UNC Women's Care

Zika Update from UNC OB-GYN | Aug. 1, 2016

2016-08-01T07:31:00.000-07:00

By Dr. Bill Goodnight

Dr. Bill Goodnight

Dr. Bill Goodnight is an associate professor of maternal-fetal medicine at UNC OB-GYN.

Does Zika virus cause miscarriage?

Recent case reports have demonstrated the Zika virus found following an early miscarriage. This is not entirely unexpected as other viral infections have been associated with early pregnancy complications (parvovirus, CMV) and supports that the fetus is most sensitive to infection in the first half of pregnancy.

There are some precautions women can take. Those attempting pregnancy or currently pregnant should use the same Zika precautions as recommended for all – avoid travel to affected areas, use insect repellant and avoid intercourse with partners with Zika exposure risk or use a condom with intercourse.

Whether Zika can cause or miscarriage remains unproven, but this does suggests an association. However, this does not change recommendations for testing and does not suggest that all miscarriages should be tested for Zika virus.

Were the new cases in Florida acquired there?

There are four cases in Florida, three men and one woman, all in one part of one county, that appear to be locally acquired, not a travel-related infection. This means the human infection came from mosquito bites in Florida, implying that some mosquitos in Florida now carry the Zika virus. Casual person-to-person transmission of Zika does not appear occur.

This was not all that unexpected, as we know that the range of the mosquito that carries the Zika virus includes Florida, the South East and southern U.S. It is recommend that pregnant women continue to practice avoidance techniques to avoid risk of acquiring Zika. Sleep in air-conditioned or screened areas, use insect repellant, avoid travel to areas with active local transmission and use condoms for intercourse with partner who may have Zika exposure.

Should pregnant women cancel vacations to Florida this summer?

The CDC does not currently include Florida in its Zika travel advisory, but if in the next few weeks these cases are confirmed, pregnant women may need to consider avoiding unnecessary travel to Florida. In addition, those living in Florida should continue to use mosquito avoidance practices. The most up to date information on areas where pregnant women should limit travel includes the CDC website: www.cdc.gov and the Florida health department website.

What’s new with Zika?

The most recent CDC updates (as of 7/25/16) include changes in the type of maternal testing – RT-PCR test is used for the detection of the virus in urine and serum, and can now be done up to two weeks after exposure.

Ultrasound monitoring remains unchanged and includes a detailed anatomic evaluation and follow up ultrasounds based on results of maternal testing (if done) and potential for exposure: http://www.cdc.gov/zika/pdfs/testing_algorithm.pdf

Visit our Zika page for more information on how UNC OB-GYN is contributing to the Zika virus conversation.

Endometrial albation | What women should know

2016-06-10T06:41:00.000-07:00

By Dr. Janelle Moulder

Dr. Janelle Moulder, a faculty member in UNC OBGYN’s Division of Minimally Invasive Gynecologic Surgery, recently co-published in Current Opinions in Obstetrics and Gynecologyan update and review on endometrial ablation as a treatment for abnormal uterine bleeding, including modifications to initial treatment guidelines and current data on long-term outcomes.

Here she gives a rundown on the procedure, which many women start hearing about when they investigate solutions to their heavy menstrual bleeding.

Dr. Janelle Moulder

What is endometrial ablation?

Heavy menstrual bleeding can be very disruptive to a woman’s everyday life. Endometrial ablation is a relatively common procedure that surgically ablates or “burns” the lining of the uterus – or the endometrium. By destroying the lining, menstrual flow will be greatly reduced and sometimes even stopped for good.

What is the benefit to this method of controlling heavy uterine bleeding?

Over the last decade, the technique itself has changed considerably – it’s easier on the patient and easier for the physician to perform. This continues to be a successful treatment for abnormal uterine bleeding in many patients, and can be a less invasive alternative to a hysterectomy with fewer days away from work.

Who is a good candidate for ablation?

Women who are experiencing heavy bleeding, are finished having children, and have had a thorough evaluation of the source of abnormal bleeding would find this procedure helpful. With proper patient selection, ablation is considered to be very successful – 80 to 90% of patients see a reduction in their heavy menstrual flow. Providers should always talk to their patients about success rates, factors associated with failure, alternative treatments to ablation and the long-term consequences related to ablation.

Which patients are not right for this procedure?

I wouldn’t recommend this for my younger patients – women who are under 40 and who have not yet started a family – or who may desire more children. Ablation of the endometrial layer could have a very negative impact on a pregnancy that is able to implant after the procedure. If you have a history of pelvic pain or have a history of tubal ligation, this procedure could lead to an increase in pelvic pain. Finally, if your doctor thinks you may be at risk for endometrial hyperplasia or endometrial cancer, this procedure may limit the ability to make a diagnosis of these conditions in the future.

What should women consider before undergoing an endometrial ablation?

Endometrial ablation may make it harder for your doctor to sample the uterine lining if you have new abnormal bleeding in the future. And, it’s important to remember that it isn’t curative: between 13 to 30% of women will go on to have a hysterectomy, some within two years of the ablation.

Also, endometrial ablation isn’t a sterilization technique. Women should have reliable contraception following ablation, due to the procedure’s negative impact on a pregnancy, should one occur.

Carolina helps fill the gaps on fibroid research

2015-11-20T05:52:00.000-08:00

By Dr. Wanda Nicholson

The Duke Clinical Research Institute (DCRI) will serve as the research and data coordinating center for a five-year, $20 million project to evaluate the effectiveness of different treatment strategies for women with uterine fibroids. The University of North Carolina at Chapel Hill is one of nine participating sites for the project, called Comparing Options for Management: Patient-Centered Results for Uterine Fibroids (COMPARE-UF). Dr. Wanda Nicholson, professor of obstetrics and gynecology at UNC-Chapel Hill, and director of the PoWER program, is the principal investigator for the UNC site.

Dr. Wanda Nicholson

What are the symptoms of uterine fibroids?

Fibroids are considered to be benign tumors of the uterus, not cancerous, but they can negatively impact day-to-day life in terms of how you feel. Two key symptoms are pain and bleeding. A patient may have one or the other, or both in combination. So, you can imagine that either one of those symptoms will prompt women to seek medical advice. These are symptoms that can be very stressful or anxiety provoking. If someone is in pain at work, they are not going to enjoy work, and they are not going to be as effective. Fibroids can also affect a woman’s plans for pregnancy.

What should women know about fibroids?

Fibroids are common among all women, and they can be even more common in certain subgroups of women. For example, African-American women are twice as likely to have uterine fibroids. While we manage fibroids on a daily basis, there are big gaps in our knowledge about what causes or contributes to them. We don’t yet have all the answers about what the best treatment is for each individual woman.

We have a wide range of treatments for fibroids, and we try to cater them to women based on preferences for surgery or medical treatment, based on where they are in their lives. But, the truth is, women have a broad lifespan and fibroids can occur at any time. We still have some gaps into what’s the best individual treatment for the women who is sitting across from you in the exam room.

How are fibroids treated?

Fibroids treatments fall into three broad categories ranging from no intervention to surgical intervention:

Watchful waiting: We don’t do any management here. We watch and see whether the symptoms might worsen or stabilize, and there are a lot of women who elect that management.

Medical therapy: We sometimes manage the symptoms of fibroids with medications, like pain medications that might be a simple as over-the-counter ibuprofen. We also have hormonal medications that we might use to control the bleeding, like birth control pills, progesterone pills or hormonal injections.

Surgical treatments: This could be something as minor as endometrial ablation, a one-day outpatient procedure, or something more involved like a myomectomy or hysterectomy.

What causes fibroids?

That’s one of the big gaps in science – we don’t know yet. There’s an incredible amount of research taking place from investigators from across the country that are funded by the National Institutes of Health (NIH), which is committed to better understanding what causes uterine fibroids. We think fibroids can be caused by a host of reasons, and there are studies taking place right now looking at the effects of certain environmental exposures. It could be lifestyle, or maybe part of it is diet or hormonal influences. There’s also suggestion of genetic implications related to fibroids, since we know they run in families of women.

African-American women are twice as likely to suffer from this condition. Do we know why?

That’s another our gap in knowledge that we are currently working to find out. We aren’t quite sure why it’s so common or what’s contributing to it. As we look at African-American women, we are looking at what is happening in their lives that is making it twice as likely they’ll develop fibroids. We also know that when they occur in African-American women, fibroids can grow quicker and larger and occur early in the lifespan, which can impact childbearing years. We are also looking at how this impacts stress and anxiety. It can impact your job if you’re having pain and bleeding. It can affect your quality of life: work like, family life, social life in so many different ways.

How does the Compare-UF study differ from the ways fibroids research has been done in the past?

The size. Compare-UF is a five-year study, and our goal is to recruit 10,000 women across 9 sites in the U.S. Once we enroll you, we’ll follow you over time for three-to-five years, depending on when you enroll. We follow you long term to evaluate you before treatment and in the years after. This kind of study reflects the commitment to research in this area to really try to fill these gaps. For a long time, those of us in the field have recognized that we needed a larger population of women, women across the age spectrum and across the US to be able to have results for all women. This study gives us enough time to follow women the way we need to.

Who can participate in the study?

We want to hear from all women between the ages of 18 and 54 who have symptomatic fibroids. What we mean by that is pain, bleeding, difficulty with getting pregnant, or some combination of that, and women who, because of those symptoms, have been diagnosed by their doctor with uterine fibroids through an ultrasound or MRI. If you meet those criteria, we want to hear from you. You can live anywhere in the Triangle area. So, if you got care at UNC, if you got care at Duke, if you got care at Rex, you can participate here.

What makes UNC a good site for this study?

At an institutional level, UNC is committed to the health of everyone in North Carolina, so this reflects our commitment to health improvement and our commitment to population health. With regard to our Department of Obstetrics and Gynecology, it reflects our commitment to the health of women. Participating in this study reflects our clinicians and other investigators’ commitment to improving the lives of women with uterine fibroids. We recognize that there are gaps in science that need to be filled and part of fulfilling our mission for providing better care is our ability to participate in the studies. They will give us the data that we can translate into providing better care. So, we’re on both sides of the spectrum: providing great care using the expertise of our clinicians and surgeons, and at the same time, being engaged on the pulse of ongoing research that’s going to further influence the care of women.

To find out how to enroll in the study, visit compare-uf.org

Family planning after childbirth

2015-11-12T12:09:00.000-08:00

By Dr. Matthew Zerden, Clinical Assistant Professor in the Division of Family Planning at UNC OB-GYN

Choosing the right contraception after a pregnancy can take time and may require a series of discussions. I encourage patients to be proactive about considering their contraception early in their prenatal course, and not waiting until after they’ve given birth. Pregnancy can be an opportunity for a patient to engage her provider so that she ends the postpartum period with a reliable and effective form of birth control that allows her to achieve her family-planning goals.

We at UNC (with partners at WakeMed and the Wake County Health Department) led a study on this topic that was recently selected as a Women's Health Issues Editor's Choice article and appears in the November/December issue of Women’s Health Issues. Here, I note some highlights of the work my team and I have done on long-acting reversible contraception (LARC) as well as what these findings mean for women:

1. Spacing pregnancies is a good idea.

Research tells us that the ideal spacing of pregnancies for maternal and subsequent infant health is 18-24 months after delivery. For this reason, we know that it is very important to be able to plan for a pregnancy – especially for the health and well being of mom and the upcoming pregnancy.

2. Women have many choices for birth control, but some are more effective at preventing pregnancies than others.

ZERDEN

The most effective forms of reversible contraception are the intrauterine device (IUD) and the contraceptive implant – LARC methods. These devices are very safe, last multiple years, and best of all, they do not require the user to do anything on a daily, weekly or monthly basis. They are as effective as surgical sterilization (i.e., having your tubes tied or your husband having a vasectomy), yet they are reversible. In other words, to become pregnant again, simply have the LARC removed.

3. Most hospitals don’t offer LARC placement during delivery hospitalization – but that could change.

While it is safe and effective to have LARC placed before delivery discharge, we do know that IUD’s placed immediately after delivery are slightly more likely to fall out of the uterus compared with ones placed at other times, including at the postpartum visit (which typically occurs at 6 weeks postpartum). However, women can get pregnant again as early as the fourth postpartum week if they are not exclusively breastfeeding, and many women experience challenges returning for a postpartum visit. The combination of a delayed or missed postpartum visit with the bodies return to fertility places women at risk of an unintended pregnancy.

4. Women who are interested in obtaining LARC after delivery should bring up the topic during prenatal care.

Pregnancy offers a great opportunity for patients to have a strong connection with their obstetrical team. It is important to find out if your obstetrical team is able to place LARC in the hospital. It is also important to discuss breastfeeding and other considerations, such as which LARC you desire: there are currently four IUD’s on the market, and one contraceptive implant.

5. It’s up to you.

Of course, the best time in the postpartum period to have LARC placed is an individual decision that needs to be discussed between a patient and doctor. A lot of patients who may be interested in LARC have read on the Internet about a patient with a bad outcome. Although these rare events do occur, we know that LARC is overall very safe, very effective at preventing pregnancy, and has very high rates of patient satisfaction – higher than most of the other traditional forms of contraception such as the birth control pill, patch or ring. LARC works extremely well at preventing pregnancy, but for those women who are not in a single relationship, they should remember to use barrier protection (such as condoms) to prevent sexually transmitted infections (STIs).

Dr. Matthew Zerden’s study "Barriers to Receiving Long-acting Reversible Contraception in thePostpartum Period," was recently selected as a Women's Health Issues Editor's Choice article and appears in the November/December issue of Women’s Health Issues. Dr. Gretchen Stuart, director of the Division of Family Planning, and Dr. Sarah Verbiest, executive director for the UNC Center for Maternal and Infant Health, and Dr. Jennifer Tang, assistant professor of Global Women's Health, are also featured authors on this study.

UNC Global Women's Health a strong presence at 2015 FIGO World Congress

2015-10-12T09:14:00.000-07:00

By Dr. Jennifer Tang, assistant professor of Global Women's Health in the UNC Department of Obstetrics and Gynecology

DR. JENNIFER TANG

This past week was a productive one for UNC OB/GYN's Division of Global Women's Health team in Malawi. Dr. Lameck Chinula, our fellow Dr. Dawn Kopp and I presented at the 2015 FIGO World Congress of Gynecology& Obstetrics, which was held in Vancouver, Canada from October 4-9, 2015. More than 6,000 OB/GYNs from 140 countries attended this important meeting, which is the largest international conference of OB/GYNs from around the world and held only once every 3 years.

The Malawi team had a combined total of five oral presentations and two posters, including a talk on the use of an innovative Doppler ultrasound fetal heart monitor in labor (Dr. Chinula), findings from an NIH-funded study of family planning use among postpartum Malawian women (Dr. Kopp) and the results from an ACOG-funded study on the ultrasonographic and hormonal characteristics of obstetric fistula patients (Dr. Tang).

In addition, we were all inspired by UNC OB/GYN profesor Dr. Bert Peterson's keynote lecture on "Great Moments in Global Health and Why We are in One Now!," which helped to remind us of the important advances that have been made towards meeting the Millennium Development Goals and how successful implementation of our research findings will lead to even greater global women's health achievements in the years to come.

Our team's successful representation at the FIGO conference illustrates the impact that the UNC Global Women's Health Division has on improving the lives of women in a country with one of the highest maternal mortality ratios in the world.

Why I Chose Midwifery: A Q&A with UNC Midwife Jenny Cox

2015-10-09T05:50:00.000-07:00

In our last National Midwifery Week (Oct. 4-10, 2015) blog, UNC Midwife Jenny Cox talks about midwifery as ‘a wonderful way to take care of women’ and debunks myths about childbirth. See here and here for our other blogs with members of the UNC Midwives team on why midwife-led care matters.

JENNY COX

Why does midwifery matter at UNC?

Midwifery matters everywhere quite simply because women matter. UNC is just a small part of this, but is a shining example of how to offer a full range of options in a safe environment. Midwife means ‘with woman’ and women need individualized care for their pregnancies and childbirth. When we see women prenatally, 90 percent of what we do is what I refer to as ‘social call’ – getting to know people, establishing trust and rapport so when the birthday comes, there is as much ease as possible for that woman and her family. While most midwives focus on pregnancy and childbirth, we do gynecologic care as well. To see the same women year after year (and her growing child) is the best!

The International Confederation of Midwives has a vision of a ‘a midwife for every mother.’ That doesn’t mean that midwifery care is all every woman needs, but for normal, healthy pregnancy and childbirth, midwives are the experts. I have been with countless women in labor, and when you are ‘with woman’ during childbirth, when you really sit and observe the process, you know what normal looks like. Normal should be the standard against which we judge abnormal. If the process is no longer normal, midwives collaborate with physicians and other members of the healthcare team to deliver the proper services to optimize the health the mother and baby.

What are some of the different things a midwife might be looking for in knowing how best to support a patient through her birth experience?

Women come to pregnancy and childbirth with different health and life experiences, which shape their needs and desires. On top of that, pregnancy can be a very vulnerable experience for many women for a variety of reasons. In a perfect world, we would have limitless time to talk with women about their hopes and fears. For some women this may be related to the pain of labor, for others it could be trepidation at becoming a parent. While midwives have a lot of information we want to impart to women during a pregnancy and childbirth, it usually is not all that they want to know. If we just listen to women and their questions, we really don’t have to look very far to know what sort of support they need.

What is a common misconception about a woman who wants to have a say in how she delivers a baby?

This one is easy, and it is the belief that women with detailed birth plans care more about their experience in labor than the health of their baby. A healthy infant is invariably at the top of the list of a pregnant woman’s desires, and that never needs to be questioned. Sometimes plans change in labor by choice or circumstance, and we have to figure out a new path, but there are many choices and scenarios that can lead us to the same end point.

You were heavily involved in the hospital’s first clear-drape cesarean section procedure – Tabitha Dawes was your patient and brought the request to you. What was that like?

My job is to acknowledge what a woman wants, recognize the realities of what will work, and try to make the two come together as close as I can. When Tabitha and I first started talking about this, we made a list of her ‘pie in the sky’ desires. I spoke with her frankly about what I thought was realistic and what was not. That said, I proposed her whole list to the greater team because I’m not afraid to be told no! The team was interdisciplinary, including anesthesia, nursing, obstetrics and midwifery. Everyone involved was super-supportive of the Tabitha’s needs and of the midwives’ advocacy for Tabitha. It took a lot of right place/right time circumstances but now this option is available to all women and that feels great. Thanks for pushing the limits, Tabitha!

Why did you choose midwifery?

That’s a long story, but like many midwives, I feel this profession was a calling. The status of women’s health is a reflection of their overall status in society. Practicing midwifery is a wonderful way to take care of women – we are half the population, and we can get left behind. Contributing positively to this end is what keeps me coming back to work everyday.

Midwifery as part of evidence-based obstetrical care at UNC

2015-10-07T10:25:00.003-07:00

KATHY HIGGINS

In this Q&A, Kathy Higgins, certified nurse midwife and division director of UNC Midwives, explains how midwifery has fit in to -- and positively influenced -- obstetrical care at UNC OB/GYN.

To celebrate National Midwifery Week (Oct. 4-10, 2015), we'll be posting blogs with members of the UNC Midwives team on why midwife-led care matters. See here and here for this week's other blogs on midwifery.

Why does midwifery matter at UNC?

UNC is a medical tertiary care center geared to provide the highest quality care in complex cases. While there are some medical conditions that can complicate childbirth, overall birth is a normal process. Midwifery matters at UNC because it focuses on supporting rather than intervening in the normal process of childbirth. Having obstetricians of various specialties to deliver high-risk women and midwifery to provide support in low-risk women demonstrates UNC‘s commitment to women and their healthcare choices during pregnancy. It provides women and families an environment for freedom of choice in their birth experience with the confidence that in whatever their choice they will receive evidenced-based quality care.

What does it mean to have that choice?

It is important to meet women’s expectations of being involved in valuable and personal decisions about their healthcare. One of the most valuable life experiences is childbirth. Research shows that involvement in the decisions and care during their childbirth experience directly impacts women’s satisfaction and positive memories of the birth their children. The absolute core of midwifery is that childbirth is a natural process and a valuable life event. Midwives spend time with women and their families to determine what is important to them during pregnancy and birth. Exploration of their fears and what they identify as an experience that they value during birth is a primary focus for midwifery. Finding ways to alleviate fears or provide support in women’s birth care wishes while monitoring her and the baby’s safety and intervening when necessary identifies the practice of midwifery. Woman should have a choice for their childbirth experience and be able to choose the provider – obstetrician or midwife – that best meets their needs and desires.

What was it like to start the UNC Midwives division at UNC OB/GYN?

UNC has always delivered quality obstetrical care to the women of North Carolina. Electing to begin a Midwifery Service impressed upon me UNC’s desire to meet not only the physical needs of women but also the acknowledgement that women want a choice in the type of obstetrical and gynecological care they desire and need. I began the midwifery service in 1999. It has been amazing to see the changes to obstetrical care at UNC with the addition of midwives. There was a cultural change effecting a more conscious awareness for the nursing and provider staff to ask a woman’s plan for her birth, to individualize care, to provide intervention only when it was medically indicated, and to provide tools to assist women choosing a non-medicated birth: birthing balls, mirrors to view births, birthing bars. It is now an active process at UNC to learn from women what they value in childbirth and to explore opportunities to make their experience positive. This led to obtaining nitrous oxide as a pain management alternative, obtaining clear sterile sheets for cesareans to allow women to view their baby's moments after birth and Centering Groups, which are a group form of prenatal care.

What is next for UNC Midwives?

My vision for UNC Midwives is to continue being a driving force in innovation (like the option for nitrous oxide during labor) at UNC. I would also like to see the expansion of midwives' involvement within the healthcare systems policies to continue the support the culture where women have a choice in their care. In addition, for midwives to actively participate in research to investigate if long-held practices are myth vs fact in the continued effort to provide quality evidenced-based care. I would like to see the Midwifery Service at UNC become actively involved in the national conversation on midwifery and women’s healthcare.

What would you want a potential prenatal patient to know about midwifery at UNC?

Some people still don’t know that we’re here! Some people believe that all midwives deliver in the home or only work with women who want “natural childbirth without option for pain medication.” UNC Midwives deliver at N.C. Women’s Hospital, and there are a wide-range of pain management options available as desired. Mostly, I’d like women to know that they have options for their prenatal care at UNC. Women should think about the type of experience they desire, consider their medical health and investigate what choices in prenatal care are available to them at UNC. Women should feel empowered to seek the type of prenatal care and childbirth experience they desire. The UNC Midwives provide evidence-based care with the goal of giving women and their families involvement in their care and a positive birth experience. We work within a healthcare system with many resources available including obstetrician care for consultation or referral should their condition warrant that.

Why Midwifery Matters: A Q&A with UNC Midwife Meg Berreth

2015-10-06T08:34:00.002-07:00

MEG BERRETH, CERTIFIED NURSE MIDWIFE AT UNC OB/GYN

MEG BERRETH

Why does midwifery matter at UNC?

Midwifery matters at UNC because it offers women the full range of options that are available in the U.S. for their care. Midwifery focuses on low-intervention births and on the normal side of the childbirth process, and providing that service for women of this area is very important. Midwives are also available for women who have more complicated pregnancies but who would like that approach during their labor as well.

UNC has obstetricians and midwives. How do they work together?

Most patients specify early in their pregnancy if they want midwife or obstetrical care, and so for a lot of our patients, they only see a doctor at their ultrasound. But at UNC, obstetricians are are always available if a woman develops a complication during her pregnancy that necessitates a physician, whether that means a one-time consult or transfer of care. During labor, obstetricians are available if a complication arises, so that’s a really lovely safety net for our patients to have. We’re not surgeons, so if we need assistance with a surgical delivery they can help us with that. We work together so that it is a very smooth transition, if needed.

What is special about midwife-led care?

Midwife-led care has been shown in research to be as good as or better than physician-led care for low-risk women in terms of optimizing healthy outcomes for mom and baby. Midwives believe philosophically that labor and delivery are normal and that our job is to support a woman and help her and her family through that process. We spend time guiding our patients and helping them understand what to expect and making sure they understand the best ways to care for themselves. In labor we offer a lot of support for our patients and provide them with options that are research-based. So, I always say to my patients, if there’s more than one safe way to do something, I’m going to present those options and let you choose.

What kinds of myths do midwives encounter?

Yesterday, I told someone I was a midwife, and he said, ‘that sounds so turn-of-the-century,’ so I think the biggest myth we encounter is that people hear ‘midwife’ and assume that means delivering at home! While that is certainly something midwives do in this country, the majority of midwives deliver in the hospital setting, and that’s what I’ve always done.

People also assume that with midwife care you can’t have any pharmaceutical options for pain management. We certainly attract patients who are motivated for a non-medicated birth, and it is a normal part of our labor management to encourage coping techniques. We don’t induce labor without medical reasons, and we encourage the patient to move around on their own, wear their own clothing and eat if it’s appropriate.

But, about half our patients get epidurals and another small percentage use nitrous oxide or IV pain medication. I’d never want a patient to feel like its forced natural childbirth. It’s about a healthy mom, healthy baby and an experience a mom can feel good about.

Why do you practice at UNC?

I’ve been a midwife for 14 years, and UNC is my third hospital job as a midwife. Of the jobs I’ve had, UNC has got such an amazing balance for women. For the woman who has no complications and is low-risk, the nursing staff, physicians and midwives have created a culture where they support women in leading their own process, but in the safest way possible. I’ve seen places that did high-risk births very well, but with a low-risk woman, they wanted to intervene where it wasn’t necessary. I’ve seen others where they handled low-risk really well, but couldn’t really handle certain complications. At UNC, if something goes wrong here, we have every possible bell and whistle you could ever need to have a good outcome. To me, that is the ideal balance.

Cell-free DNA Screening for Fetal Aneuploidy: ACOG Weighs In

2015-07-06T12:20:00.003-07:00

Dr. Neeta Vora

by Neeta Vora, MD

Director of Reproductive Genetics, UNC-Chapel Hill

The American College of Obstetricians and Gynecologists has just released a new committee opinion on cell-free DNA screening for fetal aneuploidy, a condition in which a person has an extra or missing chromosome.

This opinion states that “any patient may choose cell-free DNA analysis as a screening strategy for common aneuploidies”. However, they still recommend that conventional screening methods (i.e, first trimester combined, integrated, or second trimester maternal serum screening) remain the most appropriate choice for first-line screening for most women in the general obstetric population.

What are the most important points for the obstetric care provider to know about this recommendation and cell-free DNA screening for aneuploidy?

Decisions regarding pregnancy management, including termination of pregnancy, should not be based on the results of cell-free DNA screening alone as it is a screening test and false positive and false negative results can occur.
While the sensitivity and specificity are high (≥98%) for trisomy 21 and trisomy 18, the positive predictive is low for young women, and can be as low as 10-35%. Sensitivity is lower for trisomy 13 and sex chromosome abnormalities (80-90%).
Only one laboratory is currently reporting positive predictive value for abnormal results. A positive predictive value calculator is available on-line (Grace M, et al, AJOG 2015) at: http://mombaby.org/nips_calculator.html
Pre-test counseling for cell free DNA screening is strongly recommended. If the provider orders cell-free DNA screening, pre-test counseling should include a discussion of alternative screening and diagnostic testing options. The limitations of screening tests, including potential for false positive and false negative results, should be discussed.
Genetic counseling is recommended for all women who have an abnormal result. Abnormal cell-free DNA screening results can have implications for the fetus, placenta, and/or maternal health.
When a fetal abnormality is present, cell-free DNA is not the preferred first line test. Instead, a diagnostic test (chorionic villus sampling or amniocentesis) provides the most accurate and comprehensive information about the pregnancy.
Cell-free DNA screening is not recommended for multiple gestations or for microdeletions.
Women whose results are not reported, indeterminate, or uninterpretable because of low fetal fraction should be referred for genetic counseling and offered ultrasound and diagnostic testing because of an increased risk for aneuploidy.
Cell-free DNA screening should not be sent before 9-10 weeks’ gestation.
Ultrasound should be performed at the time of cell-free DNA screening for accurate dating, and to rule out multiple gestations, fetal abnormalities (cystic hygroma, increased nuchal translucency), and fetal demise.

Why not perform cell-free DNA screening as a first line test in the general obstetric population?

The positive predictive value for an abnormal result is lower in the general obstetric population than in the high-risk population (precise estimates will vary by testing platform):

For example, among low-risk patients age 22 years that have a positive cell-free DNA screening test for trisomy 21, 65% will have a fetus without Down syndrome:

	Trisomy 21 PPV	Trisomy 18 PPV	Trisomy 13 PPV
38 at delivery	~80%	~50%	~50%
22 at delivery	~35%	~10%	~10%

While trisomies make up ~90% of the chromosome abnormalities seen in high-risk women, trisomies only make up about 2/3 of the chromosome abnormalities seen in the general obstetric population. Many chromosome abnormalities that would be detected as “incidental findings” with conventional screening (first trimester combined, integrated, or second trimester maternal serum screening) will be missed by cell-free DNA screening for aneuploidies. One study showed that up to 17% of clinically significant chromosome abnormalities detected by conventional screening will be missed by cell-free DNA screening for aneuploidy.
Insurance will most likely not cover the cost of cell-free DNA screening in women who have no risk factors for aneuploidy or women who have a multiple gestation, as it is not recommended as first-line testing in these groups. Patients from these groups who are interested in cell-free DNA screening may want to find out what laboratory their provider sends this testing to and explore insurance coverage and out-of-pocket costs before proceeding with testing.

UNC Fertility and Breast Cancer Awareness Month; Providing Treatment and Understanding to Patients Newly Diagnosed with Cancer

2014-10-09T06:18:00.003-07:00

Contact: Erica Wilkens

919-908-0014 / Erica.Wilkens@integramed.com

Dr. Jennifer Mersereau

For young women facing a cancer diagnosis, fertility preservation methods are the key to preserving family-building options for their future

(Raleigh, NC-October 9, 2014) In recent years, the month of October has become synonymous with the color pink for nearly 232,570 reasons; for the women who are diagnosed with breast cancer every year*. Breast cancer is the most commonly diagnosed cancer in women, with 7% of those women being of reproductive age, UNC Fertility is proud to offer services to those in need of fertility preservation.

Dr. Jennifer Mersereau, Medical Director of UNC Fertility, explains, “For some women that are diagnosed with cancer, they find that natural conception and childbearing are no longer options after going through chemotherapy or radiation treatment.” Dr. Mersereau continued, “Each patient is unique. We strive to specifically tailor every preservation treatment based on the needs of our patients in order to have the most successful outcome: family-building options for women who have successfully beat cancer.”

Research into how cancer affects reproductive health— as well as preservation options— is growing, sparked in part by the increase in the survival rate of cancer patients. Appropriate treatment options are based on the patient’s age, cancer diagnosis, type of chemotherapy and time available before chemotherapy treatment begins. Options available at UNC Fertility for female patients include consultation appointments, embryo banking, egg banking, and GnRH agonist treatments. Additionally, UNC Fertility provides financial support to cancer patients whose treatments present the risk of infertility.

“Receiving a cancer diagnosis is scary enough and coupled with medical bills, it can become overwhelming,” said Dr. Mersereau. “UNC Fertility works to make fertility preservation not only a reality, but also affordable.”

About UNC Fertility

UNC Fertility, located in Raleigh, NC, provides the full range of treatment opportunities for reproductive age women and men who are about to undergo treatments that threaten future fertility. Their IVF Program includes four board-certified reproductive endocrinologists and infertility specialists, highly experienced embryologists and laboratory support staff, specially trained nurses, and the most advanced technology available. In addition, UNC ‘s Fertility Preservation Program is part of the National Physician’s Cooperative, which is a national, interdisciplinary initiative designed to explore the reproductive future of cancer survivors through basic science and translational research. For more information about UNC Fertility, visit http://uncfertility.com/or call 877-338-4693

*American Cancer Society

Pitocin and Autism | Reviewing the Research

2013-10-29T05:06:00.002-07:00

Thomas S. Ivester, MD, MPH, Associate Professor with UNC Maternal-Fetal Medicine talks about the recent JAMA-Pediatrics article 'Association of autism with induced or augmented childbirth in North Carolina birth record...' by S. Gregory, et al.

Given the potential ramifications for obstetrical practices, it is important that providers and patients are prepared for these discussions. Toward such, UNC would like to offer the following response and perspective.

Pitocin is a common and important tool in the practice of obstetrics, facilitating safe and effective delivery for mothers and infants every day. Pitocin is a high alert medication, and is recognized and respected as such by the obstetrical providers at UNC. Thus, we have established stringent, evidence-based protocols for the safe use of oxytocin on our unit. Nurses and providers receive extensive training and have a long track record of safe use of oxytocin. With regards to our practice, the recent birth cohort study, and the balance of evidence regarding synthetic oxytocin use, we offer the following key points:

There is no causal linkage established between induction or Pitocin and autism. Association does not equate to causation, and this type of study cannot establish causation. Even any association based on this study is questionable (see below)

The early years of the trial used diagnostic criteria for autism that have since been abandoned. The latter years of the trial, which used the current criteria for diagnosis, did NOT show an association.

The trial ignores numerous critical factors more likely to be important for autism association, including indication for induction / augmentation, other medical conditions, and family history.
Related to this, if any association were confirmed, it is most likely that induction serves as a marker for the actual causes, but is not the cause. This relates to indication for induction, gestational age, etc.

The study actually found decreased autism among children of mothers who smoked, and no association with hypertension/preeclampsia - both of which have been established associations through numerous studies.

The group of 'term' infants included gestational ages from 37 to 42 weeks. There is mounting evidence that both early term and post-term births may be associated with abnormal neurobehavioral outcomes.

The extent to which synthetic oxytocin even crosses the placenta is questionable, with some studies unable to identify a significant quantity in cord blood. Also, synthetic oxytocin does NOT cross the blood-brain barrier.

Pitocin is a high alert medication with potential for harm. However, the overwhelming majority of complications come from its misuse - not use under well-established protocols. By many accounts, the protocols used at UNC are at the conservative end of the spectrum, and we do NOT deviate.

Fetal harm associated with oxytocin (rare occurrence) is most often related to misuse/deviation from protocols. As such, fetal/perinatal harm are likely associated with uteroplacental perfusion deficits resulting from tachysystole and related events.

The recommendation to utilize Pitocin or other means of labor induction is not taken lightly. It is always approached with consideration of alternative options. In most cases, use of Pitocin or labor induction is safer than continuing pregnancy or Cesarean delivery.

www.UNCwomenscare.org

Don't Ignore | Your Fertility Window

2012-04-27T07:29:00.001-07:00

The Fertile Window - A Crash Course!
By Dr. Emily Evans-Hoeker

WHAT IS THE FERTILE WINDOW?
The fertile window refers to the time during the menstrual cycle when intercourse is most likely to result in pregnancy. It is typically a 6 day window beginning 5 days before ovulation and ending on the day of ovulation. The MOST fertile days during this window are typically the 1-2 days before ovulation and the day of ovulation.

WHEN DOES IT TYPICALLY OCCUR?
Many women are under the misconception that ovulation must occur around cycle day 14 (with cycle day 1 being the first day of menstrual bleeding), however, that is not the case for many women. Ovulation typically occurs about 14 days BEFORE your NEXT menstrual period, so if you have regular 28 day cycles (cycle length is from 1st day of menstrual bleeding to the 1st day of menstrual bleeding for the following cycle) then cycle day 14 might be your day of ovulation (28-14=14). On the other hand, if you are someone who has regular 34 day cycles, then it would be very unlikely for ovulation to occur on cycle day 14. For a 34 day cycle, ovulation should occur around cycle day 20 (34-14=20).

HOW CAN I DETECT MY FERTILE WINDOW?
There are many methods available to assist you in detecting your fertile window.

Click to enlarge

If you have regular cycles you can estimate when ovulation might occur by using the following formula: cycle length (in days)-14 = estimated day of ovulation (plus or minus 2-3 days). If you do not have regular cycles, this method can be extremely difficult to use and can be imprecise.
Basal body temperature (BBT) monitoring can be used to improve the above formula’s precision. The formula to estimate ovulation assumes that your luteal phase (the phase of the cycle from ovulation to the next menstrual period) is 14 days, which is not true for every woman. With BBT monitoring you should detect an increase in your temperature approximately 1-2 days after ovulation occurs. You can personalize the above formula as follows: cycle length (in days) – number of days in luteal phase (from temp increase to next period + 2)= estimated day of ovulation (plus or minus 2-3 days). For example, if you have regular 34 day cycles and typically have 10 days from your increase in temperature to your next period, your formula would be: 34-(10+2)=22. Your estimated day of ovulation is cycle day 22.
Cervical mucus monitoring (CMM) is an easy and inexpensive way to detect your fertile window. For more information and instructions please refer to our blog about CMM or our brochure.

Ovulation predictor kits (OPK) are another method for detecting the 2-3 most fertile days of the cycle. OPKs typically become positive 1-2 days before ovulation occurs. You should start using daily OPKs at the expected beginning of your fertile window. When it turns positive you should have intercourse that day and the following two days. You can buy OPKs at places such as Walmart, Target, many grocery stores, CVS, Walgreens, etc. We recommend checking daily between 11 am-3 pm, using the “Clearblue Ovulation Test” kit.

THAT’S TOO COMPLICATED! ISN’T THERE AN EASIER WAY?
To ensure that you are having intercourse during your fertile window without having to calculate formulas, check temperatures, mucus or OPKs you could simply have intercourse every 2-3 days throughout your cycle. By having intercourse this frequently you should end up with at least 2 acts of intercourse during your fertile window.

http://www.resolve.org/infertility101 (Basic understanding of the disease of infertility.)
http://www.resolve.org/national-infertility-awareness-week/about.html (About NIAW)

Don't Ignore | Myths and Facts

2012-04-27T04:49:00.000-07:00

Monitoring Your Cervical Mucus While Attempting Conception: The Myths, the Facts and the How To's

By Dr. Emily Evans-Hoeker

MYTHS

I have to insert my fingers into my vagina to get cervical mucus.
False Cervical mucus monitoring can be performed by assessing the toilet tissue after wiping.

If I make my cervical mucus thinner I will have a better chance of getting pregnant.
False It is not known how altering your cervical mucus affects your fertility.
I will not get pregnant if I don’t achieve the most fertile type of cervical mucus.
False: You do not have to achieve the most fertile type of cervical mucus to conceive.

FACTS

Monitoring my cervical mucus can help me detect my fertile window.
True Studies have shown that cervical mucus monitoring is an excellent way to identify the most fertile time of your cycle.
Cervical mucus monitoring is easy and inexpensive.
True You do not need to purchase anything to monitor cervical mucus and it should take you less than 5 minutes each day.

HOW TO USE CERVICAL MUCUS MONITORING

Note the sensations felt at the vulva (i.e. the lips of the vagina) and the appearance of the mucus.
Sensation - dry, damp or wet/slippery.
Appearance - Note if any cervical mucus is present, its consistency, and color.
Check the toilet tissue after wiping each day that you do not have your period.
If you do not notice any mucus you may place a finger into the vagina to obtain mucus or you can count that day as “nothing seen.”
Determine the type of mucus present.
If you have had intercourse recently you should wait 12-14 hours to check your cervical mucus so that you do not confuse it with semen or arousal fluid.

TYPES OF CERVICAL MUCUS

Type 1 (lowest fertility):

Appearance - nothing seen
Sensation - dry, rough and itchy or nothing felt
Am I fertile today? - This type typically occurs outside of the fertile part of the cycle.

Type 2 (low fertility):

Appearance - nothing seen
Sensation - damp
Am I fertile today? - This type typically occurs outside of the fertile part of the cycle.

Type 3 (intermediate fertility):

Appearance - mucus is thick, creamy, whitish or yellowish, and sticky, not stretchy/elastic.
Sensation - damp
Am I fertile today? - This type typically indicates the beginning of the fertile window. Intercourse during this upcoming time period will likely increase your chances of pregnancy.

Type 4 (highest fertility):

Appearance - mucus is transparent, like raw egg white, stretchy/elastic, liquid, or watery.
Sensation - wet, slippery, smooth.

Am I fertile today? - This type indicates your most fertile time of the cycle and studies suggest that the best chance of pregnancy is when intercourse occurs on a day near ovulation with this type of cervical mucus.

To view a brochure on cervical mucus monitoring, click here visit our website.

http://www.resolve.org/infertility101 (Basic understanding of the disease of infertility.)
http://www.resolve.org/national-infertility-awareness-week/about.html (About NIAW)

Don't Ignore | Your Uterus

2012-04-26T04:43:00.000-07:00

Could My Uterus Be Causing My Infertility?

By Steven L. Young MD, PhD

Patients often ask me whether infertility itself or failure of infertility therapy is due to an abnormality of the uterus. Since the uterus is the place where the embryo implants and makes a home for itself during pregnancy, the question is a good one. The answer, however, can be complex. Some uterine issues definitely contribute to a reduction in fertility, while the relationship between other aspects of uterine function and infertility are less clear.

By way of background, I am a clinical reproductive endocrinologist, but I also direct a research laboratory, in which we study the lining tissue of the inside of the uterus, called the endometrium. The endometrium is where the embryo attaches during pregnancy. Following attachment, the embryo invades deeply into the endometrium, in a process called implantation. The endometrium appears to play an active role in whether the attachment and implantation of the embryo are effective, and will therefore allow the embryo to survive and further develop.

The endometrium can be abnormal when it overlies uterine structural abnormalities, including certain types of fibroids. The endometrium overlying a “septum”, the consequence of a mild birth defect in the uterus, may also function abnormally. In addition, the endometrium, itself, can develop and abnormal structure called a polyp. A less common disorder, in which some of the endometrium is replaced by scar, has multiple names, including uterine synechiae, intrauterine adhesions, and Asherman’s syndrome. Asherman’s syndrome can occur after a D&C, and is more common when the D&C is performed after pregnancy on an infected uterus. Some infections (e.g. tuberculosis and schistosomiasis) can act alone, without D&C, to cause this disorder.

Diagnosis of all of these problems can be made surgically or by imaging. Commonly helpful imaging techniques include transvaginal ultrasound, with introduction of water in to the uterine cavity (hydrosonogram) and an x-ray test, called a hyterosalpingogram (HSG). Rarely, MRI images may be of additional assistance. The treatment of uterine structural abnormalities is usually to simply remove the abnormal structure. The surgery can usually be accomplished with a hysteroscope passed through the cervix, thereby avoiding abdominal incisions and allowing rapid recovery.

So far, I have discussed structural problems with the uterus, visible on imaging, that lead to endometrial dysfunction. In addition to these structural disorders, the endometrium may also be affected by purely functional disorders. Some research has suggested that the endometrium functions abnormally in some infertile women with endometriosis, endometritis, or unexplained infertility. In these women, the endometrium may be less able to accept an implanting embryo. Experiments in animals and on human tissue strongly suggest that some women have a functionally abnormal endometrium as a cause of infertility, but we lack proven diagnostic tests and proven therapy for these disorders. Luckily, standard infertility therapies likely overcome many or most functional abnormalities. Furthermore, scientists, including those in our lab, continue to work toward a more complete understanding of endometrial regulation of embryo implantation so that we can develop clinical tests and new therapies.

http://www.resolve.org/infertility101 (Basic understanding of the disease of infertility.)
http://www.resolve.org/national-infertility-awareness-week/about.html (About NIAW)

Don't Ignore | Your Age

2012-04-25T08:12:00.000-07:00

Getting older? Worried about your eggs?
By Dr. Anne Steiner

While age is a good predictor of your overall fertility, clearly women of the same age vary in their reproductive potential.

Is there a test that can tell you how many eggs you have left? or whether you remain fertile?
UNC's Time to Conceive is an on-going study, which seeks to determine if various hormone levels measured in blood in urine, can be used to determine a woman's fertility.

Here are 2 of the hormones we are studying in Time to Conceive.

Antimüllerian Hormone: What is it?

Antimüllerian hormone (AMH) is a protein made by granulosa cells in the ovary. Granulosa cells form the follicle that surrounds the oocytes (eggs) in the ovary. The more eggs/follicles a woman has, the more AMH is produced. Women with lots of eggs have high AMH levels; women with fewer eggs have low AMH levels. AMH can be measured in blood, but not in urine. There is hope that AMH can be measured in a blood spot from a simple finger prick. Unlike other hormones, AMH does not appear to be affected by other hormones, thus it can be measured at any point in the menstrual cycle.

Follicle Stimulating Hormone: An Old Standby

Follicle stimulating hormone (FSH) is produced by the pituitary gland in the brain. FSH stimulates the ovary to produce estrogen. FSH levels rise and fall over the menstrual cycle in response to other hormones. A hormone, inhibin, is produced by the ovary. Inhibin inhibits FSH production. As an ovary ages, it makes less inhibin, and FSH levels rise. Therefore a woman with fewer eggs will have higher FSH levels. Because, FSH levels vary during the menstrual cycle, it has to be measured around the time of a woman's period (usually cycle day 2, 3, or 4). When a woman becomes menopausal, her FSH level becomes very high. FSH can be measured in blood or urine. Over-the-counter fertility tests such as Fertel, measure FSH in urine.

http://www.resolve.org/infertility101 (Basic understanding of the disease of infertility.)
http://www.resolve.org/national-infertility-awareness-week/about.html (About NIAW)

Don't Ignore | Your Weight

2012-04-25T05:30:00.000-07:00

Body Weight and Fertility

By Dr. Kathryn C. Calhoun

Take Charge of Your Fertility!

Patients often ask me what they can do to maximize their fertility. In addition to reducing stress, there is a lot to be said for eating right, staying active and maintaining a normal body weight.

This is one aspect of your fertility that you can control.

Calculate your BMI

A normal BMI is between 19-24.9 kg/m2.
Elevated BMI is associated with medical problems (heart disease, diabetes, stroke, cancer, depression) and death at an earlier age.

Being overweight makes you less likely to deliver a healthy baby.

WOMEN who are overweight are more likely to have irregular periods and poorer response to fertility treatments. They are also more likely to suffer birth defects, miscarriage and other pregnancy complications.
MEN who are overweight often have lower testosterone and poorer quality sperm.

You Are Not Alone

34% of American adults are obese and 74% of American adults above their ideal body weight
After age 18, everybody’s metabolism decreases (about 2% a year) – we will all gain weight if we don’t do something!

What Can I Do?

You need to burn more calories than you eat. The recipe is simple, but changes are hard.

The good news: Improvements in fertility can be seen with modest weight loss (5-10% of body weight.)

Diet:

Set a daily calorie limit. Calculate how many calories you need to eat to lose 1-2 pounds per week. You should not lose weight any faster than 1-2 pounds/week. You should not go lower than 1,200 calories per day. To calculate, click here.
Build a daily meal plan from the food group building blocks. You will need to learn how many calories are in one portion of each type of food and what one portion actually looks like – this will take practice and study but there are many tools to help: http://www.fruitsandveggiesmatter.gov/index.html.
Keep a food diary. Buy a spiral notebook and write down (no phone apps!!) every single thing you consume, including portion size, calories and time of day.
Plan in advance. Try to grocery shop for your whole week on Sunday. Divide snack foods into single-serving, easy-to-grab sizes. It is easier to pick the right snack when it’s already prepared.
Avoid alcohol. Alcohol is the ultimate gateway drug to empty calories and over-eating.
Eat at home until you have developed a strong knowledge of portion sizes and healthy choices.
Strategies for eating out. When you do go to a restaurant, pick one that gives nutritional information and will allow modification of orders (i.e. dressing on the side, grilled instead of fried.) Ask your waiter to box up one half of your meal before it is served – restaurants often give you 5-6 servings of each food.
Consider joining a group. Lifestyle changes are easier with social support. Enlist a family member or friend to diet with you and/or join a weight loss group: Weight Watchers or Jenny Craig.

Exercise:

Inject extra activity into every day

Take the stairs.
Park your car at the edge of the parking lot.
Do sit-ups at commercial breaks.

Make time for more intense exercise at least 3 times per week.

You should sweat and your heart rate should be up.
Short bursts of intense exercise (interval training) may be more productive than longer, slower work-outs: http://www.intervaltraining.net or http://www.webmd.com/fitness-exercise/features/interval-training-how-to-do-it
Pick an activity that is FUN for you – you don’t have to stick to running or swimming – just MOVE your body:
http://www.zumba.com/about/
http://www.rentabikenow.com/
http://www.fredastaire.com/

Get a buddy, a personal trainer and/or a gym membership. Lifestyle changes are easier with social support.
http://www.curves.com/
http://o2fitnessclubs.com/
www.goldsgym.com
Personal Training: marcyluna05@yahoo.com

Be patient with yourself but keep trying.

Lifestyle changes are awkward and frustrating. Learning to diet and exercise is just like learning any other new skill – it takes practice and there will be mistakes. If you go over your calorie limit or forget to exercise, don’t give up – just do your best for the rest of the day and begin again the next day.

But, that’s ok! If you stick with it, there will be rewards.

Remember, this is a lifelong commitment to health.

It’s not working.

If you’ve tried diet and exercise for 6 months without results, talk to your doctor about more aggressive options, especially if your BMI is above 40 or if you have problems with diabetes, cholesterol or high blood pressure.

Medication or weight loss surgery can be added to a diet and exercise program:

http://www.med.unc.edu/gisurgery/patientinfo/Weight-loss%20Surgery/

http://www.resolve.org/infertility101 (Basic understanding of the disease of infertility.)
http://www.resolve.org/national-infertility-awareness-week/about.html (About NIAW)

Don't Ignore | Blocked Tubes

2012-04-24T04:52:00.000-07:00

Are My Tubes REALLY Blocked?

By Dr. Marc Fritz

During an evaluation for infertility, the most common test performed to determine whether the fallopian tubes are open or blocked is the hysterosalpingogram, or HSG. The test involves injection of about 1-2 teaspoons of x-ray dye through the cervix while watching on x-ray monitor. The dye should fill the uterine cavity, revealing its size and shape, then enter and travel through both fallopian tubes, and finally escape out of their ends into the abdomen. In a normal test, the uterine cavity should be roughly triangular in shape with smooth outlines, and the dye should flow easily through both tubes and spill into the abdomen, as shown in the picture.

When the tubes are not open, the dye goes only as far as the site of the blockage. When the tubes are blocked on the ends furthest from the uterus, the dye collects in the tubes and causes them to enlarge, as shown in the picture. When the HSG test reveals such a blockage, the finding is very reliable and the blockage is quite real.

When the tubes are blocked on the ends where they join the uterus, the dye cannot enter the tubes and they are not seen, as shown in the picture. However, when the HSG test reveals such a blockage in one or both tubes, the finding is NOT reliable because, most of the time, the apparent blockage is NOT real and the tubes are really open. This happens because the uterus is a hollow muscular organ and the tubes are surrounded by muscle where they enter the uterus. When dye is injected, the uterine muscle contracts, often causing a cramp-like pain, which squeezes the openings of the tubes and prevents dye from entering, making them look blocked when, in truth, they are not. At other times, the tip of the catheter through which the dye is injected is very close to the opening of one tube, so dye passes easily through one tube, but not the other.

When the HSG test SUGGESTS that one or both tubes are blocked where they enter the uterus, additional testing is required to determine whether the blockage is real or not. One option is to repeat the HSG test at another time to see if the blockage is consistent. Another is to perform laparoscopic surgery, under anesthesia, inserting a telescope through the belly button to see if dye injected through the cervix enters the tubes and escapes from their ends. If either test still shows a blockage, fluid can be injected through a specialized catheter after the tip has been inserted directly into the opening of the tube from inside the uterus; if the fluid still does not flow into and through the tube(s), one can be confident that the blockage is real. In some cases, after considering your age and the results of other fertility testing, you and your physician may decide to just accept the HSG finding of blockage, acknowledging that it may not be real, and plan treatment accordingly.

http://www.resolve.org/infertility101 (Basic understanding of the disease of infertility.)
http://www.resolve.org/national-infertility-awareness-week/about.html (About NIAW)

Don't Ignore | Fertility and Cancer

2012-04-23T05:00:00.001-07:00

Fertility and Cancer: Are medical providers telling patients what they need to know?

By Dr. Jennifer Mersereau

A new diagnosis of cancer is hard for anyone.

However, reproductive-aged men and women with cancer face added concerns about the affect of their life-saving cancer treatments on their future chances of having children.

Depending on the specific type of treatments a patient receives, they may have:

no problems getting pregnant in the future

future infertility, despite getting regular menstrual cycles

or they may have permanent damage to their reproductive organs that make future pregnancy impossible.

“Fertility preservation (FP)” is a field of medicine dedicated to helping young cancer patients to preserve their fertility options after treatments such as chemotherapy and radiation, with options like IVF with embryo or egg banking.

Are cancer patients being referred to fertility specialists to discuss FP?

Recognizing the importance of fertility to cancer survivors, the American Society of Clinical Oncology (ASCO) and the American Society of Reproductive Medicine (ASRM) developed guidelines for oncology professionals. These guidelines recommend that discussion of treatment-related infertility, basic FP options and referral of interested patients to a reproductive specialist for FP consultation should occur at the earliest possible juncture prior to cancer treatment.

So, how are we doing?? Turns out, medical professionals could do a much better job at educating appropriate patients about fertility preservation:

Patients are not satisfied with FP information:
Despite the recognized benefits of discussion and referral, in one survey by Schover, less than half of young cancer patients remember fertility being discussed before cancer treatments began. In addition, of those that do recall discussions, many were unsatisfied with the quality and amount of information provided.

Many patients are referred for FP consultation:
A nationwide survey in 2010 by Forman et al. found that of 250 oncologists, over half (61.1%) rarely or never refer patients for consultation with a reproductive specialist.

Certain types of patients are referred more often:
At UNC, a study by Goodman found that, not surprisingly, younger women and those who didn’t already have children were more likely to be referred for FP consultation. However, Caucasian women were two times more likely to be referred compared to women of other races. And women with breast cancer were seen by a fertility specialist 10 times more often than women with other cancer types.

Clearly, the FP referral system needs some work. How do you think medical professionals could do a better job about telling young women and men with cancer about fertility preservation??

For more information about fertility preservation at UNC, visit us at www.UNCfertilitypreservation.org.

http://www.resolve.org/infertility101 (Basic understanding of the disease of infertility.)
http://www.resolve.org/national-infertility-awareness-week/about.html (About NIAW)

A New Unit: An Age Old Problem

2012-03-08T04:52:00.002-08:00

Renovated maternity unit in Bwaila

By Dr. Jeffrey Wilkinson

We are close to the opening of the renovated maternity hospital, Bwaila "Bottom" here in Lilongwe. This renowned building will serve as the new Obstetric Fistula Unit for the Freedom from Fistula Foundation in Malawi. There is a long rectangle shaped room that will be the ward for the fistula patients. It is bright and cheery now with freshly painted walls and beds with brand new kelly green mattresses still wrapped in their plastic covers. Only a few years ago, this room was the labor ward for one of the busiest hospitals in southern Africa. Up to 40 women at a time would labor in this ward in near silence. Electricity and water would be out for hours to days. A nurse midwife delivered one baby only to find five more immediately on the way or already out on the bed or on the floor. So many joyful moments here welcoming in new life. However, countless women and babies never left this unit alive due to chronic shortages of medications, instruments, blood and staff. One can at once feel the beauty and the loss of the place when walking through. These shortages persist in Malawi and much of Africa. Maternal Mortality remains high with minimal progress towards the millenium development goal (MDG) of a 75% reduction by 2015. The UN reports that the MDG goal for provision of clean drinking water to the masses has already been surpassed. On this International Women's Day, please reflect on the persistent dire state of maternal health throughout the world and be a part of the change that needs to happen to obviate our need for an obstetric fistula unit. Help us ensure the safety of women and babies and make childbirth a time of joy for mother,family and community.

Visit us on Facebook at http://www.facebook.com/MalawiMaternalHealth or Twitter www.twitter.com/malawimathealth.

Also UNC Malawi Project.

Stem Cells in Mother’s Milk

2012-01-12T09:57:00.000-08:00

By Dr. Alison Stuebe

For the past 2 months, I’ve been learning about a fascinating study in Chapel Hill. Foteini Hassiotou, a researcher from the University of Western Australia, is working with Pilar Blancafort, a UNC faculty member, to study the cells in mother’s milk.

I’ve known for a long time that human milk contains infection-fighting immune cells. Indeed, one of my favorite images (right) compares the view under the microscope of mother’s milk, rich in infection-fighting cells and neatly packaged nutrients, with a bland splotch of infant formula.

It wasn’t until I met Dr. Hassiotou, however, that I learned that mother’s milk also contains cells from the milk-secreting structures in the breast. She has also isolated cells from milk that appear to have the potential to turn into many different structures, including bone, liver, pancreas and brain cells, much like embryonic stem cells. She’s now collecting milk samples from mothers in Chapel Hill to study the properties of these stem cells and try to determine their role in the health and development of breastfed babies.

Mothers wishing to participate come to the UNC Medical School campus to express 1-2 ounces of milk for the study and complete a brief questionnaire.

For more details, see the study flyer below, or contact Dr. Hassiotou at foteini.hassiotou@uwa.edu.au.

Enabling Mothers to Meet Breastfeeding Goals

2011-11-14T08:35:00.001-08:00

By Dr. Alison Stuebe

N.C. Women’s Hospital earns 5 stars for enabling mothers to meet their breastfeeding goals

Starting to breastfeed is a bit like learning to ride a bike. In the beginning there is a fair amount of wobbling, and even some crashing and burning, as mother and baby figure out to keep their balance in a completely new environment. And then one day, you start peddling, and you wonder why this was ever a struggle.

Just like learning to ride a bike, learning to breastfeed is easier if you start out on a soft surface, with training wheels, and with someone running along behind you to keep you upright. For most new moms, that learning process starts in the hospital, and multiple studies have shown that routine maternity care practices make a tremendous impact on whether mothers and babies build confidence and succeed, or crash and burn.

This week, North Carolina Women’s Hospital was one of just two maternity centers in North Carolina to earn 5 stars for protecting, supporting and promoting breastfeeding. N.C. Women’s earned this award for implementing all ten of the Ten Steps to Successful Breastfeeding, a World Health Organization initiative that is designed to ensure mothers and babies have the best chance of breastfeeding successfully. Think of it as the learning-to-breastfeed equivalent of taking off the training wheels on a very gentle, grassy incline with a well-rested and patient parent running along behind.

Multiple studies have shown that the Ten Steps play a crucial role in enabling mothers to achieve their own breastfeeding goals. A recent study followed breastfeeding outcomes among women who had planned to breastfeed for at least 2 months, and asked women about six of the Ten Steps.

Among those who received six out of six Steps, 97% were still breastfeeding at 6 weeks.
Among mothers who did not experience any of the Steps, 30% had weaned by 6 weeks. Put another way, almost a third of mothers who delivered in no-Steps hospitals failed to achieve their own breastfeeding goals.

For families giving birth at UNC, the 5 star designation means they will receive state-of-the-art care to enable them to achieve their infant feeding goals. For example, Step Four makes it routine practice to place babies skin-to-skin after birth. This practice keeps babies warm and calm, helping them transition to life in the outside world. Studies have shown that skin-to-skin care also markedly increases breastfeeding duration – in randomized trials, mothers and babies that cuddle skin-to-skin in the first hour after birth breastfeed 6 weeks longer than babies who are swaddled in a blanket.

As part of Ten Steps care, babies also stay in the room with their mothers, so that moms can pick up on early feeding cues, such as baby’s rooting or sucking on fingers, rather than waiting until a frantically hungry infant is brought in from the nursery. To support new families, all UNC staff completed comprehensive breastfeeding training.

After moms and babies leave the hospital, UNC provides outpatient lactation support through the UNC Pediatrics Clinic, where experienced lactation consultants touch base during well-baby checks and see mother and babies who are struggling with pain, low milk supply, and other difficulties. I also see patients in my Maternal Fetal Medicine Clinic, working with a lactation consultant to help mothers and babies achieve their feeding goals.

Over the past 3 years, we have worked with an interdisciplinary team of physicians, nurses, and researchers to develop a set of treatment algorithms for mothers with breastfeeding-associated pain. The mission of UNC’s Lactation Program is to provide integrated, evidence-based lactation care for the mom-baby dyad, thereby empowering all mothers to meet their breastfeeding goals. With data analysis underway for several pilot studies, we are hopeful that we’ll be able to find new approaches to help mothers who encounter obstacles to have a positive breastfeeding experience.

The Thin Red Line of Motherhood in Malawi

2011-11-07T05:31:00.000-08:00

By Dr. Jeffrey Wilkinson

Two women stood across this red line outside the operating room at Bwaila hospital Freedom from Fistula Foundation clinic in Lilongwe, Malawi last week. Each was asked if we could take her photo to share with people from different countries in order for others to understand her condition. Both readily agreed.

One woman is pictured here with her 13-month baby. She delivered at home for the third time at age 19. With the delivery, she experienced a tear of the vagina in to the rectum that remained unrepaired because there was no skilled birth attendant present. She was left with incontinence of stool for the last year and presented for care at the fistula center a couple weeks ago. The other patient, pictured alone here, also delivered at home, but ten years ago and experienced obstructed labor, delivery of a stillborn baby and was left with a fistula and unrelenting urinary incontinence since the delivery. Her injuries were so severe that she will never be capable of having a child. Her reproductive tract was irreparably scarred. Both women were fortunate to survive delivery far from a health center or hospital. Both women experienced relief of incontinence from their surgery, but go home to lead vastly different lives: One with a family and three healthy children. One left forever barren and divorced.

Straddling the thin red line of motherhood in Malawi are the nearly 1% of mothers who die in childbirth, the 6% of babies that are stillborn or die shortly after birth and the countless families that are left without wife, daughter, mother or child; Communities irreparably injured by lost persons or lost potential. The line separating the happy outcomes from the tragedies can be something as simple as 50 cent medication, a few hours worth of training, $2.00 for a ride to the hospital or an operating room with electricity and functioning lights. The line can be as thin as a few cell layers in the bladder that make the difference between total incontinence with isolation and shame or a life fully lived.

The balance across this line can be fundamentally altered in a positive direction with education of girls and boys, capacity building, access to family planning services and cost-conscious improvements in health delivery systems across the developing world. Poor countries such as Sri Lanka, Honduras and Bangladesh have proven the skeptics wrong by improving maternal health care outcomes despite persistent poverty. The balance can be shifted in Malawi as well.

Message from Malawi: Meet Agogo

2011-10-04T07:14:00.000-07:00

Dr. Jeffrey Wilkinson

By Dr. Jeffrey Wilkinson
Beginning in September, UNC's Dr. Jeffrey Wilkinson relocated to Southern Africa. Read more..

Below is the first in a series of blogs from Dr. Wilkinson about his experiences there.

Monday, September 26, 2011

I'm slowly settling in to life in Lilongwe.

We have seen 18 women in the fistula unit and have done 12 surgeries. Our two hospital rooms dedicated to the fistula patients are full with a third of the women sleeping on mattresses on the floor. This is still better than the average occupancy of the maternity wing in general at Bwaila Hospital which is 300% full at times. I occasionally will get messages from Dr. Clarke-Pearson about bed shortages at UNC and wonder if some people there would mind sharing a bed with their neighbor or sleeping on the floor. I suspect it would not pass JCAHO muster.

Meet Grandma or "Agogo"

This patient is 60 years old and has had a fistula for 32 years. She had been pregnant 10 times and had only one living child. About 70% of fistula patients never have a living child so she is still the exception. We have been calling her Grandma, or Agogo, in Chichewa. She waited for 32 years to get care for the fistula because she was unaware of any place she could go for care.

Her surgery was Thursday and we have high hopes for her full recovery.

Should Cystic Fibrosis Carrier Screening Be Offered?

2011-08-02T08:01:00.000-07:00

Patricia Devers, MS, CGC

Should we offer cystic fibrosis carrier screening to preconception or pregnant women now that cystic fibrosis has been added to the North Carolina newborn screen?

YES.

In 2001, the American College of Obstetricians and Gynecologists (ACOG) and the American College of Medical Genetics (ACMG) introduced guidelines for prenatal and preconception carrier screening for cystic fibrosis (CF). These guidelines were updated in 2005. In these guidelines, it was recommended that CF carrier screening be made available to all women who were considering pregnancy or were pregnant. In addition, it was recommended that CF carrier screening be verbally offered to women in the ‘high-risk’ group who were considering pregnancy or were pregnant. The ‘high-risk’ group was defined as non-Jewish Caucasians and Ashkenazi Jews or individuals of any ethnicity with a family history of CF. An emphasis on preconception testing was encouraged. These guidelines remain the current standard of care in the obstetrical field.

As of April 13, 2009, the North Carolina State Laboratory of Public Health (NCSLPH) began testing all newborn screening specimens for CF. Testing is performed with a two-tier screening process. First, the specimen is tested to determine the concentration of immunoreactive trypsinogen (IRT). The specimens with the highest 5% IRT values then undergo DNA testing using a panel of over 40 common CF mutations. Specimens with an IRT value less than or equal to 175 ng/mL and no identified mutations are reported as normal. Specimens with one or two identified mutations, or with an IRT value greater than 175 ng/mL and no identified mutations are reported as abnormal. All abnormal results are reported to the child’s health care provider to arrange for sweat testing at an accredited CF center.

So, if children with CF will be identified through newborn screening, what are the benefits of parental carrier screening?

PROS of carrier screening:

Identifies couples who may have an increased risk for CF in subsequent pregnancies, while a normal result on newborn screening does not provide information regarding future pregnancies.
Identifies families in whom a CF mutation is carried, allowing for preconception/prenatal testing for other family members – and for the children of the couple who have a much higher carrier risk
Allows prenatal diagnosis of CF and the option of pregnancy termination, adoption, or parental preparation
Allows other reproductive options to carrier couples, including donor egg or sperm, adoption, and pre-implantation genetic diagnosis

CONS of carrier screening:

May create anxiety when one member of the couple is found to be a carrier and the other is unavailable for testing or has a negative carrier screen
May increase anxiety for couples in which both partners are found to be carriers, but who are not interested in pursuing prenatal diagnosis
Cost of carrier screening is carried either by the patient or her insurance provider

So, while the guidelines state that preconception and prenatal carrier screening for CF should be made available to all women and offered to women who are considered ‘high-risk,’ the incorporation of CF in newborn screening is another factor for women to consider when electing or declining carrier screening. Couples should be informed of the inclusion of CF on newborn screening in order to make the most appropriate decision for their family.
________________________________________
References:

American College of Obstetricians and Gynecologists, American College of Medical Genetics. Preconception and prenatal carrier screening for cystic fibrosis: clinical and laboratory guidelines. Washington, DC: ACOG; Bethesda (MD): ACMG; 2001.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 325: Update on carrier screening for cystic fibrosis. Obstet Gynecol 2005; 106: 1465-8.

http://slph.state.nc.us/newborn/

What is Genetic Counseling?

2011-07-08T10:02:00.000-07:00

By Emily Hardisty, MS, CGC

I’m referring a patient for ultrasound and genetic counseling because she will be over 35 at delivery. She asked me what to expect from genetic counseling. While I know what genetic counseling is, I’m not sure how to explain it to her.

A formal definition of genetic counseling is a good starting point. According to the National Society of Genetic Counselors:

“Genetic counseling is the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease. This process integrates the interpretation of family and medical histories to assess the chance of disease occurrence or recurrence, education about inheritance, testing, management, prevention, resources and research, and counseling to promote informed choices and adaptation to the risk or condition” (NSGC, 2005).

So, genetic counseling is a process that includes information gathering, emotional support, and education. At our center, genetic counseling is provided by specially trained genetic counselors. All of the genetic counselors at the UNC Prenatal Diagnosis Center have a Master of Science in Genetic Counseling or a related field and are either board certified genetic counselors (CGC) or board eligible (BE) genetic counselors. These genetic counselors work closely with the maternal fetal medicine physicians and sonographers to help provide patients with comprehensive and clear information about their pregnancy.

When coming to our center for genetic counseling, patients can expect the following:

A review of their family and medical history. This information is used to determine if the family is at increased risk for any birth defects or genetic conditions. If warranted, additional testing may be discussed based on this family history.
An assessment of their risk in the current pregnancy. All pregnancies have some risk for birth defects. These risks may be increased as a result of increased maternal age, abnormal screening results, or abnormal ultrasound findings.
A discussion of testing options available in the current pregnancy. These testing options may include screening tests (such as first trimester screening or second trimester maternal serum screens), ultrasound, CVS, amniocentesis, or additional genetic tests.
A discussion of how the patient’s beliefs, values, and desires for the pregnancy may impact their decisions and attitudes regarding the risks in the pregnancy and their testing options.

Patient’s often come to us with misconceptions about genetic counseling based on word-of-mouth or internet research. We find that patient’s who are informed by their physician or nurse that they are being referred for genetic counseling and who are provided with some information about what to expect from genetic counseling are often the most receptive to and benefit the most from the genetic counseling process.

For more information about the UNC Prenatal Diagnosis Center, visit us on the web at www.mombaby.org or www.UNCmfm.org.