I’m going to wade right in here. I am not a fan of abortions, but neither am I of amputations. Both are sometimes necessary. To me, too often abortion opponents forget the mother. She is a life present before us. Her care should not be forgotten.
I have been listening and reading the discussions over how the abortion coverage may sink health care reform. I think it would be a shame if this one issue does sink reform.
If my understanding of the Hyde Amendment (and it’s amendments over the years) is correct the Federal Government covers the cost of abortions in cases of rape or incest or when the life of the mother is at risk. It does not cover the cost when the health of the mother is at risk:
With these bans, the federal government turns its back on women who need abortions for their health. Women with cancer, diabetes, or heart conditions, or whose pregnancies otherwise threaten their health, are denied coverage for abortions. Only if a woman would otherwise die, or if her pregnancy results from rape or incest, is an abortion covered. The bans thus put many women’s health in jeopardy.
I agree with opponents who do not wish to cover abortions for simply any reason (i.e. the timing for a pregnancy is not good, etc). Abortion should never be used for birth control. That should be done using birth control pills, condoms, abstinence, etc.
Currently, the only abortions available under Medicaid are the ones mentioned above. I think it’s a shame that distinctions can not be made to provide coverage for a woman who’s HEALTH would be negatively affected by her pregnancy. All insurance policies should do so in my opinion.
Opponents of abortion want language that would prohibit any private insurance company that accepts federal funds from offering to policyholders abortions other than those already eligible under Medicaid.
Two nice articles in the June edition of the Journal of Plastic and Reconstructive Surgery. Full references are given for both below.
There are many techniques used for nipple reconstruction which should tell you that none is perfect. One of the main issues is loss of nipple projection over time. So if it is safe to spare the nipple when doing a mastectomy so no nipple reconstruction is needed – perfect!
The first article below looks at when it can be safely spared in prophylactic mastectomy (risk-reduction mastectomy) and therapeutic mastectomy clinical scenarios. Spear and colleagues did a literature review and came to the following conclusion:
It is clear from a review of the literature of the past 15 years that the subject of nipple-sparing mastectomy is complex and evolving. The subject is properly divided into two parts: risk prevention and therapeutic mastectomy.
There now seems little doubt that nipple-sparing mastectomy is an oncologically safe approach to prophylactic mastectomy. For that purpose, proper patient selection and technique remain open questions. ……….
Nipple-sparing mastectomy at the time of therapeutic mastectomy remains more controversial. There is developing consensus by those interested in nipple-sparing mastectomy as a possibility with therapeutic mastectomy that it is best suited for women who meet certain criteria. …….
The collective data suggest that, using the above below criteria, the risk of occult tumor in the nipple should be 5 to 15 percent; that frozen section of the base of the nipple will identify many if not most of those occult tumors; and that the risk of occult tumor still being present in patients screened as above with frozen section-negative findings is as low as 4 percent.
The tumor criteria listed include:
The tumor should be 3 cm in diameter or less
The tumor should be 2 cm away from center of the nipple
Clinically negative axillae or sentinel node negative
No skin involvement, and no inflammatory breast cancer.
If possible, they should undergo preoperative magnetic resonance imaging of the breast to further exclude nipple involvement.
When the nipple can be spared then there is no need for nipple reconstruction. When it can’t be, then the nipple sharing technique can be useful. As with the above, the cancer risk is addressed:
Fears of cancer in the transplanted nipple and concerns for surveillance are thus far unfounded. This occurrence has never been described in the literature. Furthermore, as more liberal use of nipple-sparing mastectomy occurs, a large cohort of patients with retained nipples will be able to be followed over time to see whether we even need to be concerned. For now, simple self-examination as performed by these patients is appropriate.
The article gives a good description of two different ways to perform the nipple sharing depending on the shape of the donor nipple.
Both articles are worth your time to read.
REFERENCES
Nipple-Sparing Mastectomy; Plast & Recontr Surg 123(6):1665-1673, June 2009; Spear, Scott L.; Hannan, Catherine M.; Willey, Shawna C.; Cocilovo, Costanza
Many of the surgeries I do are elective. They can and should be scheduled to be convenient. It happens – God laughs at our plans or life interrupts or …..
Last week was such a time for one patient. She called, very apologetic, “Dr Bates, I need to reschedule my surgery. My father is having tests done. He hasn’t been feeling well.”
I quickly assure her that no apology is necessary. Her family comes first. I suggest we simply cancel the surgery for now until the “dust settles.” She can call me back when she is sure things are okay with her family. We’ll reschedule then.
She is still worried. “The surgery center called me today. Do I need to call them? Will I need to pay them or anesthesia or you for the canceled time?”
Again I reassure her, “No, I’ll call them and take care of canceling the surgery. No, we don’t charge you for surgery we don’t do. It happens. It’s okay to cancel surgery for whatever reason – another family member gets sick, an accident happens, you just get scared.”
It happens on both sides. Sometimes (as for me earlier this year when my mother had surgery) it’s the doctor who has to cancel or reschedule. Sometimes it’s the patient. I once had a patient not show up for surgery, only to find out later she had been in a motor vehicle accident the evening before her scheduled surgery. She turned out to be okay, but it really cemented how I fell about patients who call to cancel or reschedule. It’s okay. No need to apologize. Thank you for letting me know.
After surgery I am often asked, “When can I get back in the tanning bed?” I say something like, “I would rather you not use a tanning bed. You need to protect you new scar from the sun, that includes tanning beds, for at least 6 months.”
“But, if I cover up the scar, when can I get back in the tanning bed?” is the usual response.
I then counter with, “IF you feel you must, then yes cover the scars. Please, limit or reduce the time you spend in the tanning bed. I would rather you not use a tanning bed.”
Most see “no harm” in using a tanning bed. After all, it’s not like laying out in the sun for hours. Too many see tanning beds as a “safe” way to get a tan. It isn’t.
These same experts have moved tanning beds and ultraviolet radiation into the top cancer risk category, deeming both to be as deadly as arsenic and mustard gas. The new classification also puts them in the list of definite causes of cancer, alongside tobacco, the hepatitis B virus and chimney sweeping, among others.
I would not mind tanning bed extinction. Regular use increased the risk of melanoma. It is much better to have a “peaches and cream” complexion or to use self-tanning creams. Skin cancer is no fun.
Granted I am not generally asked about nipple pain in pregnant women. Those questions tend to go to folk like TBTAM or ER’s Mom.
The article describes a case report of a 25 yo woman in her 2nd trimester with “frequentepisodes of extreme bilateral nipple pain. A typical episodelasted between 5 and 15 minutes and was so painful as to bringher to tears.”
The article discusses Raynaud’s phenomenon of the nipple and share these photos (credit) taken with a camera phone with us. The text with the photo:
Vasospasm of the arterioles manifesting as pallor (left), followed by cyanosis, and then erythema (centre). The right hand image shows the normal, asymptomatic, status.
As with Raynaud’s of the hand (which I am more familiar with), the phenomenon tends to occur when the ambienttemperature drops below a certain threshold that is specificto each individual. Exposure to cold should be avoided, as is avoidance of caffeine, nasal vasoconstrictors,and tobacco.
Additional treatment for Raynaud’s of the nipple:
Women with persistent pain require immediate relief to continuebreastfeeding successfully. Recommended treatment is 30 mg nifedipineof sustained-release once-daily formulation, and most womenrespond within two weeks.
REFERENCE
An Underdiagnosed Cause of Nipple Pain Presented on a Camera Phone; BMJ 2009;339:b2553; O L Holmen, B Backe
Vasospasm of the Nipple–a manifestation of Raynaud’s phenomenon: case reports; BMJ 1997 314: 644; Laureen Lawlor-Smith and Carolyn Lawlor-Smith
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