A report by Stuebe et al in the November 23/30, 2005 issue of the Journal of the American Medical Association states that there is another benefit to breastfeeding, that being that the risk of developing type 2 diabetes (“adult onset diabetes”) is inversely related to the length of time the mother nurses her infant. This study looked at two groups of women, one a prospective study of 83,585 women, and the other a retrospective study of 73,418 women. Results from both study groups demonstrated a 14-15% decrease in the risk of developing the onset of diabetes later in life, even after controlling for body mass index (a statistical measurement of obesity using height and weight) and other risk factors for developing diabetes.

There are several possible reasons why this relationship may occur. Nursing may increase weight loss following delivery. Nursing may also decrease insulin resistance, and it also may affect pituitary gland hormone production in a fashion that offers some protection against the later onset of diabetes. These studies demonstrated that the longer a mother nurses her infant, the greater the degree of protection against diabetes.

At University Ob/Gyn of Texas, we are committed to helping you have a successful breastfeeding experience for as long as you are willing and able to do so. The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics have suggested that nursing an infant for one year following delivery is a worthy goal for us to achieve, and we agree with that. Not only is it good for your infant; it is probably going to help you reduce your risk for developing diabetes later in life.

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The “Flu” and Flu Vaccinations. November 2005

At this time of year, we are frequently asked by our patients, especially our ob patients, if they should receive the flu vaccine. The answer is a resounding “YES”. The American College of Obstetrics and Gynecology has looked at this issue thoroughly, and it is unequivocally in your best interest and in the interest of your fetus to get vaccinated and to avoid the flu. It does not make any difference which trimester you are in your pregnancy—please get vaccinated. We ordered enough vaccine to be able to vaccinate all of our pregnant patients, and the supply was quickly depleted, so if you are pregnant and not yet vaccinated, please go anywhere there is a supply of flu vaccine and get it. And yes, we recommend that our non-pregnant patients receive the vaccine as well.

The current flu vaccine will not protect you against “bird flu”, and that has not yet been a problem in the U.S. Bird flu has occurred only in Asia, among people who work directly with poultry, and who come into direct contact with bird blood or bird feces. The virus which causes bird flu is not believed to experience air borne transmission to humans. Our concern, and the news that you may have heard about bird flu, is the distinct possibility that that this virus may mutate, especially if it gets to Africa, where animals and humans live in closer contact with each other than they do here. If the virus mutates and can easily infect humans, especially as an air borne virus, then we face the possibility of a worldwide pandemic. Until the virus mutates into a form that will infect humans, then we cannot create a vaccine to protect ourselves against it.

In the interim, it is safe to eat eggs and chicken, and it is safe to have a pet bird in your home? Yes, and yes.

Is it time to worry yet? No, we don’t think worrying ever helps anything. In the interim, get your flu vaccination, cover your mouth when you cough, and wash your hands before eating.

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The FDA and the “Morning-After” Pill. October 2005

The September 22, 2005 issue of the New England Journal of Medicine has an excellent article by Dr. A.J.J. Wood, of Vanderbilt University, regarding the recent (in)decision by the Food and Drug Administration regarding the approval process for emergency contraception pills to be sold over-the-counter to anyone who wishes to purchase them. “Plan B” is the name of the product manufactured by Barr Labs. The drug consists of two 0.75 mg tablets of levonorgestrel, a progestin, to be taken twelve hours apart as soon as possible (usually within 72 hours) of unprotected intercourse, contraceptive failure, or sexual assault. The drug is extremely effective in preventing unintended pregnancy. It is demonstrably safer, in terms of the number of deaths caused each year, than either aspirin or acetaminophen (Tylenol), both of which are readily available as over-the-counter drugs. The advisory committee to the FDA consisting of ob/gyn’s and experts in over-the-counter drug availability, voted 23-4 to recommend that the FDA approve the drug, and the four opposing voters indicated that they did so not because of concerns about the drug’s safety or efficacy. In spite of this advisory committee opinion, the FDA has failed to act to approve the over-the-counter use of this drug.

We can only conclude that political, and not scientific considerations are at work in this instance. The credibility of the FDA has been sorely weakened, and American women are once again pawns of the political process. We think it is time for you to write your elected representatives and voice your opinion.

In the interim, please know that at University Ob/Gyn of Texas, we will be happy to write a prescription for “Plan B” for you to keep in your possession until you can (hopefully) buy it over-the-counter.

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Meconium Aspiration Syndrome and Amnioinfusion. September 2005

The current (9/1/05) issue of the New England Journal of Medicine has an excellent article by Fraser and associates, and an accompanying editorial by Ross, discussing the concept of amnioinfusion as treatment for the fetal passage of meconium discovered during labor. Meconium is the material present in the fetal large intestine that is released about 12% of the time while a patient is in labor. In most instances, this is of no consequence, and why this happens in the first place is not known with certainty, but when there is meconium passage, about 5% of these infants will aspirate this material into their lungs, and if the meconium aspiration syndrome develops, some 4% of these infants may not survive. The study by Fraser evaluated almost 2000 women, randomizing half of them to a treatment group (amnioinfusion) in which fluid was instilled into the uterus while the women were laboring, in an attempt to wash out, or at least dilute the meconium, and a control group in which no therapeutic measures were used. Unfortunately, there was no difference seen in the two groups, indicating that attempts to treat this problem are not helpful.

In spite of this, across the country in the years between ’90 and ’98, the incidence of meconium aspiration syndrome has decreased almost four fold, primarily because we are doing a better job of dating pregnancies early on, and we do not allow women to go significantly beyond their due date. So, when we suggest to you that induction of labor at term is possibly a good idea, especially if your cervix is favorable, realize that we are aware that we may be helping your infant avoid a potential serious complication associated with a post-dates pregnancy.

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Supracervical Hysterectomy. August 2005

Within the last several years, especially due to the increased use of laparoscopy in gynecology, it has become possible to perform a procedure named “laparoscopic supracervical hysterectomy,” which means that the body of the uterus is removed, but the cervix is allowed to remain in place. Forty or fifty years ago, supracervical hysterectomy was commonly performed by general practitioners. However, with the growth of gynecology as a specialty, removal of the cervix, along with the body of the uterus, whether via the abdominal or vaginal route, has become the standard of care for gynecologists. Re-introduction of laparoscopic supracervical hysterectomy into the mix has become touted because of the supposed advantage of leaving the cervix in place to prevent prolapse, to provide for increased sexual satisfaction, and to provide better bladder function. Scientific evidence for any/all of these proposed advantages is not available, nor is it likely to be forthcoming.

Reporting to the annual meeting of the Society of Gynecologic Surgeons, Dr. Wesley Hilger and his associates noted that the rate of supracerical hysterectomy nationwide has increased from 0.7% to 2% between ’90 and ’97. As one might expect, leaving the cervix in place increases the risk that it will eventually need to be removed. Dr. Hilger confirmed these expectations, noting that prolapse of the cervix was the most common reason to require its removal. The development of a cervical mass was the second most common reason to require its removal, and in third place was the development of cervical cancer or its precursor, cervical dysplasia.

At University Ob/Gyn of Texas, we generally find reasons to avoid hysterectomy, but if your condition requires removal of the uterus, we will, with rare exception, remove the entire uterus, including the cervix. Laparoscopic supracervical hysterectomy is rarely indicated in 2005, and we will not leave part of your uterus in place only to have to go back and remove it at some later date.

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Human Papilloma Virus Vaccine. July 2005

Elsewhere on our web site, in the FAQ section, we have information about Pap smears and new Pap smear technology. On the horizon is a new vaccine which may eventually eliminate the need for Pap smears altogether. In Lancet, in 2004, there is an article by Harper et al describing their work with a vaccine against HPV-16 and HPV-18, the two types of the papilloma virus that are most likely to result in the later development of cervical cancer. This study, like others which have preceded it, demonstrates nicely that the vaccine is safe, almost 100% effective in preventing infection with these viruses, and thereby allowing patients to avoid later cervical dysplasia or cervical cancer.

However, whether these vaccines will ever come to market is another story altogether. The vaccines have already generated a political firestorm, because the viruses and the cervical cancer they are capable of causing are sexually transmitted diseases. For the vaccines to be effective, they need to be given to children well before the onset of any sexual activity. There is a formidable lobby organizing against the further development and eventual marketing of these vaccines, because their opponents argue that to administer the vaccine to children is to promote and foster pre-marital and extra-marital sexual activity. Gynecologists have countered by stating that survey after survey in America indicates that the majority of both male and female high school graduates, right or wrong, have already initiated sexual activity, and that we just wish to provide them with protection should they choose to have sex, at whatever time they choose to initiate sexual activity.

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Meningococcal Vaccine. June 2005

As most of our patients know, the relationships that we develop with them tend to be long-lasting over decades. We ask about the accomplishments of the infants we delivered, and seem to learn suddenly that they have graduated from high school and are about to begin their college careers. There are many potential pitfalls that these adolescents can encounter, but being susceptible to meningococcal meningitis should not be one of them.

A recent article in the Wall Street Journal by Tara Parker-Pope highlights the availability of a relatively new meningococcal vaccine, which is uniquely designed to be effective against the 4 prevalent strains of meningococcal meningitis. It is also likely to confer lifetime immunity, with few significant side effects. Last month an advisory committee to the Center for Disease Control recommended that this new vaccine, Menactra, be given to all 11 and 12 year olds before entering middle school. Since the summer camping season is just getting under way, it is also advisable that your teen-agers be vaccinated before leaving for summer camp. Since this is a new vaccine, it would be wise to be sure that your recent high school graduates get vaccinated before heading off to college this Fall, especially since the risk to freshman college students for contracting meningococcal meningitis is increased by 9-23%, especially if they are living in a college dorm setting.

Please check with your pediatrician to schedule your child’s vaccination, or give us a call if you would like us to vaccinate your daughters if they fit into the 11-19 year old category. We have the vaccine in stock in the office.

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Newsletter-Neonatal Withdrawal Syndrome and SSRI's. May 2005

An article in a recent issue of "Ob/Gyn News" by Dr. Lee Cohen discussed the issue of women who need to take anti-depressant medication during the course of a pregnancy, and the potential problems encountered by the newborn after birth. Dr Cohen stresses the fact that what the newborn will experience as a result of the birth process and no longer being exposed to drugs the mother had been taking, such as Prozac, Paxil or Zoloft, ("SSRI"s-selective serotonin reuptake inhibitors) is not at all akin to the adverse effects that an infant would experience if the mother had been using heroin or methadone, and the infant then had to withdraw from those narcotics after being born.

In our practice, especially because we have close relationships with many psychiatrists who refer pregnant patients to us who are on anti-depressants, we have a significant population of women who need to stay on anti-depressants during and after pregnancy because of their history of significant post-partum depression. We know that post partum depression can be devastating, and we have managed, along with their psychiatrists, to successfully manage those patients through a happy and fulfilling pregnancy.

Dr. Cohen's article suggests that whatever withdrawal symptoms the infant may experience, such as "transient restlessness, jitteriness, tremulousness, and difficulty feeding," are usually short lived and are of no long term consequence. We agree. In the case of the SSRI anti-depressants, we know they can be lifesaving, and we feel like the benefits far outweigh the risks with this classification of drugs, and prefer to keep our moms on these medications during pregnancy.

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Reconstructive Pelvic Surgery. April 2005

Within the past few years, the field of gynecological surgery has experienced some rather dramatic changes. Certainly all types of surgery are in constant evolutionary change, but within gynecology, we have made some substantial changes in our techniques for helping women who have difficulty with incontinence of urine, stool, or gas. Previously, surgery to correct these conditions would require a combination of vaginal and abdominal surgery and a lengthy hospital stay, and the distinct possibility that the surgical procedures would be effective for only a decade or so.

Certainly, no one wants to have surgery for a recurrent problem, and today our surgical procedures for uterovaginal prolapse are lasting longer than ever before, primarily because of new technology. Borrowing a concept from our general surgery colleagues, we now recognize that vaginal defects which we call “cystoceles” and “rectoceles” are best conceptualized as hernias in the roof and the floor of the vagina. Using hernia repair concepts, we now reinforce our repairs of these defects with either natural or synthetic graft material, which greatly lengthens the effectiveness of the surgical procedure. Hospital stays are shorter, and recovery is faster, and the long term surgical results appear to be much improved. We hope you do not need to have any surgery for these problems, but if you do, we feel confident that we’ll be able to offer you a superior surgical result.

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Cord Blood Banking. March 2005

Within the last several years, there has been a new technology which is being aggressively marketed to our pregnant patients, that being the concept of storing several ounces of your infant’s umbilical cord blood for potential future use should your child develop a catastrophic illness, such as leukemia or another malignancy, for which the use of fetal stem cells may be lifesaving. We do not have any quarrel with the fact that for some childhood illnesses, these stem cells may be lifesaving. What we do wish to suggest is that, based on 2005 technology, the number of potential uses for these stem cells is quite limited, and this is an expensive luxury for new parents to consider. The current costs, depending on the company one chooses to use, range from about $1600-$1800, and there is an annual fee of about $100 to keep the cells frozen and available for potential use. We are unaware of any insurance companies which will cover this cost.

The American College of Obstetricians and Gynecologists has made the following statement regarding this issue: “ACOG believes that there are many questions about this technology that remain unanswered. Parents should not be sold this service without a realistic assessment of their likely return on the investment. The odds of needing a stem cell transplant are low -- estimated at between 1 in 1,000 and 1 in 200,000 by age 18. Commercial cord blood banks should not represent the service they sell as "doing everything possible" to ensure the health of children, nor should parents be made to feel guilty if they are not eager or able to invest considerable sums in such a highly speculative venture. “

We have little doubt that the list of diseases which stem cells will be used to treat in the future is likely to grow, but we do not know what these diseases are, or when they will be amenable to stem cell therapy. Like many issues confronting our patients in 2005, we believe that it is our responsibility to make you aware of your choices, and to present you with options and information so you may choose which course of action you desire. We hope that in the future, there may be the possibility of universal cord blood banking and stem cell access for all Americans. That is an expensive dream, and when this will be realized is uncertain. In the interim, should you desire to collect your infant’s stem cells, we will be happy to facilitate this, and we have kits in the office to carry to labor and delivery for this purpose.

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Hormonal Contraceptive Failure and Body Weight. February 2005

The January issue of Obstetrics and Gynecology has an article by Holt et al discussing the risk of hormonal contraceptive failure as a function of the patient’s weight.
The study looked at 248 members of a health maintenance organization who conceived while using oral contraceptives (OCs) between 1998 and 2001, compared to 533 women using OCs who did not conceive. The authors concluded that the women in the highest weight category had the greatest risk for becoming pregnant, and they also indicated that this risk would be present for women using any form of hormonal contraception, whether OCs, a birth control patch, or the vaginal contraceptive ring. While there are no absolute weights above which this becomes problematic, the study suggests that contraceptive effectiveness starts to decrease at weights above 165 pounds.

The reasons suggested for increased weight and contraceptive failure include:
1) a higher basal metabolic rate associated with obesity, decreasing the duration of action of hormones;
2)increased speed of liver clearance of hormones due to obesity induced liver enzyme activity;
3) increased fatty tissue in overweight women binds the hormones in the contraceptive, resulting in lower active hormone levels, thus decreasing the effectiveness of the contraceptive.

The conclusions to be drawn from this study include losing weight to maintain contraceptive effectiveness. Also, women weighing greater than 165 pounds should consider additional contraception such as condoms.

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As most of you who have been our long-term patients are aware, Drs. Nebgen and Reeves have been active members of the Baylor College of Medicine teaching faculty. We are frequently asked if the decision by Baylor to shift its primary private teaching hospital from Methodist to St. Luke’s will have any effect on our practice. The short answer is no. Baylor and Methodist parted ways for reasons too complex to discuss in this setting, but primarily because Baylor felt that it could function better financially if it had its own clinical facility.

We continue to do the vast majority of our work at Methodist, and see no reason to change that practice pattern. As a result of the shift in the Baylor relationship, Methodist is actively pursuing a closer relationship with Weill Cornell Medical School in New York, and both Drs. Nebgen and Reeves are pursuing clinical faculty appointments in the Weill Cornell ob/gyn department. (However, we do not have any plans to move to New York!) We anticipate that Methodist will adopt the model used by other large hospitals in cities such as New York and Boston, where residents from several different medical schools will rotate through the same institution. Regardless, we foresee Methodist continuing to provide the same degree of excellence which you all have appreciated for the length of our practice in this hospital, and which is nationally ranked for the quality of its gynecology service.

Dr. Nebgen has recently been appointed chair of the obstetrical quality assurance committee at Methodist, and Dr. Reeves continues to serve as medical director of the gynecology unit at Methodist. Both have several other committee appointments integral to the smooth functioning of Methodist Hospital and the Methodist ob/gyn service.

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