learn about the different ways food is produced, including the conditions of the farms, factories and people involved, you will most likely care. What you will find is that the bad is really bad, and the good is really good. The obtaining, preparing, serving and eating of food becomes something greater, and something of which you can be proud. And, somewhat incidentally, the food is better. 

As a relevant side note, when you eat food of this quality, it will enhance your health. Since high quality natural food is best prepared simply, it is generally healthy. It is more expensive, and not the kind of thing one overeats. You will be too busy savoring it. You will be come interested in quality not quantity. Most likely, your weight will gravitate toward normal if it is not already there. 

I was hoping to also find some wild asparagus in the fields. Plus, strawberries and rhubarb are due soon. But I am impatient, and have been looking at strawberries in the stores, both organic and not. So, naturally, I was interested when a headline flashed onto my newsfeed: 

The #1 Most Contaminated Fruit You’re Buying Is...

I clicked on it, only to find that the answer is strawberries. The link led me to an articles about two very important lists which I want to share with you: 

The Dirty Dozen

and

The Clean Fifteen

These are lists produced by the Environmental Working Group (ewg.org), a nonprofit which is endorsed by The American Academy of Pediatrics. They strive to educate and protect the public from pesticide residue in food, and they use USDA ( US Department of Agriculture) and FDA (Food and Drug Administration) data to do it. 

The Dirty Dozen is the 12 most pesticide laden produce items in stores, in order of contamination. The Clean Fifteen lists the fifteen least contaminated non-organic produce items. Of course, the ideal is to buy organic. But if you cannot, you should avoid the items on the Dirty Dozen. If you can only buy a little bit of your produce as organic, then concentrate on the ones high on the Dirty Dozen list. Conversely, you can feel reasonably good about buying non-organic produce if you choose from the Clean Fifteen. You can download these lists for free on ewg.org. Take your hunting and gathering to the next level. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Good Monday.

First the Zika news. Dr. Anne Schuchat, the principal deputy director of the CDC (Centers for Disease Control) has stated that "everything we look at with this virus seems to be a bit scarier than we initially thought”, noting that "the virus has been linked to a broader array of birth defects throughout a longer period of pregnancy, including premature birth and blindness in addition to the smaller brain size caused by microcephaly”. Additionally, she announced that "the mosquito that carries the Zika virus is present in 30 states, more than twice what officials originally thought. The maps at right indicated the territory of these mosquitos. Click on the image to take you to the CDC site on the subject. 

The White House has shifted nearly $589 million or over half a billion dollars in leftover Ebola funds in order to fight the Zika virus. This comes well short of the $1.9 billion that has been requested by the National Institute on Allergy and Infectious Diseases. Dr. Anthony Fauci, the Director of this organization has announced that he will also be diverting funds from other areas in order to close the gap on funding what he views as critical efforts.

Florida leads the nation in number of Zika cases which last week totaled 84. Zika cases in Florida account for 23% of all cases in the states. Mosquito activity is of course greater in warm climates. It is expected that when the rest of the southern part of the country achieves these temperatures that Zika transmission will increase. The CDC has reiterated that insect repellent containing DEET are safe to use at any stage of pregnancy.

Zika is now associated a third clearcut disease entity. We already know a fair amount about microcephaly which is incurred by the fetus when a pregnant woman acquires a Zika infection during pregnancy. We also know about Guillain-Barré syndrome, post viral paralysis, which can effect of minority of people after a Zika infection. Researchers in Brazil are now reporting that the virus may be linked to "an autoimmune disorder known as acute disseminated encephalomyelitis or ADEM. In this syndrome neurological symptoms could start right away or as long as two weeks later. 

New research from the CDC indicates that white women between the ages of 30s and 50s are dying at increasing rates. This is been attributed to poor access to healthcare in rural America. In related news, a new study from Delaware has indicated that women enrollees in their state Medicaid program outnumber men to 2 to 1. State officials are interpreting this as an indication of increased poverty among women.

California has expanded the care that pharmacists are able to give. Perhaps most significantly, they are now able to prescribe contraceptives without the patient having to visit to another caregiver. While three quarters of physicians in one poll do not support the dispensing of birth control by a pharmacist, the American Congress of Obstetricians and Gynecologists support this legislation wholeheartedly.

Delaware has modified its Medicaid policy to require that contraceptive costs be bundled with the hospital’s charge for obstetric care. The Governor of the state, Jack Markell, recently wrote an op-ed for the New York Times describing this change and indicating his belief that it would allow for better family planning. He also went on to argue that contraception is vital to prosperity. 

The Guttmacher Institute recently released a study showing that teen abortion and pregnancy rates have dropped to historic lows. Teen pregnancy rates in particular have been cut in half between the years 1990 and 2011. The teen pregnancy rate in 2011 was 52.4 per thousand and, also of interest, is nearly 25% lower than the rate in 2008.

That seems like plenty to think about this week. Stay tuned next week for more news from the amazing world of Ob/Gyn. 

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

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

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

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

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

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

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

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

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

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

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

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. 

Food Friday: Skin Food- Cocoa Butter and Coconut Oil Body Cream

You all know how I love chocolate. What if you could indulge in chocolate without a single calorie ? That wonderful smell of cocoa butter is the answer. I make my own body cream out of cocoa butter and coconut oil. I have very dry and very sensitive skin due to my lupus. I have found this is well tolerated and very helpful. 

The internet abounds with recipes for homemade cream such as this. I will provide a no frills version PLUS some extra tips to ensure the process is hassle free. 

Prepare all your supplies first:

• Cocoa butter and coconut oil in 1:1 ratio
• powerful mixer with whisk attachment 
• glass bowl for microwave
• spatula and ladle
• final containers such as mason jars with lids 
• roll of paper towels for covering the work surface, covering the mixer and for cleanup
• a handy garbage bag
• Stovetop with good ventilation
• shallow metal pan or bowl for cooling 

Steps: 

Place equal volumes of each fat in a microwave bowl. Warm as little as possible to get it all completely melted and mixed. You can do the same on a stovetop with a double boiler or simply a bowl over a pot of hot water. Stir. Ensure good ventilation. 

Cool in metal pan until solids are just beginning to reform. While still mostly liquid beat mixture in powerful mixer, covering mixer with paper towel to avoid spray. Stop at the yellow slightly thickened stage for a product that is like butter. Whip to stiffer white peaks for a creamy body spread. Work quickly at this stage since it will harden on your utensils. 

Spoon or pour into mason jars or other decorative containers and place lids. 

Clean up all thick material with the paper towels. Hot water will dissolve this stuff, but when it gets cool again in your drain, it will clog it. Get as much off with your paper towels and then wash up the faint residue with hot soapy water. 

This stuff smells wonderful and would be great for pregnant bellies, healing scars, or dry winter skin. I hope you like it. 

Wellness Wednesday: The Common Cold

What is a cold ?  

A cold is an upper respiratory infection caused by one of hundreds of viruses. According to mayoclinic.org, they normally last 1-2 weeks. They normally occur a few times each year even in healthy adults. Children have them more frequently than adults, and there are usually sicker than adults with it. 

Cold symptoms:

It is important that you can distinguish a garden variety common cold from something more serious. Here are the most common cold symptoms.

• Runny or stuffy nose 
• Itchy or sore throat 
• Cough 
• Congestion 
• Slight body aches or a mild headache 
• Sneezing 
• Watery eyes 
• Low-grade fever 
• Mild fatigue

Cold symptoms are caused my the immune system’s response to the virus. These responses can cause their own problems, such as excess secretions and swelling of the passageways. This combination of increased secretions and narrowed passageways can  in turn can foster secondary bacterial infections in the sinuses, ear or throat. These complications require treatment. 

When adults should contact the doctor:

• Fever of 103 F (39.4 C) or higher 
• Fever accompanied by sweating, chills and a cough with colored phlegm 
• Significantly swollen glands 
• Severe sinus pain

When the doctor should be called for children: 

• Fever of 100.4 F (38 C) in newborns up to 12 weeks 
• Fever that rises repeatedly above 104 F (40 C) in a child of any age 
• Signs of dehydration, such as urinating less often than usual 
• Not drinking adequate fluids 
• Fever that lasts more than 24 hours in a child younger than 2 
• Fever that lasts more than three days in a child older than 2 
• Vomiting or abdominal pain 
• Unusual sleepiness 
• Severe headache 
• Stiff neck 
• Difficulty breathing 
• Persistent crying 
• Ear pain 
• Persistent cough
• Pregnant women should call for any illness, just to make their caregivers aware and to discuss pregnancy safe management options. 

High fever, severe sore throat or body aches may indicate a special pathogen like influenza or strep which requires a specific treatment.  Without a doubt, there is little downside to calling your doctor and asking if they think you or your chlld needs to be examined or tested. 

Prevention of Colds

Cold viruses are spread by touch or particles in the air. We probably encounter them much more often than we get sick. Sometimes the immune system deals with them easily and we don’t really get sick. Getting sick happens when we encounter a particularly virulent (strong) virus, or when we are run down, or both. 

Prevention is a matter of not getting run down ( easier and than done) avoiding contact with sick people or viruses. Hand washing with soap and keeping surfaces with clean with antimicrobial cleaner is critical. When my kids were growing up, we established a tradition of washing hands whenever we arrived home from elsewhere. 

I also believe good oral hygiene is key to preventing upper respiratory infections. This means keeping up on the toothbrushing, flossing and dental repairs. A peroxide based mouthwash before bed is very helpful too. 

Treatment of Colds

Treatment is largely supportive. This means we try to ensure that patients hydrate well and rest. We also like them to keep their nasal passages clear and cough down so they do not get secondary bacterial infections from all the congestion. This can be accomplished with over the counter decongestants and cough suppressants. (Though it is important to note that aspirin is not given to children and cough syrup is not given to children under 4. )  Better yet decongesting is accomplished with frequent steamy showers and lots of herb tea, to keep the passages clear. Good oral hygiene probably hastens healing too.

Did you know that chicken soup is actually ideal for the cold sufferer ? There is actually an old research study showing it has anti-inflammatory effects, and certainly we know it helps to hydrate and nourish. While it is hydration that is often emphasized, people recovering from a cold need at least as many calories as normal. While one should feed a cold, one should NOT “ starve a fever”. 

I generally make my soup stock and my chicken soup from scratch. However that is not a quick proposition. For this reason, I like to keep some high quality canned chicken soup on hand just in case I am pressed for time and someone is under the weather. There, that is the ONE time I will recommend a “store bought, pre-made”  food. 

So in this case as in many, an ounce of prevention is worth a pound of cure. Stay in your exercise routine, sleep adequately, eat well, and practice good hygiene. Those things are a lot more fun than getting sick. If you do get sick, follow these measures. Treat yourself to some good soup, a steamy bath or shower, and a first rate Netflix binge. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Good Monday.

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

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

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

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

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

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

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

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

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

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

Medical Monday: Breaking News 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

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. 

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

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.