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

In policy news, President Trump has publicly declared the Opioid Crisis a “Public Health Emergency”. In concrete terms, this means that Medicaid money can be used to combat the problem. Trump also explained it also meant there would be money spent in an effort to develop non-addictive painkillers. Thirdly he indicated that there would be an advertising campaign to address the problem. 

The idea about non-addictive pain killers is interesting to me. I do not view the opioid crisis as an issue of pain control. I view it as an issue of coping with life. Opioid use may start with need for pain control, but then abuse and addiction develop later from different factors. The FDA( Food and Drug Administration) Commissioner Scott Gottlieb as recommended MAT, or Medication assisted therapy, which combines medication treatment of addiction with counseling. 

An undocumented 17 year old at 16 weeks of gestation has succeeded in her appeal to obtain an abortion. Since September, this undocumented immigrant has been detained in a federally funded shelter and has been requesting an abortion. Her case has highlighted the fact that the Trump administration has quietly changed policy on the matter, and now denies abortions to minors in custody. The particular memo is in an email from E. Scott Lloyd, director of HHS (Health and Human Services) Office of Refugee Resettlement. It states “…government funded shelters… should not be supporting abortion services pre or post release; only pregnancy services and life affirming options counseling. “ The position of the Justice Department on the matter was that it did not dispute the Constitutional Right to abortion. However, it asserted that it was not obligated to facilitate abortion by releasing her from federal custody. In order to obtain an abortion, she could either leave the country or find a custodial sponsor. Some accused HHS "anti-abortion zealots" of “holding her hostage” to prevent her from obtaining an abortion. E. Scott Lloyd was an avowed and zealous anti-abortion activist before he was appointed by the Trump administration to the Department of Health and Human Services. 

The lawsuit against the Trump administration over the plan to end insurance subsidies was denied by a US District Judge Vince Chhabria. At issue was whether the cessation of subsidies would cause immediate harm to consumer. Somewhat ironically, the Judge argued that since many States had, on an emergency basis, anticipated and provided for shortfalls, that no immediate harm would come to pass. This decision, of course, simply sanctions the transfer of insurance expenses from the Fed to the States, who are variably able to afford them. The Judge also wrote that it was a “close case” and that it was in an “early stage”. 

In medical news, it is once again confirmed that the teen birth rate and the US abortion rate fell during the years of the ACA (Affordable Care Act). The US teen birth rate has fallen to its lowest rate since the 1940s. The abortion rate fell the fastest among American teens. Evidence points to contraceptive availability as the cause of the decreases. 

At the same time, use of fertility treatments has doubled in the past decade. Twelve percent of reproductive aged women use these services. 

Yet another case has been added to a list of cases of babies who have developed a life threatening infection after water birth. While ACOG ( American College of Obstetricians and Gynecologists) supports water labor, it does not support water birth where there is  potential for babies to inhale not only water, but particulate matter such as non-sterile blood clot and fecal material, not to speak of whatever else in is the pool. Readers should remember that human lungs are not made to accommodate water, even sterile water or saline. Amniotic fluid may look like water, but its chemical composition and properties are far different. 

In the troubling and should-be-easy-to-fix department, we consider US Maternal Morbidity and Mortality. The CDC (Centers for Disease Control) identifies maternal deaths through death certificates. Death certificates are very short documents and do not allow for elaboration. This limited source of information does not allow us to calculate the true rates of maternal mortality or late complications, much less to determine which deaths were preventable. Being simple and brief, these forms foster a gross under-reporting. Surely a more informative digital cloud based solution could be devised. 

Texas continues to struggles with a crisis in maternal morbidity and mortality. In particular, African American women are dying or pregnancy and birth related complications at an alarming rate. These women account for 11.8% of Texas births, but 29% percent of Texas pregnancy and birth related deaths.  Experts believe potential causes relate to obesity, poverty, diabetes, delayed prenatal care, higher C section rates which result form these other factors, drugs, hypertension and related cardiovascular problems. 

In major scientific news, result of the OncoArray Consortium have been published. This is a global project wherein 550 researchers shared genetic data from 300 institutions and 275,000 women, 146,000 of whom have had breast cancer. The work, published in Nature and Nature Genetics, has identified many more previously unknown genetic mutations associated with breast cancer. We have long suspected and counseled patients that BRCA1 and BRCA 2 are probably not the only cancer mutations. Now we have specific confirmation on this. While these results may initially seem daunting, they are the kind of data that can lead to better “precision" methods of diagnosis, prevention and treatment in the not so distant future. 

Reader should take note of the multilaterally of this OncoArray Project. The non-academic person understands that research studies take money, time and test subjects. They also understand that more money, subjects and time mean higher quality results. One might ask then why has it taken this long for researchers the world round to combine resources to get truly powerful results ? Indeed perverse incentives have, until recently, been in place to silo, hoard or hide data, one researcher from the next, or one institution to the next, in a climate of competition for research dollars and accolades. Even at present, the open date movement is not mainstream among researchers, nor is the idea of sharing medical record information including genetic information popular among patients. There are costs to sharing data, but the benefits may well prove to be greater. 

Did you know that there are various sizes and types of IUDs ? There is most likely one that is suitable for everyone, including teens, women who have not had children, and women near menopause. Many misconceptions about IUDS arise among patients and caregivers. For example, we used to believe that IUDs prevent implantation of a fertilized egg. However, ACOG now recognizes that IUDs prevent fertilization. Many who oppose a method which fosters non-implantation of the fertilized egg will be comfortable using this method knowing its mechanism of action. 

“Vaginal seeding” is the deliberate transfer of a mother’s vaginal flora to the infant’s nose mouth or skin. This procedure is under research investigation and should not be attempted at home. Women who undergo C section may have an interest in this as their newborns have not been exposed to vaginal flora like an infant born vaginally would have been. There are very real risks to vaginal seeding, because, as with many things, the devil is in the details. It turns out that vaginally born and cesarean born babies microbiota are slightly different, but that they equalize after about 6 months. It also turns out that breastfeeding provides the best and safest transfer of flora.

Stay tuned next week for more fascinating news from the world of Obstetrics an Gynecology.   

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

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

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

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

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

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

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

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

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

On to the medical news. 

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

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

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

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

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

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

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

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

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

In policy news we find more of the same. Texas again figures prominently, so much so that I have decided to create a new category: Texas news. Texas is an unmitigated perinatal disaster and is an embarrassment to this country, particularly to its medical establishment. But make no mistake, if current trends in law and politics are any indication, women's healthcare in every state will be like Texas.

To wit: a new study through the Commonwealth Fund has shown that one quarter of working age Texas women still lack insurance of any kind. A significant percentage of those who are insured struggle to pay medical bills and admit to having skipped needed care because of cost. Texas did chose not to expand its Medicaid, and this is believed to be one of the causes for these phenomena.

Also in Texas, ordinary standard insurance does not cover abortion. A new bill passing the Texas House will require women to buy supplemental insurance coverage for this procedure. It also increases reporting on complications after abortion and on the incidence of minors receiving the procedure. 

Finally in the Texas news, the Texas physician Dr. Brett Giroir, a Pediatrician, has been nominated for assistant Secretary of Health at the Department of Health and Human Services. However, Democratic Senators have delayed his confirmation on concerns that he would not support women's health programs. And they wonder why Texas is in the state it's in.

The Trump administration has cut funding for the Texas Teen Pregnancy and Prevention Program. Now it proposes eliminating funding for all such programs across the country. Moreover the fundamental research for the Teen Pregnancy Prevention Project is situated at Texas A&M University and theses researchers have recently been notified that their funding has been cut.

In Texas, Planned Parenthood has been barred from receiving Medicaid reimbursement. As a result the number of comments coming in to the Center for Medicaid Services (CMS) have doubled from 9,000 per week to 18,000 per week. According to the Center for Public Policy Priorities this will remove healthcare access from 45,000 people.

In the good news department, a bipartisan group of high ranking Senators are trying to strengthen existing law regarding health care. They are recommending that the Federal government continue paying subsidies, and that all Americans enroll in coverage. They also recommend renewal of the Children’s Health Insurance Program. Even Senate Majority Leader Mitch McConnell has said that he would consider such a bipartisan effort to shore up subsidy payments to insurers to stabilize current insurance markets.

In the medical news, one is seven women experience anxiety or depression in the first year after giving birth. This remains vastly under-diagnosed untreated with only 15% of those affected seeking help. Obstetricians have been alerted to increase screening for these debilitating conditions. 

In other concerning news, the team suicide rate among girls has reached a 40 year high. This is according to a new report from the Centers for Disease Control and Prevention published this last week in the Morbidity and Mortality Weekly Report. As of 2015 it sits at about 5 per 100,000. 

Preterm birth has continued to be a significant perinatal problem and one that has been resistant to explanation and treatment. However, new research published in Obstetrics and Gynecology has indicated that sleep disorders may play a role in some cases. Data from over three million birth was studied, with conditions like apnea and insomnia being tied to preterm birth. 

New research indicates that risk of stroke is decreasing for men but not women. Stroke risk is related to the incidence of several medical conditions, including obesity, smoking, high blood pressure, diabetes, and high cholesterol. These conditions are on the rise among women. 

Physicians and patients, listen up: Physicians are doing a BAD Job at educating patients about marijuana use in pregnancy. Increasing State legalization has led many to believe marijuana is entirely safe under varied conditions. (Since when do we believe what politicians have to say about science and medical care ? ) This has not been substantiated. According to researchers at the University of Colorado in Denver, the data available is limited, and sometimes flawed. However, there is “ moderate evidence that the use of marijuana in pregnancy is associated with increased risk of reduced fetal growth, lower IQ scores in young children, adverse effects on a child's cognitive functioning and academic ability, an increase in attention problems” There may also be associations with low birth weight and preterm birth. Patients need to be honest with their caregivers, and caregivers have to help patients to meet their needs some other way than to use marijuana.

Stay tuned form more fascinating and important news from the word of Obstetrics and Gynecology, next week, on Medical Monday. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medical Monday: Delayed Edition

After I got my diagnostics squared away, I discovered ACOG’s ( American College of Obstetrics and Gynecology) news site was down. Members like me have access to their news and research paper aggregator. I use it as my starting point for creating your news digest blog post page Medical Monday. Finally, all is well and we have some catching up to do. 

GOP leaders have once again announced a deadline for a vote on their health care plan, the American Health Care Act (ACHA). The deadline is to be the end of June. However, as of this writing, there are still significant disagreements over the particulars. Moreover, the drafting of the bill has now gone behind closed doors. This has met with consternation not only from Democrats but from Republicans too, since such interested stake holders cannot have a say or even see what is going on. 

The Department of Health and Human Services, (HHS) has a nonpartisan economic unit called The Office of the Actuary. According to a recent analysis done by this office, adoption of the ACHA would cause out of pocket expenses to rise about 61%. This means premiums and deductibles would rise 61% for the consumer. While the real cost of the premiums would be somewhat lower, the government subsidies to defray them would diminish, leaving the consumer to pay the difference. The current administration wants to pay less, and wants we consumers to pay more. Remember that the government’s money is really our money, collected in the form of our tax dollars. While about 29% of the American public supports the ACHA, it is not formally supported by a single State government. This is because the Fed is trying to do to States what it is doing to us. It is trying to shift more of the financial cost of health care off of itself and onto the States. If the current administration succeeds in shifting health care costs to the consumer and the States, it will claim it is saving taxpayer money.

Many of you are already aware that Texas is facing a crisis in maternal morbidity and mortality. Concern is mounting that the crisis will only get worse if the ACHA is passed, since it will reduce already limited funds for the care of women and pregnant women. 

Business leaders are starting to register concern about the looming changes in health care. In particular, the cancellation of the contraceptive benefit is projected to have huge economic and social repercussions for American families, such as spikes in unplanned pregnancies, and ripple effects though the workplace. A statement by Allan Peace of Trillium Asset Management notes that “ institutional investors… see compelling evidence that widespread access to sexual and reproductive health care benefits” promotes  the “interrelated outcomes” of women having greater control over their lives and the facilitation of economic growth. I would add that this has been demonstrated not only domestically, but around the world. Yes, prosperity and the status of women are directly related. 

In the good news department, Maine is the next in a line of States taking matters into their own hands. They have passed legislation requiring insurers to pay for up to 12 months of birth control at a time, and have prohibited insurers from charging copays for birth control. They cited data from California indicating that the unintended pregnancy rate fell by 30% when they enacted similar measures. Twenty eight states now have some sort of contraceptive equity law, aiming to make contraception very affordable or free. Let’s hope we get 50. 

The Royal College of General Practitioners has presented research again confirming that oral contraceptive use does not confer increased long term cancer risk. 

In further good news, the City of San Francisco has spelled out clearer rights for breastfeeding women in the workplace. This includes the stipulation that employers provide a clean private space with electricity, a surface and a chair. 

In medical news, Zika is back. Zika is a virus carried by the Aedes Aegyptae mosquito found from the southern US southward. When contracted by pregnant women, it causes serious malformations in the nervous systems of developing babies. 1900 women in the US have had confirmed Zika infections. The proposed White House budget proposes an emergency fund for Zika but would also cut billions from budgets of the National Institute of Allergy and Infectious Disease and the CDC (Centers for Disease Control) where work is underway on a vaccine. The first cases of the 2017 Zika season have come in from … Texas. 

A new study confirms from JAMA Pediatrics indicates that even small amounts of alcohol in pregnancy may result in babies with slight facial abnormalities. 

Obesity (BMI of 30 or more) is a huge problem. However being overweight (BMI 25-29) takes its toll as well. New research published in the New England Journal of Medicine indicates that, worldwide,10% of people are overweight. Altogether 30 % of the world are affected by weight problems. The US leads the world in obesity in children and young adults. The US also has the greatest number of obese adults. Excess weight accounts for 4 million deaths worldwide, seventy percent of which are from cardiovascular disease. 

A new and large study from Sweden indicates that the risk of major birth defects increases proportional to the severity of a mother’s obesity. These patients are also at greatly increased risk of hypertension ( high blood pressure ) and diabetes. 

That gets us up to date with the news from the world of Obstetrics and Gynecology. 

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

This week, the health care sector spent most of its time digesting the health care policy news from the end of last week. Reactions are coming in regarding Theresa Manning, Trump’s head of Title X family planning program. Here is a woman who criticizes the American College of Obstetrics and Gynecology (ACOG) on its endorsement of Plan B, the morning after pill, and who openly claims that contraception doesn’t work. 

Did you know that 22% of pregnant Texans under 18 have had multiple children ? Texas, the State recently enacting several curtailments to women’s reproductive services, is now grappling with it’s varied distinctions such as having sky high maternal mortality rates, and the highest repeat teen pregnancy rates in the Union. In a near comical about face, Texas is now considering a bill to provide free contraception to minors without parental consent. They have just now figured out this will reduce maternal morbidity, mortality, abortion rates and Medicaid costs. WOW. 

Reactions at a town hall meeting on New Jersey were quite clear, as participants boo’d their elected Senate Representative Tom MacArthur as he explained that rape victims could potentially be excluded from coverage. Talk about adding insult to injury. 

Pregnancy stands to be much more expensive under the ACHA. Those with prior Obstetrical complications such as C sections may fall under preexisting conditions and be charged exorbitant premiums. 

Senate Conservatives plan to drop millions of adults from Medicaid, which they say will reduce health care spending. They had originally said that tax credits instead would help people pay for health care, but now they wish to limit those on the fear that some may use their tax credit cash to pay for abortions. Paranoid much ? Moderate Republican Senators wish to keep the Medicaid expansion, citing it’s many benefits to their States. 

The Congressional Budget Office still appears to have teeth. They are the nation’s bean counters and they have yet to weigh in with REAL FACTS not #alternativefacts on how much the current administration’s ACHA (American Health Care Act) health care proposal will cost. This will include not only the cost of the insurance, but the uncovered health care costs incurred by those who lose their insurance. Polls show support of the ACHA is waning, and is down to around a third of Americans. 

A new study has shown that the credit card debt jumps for women but not men after a year of major medical expenses. Combine this with the fact that women have, on average, 20 % less income and spending power compared to men. Still ? 

As the weather gets warmer, Zika is back in the news. The CDC is now recommending all women at risk for Zika get a baseline Zika blood test. Once pregnant, they are to be retested every trimester. The CDC anticipates that this proactive schedule of testing will unearth many more cases of Zika this year. 

Hepatitis C has tripled its incidence between 2010 and 2015. Federal officials feel that the heroin epidemic is driving this. Among pregnant women, the infection rate has doubled. 

Perhaps in response to all the anti-contraceptive politics or perhaps for a variety of other reasons, the use of LARCs (Long acting reversible contraceptives such as IUDs) has increased seven fold between the years of 2008 and 2013. These are considered very good but still  underutilized methods. 

A new study presented at the annual meeting of the Association for Research in Vision and Ophthalmology states that marijuana smoked by pregnant women could damage the retinas of unborn children. The study utilized an animal model which showed this effect. 

Research presented at ACOG’s recent annual meeting indicated that patient information presented on Society Websites is too advanced for patients. These education materials do not meet the so-called health literacy standards, which are meant to ensure that information reaches it’s target. This is of particular concern to me as medical writer whose aim it is to convey information to a lay public and to my patients. 

What do you think ? Would you rather information be a little too simple or a little too complex ? It is quite hard to get it just right. 

Stay tuned for more breaking news next week on Medical Monday. 

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

Greetings from the heart of Silicon Valley. Please excuse the blog silence over the last few days as, believe it or not, I have suffered from sporadic Internet connection. I have been attending a very busy conference, Stanford MedX, on which I will fully brief you later. I could not blog at the conference but I took a lot of notes and pictures and they will serve as the basis for my reports to you sometime late on Wednesday. Where I stayed was a beautiful residence deep in a grove of old-growth trees so dense that it interfered with us cellular and local Wi-Fi coverage. So I right now without pictures, I will make this dispatch to you because I think medical Monday is so important. Text will go, but pictures will have to wait.

Some continue to doubt the association of the Zika virus infection with the development of microcephaly. However this latest study should put this to rest. The Journal Lancet Infectious Disease reported work that studied newborn Zika babies both with microcephaly and without. It turns out that babies with microcephaly we're 55 times more likely to have been infected with the Zika virus in utero. However, none of the 62 newborns in the comparison group who appeared normal showed any sign of infection.

Of chilling significance is another story published the Journal of Emerging Infectious Diseases. Those authors note that "for infants about four months and up to eight months of age" babies were "born on average on measures of weight length and head circumference" but "fell even further below average as time passed".

The CDC (Centers for Disease Control and Prevention) has now indicated that Zika virus can spread through "contact with bodily fluids such as tears, discharge from infected eyes, saliva, vomit, urine or stool." This has obvious implications for those living with and caring for those affected by the Zika virus.

Florida may offer free Zika virus testing, but that does not mean women are getting results. Apparently results that take a private lab a few days to report are taking weeks for the state run service. Time is of the essence when inquiring about Zika virus infection in pregnancy, since many women consider the option of abortion if there is evidence that their baby could be or is infected. Access to abortion is more restricted in what now could be called the Zika belt of our country.  Women consider this drastic measure because central nervous system manifestations of Zika virus in pregnancy are often devastatingly severe. We now know they're also potentially progressive even after the baby is born.

A recent poll suggests that the risks of Zika virus to pregnant women have caused some Americans to soften their view on abortion. 62% of voters living in the 10 battleground states in the south and along the Gulf Coast have said that they "support abortions after 24 weeks if a doctor believes there is a serious possibility that a woman's fetus could have severe birth defects from the Zika virus."

As of this writing the funding to combat the Zika virus is virtually spent. The Obama administration as well as the CDC, the American College of Obstetricians and Gynecologists and others have appealed to Congress to put aside partisan politics and fund the fight against the crisis

It is worth reiterating news from last week coming to us from the Zika belt state of Texas. Texas maternal mortality spiked from 18.6 maternal deaths per 100,000 live births in 2010 two more than 30 per 100,000 into thousand and 11 and remains at that level through 2014. This statistic may not seem huge but it has increased dramatically and is a higher rate than anywhere else in the country. It is also higher maternal mortality rate than in most other industrial countries. Numerous writers, ACOG and the State Heath Services of Texas maternal mortality task force all recommend an increase in health care services to women as the solution.

Global maternal mortality rates are not where they should be. The United Nations sustainable development goals (SDG) indicate the rate would have to fall by nearly 70% to meet the target globally of 70 maternal deaths per 100,000 live births. It is felt that this should be accomplished by adding an estimated 18 million Women's Health workers including midwives and obstetricians.

A new study by the Urban Institute has indicated that only 31% of women know about the most effective forms of birth control, the LARCs, the long acting reversible contraceptives. ACOG has said that such IUDs and implants are the most effective reversible contraceptives available and are safe to use by almost all women of reproductive age. Of note, weeks ago it was reported that Puerto Rico, which is greatly affected by the Zika virus, had been given a large supply of IUDs but was unable to fully utilize them due to the lack of providers trained to insert them. LARC use in Texas is on the rise.

The rest of the news in brief:

US preventive services task force recommend screening all nonpregnant adults and adolescents at risk for syphilis, which is on the rise.

The British medical Journal reports that pregnant women with higher ambient glucose levels who are not meeting the criteria for gestational diabetes still have an increased risk of complications. These complications would include preeclampsia and overly large infants (macrosomia). Additionally, related complications are noted, such as shoulder dystocia, which is the condition where babies are dangerously difficult to deliver due to a larger girth at the shoulders.

The national Cancer institute is once again encouraging all children adolescents and young adults 26 years of age or younger to obtain the vaccine against the human papilloma virus, HPV. Only 40% of eligible girls and 21% of eligible boys have received the vaccine. Vaccination rates in Australia and the United Kingdom are in the range of 75 to 92%

In the good news and we already knew this department, an article in the Annals of Oncology has reminded us that use of oral contraceptives decreases ovarian cancer risk by 50%. For the record, having children and breast-feeding them also decreases this risk.

In the good news department, The number of Americans without health insurance has fallen to a recent level of less than 10%. This is attributed to people buying insurance on the Affordable Care Act (ACA) exchange.

Stay tuned for more exciting news from the world of Obstetrics , Gynecology, and Women's Health, next week on Medical Monday.

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

As per recent precedent and priority, we start with the Zika news. 

Three of nineteen traps in the Miami area have trapped mosquitos which have tested positive for the Zika Virus. New readers will note that this virus is transmitted to humans through mosquitos bites and sex. If a pregnant women acquires the virus, it often leads to severe brain damage to the baby most notably in the form of microcephaly, which means small brain. It also leads to hearing loss. Dr. Anthony Fauci of the National Institute of Allergy and Infectious Disease Control and Prevention warned that microcephaly may be “ the top of the iceberg” and that the full impact of Zika may not be apparent until they grow older. Thus it is of paramount public health important especially with regards to the care of pregnant and potentially pregnant women. 

Zika virus infection can also increase the risk of post viral paralysis,Guillain-Barre syndrome, in those who are infected. New research published in the New England Journal of Medicine has confirmed the association with Guillain-Barre in seven different countries.

The FDA has recommended that all donated blood be screened for Zika, even in places where the virus is not present. Zika testing is currently expensive and time consuming, but officials feels this is necessary, given the seriousness of the infection and the fact that many Zika infections are asymptomatic. 

The mosquito vector which carries the Zika virus has a territory spanning only part of the United States. For this reason, officials believe the sexual route of transmission may become more important here that mosquito transmission. 

The director of the CDC (Centers for Disease Control) has stated that federal funds to fight the Zika virus will be exhausted by the end of September. It has already spent $194 million of the $222 million it was allocated. Congress must then act to provide funding to fight the virus effectively.

Postmenopausal hormone therapy is back in the news. Current practice is largely dictated by a landmark study called the Women’s Health Initiative (WHI), which was released in 2002. One of the principal investigators of the WHI, Dr. JoAnne Manson, said the “ WHI findings have been seriously misunderstood and misinterpreted. She indicated that the benefits still outweigh the risk for women of average risk for breast cancer." Aye there’s the rub. To calculate risk, you will need to have a good history taken, including a family history, a physical exam, a mammogram, and maybe even a visit to the genetics counselor. The plot thickens. 

Texas maternal mortality rates have doubled in the last four years and no one knows why. Numerous commentators have now published about this, and most have noted the political and funding challenges to women’s health care there and in the whole bible belt. There is serious speculation as to whether slashing funding for women’s health and the increase in maternal mortality is related.  Some would say that amidst the ardor to defund clinics which provide reproductive health care services like abortion and contraception, that Texas has also weakened its ability to care for pregnant women. In effect, Texas may have shot itself in the foot. It is believed that family planning clinics are an entry point into health care for many women of modest means. It is often the place where pregnancy is diagnosed. Without these clinics, prenatal care is delayed or absent. An editorial in the Dallas Morning News indicated that if were Texas a country, it would rank 31st in the OEC (Organization for Economic Cooperation and Development) for maternal mortality.

Unpacking this further we see that this jump in mortality is predominantly occurring in black women. Heart problems, prescription drug overdoses, and hypertensive disorders of pregnancy like preeclampsia (aka toxemia) are the leading causes of death in these women. I can tell you that to properly follow a women with cardiovascular or blood pressure problems in pregnancy is big undertaking. It involves frequent if not weekly visits, fetal monitor strips, serial Ultrasounds, and social support so the patient can rest. Maternal mortality is the worst complication one can imagine. Complications can happen anywhere, but deaths should be a rarity if care is adequate. According to research in the Journal Obstetrics and Gynecology, Texas maternal mortality rates are the worst in the nation and among the worst in the developed world. Truthfully it’s a disgrace. 

In the practicing medicine without a license department, Ohio passed a law in 2011 stipulating that providers of medical abortion had to use a FDA ( Food and Drug Administration) protocol for the doses of the 2 medications involved, mifepristone and misoprostol. Basically the law required them to follow the package insert, or “ the labelling”. This protocol was developed in 2000. By 2003, specialist organizations such as the American College of Obstetricians and Gynecologists and the World Health Organization, found shortcomings with the protocol and recommended changes in the package insert, allowing for the simpler and more effective dosing protocol, but also the evidence based extension of the gestational age for which the drug would be effective, and the ability for women to take the medication at home. However these changes weren’t made due to political reasons.  It now appears that since the law was enacted, women taking the suboptimal dose are more than three times more likely than before to have complications requiring additional intervention, often surgical. In other states without this law, medical providers would simply follow the most up to date recommendations of their professional governing body, including an up to date dosing protocol, regardless of the FDA labelling. This is called “ off-label use” of FDA approved medications. In many cases, in many fields of medicine, off label use is common and necessary to take the best care of patients. Up until May of this year, however, it was illegal to do so in Ohio. I wonder what they did to the rebel caregivers who gave the correct doses ? It would be tough to be a doctor in this climate. If the law didn't get you for off label use of meds, the lawyers could for knowingly giving a potentially unsafe dose of a medication to a patient. 

In May of this year, the FDA corrected the package labeling to reflect the most up to date science on the subject. Regardless of how you feel about abortion, you would not want to give a patient part of a dose of medication to only evacuate her uterus partially, since this can cause hemorrhage and infection !  Dangerous !

You may recall that a few weeks past I reported on the decline in teen pregnancy. At that time we were not precisely sure why. However, now, parsed the data and we have nailed it down. Drum roll please…..It’s…. you guessed it…. contraception !!! It turns out sexual activity did not vary in that time frame. Use of contraception did. It increased from 86% use from 78%. Science !

Perform labor is in the news. The causation of preterm labor has remained a bit of a mystery. To show you how nascent is our science, I present the findings of two recent studies, both retrospective. The first, published in the Maternal and Child Health Journal examined 400,000 births. Resistance to preterm labor seemed to be conferred by three things: birth spacing, optional weight at the beginning of pregnancy, and appropriate weight gain in the pregnancy. Pretty vague, I grant you. Next, is an NIH(National Institute of Health) study of 200,000 women. In this group  they were able to unearth the uncanny fact that women exposed to extremes of temperature early in pregnancy were more likely to deliver preterm. OK. What if they wore appropriate clothing and used climate control devices ? Gosh that is unhelpful information. Whereas, any old crusty Obstetrician can spot preterm labor risk as it walks through the door. She or he might notice the frenzy with which the patient blew in, the smell of cigarettes, the poor nutritional status, or poor dentition (teeth). We need studies which tell us about factors we can change - not the weather ! 

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