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: 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.

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

As the northern hemisphere encounters fall and winter weather, mosquito activity and the risk of Zika infection by mosquito falls but does not go to zero. Of course, sexually and birth related (perinatal) transmission are not affected and can continue unabated. 

Researchers at the University of California, San Diego, have honed in on the mechanism of action of the Zika Virus on human cells. It appears that Zika virus alters our RNA directly. 

We now know that Zika can persist in vaginal secretions for two weeks after onset of infection. During this time, a woman can pass infection on to a partner. Additionally, it has been determined that Zika is detectable in serum ( the liquid portion of blood) for a week. However it is present in whole blood for at least 80 days. These insights have been made possible through the contribution of one particular patient infected with Zika since the beginning of the epidemic. Through frequent and repeated testing on her, we have been able to ascertain these findings. We use a debt of gratitude to this female Zika patient who has allowed herself to be the subject of invasive scientific study since the beginning of the crisis. 

Everyone has heard of menstrual migraines. Some happen right before the period and some happen during the period. Those preceding the period are believed to arise from sharply falling estrogen levels. It turns out that the late-cycle migraines may be related to low ferritin levels from the blood loss of the period. This could lend insight into prevention, which of course might involve ongoing iron supplementation. 

In the things-we-already-knew-but-had-not-yet-been-conclusively-documented department, research published on the Arthritis Care and Research site indicated that systemic lupus wanes during pregnancy and flares in the postpartum period. Nonetheless, the research is quite welcome in that it sheds concrete insight into the baseline mechanisms of lupus and autoimmunity in women. Autoimmune disease as a whole is prevalent and predominantly affects women. Most patients are on current treatment strategies which decades old and are rife with significant side effects. This lupus patient applauds any sound research into autoimmunity in general and lupus in particular. 

Also in this same journalistic department we are now assured that smoking and alcohol are linked to 11 of 15 of the worst cancers. By worst, we mean those cancers most "responsible for premature death and loss of healthy life years”. Any second year med student can assure you conclusively of this. 

Pediatricians are being encouraged to change their counseling of parents about the HPV (Human Papilloma Virus) vaccine. Instead of highlighting the prevention of sexually transmitted HPV infection which can lead to warts, they are being encourage to highlight the cancer prevention aspects of the vaccine. It would be nice if we could simply explain that the HPV virus causes genital warts, precancerous changes on the cervix, which can then develop into cervical, vaginal, penile and even oropharyngeal (mouth and throat) cancer. I am tempted to think that we oversimplify subjects too much for people. People are capable of understanding a great deal if someone takes the time to explain it to them. 

In related news, new data has demonstrated that those children who obtain the HPV vaccine before 15 years of age only need two shots rather than three. Even more incentive to gets your kids done ! 

New research from the Agency for Healthcare Research and Quality have show that the C section rate for low risk patients is about 16%, whereas the C section rate for high risk patients is about 76%. Intellectually, I am a splitter rather than a lumper. Consequently, thinking about C section rates in this way is much more useful that saying, the C section rate in the United States is about 32%. I think information presented in this way will help patients understand their own risk factors, and how to prospectively stack the deck in their favor in the future. 

Here is some sobering but critically important news that I suspect will be woefully underreported. Maternal body mass index (BMI) is inversely correlated with newborns’ telomere length. Whoa, what does that mean ? Basically, the heavier a mother is, the less robust her newborn’s DNA strands will be. DNA is protected at it’s ends by segments known as telomeres, and when they are short, DNA is more apt to be damaged. Shorter telomeres means shorter DNA lifespan, which most likely means shorter lifespan overall. 

We have all heard by now of the micro biome, which means the healthy or not so healthy populations of bacteria and other organisms that populate our body. Women mostly focus on the micro biome of the vagina, knowing that if it becomes disturbed, yeast or bacterial vaginosis can result. However, the vagina is not the only concern. It turns out that the breast has a micro biome. Moreover, it turns out that breasts sampled and found to have benign disease versus those with cancer have very different micro biomes. This could be a clue to something, I’m not sure what. But is is a new and interesting concept. 

In disappointing news, the CDC (Centers for Disease Control) reports that rates of common sexually transmitted diseases have reached all times highs. This include syphilis, gonorrhea, and chlamydia. I’m going to give a shout out to bad parenting and network TV here. Thanks so much, guys. Oddly, syphilis was at an all time low in 2001, and gonorrhea was as recently as 2009. 

In surprising news, 43% of those with no type of health insurance could qualify for either Medicaid or coverage through the Affordable Care Act exchange. The reasons for this are unclear. I will say that some people seem to have quite a bit of trouble filling out the forms online. I have joked to my office staff that the government  should outsource both health care and the elections to reliable companies like Amazon or Google who can design a nice reliable website. 

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

Structure Sunday: STI testing in Prenatal Labs

You've no doubt heard of or gotten a prenatal lab panel. The panel includes a number of tests for infections that might have an effect on mother or baby during the pregnancy. 

For most common infectious diseases, like the flu,  you know you have it almost right away. Others can be carried silently for years, and what we test includes them. If we know about them, we have a chance at treating them before they can cause harm to mom or baby. Learn more HERE.