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

Policy News:

Medical and civil rights organizations have come together to oppose the detention of pregnant women by the agency on Immigration and Customs Enforcement (ICE). They have cited harmful effects on the health of these individuals due to lack of access to proper prenatal care and due to the high risk of rape while detained. 

Senator Tammy Duckworth (D-Illinois) has been the first Senator to have a baby while in office. Adequate lactation rooms were ensured through a measure by Senator Nancy Pelosi in 2008 so that breastfeeding Senators could comply with breastfeeding recommendations from the American Academy of Pediatrics. However, the post partum senator may have more difficulty attending votes unless the current rules barring children from the Senate floor are modified. 

The Trump administration has added two new exemptions to the individual mandate which is the rule that says people must carry individual health insurance or pay penalties. One is an exemption for those who live in a place with only one ACA (Affordable Care Act) insurance carrier whose coverage includes abortion services. On the basis of paying into a fund whose services include abortion, they can be exempted. I can see why people feel such consumers should not be obligated to use such a plan. I believe, however, that same anti-abortion consumer should be obligated to follow through with their execution of conscience and be required, under pain of penalty to buy private health insurance so that the rest of society does not end up footing the bill for their conscience driven but unfunded health care.  

The second exception the the individual mandate is nonsense. It is a “hardship” exemption. Who more than those under hardship need quality health care ? This particular exemption is a recipe for making the poor or those under hardship even poorer. And what does it gain? It gains political brownie points under the guise of freedom, and a better appearing Federal spreadsheet for this administration to tout to the voting taxpayers. We need to do a better job a making it clear to people that they stand to gain much more buying health insurance than they do forgoing it. 

Four abortion restricting laws have been passed by the 2017 Arkansas legislators. However, several influential groups have filed amicus briefs at the 8th Circuit Court of Appeals in St. Louis. One is the American College of Obstetricians and Gynecologists pertaining to the criminalization of “D & E”, the procedure dilation and curettage. This procedure is a safe and effective method for abortion, the safest in fact for the second trimester, and is used in many medically indicated cases where the patient’s life is at stake. 

The New York Times has reported that Scott Lloyd, the director of the Office of Refugee Resettlement keeps a spreadsheet of all detained unaccompanied minors who are pregnant and are requesting abortion. Lloyd has directed that this "captive audience" received non medical “counseling”  regarding their requests. Does anyone else view this as a misuse of power ? Does anyone else view this an incursion of a non-medical authority into the realm of medicine and counseling ?

Medical News: 

 Ever heard of the term “Previvor”? Me neither.  Previvors are those that know they carry a genetic mutation for cancer but have not yet developed cancer. Many are people who have discovered their mutation through non- medical genetic screening such as through the popular company “23 and me”. Others are those with family member with cancer who have been advised to do testing. Either way they are in a grey zone, and do not always get the care they need to address their relatively new predicament. Enter Dr. Heather Macdonald, an Obstetrician Gynecologist at Hoag Hospital in Newport Beach, California. She has created a special tailored program for these patients. It is called the “ Breast and Ovarian Cancer Prevention Program. In it she has outlined the possible ways to address risk, which may range from surgery, to medication to health maintenance strategies. 

The nation is finally mobilizing on the issue of maternal morbidity and mortality. Five states were in on the creation of the Alliance for Innovation on Maternal Health (AIM), California, Florida, Illinois ,Michigan, and Oklahoma. Texas, the nation’s worst offender, has now joined. The initial states have since seen significant decreases in maternal morbidity using protocols called “safety bundles”. 

Young women still suffer stigma even in the confines of an office visit. New research indicated fully half of teens and young women do not feel comfortable discussing sexually transmitted infections (STIs). Moreover, over a quarter lie to their caregivers about their sexual history. Separate research has shown that that the incidence of STIs is at a many decade high. Nonetheless, 62% of women under 25 do not consider themselves at risk for STIs. Only 40% use condoms. What might be a way to change all this ? 

A recent study published in Obstetrics and Gynecology indicates that marijuana does show up in the breastmilk of using mothers. Infants who breastfed exclusively ingested about 2.5 percent of the maternal dose and peaked one hour after smoking. ACOG’s position on marijuana in pregnancy and breastfeeding is as follows: 

There are “...concerns regarding impaired neurodevelopment, as well as maternal and fetal exposure to the adverse effects of smoking”. 

"There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.”

Reference: 

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Marijuana-Use-During-Pregnancy-and-Lactation

PCO or polycystic ovarian syndrome is a complex medical condition that comprises problems with ovulation, fertility, menstruation and excess male hormones, and problems with acne and unwanted hair growth. It also includes problems with carbohydrate metabolism and may lead to cardiovascular disease and diabetes. New research also indicates is is associated with a higher prevalence of several psychiatric conditions including depression and anxiety. 

Initial testing of a personalized vaccine against recurrent ovarian cancer cells is showing promise. A patient’s own dendrite cells (DC) are treated and given separately or together with other immunotherapy. The DC vaccine induced potent anti tumor T cell responses and was well tolerated, and was associated with a better prognosis. Further clinical testing is planned. 

New research in the Journal Menopause has unearthed a connection between the severity of menopausal symptoms and the risk of heart disease. The research found that increased symptoms such as hot flashes were associated with artery stiffness and dysfunction. This research may come to influence the way we think about postmenopausal hormone replacement therapy which reduces both symptoms and arterial dysfunction. 

The biggest news of the week may be that alcohol is not as safe as once previously believed. A new international study has shown that even one drink of beer or wine per day can increase the odds of hypertension, stroke and heart disease and significantly shorten life. Numerous national and international recommendations are likely to be changed based on this. 

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

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

POLICY NEWS :

From the “back in my day” department we have the following dispatch: If one of us residents were to refuse to care for a patient out of moral objection or fear for our safety, we would have gotten in big trouble. We would have been told to get cracking or get packing. I remember being horrified one day after I had taken care of a beautiful young Moslem woman who had endured the severest from of ritual Female Genital Mutilation. (FGM) Not only had her labia and clitoris been removed, but her skin had been sewn together to barely leave enough opening, on stretch, to have intercourse.  She had just had a normal vaginal delivery and it was all broken open. Despite the fact that she had frequent urinary tract infections and and constant pain with intercourse, she insisted that I put it all back together after the birth. I spent a great deal of time trying to reason with her about the medical inadvisability of this procedure. Despite my personal and professional objections, I had to do it. The patient explained to me that she would have felt humiliated in the eyes of her family if it were not repaired. It was an awful situation for me. I wonder now what would be the requirements for me in the same setting, given that “moral objections" are playing a role in medical care.

A new Harris Poll based study has revealed that 8 in 10 Americans “ do not believe doctors, nurses, pharmacists….” “ should be allowed to use their conscience or beliefs to refuse care.” Of course this pertains to many issues in Obstetrics and Gynecology, where one might be facing requests for routine abortion, or for abortion for grave anomalies not compatible with life outside the womb. Some people do not believe in birth control. Some do not believe that welfare mothers should have large numbers of children. Some people do not believe in women having multiple partners. Some people do not believe gay couples or single people should be able to use assisted reproductive technologies. The list goes on. 

A recent paper described a possible option of 12 weeks of paid family leave secured in a fiscally responsible way. Parents would have a choice to trade 6 weeks of delay in the disbursement of their Social Security checks later in life in exchange for 12 weeks of family leave earlier in life. We’ll see if the idea gets any takers Washington. 

As of this last Wednesday the Department of Health and Human Services (HHS) has stated Family Planning will continue to be refunded. The grant money for the program is called Title X and amounts to 260 million dollars. 

North Carolina is connecting the dots. A bipartisan program, YES let me repeat that- BIPARTISAN program in the state, Carolina Cares, is advocating to expand Medicaid. The fetal and infant mortality in the state is unacceptable and available data indicates that expansion of Medicaid can decrease fetal and infant mortality simultaneously. Care through Medicaid targets exactly what places mothers and infants at risk: poverty, violence, lack of education, nutrition, and prenatal care. 

Several States are considering lifetime caps on Medicaid for those who are not children, pregnant, or disabled. If you are not any of these things, why should you need Medicaid ? The Conservative in me says you wouldn’t since you would simply work and earn and pay for insurance. The Liberal in me says, insurance is expensive, and there will always be people who are just poor, and they need comprehensive medical care more than anyone for them to even stand a chance at a decent life and productivity. 

Several States are leaving the Federal Government behind, and beginning work on their own versions of the Individual Mandate. These include Maryland, California, Hawaii, Minnesota, New Jersey, Rhode Island, Vermont and Washington, and DC. As reported previously, even more states have begun or finished work on laws guaranteeing contraceptive coverage for their citizens. 

MEDICAL NEWS: 

In the "we already knew this" department, new research has shown that induction may lower complication rates. But the devil is in the details…angels too. It turns out inducing at 39 weeks was associated with less need for C section and fewer complications for mother and baby. However, dates must be accurate and the cervix must be soft and favorable to even consider it. The quality of the study was good and it was presented at the Society for Maternal Fetal Medicine. 

Think only old women lose urine? Think again. One third of women leak urine before thier first pregnancy. Talk to your doctor if you think there is a problem. Urine loss may signal infection or other medical conditions. Most of the time it is just de-conditioned muscles and bad habits. 

Ever have preeclampsia ? This disorder, also called toxemia, will go away after delivery. However, mothers who had it either had a pre-existing tendency to high blood pressure beforehand or retain this tendency to high blood pressure afterward. If you had preeclampsia, check your BP regularly and know that you are at risk. I hear they make smart phone connected BP cuffs! 

The Journal of the American Medical Association has published a report indicating that as many as 10% of US babies are affected in some measure by fetal alcohol syndrome (FAS). This has been unearthed by interviewing mothers of neurologically or behaviorally abnormal children. What was once believed to be primary neurological disorders are now felt to be related to maternal alcohol consumption in pregnancy. Likewise, I am very concerned about what we suspect but have not yet conclusively proven about the effect of marijuana on the brains of the unborn. 

Syphilis is on the rise, and herpes on the decline. Both infectious diseases are easy to detect, manageable to treat, and potentially catastrophic in pregnancy. Get screening if you have any doubts. 

Probiotics for babies? Experts are beginning to focus on the neonatal microbiome. That is the group of organisms in and on the baby which are considered to be normal and beneficial. Many of these come from mother, via delivery and breastfeeding. But what if a C section takes place and what if breastfeeding is curtailed? While amateur “seeding” of the flora has been tried, ACOG (American College of Obstetricians and Gynecologists) does not recommend it. However, research interest in this topic is increasing. We do know that pregnant women should eat a pre-biotic diet rich in fruit vegetables and probiotic foods such as plain yogurt, kefir, fermented vegetables, and even Kombucha in moderation. 

Stay tuned next for more exciting news from teh workd of Obstetrics and Gynecology, here on Medical Monday.