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

Policy

The GOP appears to be giving up on repealing the Affordable Care Act (ACA). Those who support the patient care aspects of the ACA may cheer, but they should not breathe a sign of relief, since the funding mechanisms of this plan remain somewhat undetermined. Encouragingly, there is increasing GOP interest in crafting legislation which will make the plan more fiscally stable. The goals in this case would be to guarantee Federal subsidies to insurers, and to reduce patient premiums while keeping essential benefits.

Do you think that people realize that the more people sign up for the ACA, the more stable it will be ? Well, it's true. It's easy. Go to heathcare.gov to see if you qualify. 

South Carolina has argued that a “ human being is a person at fertilization”. They have created a legal category “preborn humans” which incidentally my spell check refuses to recognize, and they propose these preborn humans be afforded due process and all protections under the law. ACOG, the American College of Obstetricians and Gynecologists, opposes the bill since it is not based on science. 

A 20 week ban on abortion failed the Senate. The bill’s proponents advanced the bill on the basis of their belief that 20 week fetuses can feel pain. ACOG has gone on record saying “ the fetus does not have the physiological capacity to perceive pain until at least the 24th week of gestation.”. We as a medical culture have a great deal of experience with 24 week babies since they routinely come to any large newborn ICU. Had the bill passed, it would have been challenged under the standing Roe V. Wade. 

Idaho has introduced a bill which introduces misinformation into the informed consent language for medical (pill based) abortion. The bill’s language asserts that medical abortion can be halted after the first of two pills is taken. The bill further requires providers to provide a list of other providers who can advise about “ abortion reversals”. None of the bills assertions are based in fact. A patient contemplating a medically induced abortion should not proceed if she has any doubts, since there is no evidence reversal is possible. I feel angry on behalf of distraught women who may be told this misinformation and who try to rely on it. 

A group of private donors has bankrolled the provision of medical abortion services for all public universities in California. A bill is under debate which will require public universities to provide this service. 

Another bill proposed in California would require larger businesses with new construction to provide space for breastfeeding. The bill stipulates these areas need to be be in place by 2019. 

The Utah bill which will require the offering of IUDs through Medicaid has passed the House and is heading to the Utah Senate. Republican lawmaker Ray Ward, has proposed the measure to decrease unplanned pregnancies, teen pregnancies, and abortions. 

Medicaid expansions may be able to move forward in several traditionally red states if they are paired with work requirements. What do you think ?

Medicine

 

Researchers out of UC San Francisco have come out highlighting the adverse effect of marijuana on the unborn. Dr. Dana Gossett has cited several recent studies which indicate marijuana increases risk of still birth and adversely affects how the babies brain develops. ACOG has already come out formally warning pregnant women not to use. This could potentially turn out to be a huge generational problem if these children, as a generation, have significant delays. This research also raises the question of what is marijuana does to the brains of children and adults who use. This research also raises the issue that state policy on marijuana has been made without any reference whatsoever to available science. 

Preliminary date from a Dutch population based study indicate that women with implants may be somewhat more likely to develop anaplastic large cell lymphoma. Further studies are needed to clarify the risk. 

It has been well established that obese women have an increased incidence of breast cancer based on weight aone. However it is now becoming clear that even fat/skinny women are also at increased risk. This means even a woman of normal overall weight with a high body fat percentage has increased risk. 

TDAP stands for tetanus diphtheria and acellular pertussis. This vaccine is given to children and to pregnant women. It turns out that that protection is afforded to the baby through the mother no matter when mother gets the vaccine in her pregnancy. Upshot: It is never too late to get a TDAP in pregnancy. Babies first vaccinations are not until 2 months, so baby needs passively acquired immunity from mom getting her shot in pregnancy. 

This season’s flu is on tract to be the worst of the decade. already it has surpassed the 2009 “ swine flu” epidemic. As f this writing, flu has led to 37 pediatric deaths nationwide. You may have heard that this year’s vaccine is only partially effective. This is true, but some protection is better than none. Get you and your loved ones vaccinated. Do not go to work of you are sick. Ask sick co-workes to go home. Do not take sick children to day care. Wash you hands twitch soap when you arrive at home. Be assertive ! If you think you have been exposed to flu, call your health care provider. You may be eligible for preventive medication, and certainly are if you are pregnant or immunocompromised. 

A new Zika vaccine has been fast tracked by the FDA. It is called TAK-426 and is currently being tested on 240 people between the ages of 18 and 49. 

Women have autoimmune disease 9 times more often then men. I will therefore report on two news items of interest to those with autoimmunity. The first pertains to Rheumatoid Arthritis. A new study has shown that women with Rheumatoid Arthritis tend to deteriorate after menopause. This hints at a relationship between autoimmunity and reproductive hormones. Unfortunately the relationship is not yet clear. Meanwhile, those with these issues should talk to their Gynecologist about navigating through menopause in a way that minimizes difficulty and risk. 

The second has to do with lupus, a condition which I have. New research indicates that a gene called “ Toll Like Receptor 7 (TLR-7) ” may be involved. Normally, only one copy (allele) a gene is active in a given individual. However, in lupus patients the second copy of TLR-7 does not deactivate as it should. The normal role of TLR-7 involves activation of type 1 interferon signaling which is critical to antiviral immunity. However too much of this powerful immune response can be damaging. Lupus nerds stay tuned with cautious optimism. 

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

Medical Monday: Delayed Edition

Policy has marched on, despite my delay. Last week, the Graham Cassidy Bill to replace the Medicaid Expansion with State Block grants fell with a thud without even being brought to a vote. This is because it did not even have enough Republican support. 

Early in the week, the Secretary of the Department of Health and Human Services resigned amidst constroversy. He was criticized for his extensive use of taxpayer funded charter flights. He was, by those in the medical community, not considered to be a friend of health care. He was viewed as a political appointee there to tow the party line. 

Most recently, Senator Bernie Sanders has revealed that this administration has been giving consideration to cutting Medicare as well as Medicaid. Medicare is the Federal Health Insurance Program for the elderly and the disabled, which Medicaid is the health insurance program for the poorest sector. Democrats allege these cuts in health care for vulnerable populations would be used to finance tax cuts “for the rich”. 

Premium prices for those purchasing health insurance through the ACA will most assuredly increase. Some increases will be more than 50%. This increase in cost of insurance premiums is NOT based on any definite information of federal subsidies reductions. Instead it is based on the THREAT of reduced or eliminated subsidy payments. Uncertainty and instability from the Federal government is causing insurers to raise prices, and is causing in insurance commissioners to allow them to do so. All premiums for all insurance plans are likely to rise. 

Prescription drug prices are likely to rise. The FDA (Food and Drug Administration) Commissioner Dr. Scott Gottleib, has declared that these high prices are a public health concern. In response, he has indicated a commitment to “more efficient generic drug development, review and approval”. 

Such uncertainty means hospitals and insurers will be unable to predict their income. This is causing them to take conservative positions across the board. This has also resulted in the closure of many rural hospitals, and the closure of maternity units within otherwise operational hospitals. More than half of all rural counties to not have a a prenatal clinic or Ob care facility. 

As discussed previously, several states have taken matters into their own hands. A red state, Utah, is fielding a proposal to expand access to birth control for low income women. Utah State Representative Ward has cited patient autonomy and cost savings as the driving benefits behind the bill. 

The morning after pill, widely considered in medical circles to be utterly safe, is now being dispensed from vending machines on certain college campuses. 

Massachusetts is considering a bill ensuring the provision of free birth control. This bill required the input of the third party payers, the insurance companies, as well as reproductive health advocates. It is expected to pass. 

In medical news, I am happy to announce the official eradication of infant and maternal tetanus. This infection once killed 10,000 newborns per year in the Western hemisphere. This has been at least in part due to the successful vaccination program using DPT in the past, and TDAP more recently. 

TDAP stands for tetanus, diphtheria, and acellular pertussis. Pertussis, also known as whooping cough, is a bad nuisance for healthy adults. However, it can be fatal in infants. All pregnant women are encouraged to get a TDAP booster in the third trimester. This turns out to confer 90% pertussis protection to the newborn. However, only half of all pregnant women got the vaccine. 

Confirmed: hormone containing IUDs do not adversely impact breastfeeding. A new study confirms what we would already expect. We expect this because hormone containing IUDs do not send hormone into the greater circulation; only to the lining of the uterus itself.  This is also the reason why they do not confer systemic side effects. 

In the bad news department, the CDC (Centers for Disease Control) report that sexually transmitted diseases are at record highs, for a second year in a row. This includes Chlamydia, gonorrhea, and syphilis. This is attributed to budget cuts impacting screening and treatment clinics but also to better testing methods. Chladmydia is soaring in women, while syphilis is most prominently increasing in gay and bisexual men. 

Much needed increased attention is being paid to post partum depression. I attended a conference today where it was highlighted that depression in this case is really a misnomer. The most common presentation of postpartum depression is anger or anxiety. A new study highlights that post partum depression is 27-47 times more likely to recur in a patient who has had it once. Postpartum depression has good treatments. More awareness and aggressive screening in the early post partum period is our best defense. 

Now we are up to date ! Stay tuned for more exciting news from the world of Obstetrics and Gynecology , here, next week, on Medical Monday.