September 1st, 2009 by RamonaBatesMD in Better Health Network, Opinion
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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.
Sources
How Abortion Could Imperil Health-Care Reform by Michael Scherer; Monday, Aug. 24, 2009; Times.com
What is the Hyde Amendment? (July 21, 2004); ACLU
*This blog post was originally published at Suture for a Living*
August 9th, 2009 by KerriSparling in Better Health Network, True Stories
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I stood there with my best friend as she rubbed her pregnant belly. The whole waiting room was filled with these lovely women and their round beachball bellies of varying sizes.
And I felt oddly self-conscious with my lack of roundness.
Last Friday was my first official appointment at the Joslin pregnancy clinic. It’s located at Beth Israel in Boston and is a beautiful hospital, different from the Joslin Clinic across the street that feels like home at this point. I’m not pregnant, and we aren’t trying to become pregnant YET, but this appointment puts things into full swing to bring me to a safe level of pre-pregnancy health.
Sigh. This all sounds redundant, even to me. I’ve talked the Big Talk before. “Oooh, look at me! I’m going to really wrangle in my numbers and have an A1C you can bounce a quarter off!” And I’m all gung-ho for a week or two, armed with my little log book and my good intentions, but within a few days, Other Things start to creep in. Like work. And stress. And getting to the gym. And social stuff, like hanging out with my friends and going to RI on weekends. Eventually my good intentions end up in the spin cycle, and my log book starts to gather dust. My workload piles up. And my stress levels skyrocket.
I’m so frustrated because I want to have a career. And I want to have a baby. (I’d also love some tight control of my diabetes, too.) These things would be excellent, but it feels like tightly managing type 1 diabetes is a full time job unto itself. Slacking off is easy, and frustrating, and not healthy for me or any baby I’d like to have.
But I also realize this is one of my biggest hurdles when it comes to pregnancy planning – the whole “sticking with the pre-program.” This becomes more and more obvious to me when I go back and re-read old blog posts where I’m so excited to get back into better control, only to be derailed by those Other Things. So during the course of my appointments on Friday with the endocrinologist, the registered dietician, and the certified diabetes educator, I admitted my faults freely.
“I need help being held accountable.”
They didn’t quite hear me at first. “We can do some tweaking, and in a month or two, we can revisit your A1C and see if it’s lower and then we can give you the green light for pregnancy.”
I knew I needed more than that. I had to be completely honest.
“Guys, I really need to be held accountable. I know this sounds crazy and I seem very compliant, but I have trouble following through. I’m great out of the gate, but I lose steam after a few weeks and I’m at the point where it isn’t good enough anymore. I’m out of excuses. And I’d really like to join the ranks of those pretty pregnant ladies out there. Please help me?”
And they listened. We spent the rest of the day working out a plan for me. One that will actually make a difference. One that will get me there.
I’ll be in Boston every three weeks until I’m pregnant. This is a huge commitment but I need to make diabetes a priority without fail. I want this. I want to succeed at this more than anything else. I’ll have my blood sugars logged for those three weeks and we (my husband and my diabetes team and I) will all review them together. Chris is in charge of my meals, in that he’ll be helping me plan my day, food-wise, and he’ll be counting carbs and measuring things for me. I’ll be eating relatively similar items every day so I can manage the trends and control them. I’ll continue to test all the live long day and wear the pump and the CGM, but I’ll actually use these devices to their fullest potential, instead of just going through the motions.
With these appointments spaced just a few weeks from one another, I hope I can stay tuned in to intense diabetes management for three week stints. Being sent out for three or four months is too much for me. Obviously, because I burn out well before my follow-up appointments. I just plain can’t pay rapt attention for that long. But three weeks? Can I do that?
I have to do that.
I will do that.
*This blog post was originally published at Six Until Me.*
August 6th, 2009 by RamonaBatesMD in Better Health Network, News
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This article would have been off my radar had it not been for the interaction on twitter.
jeffreyleow RT @paulinechen: Camera Phones [patients taking pics] helps doctor make rare diagnosis http://3.ly/CXr (via @EllenRichter)
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 “frequent episodes of extreme bilateral nipple pain. A typical episode lasted between 5 and 15 minutes and was so painful as to bring her 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 ambient temperature drops below a certain threshold that is specific to 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 continue breastfeeding successfully. Recommended treatment is 30 mg nifedipine of sustained-release once-daily formulation, and most women respond 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
*This blog post was originally published at Suture for a Living*
July 20th, 2009 by Kenneth Trofatter, M.D., Ph.D. in Better Health Network, Health Tips
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I received the two comments below from readers and use this opportunity of their tragic experiences to revisit a concern that I raised about two years ago regarding methotrexate therapy for the presumptive diagnosis of ectopic pregnancy….
Melissa O. said…
I was told I had an ectopic pregnancy and was advised I was in need of a Methotrexate shot. I got it. One week later my hormone level was continuing to rise. Low and behold 4 days later my ultrasound showed I was carrying twins. The Dr.’s had presumed ectopic too early. Getting the shot caused me to loose Twin A and to give birth to a very much underweight 28 weeker. This experience has changed my life forever. My son fought to survive…he continues to today now 13 months old. I would hope anyone who is told they have an ectopic pregnancy would be cautious when it comes to this shot. Yes I agree it helps if your life is in danger due to an ectopic pregnancy. Just take time to ensure there is no doubt that’s what it is. My Dr couldn’t see the baby so assumed ectopic, however carrying twins like I was you’re not able to see as early as a single pregnancy. My son is paying everyday because of my mistake and doing as one Dr. said make sure you have more than one confirmation, it could cost you a perfectly healthy baby in the end.
Fri Jun 19, 05:45:00 PM 2009
Anonymous said…
Hi can someone help me? My husband and I were trying for a baby and I fell pregnant (good news). I started having a few brown spotting and slight cramping which I was advised by my GP to go to the hospital for a scan. Whilst there I had many tests and the doctors thought it might be ectopic and said he was going to keep me in for a few days to monitor my blood levels. I had a scan but being only five weeks it was hard to say. I was referred to another doctor on the ward and he told me it was ectopic. I trusted his knowledge and he said he needed to give me methotrexate now as it was Friday so the pharmacy would be shut. I was shocked but agreed of course. 3 days later I was told the baby is still alive and is in my womb. My blood levels increased after 3 days and then decreased from 7000 to 6000 on the 7 days. How long will it take to lose my baby as it’s hard to know its alive?
Fri Jul 03, 11:15:00 AM 2009
Ever since methotrexate became popular for treating ectopic pregnancies, I have seen the unfortunate scenario reported by our readers above played out time and time again. Methotrexate (MTX) is an analog of folic acid. It binds tightly to an enzyme called dihydrofolate reductase and when it does so, interferes with the production of tetrahydrofolates. In the end, this interferes with the normal production and repair of DNA by limiting the production of a key nucleotide, thymidine. Other metabolic effects are also known, but the take home message is that MTX can result in lethal damage to cells that are replicating, particularly those that are replicating rapidly, like certain cancer cells.
Because of its documented efficacy in the treatment of malignant trophoblastic cells (choriocarcinoma), MTX has been employed in recent years as an alternative to surgical therapy in selected cases of ectopic pregnancy (Lipscomb, et al. NEJM 2000;343:1325-29). Ectopic pregnancies, by definition, implant ‘outside the uterus’ with more than 95% occurring in the fallopian tubes and about 2.5% in the cornua of the uterus (where the fallopian tubes enter the uterus). For that reason, they are frequently referred to as ‘tubal pregnancies,’ although they can also occur in the cervix, ovary and intra-abdominally. The fallopian tubes cannot restrict the growth of invasive placental tissues, as can the endometrium, and they certainly cannot accommodate a growing embryo beyond a certain point before they rupture and hemorrhage. Indeed, ectopic pregnancies can be quite deadly if not treated appropriately. They are still a major cause of maternal mortality, accounting for 10-15% of all maternal deaths, and they are the leading cause of death in pregnant women in the first trimester. A ruptured ectopic pregnancy is a true medical emergency.
Because of the rising incidence of ectopic pregnancy, the risk (maternal and medical-legal) of not identifying and treating an ectopic pregnancy in a timely fashion, and the widespread acceptance and success of MTX therapy as an alternative to surgical management of an ectopic pregnancy if caught early enough, there has been a coincident increase in the inadvertent use of MTX in unrecognized early intrauterine pregnancies. The usual scenario is one in which the pregnancy is not quite as far along as anticipated and the patient happens to present with complaints of abdominal pain or some spotting and no clear intrauterine pregnancy is identified by ultrasound. The ‘absence’ of an intrauterine pregnancy can be misdiagnosed because the pregnancy really is too early, but in at least one of the scenarios above was more likely the result of the inexperience of the individual(s) performing the ultrasound study.
This situation can be especially confusing if the pregnancy hormone levels (hCG) appear to be low for the expected gestational age based on last menstrual period (as is often seen in women who ovulate later, and hence conceive later, in their cycles) or if a woman has a tender adnexal mass because a hemorrhagic corpus luteum (intraovarian bleeding at the site from which the egg was ‘hatched’) or torsion of an adnexal mass (rare this early in pregnancy) which might be very difficult to differentiate from an ectopic pregnancy.
Since MTX is a category X drug, known to be teratogenic in humans, it is important to ascertain the presence of an ectopic pregnancy rather than simply to use it empirically. Unfortunately, its inadvertent use with an intrauterine pregnancy is most likely to occur during the time of neural tube and very early cardiac development, both of which rely on folate-dependent pathways. Various algorithms are in place that employ ultrasound imaging, quantitative hCG levels, and progesterone levels to differentiate abnormal from potentially normal pregnancies and these protocols can be useful in minimizing the chance of the inadvertent use of MTX and also in directing its use when appropriate for the management of an ectopic pregnancy. Perhaps the greatest risk of ectopic pregnancy is not suspecting that one could be present. Patients who are adequately counseled and followed closely are much less likely to end up in emergency situations.
To our readers above, I am SO SORRY for both of you. This is a failing of the medical system and is a growing concern of mine due to the ready accessibility and simplicity of use of methotrexate (and also another drug, misoprostol, that is used in the ‘medical evacuation’ of the uterus when an inevitable miscarriage is suspected).
My feeling is that it should never be used in an asymptomatic or minimally symptomatic patient until either an ectopic pregnancy is seen, no intrauterine pregnancy is documented (by a competent sonographer) at hCG levels where an intrauterine pregnancy should readily be visible, the patient has significant ‘risk factors’ for an ectopic pregnancy (e.g., previous ectopic, known history of pelvic inflammatory disease or tubal reconstructive surgery) or when there are well-documented abnormalities in the rise of hCG that are highly suggestive of an ectopic pregnancy. My heart goes out to both of you.
Kind regards,
Dr T
This post, Accidental Abortion: Use Of Methotrexate For Misdiagnosed Ectopic Pregnancies, was originally published on
Healthine.com by Kenneth Trofatter, M.D., Ph.D..
July 1st, 2009 by SteveSimmonsMD in Better Health Network, Primary Care Wednesdays
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When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.” Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.
I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred. Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.” Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.” The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine. “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”
I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes. Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement. I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.
I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court. Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion. In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy. This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.
In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change. Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise. Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births. Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.
On the other hand, tort reform has resulted in major shifts in the physician workforce. In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff. The limit for a wrongful death case was set at 1.6 million dollars. Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.
In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today. I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with. The time for reform is here, action appears inevitable, and the moment to speak out is now.
Until next week, I remain yours in primary care,
Steve Simmons, MD
