When confronted with so many different types of infections and viruses that can threaten the health of an unborn baby, it’s unfortunate that drinking during pregnancy is still the leading cause of birth defects in this country and abroad. Without knowledge of the devastating effects, it’s easy to have a casual attitude toward drinking but when a fetus is exposed to any amount of alcohol it can lead to a number of permanent and debilitating conditions. These are known as fetal alcohol spectrum disorders (FASD) and can include anything from severe brain damage and growth deficits to lifelong learning and behavioral problems in children. September is designated as FASD Awareness Month but my hope is that at some point in the near future there is no longer a need to observe it because the fact is—FASD is 100 percent preventable.
The White House has declared this week Zika Provider Action Week. This call to action could not come at a better time. The Zika virus has occupied our profession and our patients nearly non-stop since news of it broke last fall. There is no doubt that Zika presents a very real concern to patients and challenge to health care providers. With the discovery of virus transmission by mosquitoes here in the United States, many of us are faced with the even more real possibility of treating patients with potential or confirmed exposure.
As ob-gyns, we are on the front lines of patients’ concerns about Zika. As each new finding is played out in the news, our patients call or come in looking for answers to help their understanding of the risk, and more often than not, assuage their fears. Unfortunately, in the instance of Zika, we too are often scrambling for knowledge, seeking elusive answers from research institutions and government agencies. The Centers for Disease Control and Prevention (CDC) has done an admirable job working quickly and efficiently to assess, address, and educate the American public about the Zika outbreak.
For some women, alcohol is an occasional indulgence – a glass of wine with dinner, a cocktail at a special event. For other women, drinking is a much more frequent and dangerous activity. Thirteen percent of women in the US consume more than seven drinks per week, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). And according to the Centers for Disease Control and Prevention (CDC), about 1 in 8 women and 1 in 5 high school girls report binge drinking.
According to the CDC, birth defects affect 1 in 33 babies in the US every year, and 18 babies die each day as a result of a birth defect. Some are caused by genetic factors such as Down syndrome or sickle cell anemia. Others are caused by certain chemicals or drugs, including alcohol and tobacco. Unfortunately, however, the cause of many birth defects is not yet known.
In our society, exposure to chemicals is unavoidable. As a physician with a PhD in environmental biology, I have a longstanding interest in the many chemicals we come in contact with every day and their impact on our health. These answers do not come quickly. It can take many years and millions of exposures to fully assess the potential impact that chemicals have on humans.
Unlike the pharmaceutical industry—where the burden is on drug makers to prove a new medication is safe—there is no requirement that any chemical be registered or proven safe before release. Of the more than 84,000 chemicals produced, fewer than 200 have been studied, only 12 have been restricted, and FIVE banned in 35 years. With such lack of regulation, we can’t assume these chemicals are safe, especially as a growing field of research suggests that some lead to reproductive health problems and can negatively affect developing fetuses.
This week, ACOG and the American Society for Reproductive Medicine (ASRM) released a new statement warning of the reproductive health effects of exposure to certain environmental chemicals. The goal of this document is not to scare pregnant women or those considering having a baby, but to increase awareness in the health care community and with our patients about chemical exposures and to promote efforts to reduce these exposures where possible. (Find more resources on environmental chemicals and reproductive health here.)
Ob-gyns must be attuned to the risks of environmental exposures and understand how our patients might be affected. For example, minorities are more likely than whites to live in the counties with the highest levels of outdoor air pollution and to be exposed to a variety of indoor pollutants, including lead, allergens, and pesticides. Farm workers are also at higher risk for health problems because they repeatedly come in contact with toxic chemicals in pesticides. Knowing about our patients’ potential exposures will help us anticipate related health outcomes and properly educate them about their risks.
ACOG and ASRM recommend that health care professionals:
• Learn about toxic environmental agents common in their community
• Educate patients on how to avoid toxic environmental agents
• Take environmental exposure histories during preconception and first prenatal visits
• Report identified environmental hazards to appropriate agencies
• Encourage pregnant and breastfeeding women and women in the preconception period to eat carefully washed fresh fruits and vegetables and avoid fish containing high levels of methyl-mercury (shark, swordfish, king mackerel, tilefish)
• Advance policies and practices that support a healthy food system
• Advocate for government policy changes to identify and reduce exposure to toxic environmental agents
By advocating for a cleaner environment now, we can stand up for the health of our patients and of many generations to come.
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This week, the Breast Cancer Fund released a new and important report drawing attention to prenatal exposure to Bisphenol A (BPA). BPA is a synthetic estrogen and known endocrine disruptor. It is a relative of diethylstilbestrol (DES), a drug that caused genetic mutations and increased reproductive health problems and certain cancers among women whose mothers had taken the drug during pregnancy in the 1940s–1970s. Used widely as a can lining in canned foods and for plastic production, BPA has become ubiquitous in the US food supply. According to the new report, more than 92% of Americans have BPA in their bodies. Unfortunately, most research on BPA is based on animal models, which leaves us to infer risks to humans rather than to study them in a controlled fashion.
Based on animal models, support is building that BPA exposure in utero and shortly after birth is linked to future health problems including breast cancer, prostate cancer, metabolic changes, decreased fertility, early puberty, neurological problems, and immunological changes. To reduce BPA exposure among infants, the substance was banned from use in baby bottles in 2012. However, by the time a child is delivered, some level of exposure has already happened. Pregnant women who consume BPA expose their developing fetus to the compound, often during the first weeks of pregnancy, a crucial time for fetal development.
At this point, potential toxins are released freely into the environment and used broadly without any research assuring their safety before their use. ACOG’s most important role will be in supporting legislation that prevents exposure to chemical sources until those chemicals are studied and deemed safe for us. In the meantime, this new report encourages reproductive health providers to make women aware of the potential risks of BPA. It provides guidance on simple ways to reduce BPA-exposure, such as using glass, ceramic, or stainless steel for food storage, avoiding cooking or reheating in plastic containers, and choosing fresh or frozen foods instead of canned. Anything we can do to increase BPA awareness among physicians and patients will help us to collectively move in the right direction so we can all be BPA-free.
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During pregnancy, ob-gyns use routine lab and diagnostic tests to help monitor the health of women and their babies, identify problems, and develop treatment plans. Most women will receive these common screenings as part of their prenatal care:
- Blood glucose tests screen for the amount of sugar (glucose) in the bloodstream. High levels can signal diabetes. Unchecked diabetes can lead to liver damage, birth defects, stillbirth, and other complications for mother and baby.
- Blood type and antibody testing determines a woman’s blood group (A, B, AB, or O) and Rh type (positive or negative). Fetal problems may occur when an Rh negative woman carries a fetus that is Rh positive.
- Screening for birth defects (such as Down Syndrome) may be performed in the first and/or second trimester.
- Late in pregnancy, women are tested for group B streptococcus (GBS) bacteria, which can cause infections of the blood, lungs, brain, or spinal cord in infants. GBS can be transmitted from an infected mother to the baby during delivery.
- Hemacrit and hemoglobin tests check the blood for low iron levels (anemia).
- HBV testing screens for Hepatitis B, a virus that affects the liver and can cause severe complications in newborns if passed from mother to baby.
- All pregnant women should be screened for HIV infection—a disease that attacks the body’s immune system. Treatment of HIV-positive mothers during pregnancy can drastically reduce the risk that the infants will become infected and help improve the mother’s health.
- A blood test is used to check for signs of past rubella (German measles) infection. Pregnant women who have not had or not been vaccinated against rubella should avoid any infected individuals and be vaccinated after delivery.
- Screening for sexually transmitted diseases, such as chlamydia, gonorrhea, and syphilis, may be recommended. They can cause preterm birth, miscarriage, eye infections, birth defects, or other problems.
- At each prenatal visit, urine analysis checks for elevated blood sugar and protein levels and signs of bladder and kidney infections.
Depending on a woman’s age, health history, or ethnic background, additional screenings may be offered for genetic disorders and birth defects, such as cystic fibrosis or spina bifida. Learn more about prenatal screenings on ACOG’s website.
Pop Quiz: What vitamin is associated with a 50–70% reduction in birth defects? Answer: Folic Acid
I recently wrote about the importance of eating your vitamins through food, but getting enough folic acid from natural sources can be tough. Folic acid is an essential B vitamin necessary for proper cell growth. It’s vital to the development of a baby’s brain, spinal cord, and central nervous system and integral in preventing birth defects such as spina bifida, anencephaly, and cleft lip and palate. Here’s the catch: In order for folic acid to provide the best protection against birth defects, levels of the vitamin need to be high in a woman’s body before she becomes pregnant and through the first three months of pregnancy.
Because nearly half of the pregnancies in the US are unintended, it’s important that reproductive-age women build up their folic acid stores, whether planning a pregnancy or not. ACOG recommends that all childbearing-age women take 400 micrograms of folic acid each day. Women who have had a child with a neural tube defect or certain other birth defects, are pregnant with twins, have particular medical conditions (such as sickle cell disease), or take some forms of medication (such as antiseizure medication) may need more.
Our bodies can’t process folate—the naturally occurring form of folic acid found in leafy green vegetables, citrus fruits, and beans—as easily as the man-made form. Folic acid-enriched breakfast cereals, breads, flours, pastas, rice, and other grains can help, but even women who eat diets high in these sources may not get enough. To make sure you get the recommended amount, take a daily supplement or multivitamin containing 0.4 milligrams or 400 micrograms of folic acid.