Women's Health

Louisiana has joined a handful of other states in passing a so-called fetal heartbeat bill that would ban abortions as early as 6 weeks, about the time a heartbeat is usually detectable.

The legislation, which does not include an exception for rape or incest cases, passed by a 79-23 vote on May 29 in the Louisiana House. The bill does allow exceptions if the woman’s life is in danger, if the pregnancy poses risk of serious impairment to a woman’s body, of if the pregnancy is deemed medically futile. Democratic Gov. John Bel Edwards said he plans to sign the measure when it hits his desk.

“In 2015, I ran for governor as a pro-life candidate after serving as a pro-life legislator for 8 years,” Gov. Edwards said in a May 29 statement. “As governor, I have been true to my word and my beliefs on this issue. As I prepare to sign this bill, I call on the overwhelming bipartisan majority of legislators who voted for it to join me in continuing to build a better Louisiana that cares for the least among us and provides more opportunity for everyone.”

Six other states have enacted similar abortion bans: Alabama, Georgia, Kentucky, Mississippi, Missouri, and Ohio. While most of the laws bar abortions after a heartbeat is detected, Alabama’s measure prohibits abortion at every pregnancy stage and penalizes physicians with a Class A felony for performing an abortion and a Class C felony for attempting to perform an abortion. Alabama Gov. Kay Ivey (R) signed the bill into law on May 15.

A number of lawsuits have been filed against the bans, including a May 24 legal challenge against Alabama’s law by Planned Parenthood Federation of America and the American Civil Liberties Union (ACLU), and a May 15 legal challenge against Ohio’s law by the ACLU and Planned Parenthood of Greater Ohio.

The U.S. Supreme Court on May 28 upheld part of an Indiana law that requires burial or cremation of fetal remains after an abortion, but the justices declined to address the measure’s prohibition on abortions sought because of race, sex, or disability of the fetus.

Court analysts say it’s only a matter of time before the Supreme Court takes up one of the abortion ban cases, most likely the legal challenge against Alabama’s law. Abortion critics have been encouraged by the Supreme Court appointment of right-leaning Justice Brett M. Kavanaugh, and hope the Alabama measure will drive the Supreme Court to reconsider its central holding in Roe v. Wade, court watchers said.

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Louisiana has joined a handful of other states in passing a so-called fetal heartbeat bill that would ban abortions as early as 6 weeks, about the time a heartbeat is usually detectable.

The legislation, which does not include an exception for rape or incest cases, passed by a 79-23 vote on May 29 in the Louisiana House. The bill does allow exceptions if the woman’s life is in danger, if the pregnancy poses risk of serious impairment to a woman’s body, of if the pregnancy is deemed medically futile. Democratic Gov. John Bel Edwards said he plans to sign the measure when it hits his desk.

“In 2015, I ran for governor as a pro-life candidate after serving as a pro-life legislator for 8 years,” Gov. Edwards said in a May 29 statement. “As governor, I have been true to my word and my beliefs on this issue. As I prepare to sign this bill, I call on the overwhelming bipartisan majority of legislators who voted for it to join me in continuing to build a better Louisiana that cares for the least among us and provides more opportunity for everyone.”

Six other states have enacted similar abortion bans: Alabama, Georgia, Kentucky, Mississippi, Missouri, and Ohio. While most of the laws bar abortions after a heartbeat is detected, Alabama’s measure prohibits abortion at every pregnancy stage and penalizes physicians with a Class A felony for performing an abortion and a Class C felony for attempting to perform an abortion. Alabama Gov. Kay Ivey (R) signed the bill into law on May 15.

A number of lawsuits have been filed against the bans, including a May 24 legal challenge against Alabama’s law by Planned Parenthood Federation of America and the American Civil Liberties Union (ACLU), and a May 15 legal challenge against Ohio’s law by the ACLU and Planned Parenthood of Greater Ohio.

The U.S. Supreme Court on May 28 upheld part of an Indiana law that requires burial or cremation of fetal remains after an abortion, but the justices declined to address the measure’s prohibition on abortions sought because of race, sex, or disability of the fetus.

Court analysts say it’s only a matter of time before the Supreme Court takes up one of the abortion ban cases, most likely the legal challenge against Alabama’s law. Abortion critics have been encouraged by the Supreme Court appointment of right-leaning Justice Brett M. Kavanaugh, and hope the Alabama measure will drive the Supreme Court to reconsider its central holding in Roe v. Wade, court watchers said.

[email protected]

Louisiana has joined a handful of other states in passing a so-called fetal heartbeat bill that would ban abortions as early as 6 weeks, about the time a heartbeat is usually detectable.

The legislation, which does not include an exception for rape or incest cases, passed by a 79-23 vote on May 29 in the Louisiana House. The bill does allow exceptions if the woman’s life is in danger, if the pregnancy poses risk of serious impairment to a woman’s body, of if the pregnancy is deemed medically futile. Democratic Gov. John Bel Edwards said he plans to sign the measure when it hits his desk.

“In 2015, I ran for governor as a pro-life candidate after serving as a pro-life legislator for 8 years,” Gov. Edwards said in a May 29 statement. “As governor, I have been true to my word and my beliefs on this issue. As I prepare to sign this bill, I call on the overwhelming bipartisan majority of legislators who voted for it to join me in continuing to build a better Louisiana that cares for the least among us and provides more opportunity for everyone.”

Six other states have enacted similar abortion bans: Alabama, Georgia, Kentucky, Mississippi, Missouri, and Ohio. While most of the laws bar abortions after a heartbeat is detected, Alabama’s measure prohibits abortion at every pregnancy stage and penalizes physicians with a Class A felony for performing an abortion and a Class C felony for attempting to perform an abortion. Alabama Gov. Kay Ivey (R) signed the bill into law on May 15.

A number of lawsuits have been filed against the bans, including a May 24 legal challenge against Alabama’s law by Planned Parenthood Federation of America and the American Civil Liberties Union (ACLU), and a May 15 legal challenge against Ohio’s law by the ACLU and Planned Parenthood of Greater Ohio.

The U.S. Supreme Court on May 28 upheld part of an Indiana law that requires burial or cremation of fetal remains after an abortion, but the justices declined to address the measure’s prohibition on abortions sought because of race, sex, or disability of the fetus.

Court analysts say it’s only a matter of time before the Supreme Court takes up one of the abortion ban cases, most likely the legal challenge against Alabama’s law. Abortion critics have been encouraged by the Supreme Court appointment of right-leaning Justice Brett M. Kavanaugh, and hope the Alabama measure will drive the Supreme Court to reconsider its central holding in Roe v. Wade, court watchers said.

[email protected]

All pregnant women should be screened for preterm preeclampsia (PE) in the first trimester using a combined test with maternal risk factors and biomarkers as a one-step procedure, according to new recommendations from The International Federation of Gynecology and Obstetrics (FIGO).

FIGO “encourages all countries and its member associations to adopt and promote strategies to ensure [universal screening],” Liona C. Poon, MD, of Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, and colleagues wrote in a guide published in the International Journal of Gynecology & Obstetrics.

“The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI),” the authors said, noting that the baseline screening test plus a combination of maternal risk factors with MAP is an alternative when PLGF and/or UTPI can’t be measured.

The FIGO recommendations are the culmination of an initiative on PE, which involved a group of international experts convened to discuss and evaluate current knowledge on PE and to “develop a document to frame the issues and suggest key actions to address the health burden posed by PE.” Among the group’s objectives are raising awareness of the links between PE and poor outcomes, and demanding a “clearly defined global health agenda” to address the issue because preeclampsia affects 2%-5% of all pregnant women and is a leading cause of maternal and perinatal morbidity and mortality.

The recommendations represent a consensus document that provides guidance for the first trimester screening and prevention of preterm PE.

“Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of preeclampsia in singleton pregnancy,” the authors said, explaining that “[it] provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings” (Int J Gynecol Obstet. 2019;145[Suppl. 1]:1-33).


Specific suggestions are made based on region and resources, and research priorities are outlined to “bridge the current knowledge and evidence gap.”

In addition to universal first trimester screening for PE, the guide stresses a need for improved public health focus, and contingent screening approaches in areas with limited resources (including routine screening for preterm PE by maternal factors and MAP in most cases, with PLGF and UTPI measurement reserved for higher-risk women). It also recommends that women at high risk should receive prophylactic measures such as aspirin therapy beginning at 11–14⁺⁶ weeks of gestation at a dose of about 150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed.

Mary E. D’Alton, MD, a maternal-fetal medicine specialist who is chair of the department of obstetrics and gynecology and the Willard C. Rappleye Professor of Obstetrics & Gynecology at Columbia University, New York, was asked to comment on Dr. Sibai’s concerns about the guidelines. “I would simply say that ACOG and SMFM are the organizations in the United States [that] provide educational guidelines about practice in the United States.” Dr. D’Alton assisted Dr. Poon and her associates on the guidelines as an expert on preeclampsia.

Dr. Poon, given a chance to comment on the concern that the FIGO guidelines diverged from those of ACOG and SMFM, responded in an interview, “FIGO, being the global voice for women’s health, likes to ensure that our recommendations are resource appropriate. The objective of these guidelines is to provide a best practice approach, and also offers other pragmatic options for lower resource settings to ensure that preeclampsia testing can be implemented globally. We urge the broader membership of FIGO to adapt these guidelines to their local contexts.”*

She also emphasized that “PerkinElmer’s sponsorship was an unrestricted grant. The company had no involvement in writing the guideline.”*


This work was funded by an unrestricted grant from PerkinElmer, which markets an assay used for first trimester preeclampsia screening. Dr. Poon and her associates reported having no conflicts of interest.

[email protected]

*This article was updated 5/31/2019.

All pregnant women should be screened for preterm preeclampsia (PE) in the first trimester using a combined test with maternal risk factors and biomarkers as a one-step procedure, according to new recommendations from The International Federation of Gynecology and Obstetrics (FIGO).

FIGO “encourages all countries and its member associations to adopt and promote strategies to ensure [universal screening],” Liona C. Poon, MD, of Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, and colleagues wrote in a guide published in the International Journal of Gynecology & Obstetrics.

“The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI),” the authors said, noting that the baseline screening test plus a combination of maternal risk factors with MAP is an alternative when PLGF and/or UTPI can’t be measured.

The FIGO recommendations are the culmination of an initiative on PE, which involved a group of international experts convened to discuss and evaluate current knowledge on PE and to “develop a document to frame the issues and suggest key actions to address the health burden posed by PE.” Among the group’s objectives are raising awareness of the links between PE and poor outcomes, and demanding a “clearly defined global health agenda” to address the issue because preeclampsia affects 2%-5% of all pregnant women and is a leading cause of maternal and perinatal morbidity and mortality.

The recommendations represent a consensus document that provides guidance for the first trimester screening and prevention of preterm PE.

“Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of preeclampsia in singleton pregnancy,” the authors said, explaining that “[it] provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings” (Int J Gynecol Obstet. 2019;145[Suppl. 1]:1-33).


Specific suggestions are made based on region and resources, and research priorities are outlined to “bridge the current knowledge and evidence gap.”

In addition to universal first trimester screening for PE, the guide stresses a need for improved public health focus, and contingent screening approaches in areas with limited resources (including routine screening for preterm PE by maternal factors and MAP in most cases, with PLGF and UTPI measurement reserved for higher-risk women). It also recommends that women at high risk should receive prophylactic measures such as aspirin therapy beginning at 11–14⁺⁶ weeks of gestation at a dose of about 150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed.

Mary E. D’Alton, MD, a maternal-fetal medicine specialist who is chair of the department of obstetrics and gynecology and the Willard C. Rappleye Professor of Obstetrics & Gynecology at Columbia University, New York, was asked to comment on Dr. Sibai’s concerns about the guidelines. “I would simply say that ACOG and SMFM are the organizations in the United States [that] provide educational guidelines about practice in the United States.” Dr. D’Alton assisted Dr. Poon and her associates on the guidelines as an expert on preeclampsia.

Dr. Poon, given a chance to comment on the concern that the FIGO guidelines diverged from those of ACOG and SMFM, responded in an interview, “FIGO, being the global voice for women’s health, likes to ensure that our recommendations are resource appropriate. The objective of these guidelines is to provide a best practice approach, and also offers other pragmatic options for lower resource settings to ensure that preeclampsia testing can be implemented globally. We urge the broader membership of FIGO to adapt these guidelines to their local contexts.”*

She also emphasized that “PerkinElmer’s sponsorship was an unrestricted grant. The company had no involvement in writing the guideline.”*


This work was funded by an unrestricted grant from PerkinElmer, which markets an assay used for first trimester preeclampsia screening. Dr. Poon and her associates reported having no conflicts of interest.

[email protected]

*This article was updated 5/31/2019.

All pregnant women should be screened for preterm preeclampsia (PE) in the first trimester using a combined test with maternal risk factors and biomarkers as a one-step procedure, according to new recommendations from The International Federation of Gynecology and Obstetrics (FIGO).

FIGO “encourages all countries and its member associations to adopt and promote strategies to ensure [universal screening],” Liona C. Poon, MD, of Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, and colleagues wrote in a guide published in the International Journal of Gynecology & Obstetrics.

“The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI),” the authors said, noting that the baseline screening test plus a combination of maternal risk factors with MAP is an alternative when PLGF and/or UTPI can’t be measured.

The FIGO recommendations are the culmination of an initiative on PE, which involved a group of international experts convened to discuss and evaluate current knowledge on PE and to “develop a document to frame the issues and suggest key actions to address the health burden posed by PE.” Among the group’s objectives are raising awareness of the links between PE and poor outcomes, and demanding a “clearly defined global health agenda” to address the issue because preeclampsia affects 2%-5% of all pregnant women and is a leading cause of maternal and perinatal morbidity and mortality.

The recommendations represent a consensus document that provides guidance for the first trimester screening and prevention of preterm PE.

“Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of preeclampsia in singleton pregnancy,” the authors said, explaining that “[it] provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings” (Int J Gynecol Obstet. 2019;145[Suppl. 1]:1-33).


Specific suggestions are made based on region and resources, and research priorities are outlined to “bridge the current knowledge and evidence gap.”

In addition to universal first trimester screening for PE, the guide stresses a need for improved public health focus, and contingent screening approaches in areas with limited resources (including routine screening for preterm PE by maternal factors and MAP in most cases, with PLGF and UTPI measurement reserved for higher-risk women). It also recommends that women at high risk should receive prophylactic measures such as aspirin therapy beginning at 11–14⁺⁶ weeks of gestation at a dose of about 150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed.

Mary E. D’Alton, MD, a maternal-fetal medicine specialist who is chair of the department of obstetrics and gynecology and the Willard C. Rappleye Professor of Obstetrics & Gynecology at Columbia University, New York, was asked to comment on Dr. Sibai’s concerns about the guidelines. “I would simply say that ACOG and SMFM are the organizations in the United States [that] provide educational guidelines about practice in the United States.” Dr. D’Alton assisted Dr. Poon and her associates on the guidelines as an expert on preeclampsia.

Dr. Poon, given a chance to comment on the concern that the FIGO guidelines diverged from those of ACOG and SMFM, responded in an interview, “FIGO, being the global voice for women’s health, likes to ensure that our recommendations are resource appropriate. The objective of these guidelines is to provide a best practice approach, and also offers other pragmatic options for lower resource settings to ensure that preeclampsia testing can be implemented globally. We urge the broader membership of FIGO to adapt these guidelines to their local contexts.”*

She also emphasized that “PerkinElmer’s sponsorship was an unrestricted grant. The company had no involvement in writing the guideline.”*


This work was funded by an unrestricted grant from PerkinElmer, which markets an assay used for first trimester preeclampsia screening. Dr. Poon and her associates reported having no conflicts of interest.

[email protected]

*This article was updated 5/31/2019.

The causes of death differ throughout pregnancy and postpartum. Overall, heart disease and stroke cause > 1 in 3 deaths. At delivery, most deaths are due to obstetric emergencies, such as severe bleeding and amniotic fluid embolism. In the week after delivery, severe bleeding, high blood pressure, and infection are most common.  But one-third of the deaths happen 1 week to 1 year after delivery, most often caused by cardiomyopathy.

The findings also confirm racial disparities, the CDC says. Black and Native American women were about 3 times as likely as white women to die of a pregnancy-related cause.

The researchers analyzed 2011-2015 national data on pregnancy mortality and 2013-2017 data from 13 state maternal mortality review committees. Their analysis revealed that most pregnancy-related deaths were preventable regardless of race or ethnicity. Each death represents a “web of missed opportunities,” the CDC says. The mortality review committees determined that each death was associated with several contributing factors, including lack of access to appropriate care, missed or delayed diagnoses, and lack of knowledge among patients and providers about warning signs.

The CDC offers advice on how to help keep patients safe during and after pregnancy. For example:

• Help patients manage their chronic conditions;
• Teach patients about warning signs; and
• Use tools to flag warning signs early so women can receive timely treatment

Hospitals also can standardize patient care, the CDC advises, including delivering high-risk women at hospitals with specialized providers and equipment. They can train nonobstetric providers to consider the patient’s recent pregnancy history. Importantly, health care practitioners should continue to provide high-quality care for mothers up to at least 1 year after birth.

The causes of death differ throughout pregnancy and postpartum. Overall, heart disease and stroke cause > 1 in 3 deaths. At delivery, most deaths are due to obstetric emergencies, such as severe bleeding and amniotic fluid embolism. In the week after delivery, severe bleeding, high blood pressure, and infection are most common.  But one-third of the deaths happen 1 week to 1 year after delivery, most often caused by cardiomyopathy.

The findings also confirm racial disparities, the CDC says. Black and Native American women were about 3 times as likely as white women to die of a pregnancy-related cause.

The researchers analyzed 2011-2015 national data on pregnancy mortality and 2013-2017 data from 13 state maternal mortality review committees. Their analysis revealed that most pregnancy-related deaths were preventable regardless of race or ethnicity. Each death represents a “web of missed opportunities,” the CDC says. The mortality review committees determined that each death was associated with several contributing factors, including lack of access to appropriate care, missed or delayed diagnoses, and lack of knowledge among patients and providers about warning signs.

The CDC offers advice on how to help keep patients safe during and after pregnancy. For example:

• Help patients manage their chronic conditions;
• Teach patients about warning signs; and
• Use tools to flag warning signs early so women can receive timely treatment

Hospitals also can standardize patient care, the CDC advises, including delivering high-risk women at hospitals with specialized providers and equipment. They can train nonobstetric providers to consider the patient’s recent pregnancy history. Importantly, health care practitioners should continue to provide high-quality care for mothers up to at least 1 year after birth.

The causes of death differ throughout pregnancy and postpartum. Overall, heart disease and stroke cause > 1 in 3 deaths. At delivery, most deaths are due to obstetric emergencies, such as severe bleeding and amniotic fluid embolism. In the week after delivery, severe bleeding, high blood pressure, and infection are most common.  But one-third of the deaths happen 1 week to 1 year after delivery, most often caused by cardiomyopathy.

The findings also confirm racial disparities, the CDC says. Black and Native American women were about 3 times as likely as white women to die of a pregnancy-related cause.

The researchers analyzed 2011-2015 national data on pregnancy mortality and 2013-2017 data from 13 state maternal mortality review committees. Their analysis revealed that most pregnancy-related deaths were preventable regardless of race or ethnicity. Each death represents a “web of missed opportunities,” the CDC says. The mortality review committees determined that each death was associated with several contributing factors, including lack of access to appropriate care, missed or delayed diagnoses, and lack of knowledge among patients and providers about warning signs.

The CDC offers advice on how to help keep patients safe during and after pregnancy. For example:

• Help patients manage their chronic conditions;
• Teach patients about warning signs; and
• Use tools to flag warning signs early so women can receive timely treatment

Hospitals also can standardize patient care, the CDC advises, including delivering high-risk women at hospitals with specialized providers and equipment. They can train nonobstetric providers to consider the patient’s recent pregnancy history. Importantly, health care practitioners should continue to provide high-quality care for mothers up to at least 1 year after birth.

ST. LOUIS – As the last abortion clinic in Missouri warned that it will have to stop providing the procedure as soon as May 31, abortion providers in surrounding states said they are anticipating an uptick of even more Missouri patients.

At Hope Clinic in Granite City, Ill., just 10 minutes from downtown St. Louis, Deputy Director Alison Dreith said on May 28 that her clinic was preparing for more patients as news about Missouri spread.

“We’re really scrambling today about the need for increased staff and how fast can we hire and train,” Dreith said.

And at a Trust Women clinic in Wichita, Kan., that already has to fly in doctors, the staff didn’t know what it would mean for their overloaded patient schedule.

“God forbid we see that people can’t get services in Missouri,” said Julie Burkhart, Trust Women founder and CEO. “What is that going to mean on our limited physician days?”

If St. Louis’ Planned Parenthood clinic is unable to offer abortions, the group said, Missouri would be the only state in the country to not have an operating abortion clinic. Five other states – Kentucky, Mississippi, North Dakota, South Dakota and West Virginia – reportedly have only one abortion clinic. And 90% of U.S. counties didn’t have an abortion clinic as of 2014, according to the Guttmacher Institute, a reproductive rights research and advocacy group.

For some, this echoes back to the days before abortion was legalized nationwide in 1973 with the Supreme Court’s Roe v. Wade decision, when patients who could afford to travel would go to more liberal states like California or New York where abortion was legal.

But providers in Kansas and Illinois say this influx from Missouri isn’t new. About half of their clients already come from the Show Me State. To the south, in neighboring Arkansas, where a 72-hour waiting period will go into effect in July, the vast majority of its patients still live within the state.

Over the past 10 years, four Missouri abortion clinics have closed because of increased regulations, including a mandatory 72-hour waiting period after receiving counseling on abortion, thus requiring two trips to a facility; requirements that physicians have hospital admitting privileges within 15 minutes of their clinics; and a rule requiring two-parent notification for minors and one-parent notarized consent. All those limits left one clinic in downtown St. Louis to serve the whole state.

Now Planned Parenthood, which operates that final abortion clinic, said on May 28 that it will be forced to end its abortion services altogether by May 31 if the state suspends its license. The closure is not related to new anti-abortion laws that Missouri Gov. Mike Parson, a Republican, signed on May 24 to ban most abortions after 8 weeks of pregnancy. The new laws don’t take effect until August.

Already the number of patients in Missouri seeking an abortion at the clinic from April 2018 until this April had dropped by 50% compared with the same period the previous year. Planned Parenthood spokesman Jesse Lawder attributes two-thirds of the decrease to the clinic’s refusal to do pelvic exams for abortions performed through medication – recently required by the state – thus forcing all such abortions to be performed out of state.

For Dreith, while she expects the Missouri numbers to continue to grow at her Illinois clinic across the Mississippi River, it’s not the only state sending patients her way.

“Patients were literally coming to us from the last remaining clinics in Kentucky ... so that they wouldn’t get past 24 weeks,” Dreith said. “We don’t want these patients in surrounding states traveling [to] New York [or] California like they once had to.”

That’s how it was prior to the Roe v. Wade ruling, according to Mary Ziegler, a professor at Florida State University College of Law who is writing her third book on the history of the legal battle around abortion access. She anticipates the pattern of privilege will repeat itself.

“You would still expect women with resources to be able to travel as far as they needed,” she said. “And you would expect women without resources to not be able to travel. ... The more the court retreats from protecting abortion rights, the more stark those differences will become.”

For Dreith, the historical comparison to the pre-Roe era rings true, albeit with improved medical practices.

There are safer, easier, and more effective ways to perform abortions now than the “horror stories that we saw pre-Roe,” said Dreith. “But I think the travel will be one of the huge throwbacks and the scariest part will be the criminalization.”

States such as Missouri could feel pressure to start arresting women who perform their own abortions with pills at home or travel out of state, Ziegler said. But, she said, “punishing women isn’t something that’s thought to be very popular.”

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

ST. LOUIS – As the last abortion clinic in Missouri warned that it will have to stop providing the procedure as soon as May 31, abortion providers in surrounding states said they are anticipating an uptick of even more Missouri patients.

At Hope Clinic in Granite City, Ill., just 10 minutes from downtown St. Louis, Deputy Director Alison Dreith said on May 28 that her clinic was preparing for more patients as news about Missouri spread.

“We’re really scrambling today about the need for increased staff and how fast can we hire and train,” Dreith said.

And at a Trust Women clinic in Wichita, Kan., that already has to fly in doctors, the staff didn’t know what it would mean for their overloaded patient schedule.

“God forbid we see that people can’t get services in Missouri,” said Julie Burkhart, Trust Women founder and CEO. “What is that going to mean on our limited physician days?”

If St. Louis’ Planned Parenthood clinic is unable to offer abortions, the group said, Missouri would be the only state in the country to not have an operating abortion clinic. Five other states – Kentucky, Mississippi, North Dakota, South Dakota and West Virginia – reportedly have only one abortion clinic. And 90% of U.S. counties didn’t have an abortion clinic as of 2014, according to the Guttmacher Institute, a reproductive rights research and advocacy group.

For some, this echoes back to the days before abortion was legalized nationwide in 1973 with the Supreme Court’s Roe v. Wade decision, when patients who could afford to travel would go to more liberal states like California or New York where abortion was legal.

But providers in Kansas and Illinois say this influx from Missouri isn’t new. About half of their clients already come from the Show Me State. To the south, in neighboring Arkansas, where a 72-hour waiting period will go into effect in July, the vast majority of its patients still live within the state.

Over the past 10 years, four Missouri abortion clinics have closed because of increased regulations, including a mandatory 72-hour waiting period after receiving counseling on abortion, thus requiring two trips to a facility; requirements that physicians have hospital admitting privileges within 15 minutes of their clinics; and a rule requiring two-parent notification for minors and one-parent notarized consent. All those limits left one clinic in downtown St. Louis to serve the whole state.

Now Planned Parenthood, which operates that final abortion clinic, said on May 28 that it will be forced to end its abortion services altogether by May 31 if the state suspends its license. The closure is not related to new anti-abortion laws that Missouri Gov. Mike Parson, a Republican, signed on May 24 to ban most abortions after 8 weeks of pregnancy. The new laws don’t take effect until August.

Already the number of patients in Missouri seeking an abortion at the clinic from April 2018 until this April had dropped by 50% compared with the same period the previous year. Planned Parenthood spokesman Jesse Lawder attributes two-thirds of the decrease to the clinic’s refusal to do pelvic exams for abortions performed through medication – recently required by the state – thus forcing all such abortions to be performed out of state.

For Dreith, while she expects the Missouri numbers to continue to grow at her Illinois clinic across the Mississippi River, it’s not the only state sending patients her way.

“Patients were literally coming to us from the last remaining clinics in Kentucky ... so that they wouldn’t get past 24 weeks,” Dreith said. “We don’t want these patients in surrounding states traveling [to] New York [or] California like they once had to.”

That’s how it was prior to the Roe v. Wade ruling, according to Mary Ziegler, a professor at Florida State University College of Law who is writing her third book on the history of the legal battle around abortion access. She anticipates the pattern of privilege will repeat itself.

“You would still expect women with resources to be able to travel as far as they needed,” she said. “And you would expect women without resources to not be able to travel. ... The more the court retreats from protecting abortion rights, the more stark those differences will become.”

For Dreith, the historical comparison to the pre-Roe era rings true, albeit with improved medical practices.

There are safer, easier, and more effective ways to perform abortions now than the “horror stories that we saw pre-Roe,” said Dreith. “But I think the travel will be one of the huge throwbacks and the scariest part will be the criminalization.”

States such as Missouri could feel pressure to start arresting women who perform their own abortions with pills at home or travel out of state, Ziegler said. But, she said, “punishing women isn’t something that’s thought to be very popular.”

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

ST. LOUIS – As the last abortion clinic in Missouri warned that it will have to stop providing the procedure as soon as May 31, abortion providers in surrounding states said they are anticipating an uptick of even more Missouri patients.

At Hope Clinic in Granite City, Ill., just 10 minutes from downtown St. Louis, Deputy Director Alison Dreith said on May 28 that her clinic was preparing for more patients as news about Missouri spread.

“We’re really scrambling today about the need for increased staff and how fast can we hire and train,” Dreith said.

And at a Trust Women clinic in Wichita, Kan., that already has to fly in doctors, the staff didn’t know what it would mean for their overloaded patient schedule.

“God forbid we see that people can’t get services in Missouri,” said Julie Burkhart, Trust Women founder and CEO. “What is that going to mean on our limited physician days?”

If St. Louis’ Planned Parenthood clinic is unable to offer abortions, the group said, Missouri would be the only state in the country to not have an operating abortion clinic. Five other states – Kentucky, Mississippi, North Dakota, South Dakota and West Virginia – reportedly have only one abortion clinic. And 90% of U.S. counties didn’t have an abortion clinic as of 2014, according to the Guttmacher Institute, a reproductive rights research and advocacy group.

For some, this echoes back to the days before abortion was legalized nationwide in 1973 with the Supreme Court’s Roe v. Wade decision, when patients who could afford to travel would go to more liberal states like California or New York where abortion was legal.

But providers in Kansas and Illinois say this influx from Missouri isn’t new. About half of their clients already come from the Show Me State. To the south, in neighboring Arkansas, where a 72-hour waiting period will go into effect in July, the vast majority of its patients still live within the state.

Over the past 10 years, four Missouri abortion clinics have closed because of increased regulations, including a mandatory 72-hour waiting period after receiving counseling on abortion, thus requiring two trips to a facility; requirements that physicians have hospital admitting privileges within 15 minutes of their clinics; and a rule requiring two-parent notification for minors and one-parent notarized consent. All those limits left one clinic in downtown St. Louis to serve the whole state.

Now Planned Parenthood, which operates that final abortion clinic, said on May 28 that it will be forced to end its abortion services altogether by May 31 if the state suspends its license. The closure is not related to new anti-abortion laws that Missouri Gov. Mike Parson, a Republican, signed on May 24 to ban most abortions after 8 weeks of pregnancy. The new laws don’t take effect until August.

Already the number of patients in Missouri seeking an abortion at the clinic from April 2018 until this April had dropped by 50% compared with the same period the previous year. Planned Parenthood spokesman Jesse Lawder attributes two-thirds of the decrease to the clinic’s refusal to do pelvic exams for abortions performed through medication – recently required by the state – thus forcing all such abortions to be performed out of state.

For Dreith, while she expects the Missouri numbers to continue to grow at her Illinois clinic across the Mississippi River, it’s not the only state sending patients her way.

“Patients were literally coming to us from the last remaining clinics in Kentucky ... so that they wouldn’t get past 24 weeks,” Dreith said. “We don’t want these patients in surrounding states traveling [to] New York [or] California like they once had to.”

That’s how it was prior to the Roe v. Wade ruling, according to Mary Ziegler, a professor at Florida State University College of Law who is writing her third book on the history of the legal battle around abortion access. She anticipates the pattern of privilege will repeat itself.

“You would still expect women with resources to be able to travel as far as they needed,” she said. “And you would expect women without resources to not be able to travel. ... The more the court retreats from protecting abortion rights, the more stark those differences will become.”

For Dreith, the historical comparison to the pre-Roe era rings true, albeit with improved medical practices.

There are safer, easier, and more effective ways to perform abortions now than the “horror stories that we saw pre-Roe,” said Dreith. “But I think the travel will be one of the huge throwbacks and the scariest part will be the criminalization.”

States such as Missouri could feel pressure to start arresting women who perform their own abortions with pills at home or travel out of state, Ziegler said. But, she said, “punishing women isn’t something that’s thought to be very popular.”

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

The U.S. Supreme Court has upheld part of an Indiana law that requires burial or cremation of fetal remains after an abortion, but the justices declined to address the measure’s prohibition on abortions sought because of race, sex, or disability of the fetus.

ETIENJones/thinkstockphotos

In a three-page, unsigned opinion issued May 28, justices wrote that Indiana has a legitimate interest in proper disposition of fetal remains and that the state’s burial/cremation mandate is rational. However, justices said they would not take up the second part of the law regarding abortions based on race, sex, or disability because not enough appeals courts have decided the issue. The court emphasized it was not expressing any view on the merits of the second question.

The opinion stems from an antiabortion measure signed into law by then–Indiana Governor Mike Pence (R) in 2016. According to the law, the health facility where an abortion occurred is required to dispose of fetal remains either by cremation or internment unless the woman or an associated party take possession of the remains. The measure allows the woman or associated party to choose a location of final disposition provided that the parties pay the costs for such arrangements. The second part of the law prohibits an abortion from being performed solely because of the fetus’s expected race, sex, diagnosis, or disability.

Planned Parenthood of Indiana and Kentucky sued over the law, arguing that the measure was unconstitutional. Indiana officials countered the disposal requirements provided fetuses dignity in death and that the law’s abortion restrictions prevented discrimination of particular fetuses in light of technological advances in genetic screening. In 2018, a three-judge panel of the Court of Appeals for the 7th Circuit struck down the entire law. The panel wrote that well-established Supreme Court precedent allows a woman to terminate her pregnancy for any reason and that the Indiana law invaded a woman’s privacy by examining the underlying basis of her decision for an abortion.

In the Supreme Court’s May 28 filing, Justice Ruth Bader Ginsburg and Justice Sonia Sotomayor wrote separately, each stating they would have upheld the lower court’s ban of the entire law. Justice Clarence Thomas, meanwhile, wrote a lengthy separate opinion, agreeing with the court’s decision, but expressing concern over the use of abortion as a “tool of modern-day eugenics.”

“The court will soon need to confront the constitutionality of laws like Indiana’s,” Justice Thomas wrote. “Enshrining a constitutional right to an abortion based solely on the race, sex or disability of an unborn child, as Planned Parenthood advocates, would constitutionalize the views of the 20th-century eugenics movement.”

The Supreme Court’s decision on the Indiana law comes just weeks after two other stringent state abortion measures were signed into law. On May 7, 2019, Georgia Gov. Brian Kemp (R) signed into law a statute that bars physicians from performing an abortion after a heartbeat is detected – usually at about 6 weeks of pregnancy. On May 15, Alabama Gov. Kay Ivey (R) signed a law that would ban abortion at every pregnancy stage and penalize physicians with a Class A felony for performing an abortion and charge them with a Class C felony for attempting to perform an abortion.

Analysts say the Alabama law, in particular, could land in front of the Supreme Court as a direct challenge to Roe v. Wade. Abortion critics have been encouraged by the Supreme Court appointment of right-leaning Justice Brett M. Kavanaugh and hope the Alabama measure will drive the Supreme Court to reconsider its central holding in Roe, court watchers said.

[email protected]

The U.S. Supreme Court has upheld part of an Indiana law that requires burial or cremation of fetal remains after an abortion, but the justices declined to address the measure’s prohibition on abortions sought because of race, sex, or disability of the fetus.

ETIENJones/thinkstockphotos

In a three-page, unsigned opinion issued May 28, justices wrote that Indiana has a legitimate interest in proper disposition of fetal remains and that the state’s burial/cremation mandate is rational. However, justices said they would not take up the second part of the law regarding abortions based on race, sex, or disability because not enough appeals courts have decided the issue. The court emphasized it was not expressing any view on the merits of the second question.

The opinion stems from an antiabortion measure signed into law by then–Indiana Governor Mike Pence (R) in 2016. According to the law, the health facility where an abortion occurred is required to dispose of fetal remains either by cremation or internment unless the woman or an associated party take possession of the remains. The measure allows the woman or associated party to choose a location of final disposition provided that the parties pay the costs for such arrangements. The second part of the law prohibits an abortion from being performed solely because of the fetus’s expected race, sex, diagnosis, or disability.

Planned Parenthood of Indiana and Kentucky sued over the law, arguing that the measure was unconstitutional. Indiana officials countered the disposal requirements provided fetuses dignity in death and that the law’s abortion restrictions prevented discrimination of particular fetuses in light of technological advances in genetic screening. In 2018, a three-judge panel of the Court of Appeals for the 7th Circuit struck down the entire law. The panel wrote that well-established Supreme Court precedent allows a woman to terminate her pregnancy for any reason and that the Indiana law invaded a woman’s privacy by examining the underlying basis of her decision for an abortion.

In the Supreme Court’s May 28 filing, Justice Ruth Bader Ginsburg and Justice Sonia Sotomayor wrote separately, each stating they would have upheld the lower court’s ban of the entire law. Justice Clarence Thomas, meanwhile, wrote a lengthy separate opinion, agreeing with the court’s decision, but expressing concern over the use of abortion as a “tool of modern-day eugenics.”

“The court will soon need to confront the constitutionality of laws like Indiana’s,” Justice Thomas wrote. “Enshrining a constitutional right to an abortion based solely on the race, sex or disability of an unborn child, as Planned Parenthood advocates, would constitutionalize the views of the 20th-century eugenics movement.”

The Supreme Court’s decision on the Indiana law comes just weeks after two other stringent state abortion measures were signed into law. On May 7, 2019, Georgia Gov. Brian Kemp (R) signed into law a statute that bars physicians from performing an abortion after a heartbeat is detected – usually at about 6 weeks of pregnancy. On May 15, Alabama Gov. Kay Ivey (R) signed a law that would ban abortion at every pregnancy stage and penalize physicians with a Class A felony for performing an abortion and charge them with a Class C felony for attempting to perform an abortion.

Analysts say the Alabama law, in particular, could land in front of the Supreme Court as a direct challenge to Roe v. Wade. Abortion critics have been encouraged by the Supreme Court appointment of right-leaning Justice Brett M. Kavanaugh and hope the Alabama measure will drive the Supreme Court to reconsider its central holding in Roe, court watchers said.

[email protected]

The U.S. Supreme Court has upheld part of an Indiana law that requires burial or cremation of fetal remains after an abortion, but the justices declined to address the measure’s prohibition on abortions sought because of race, sex, or disability of the fetus.

ETIENJones/thinkstockphotos

In a three-page, unsigned opinion issued May 28, justices wrote that Indiana has a legitimate interest in proper disposition of fetal remains and that the state’s burial/cremation mandate is rational. However, justices said they would not take up the second part of the law regarding abortions based on race, sex, or disability because not enough appeals courts have decided the issue. The court emphasized it was not expressing any view on the merits of the second question.

The opinion stems from an antiabortion measure signed into law by then–Indiana Governor Mike Pence (R) in 2016. According to the law, the health facility where an abortion occurred is required to dispose of fetal remains either by cremation or internment unless the woman or an associated party take possession of the remains. The measure allows the woman or associated party to choose a location of final disposition provided that the parties pay the costs for such arrangements. The second part of the law prohibits an abortion from being performed solely because of the fetus’s expected race, sex, diagnosis, or disability.

Planned Parenthood of Indiana and Kentucky sued over the law, arguing that the measure was unconstitutional. Indiana officials countered the disposal requirements provided fetuses dignity in death and that the law’s abortion restrictions prevented discrimination of particular fetuses in light of technological advances in genetic screening. In 2018, a three-judge panel of the Court of Appeals for the 7th Circuit struck down the entire law. The panel wrote that well-established Supreme Court precedent allows a woman to terminate her pregnancy for any reason and that the Indiana law invaded a woman’s privacy by examining the underlying basis of her decision for an abortion.

In the Supreme Court’s May 28 filing, Justice Ruth Bader Ginsburg and Justice Sonia Sotomayor wrote separately, each stating they would have upheld the lower court’s ban of the entire law. Justice Clarence Thomas, meanwhile, wrote a lengthy separate opinion, agreeing with the court’s decision, but expressing concern over the use of abortion as a “tool of modern-day eugenics.”

“The court will soon need to confront the constitutionality of laws like Indiana’s,” Justice Thomas wrote. “Enshrining a constitutional right to an abortion based solely on the race, sex or disability of an unborn child, as Planned Parenthood advocates, would constitutionalize the views of the 20th-century eugenics movement.”

The Supreme Court’s decision on the Indiana law comes just weeks after two other stringent state abortion measures were signed into law. On May 7, 2019, Georgia Gov. Brian Kemp (R) signed into law a statute that bars physicians from performing an abortion after a heartbeat is detected – usually at about 6 weeks of pregnancy. On May 15, Alabama Gov. Kay Ivey (R) signed a law that would ban abortion at every pregnancy stage and penalize physicians with a Class A felony for performing an abortion and charge them with a Class C felony for attempting to perform an abortion.

Analysts say the Alabama law, in particular, could land in front of the Supreme Court as a direct challenge to Roe v. Wade. Abortion critics have been encouraged by the Supreme Court appointment of right-leaning Justice Brett M. Kavanaugh and hope the Alabama measure will drive the Supreme Court to reconsider its central holding in Roe, court watchers said.

[email protected]

TORONTO – Patients with osteoarthritis often want to know if their debilitating disease is likely to be passed on to their children. Karin Magnusson, PhD, believes she can answer that question based upon an analysis of two large Nordic studies.

Bruce Jancin/MDedge News

“OA in the mother, but not in the father, increases the risk of surgical and clinically defined hip, knee, and hand OA in the offspring, and particularly in daughters,” she reported at the OARSI 2019 World Congress.

Dr. Magnusson, an epidemiologist at Lund (Sweden) University, and her coinvestigators, turned to the Musculoskeletal Pain in Ullensaker Study (MUST) of 630 individuals aged 40-79 with rheumatologist-diagnosed hand, hip, or knee OA by American College of Rheumatology clinical criteria and their offspring, as well as the Nor-Twin OA Study of 7,184 twins, aged 30-75, and their children. Linkage with a national registry that records virtually all joint arthroplasties performed in Norway enabled the investigators to identify which subjects in the two studies had joint surgery for OA, she explained at the meeting, sponsored by the Osteoarthritis Research Society International.

The main outcome in this analysis was the relative risk of hip, knee, or hand OA in the sons and daughters of families in which a parent had OA at those sites, compared with the rate when neither parent had OA. The key finding: If the mother had OA, her daughters had a 13% increased risk of OA in MUST and a 44% increased risk in the Nor-Twin OA Study when compared with daughters of women without OA. In contrast, the sons of a mother with OA had no significant increase in risk of OA. And when OA was present in the father, there was no increased risk of OA at any site in his daughters or sons.

“The implication is the heredity of OA is linked to maternal genes and/or maternal-specific factors, such as the fetal environment,” according to Dr. Magnusson.

And for clinical practice, the implication is that it’s important to ask about family history of OA, and in which parent, to better predict future risk of disease transmission to the children, she added.

These Norwegian study results open the door to exploration of the possible role of mitochondrial DNA in familial clustering of OA, since mitochondrial DNA is inherited only from the mother, Dr. Magnusson noted.

David T. Felson, MD, rose from the audience to say, “I’m a little bit worried” about the fact that when he and other Framingham Heart Study investigators looked specifically for possible mother/daughter, mother/son, father/daughter, and father/son associations for knee and hip OA, “we really didn’t find any.

“You can go through all of the explanations that you want about maternal inheritance, but I’m not sure that’s the best explanation. It might just be that what’s going on here is you’re seeing guys who are relatively young and who got their OA through injury or sports, which is fairly common in young men, and not through inheritance,” said Dr. Felson, professor of medicine and epidemiology at Boston University.

So a third observational study in an independent cohort might be needed as a tie breaker regarding the issue of OA inheritance.

Dr. Magnusson reported having no financial conflicts regarding her study, conducted free of commercial support.

[email protected]

SOURCE: Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S47, Abstract 33

TORONTO – Patients with osteoarthritis often want to know if their debilitating disease is likely to be passed on to their children. Karin Magnusson, PhD, believes she can answer that question based upon an analysis of two large Nordic studies.

Bruce Jancin/MDedge News

“OA in the mother, but not in the father, increases the risk of surgical and clinically defined hip, knee, and hand OA in the offspring, and particularly in daughters,” she reported at the OARSI 2019 World Congress.

Dr. Magnusson, an epidemiologist at Lund (Sweden) University, and her coinvestigators, turned to the Musculoskeletal Pain in Ullensaker Study (MUST) of 630 individuals aged 40-79 with rheumatologist-diagnosed hand, hip, or knee OA by American College of Rheumatology clinical criteria and their offspring, as well as the Nor-Twin OA Study of 7,184 twins, aged 30-75, and their children. Linkage with a national registry that records virtually all joint arthroplasties performed in Norway enabled the investigators to identify which subjects in the two studies had joint surgery for OA, she explained at the meeting, sponsored by the Osteoarthritis Research Society International.

The main outcome in this analysis was the relative risk of hip, knee, or hand OA in the sons and daughters of families in which a parent had OA at those sites, compared with the rate when neither parent had OA. The key finding: If the mother had OA, her daughters had a 13% increased risk of OA in MUST and a 44% increased risk in the Nor-Twin OA Study when compared with daughters of women without OA. In contrast, the sons of a mother with OA had no significant increase in risk of OA. And when OA was present in the father, there was no increased risk of OA at any site in his daughters or sons.

“The implication is the heredity of OA is linked to maternal genes and/or maternal-specific factors, such as the fetal environment,” according to Dr. Magnusson.

And for clinical practice, the implication is that it’s important to ask about family history of OA, and in which parent, to better predict future risk of disease transmission to the children, she added.

These Norwegian study results open the door to exploration of the possible role of mitochondrial DNA in familial clustering of OA, since mitochondrial DNA is inherited only from the mother, Dr. Magnusson noted.

David T. Felson, MD, rose from the audience to say, “I’m a little bit worried” about the fact that when he and other Framingham Heart Study investigators looked specifically for possible mother/daughter, mother/son, father/daughter, and father/son associations for knee and hip OA, “we really didn’t find any.

“You can go through all of the explanations that you want about maternal inheritance, but I’m not sure that’s the best explanation. It might just be that what’s going on here is you’re seeing guys who are relatively young and who got their OA through injury or sports, which is fairly common in young men, and not through inheritance,” said Dr. Felson, professor of medicine and epidemiology at Boston University.

So a third observational study in an independent cohort might be needed as a tie breaker regarding the issue of OA inheritance.

Dr. Magnusson reported having no financial conflicts regarding her study, conducted free of commercial support.

[email protected]

SOURCE: Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S47, Abstract 33

TORONTO – Patients with osteoarthritis often want to know if their debilitating disease is likely to be passed on to their children. Karin Magnusson, PhD, believes she can answer that question based upon an analysis of two large Nordic studies.

Bruce Jancin/MDedge News

“OA in the mother, but not in the father, increases the risk of surgical and clinically defined hip, knee, and hand OA in the offspring, and particularly in daughters,” she reported at the OARSI 2019 World Congress.

Dr. Magnusson, an epidemiologist at Lund (Sweden) University, and her coinvestigators, turned to the Musculoskeletal Pain in Ullensaker Study (MUST) of 630 individuals aged 40-79 with rheumatologist-diagnosed hand, hip, or knee OA by American College of Rheumatology clinical criteria and their offspring, as well as the Nor-Twin OA Study of 7,184 twins, aged 30-75, and their children. Linkage with a national registry that records virtually all joint arthroplasties performed in Norway enabled the investigators to identify which subjects in the two studies had joint surgery for OA, she explained at the meeting, sponsored by the Osteoarthritis Research Society International.

The main outcome in this analysis was the relative risk of hip, knee, or hand OA in the sons and daughters of families in which a parent had OA at those sites, compared with the rate when neither parent had OA. The key finding: If the mother had OA, her daughters had a 13% increased risk of OA in MUST and a 44% increased risk in the Nor-Twin OA Study when compared with daughters of women without OA. In contrast, the sons of a mother with OA had no significant increase in risk of OA. And when OA was present in the father, there was no increased risk of OA at any site in his daughters or sons.

“The implication is the heredity of OA is linked to maternal genes and/or maternal-specific factors, such as the fetal environment,” according to Dr. Magnusson.

And for clinical practice, the implication is that it’s important to ask about family history of OA, and in which parent, to better predict future risk of disease transmission to the children, she added.

These Norwegian study results open the door to exploration of the possible role of mitochondrial DNA in familial clustering of OA, since mitochondrial DNA is inherited only from the mother, Dr. Magnusson noted.

David T. Felson, MD, rose from the audience to say, “I’m a little bit worried” about the fact that when he and other Framingham Heart Study investigators looked specifically for possible mother/daughter, mother/son, father/daughter, and father/son associations for knee and hip OA, “we really didn’t find any.

“You can go through all of the explanations that you want about maternal inheritance, but I’m not sure that’s the best explanation. It might just be that what’s going on here is you’re seeing guys who are relatively young and who got their OA through injury or sports, which is fairly common in young men, and not through inheritance,” said Dr. Felson, professor of medicine and epidemiology at Boston University.

So a third observational study in an independent cohort might be needed as a tie breaker regarding the issue of OA inheritance.

Dr. Magnusson reported having no financial conflicts regarding her study, conducted free of commercial support.

[email protected]

SOURCE: Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S47, Abstract 33

Women experiencing syncope during pregnancy and their offspring have elevated rates of adverse outcomes that may warrant closer follow-up, a retrospective population-based cohort study finds. Risks appeared highest with first-trimester syncope.

“There are very limited data on the frequency of fainting during pregnancy,” Padma Kaul, Ph.D., senior study author and professor of medicine at the University of Alberta, Edmonton, said in a statement. “In our study, fainting during pregnancy occurred in about 1%, or 10 per 1,000 pregnancies, but appears to be increasing by 5% each year.”

“Fainting during pregnancy has previously been thought to follow a relatively benign course,” Dr. Kaul said. “The findings of our study suggest that timing of fainting during pregnancy may be important. When the faint happens early during pregnancy or multiple times during pregnancy, it may be associated with both short- and long-term health issues for the baby and the mother.”

First authors Safia Chatur, MD, of the University of Calgary (Alta.) and Sunjidatul Islam, MBBS, of the Canadian Vigour Centre, Edmonton, Alta., and associates analyzed 481,930 pregnancies occurring during 2005-2014 in the province.

Study results, reported in the Journal of the American Heart Association, showed that syncope occurred in almost 1% of pregnancies (9.7 episodes per 1,000 pregnancies) overall. Incidence increased by 5% per year during the study period.

Syncope episodes were distributed across the first trimester (32%), second trimester (44%), and third trimester (24%). Eight percent of pregnancies had more than one episode.

Compared with unaffected peers, women who experienced syncope were younger (age younger than 25 years, 35% vs. 21%; P less than .001) and more often primiparous (52% vs. 42%; P less than .001).

The rate of preterm birth was 18%, 16%, and 14% in pregnancies with an initial syncope episode during the first, second, and third trimester, respectively, compared with 15% in pregnancies without syncope (P less than .01 across groups).

With a median follow-up of about 5 years, compared with peers of syncope-free pregnancies, children of pregnancies complicated by syncope had a higher incidence of congenital anomalies (3.1% vs. 2.6%; P = .023). Incidence was highest in pregnancies with multiple episodes of syncope (5% vs. 3%; P less than .01).

In adjusted analyses that accounted for multiple pregnancies in individual women, relative to counterparts with no syncope during pregnancy, women who experienced syncope during the first trimester had higher odds of giving birth preterm (odds ratio, 1.3; P = .001) and of having an infant small for gestational age (OR, 1.2; P = .04) or with congenital anomalies (OR, 1.4; P = .036). Women with multiple syncope episodes versus none were twice as likely to have offspring with congenital anomalies (OR, 2.0; P = .003).

Relative to peers who did not experience syncope in pregnancy, women who did had higher incidences of cardiac arrhythmias (0.8% vs. 0.2%; P less than .01) and syncope episodes (1.4% vs. 0.2%; P less than .01) in the first year after delivery.

“Our data suggest that syncope during pregnancy may not be a benign occurrence,” Dr. Chatur and associates said. “More detailed clinical data are needed to identify potential causes for the observed increase in syncope during pregnancy in our study.“Whether women who experience syncope during pregnancy may benefit from closer monitoring during the obstetric and postpartum periods requires further study,” they concluded.

The investigators disclosed no relevant conflicts of interest. This study was funded by a grant from the Cardiac Arrhythmia Network of Canada.

SOURCE: Chatur S et al. J Am Heart Assoc. 2019;8:e011608.

Women experiencing syncope during pregnancy and their offspring have elevated rates of adverse outcomes that may warrant closer follow-up, a retrospective population-based cohort study finds. Risks appeared highest with first-trimester syncope.

“There are very limited data on the frequency of fainting during pregnancy,” Padma Kaul, Ph.D., senior study author and professor of medicine at the University of Alberta, Edmonton, said in a statement. “In our study, fainting during pregnancy occurred in about 1%, or 10 per 1,000 pregnancies, but appears to be increasing by 5% each year.”

“Fainting during pregnancy has previously been thought to follow a relatively benign course,” Dr. Kaul said. “The findings of our study suggest that timing of fainting during pregnancy may be important. When the faint happens early during pregnancy or multiple times during pregnancy, it may be associated with both short- and long-term health issues for the baby and the mother.”

First authors Safia Chatur, MD, of the University of Calgary (Alta.) and Sunjidatul Islam, MBBS, of the Canadian Vigour Centre, Edmonton, Alta., and associates analyzed 481,930 pregnancies occurring during 2005-2014 in the province.

Study results, reported in the Journal of the American Heart Association, showed that syncope occurred in almost 1% of pregnancies (9.7 episodes per 1,000 pregnancies) overall. Incidence increased by 5% per year during the study period.

Syncope episodes were distributed across the first trimester (32%), second trimester (44%), and third trimester (24%). Eight percent of pregnancies had more than one episode.

Compared with unaffected peers, women who experienced syncope were younger (age younger than 25 years, 35% vs. 21%; P less than .001) and more often primiparous (52% vs. 42%; P less than .001).

The rate of preterm birth was 18%, 16%, and 14% in pregnancies with an initial syncope episode during the first, second, and third trimester, respectively, compared with 15% in pregnancies without syncope (P less than .01 across groups).

With a median follow-up of about 5 years, compared with peers of syncope-free pregnancies, children of pregnancies complicated by syncope had a higher incidence of congenital anomalies (3.1% vs. 2.6%; P = .023). Incidence was highest in pregnancies with multiple episodes of syncope (5% vs. 3%; P less than .01).

In adjusted analyses that accounted for multiple pregnancies in individual women, relative to counterparts with no syncope during pregnancy, women who experienced syncope during the first trimester had higher odds of giving birth preterm (odds ratio, 1.3; P = .001) and of having an infant small for gestational age (OR, 1.2; P = .04) or with congenital anomalies (OR, 1.4; P = .036). Women with multiple syncope episodes versus none were twice as likely to have offspring with congenital anomalies (OR, 2.0; P = .003).

Relative to peers who did not experience syncope in pregnancy, women who did had higher incidences of cardiac arrhythmias (0.8% vs. 0.2%; P less than .01) and syncope episodes (1.4% vs. 0.2%; P less than .01) in the first year after delivery.

“Our data suggest that syncope during pregnancy may not be a benign occurrence,” Dr. Chatur and associates said. “More detailed clinical data are needed to identify potential causes for the observed increase in syncope during pregnancy in our study.“Whether women who experience syncope during pregnancy may benefit from closer monitoring during the obstetric and postpartum periods requires further study,” they concluded.

The investigators disclosed no relevant conflicts of interest. This study was funded by a grant from the Cardiac Arrhythmia Network of Canada.

SOURCE: Chatur S et al. J Am Heart Assoc. 2019;8:e011608.

Women experiencing syncope during pregnancy and their offspring have elevated rates of adverse outcomes that may warrant closer follow-up, a retrospective population-based cohort study finds. Risks appeared highest with first-trimester syncope.

“There are very limited data on the frequency of fainting during pregnancy,” Padma Kaul, Ph.D., senior study author and professor of medicine at the University of Alberta, Edmonton, said in a statement. “In our study, fainting during pregnancy occurred in about 1%, or 10 per 1,000 pregnancies, but appears to be increasing by 5% each year.”

“Fainting during pregnancy has previously been thought to follow a relatively benign course,” Dr. Kaul said. “The findings of our study suggest that timing of fainting during pregnancy may be important. When the faint happens early during pregnancy or multiple times during pregnancy, it may be associated with both short- and long-term health issues for the baby and the mother.”

First authors Safia Chatur, MD, of the University of Calgary (Alta.) and Sunjidatul Islam, MBBS, of the Canadian Vigour Centre, Edmonton, Alta., and associates analyzed 481,930 pregnancies occurring during 2005-2014 in the province.

Study results, reported in the Journal of the American Heart Association, showed that syncope occurred in almost 1% of pregnancies (9.7 episodes per 1,000 pregnancies) overall. Incidence increased by 5% per year during the study period.

Syncope episodes were distributed across the first trimester (32%), second trimester (44%), and third trimester (24%). Eight percent of pregnancies had more than one episode.

Compared with unaffected peers, women who experienced syncope were younger (age younger than 25 years, 35% vs. 21%; P less than .001) and more often primiparous (52% vs. 42%; P less than .001).

The rate of preterm birth was 18%, 16%, and 14% in pregnancies with an initial syncope episode during the first, second, and third trimester, respectively, compared with 15% in pregnancies without syncope (P less than .01 across groups).

With a median follow-up of about 5 years, compared with peers of syncope-free pregnancies, children of pregnancies complicated by syncope had a higher incidence of congenital anomalies (3.1% vs. 2.6%; P = .023). Incidence was highest in pregnancies with multiple episodes of syncope (5% vs. 3%; P less than .01).

In adjusted analyses that accounted for multiple pregnancies in individual women, relative to counterparts with no syncope during pregnancy, women who experienced syncope during the first trimester had higher odds of giving birth preterm (odds ratio, 1.3; P = .001) and of having an infant small for gestational age (OR, 1.2; P = .04) or with congenital anomalies (OR, 1.4; P = .036). Women with multiple syncope episodes versus none were twice as likely to have offspring with congenital anomalies (OR, 2.0; P = .003).

Relative to peers who did not experience syncope in pregnancy, women who did had higher incidences of cardiac arrhythmias (0.8% vs. 0.2%; P less than .01) and syncope episodes (1.4% vs. 0.2%; P less than .01) in the first year after delivery.

“Our data suggest that syncope during pregnancy may not be a benign occurrence,” Dr. Chatur and associates said. “More detailed clinical data are needed to identify potential causes for the observed increase in syncope during pregnancy in our study.“Whether women who experience syncope during pregnancy may benefit from closer monitoring during the obstetric and postpartum periods requires further study,” they concluded.

The investigators disclosed no relevant conflicts of interest. This study was funded by a grant from the Cardiac Arrhythmia Network of Canada.

SOURCE: Chatur S et al. J Am Heart Assoc. 2019;8:e011608.

NASHVILLE, TENN. – A novel rapid urine test strongly correlates with preeclampsia, according to findings from a study of urine samples from a prospective cohort of women referred to a labor and delivery triage center to rule out the condition.

The study involved the evaluation of 349 frozen urine samples from the cohort, which included 89 preeclampsia cases (26%) as diagnosed by expert adjudication based on 2013 American College of Obstetricians and Gynecologists guidelines. Visual scoring by a blinded user at 3 minutes after application of urine to the test device for 329 available samples showed 84% test sensitivity, 77% test specificity, and 93% negative predictive value, compared with the adjudicated diagnoses, Wendy L. Davis reported during an e-poster session at ACOG’s annual clinical and scientific meeting.

Of the women in the study cohort, 52% were multiparous, 91% were overweight or obese, 38% were early preterm, 31% were late preterm, and 31% were at term. Cases were described by at least one referring physician as “particularly challenging and ambiguous,” said Ms. Davis, founder and CEO of GestVision in Groton, Conn., and colleagues.

The findings, which suggest that this rapid test holds promise as an aid in the diagnosis of preeclampsia, are important as preeclampsia-associated morbidity and mortality most often occur because of a delay or misdiagnosis, they explained, also noting that diagnostic criteria for preeclampsia are “inadequate even in best care situations.”

The test – an in vitro diagnostic device known as the GestAssured Test Kit – is being developed by GestVision based on data showing that aberrant protein misfolding and aggregation is a pathogenic feature of preeclampsia. That data initially led to development of the Congo Red Dot test as a laboratory batch test, followed by development and validation of a point-of-care version of the test to allow for better integration in clinical work flow.

The GestAssured Test Kit currently in development for commercial use is based on that technology, and the current data suggest that it has slightly higher sensitivity, slightly lower specificity, and slightly higher negative predictive value than the Congo Red Dot test.

“The GestAssured test was developed specifically for preeclampsia and has a high negative predictive value, suggesting that this device, in conjunction with ACOG task force guidelines for hypertension in pregnancy, can assist in ruling out disease in patients suspected of preeclampsia,” the investigators wrote.

“[It is] particularly useful in a triage setting where you have a complex collection of patients coming in,” Ms. Davis said during the poster presentation. “And it warrants ongoing U.S. multicenter clinical studies.”

This study was funded by GestVision and Saving Lives at Birth. Ms. Davis is an employee and shareholder of GestVision and is named as an inventor or coinventor on patents licensed for commercialization to the company.

NASHVILLE, TENN. – A novel rapid urine test strongly correlates with preeclampsia, according to findings from a study of urine samples from a prospective cohort of women referred to a labor and delivery triage center to rule out the condition.

The study involved the evaluation of 349 frozen urine samples from the cohort, which included 89 preeclampsia cases (26%) as diagnosed by expert adjudication based on 2013 American College of Obstetricians and Gynecologists guidelines. Visual scoring by a blinded user at 3 minutes after application of urine to the test device for 329 available samples showed 84% test sensitivity, 77% test specificity, and 93% negative predictive value, compared with the adjudicated diagnoses, Wendy L. Davis reported during an e-poster session at ACOG’s annual clinical and scientific meeting.

Of the women in the study cohort, 52% were multiparous, 91% were overweight or obese, 38% were early preterm, 31% were late preterm, and 31% were at term. Cases were described by at least one referring physician as “particularly challenging and ambiguous,” said Ms. Davis, founder and CEO of GestVision in Groton, Conn., and colleagues.

The findings, which suggest that this rapid test holds promise as an aid in the diagnosis of preeclampsia, are important as preeclampsia-associated morbidity and mortality most often occur because of a delay or misdiagnosis, they explained, also noting that diagnostic criteria for preeclampsia are “inadequate even in best care situations.”

The test – an in vitro diagnostic device known as the GestAssured Test Kit – is being developed by GestVision based on data showing that aberrant protein misfolding and aggregation is a pathogenic feature of preeclampsia. That data initially led to development of the Congo Red Dot test as a laboratory batch test, followed by development and validation of a point-of-care version of the test to allow for better integration in clinical work flow.

The GestAssured Test Kit currently in development for commercial use is based on that technology, and the current data suggest that it has slightly higher sensitivity, slightly lower specificity, and slightly higher negative predictive value than the Congo Red Dot test.

“The GestAssured test was developed specifically for preeclampsia and has a high negative predictive value, suggesting that this device, in conjunction with ACOG task force guidelines for hypertension in pregnancy, can assist in ruling out disease in patients suspected of preeclampsia,” the investigators wrote.

“[It is] particularly useful in a triage setting where you have a complex collection of patients coming in,” Ms. Davis said during the poster presentation. “And it warrants ongoing U.S. multicenter clinical studies.”

This study was funded by GestVision and Saving Lives at Birth. Ms. Davis is an employee and shareholder of GestVision and is named as an inventor or coinventor on patents licensed for commercialization to the company.

NASHVILLE, TENN. – A novel rapid urine test strongly correlates with preeclampsia, according to findings from a study of urine samples from a prospective cohort of women referred to a labor and delivery triage center to rule out the condition.

The study involved the evaluation of 349 frozen urine samples from the cohort, which included 89 preeclampsia cases (26%) as diagnosed by expert adjudication based on 2013 American College of Obstetricians and Gynecologists guidelines. Visual scoring by a blinded user at 3 minutes after application of urine to the test device for 329 available samples showed 84% test sensitivity, 77% test specificity, and 93% negative predictive value, compared with the adjudicated diagnoses, Wendy L. Davis reported during an e-poster session at ACOG’s annual clinical and scientific meeting.

Of the women in the study cohort, 52% were multiparous, 91% were overweight or obese, 38% were early preterm, 31% were late preterm, and 31% were at term. Cases were described by at least one referring physician as “particularly challenging and ambiguous,” said Ms. Davis, founder and CEO of GestVision in Groton, Conn., and colleagues.

The findings, which suggest that this rapid test holds promise as an aid in the diagnosis of preeclampsia, are important as preeclampsia-associated morbidity and mortality most often occur because of a delay or misdiagnosis, they explained, also noting that diagnostic criteria for preeclampsia are “inadequate even in best care situations.”

The test – an in vitro diagnostic device known as the GestAssured Test Kit – is being developed by GestVision based on data showing that aberrant protein misfolding and aggregation is a pathogenic feature of preeclampsia. That data initially led to development of the Congo Red Dot test as a laboratory batch test, followed by development and validation of a point-of-care version of the test to allow for better integration in clinical work flow.

The GestAssured Test Kit currently in development for commercial use is based on that technology, and the current data suggest that it has slightly higher sensitivity, slightly lower specificity, and slightly higher negative predictive value than the Congo Red Dot test.

“The GestAssured test was developed specifically for preeclampsia and has a high negative predictive value, suggesting that this device, in conjunction with ACOG task force guidelines for hypertension in pregnancy, can assist in ruling out disease in patients suspected of preeclampsia,” the investigators wrote.

“[It is] particularly useful in a triage setting where you have a complex collection of patients coming in,” Ms. Davis said during the poster presentation. “And it warrants ongoing U.S. multicenter clinical studies.”

This study was funded by GestVision and Saving Lives at Birth. Ms. Davis is an employee and shareholder of GestVision and is named as an inventor or coinventor on patents licensed for commercialization to the company.

Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.

Rawpixel/Thinkstock

By definition, gender identity refers to an internal experience of one’s gender, of one’s self.¹ While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.

Overall, health care providers should be careful not make assumptions about a patient’s sexual orientation based on a patient’s gender identity. When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.² The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.

With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.

A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.³ One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”

Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
 

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures

References

1. Sexual orientation and gender identity definitions. Human Rights Campaign.

2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.

3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.

Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.

Rawpixel/Thinkstock

By definition, gender identity refers to an internal experience of one’s gender, of one’s self.¹ While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.

Overall, health care providers should be careful not make assumptions about a patient’s sexual orientation based on a patient’s gender identity. When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.² The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.

With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.

A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.³ One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”

Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
 

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures

References

1. Sexual orientation and gender identity definitions. Human Rights Campaign.

2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.

3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.

Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.

Rawpixel/Thinkstock

By definition, gender identity refers to an internal experience of one’s gender, of one’s self.¹ While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.

Overall, health care providers should be careful not make assumptions about a patient’s sexual orientation based on a patient’s gender identity. When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.² The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.

With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.

A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.³ One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”

Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
 

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures

References

1. Sexual orientation and gender identity definitions. Human Rights Campaign.

2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.

3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.

NASHVILLE, TENN. – A targeted next-generation sequencing panel rapidly identifies both germline and somatic Lynch syndrome pathogenic mutations in women with – or at risk for – endometrial cancer, according to findings in a prospective patient cohort.

Sharon Worcester/MDedge News

The findings, which also suggest that the incidence of Lynch syndrome among endometrial cancer patients is higher than previously recognized, have “immediate and major implications for the individual patient with endometrial cancer ... and implications for related family members,” Maria Mercedes M. Padron, MD, reported during an e-poster session at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Of 71 patients included in the study, 67 were undergoing endometrial cancer treatment and 7 (3 among those undergoing endometrial cancer treatment and 4 who did not have endometrial cancer) were known to have Lynch syndrome.

Of the 67 undergoing treatment, 22 (33%) were identified by the direct sequencing panel as having Lynch syndrome mutations, and of those, 7 (10%) had mutations classified as high confidence inactivating mutations in either MLH1, MSH6, PMS2, or MSH2 genes, said Dr. Padron, a research scholar at Icahn School of Medicine at Mount Sinai, New York. The remaining 15 patients had rare mutations and met previously defined phenotypic criteria for Lynch syndrome pathogenicity, she reported.

The sequencing panel–based results were compared with commercially available gene tests, including immunohistochemistry (IHC) and microsatellite instability testing (MSI); 10 patients were identified by IHC to have loss of nuclear mismatch repair (MMR) protein expression, and 8 of those were Lynch syndrome mutation positive. In addition, two patients were MSI-high, and both of those were Lynch syndrome mutation positive.

Thus, two Lynch syndrome patients were missed by direct sequencing, noted Dr. Padron.

However, an additional 10 patients who were not identified as having Lynch syndrome by IHC and MSI testing were potentially identified as such using the sequencing panel, Dr. Padron said, noting that “the pathogenicity of these additional variants needs to be defined.”

Lynch syndrome is a hereditary cancer syndrome caused by germline mutations in DNA MMR genes; it is the third most common malignancy in women and it confers an increased risk of several types of cancer, including colorectal, ovarian, gastric, and endometrial cancer, among others.

“It is estimated that 3% to 5% of endometrial cancers will arise from Lynch syndrome,” Dr. Padron explained during the poster session.

Because the presence of Lynch syndrome directly affects immediate clinical management and future risk-reducing and surveillance strategies for patients and at-risk family members, screening is recommended in all women with endometrial cancer, she added, noting, however, that “the optimum screening method has yet to be established.”

The sequencing panel evaluated in this study – Swift’s Accel-Amplicon Plus Lynch Syndrome Panel – requires only low input amounts of DNA, and in an earlier test using 10 control samples, it exhibited greater than 90% on-target and coverage uniformity. The work flow allowed for data analysis within 2 days, Dr. Padron noted.

The panel then was tested in the current cohort of patients who were referred to a gynecology oncology clinic for either treatment of endometrial cancer or for evaluation of risk for endometrial cancer.

Germline/tumor DNA was isolated and 10 ng DNA was used for targeted exon-level hotspot coverage of MLH1, MSH2, MSH6, and PMS2.

The findings suggest that the prevalence of Lynch syndrome may be six to seven times greater than previously estimated, Dr. Padron said during the poster presentation.

“If confirmed, this would have huge implications for our patients and health care system,” she said, adding that the ability to perform and analyze the sequencing within 48 hours of sample collection using a very low DNA input also was of note.

Taken together, “the findings of this study support future larger studies that can be performed concurrently with current standard of care technologies,” she and her colleagues concluded, noting that such studies would better determine more robust estimates of the prevalence of Lynch syndrome in women with endometrial cancer, help define improved standard-of-care guidelines, and provide future guidance for possible universal/targeted screening programs – all with the goal of improving the clinical care of women.

Dr. Padron reported having no relevant financial disclosures.

[email protected]

NASHVILLE, TENN. – A targeted next-generation sequencing panel rapidly identifies both germline and somatic Lynch syndrome pathogenic mutations in women with – or at risk for – endometrial cancer, according to findings in a prospective patient cohort.

Sharon Worcester/MDedge News

The findings, which also suggest that the incidence of Lynch syndrome among endometrial cancer patients is higher than previously recognized, have “immediate and major implications for the individual patient with endometrial cancer ... and implications for related family members,” Maria Mercedes M. Padron, MD, reported during an e-poster session at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Of 71 patients included in the study, 67 were undergoing endometrial cancer treatment and 7 (3 among those undergoing endometrial cancer treatment and 4 who did not have endometrial cancer) were known to have Lynch syndrome.

Of the 67 undergoing treatment, 22 (33%) were identified by the direct sequencing panel as having Lynch syndrome mutations, and of those, 7 (10%) had mutations classified as high confidence inactivating mutations in either MLH1, MSH6, PMS2, or MSH2 genes, said Dr. Padron, a research scholar at Icahn School of Medicine at Mount Sinai, New York. The remaining 15 patients had rare mutations and met previously defined phenotypic criteria for Lynch syndrome pathogenicity, she reported.

The sequencing panel–based results were compared with commercially available gene tests, including immunohistochemistry (IHC) and microsatellite instability testing (MSI); 10 patients were identified by IHC to have loss of nuclear mismatch repair (MMR) protein expression, and 8 of those were Lynch syndrome mutation positive. In addition, two patients were MSI-high, and both of those were Lynch syndrome mutation positive.

Thus, two Lynch syndrome patients were missed by direct sequencing, noted Dr. Padron.

However, an additional 10 patients who were not identified as having Lynch syndrome by IHC and MSI testing were potentially identified as such using the sequencing panel, Dr. Padron said, noting that “the pathogenicity of these additional variants needs to be defined.”

Lynch syndrome is a hereditary cancer syndrome caused by germline mutations in DNA MMR genes; it is the third most common malignancy in women and it confers an increased risk of several types of cancer, including colorectal, ovarian, gastric, and endometrial cancer, among others.

“It is estimated that 3% to 5% of endometrial cancers will arise from Lynch syndrome,” Dr. Padron explained during the poster session.

Because the presence of Lynch syndrome directly affects immediate clinical management and future risk-reducing and surveillance strategies for patients and at-risk family members, screening is recommended in all women with endometrial cancer, she added, noting, however, that “the optimum screening method has yet to be established.”

The sequencing panel evaluated in this study – Swift’s Accel-Amplicon Plus Lynch Syndrome Panel – requires only low input amounts of DNA, and in an earlier test using 10 control samples, it exhibited greater than 90% on-target and coverage uniformity. The work flow allowed for data analysis within 2 days, Dr. Padron noted.

The panel then was tested in the current cohort of patients who were referred to a gynecology oncology clinic for either treatment of endometrial cancer or for evaluation of risk for endometrial cancer.

Germline/tumor DNA was isolated and 10 ng DNA was used for targeted exon-level hotspot coverage of MLH1, MSH2, MSH6, and PMS2.

The findings suggest that the prevalence of Lynch syndrome may be six to seven times greater than previously estimated, Dr. Padron said during the poster presentation.

“If confirmed, this would have huge implications for our patients and health care system,” she said, adding that the ability to perform and analyze the sequencing within 48 hours of sample collection using a very low DNA input also was of note.

Taken together, “the findings of this study support future larger studies that can be performed concurrently with current standard of care technologies,” she and her colleagues concluded, noting that such studies would better determine more robust estimates of the prevalence of Lynch syndrome in women with endometrial cancer, help define improved standard-of-care guidelines, and provide future guidance for possible universal/targeted screening programs – all with the goal of improving the clinical care of women.

Dr. Padron reported having no relevant financial disclosures.

[email protected]

NASHVILLE, TENN. – A targeted next-generation sequencing panel rapidly identifies both germline and somatic Lynch syndrome pathogenic mutations in women with – or at risk for – endometrial cancer, according to findings in a prospective patient cohort.

Sharon Worcester/MDedge News

The findings, which also suggest that the incidence of Lynch syndrome among endometrial cancer patients is higher than previously recognized, have “immediate and major implications for the individual patient with endometrial cancer ... and implications for related family members,” Maria Mercedes M. Padron, MD, reported during an e-poster session at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Of 71 patients included in the study, 67 were undergoing endometrial cancer treatment and 7 (3 among those undergoing endometrial cancer treatment and 4 who did not have endometrial cancer) were known to have Lynch syndrome.

Of the 67 undergoing treatment, 22 (33%) were identified by the direct sequencing panel as having Lynch syndrome mutations, and of those, 7 (10%) had mutations classified as high confidence inactivating mutations in either MLH1, MSH6, PMS2, or MSH2 genes, said Dr. Padron, a research scholar at Icahn School of Medicine at Mount Sinai, New York. The remaining 15 patients had rare mutations and met previously defined phenotypic criteria for Lynch syndrome pathogenicity, she reported.

The sequencing panel–based results were compared with commercially available gene tests, including immunohistochemistry (IHC) and microsatellite instability testing (MSI); 10 patients were identified by IHC to have loss of nuclear mismatch repair (MMR) protein expression, and 8 of those were Lynch syndrome mutation positive. In addition, two patients were MSI-high, and both of those were Lynch syndrome mutation positive.

Thus, two Lynch syndrome patients were missed by direct sequencing, noted Dr. Padron.

However, an additional 10 patients who were not identified as having Lynch syndrome by IHC and MSI testing were potentially identified as such using the sequencing panel, Dr. Padron said, noting that “the pathogenicity of these additional variants needs to be defined.”

Lynch syndrome is a hereditary cancer syndrome caused by germline mutations in DNA MMR genes; it is the third most common malignancy in women and it confers an increased risk of several types of cancer, including colorectal, ovarian, gastric, and endometrial cancer, among others.

“It is estimated that 3% to 5% of endometrial cancers will arise from Lynch syndrome,” Dr. Padron explained during the poster session.

Because the presence of Lynch syndrome directly affects immediate clinical management and future risk-reducing and surveillance strategies for patients and at-risk family members, screening is recommended in all women with endometrial cancer, she added, noting, however, that “the optimum screening method has yet to be established.”

The sequencing panel evaluated in this study – Swift’s Accel-Amplicon Plus Lynch Syndrome Panel – requires only low input amounts of DNA, and in an earlier test using 10 control samples, it exhibited greater than 90% on-target and coverage uniformity. The work flow allowed for data analysis within 2 days, Dr. Padron noted.

The panel then was tested in the current cohort of patients who were referred to a gynecology oncology clinic for either treatment of endometrial cancer or for evaluation of risk for endometrial cancer.

Germline/tumor DNA was isolated and 10 ng DNA was used for targeted exon-level hotspot coverage of MLH1, MSH2, MSH6, and PMS2.

The findings suggest that the prevalence of Lynch syndrome may be six to seven times greater than previously estimated, Dr. Padron said during the poster presentation.

“If confirmed, this would have huge implications for our patients and health care system,” she said, adding that the ability to perform and analyze the sequencing within 48 hours of sample collection using a very low DNA input also was of note.

Taken together, “the findings of this study support future larger studies that can be performed concurrently with current standard of care technologies,” she and her colleagues concluded, noting that such studies would better determine more robust estimates of the prevalence of Lynch syndrome in women with endometrial cancer, help define improved standard-of-care guidelines, and provide future guidance for possible universal/targeted screening programs – all with the goal of improving the clinical care of women.

Dr. Padron reported having no relevant financial disclosures.

[email protected]