As I leave for a brief vacation over the holiday, I wonder (as do most Americans) what’s going to happen to that impending fiscal cliff. Somehow, I reassure myself our divided congress will get this settled. But I am less complacent about the outcome for healthcare in the year and years to come. Just before I got on a plane, I glanced at the New England Journal of Medicine (my reading choices are not as literate as they should be) and came across a special report titled: “Implications of the 2012 Election for Health Care- The Voters’ Perspective.”  So as we go into the new year, I thought it might be appropriate to share the results of this report with you…

Obama won! (Excuse the exclamation point.) We also now know how those who voted for him felt about health care. Here are the stats: Obama voters were three times as likely to say that healthcare was the most important problems facing the country as those who voted for Romney. Obama voters want the Affordable Care Act  (ACA, also known as Obama care) implemented and not repealed. Obama voters want a more activist federal government intervening in the US healthcare system over the next four years. Seventy eight percent of Obama voters favor implementing or expanding the ACA and having the federal government continue its efforts to ensure that most Americans have health insurance coverage. And 85% of Obama voters support having the government try to fix the healthcare system, including 55% who believe that the federal government should have more responsibility than state governments for fixing it. And, (just a few more statistics) the majority of Obama voters upholds changing the structures of the current Medicare program ( 83%) and Medicaid program (78%). Finally 8 in 10 Obama voters believe abortion should be legal in all or most cases.

Yes, we live in a democracy but that doesn’t mean that what the majority of voters favor will, indeed, be accomplished. Thirty of the nation’s 50 states will have Republican governors in 2013, many of whom may not consider the establishment of state health insurance exchanges and Medicaid expansion as their state’s mandate. It’s clear that this may become a contentious year for many reasons and healthcare may lead the “it’s not for us” list.

Meanwhile, back to the personal, each of us should do what we can to ensure our individual health. And I will try to continue to help you do this with timely information about prevention, diagnosis and health care innovations in the year to come.

I and my staff wish you a happy and healthy New Year!

I’m sure anyone who has read a newspaper in the past few months is aware of the fears that are engulfing (of should I say filling) the French women who have received silicone implants. A company in France produced a popular (and apparently not too expensive) implant termed the Poly Implant Prothese (otherwise known as PIP). It was sold in 65 countries throughout the world over the last decade and used for breast augmentation or reconstruction in more than 300,000 women. The company that made the implants was shut down by the French government for fraud in 2010. It turns out that they had been using industrial grade silicone that was (obviously) not approved for medical use. The concern was (aside from the fact that no woman wants her breasts augmented with the same stuff they use in building or road construction) that these implants were far more likely to rupture…. apparently of the 30,000 French women who have had these implants, 1,000 experienced a rupture or leak. The French are advising those women who still have PIP implants to have them removed. Other countries are deciding what to suggest and many are simply suggesting that the women discuss “what to do” with their physician.

Why has this not been a problem here in the USA? This timely question was addressed in an article in the January 14th issue of Lancet titled “Silicone breast implants: lessons from the USA.”

The silicon-gel implants that are used in our country have been FDA approved after a long and arduous history. Currently the FDA assures us that they are safe. Their approval has allowed 150,000 American women to get silicone-gel implants for breast augmentation and 46,000 women to get them for breast reconstruction in the last year alone. In 2010 after 2 days of public testimony from silicon implant manufacturers, surgeons and scientists, the FDA concluded that American women can “consent with confidence to procedures involving silicon implants, which are considered safe but with acceptable risk of local complications (rupture, tissue hardening, pain, inflammation, and infection).” (Note the same complications occur with non-silicone, i.e. saline implants.) And just to be more precise the FDA published a 63 page report assuring the safety of silicon-gel implants.

There is quite a chronicle that preceded this. Silicon-gel implants were available in the US since the early 1960’s, but not until 1976 were they regulated by the FDA. In 1988, the FDA classified them as devices (duh) that needed their safety and efficacy to be proven in order to stay on the market. They gave the manufacturers 30 months to provide the necessary data. Apparently they could not. In 1991, it was deemed that the data did not fully assess the risks and in 1992 (this s a history lesson!) the FDA imposed a moratorium on silicon-gel implants. They were only to be used for reconstruction (after mastectomy for breast cancer or redoes of bad previous implants) and not electively for augmentation until their safety was proven. Then all hell broke loose (at least litigiously) and in 1995 the biggest US class action lawsuit took place, for $4.3 billion. Subsequently, publications in peer-reviewed journals and a 400-page report of the Institute of Medicine failed to link systemic disease with silicon breast implants. The ban was lifted in 2006 and since then 2 manufacturers; Mentor and Allergan have supplied the US market. They have promised to conduct ongoing post-approval studies and are following 40,00 women for 10 years,

So right now we feel (sorry about the use of this word) that our silicon-gel implants are safe. The authors conclude with the statement that “some critics argue that the FDA’s approval process is too slow and bureaucratic” But they add “but at what cost to safety?”

I agree with them. We should expect no less.

This calls for a 101 on ovarian function: During our reproductive lives, the ovaries provide us with our essential female hormones… estrogen and progesterone which are taken up by receptors in every cell in our body. These hormones are produced through the development of primordial eggs or oocytes within the ovaries. The ovary of the female fetus is endowed with a huge number of oocytes… 6 to 7 million to be sort of exact. But by the time we are born, that number dwindles to “just” 1 million. And by the time we hit puberty, we have a paltry 400,000. Then during our reproductive years, thousands die each month (this is termed “atresia”) while one oocyte becomes a follicle that has the potential for ovulation. This dominant follicle develops for 2 weeks, producing more and more estrogen; it then extrudes an egg that can be fertilized.

Subsequent to ovulation the follicle, now bereft of its egg, is called a corpus luteum. It produces, in addition to estrogen, progesterone and together they create a lush environment in the uterinelining for potential implantation of a fertilized egg (now called a blastocyst).

At what point does all this change? Do regular cycles mean that pregnancy will occur at the “touch” of a sperm (or thousands of them)? It turns out that reproductive menopause can occur years or even a decade before hormonal menopause. There is a national trend to delay childbearing. In my practice in LA, I practically never see women under 35 who are ready to conceive. A common question posed by my patients is “How long can I wait?” or “Is it too late?” So I thought it would be appropriate to share some of the information that was recently published in the “Postgraduate Obstetrics and Gynecology” publication that is sent to me and my colleagues biweekly for continuing education.

A woman’s fertility is definitely dependent on her age. The incidence of infertility in women 20 to 24 years old is 7%; this increases to 15% between ages 30 and 34 and then to 29% in women aged 40 to 44 years.  Not only does the quantity of oocytes dwindle, but so does their quality. The rate of spontaneous miscarriage is 10% before the age of 30; it almost doubles to 18% between ages of 35 and 39 years and then rises to 54% in those older than 45. It’s not the age of the uterus that counts, but that of the eggs. If donor eggs of younger women are used, the pregnancy and miscarriage rates are the same in women younger and older than 40.

IVF success with a woman’s own eggs is dependent on the age of her eggs. (This obviously means her own age, no matter how young she looks!) According to the Society for Assisted Reproductive Technology, women between the ages of 35 and 37 have a 37.3% live birth rate, women between 38 and 40 a 28.2% live birth rate and women between 41 and 42 a 16.7% live birth rate with their own eggs.

There are several ways to assess ovarian reserve and get some reassurance as to whether the oocytes are good enough for a successful pregnancy. (By success we mean a live birth, not whether the child can get into an Ivy League school.) Simply having regular periods is not sufficient evidence.

The first test that most doctors will run is a follicular stimulation hormone (FSH) blood test. FSH is the messenger hormone produced by the pituitary. It “commands” the ovaries’ oocytes to begin the steps towards ovulation. If the estrogen level is low (which is what happens with the onset of the period), the FSH revs up and oocytes’ development takes off. Once a dominant follicle develops and it produces its estrogen, the FSH level goes down (negative feedback). If there are not enough oocytes to pass “go” and the ovary’s reserves are low, the FSH continues to be secreted in a desperate attempt to get those oocytes to do their thing. High levels of FSH in the beginning of the cycle (we usually check around day 2 or 3 after the menstrual cycle has begun) indicate poor ovarian response. And FSH will stay up permanently once the ovaries have run out of oocytes, i.e. throughout menopause. In general, the FSH level should be between 4 and 10 mIU/mL during the early part of an “ovulatory” menstrual cycle. Levels higher than 10 to 15 are considered borderline and those higher than 16 mIU/mL are considered abnormally elevated, indicating poor reserves and predicting diminished success with fertility treatment.

There are other endocrine markers that may show low ovarian reserves. One is called antimullerian hormone or AMH. It is produced by ovarian cells from 36 weeks of gestation until menopause. With menopause it decreases to undetectable levels. AMH is not affected by pregnancy or birth control pills and may be the first ovarian reserve marker that declines. Another endocrine test that can predict potential fertility issues with age is a blood test for inhibin B, a growth factor in the ovary. It rises in the beginning of the cycle and then goes down during the second half. Low levels in the early cycle indicate diminished ovarian reserve.

Finally, ultrasound may help predict the ovaries’ reserve. The number of small “ready to go” follicles can be counted and if there are 10 or less that are seen in a scan, ovarian reserve may be compromised.

If you or a family member question whether you can wait or if it’s too late to try to conceive with your own eggs (especially if you are considering expensive and potentially invasive fertility procedures); screening for ovarian reserve should be done. The easiest test is an FSH level on day 2 of your cycle. It can be done in conjunction with these other tests, but it probably remains the simplest and least expensive method of reserve determination. The question, “How many eggs are left?”, is valid for all women who want to postpone pregnancy.

So a patient comes in to my office (sorry if this sounds like the beginning of one of those bar jokes) and as part of my due diligence I update her chart with her current medications. Upon enquiring as to what she is now taking, I may be given a container of various pills with the statement “I take these once a day”. Or I might get a description of the medication “I now take the pink pills that lower cholesterol; I’m not sure of the name…it’s a small dose; it used to be yellow”. Yes, this sounds ridiculously ambiguous but it’s not her fault. The names, colors and shapes of medications are no longer stable. (And this has nothing to do with their expiration date.) At least 70% of U.S. prescriptions are generic. The good news is that they are a lot less expensive than brand prescription drugs and indeed make up less than 20% of current prescription drug costs in the U.S..

An article about our lack of pill recognition titled “Why Do the Same Drugs Look Different? Pills, Trade Dress, and Public Health” was recently published in The New England Medical Journal. I thought I would share it with you in this week’s newsletter.

The clinical effects of brand and generic medications are supposed to be the same (or according to the authors “interchangeable”) but they often look very different. Whereas a brand medication will always appear identical with each refill, generic medications can vary in size, color and shape depending on the manufacturer supplying the pharmacy. (Need I say the cheapest brands will most likely be the ones that are supplied?) They all have to be approved by the FDA, so cheaper does not mean that quality or concentration of the medication has been compromised. An example that was given in the article (along with pictures) is fluoxetine (brand name Prozac). There are at least 10 generic versions that are pharmacologically equivalent to the original drug yet they vary in their color patterns.

No, this was not done on purpose to confuse the consumer or test the memory of her physician. It turns out that color and shape-shift has its basis in U.S. intellectual-property law. Drug manufacturers have had exclusive ownership of the physical aspects of their products, including their size, shape, color, texture, aroma and flavor. These properties are considered private property under a subset of trade law called “trade dress”.  (I immediately associated this title with words like designer, exclusive and whatever other branding adjectives makes “not-off-the-rack” fashion so unique.) To be fair…. the companies that do research and development of drugs should be compensated for the tremendous costs they assume. Often millions of dollars are spent on trials that have to be abandoned, because the medications that undergo testing are not significantly effective or are found to cause serious side effects in humans.  Without pharmaceutical company development of new drugs that meet the standards that are required for FDA approval, many diseases and conditions would remain untreated and we would all suffer. (Lack of special designer clothes would obviously not have the same effect!)

There were several reasons that pharmaceutical companies were granted broad based legal protections in the mid-20th century.  There was a valid concern that counterfeit drugs would be “palmed -off” to unsuspecting patients (and even their pharmacies) if they had the same appearance and packaging as brand-name drugs. At some point, the Third Circuit Court of Appeals upheld trade-dress protection because near-identical pills would facilitate the practice of “unscrupulous pharmacists” in “substituting less expensive generic drugs for the brand name drugs prescribed without informing their customers and without passing along the benefit of the lower price.” The courts also felt that allowing trade-dress protection served a public health function by preventing the substitution of one drug that was similar but not identical to another.

The 1997 FDA guidelines for expanding direct -to -consumer advertising of prescription drugs also made the images of pills more important to the drug companies. An example is sildenafil (you know it as Viagra, that diamond shaped light blue pill.) We all know about that “little blue pill”…it has become a stand up cultural phenomenon.

But now, that legal protection has begun to unravel. In 2003, there was a legal dispute about Adderall, a medication prescribed for children with attention deficit-hyperactivity disorder. The company that first produced it in 1996 stated that the color, shape and size of various doses helped children adhere to their prescribed regimens. When a generic company (Barr) tried to copy these color schemes the court agreed to let them; after all the original company (Shire) had claimed the importance of the color trade dress.  In the tradition of “if you can’t beat them join them” over the last 5 years, brand-name pharmaceutical companies have begun to license their trade dress to the manufacturers of authorized generics. And (for a price), some generics look the same as the name brand.

The suggestion offered by the authors of the article in NEJM seems to be truly appropriate: “Instituting a more consistent and organized system of pill appearance would increase patient adherence, reduce the complexity of medical regimens, reduce medication error, and encourage the rational use of bioequivalent generic drugs.”  I would also suggest that you bring in your bottle of current drugs so that your doctor or nurse can check the name, dosage and directions for use. None of us should rely on color, shape, aroma or flavor to identify a medication… No matter what it now looks like, it should be taken as directed.

Over the years many of my patients have come in with the happy announcement that their home pregnancy test was positive, but then voice their concern: ” I drank (wine, beer, the hard stuff) before I knew I was pregnant. Does this mean that I damaged the pregnancy? Should I worry?” (This is LA, some were already planning the preschool, grade school, high school and ivy league school that the 7 week old fetus would eventually be attending and worry that her or his chances were ruined!)

Fetal alcohol syndrome has been recognized for over a century. (It obviously has been around for as long as fermented beverages have been consumed; although when I watch all those television series about 16th century nobility, the males seem to be imbibing while the erstwhile maids, women and even princesses and queens are rarely portrayed sipping wine or mead. Considering the absence of birth control, some must have been pregnant.) Full blown fetal alcohol syndrome is pretty hard to miss: it manifests as low set ears, facial changes small chin and jaw, small head circumference, joint contractures, cardiac defect, varying degrees of mental retardation, behavioral abnormalities, hyperactivity and developmental delays. This array of fetal malformations can vary but, in general, has been associated with alcohol abuse (5 or more drinks a day) that continues throughout the pregnancy. So, could a mere drink or two a week in the first trimester do harm?

This question was addressed in a study published in a 2010 British Journal of Obstetrics and Gynecology and recently reviewed in the journal titled Obstetrical and Gynecologic Survey. (The latter allows me to catch up on the myriad articles published in my field.) The article detailed a prospective study of 2900 pregnancies in Australia (where I guess alcohol is readily available) between 1989 and 1999. A 14-year follow up of the children born to the women allowed the researchers to ascertain if alcohol had been harmful to the children’s behavior and development.

During various times in their pregnancy, the women were asked if they were or had been abstaining from all alcohol or occasionally drank (up to one standard drink per week), drank lightly (2-6 standard drinks per week), moderately (7-10 standard drinks per week) or heavily (11 or more standard drinks per week). The children from their pregnancies were then studied at birth and at 2, 5, 8, 10 and 14 years. The researchers also tried to correct for variables that could influence a child’s behavior, such as maternal age and education, the occurrence of stressful events during the pregnancy, maternal smoking and the presence of the father in the home as well as family income.

The results were somewhat surprising: In this analysis, the offspring of women who drank 2 to 6 or 7 to 10 drinks per week during the first 3 months of pregnancy did not have behavior problems up to the age of 14, and in fact had better behavioral scores than the offspring of mothers who did not drink at all!
The author of the review article points out that fetal susceptibility to alcohol is now known to be partially dependent on how rapidly alcohol is metabolized by the mother. Those who metabolize it more slowly have a higher peak blood alcohol level for a longer time than “fast metabolizes”. Alcohol breakdown (not that of the drinker, but that of the intoxicant) is dependent on possessing certain alleles (or genes), called ADH1B2 and ADH1B3. (Of note ADH1B3 has a high frequency among African Americans; unfortunately, the Australian study did not report the race of their participants.) But then how many women know their alcohol allele status? So although the allele data is interesting, it probably won’t help most women’s concerns regarding their alcohol consumption, especially in early pregnancy.

Bottom line: There are many factors that influence fetal susceptibility to alcohol, and it’s certainly best to “play it safe” and just not drink during pregnancy. But the current study allows physicians to continue reassuring their patients that have drunk less than 11 drinks per week in their first trimester that this was unlikely to have caused adverse fetal affects. And I have to add…. no one can guarantee the “right” school admission

I just returned from New York, so I am in “a talk about air travel” frame of mind.  (The reason for the trip was a board meeting for Save The Children. They are doing some amazing work to help children, mothers and families in Haiti as well as the USA and developing countries around the world….please go on their website http://www.savethechildren.org for more information.)

As usual, I felt that the flight was interminably long, the air was dry and the food….well, I won’t discuss it here, I already did a segment about microbes on the plane. But what I haven’t addressed in the past is whether it is safe for pregnant women to fly.  ACOG (the American College of Obstetricians and Gynecologists) issued a new committee opinion in October 2009. Here is a brief summary…

If there is a complication in pregnancy, it will usually occur in the first or last trimester (bleeding and miscarriage initially, premature labor and delivery the last trimester). Most commercial airlines allow pregnant women to fly up to 36 weeks. Some may be more restrictive when it comes to international flights. (I know my daughter was told she could not fly on El AL after 32 weeks and she had to bring a letter from her obstetrician to show that she was less than that on her last flight).

Air travel is certainly not recommended during pregnancy for women who have medical problems (especially cardiac) or obstetrical problems. (The latter would include bleeding, a possible impending miscarriage, pre-eclampsia, a history or risk of premature labor, a pregnancy complicated by hypertension, diabetes or failure of normal growth of the fetus). The airlines and your doctor do not want you to go into labor on a long flight, begin to hemorrhage, or rupture your membranes (even if you are the at-that time-Alaskan governor!)

All travelers should avoid dehydration and immobilization for long periods of time; we all know about the risk of deep vein thrombosis… this is even more of an issue if you are pregnant. So wear support stockings, drink plenty of water (my advice is a 6 ounces for every hour of flight), move your lower extremities (well, if you drink enough you’ll have to make frequent trips to the bathroom!), avoid restrictive clothing (no tights) and don’t consume gas-producing drinks (carbonated sodas) or foods before flying.

And remember, there is no way to predict sudden turbulence. So keep that seat belt fastened below your hipbones while seated.

Now, let’s consider radiation exposure which increases at high altitudes. The current recommendation is not to be exposed to more than 1mSv over the course of a 40-week pregnancy. Even the longest intercontinental flights will expose passengers to no more than 15% of this limit. (So round trip should be 30%.) For the “average” pregnant flier, this should not be a problem. But if you are a frequent flier or are a part of the air crew, you should check with your employer and the Federal Aviation Administration.

Final recommendation by ACOG: “In the absence of a reasonable expectation for obstetrical or medical complications, occasional air travel is safe for pregnant women.”

And I would like to add… especially if you don’t have to fly coach!

We have all heard about the importance of breast feeding….for the baby. But less attention has been paid to what lactation can do for a Mom’s future risk of cardiovascular disease. So here are some breast-to-heart facts: Breast feeding increases caloric expenditure by approximately 480 calories a day, which of course means that pregnancy weight is more easily lost postpartum. Lactation improves glucose tolerance. (This means that when you do consume sugar or anything converted to glucose, your insulin levels won’t instantly surge; as you know surging insulin is not good, it can cause fat storage and increased “bad” triglycerides). Breast feeding also helps general fat metabolism and will lower the C-reactive protein profile. (C-reactive protein is a marker for inflammation and is correlated with the inflammatory process that increases development of plaque and cardiovascular disease). There are also a number of studies that have shown a long term benefit for lactation on midlife metabolic syndrome (high blood pressure, high triglycerides and obesity) and cardiovascular disease.

A new study published in the January Journal of Obstetrics and Gynecology gave additional credence to the “breast feeding is good for a Mom’s heart” theory. (Of course it’s good for emotional heart aspects, but that’s not what this article is about). In 1996 and 1997, The Study of Women’s Health Across the Nation (aptly acronymed SWAN) was established. Women between the ages of 42 and 52 were followed in seven sites. Two hundred and ninety seven of these women who reported at least one live birth on enrollment were enrolled in this aspect of the study; 121 women consistently breast fed all their children for at least 3 months, 84 inconsistently did so and 92 did not. Special electronic beam tomography scans were done on all the women to measure the amount of calcification in their coronary arteries and aorta. (Note calcification of these areas indicates the presence of atherosclerotic plaque and its presence has been show to increase the risk of heart attack or stroke.)

Those women who did not breast feed were more likely to be African American, more likely to smoke, consume fatty food, and ingest more calories. They were also less likely to be college graduates than the women who breast fed. But before we say voila, maybe these factors were more important than whether they breast fed, note that the statisticians adjusted for all of these factors. And they still found that mothers who had not breast fed were 3.82 more like to have aortic calcification and 2.78 more likely to have coronary artery calcification than those who had.

Bottom line: The decision to breast feed has implications not just for the health of the baby, but also for the heart of the Mom. Breast feeding may help her stay healthy longer and allow her to care for and cherish her children. Let’s make sure we, our daughters and any friends who plan to have a baby are aware of this!

Exposes about food contamination have been the subject of socially and nutritionally minded authors for hundreds of years. In 1906 Upton Sinclair wrote the book “The Jungle” which detailed the horrible conditions in Chicago’s meat packing houses. (Remember he wrote about workers who fell into rendering tanks and were ground along with animal parts!) Although conditions for the workers (but not necessarily the cows) have vastly improved, contamination of meat products (usually from bacteria) as well as vegetables and fruit are still common, especially as food sources go global. (Do you know where your strawberries come from? What about your fish?) And when a particular pathogen enters the food chain and causes sickness or death to the consumer, it enters so many widely distributed products that identifying its final “resting place” (other than the GI system of the unfortunate person who ate it) requires extraordinary food surveillance. The CDC estimates that 5,000 Americans die from 76 million cases of food-borne illness in the United Stated every year. The most susceptible are the very young, the very old, the immunocompromised, pregnant women and their fetuses.

Pregnancy can diminish immune resistance and an unfettered infection can cause miscarriage as well as fetal malformations, disability, illness and death to the newborn. Hence food safety and safe food choices are especially important in pregnancy. Here are some of the food-borne pathogens and the foods that may contain them that merit special attention…

Listeria monocytogenes

This bacterium is usually killed by pasteurization and cooking. It can, however be airborne and contaminate treated foods. And to make matters worse it can grow inside a refrigerator!

Foods likely to be contaminated: Unpasteurized milk products, refrigerated and ready-to-eat- products (dairy, meats, poultry and seafood and deli products). The prevalence of Listeria in these foods is estimated to be nearly 2%. Food packaged in the store is less safe than that packaged by the original manufacturer.

Symptoms: Typically mild…low grade gastroenteritis, or flu like symptoms. More serious infection (called listeriosis) causes vomiting, abdominal pain, diarrhea with fever and in some cases meningitis and overwhelming infection (septicemia). Pregnant women are 20 times more likely to develop listeriosis than all other individuals, indeed one third of all cases occur during pregnancy. And even if the initial symptoms are mild, the bacteria may cross the placenta and infect the fetus.

The FDA and CDC have issued guidelines for safe eating in pregnancy in order to avoid listeria infection. These include:

* Avoid cross-contamination with fluid from hot dog packages.
* Keep raw meets separated from vegetables, cooked food and ready-to-eat foods.
* Eat perishable foods as soon as possible.
* Throw out expired food.
* Wipe spills immediately and clean the refrigerator regularly with hot water, liquid detergent and then rinse.
* Eat lower risk food and avoid unpasteurized milk or any foods from raw milk!
* Don’t eat hot dogs, luncheon meats or deli meats unless reheated or steamed. Don’t eat refrigerated pates or meat spreads. (OK if canned)
* Don’t eat refrigerated smoked seafood unless it’s in a cooked dish. These are often labeled “nova-style”, “smoked”, “kippered” or “jerky”. (So there goes that bagel, cream cheese and lox…I guess the bagel and cream cheese can stay as long as the latter is pasteurized!)

Toxoplasma gondii:

This is a parasite which can cross the placenta and cause surviving children to have long-term problems (specifically serious eye and brain damage). Most pregnant women have no symptoms when infected. The fetus is at risk if the mother is exposed just before or during her pregnancy, but is unlikely to become infected if the mother has had the infection in the past. (This can be checked with a special antibody test; however, the test is not routinely done in the US because there are no established effective treatments.)

Food Sources: Contaminated meat, especially wild game (if undercooked or raw), unpasteurized milk, unwashed fruits and vegetables, contaminated water.

Other Sources: Cats are hosts to this parasite and become infected if they are kept outdoors, hunt and/or eat raw meet. They excrete the toxoplasmosis as cysts or eggs in their feces. The chance of infection from a cat is low if it is kept indoors, doesn’t hunt or eat raw meat. (Cat food manufacturers know this.)

Here are the CDC guidelines to prevent Toxoplasmosis infection:

* Freeze meat for several days before cooking
* Cook meats to at least 160 degrees (or higher to kill other pathogens). Note meats that are smoked, cured in brine, or dried may still be infectious.
* Keep children’s sandboxes covered.
* Wear gloves when gardening or handling sand in sand boxes.
* Peel and thoroughly wash fruits and vegetables before eating.
* Keep your cat indoors; don’t feed it raw or undercooked meats or unpasteurized milk
* If possible have someone else change the litter box, if not, wash your hands and disinfect the litter box daily with near boiling water for 5 minutes.
* Don’t get a new cat while pregnant or handle stray cats, especially kittens.
* Don’t drink unpasteurized milk, including goat’s milk.
* Don’t drink water from the environment unless it’s boiled. (I guess they mean water from rivers and streams…. This seems like a good idea in general.)
* Control rodents (I won’t comment on this one).
* If you butcher wild game or venison, bury the organs so that feral cats can’t eat them and spread infection. (I guess this applies to very few of us, oh, but wait…there’s Sarah Palin!)

Raw Fish:

This is where raw sushi and sashimi get boycotted by pregnant women. Raw fish can harbor parasites such as roundworms, tapeworms and flatworms as well as bacteria and viruses. And don’t forget, ceviche (fish prepared in acid and not really cooked) is included in the raw category. If you do dine in a Japanese restaurant during pregnancy order the vegetable or cooked sushi, although some purists might worry that these are prepared with the same utensils as the raw stuff. Maybe you should just get the teriyaki or the noodle soup…

Sprouts:

Just when you thought that you could and should consume healthy vegetables such as sprouts (alfalfa, clover and radishes), I have disappointing news. It turns out that sprouts have been found to contain E.coli and Salmonella. (A 2007 survey of retail foods in the US found a bad strain of E.coli in 1.5% of alfalfa sprouts compared to 0.17% of ground beef that they sampled!). Sprouts are produced under warm, moist conditions which encourage the growth of bacteria. They become internalized in the seed during sprouting. So washing doesn’t remove the bacteria! The only safe way to eat sprouts during pregnancy is to cook them.

Eggs:

So many chickens live in crowded squalor, infecting one another and their eggs with salmonella. The current estimates are that 1/20,000 eggs contain this bacteria. We are not talking abstention here….just cook the egg until the whites and yolks are firm. If you are making Cesar salad or a food that requires raw egg, use pasteurized egg. And always wash you hands after handling eggs.

Peanuts:

Strictly speaking, this legume should not be part of a discussion of contaminated foods. But peanut allergy is such a concern, I have included it in this article.

Should a pregnant woman avoid eating peanuts in order to diminish the risk of peanut allergy in her child? We used to tell pregnant women that this was a forbidden nut. But statistics subsequent to this admonition have shown that it doesn’t seem to make a difference and peanut allergy in children has increased. Indeed a 2008 study showed that sensitization does not appear to occur from intra uterine exposure. According to the American Academy of Pediatrics there is a lack of evidence that maternal dietary restrictions during pregnancy play a significant role in the prevention of peanut (and other) allergies in infants. So if you have some peanut butter, don’t feel guilty.

Water:

Municipal water is generally very safe in the US. (Although I probably should modify this statement… there was a recent article in the New York Times that exposed water contamination that was not reported nor efficiently dealt with by the EPA….mostly in smaller communities.). Most bottled water does not contain fluoride which will benefit the future teeth of the developing fetus. And if water is sold in certain types of plastic containers it can become contaminated with potentially harmful chemicals.

I have not dealt with “the fish or no fish” debate (other than the raw kind) nor have I begun to discuss organic versus non organic, processed food, fats or caloric intake. I’ll leave all that for another article (or more). But I hope that the above gives you (if you are pregnant) or someone you care about (i.e. daughters, relatives and friends) a sense of which foods and food preparations are potentially harmful to a pregnant women and her baby. When it comes to contamination and infection, she is eating for two.

My daughter is pregnant and she, like many pregnant women, has been offered the possibility of private umbilical cord blood banking. She might ask my opinion.

I get offers to put oodles of information and brochures in my waiting room for expectant parents (I don’t, since I no longer deliver babies). Absent information directly proffered by obstetricians, women are targeted by private cord banking companies through direct to pregnant –consumer advertising in prenatal magazines, web sited and the peer pressure established among pregnant women and their families as they traverse the studies, tests and tribulations of their gestation. So when that final push for a healthy baby is made by the Mom (or by the obstetrician if she has a C Section), should there be one more painless procedure performed? Should cord blood with its special stem cells be removed and sent for private storage for the next 20 years just in case it can be used as “biologic insurance” against a future disease of the child or a sibling?

A recent review that addressed cost-effectiveness of this procedure was published in the Journal of Obstetrics and Gynecology. They cited a survey by the American Society for Blood and Bone Marrow Transplantation of private umbilical cord blood banks; of approximately 460,000 private banked cord blood units, only 99 had been shipped for transplantation. Another survey of 93 pediatric specialists who perform the transplantations in the United States and Canada reported that only 49 transplants had been done in the donor child or its siblings; moreover in 36 of the instances, there was a known disease in a sibling and the blood had been collected preemptively.
There are several problems that may cause this minimal use: Some of the samples were contaminated by bacteria, others were improperly labeled. The literature indicates that 25% to 56% of cord blood specimens could not be used either because the stem cell count within the blood was too small or because of problems with the blood’s storage. Then there is the issue of whether the transplantation will help the disorder for which it is given. Currently the estimate of probability of future need for cord blood for treatment of the donor child is 1 in 2,500 or 0.04%. (It is currently used for bone marrow failure which can cause aplastic anemia or for blood malignancies such as leukemia as well as certain metabolic disorders.) However, if the donor child does develop leukemia there is concern about transplanting his or her own stem cells since they may have the propensity to become malignant. This would not be a problem if a sibling needs the stem cells obtained from the cord blood of a presumably healthy donor child. Hence the probability of using umbilical cord blood for a sibling is a little greater, but still rare, 1 in 1,425 or 0.07%.

The cost of private umbilical cord banking and storage for 20 years is high and according to Web sites ranges from $3,620 and $4,170.

The final assessment in what the statisticians call “base case analysis” (sorry but you might as well learn some new terms) is that private umbilical cord blood banking results in a lifetime gain of 0.0026 years. And if the cost is $3,620 (compared to $0 if not done) this amounts to an additional expenditure of $1,374,246 per life year saved.

The only way it might be “cost effective” (a term we will hear more and more as we strive to reduce the cost of health care) is if the likelihood of a child needing its own stem cell transplant was greater than 1 in 110 or of the likelihood of a sibling needing a stem cell transplant rose to 1 in 43…and/or the cost of umbilical cord blood banking was reduced to $262 (or less than 7% of what it is now).

The American College of Obstetricians and Gynecologists and The American Association of Pediatrics have already made statements recommending against private cord blood banking unless there is a family member with a known diagnosis that could be treated by umbilical cord blood. Despite this many patients still want to “play it safe” probably because they don’t understand the statistics and overestimate the probability of the need for its use. (And the data may not be appropriately explained.) Let’s also acknowledge the medical magic implied in the term “stem cells”. If we can get them for our progeny, it can’t be unnecessary or too expensive.  Obstetricians are placed in a difficult position and often have to accommodate their patient’s request. Dissuading is harder than accommodating.

The cost benefit for use of umbilical cord blood transplants would greatly benefit from a program of public cord banking. But alas this is not available in most areas of the United States.

Bottom line (and I’ll try to convince my daughter)…private umbilical cord blood banking is cost effective only for families with rare blood diseases in which a child has a very high risk of requiring a stem cell transplant. The for-profit private cord banking facilities are unlikely to stress these facts.

We could ask our kids (rarely works), speak to the school administrators (they are probably the last to know),  read Seventeen and Cosmo or just look with despair at the promiscuous styles offered to and requested by young girls (and boys).

In my perusal of journals, I found a fascinating study which addresses this question. It comes from the National Youth Risk Behavior Survey conducted from 1999 though 2007. (Remember it takes a year or two to collect, analyze and publish information of this sort, hence it did not include ‘08 and ‘09.) Researches analyzed data from this survey to determine age at first intercourse in 66,882 black, Latino and Latina, white and Asian students in grades 9 though 12. According to the students’ anonymous self reports, the probability for “coital debut” by their 17th birthday (I’m assuming they meant vaginal intercourse, the use of euphemisms in medical reportage is astounding!) was: 82% for black males, 74% for black females, 69% for Latinos, 59% for Latinas, 53% for white males, 58% for white females, 33% for Asian males and 28% for Asian females

Now before we take this report and approach our children or grandchildren with queries as to whether they fall into the above listed statistics (“did you or didn’t you?”), I should point out that the survey was based on self-reported data. Girls are more likely to underreport sexual activity, whereas boys tend to over report. The survey did not stratify the groups by parental income or educational level, nor did it differentiate between public or private school attendance. And the study did not include youths who had dropped out of school (who would, most likely, skew early coital debut to higher probability).

I realize that parents don’t always like to look at gross statistics when it comes to their own progeny. But this large study does show us that a majority of teens self report that they were sexually active before the age of 17. It’s way better than rumors… and should help parents decide when to make sure that their daughters have access to appropriate contraception. (This may have the appearance of a plug for Planned Parenthood and I should disclose that in the past I was on the board of the LA chapter of this organization). We know that timing is important for HPV vaccination. The best results will be achieved if the vaccine is given before a girl becomes sexually active. Hence most pediatricians now discuss this with parents at a time when they are not quite ready to consider that their “little girl” will engage in sexual activity. But they will… Finally this survey emphasizes what we already know; all young teens should be taught about STD’s and the need for protection before they have that first, often too early, sexual encounter.