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. 

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

We start with encouraging policy news. Republican Kevin Brady of Texas, Chairman of the House Ways and Means Committee, has asked that Congress “ immediately provide funding for subsidies to insurance companies to keep insurance premiums affordable for subscribers in 2018. This is a provision of the current law of the land, the Affordable Care Act (ACA) . It basically means that, under the Affordable Care Act, the Federal Government pays a good chunk of the originally high insurance premiums to keep them affordable for consumers. I can appreciate Texas Representative Brady’s concerns. Health care is a huge focus in his ethnically diverse state, which is part of the so called "fat-belt", and also has the highest maternal mortality rates in the Union. Keeping his poorer constituents in health insurance costs federal tax dollars to be sure. Yet these subsidies will go to provide low priced preventive measures which will in turn prevent high priced diseases. Chairman Brady knows that beyond Texas, America, the economy and the budget cannot afford for these people to lose their health care. 

In other encouraging policy news, the board of pharmacy in New Mexico has ruled to allow pharmacists to write for oral contraceptive pills. This way, most of the time, a woman will not have to visit a physician to obtain a prescription. Physicians, especially Obstetricians and Gynecologists applaud the measure since it removes barriers to contraception, and because the safety profile of oral contraceptive pills is so good. 

Delaware has had its share of abortion restrictions, including waiting periods, parental consents, provisions that there need be maternal risk, fetal abnormalities or rape, etc, etc. However Roe vs. Wade established in the 1970s that abortion is permissible until viability, and that remains the Federal Law. Delaware recently rescinded all of of these and simply reinstated the consistency of its State Law with existing Federal law. 

Connecticut failed to pass a bill to insure, on a statewide basis, the coverage of women’s health care services through insurers operating in their state. The bill tried to ensure 21 essential benefits for women, including breast cancer screenings. The bill passed the Connecticut Senate unanimously, but died on the floor when attempts were made to amend it pursuant to abortion. Hopefully it will be edited and brought forward again, in a way that will get results. 

New York is working to safeguard coverage in their state. They have drawn up their own plan to ensure the 10 basic benefits as identical to those in the ACA, which include prescriptions, hospitalizations and maternity care. 

States handle health care for their low income populations through either the ACA or Medicaid. This was possible in part due to the Medicaid expansions that took place under the ACA. A new Kaiser Family Foundation report has shown that fully 71% of Republicans, 93% of Democrats, and 83% of Independents feel that this Medicaid expansion funding should continue. Countrywide, Medicaid covers 70 million low income children, pregnant women, disabled and elderly. I do not think, especially after seeing this data, that the American people are grudging about this expenditure of their tax dollars. They do want to know, however, that that those dollars are buying them something. There is a burden on government and the medical profession alike to demonstrate with data how Medicaid dollars spent on routine care save huge monetary and societal costs later. In the field of Obstetrics and Gynecology, this sort of research has been done. For example, it has been shown that birth control is the best value on the dollar anywhere. 

Medical Monday will conclude there for tonight, at the end of our policy section. Tomorrow I will tackle the medical news, as tonight has gotten rather short. 

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

It turns out that Dr. Peter Hotez, the Dean of that National School for Tropical Medicine has been thinking about the interplay between Hurricane Matthew and the Aedes mosquito which spreads Zika. His informed speculations were that the Hurricane could provide an initial respite from the mosquitos, being essentially blown away by the tremendous winds. However, the enormous amount of standing water afterwards would provide ideal breeding ground for the virus carrying mosquitos. 

Though the Federal government has passed a limited Zika funding measure, the bulk of the costs have fallen on States. The 1.1 billion dollars recently approved requires the development of a spending plan which the Department of Health and Human Services are required to complete by the end of the month. One hundred and fifty two million will go toward vaccine development. The rest will go to local labs to speed up testing, as well as for prevention efforts like mosquito control, and education campaigns. 

Much of the press about Zika focuses rightly on its effects on pregnant women, namely microcephaly and other severe effects on the fetal and neonatal brain and nervous system. However, Zika virus effects non- pregnant women and men by increasing their chances of Guillain Barre Syndrome, post viral paralysis. In the recent new wave of such patients, 97% of these patients had symptoms of Zika 4 weeks prior, further cinching the relationship of the virus to the syndrome even further. 

At least 808 pregnant American women have Zika. It is likely that there are many more since the infection can be asymptomatic, and testing results are much delayed. Physicians and Institutions are trying to ready themselves for the increase in special needs children which will come as a result of the Zika epidemic. 

New Zika recommendations indicate that both men and women wait six months to get pregnant after Zika exposure. 

In other virus related news, studies have shown that parents are more likely to ask for HPV ( Human Papilloma Virus) vaccine to be given to their children if their child’s caregiver discusses it with them in a certain way. In particular, if caregivers highlight the parent’s role in preventing HPV infection, parents are more likely to agree to the administration of the vaccine. HPV vaccine is grossly underutilized. Researchers and physicians are trying to increase HPV vaccine utilization rates by funding the vaccine with others and by giving it in school based programs. HPV is a virus which causes serious and sometimes fatal disease processes ( cervical cancer)  for which there is an effective vaccine. Yet many will not utilize it. Once we are fortunate enough to have a Zika vaccine, I wonder if some will decline that too. 

Speaking of inadequate utilization of vaccine, over half of millennials do NOT plan to get the flu vaccine this year. Half of these people do not believe it is effective and 29% think it will give them the flu. The data do not bear out these concerns. 

Here is some bad news that is, at the same time, interesting and useful. First, people in most modern countries gain weight during the holidays. The amount and time frame varies by country. In the US, our weight is at its lowest in October, right after summer, and increases in the ten days preceding the holidays. It appears that holiday related weight gain, regardless of country, takes about FIVE months to lose. That’s right people, gain it in ten days, lose it over five months. 

In other bad but fascinating and hopefully helpful news, stress contributes to aging in a very particular and profound way. A large human DNA study has demonstrated that “ adverse events in childhood ...hasten …telomere tear down." I once read telomeres are the protective shoelace tips to our DNA shoelaces. Telomeres keep DNA from fraying as it were, and this prevents premature aging. They were able to determine that each significant stressful event in a person’s life increases the risk of shorter telomeres by 11 percent. DNA codes for what we are… in a very immediate tissue sense of the word. Damaged DNA leads to all kinds of diseases including cancer, and basically the failure to heal and renew properly. We have to start taking the prevention of childhood stress much more seriously. 

State Medicaid expansions are most costly than previously anticipated. This is because more qualifying patients have signed up, and they are sicker than had been anticipated. This should be cause for increasing the funding to the expansions, says this fiscal conservative. Why ? It is because preventive care and treatment that is earlier rather than later ALWAYS is cheaper in the long run. Never mind that it is more humane and the ethical thing to do. 

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