This is Alex. I helped his mother give birth to him in June 2010. Today I run into her by chance and she shows me his recent photo. What a great feeling!
Disclaimer: This photo has been taken and shared here with permission from Alex’s mother.
A new study published in The Lancet on April 3rd 2012 reveals a promising management for pregnant womyn at risk for preterm labor and delivery.
The study by Dr. Maria Goya from the Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona, Spain is the first multicenter randomized trial to test the use of a cervical pessary in womyn at high risk for preterm birth. The pessary was found to be an effective strategy to prevent preterm birth in pregnant womyn with a short cervix.
We already know that a short cervix early in pregnancy is one risk factor for preterm birth.
The Spanish study, called Pesario Cervical par Evitar Prematuridad (PECEP), randomly divided Pregnant womyn with cervical length of less than 2.5 cm into two groups: One group was treated with a cervical pessary and the other with watchful waiting. Spontaneous delivery before 34 weeks (8.5 months) was significantly lower (only 6%) in the cervical pessary group than in women assigned to expectant management (27%).
With the observed reduction in preterm birth, the pessary group of womyn was also found to give birth to larger infants with less complications as respiratory distress or sepsis.
Given the lack of cost-effective methods to prevent preterm delivery these findings offer new hope.
Hormonal treatment with progesterone is one method that was found to be effective in prevention of preterm birth. However, recent corporate greed might keep such effective medication away from the reach of many womyn. Even though progesterone has been available in an affordable form for more than a decade, now that the evidence of its benefits has solidified, it has been recently repackaged by a pharmaceutical company, given a name (Makena) and dropped in the market with a price that exceeds 1000 USD. Makena’s price has already caused much controversy especially that the FDA might prohibit pharmacies from compounding the cheap original formula.
Cervical cerclage is another method that has been studied significantly. So far the evidence of its benefit had been controversial. The process requires significant surgical skills and many gynecologists had not been adequately trained. It is also an invasive procedure that might be associated with significant risks such as rupture of membranes, infection, preterm delivery or miscarriage among others. Those risk, even though rare in well-trained hands remain significant given the little proven benefit of cervical cerclage.
In the above mentioned Spanish study, the use of a cervical pessary was found to be relatively safe and at low cost to patient. Side effects were limited to slight increase in vaginal discharge, and little discomfort.
The exact mechanism of action of the pessary is still not clear. But given its safety and low cost, it still stands as a promising option. I anticipate it will take some time before it becomes available in the American and Canadian market.
I received this note on Facebook in Sept. 2011 and the second photo in Feb. 2012:
Yesterday I saw you on facebook, and this remind me that I have not thanked you for helping my mom gave birth to me after two days in the delivery room (I was so tired, mom and dad too! ). So I decided to send you a picture of me to show you how much I’m cute and full of life! I wish to take a picture with you to put in my keepsake box. My mom forgot to take one.
I don’t know if you remember me, because I know you help a lot of babies being born, but me, I will never forget the first man I’ve seen in my life!
I love you Dr. Abdessamad!
Oh… I saw that you had a broken arm, I’m sorry. I hope that you will heal quickly!
9wks & 12lbs
Disclaimer: This above note and the two photos are published here unedited with permission from Amylee’s mother.
Dr. Marjorie Greenfield, UHCMC General Obstetrics & Gynecology Division Chief and author of “The Working Woman’s Pregnancy Book”, dispels myths recently propagated about pre-natal testing by presidential-hopeful Rick Santorum.
>>> debate over prenatal testing .
>> one of the things you don’t know is they require free prenatal testing . why? because free prenatal testing ends up in more abortions and less care that has to be done because we call the ranks of the disabled in our society.
>> that was one of a series of recent comments citing prenatal testing as one of the reason he’s against the president’s health care law . the christian post has an article with the headline, ob/gob/ ob/gyn, santorum was a right. what premayal care has developed into is a search and destroy mission. joining me now is dr. marjorie greenfield from case medical center . i should note your hospital is one of leading neo natal care facilities in this nation. i don’t want to get you locked up in a political or religious battle, but i want to talk about the science here. you have a colleague who is saying that this is a search and destroy mission. what is your response to that?
>> that’s really a terrible way to frame prenatal testing . it’s much more than about abortion. i think when you narrow it down that’s way, it’s politically motivated as opposed to talking about what happens with patients.
>> what are the numbers here? rick santorum says this results ting is done. i’ve read countless articles over the last ten days or first five days when first came up with this, i have to say, i’ve not seen a clear figure here. what can you tell me.
>> the decision about what you do with abnormal result s a personal decision. when owe talk about prenatal testing . wh what are we talking about? an ultra sound is k detect fetal abnormalities. the other tests are blood tests that can be done or a sampling which are the diagnostic tests that give you the true, final answer of what’s going on with chromosones. he used the term prenatal testing which is a much broader term than that.
>> i know you’ve written about how emotional this is. some families don’t want to do testing because they don’t want to face the decision of what to do next. it is a personal and a family’s choice here. you’re in contact with people every day who decide on testing. just take me through your world and the perspective of what women are looking for when they decide to go ahead with this.
>> when i frame this with patients, i say that people fall into three groups. there’s a group that don’t want to do any of this testing or screening because they know that they would not change their behavior at all based on the results and they don’t want to be worried about this during the pregnancy. there’s another group that knows that they would terminate an abnormal pregnancy and they want the information that they can get so they can make that decision. then there’s a large group in the middle that wants to know about the health of their baby so they can make the best possible decisions. they might decide to get in contact with asupport group so that they would learn more about this condition so they could make a good decision about what to do for themselves or they might, sometimes we’re talking bt about a condition that’s not compatible with survival. sometimes we get hospice involved for people that would not terminate but want as much information as possible. these decisions are incredibly personal decisions. the other thing i want to make sure people understand is that amnio is done for anybody that’s at increased risk for finding a problem. most are carrying healthy fetuses. one thing it turns out to be reassurance for the family and the baby ent doesn’t have a problem.
>> in most cases the baby is healthy?
>> the vast majority doesn’t find a problem.
>> you’ve said that overall this is commonly accepted and one of quotes is that this is like not covering an ultra sound . the ideas that are coming from rick santorumin that he would not want insurance to cover the prenatal testing .
>> right. you can do an ultrasound and find a very severe problem on a fetus that would not be detected by amnio. it’s an anatomical problem that could be severe and not compatible with survival or quality of life that family would go forward with. would that mean that the doctor would be not supposed to tell the family that this abnormal finding was there because the family might make a decision for abortion. you end up going down a path that really interferes with the doctors ability to take care of the patients and the family’s independence.
>> it’s a rejection for some of science here. this is science used to, as you pointed out, help with the mother to have a healthier child in the end here. if insurance cover it, that would mean on the wealthy perhaps would have the ability to have this testing done. i would imagine it’s quite expensive.
>> i looked into it. there’s quite a range of charges across the country but we’re talking about $2,000. that’s really going to be unreachable for a lot of people.
>> if you’re rich, you’d be able to do it and have this testing but obviously the other 99%, as we like to say, would not.
>> right. what you could end up having, for instance, i can give you an example of a patient that has a routine ultrasound, they see shotgun that makes it likely you find a problem and the family would have to make a decision, are they going to spend the money for the amnio or just be terrified for the rest of the pregnancy when it could be just fine.
>> we greatly appreciate it. we have been trying to get you on for two days. i’m glad you were able to make it. thank you so much.
>> happy to be here. thank you.
This post is about a recent study released online on Feb. 10th 2012 in The Lancet Oncology as an early publication. In brief the study assessed “children who were prenatally exposed to maternal cancer staging and treatment, including chemotherapy.” They examined 68 pregnancies who were exposed to 236 cycles of different kinds of chemotherapies. 70 children were assessed at age 18 months, 5—6, 8—9, 11—12, 14—15, and 18 years. Assessment included examining neurological and cognitive functioning or IQ, heart functioning, general health and development, hearing, memory, attention and behaviour.
The study concluded that “fetal exposure to chemotherapy was not associated with increased CNS, cardiac or auditory morbidity, or with impairments to general health and growth compared with the general population.”
The importance of this study lies in providing a perspective on long-term outcomes of newborns after exposure to chemotherapy during pregnancy. With such reassuring findings, we should consider avoiding early deliveries that subjects those newborns to risks of prematurity.
It is important to realize that not all chemotherapies are safe and the ones included in this study are those that are know to be tolerated during pregnancy.
Below is an Arabic version:
أثبتت دراسة أوروبية حديثة أن إخضاع السيدة الحامل للعلاج الكيميائي لا يؤثر على صحة الجنين، خاصة إذا حدث ذلك في الفترة الممتدة ما بين الشهر الرابع والسادس من الحمل.حيث قام أخصائيون أوروبيون تابعون لـLeuven Catholic University في علاج السرطان بمراجعة حالة 68 سيدة حامل أنجبن 70 طفلا بعد أن خضعن لعلاج الكيميائي ضد السرطان، وفحصوا صحة الأطفال عند مولدهم كما عند بلوغهم 18 شهرا، ثم بعد ذلك عند بلوغهم سن الخامسة وحتى بلوغهم 18 عاما.وقد شمل الفحص الحالة الصحية العامة للأطفال، كما تم تفحص ما إذا كان لديهم قصور في الجهاز العصبي المركزي أو القلب أو السمع وتم اختبار مهاراتهم المعرفية والعقلية كذلك.
وقد تبين للباحثين عدم وجود أي دليل على تضرر صحة الأطفال من جراء العلاج الكيميائي الذي خضعت له والداتهن أثناء الحمل بهم، إلا أن الأطفال الذين ولدوا قبل الميعاد الطبيعي أظهروا مهارات معرفية أقل من الباقين، ولكن هذه مشكلة عادة ما تصيب كل الأطفال الذين يولدون قبل الميعاد، حتى دون تعرضهم لعلاج كيميائي.
وقد أوصت الدراسة بعدم القلق في إخضاع الأم الحامل للعلاج الكيميائي، ونصحت الأطباء بألا يحثوا المرأة الحامل المصابة بالسرطان بالولادة قبل ميعادها لإخضاعها لاحقاً للعلاج.
وأشارت الدراسة إلى أنه “يمكن إخضاع السيدة الحامل للعلاج الكيميائي بدءاً من الأسبوع الرابع عشر من الحمل، ولكن كي يستعيد النخاع العظمي قوته ولتقليل مخاطر تسمم الأم والجنين أو حدوث نزيف يجب أن يتم التخطيط للولادة على الأقل بعد ثلاثة أسابيع من آخر جرعة كيماوية تعطى للحامل، كما يجب أن تتوقف الجرعات عند الأسبوع الـ35 وذلك تلافيا لحدوث ولادة تلقائية في ذلك الوقت”.
ولكن يقر فريق الباحثين بوجود حاجة لعمل المزيد من الدراسات لمعرفة ما إذا كان للعلاج الكيميائي تأثير على هؤلاء الأولاد في الأمد البعيد. المصدر
من المهم أن نتذكر أن هذا الحديث لا ينطبق على كل علاج كيميائي انما على بعض الأدوية التي كنا نعتقد أنها أمنة، فتأتي هذه الدراسة الآن لتؤكد ذلك.
A new study by Dr. Elizabeth Raynmond and Dr. David Grimes published in the Green Journal (Obstetrics & Gynecology) in Feb. 2012 concluded that:
Legal induced abortion is markedly safer than childbirth. The risk of death associated with childbirth is approximately 14 times higher than that with abortion. Similarly, the overall morbidity associated with childbirth exceeds that with abortion.
This sounds common sense to an Obstetrician & Gynecologist regardless of their political or moral position on abortion. Now, we have it in print. In the golden era of evidence based medicine, this piece of common sense information is now supported by evidence.
Raymond & Grimes reviewed data from the CDC’s Pregnancy Mortality Surveillance System, birth certificates and Guttmacher Institute surveys to estimate mortality rates associated with live births and legal induced abortions in USA from 1998 to 2005. They also searched population-based data comparing the morbidity of abortion and childbirth.
Here are the figures they found:
Legal abortion has been found to be safe in multiple studies. Allegations that abortion can lead to breast cancer or mental illness have been refuted.
It is true that abortion might be regretted, but so could delivery of an unwanted pregnancy. It is true that depression can be diagnosed after an abortion, but it can more so be diagnosed after a delivery.
I am not pro-choice. I am not pro-life. Actually those two terms are relatively new to me. Having studied medicine in Lebanon, the issue of abortion does not even come up in the curriculum, not even in residency training. Apparently, unwanted pregnancies do not occur in Lebanon; neither does pre-marital sex! Rape and incest in some magical way do not get womyn pregnant in the Sin City of the Middle East. Abortion is illegal in Lebanon. A woman can spend up to 5 years in prison for getting one. Abortions are being performed in Lebanon. It costs 500 to 2000 USD per abortion in a country where minimum wage is 448 USD. RU486 or mefiprostone is illegal in Lebanon but can still be found in Black Market. Read more about Lebanon’s abortion question.
After 4 years in USA, I learned all about the choice vs. life controversy. I still could not identify with either. When asked, I say I am pro-patient. As a physician, I can not and should not impose my set of moral rules on my patients. Regardless of what my personal feelings about abortion are, I am obliged to provide my patients with facts. I owe it to them. The facts as I know it stated simple and clear: Abortion is not riskier than continuing with an unwanted pregnancy, it actually appears to be safer.
So the controversy is political and not medical. I did not spend 13 years of my life studying as much as I did to allow politics to influence my medical decisions. Patient’s safety and well being should remain the focus of any health advocate. There are more serious risks to which womyn are exposed and to which governments pay less attention. Poverty should be illegal, it is a great health risk. Smoking claims 3.1 million deaths over 7-years in USA (Pregnancy claims 2856 and abortion 64 deaths).
Dr. Mitchell Creinin stated in an editorial for the Green Journal this month that:
Abortion is safer than delivery. Regardless of personal views, every woman deserves factual medical information whenever she is faced with a decision of whether or not to terminate her pregnancy. Government should be concerned about important issues that create public health hazards. With pregnancy and abortion, more laws are promoted to limit access to a safe procedure when the alternative is riskier.
The ethical controversy will continue. We will always agree to disagree. In the meantime facts should be provided to womyn to empower them in making well-informed decisions.
I just passed the oral examination for the American Board of Obstetrics and Gynecology (ABOG). I am now an American board-certified Obstetrician and Gynecologist.
What a great way to start the new year, potentially adding a third title to my name:
Hasan Abdessamad, MD, FRCSC, “FACOG”
FRCSC: Fellow of the Royal College of Surgeons of Canada
FACOG: Fellow of the American Congress of Obstetricians and Gynecologists (application pending)
In USA, board certification involves a two-part exam, usually taken over a two-year period. The first part is a written exam, which is taken when the candidate is still considered board “eligible”. The second part is an oral exam, taken the year after the written exam is passed. The oral examination is based largely on a collection of a year’s worth of medical and surgical cases known as the “case list”. The oral exam is offered once a year in Dallas.
In Canada, both the written and oral examinations are done simultaneously over 2 days in Ottawa. The Canadian oral examination is based largely on performance with simulated patients. There is no assessment of previous performance or “case list”. The Canadian written exam has multiple choice questions like the American exam but in addition it has has a section for short answered questions.
In USA, residency training for Obstetrics and Gynecology (ObGyn) requires four years. In Canada, 5 years of training are needed. This limits the chance for any AMerican trained ObGyn to sit for the Canadian exam without having to train for one additional year. I was eligible to sit for the Canadian exam even though I trained in USA because the Canadian board took into account the year of ObGyn internship I did in Lebanon (The American University of Beirut 2003-2004).
On Aug. 22 2011, the American College of Obstetricians and Gynecologists (The College) announced new recommendations to prevent blood clots during Cesarean Deliveries.
The new guidelines will be published in Sept. 2011 issue of the Green Journal. Blood clots, medically known as venous thromboembolic events (VTEs), are a leading cause of maternal mortality in USA and Canada. The College now recommends that all women having a cesarean delivery receive preventive intervention at the time of delivery. The most cost effective method would be sequential compressive devices (SCDs) to be placed on the lower extremities of a patient before a Cesarean and removed after surgery only when adequate ambulation is attained.
The risk of developing blood clots is increased four folds during pregnancy and two folds during and after a Cesarean delivery. Blood clots can block blood flow and cause damage to certain organs. The most common site of a blood clot in a pregnant patient is the left lower leg but other sites are commonly affected. Symptoms include swelling and pain in affected limb. If a clot gets dislodged, it can travel to the lungs causing a life-threatening condition known as pulmonary embolism (PE). Symptoms include sudden shortness of breath, chest pain, and coughing.
The recommendations explain how to monitor women for these events, address certain risk factors, and treat suspected or acute cases of VTE. “It’s important for ob-gyns to adopt these recommendations to help reduce maternal deaths.” said Dr. Andra H. James who helped develop the guidelines.
The Society of Obstetricians and Gynecologists of Canada (SOGC) has no clear recommendations on using VTE prevention during a Cesarean delivery for patients who are at low risk. Regardless of the plethora of new research on this topic, the SOGC guidelines were last updated in 2000. (See Prevention and Treatment of Venous Thromboembolism (VTE) in Obstetrics).
If you or someone you know are undergoing a Cesarean delivery ask the doctor about methods of VTE prevention she/he are implementing.
Another little miracle born, an adorable baby girl with a nice story behind her chosen name.