Women's Health

Monkeypox cases in the United States continue to be rare in children younger than 15, women, and in individuals older than 60, according to new data released by the Centers for Disease Control and Prevention. Men aged 26-40 make up the highest proportion of cases.

The age distribution of cases is similar to those of sexually transmitted infections, said Monica Gandhi, MD, MPH, associate chief of the division of HIV, infectious diseases, and global medicine at the University of California, San Francisco. It is most common in younger to middle-aged age groups, and less common in children and older individuals. As of Aug. 21, only 17 children younger than 15 have been diagnosed with monkeypox in the United States, and women make up fewer than 1.5% of cases.

“This data should be very reassuring to parents and to children going to back to school,” Dr. Gandhi said in an interview. After 3 months of monitoring the virus, the data suggest that monkeypox is primarily spreading in networks of men who have sex with men (MSM) through sexual activity, “and that isn’t something we worry about with school-spread illness.”

In addition to the reassuring data about children and monkeypox, the CDC released laboratory testing data, a behavioral survey of MSM, patient data on the antiviral medication tecovirimat (TPOXX), and other case demographics and symptoms.

Though the number of positive monkeypox tests have continued to rise, the test-positivity rates have declined over the past month, data show. Since July 16, the positivity rate has dipped from 54% to 23%. This trend is likely because of an increase in testing availability, said Randolph Hubach, PhD, MPH, the director of the Sexual Health Research Lab at Purdue University, West Lafayette, Ind.

“We also saw this with COVID early on with testing: it was really limited to folks who were symptomatic,” he said in an interview . “As testing ramped up in accessibility, you had a lot more negative results, but because testing was more widely available, you were able to capture more positive results.”

The data also show that case numbers continue to grow in the United States, whereas in other countries that identified cases before the United States – Spain, the United Kingdom, and France, for example – cases have been leveling off, noted Dr. Gandhi.

The CDC also shared responses from a survey of gay, bisexual, and other MSM conducted from Aug. 5-15, about how they have changed their sexual behaviors in response to the monkeypox outbreak. Half of respondents reported reduced one-time sexual encounters, 49% reported reducing sex with partners met on dating apps or at sex venues, and 48% reported reducing their number of sex partners. These responses are “heartening to see,” Dr. Gandhi said, and shows that individuals are taking proactive steps to reduce their potential exposure risk to monkeypox.

More detailed demographic data showed that Black, Hispanic, or Latinx individuals make up an increasing proportion of cases in the United States. In May, 71% of people with reported monkeypox infection were White and 29% were Black. For the week of August 8-14, about a third (31%) of monkeypox cases were in White people, 32% were in Hispanic or Latinx people, and 33% were in Black people.

The most common symptoms of monkeypox were rash (98.6%), malaise (72.7%), fever (72.1%), and chills (68.9%). Rectal pain was reported in 43.9% of patients, and 25% had rectal bleeding.

The CDC also released information on 288 patients with monkeypox treated with TPOXX under compassionate use. The median age of patients was 37 and 98.9% were male. About 40% of recipients were White, 35% were Hispanic, and about 16% were Black. This information does not include every patient treated with TPOXX, the agency said, as providers can begin treatment before submitting paperwork. As of Aug. 18, the CDC had received 400 patient intake forms for TPOXX, according to its website.

The agency has yet to release data on vaccination rates, which Dr. Hubach is eager to see. Demographic information on who is receiving vaccinations, and where, can illuminate issues with access as vaccine eligibility continues to expand. “Vaccination is probably going to be the largest tool within our toolbox to try to inhibit disease acquisition and spread,” he said.

A version of this article first appeared on Medscape.com.

Monkeypox cases in the United States continue to be rare in children younger than 15, women, and in individuals older than 60, according to new data released by the Centers for Disease Control and Prevention. Men aged 26-40 make up the highest proportion of cases.

The age distribution of cases is similar to those of sexually transmitted infections, said Monica Gandhi, MD, MPH, associate chief of the division of HIV, infectious diseases, and global medicine at the University of California, San Francisco. It is most common in younger to middle-aged age groups, and less common in children and older individuals. As of Aug. 21, only 17 children younger than 15 have been diagnosed with monkeypox in the United States, and women make up fewer than 1.5% of cases.

“This data should be very reassuring to parents and to children going to back to school,” Dr. Gandhi said in an interview. After 3 months of monitoring the virus, the data suggest that monkeypox is primarily spreading in networks of men who have sex with men (MSM) through sexual activity, “and that isn’t something we worry about with school-spread illness.”

In addition to the reassuring data about children and monkeypox, the CDC released laboratory testing data, a behavioral survey of MSM, patient data on the antiviral medication tecovirimat (TPOXX), and other case demographics and symptoms.

Though the number of positive monkeypox tests have continued to rise, the test-positivity rates have declined over the past month, data show. Since July 16, the positivity rate has dipped from 54% to 23%. This trend is likely because of an increase in testing availability, said Randolph Hubach, PhD, MPH, the director of the Sexual Health Research Lab at Purdue University, West Lafayette, Ind.

“We also saw this with COVID early on with testing: it was really limited to folks who were symptomatic,” he said in an interview . “As testing ramped up in accessibility, you had a lot more negative results, but because testing was more widely available, you were able to capture more positive results.”

The data also show that case numbers continue to grow in the United States, whereas in other countries that identified cases before the United States – Spain, the United Kingdom, and France, for example – cases have been leveling off, noted Dr. Gandhi.

The CDC also shared responses from a survey of gay, bisexual, and other MSM conducted from Aug. 5-15, about how they have changed their sexual behaviors in response to the monkeypox outbreak. Half of respondents reported reduced one-time sexual encounters, 49% reported reducing sex with partners met on dating apps or at sex venues, and 48% reported reducing their number of sex partners. These responses are “heartening to see,” Dr. Gandhi said, and shows that individuals are taking proactive steps to reduce their potential exposure risk to monkeypox.

More detailed demographic data showed that Black, Hispanic, or Latinx individuals make up an increasing proportion of cases in the United States. In May, 71% of people with reported monkeypox infection were White and 29% were Black. For the week of August 8-14, about a third (31%) of monkeypox cases were in White people, 32% were in Hispanic or Latinx people, and 33% were in Black people.

The most common symptoms of monkeypox were rash (98.6%), malaise (72.7%), fever (72.1%), and chills (68.9%). Rectal pain was reported in 43.9% of patients, and 25% had rectal bleeding.

The CDC also released information on 288 patients with monkeypox treated with TPOXX under compassionate use. The median age of patients was 37 and 98.9% were male. About 40% of recipients were White, 35% were Hispanic, and about 16% were Black. This information does not include every patient treated with TPOXX, the agency said, as providers can begin treatment before submitting paperwork. As of Aug. 18, the CDC had received 400 patient intake forms for TPOXX, according to its website.

The agency has yet to release data on vaccination rates, which Dr. Hubach is eager to see. Demographic information on who is receiving vaccinations, and where, can illuminate issues with access as vaccine eligibility continues to expand. “Vaccination is probably going to be the largest tool within our toolbox to try to inhibit disease acquisition and spread,” he said.

A version of this article first appeared on Medscape.com.

Monkeypox cases in the United States continue to be rare in children younger than 15, women, and in individuals older than 60, according to new data released by the Centers for Disease Control and Prevention. Men aged 26-40 make up the highest proportion of cases.

The age distribution of cases is similar to those of sexually transmitted infections, said Monica Gandhi, MD, MPH, associate chief of the division of HIV, infectious diseases, and global medicine at the University of California, San Francisco. It is most common in younger to middle-aged age groups, and less common in children and older individuals. As of Aug. 21, only 17 children younger than 15 have been diagnosed with monkeypox in the United States, and women make up fewer than 1.5% of cases.

“This data should be very reassuring to parents and to children going to back to school,” Dr. Gandhi said in an interview. After 3 months of monitoring the virus, the data suggest that monkeypox is primarily spreading in networks of men who have sex with men (MSM) through sexual activity, “and that isn’t something we worry about with school-spread illness.”

In addition to the reassuring data about children and monkeypox, the CDC released laboratory testing data, a behavioral survey of MSM, patient data on the antiviral medication tecovirimat (TPOXX), and other case demographics and symptoms.

Though the number of positive monkeypox tests have continued to rise, the test-positivity rates have declined over the past month, data show. Since July 16, the positivity rate has dipped from 54% to 23%. This trend is likely because of an increase in testing availability, said Randolph Hubach, PhD, MPH, the director of the Sexual Health Research Lab at Purdue University, West Lafayette, Ind.

“We also saw this with COVID early on with testing: it was really limited to folks who were symptomatic,” he said in an interview . “As testing ramped up in accessibility, you had a lot more negative results, but because testing was more widely available, you were able to capture more positive results.”

The data also show that case numbers continue to grow in the United States, whereas in other countries that identified cases before the United States – Spain, the United Kingdom, and France, for example – cases have been leveling off, noted Dr. Gandhi.

The CDC also shared responses from a survey of gay, bisexual, and other MSM conducted from Aug. 5-15, about how they have changed their sexual behaviors in response to the monkeypox outbreak. Half of respondents reported reduced one-time sexual encounters, 49% reported reducing sex with partners met on dating apps or at sex venues, and 48% reported reducing their number of sex partners. These responses are “heartening to see,” Dr. Gandhi said, and shows that individuals are taking proactive steps to reduce their potential exposure risk to monkeypox.

More detailed demographic data showed that Black, Hispanic, or Latinx individuals make up an increasing proportion of cases in the United States. In May, 71% of people with reported monkeypox infection were White and 29% were Black. For the week of August 8-14, about a third (31%) of monkeypox cases were in White people, 32% were in Hispanic or Latinx people, and 33% were in Black people.

The most common symptoms of monkeypox were rash (98.6%), malaise (72.7%), fever (72.1%), and chills (68.9%). Rectal pain was reported in 43.9% of patients, and 25% had rectal bleeding.

The CDC also released information on 288 patients with monkeypox treated with TPOXX under compassionate use. The median age of patients was 37 and 98.9% were male. About 40% of recipients were White, 35% were Hispanic, and about 16% were Black. This information does not include every patient treated with TPOXX, the agency said, as providers can begin treatment before submitting paperwork. As of Aug. 18, the CDC had received 400 patient intake forms for TPOXX, according to its website.

The agency has yet to release data on vaccination rates, which Dr. Hubach is eager to see. Demographic information on who is receiving vaccinations, and where, can illuminate issues with access as vaccine eligibility continues to expand. “Vaccination is probably going to be the largest tool within our toolbox to try to inhibit disease acquisition and spread,” he said.

A version of this article first appeared on Medscape.com.

The human pregnancy data reported for these 16 agents are very limited as only 8 of the drugs have this data. However, the 8 reports indicated that the use of these drugs was highly important for the mother and did not cause embryo/fetal harm.

• Acetylcysteine

The need for this antidote in a pregnant or lactating woman is most likely a rare requirement. However, the need for this agent does occur in women who have taken a potentially hepatic toxic dose of acetaminophen (e.g., Tylenol).

• Black widow spider antivenin

Only three reports of the use of this agent in a pregnant woman have been located. In each case, the symptoms from the spider bite did not respond to other therapies but did within 1 hour to the antivenin. There was no fetal harm in these cases.

• Deferasirox

This agent is an oral iron-chelating agent used for the treatment of chronic iron overload. Five case reports have described its use without causing any fetal harm.

• Deferoxamine

This agent has been used in more than 65 pregnancies for acute iron overdose or for transfusion-dependent thalassemia. No reports have observed adverse human developmental effects.

• Digoxin immune FAB (ovine)

Several reports have described the use of this agent in pregnancy. No fetal harm has been observed, but none of the reports involved exposure during organogenesis. However, in cases of digoxin overdose, the maternal benefits of therapy should take priority over the embryo/fetus.

• Dimercaprol

Although the limited animal data suggest low risk, there are no reports of the use of this drug in human organogenesis. The absence of data prevents an assessment of the embryo-fetal risk, but the maternal benefit and indirect embryo-fetal benefit appears to outweigh that risk.

• Edetate calcium disodium

This agent is used to treat acute or chronic lead poisoning. It is compatible in pregnancy because the maternal and possibly the embryo-fetal benefit appears to outweigh any unknown direct or indirect risks.

• Flumazenil

The use of this drug in the third trimester has been reported in two cases. Because the drug is indicated to reverse the effects of benzodiazepines on the central nervous system, the maternal benefit should far outweigh the unknown embryo-fetal risk.

• Glucagon

The embryo-fetal risks appear to be very low. Apparently, the drug does not cross the placenta.

• Glucarpidase

This drug is indicated for the treatment of methotrexate toxicity. There are no reports describing the use of this drug in pregnancy or during breastfeeding.

• Idarucizumab

This agent is a humanized monoclonal antibody fragment that is indicated for the reversal of the anticoagulant effects of dabigatran. No reports describing its use in human or animal pregnancy have been located. However, the maternal benefit appears to be high and probably outweighs the unknown risk to the embryo/fetus.

• Lanthanum carbonate

There are no human pregnancy or lactation data. It is used to reduce blood levels of phosphate in people with kidney disease.

• Pralidoxime

This agent relieves the paralysis of the muscles of respiration caused by an organophosphate pesticide or related compound. The human pregnancy experience is limited to two cases, one at 36 weeks and the other at 16 weeks, both of which delivered normal infants.

• Sapropterin

Four reports have described the use of sapropterin to lower blood phenylalanine levels in 31 pregnancies. There were no embryo-fetal adverse effects attributable to the drug.

• Sevelamer

Sevelamer is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. There are no human pregnancy or breastfeeding data.

• Succimer

This drug is a heavy metal–chelating agent that is indicated for the treatment of lead poisoning in pediatric patients. The drug was teratogenic in rats and mice. Two reports described the use of the drug in two pregnant women for lead poisoning. It has also been used as an antidote for the treatment of arsenic, mercury, and cadmium poisoning in adults, but there have been no reports of this use in pregnant patients.

Mr. Briggs, now retired, was a clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at [email protected].

The human pregnancy data reported for these 16 agents are very limited as only 8 of the drugs have this data. However, the 8 reports indicated that the use of these drugs was highly important for the mother and did not cause embryo/fetal harm.

• Acetylcysteine

The need for this antidote in a pregnant or lactating woman is most likely a rare requirement. However, the need for this agent does occur in women who have taken a potentially hepatic toxic dose of acetaminophen (e.g., Tylenol).

• Black widow spider antivenin

Only three reports of the use of this agent in a pregnant woman have been located. In each case, the symptoms from the spider bite did not respond to other therapies but did within 1 hour to the antivenin. There was no fetal harm in these cases.

• Deferasirox

This agent is an oral iron-chelating agent used for the treatment of chronic iron overload. Five case reports have described its use without causing any fetal harm.

• Deferoxamine

This agent has been used in more than 65 pregnancies for acute iron overdose or for transfusion-dependent thalassemia. No reports have observed adverse human developmental effects.

• Digoxin immune FAB (ovine)

Several reports have described the use of this agent in pregnancy. No fetal harm has been observed, but none of the reports involved exposure during organogenesis. However, in cases of digoxin overdose, the maternal benefits of therapy should take priority over the embryo/fetus.

• Dimercaprol

Although the limited animal data suggest low risk, there are no reports of the use of this drug in human organogenesis. The absence of data prevents an assessment of the embryo-fetal risk, but the maternal benefit and indirect embryo-fetal benefit appears to outweigh that risk.

• Edetate calcium disodium

This agent is used to treat acute or chronic lead poisoning. It is compatible in pregnancy because the maternal and possibly the embryo-fetal benefit appears to outweigh any unknown direct or indirect risks.

• Flumazenil

The use of this drug in the third trimester has been reported in two cases. Because the drug is indicated to reverse the effects of benzodiazepines on the central nervous system, the maternal benefit should far outweigh the unknown embryo-fetal risk.

• Glucagon

The embryo-fetal risks appear to be very low. Apparently, the drug does not cross the placenta.

• Glucarpidase

This drug is indicated for the treatment of methotrexate toxicity. There are no reports describing the use of this drug in pregnancy or during breastfeeding.

• Idarucizumab

This agent is a humanized monoclonal antibody fragment that is indicated for the reversal of the anticoagulant effects of dabigatran. No reports describing its use in human or animal pregnancy have been located. However, the maternal benefit appears to be high and probably outweighs the unknown risk to the embryo/fetus.

• Lanthanum carbonate

There are no human pregnancy or lactation data. It is used to reduce blood levels of phosphate in people with kidney disease.

• Pralidoxime

This agent relieves the paralysis of the muscles of respiration caused by an organophosphate pesticide or related compound. The human pregnancy experience is limited to two cases, one at 36 weeks and the other at 16 weeks, both of which delivered normal infants.

• Sapropterin

Four reports have described the use of sapropterin to lower blood phenylalanine levels in 31 pregnancies. There were no embryo-fetal adverse effects attributable to the drug.

• Sevelamer

Sevelamer is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. There are no human pregnancy or breastfeeding data.

• Succimer

This drug is a heavy metal–chelating agent that is indicated for the treatment of lead poisoning in pediatric patients. The drug was teratogenic in rats and mice. Two reports described the use of the drug in two pregnant women for lead poisoning. It has also been used as an antidote for the treatment of arsenic, mercury, and cadmium poisoning in adults, but there have been no reports of this use in pregnant patients.

Mr. Briggs, now retired, was a clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at [email protected].

The human pregnancy data reported for these 16 agents are very limited as only 8 of the drugs have this data. However, the 8 reports indicated that the use of these drugs was highly important for the mother and did not cause embryo/fetal harm.

• Acetylcysteine

The need for this antidote in a pregnant or lactating woman is most likely a rare requirement. However, the need for this agent does occur in women who have taken a potentially hepatic toxic dose of acetaminophen (e.g., Tylenol).

• Black widow spider antivenin

Only three reports of the use of this agent in a pregnant woman have been located. In each case, the symptoms from the spider bite did not respond to other therapies but did within 1 hour to the antivenin. There was no fetal harm in these cases.

• Deferasirox

This agent is an oral iron-chelating agent used for the treatment of chronic iron overload. Five case reports have described its use without causing any fetal harm.

• Deferoxamine

This agent has been used in more than 65 pregnancies for acute iron overdose or for transfusion-dependent thalassemia. No reports have observed adverse human developmental effects.

• Digoxin immune FAB (ovine)

Several reports have described the use of this agent in pregnancy. No fetal harm has been observed, but none of the reports involved exposure during organogenesis. However, in cases of digoxin overdose, the maternal benefits of therapy should take priority over the embryo/fetus.

• Dimercaprol

Although the limited animal data suggest low risk, there are no reports of the use of this drug in human organogenesis. The absence of data prevents an assessment of the embryo-fetal risk, but the maternal benefit and indirect embryo-fetal benefit appears to outweigh that risk.

• Edetate calcium disodium

This agent is used to treat acute or chronic lead poisoning. It is compatible in pregnancy because the maternal and possibly the embryo-fetal benefit appears to outweigh any unknown direct or indirect risks.

• Flumazenil

The use of this drug in the third trimester has been reported in two cases. Because the drug is indicated to reverse the effects of benzodiazepines on the central nervous system, the maternal benefit should far outweigh the unknown embryo-fetal risk.

• Glucagon

The embryo-fetal risks appear to be very low. Apparently, the drug does not cross the placenta.

• Glucarpidase

This drug is indicated for the treatment of methotrexate toxicity. There are no reports describing the use of this drug in pregnancy or during breastfeeding.

• Idarucizumab

This agent is a humanized monoclonal antibody fragment that is indicated for the reversal of the anticoagulant effects of dabigatran. No reports describing its use in human or animal pregnancy have been located. However, the maternal benefit appears to be high and probably outweighs the unknown risk to the embryo/fetus.

• Lanthanum carbonate

There are no human pregnancy or lactation data. It is used to reduce blood levels of phosphate in people with kidney disease.

• Pralidoxime

This agent relieves the paralysis of the muscles of respiration caused by an organophosphate pesticide or related compound. The human pregnancy experience is limited to two cases, one at 36 weeks and the other at 16 weeks, both of which delivered normal infants.

• Sapropterin

Four reports have described the use of sapropterin to lower blood phenylalanine levels in 31 pregnancies. There were no embryo-fetal adverse effects attributable to the drug.

• Sevelamer

Sevelamer is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. There are no human pregnancy or breastfeeding data.

• Succimer

This drug is a heavy metal–chelating agent that is indicated for the treatment of lead poisoning in pediatric patients. The drug was teratogenic in rats and mice. Two reports described the use of the drug in two pregnant women for lead poisoning. It has also been used as an antidote for the treatment of arsenic, mercury, and cadmium poisoning in adults, but there have been no reports of this use in pregnant patients.

Mr. Briggs, now retired, was a clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at [email protected].

The drive from Texas to the clinic in Albuquerque, N.M., took 10 hours. It was mid-April of this year. There wasn’t much to see along the mostly barren stretch, and there wasn’t much for Kailee DeSpain to do aside from think about where she was going and why.

Her husband was driving. She sensed his nervous glances toward the passenger seat where she sat struggling to quiet her thoughts.

No, she wasn’t having any pain, she told him. No, she wasn’t feeling like she did the last time or the two times before that.

This pregnancy was different. It was the first in which she feared for her own life. Her fetus – Finley – had triploidy, a rare chromosomal abnormality. Because of the condition, which affects 1%-3% of pregnancies, his heart, brain, and kidneys were not developing properly.

At 19 weeks, Finley was already struggling to draw breath from lungs squeezed inside an overcrowded chest cavity. Ms. DeSpain wanted nothing more than to carry Finley to term, hold him, meet him even for a moment before saying goodbye.

But his condition meant he would likely suffocate in utero well before that. And Ms. DeSpain knew that carrying him longer would likely raise her risk of bleeding and of her blood pressure increasing to dangerous highs.

“This could kill you,” her husband told her. “Do you realize you could die bringing a baby into this world who is not going to live? I don’t want to lose you.’”

Unlike her other pregnancies, the timing of this one and the decision she faced to end it put her health in even greater danger.
 

Imminent danger

On Sept. 1, 2021, a bill went into effect in Texas that banned abortions from as early as 6 weeks’ gestation. Texas Senate Bill 8 (SB8) became one of the most restrictive abortion laws in the country. It prohibited abortions whenever a fetal heartbeat, defined by lawmakers, could be detected on an ultrasound, often before many women knew they were pregnant.

The Texas abortion law was hardly the last word on the topic. Ms. DeSpain didn’t know it on her drive to New Mexico in April, but the U.S. Supreme Court was weeks away from overturning the landmark Roe v. Wade decision.

On June 24, the Supreme Court delivered its 6-3 ruling overturning Roe v. Wade, the 1973 case that granted women the right to abortion.

This decision set in motion “trigger laws” in some states – laws that essentially fully banned abortions. Those states included Ms. DeSpain’s home state of Texas, where abortion is now a felony except when the life of the mother is in peril.

However, legal definitions of what qualifies as “life-threatening” remain murky.

The law is unclear, says Lisa Harris, MD, PhD, professor in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor. “What does the risk of death have to be, and how imminent must it be?” she asked in a recent editorial in the New England Journal of Medicine. Is 25% enough? 50%? Or does a woman have to be moments from dying?

“This whole thing makes me so angry,” says Shikha Jain, MD, a medical oncologist at University of Illinois Health, Chicago. “A patient may not be experiencing an emergency right now, but if we don’t take care of the situation, it may become an emergency in 2 hours or 2 days.”

Even before the Roe v. Wade decision, pregnancy had been a high-stakes endeavor for many women. In 2019, more than 750 women died from pregnancy-related events in the United States. In 2020, that number rose to 850. Each year dozens more suffer pregnancy-related events that require lifesaving interventions.

Now, in a post-Roe world, the number of maternal deaths will likely climb as more abortion bans take effect and fewer women have access to lifesaving care, experts say. A 2021 study that compared 2017 maternal mortality rates in states with different levels of abortion restrictions found that the rate of maternal mortality was almost two times higher in states that restricted abortion access compared with those that protected it – 28.5 per 100,000 women vs. 15.7.

Some women living in states with abortion bans won’t have the resources to cross state lines for care.

“This is just going to widen the health care disparities that are already so prevalent in this country,” Dr. Jain says.
 

Navigating a crossroads

Ms. DeSpain’s medical history reads like a checklist of pregnancy-related perils: chronic high blood pressure, persistent clotting problems, and a high risk of hemorrhage. She was also diagnosed with cervical cancer in 2020, which left her body more fragile.

Cardiovascular conditions, including hypertension and hemorrhage, are the leading causes of maternal mortality, responsible for more than one-third of pregnancy-related deaths. Preeclampsia, characterized by high blood pressure, accounts for more than 7% of maternal deaths in the United States. Although less common, genetic disorders, such as spinal muscular atrophy and triploidy, or cancer during pregnancy can put a mother and fetus at risk.

Cancer – which affects about 1 in 1,000 pregnant women and results in termination in as many as 28% of cases – brings sharp focus to the new dangers and complex decision-making patients and their doctors face as abortion bans take hold.

Before the Supreme Court decision, a pregnant woman with cancer was already facing great uncertainty. The decision to treat cancer during pregnancy involves “weighing the risk of exposing the fetus to medication vs. the risk to the mother’s untreated illness if you don’t expose the fetus to medication,” Elyce Cardonick, MD, an obstetrician at Cooper University Health Care, Camden, N.J., who specializes in high-risk pregnancies, told the National Cancer Institute.

Oncologists generally agree that it’s safe for pregnant women to receive chemotherapy during the second and third trimesters. But for women with aggressive cancers that are diagnosed in the first trimester, chemotherapy is dangerous. For women who need immunotherapy, the risks of treatment remain unclear.

In these cases, Alice S. Mims, MD, must broach the possibility of terminating the pregnancy.

“Cancer is a very urgent condition,” says Dr. Mims, a hematology specialist at the Ohio State University Comprehensive Cancer Center, Columbus, who sees patients who are pregnant. “These women may have other children at home, and they want to do their best to fight the disease so they can be around for their family long term.”

Now the changing legal landscape on abortion will put hundreds more pregnant women with cancer in danger. In a recent viewpoint article published in JAMA Oncology, Jordyn Silverstein and Katherine Van Loon, MD, MPH, estimate that during the next year, up to 420 pregnant women living in states with restricted abortion access will face threats to their cancer care and potentially their life.

“The repercussions of overturning Roe v. Wade – and the failure of the Supreme Court to provide any guidance on exceptions related to the life and health of the mother – are potentially catastrophic for a subset of women who face a life-threating diagnosis of [pregnancy-associated cancer],” they write.

The choice Ms. DeSpain faced after her cervical cancer diagnosis was different. She was not pregnant at the time, but she was at a crossroads.

Although it was caught early, the cancer was aggressive. Her oncologist recommended that she undergo a hysterectomy – the surgery that would give her the best chance for a cancer-free future. It would also mean she could no longer become pregnant.

With a less invasive procedure, on the other hand, she could still carry a child, but she would face a much greater chance that the cancer would come back.

At 27, Ms. DeSpain was not ready to close the pregnancy door. She opted for a surgery in which part of her cervix was removed, allowing her to try for another baby.

But she faced a ticking clock in the event her cancer returned.

If you want to have a baby, “try soon,” her doctor warned.
 

A dead end

After her cancer surgery and a third miscarriage, Ms. DeSpain and her husband were surprised and excited when in late 2021 she again became pregnant.

The first trimester seemed blissfully uneventful. As the weeks passed, Finley’s heart started to beat.

But the 16-week ultrasound signaled a turning point. The sonographer was too quiet.

“This is really bad, isn’t it?” Ms. DeSpain asked her sonographer.

The doctors told her he wouldn’t survive. Finley had no heart chambers. His heart couldn’t pump blood properly. He was missing one kidney, and his brain was split in the back. With almost no amniotic fluid, her doctor said he would likely die in utero, crushed to death without support from the protective liquid.

She fought for him anyway. She sought specialty care, followed bed rest orders, and traveled 3 hours to Houston to enroll in a clinical trial.

But every road was a dead end.

Ultimately, testing revealed Finley had triploidy, and all lines led to one point.

“There were too many things wrong, too much wrong for them to fix,” says Ms. DeSpain, recalling the news from her doctor in Houston. “I was in shock. My husband was just sitting with his hands flat on the table, staring at nothing, shaking a little bit.”

However, Finley still had a heartbeat, making an abortion after 6 weeks a felony in Texas. Even a compassionate induction was now out of the question unless her death was imminent.

Ms. DeSpain called the abortion clinic in Albuquerque and made an appointment. She would have to wait 2 weeks because of an influx of pregnant patients coming from Texas.

She welcomed the wait … just in case she changed her mind.

“At that point I wanted to carry him as far as I could,” she says.

For those 2 weeks, Ms. DeSpain remained on bed rest. She cried all day every day. She worried that Finley was experiencing pain.

Through this process, her doctor’s support helped keep her grounded.

“She cried with us in her office and said, ‘I wish that you didn’t have to go, but I think you’re doing the right thing, doing what keeps you safest,’ “ Ms. DeSpain recalls.

Ms. DeSpain declined to share the name of her doctor out of fear that even expressing compassion for a patient’s safety could put the physician in legal jeopardy and provoke harassment.

That fear is warranted. Some doctors will be forced to choose between doing what is legal – even though the law is vague – and doing what is right for patients, says law professor Jamie Abrams, who was recently diagnosed with breast cancer.

To live in a world where there’s talk of criminalizing doctors for taking care of their patients, where there’s “this national movement to position some women to be shunned and exiled for seeking care that’s right for them, their health, and might save their life is staggering and beyond comprehension,” says Ms. Abrams, professor of law at the American University Washington College of Law.

Ms. Abrams, who was diagnosed with hormone receptor–positive invasive breast cancer the same day she read the leaked Supreme Court draft on the decision to end of Roe v. Wade, said that “overnight, I became a person who would need an abortion if I became pregnant, because my treatment would compromise a healthy birth or delay necessary cancer care.” Ms. Abrams was also told she could no longer use hormonal contraception.

Dr. Harris’s advice to clinicians is to try to do what they feel is best for patients, including referring them to centers that have legal resources and protections regarding abortions.

Dr. Mims agrees and recommends that doctors reach out to those with more resources and legal backing for support. “I would advise doctors in [states with restrictive laws] to familiarize themselves with available resources and organizations taking action to deal with questionable cases,” Dr. Mims says.
 

‘Baby killers work here’

Following her 10-hour drive to Albuquerque, Ms. DeSpain encountered lines of protesters at the clinic. They were holding signs that said, “Abortion is murder,” and “Baby killers work here.”

“Please don’t kill your baby – we have resources for you,” a woman screeched through a megaphone as Ms. DeSpain, nearly 20 weeks’ pregnant, stepped out of the car to enter the clinic.

“I remember turning around, looking at her and making eye contact, and yelling back, ‘My baby has triploidy – he is dying! He is going to suffocate if I carry him full term. You don’t know what you’re talking about!’ “

A nurse held her hand during the procedure.

“He said, ‘You’re doing great, you’re okay,’ “ she recalls. She knew there was a chance that Finley’s face would be crushed by contractions during labor because of the lack of amniotic fluid, but she hoped not. Ms. DeSpain longed for a photo.

There was no photo to take home the next day, but Ms. DeSpain did receive Finley’s footprints, and his heartbeat – as captured by the specialty team in Houston – lives on in a stuffed giraffe.

His ashes arrived a few weeks later.

By then, the Supreme Court draft had been leaked. Ms. DeSpain knew her predicament in Texas would soon affect women across the United States and make any future pregnancy attempt for her even more risky.

The weeks and months that followed were a blur of grief, anger, and medical testing.

But she received some good news. A second triploidy pregnancy was extremely unlikely.

Several weeks later, Ms. DeSpain got more good news.

“I had a follow-up cancer appointment, and everything was completely clear,” she says.

She remains hopeful that she will be able to give birth, but her doctor cautioned that it’s no longer safe to become pregnant in Texas.

“I need you to understand that if you get pregnant and you have complications, we can’t intervene unless the baby doesn’t have a heartbeat, even if it would save your life,” Ms. DeSpain recalls her doctor saying.

If Texas remains a dangerous place to be pregnant, Ms. DeSpain and her husband will have to move.

For now, Ms. DeSpain wants people to know her story and to continue to fight for her right to govern her body.

In a public post to Facebook, she laid bare her pregnancy journey.

“No one should have to share a story like mine to justify abortion,” she wrote. “My choice is not yours to judge, and my rights are not yours to gleefully take away.”

Ms. Abrams, Ms. DeSpain, Dr. Harris, Dr. Jain, and Dr. Mims have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The drive from Texas to the clinic in Albuquerque, N.M., took 10 hours. It was mid-April of this year. There wasn’t much to see along the mostly barren stretch, and there wasn’t much for Kailee DeSpain to do aside from think about where she was going and why.

Her husband was driving. She sensed his nervous glances toward the passenger seat where she sat struggling to quiet her thoughts.

No, she wasn’t having any pain, she told him. No, she wasn’t feeling like she did the last time or the two times before that.

This pregnancy was different. It was the first in which she feared for her own life. Her fetus – Finley – had triploidy, a rare chromosomal abnormality. Because of the condition, which affects 1%-3% of pregnancies, his heart, brain, and kidneys were not developing properly.

At 19 weeks, Finley was already struggling to draw breath from lungs squeezed inside an overcrowded chest cavity. Ms. DeSpain wanted nothing more than to carry Finley to term, hold him, meet him even for a moment before saying goodbye.

But his condition meant he would likely suffocate in utero well before that. And Ms. DeSpain knew that carrying him longer would likely raise her risk of bleeding and of her blood pressure increasing to dangerous highs.

“This could kill you,” her husband told her. “Do you realize you could die bringing a baby into this world who is not going to live? I don’t want to lose you.’”

Unlike her other pregnancies, the timing of this one and the decision she faced to end it put her health in even greater danger.
 

Imminent danger

On Sept. 1, 2021, a bill went into effect in Texas that banned abortions from as early as 6 weeks’ gestation. Texas Senate Bill 8 (SB8) became one of the most restrictive abortion laws in the country. It prohibited abortions whenever a fetal heartbeat, defined by lawmakers, could be detected on an ultrasound, often before many women knew they were pregnant.

The Texas abortion law was hardly the last word on the topic. Ms. DeSpain didn’t know it on her drive to New Mexico in April, but the U.S. Supreme Court was weeks away from overturning the landmark Roe v. Wade decision.

On June 24, the Supreme Court delivered its 6-3 ruling overturning Roe v. Wade, the 1973 case that granted women the right to abortion.

This decision set in motion “trigger laws” in some states – laws that essentially fully banned abortions. Those states included Ms. DeSpain’s home state of Texas, where abortion is now a felony except when the life of the mother is in peril.

However, legal definitions of what qualifies as “life-threatening” remain murky.

The law is unclear, says Lisa Harris, MD, PhD, professor in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor. “What does the risk of death have to be, and how imminent must it be?” she asked in a recent editorial in the New England Journal of Medicine. Is 25% enough? 50%? Or does a woman have to be moments from dying?

“This whole thing makes me so angry,” says Shikha Jain, MD, a medical oncologist at University of Illinois Health, Chicago. “A patient may not be experiencing an emergency right now, but if we don’t take care of the situation, it may become an emergency in 2 hours or 2 days.”

Even before the Roe v. Wade decision, pregnancy had been a high-stakes endeavor for many women. In 2019, more than 750 women died from pregnancy-related events in the United States. In 2020, that number rose to 850. Each year dozens more suffer pregnancy-related events that require lifesaving interventions.

Now, in a post-Roe world, the number of maternal deaths will likely climb as more abortion bans take effect and fewer women have access to lifesaving care, experts say. A 2021 study that compared 2017 maternal mortality rates in states with different levels of abortion restrictions found that the rate of maternal mortality was almost two times higher in states that restricted abortion access compared with those that protected it – 28.5 per 100,000 women vs. 15.7.

Some women living in states with abortion bans won’t have the resources to cross state lines for care.

“This is just going to widen the health care disparities that are already so prevalent in this country,” Dr. Jain says.
 

Navigating a crossroads

Ms. DeSpain’s medical history reads like a checklist of pregnancy-related perils: chronic high blood pressure, persistent clotting problems, and a high risk of hemorrhage. She was also diagnosed with cervical cancer in 2020, which left her body more fragile.

Cardiovascular conditions, including hypertension and hemorrhage, are the leading causes of maternal mortality, responsible for more than one-third of pregnancy-related deaths. Preeclampsia, characterized by high blood pressure, accounts for more than 7% of maternal deaths in the United States. Although less common, genetic disorders, such as spinal muscular atrophy and triploidy, or cancer during pregnancy can put a mother and fetus at risk.

Cancer – which affects about 1 in 1,000 pregnant women and results in termination in as many as 28% of cases – brings sharp focus to the new dangers and complex decision-making patients and their doctors face as abortion bans take hold.

Before the Supreme Court decision, a pregnant woman with cancer was already facing great uncertainty. The decision to treat cancer during pregnancy involves “weighing the risk of exposing the fetus to medication vs. the risk to the mother’s untreated illness if you don’t expose the fetus to medication,” Elyce Cardonick, MD, an obstetrician at Cooper University Health Care, Camden, N.J., who specializes in high-risk pregnancies, told the National Cancer Institute.

Oncologists generally agree that it’s safe for pregnant women to receive chemotherapy during the second and third trimesters. But for women with aggressive cancers that are diagnosed in the first trimester, chemotherapy is dangerous. For women who need immunotherapy, the risks of treatment remain unclear.

In these cases, Alice S. Mims, MD, must broach the possibility of terminating the pregnancy.

“Cancer is a very urgent condition,” says Dr. Mims, a hematology specialist at the Ohio State University Comprehensive Cancer Center, Columbus, who sees patients who are pregnant. “These women may have other children at home, and they want to do their best to fight the disease so they can be around for their family long term.”

Now the changing legal landscape on abortion will put hundreds more pregnant women with cancer in danger. In a recent viewpoint article published in JAMA Oncology, Jordyn Silverstein and Katherine Van Loon, MD, MPH, estimate that during the next year, up to 420 pregnant women living in states with restricted abortion access will face threats to their cancer care and potentially their life.

“The repercussions of overturning Roe v. Wade – and the failure of the Supreme Court to provide any guidance on exceptions related to the life and health of the mother – are potentially catastrophic for a subset of women who face a life-threating diagnosis of [pregnancy-associated cancer],” they write.

The choice Ms. DeSpain faced after her cervical cancer diagnosis was different. She was not pregnant at the time, but she was at a crossroads.

Although it was caught early, the cancer was aggressive. Her oncologist recommended that she undergo a hysterectomy – the surgery that would give her the best chance for a cancer-free future. It would also mean she could no longer become pregnant.

With a less invasive procedure, on the other hand, she could still carry a child, but she would face a much greater chance that the cancer would come back.

At 27, Ms. DeSpain was not ready to close the pregnancy door. She opted for a surgery in which part of her cervix was removed, allowing her to try for another baby.

But she faced a ticking clock in the event her cancer returned.

If you want to have a baby, “try soon,” her doctor warned.
 

A dead end

After her cancer surgery and a third miscarriage, Ms. DeSpain and her husband were surprised and excited when in late 2021 she again became pregnant.

The first trimester seemed blissfully uneventful. As the weeks passed, Finley’s heart started to beat.

But the 16-week ultrasound signaled a turning point. The sonographer was too quiet.

“This is really bad, isn’t it?” Ms. DeSpain asked her sonographer.

The doctors told her he wouldn’t survive. Finley had no heart chambers. His heart couldn’t pump blood properly. He was missing one kidney, and his brain was split in the back. With almost no amniotic fluid, her doctor said he would likely die in utero, crushed to death without support from the protective liquid.

She fought for him anyway. She sought specialty care, followed bed rest orders, and traveled 3 hours to Houston to enroll in a clinical trial.

But every road was a dead end.

Ultimately, testing revealed Finley had triploidy, and all lines led to one point.

“There were too many things wrong, too much wrong for them to fix,” says Ms. DeSpain, recalling the news from her doctor in Houston. “I was in shock. My husband was just sitting with his hands flat on the table, staring at nothing, shaking a little bit.”

However, Finley still had a heartbeat, making an abortion after 6 weeks a felony in Texas. Even a compassionate induction was now out of the question unless her death was imminent.

Ms. DeSpain called the abortion clinic in Albuquerque and made an appointment. She would have to wait 2 weeks because of an influx of pregnant patients coming from Texas.

She welcomed the wait … just in case she changed her mind.

“At that point I wanted to carry him as far as I could,” she says.

For those 2 weeks, Ms. DeSpain remained on bed rest. She cried all day every day. She worried that Finley was experiencing pain.

Through this process, her doctor’s support helped keep her grounded.

“She cried with us in her office and said, ‘I wish that you didn’t have to go, but I think you’re doing the right thing, doing what keeps you safest,’ “ Ms. DeSpain recalls.

Ms. DeSpain declined to share the name of her doctor out of fear that even expressing compassion for a patient’s safety could put the physician in legal jeopardy and provoke harassment.

That fear is warranted. Some doctors will be forced to choose between doing what is legal – even though the law is vague – and doing what is right for patients, says law professor Jamie Abrams, who was recently diagnosed with breast cancer.

To live in a world where there’s talk of criminalizing doctors for taking care of their patients, where there’s “this national movement to position some women to be shunned and exiled for seeking care that’s right for them, their health, and might save their life is staggering and beyond comprehension,” says Ms. Abrams, professor of law at the American University Washington College of Law.

Ms. Abrams, who was diagnosed with hormone receptor–positive invasive breast cancer the same day she read the leaked Supreme Court draft on the decision to end of Roe v. Wade, said that “overnight, I became a person who would need an abortion if I became pregnant, because my treatment would compromise a healthy birth or delay necessary cancer care.” Ms. Abrams was also told she could no longer use hormonal contraception.

Dr. Harris’s advice to clinicians is to try to do what they feel is best for patients, including referring them to centers that have legal resources and protections regarding abortions.

Dr. Mims agrees and recommends that doctors reach out to those with more resources and legal backing for support. “I would advise doctors in [states with restrictive laws] to familiarize themselves with available resources and organizations taking action to deal with questionable cases,” Dr. Mims says.
 

‘Baby killers work here’

Following her 10-hour drive to Albuquerque, Ms. DeSpain encountered lines of protesters at the clinic. They were holding signs that said, “Abortion is murder,” and “Baby killers work here.”

“Please don’t kill your baby – we have resources for you,” a woman screeched through a megaphone as Ms. DeSpain, nearly 20 weeks’ pregnant, stepped out of the car to enter the clinic.

“I remember turning around, looking at her and making eye contact, and yelling back, ‘My baby has triploidy – he is dying! He is going to suffocate if I carry him full term. You don’t know what you’re talking about!’ “

A nurse held her hand during the procedure.

“He said, ‘You’re doing great, you’re okay,’ “ she recalls. She knew there was a chance that Finley’s face would be crushed by contractions during labor because of the lack of amniotic fluid, but she hoped not. Ms. DeSpain longed for a photo.

There was no photo to take home the next day, but Ms. DeSpain did receive Finley’s footprints, and his heartbeat – as captured by the specialty team in Houston – lives on in a stuffed giraffe.

His ashes arrived a few weeks later.

By then, the Supreme Court draft had been leaked. Ms. DeSpain knew her predicament in Texas would soon affect women across the United States and make any future pregnancy attempt for her even more risky.

The weeks and months that followed were a blur of grief, anger, and medical testing.

But she received some good news. A second triploidy pregnancy was extremely unlikely.

Several weeks later, Ms. DeSpain got more good news.

“I had a follow-up cancer appointment, and everything was completely clear,” she says.

She remains hopeful that she will be able to give birth, but her doctor cautioned that it’s no longer safe to become pregnant in Texas.

“I need you to understand that if you get pregnant and you have complications, we can’t intervene unless the baby doesn’t have a heartbeat, even if it would save your life,” Ms. DeSpain recalls her doctor saying.

If Texas remains a dangerous place to be pregnant, Ms. DeSpain and her husband will have to move.

For now, Ms. DeSpain wants people to know her story and to continue to fight for her right to govern her body.

In a public post to Facebook, she laid bare her pregnancy journey.

“No one should have to share a story like mine to justify abortion,” she wrote. “My choice is not yours to judge, and my rights are not yours to gleefully take away.”

Ms. Abrams, Ms. DeSpain, Dr. Harris, Dr. Jain, and Dr. Mims have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The drive from Texas to the clinic in Albuquerque, N.M., took 10 hours. It was mid-April of this year. There wasn’t much to see along the mostly barren stretch, and there wasn’t much for Kailee DeSpain to do aside from think about where she was going and why.

Her husband was driving. She sensed his nervous glances toward the passenger seat where she sat struggling to quiet her thoughts.

No, she wasn’t having any pain, she told him. No, she wasn’t feeling like she did the last time or the two times before that.

This pregnancy was different. It was the first in which she feared for her own life. Her fetus – Finley – had triploidy, a rare chromosomal abnormality. Because of the condition, which affects 1%-3% of pregnancies, his heart, brain, and kidneys were not developing properly.

At 19 weeks, Finley was already struggling to draw breath from lungs squeezed inside an overcrowded chest cavity. Ms. DeSpain wanted nothing more than to carry Finley to term, hold him, meet him even for a moment before saying goodbye.

But his condition meant he would likely suffocate in utero well before that. And Ms. DeSpain knew that carrying him longer would likely raise her risk of bleeding and of her blood pressure increasing to dangerous highs.

“This could kill you,” her husband told her. “Do you realize you could die bringing a baby into this world who is not going to live? I don’t want to lose you.’”

Unlike her other pregnancies, the timing of this one and the decision she faced to end it put her health in even greater danger.
 

Imminent danger

On Sept. 1, 2021, a bill went into effect in Texas that banned abortions from as early as 6 weeks’ gestation. Texas Senate Bill 8 (SB8) became one of the most restrictive abortion laws in the country. It prohibited abortions whenever a fetal heartbeat, defined by lawmakers, could be detected on an ultrasound, often before many women knew they were pregnant.

The Texas abortion law was hardly the last word on the topic. Ms. DeSpain didn’t know it on her drive to New Mexico in April, but the U.S. Supreme Court was weeks away from overturning the landmark Roe v. Wade decision.

On June 24, the Supreme Court delivered its 6-3 ruling overturning Roe v. Wade, the 1973 case that granted women the right to abortion.

This decision set in motion “trigger laws” in some states – laws that essentially fully banned abortions. Those states included Ms. DeSpain’s home state of Texas, where abortion is now a felony except when the life of the mother is in peril.

However, legal definitions of what qualifies as “life-threatening” remain murky.

The law is unclear, says Lisa Harris, MD, PhD, professor in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor. “What does the risk of death have to be, and how imminent must it be?” she asked in a recent editorial in the New England Journal of Medicine. Is 25% enough? 50%? Or does a woman have to be moments from dying?

“This whole thing makes me so angry,” says Shikha Jain, MD, a medical oncologist at University of Illinois Health, Chicago. “A patient may not be experiencing an emergency right now, but if we don’t take care of the situation, it may become an emergency in 2 hours or 2 days.”

Even before the Roe v. Wade decision, pregnancy had been a high-stakes endeavor for many women. In 2019, more than 750 women died from pregnancy-related events in the United States. In 2020, that number rose to 850. Each year dozens more suffer pregnancy-related events that require lifesaving interventions.

Now, in a post-Roe world, the number of maternal deaths will likely climb as more abortion bans take effect and fewer women have access to lifesaving care, experts say. A 2021 study that compared 2017 maternal mortality rates in states with different levels of abortion restrictions found that the rate of maternal mortality was almost two times higher in states that restricted abortion access compared with those that protected it – 28.5 per 100,000 women vs. 15.7.

Some women living in states with abortion bans won’t have the resources to cross state lines for care.

“This is just going to widen the health care disparities that are already so prevalent in this country,” Dr. Jain says.
 

Navigating a crossroads

Ms. DeSpain’s medical history reads like a checklist of pregnancy-related perils: chronic high blood pressure, persistent clotting problems, and a high risk of hemorrhage. She was also diagnosed with cervical cancer in 2020, which left her body more fragile.

Cardiovascular conditions, including hypertension and hemorrhage, are the leading causes of maternal mortality, responsible for more than one-third of pregnancy-related deaths. Preeclampsia, characterized by high blood pressure, accounts for more than 7% of maternal deaths in the United States. Although less common, genetic disorders, such as spinal muscular atrophy and triploidy, or cancer during pregnancy can put a mother and fetus at risk.

Cancer – which affects about 1 in 1,000 pregnant women and results in termination in as many as 28% of cases – brings sharp focus to the new dangers and complex decision-making patients and their doctors face as abortion bans take hold.

Before the Supreme Court decision, a pregnant woman with cancer was already facing great uncertainty. The decision to treat cancer during pregnancy involves “weighing the risk of exposing the fetus to medication vs. the risk to the mother’s untreated illness if you don’t expose the fetus to medication,” Elyce Cardonick, MD, an obstetrician at Cooper University Health Care, Camden, N.J., who specializes in high-risk pregnancies, told the National Cancer Institute.

Oncologists generally agree that it’s safe for pregnant women to receive chemotherapy during the second and third trimesters. But for women with aggressive cancers that are diagnosed in the first trimester, chemotherapy is dangerous. For women who need immunotherapy, the risks of treatment remain unclear.

In these cases, Alice S. Mims, MD, must broach the possibility of terminating the pregnancy.

“Cancer is a very urgent condition,” says Dr. Mims, a hematology specialist at the Ohio State University Comprehensive Cancer Center, Columbus, who sees patients who are pregnant. “These women may have other children at home, and they want to do their best to fight the disease so they can be around for their family long term.”

Now the changing legal landscape on abortion will put hundreds more pregnant women with cancer in danger. In a recent viewpoint article published in JAMA Oncology, Jordyn Silverstein and Katherine Van Loon, MD, MPH, estimate that during the next year, up to 420 pregnant women living in states with restricted abortion access will face threats to their cancer care and potentially their life.

“The repercussions of overturning Roe v. Wade – and the failure of the Supreme Court to provide any guidance on exceptions related to the life and health of the mother – are potentially catastrophic for a subset of women who face a life-threating diagnosis of [pregnancy-associated cancer],” they write.

The choice Ms. DeSpain faced after her cervical cancer diagnosis was different. She was not pregnant at the time, but she was at a crossroads.

Although it was caught early, the cancer was aggressive. Her oncologist recommended that she undergo a hysterectomy – the surgery that would give her the best chance for a cancer-free future. It would also mean she could no longer become pregnant.

With a less invasive procedure, on the other hand, she could still carry a child, but she would face a much greater chance that the cancer would come back.

At 27, Ms. DeSpain was not ready to close the pregnancy door. She opted for a surgery in which part of her cervix was removed, allowing her to try for another baby.

But she faced a ticking clock in the event her cancer returned.

If you want to have a baby, “try soon,” her doctor warned.
 

A dead end

After her cancer surgery and a third miscarriage, Ms. DeSpain and her husband were surprised and excited when in late 2021 she again became pregnant.

The first trimester seemed blissfully uneventful. As the weeks passed, Finley’s heart started to beat.

But the 16-week ultrasound signaled a turning point. The sonographer was too quiet.

“This is really bad, isn’t it?” Ms. DeSpain asked her sonographer.

The doctors told her he wouldn’t survive. Finley had no heart chambers. His heart couldn’t pump blood properly. He was missing one kidney, and his brain was split in the back. With almost no amniotic fluid, her doctor said he would likely die in utero, crushed to death without support from the protective liquid.

She fought for him anyway. She sought specialty care, followed bed rest orders, and traveled 3 hours to Houston to enroll in a clinical trial.

But every road was a dead end.

Ultimately, testing revealed Finley had triploidy, and all lines led to one point.

“There were too many things wrong, too much wrong for them to fix,” says Ms. DeSpain, recalling the news from her doctor in Houston. “I was in shock. My husband was just sitting with his hands flat on the table, staring at nothing, shaking a little bit.”

However, Finley still had a heartbeat, making an abortion after 6 weeks a felony in Texas. Even a compassionate induction was now out of the question unless her death was imminent.

Ms. DeSpain called the abortion clinic in Albuquerque and made an appointment. She would have to wait 2 weeks because of an influx of pregnant patients coming from Texas.

She welcomed the wait … just in case she changed her mind.

“At that point I wanted to carry him as far as I could,” she says.

For those 2 weeks, Ms. DeSpain remained on bed rest. She cried all day every day. She worried that Finley was experiencing pain.

Through this process, her doctor’s support helped keep her grounded.

“She cried with us in her office and said, ‘I wish that you didn’t have to go, but I think you’re doing the right thing, doing what keeps you safest,’ “ Ms. DeSpain recalls.

Ms. DeSpain declined to share the name of her doctor out of fear that even expressing compassion for a patient’s safety could put the physician in legal jeopardy and provoke harassment.

That fear is warranted. Some doctors will be forced to choose between doing what is legal – even though the law is vague – and doing what is right for patients, says law professor Jamie Abrams, who was recently diagnosed with breast cancer.

To live in a world where there’s talk of criminalizing doctors for taking care of their patients, where there’s “this national movement to position some women to be shunned and exiled for seeking care that’s right for them, their health, and might save their life is staggering and beyond comprehension,” says Ms. Abrams, professor of law at the American University Washington College of Law.

Ms. Abrams, who was diagnosed with hormone receptor–positive invasive breast cancer the same day she read the leaked Supreme Court draft on the decision to end of Roe v. Wade, said that “overnight, I became a person who would need an abortion if I became pregnant, because my treatment would compromise a healthy birth or delay necessary cancer care.” Ms. Abrams was also told she could no longer use hormonal contraception.

Dr. Harris’s advice to clinicians is to try to do what they feel is best for patients, including referring them to centers that have legal resources and protections regarding abortions.

Dr. Mims agrees and recommends that doctors reach out to those with more resources and legal backing for support. “I would advise doctors in [states with restrictive laws] to familiarize themselves with available resources and organizations taking action to deal with questionable cases,” Dr. Mims says.
 

‘Baby killers work here’

Following her 10-hour drive to Albuquerque, Ms. DeSpain encountered lines of protesters at the clinic. They were holding signs that said, “Abortion is murder,” and “Baby killers work here.”

“Please don’t kill your baby – we have resources for you,” a woman screeched through a megaphone as Ms. DeSpain, nearly 20 weeks’ pregnant, stepped out of the car to enter the clinic.

“I remember turning around, looking at her and making eye contact, and yelling back, ‘My baby has triploidy – he is dying! He is going to suffocate if I carry him full term. You don’t know what you’re talking about!’ “

A nurse held her hand during the procedure.

“He said, ‘You’re doing great, you’re okay,’ “ she recalls. She knew there was a chance that Finley’s face would be crushed by contractions during labor because of the lack of amniotic fluid, but she hoped not. Ms. DeSpain longed for a photo.

There was no photo to take home the next day, but Ms. DeSpain did receive Finley’s footprints, and his heartbeat – as captured by the specialty team in Houston – lives on in a stuffed giraffe.

His ashes arrived a few weeks later.

By then, the Supreme Court draft had been leaked. Ms. DeSpain knew her predicament in Texas would soon affect women across the United States and make any future pregnancy attempt for her even more risky.

The weeks and months that followed were a blur of grief, anger, and medical testing.

But she received some good news. A second triploidy pregnancy was extremely unlikely.

Several weeks later, Ms. DeSpain got more good news.

“I had a follow-up cancer appointment, and everything was completely clear,” she says.

She remains hopeful that she will be able to give birth, but her doctor cautioned that it’s no longer safe to become pregnant in Texas.

“I need you to understand that if you get pregnant and you have complications, we can’t intervene unless the baby doesn’t have a heartbeat, even if it would save your life,” Ms. DeSpain recalls her doctor saying.

If Texas remains a dangerous place to be pregnant, Ms. DeSpain and her husband will have to move.

For now, Ms. DeSpain wants people to know her story and to continue to fight for her right to govern her body.

In a public post to Facebook, she laid bare her pregnancy journey.

“No one should have to share a story like mine to justify abortion,” she wrote. “My choice is not yours to judge, and my rights are not yours to gleefully take away.”

Ms. Abrams, Ms. DeSpain, Dr. Harris, Dr. Jain, and Dr. Mims have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

On a Monday morning, a group of obstetrics and gynecology residents, dressed in blue scrubs and white coats, gathered in an auditorium at Indiana University, Indianapolis. After the usual updates and announcements, Nicole Scott, MD, the residency program director, addressed the elephant in the room. “Any more abortion care questions?” she asked the trainees.

After a few moments of silence, one resident asked: “How’s Dr. Bernard doing?”

“Bernard is actually in really good spirits – I mean, relatively,” Dr. Scott answered. “She has 24/7 security, has her own lawyer.”

They were talking about Caitlin Bernard, MD, an Indiana ob.gyn. who provides abortions and trains residents at the university hospital. Dr. Bernard was recently caught in a political whirlwind after she spoke about an abortion she provided to a 10-year-old rape victim from Ohio. Dr. Bernard was the target of false accusations made on national television by pundits and political leaders, including Indiana’s attorney general.

The doctors interviewed for this article said that they are not speaking on behalf of their school of medicine but rather about their personal experiences during a tumultuous moment that they worry will affect the way they care for their patients.

The vitriol directed at Dr. Bernard hit home for this group of residents. She has mentored most of them for years. Many of the young doctors were certain they wanted to practice in Indiana after their training. But lately, some have been ambivalent about that prospect.

Beatrice Soderholm, DO, a fourth-year ob.gyn. resident, said watching what Dr. Bernard went through was “scary.” “I think that was part of the point for those who were putting her through that,” Dr. Soderholm said. They were trying “to scare other people out of doing the work that she does.”

In early August, Gov. Eric Holcomb, a Republican, signed a near-total abortion ban into law, making Indiana the first state to adopt new restrictions on abortion access since the Supreme Court struck down Roe v. Wade in June. When the ban takes effect Sept. 15, medical providers who violate the law risk losing their licenses or serving up to six years in prison.

These days, Dr. Scott, the residency program director, uses some meeting time with residents to fill them in on political updates and available mental health services. She also reminds them that legal counsel is on call round the clock to help if they’re ever unsure about the care they should provide a patient.

“Our residents are devastated,” Dr. Scott said, holding back tears. “They signed up to provide comprehensive health care to women, and they are being told that they can’t do that.”

She expects this will “deeply impact” how Indiana hospitals recruit and retain medical professionals.

A 2018 report from the March of Dimes found that 27% of Indiana counties are considered maternity care deserts, with no or limited access to maternal care. The state has one of the nation’s highest maternal mortality rates.

Dr. Scott said new laws restricting abortion will only worsen those statistics.

Dr. Scott shared results from a recent survey of nearly 1,400 residents and fellows across all specialties at IU, nearly 80% of the trainees said they were less likely to stay and practice in Indiana after the abortion ban.

Wendy Tian, MD, a third-year resident, said she is worried about her safety. Dr. Tian grew up and went to medical school in Chicago and chose to do her residency in Indiana because the program has a strong family-planning focus. She was open to practicing in Indiana when she completed her training.

But that’s changed.

“I, for sure, don’t know if I would be able to stay in Indiana post graduation with what’s going on,” Dr. Tian said.

Still, she feels guilty for “giving up” on Indiana’s most vulnerable patients.

Even before Roe fell, Dr. Tian said, the climate in Indiana could be hostile and frustrating for ob.gyns. Indiana, like other states with abortion restrictions, allows nearly all health care providers to opt out of providing care to patients having an abortion.

“We encounter other people who we work with on a daily basis who are opposed to what we do,” Dr. Tian said, adding that she and her colleagues have had to cancel scheduled procedures because the nurses on call were not comfortable assisting during an abortion.

Dr. Scott said the ob.gyn. program at the IU has provided residents with comprehensive training, including on abortion care and family planning. Since miscarriages are managed the same way as first-trimester abortions, she said, the training gives residents lots of hands-on experience. “What termination procedures allow you to do is that kind of repetition and that understanding of the female anatomy and how to manage complications that may happen with miscarriages.”

The ban on abortions dramatically reduces the hands-on opportunities for ob.gyn. residents, and that’s a huge concern, she said.

The program is exploring ways to offer training. One option is to send residents to learn in states without abortion restrictions, but Dr. Scott said that would be a logistical nightmare. “This is not as simple as just showing up to an office and saying: ‘Can I observe?’ This includes getting a medical license for out-of-state trainees. This includes funding for travel and lodging,” Dr. Scott said. “It adds a lot to what we already do to educate future ob.gyns.”

Four in 10 of all ob.gyn. residents in the United States are in states where abortion is banned or likely to be banned, so there could be a surge of residents looking to go out of state to make up for lost training opportunities. The Accreditation Council for Graduate Medical Education, the body that accredits residency programs, proposed modifications to the graduation requirements for ob.gyn. residents to account for the changing landscape.

For some of the Indiana ob.gyn. residents – including Veronica Santana, MD, a first-year resident – these political hurdles are a challenge they’re more than willing to take on. Dr. Santana is Latina, grew up in Seattle, and has been involved in community organizing since she was a teenager. One reason she chose obstetrics and gynecology was because of how the field intersects with social justice. “It’s political. It always has been, and it continues to be,” she said, “And, obviously, especially now.”

After Roe was overturned, Dr. Santana, alongside other residents and mentors, took to the streets of Indianapolis to participate in rallies in support of abortion rights.

Indiana could be the perfect battleground for Dr. Santana’s advocacy and social activism. But lately, she said, she is “very unsure” whether staying in Indiana to practice after residency makes sense, since she wants to provide the entire range of ob.gyn. services.

Dr. Soderholm, who grew up in Minnesota, has felt a strong connection to patients at the county hospital in Indianapolis. She had been certain she wanted to practice in Indiana. But her family in Minnesota – where abortion remains largely protected – has recently questioned why she would stay in a state with such a hostile climate for ob.gyns. “There’s been a lot of hesitation,” she said. But the patients make leaving difficult. “Sorry,” she said, starting to cry.

It’s for those patients that Dr. Soderholm decided she’ll likely stay. Other young doctors may make a different decision.

This story is part of a partnership that includes Side Effects Public Media, NPR, and KHN. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

On a Monday morning, a group of obstetrics and gynecology residents, dressed in blue scrubs and white coats, gathered in an auditorium at Indiana University, Indianapolis. After the usual updates and announcements, Nicole Scott, MD, the residency program director, addressed the elephant in the room. “Any more abortion care questions?” she asked the trainees.

After a few moments of silence, one resident asked: “How’s Dr. Bernard doing?”

“Bernard is actually in really good spirits – I mean, relatively,” Dr. Scott answered. “She has 24/7 security, has her own lawyer.”

They were talking about Caitlin Bernard, MD, an Indiana ob.gyn. who provides abortions and trains residents at the university hospital. Dr. Bernard was recently caught in a political whirlwind after she spoke about an abortion she provided to a 10-year-old rape victim from Ohio. Dr. Bernard was the target of false accusations made on national television by pundits and political leaders, including Indiana’s attorney general.

The doctors interviewed for this article said that they are not speaking on behalf of their school of medicine but rather about their personal experiences during a tumultuous moment that they worry will affect the way they care for their patients.

The vitriol directed at Dr. Bernard hit home for this group of residents. She has mentored most of them for years. Many of the young doctors were certain they wanted to practice in Indiana after their training. But lately, some have been ambivalent about that prospect.

Beatrice Soderholm, DO, a fourth-year ob.gyn. resident, said watching what Dr. Bernard went through was “scary.” “I think that was part of the point for those who were putting her through that,” Dr. Soderholm said. They were trying “to scare other people out of doing the work that she does.”

In early August, Gov. Eric Holcomb, a Republican, signed a near-total abortion ban into law, making Indiana the first state to adopt new restrictions on abortion access since the Supreme Court struck down Roe v. Wade in June. When the ban takes effect Sept. 15, medical providers who violate the law risk losing their licenses or serving up to six years in prison.

These days, Dr. Scott, the residency program director, uses some meeting time with residents to fill them in on political updates and available mental health services. She also reminds them that legal counsel is on call round the clock to help if they’re ever unsure about the care they should provide a patient.

“Our residents are devastated,” Dr. Scott said, holding back tears. “They signed up to provide comprehensive health care to women, and they are being told that they can’t do that.”

She expects this will “deeply impact” how Indiana hospitals recruit and retain medical professionals.

A 2018 report from the March of Dimes found that 27% of Indiana counties are considered maternity care deserts, with no or limited access to maternal care. The state has one of the nation’s highest maternal mortality rates.

Dr. Scott said new laws restricting abortion will only worsen those statistics.

Dr. Scott shared results from a recent survey of nearly 1,400 residents and fellows across all specialties at IU, nearly 80% of the trainees said they were less likely to stay and practice in Indiana after the abortion ban.

Wendy Tian, MD, a third-year resident, said she is worried about her safety. Dr. Tian grew up and went to medical school in Chicago and chose to do her residency in Indiana because the program has a strong family-planning focus. She was open to practicing in Indiana when she completed her training.

But that’s changed.

“I, for sure, don’t know if I would be able to stay in Indiana post graduation with what’s going on,” Dr. Tian said.

Still, she feels guilty for “giving up” on Indiana’s most vulnerable patients.

Even before Roe fell, Dr. Tian said, the climate in Indiana could be hostile and frustrating for ob.gyns. Indiana, like other states with abortion restrictions, allows nearly all health care providers to opt out of providing care to patients having an abortion.

“We encounter other people who we work with on a daily basis who are opposed to what we do,” Dr. Tian said, adding that she and her colleagues have had to cancel scheduled procedures because the nurses on call were not comfortable assisting during an abortion.

Dr. Scott said the ob.gyn. program at the IU has provided residents with comprehensive training, including on abortion care and family planning. Since miscarriages are managed the same way as first-trimester abortions, she said, the training gives residents lots of hands-on experience. “What termination procedures allow you to do is that kind of repetition and that understanding of the female anatomy and how to manage complications that may happen with miscarriages.”

The ban on abortions dramatically reduces the hands-on opportunities for ob.gyn. residents, and that’s a huge concern, she said.

The program is exploring ways to offer training. One option is to send residents to learn in states without abortion restrictions, but Dr. Scott said that would be a logistical nightmare. “This is not as simple as just showing up to an office and saying: ‘Can I observe?’ This includes getting a medical license for out-of-state trainees. This includes funding for travel and lodging,” Dr. Scott said. “It adds a lot to what we already do to educate future ob.gyns.”

Four in 10 of all ob.gyn. residents in the United States are in states where abortion is banned or likely to be banned, so there could be a surge of residents looking to go out of state to make up for lost training opportunities. The Accreditation Council for Graduate Medical Education, the body that accredits residency programs, proposed modifications to the graduation requirements for ob.gyn. residents to account for the changing landscape.

For some of the Indiana ob.gyn. residents – including Veronica Santana, MD, a first-year resident – these political hurdles are a challenge they’re more than willing to take on. Dr. Santana is Latina, grew up in Seattle, and has been involved in community organizing since she was a teenager. One reason she chose obstetrics and gynecology was because of how the field intersects with social justice. “It’s political. It always has been, and it continues to be,” she said, “And, obviously, especially now.”

After Roe was overturned, Dr. Santana, alongside other residents and mentors, took to the streets of Indianapolis to participate in rallies in support of abortion rights.

Indiana could be the perfect battleground for Dr. Santana’s advocacy and social activism. But lately, she said, she is “very unsure” whether staying in Indiana to practice after residency makes sense, since she wants to provide the entire range of ob.gyn. services.

Dr. Soderholm, who grew up in Minnesota, has felt a strong connection to patients at the county hospital in Indianapolis. She had been certain she wanted to practice in Indiana. But her family in Minnesota – where abortion remains largely protected – has recently questioned why she would stay in a state with such a hostile climate for ob.gyns. “There’s been a lot of hesitation,” she said. But the patients make leaving difficult. “Sorry,” she said, starting to cry.

It’s for those patients that Dr. Soderholm decided she’ll likely stay. Other young doctors may make a different decision.

This story is part of a partnership that includes Side Effects Public Media, NPR, and KHN. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

On a Monday morning, a group of obstetrics and gynecology residents, dressed in blue scrubs and white coats, gathered in an auditorium at Indiana University, Indianapolis. After the usual updates and announcements, Nicole Scott, MD, the residency program director, addressed the elephant in the room. “Any more abortion care questions?” she asked the trainees.

After a few moments of silence, one resident asked: “How’s Dr. Bernard doing?”

“Bernard is actually in really good spirits – I mean, relatively,” Dr. Scott answered. “She has 24/7 security, has her own lawyer.”

They were talking about Caitlin Bernard, MD, an Indiana ob.gyn. who provides abortions and trains residents at the university hospital. Dr. Bernard was recently caught in a political whirlwind after she spoke about an abortion she provided to a 10-year-old rape victim from Ohio. Dr. Bernard was the target of false accusations made on national television by pundits and political leaders, including Indiana’s attorney general.

The doctors interviewed for this article said that they are not speaking on behalf of their school of medicine but rather about their personal experiences during a tumultuous moment that they worry will affect the way they care for their patients.

The vitriol directed at Dr. Bernard hit home for this group of residents. She has mentored most of them for years. Many of the young doctors were certain they wanted to practice in Indiana after their training. But lately, some have been ambivalent about that prospect.

Beatrice Soderholm, DO, a fourth-year ob.gyn. resident, said watching what Dr. Bernard went through was “scary.” “I think that was part of the point for those who were putting her through that,” Dr. Soderholm said. They were trying “to scare other people out of doing the work that she does.”

In early August, Gov. Eric Holcomb, a Republican, signed a near-total abortion ban into law, making Indiana the first state to adopt new restrictions on abortion access since the Supreme Court struck down Roe v. Wade in June. When the ban takes effect Sept. 15, medical providers who violate the law risk losing their licenses or serving up to six years in prison.

These days, Dr. Scott, the residency program director, uses some meeting time with residents to fill them in on political updates and available mental health services. She also reminds them that legal counsel is on call round the clock to help if they’re ever unsure about the care they should provide a patient.

“Our residents are devastated,” Dr. Scott said, holding back tears. “They signed up to provide comprehensive health care to women, and they are being told that they can’t do that.”

She expects this will “deeply impact” how Indiana hospitals recruit and retain medical professionals.

A 2018 report from the March of Dimes found that 27% of Indiana counties are considered maternity care deserts, with no or limited access to maternal care. The state has one of the nation’s highest maternal mortality rates.

Dr. Scott said new laws restricting abortion will only worsen those statistics.

Dr. Scott shared results from a recent survey of nearly 1,400 residents and fellows across all specialties at IU, nearly 80% of the trainees said they were less likely to stay and practice in Indiana after the abortion ban.

Wendy Tian, MD, a third-year resident, said she is worried about her safety. Dr. Tian grew up and went to medical school in Chicago and chose to do her residency in Indiana because the program has a strong family-planning focus. She was open to practicing in Indiana when she completed her training.

But that’s changed.

“I, for sure, don’t know if I would be able to stay in Indiana post graduation with what’s going on,” Dr. Tian said.

Still, she feels guilty for “giving up” on Indiana’s most vulnerable patients.

Even before Roe fell, Dr. Tian said, the climate in Indiana could be hostile and frustrating for ob.gyns. Indiana, like other states with abortion restrictions, allows nearly all health care providers to opt out of providing care to patients having an abortion.

“We encounter other people who we work with on a daily basis who are opposed to what we do,” Dr. Tian said, adding that she and her colleagues have had to cancel scheduled procedures because the nurses on call were not comfortable assisting during an abortion.

Dr. Scott said the ob.gyn. program at the IU has provided residents with comprehensive training, including on abortion care and family planning. Since miscarriages are managed the same way as first-trimester abortions, she said, the training gives residents lots of hands-on experience. “What termination procedures allow you to do is that kind of repetition and that understanding of the female anatomy and how to manage complications that may happen with miscarriages.”

The ban on abortions dramatically reduces the hands-on opportunities for ob.gyn. residents, and that’s a huge concern, she said.

The program is exploring ways to offer training. One option is to send residents to learn in states without abortion restrictions, but Dr. Scott said that would be a logistical nightmare. “This is not as simple as just showing up to an office and saying: ‘Can I observe?’ This includes getting a medical license for out-of-state trainees. This includes funding for travel and lodging,” Dr. Scott said. “It adds a lot to what we already do to educate future ob.gyns.”

Four in 10 of all ob.gyn. residents in the United States are in states where abortion is banned or likely to be banned, so there could be a surge of residents looking to go out of state to make up for lost training opportunities. The Accreditation Council for Graduate Medical Education, the body that accredits residency programs, proposed modifications to the graduation requirements for ob.gyn. residents to account for the changing landscape.

For some of the Indiana ob.gyn. residents – including Veronica Santana, MD, a first-year resident – these political hurdles are a challenge they’re more than willing to take on. Dr. Santana is Latina, grew up in Seattle, and has been involved in community organizing since she was a teenager. One reason she chose obstetrics and gynecology was because of how the field intersects with social justice. “It’s political. It always has been, and it continues to be,” she said, “And, obviously, especially now.”

After Roe was overturned, Dr. Santana, alongside other residents and mentors, took to the streets of Indianapolis to participate in rallies in support of abortion rights.

Indiana could be the perfect battleground for Dr. Santana’s advocacy and social activism. But lately, she said, she is “very unsure” whether staying in Indiana to practice after residency makes sense, since she wants to provide the entire range of ob.gyn. services.

Dr. Soderholm, who grew up in Minnesota, has felt a strong connection to patients at the county hospital in Indianapolis. She had been certain she wanted to practice in Indiana. But her family in Minnesota – where abortion remains largely protected – has recently questioned why she would stay in a state with such a hostile climate for ob.gyns. “There’s been a lot of hesitation,” she said. But the patients make leaving difficult. “Sorry,” she said, starting to cry.

It’s for those patients that Dr. Soderholm decided she’ll likely stay. Other young doctors may make a different decision.

This story is part of a partnership that includes Side Effects Public Media, NPR, and KHN. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

A study aimed at determining whether behind some of the sex differences in chronic obstructive airway disease (COPD) prevalence and clinical outcomes lie structural differences in airways found that airway lumen sizes quantified through chest CT were smaller in women than in men.

The findings, published in Radiology, took into account height and lung size. The lower baseline airway lumen sizes in women conferred lower reserves against respiratory morbidity and mortality for equivalent changes, compared with men.

Alfred Pasieka/Science Source

Among key findings in a secondary analysis of consecutive participants (9,363 ever-smokers and 420 never-smokers) enrolled in the Genetic Epidemiology of COPD (COPDGene) study, airway lumen dimensions were lower in never-smoker women than in men (segmental lumen diameter, 8.1 mm vs. 9.1 mm; P < .001). Also, ever-smoker women had narrower segmental lumen diameter (7.8 mm ± 0.05 vs. 8.7 mm ± 0.04; P < .001). The investigators found also that a unit change in wall thickness or lumen area resulted in more severe airflow obstruction, more dyspnea, worse respiratory quality of life, lower 6-minute walk distance, and worse survival in women, compared with men.

While COPD is diagnosed more often in men than women, changes in smoking behavior and increasing urbanization have led to COPD prevalence in women fast approaching the rate in men. Although age-adjusted rates for COPD-related deaths have continued to decline in men, in women they have not. Indeed, never-smoking women accounted for two-thirds of COPD in a population-based study.

COPDGene, a prospective, multicenter, observational cohort study, enrolled current and former smokers, as well as never-smokers, aged 45-80 years at 21 clinical centers across the United States from January 2008 to June 2011 with longitudinal follow-up until November 2020. The investigators quantified airway disease through CT imaging using the following metrics: airway wall thickness of segmental airways, wall area percent of segmental airways, the square root of the wall area of a hypothetical airway with 10-mm internal perimeter, total airway count, lumen diameter of segmental airways, airway volume, and airway fractal dimension.

“Not all sex differences in prevalence of COPD have been explained, and structural differences may explain some of these differences. Our findings may have implications for patient selection for clinical trials,” corresponding author Surya P. Bhatt, MD, associate professor of medicine and director of the University of Alabama Imaging Core at Birmingham, said in an interview.

The investigators wrote: “Our findings have implications for airflow limitation and the consequent clinical outcomes. ... We confirmed that men have more emphysema than women with equivalent smoking burden, and our results suggest that the lower reserve conferred by smaller airways predisposes women to develop airflow limitation predominantly through the airway phenotype. All airway remodeling changes were associated with more dyspnea, worse respiratory quality of life, and lower functional capacity in women than in men. The smaller airways in women can result in higher airway resistance and more turbulent airflow, and thus place a higher ventilatory constraint during exertion. Alteration in each airway measure was also associated with worse survival in women than in men, partially explaining the comparable mortality between the sexes for COPD despite the differing degrees of emphysema.”

“I think these findings highlight underappreciated sex differences in the natural history of COPD,” Mohsen Sadatsafavi, MD, PhD, associate professor, faculty of pharmaceutical sciences, at the University of British Columbia, Vancouver, said in an interview. “To me, first and foremost, the Bhatt et al. findings highlight how the ‘one size fits all’ approach to COPD management of using exacerbation history alone to guide preventive therapies is incorrect. These findings have the potential to change the management paradigm of COPD in the long term, but before getting there, I think we need to relate these findings to clinically relevant and patient-reported outcomes.”

Noting study limitations, the authors stated that a higher proportion of men were active smokers, compared with women, and despite adjustments for smoking status, some of the airway wall differences may be from the impact of active cigarette smoking on airway wall thickness.

Five study authors reported receiving support from various government and industry sources and disclosed conflicts of interest based on relationships with industry. The rest reported no conflicts of interest.

A study aimed at determining whether behind some of the sex differences in chronic obstructive airway disease (COPD) prevalence and clinical outcomes lie structural differences in airways found that airway lumen sizes quantified through chest CT were smaller in women than in men.

The findings, published in Radiology, took into account height and lung size. The lower baseline airway lumen sizes in women conferred lower reserves against respiratory morbidity and mortality for equivalent changes, compared with men.

Alfred Pasieka/Science Source

Among key findings in a secondary analysis of consecutive participants (9,363 ever-smokers and 420 never-smokers) enrolled in the Genetic Epidemiology of COPD (COPDGene) study, airway lumen dimensions were lower in never-smoker women than in men (segmental lumen diameter, 8.1 mm vs. 9.1 mm; P < .001). Also, ever-smoker women had narrower segmental lumen diameter (7.8 mm ± 0.05 vs. 8.7 mm ± 0.04; P < .001). The investigators found also that a unit change in wall thickness or lumen area resulted in more severe airflow obstruction, more dyspnea, worse respiratory quality of life, lower 6-minute walk distance, and worse survival in women, compared with men.

While COPD is diagnosed more often in men than women, changes in smoking behavior and increasing urbanization have led to COPD prevalence in women fast approaching the rate in men. Although age-adjusted rates for COPD-related deaths have continued to decline in men, in women they have not. Indeed, never-smoking women accounted for two-thirds of COPD in a population-based study.

COPDGene, a prospective, multicenter, observational cohort study, enrolled current and former smokers, as well as never-smokers, aged 45-80 years at 21 clinical centers across the United States from January 2008 to June 2011 with longitudinal follow-up until November 2020. The investigators quantified airway disease through CT imaging using the following metrics: airway wall thickness of segmental airways, wall area percent of segmental airways, the square root of the wall area of a hypothetical airway with 10-mm internal perimeter, total airway count, lumen diameter of segmental airways, airway volume, and airway fractal dimension.

“Not all sex differences in prevalence of COPD have been explained, and structural differences may explain some of these differences. Our findings may have implications for patient selection for clinical trials,” corresponding author Surya P. Bhatt, MD, associate professor of medicine and director of the University of Alabama Imaging Core at Birmingham, said in an interview.

The investigators wrote: “Our findings have implications for airflow limitation and the consequent clinical outcomes. ... We confirmed that men have more emphysema than women with equivalent smoking burden, and our results suggest that the lower reserve conferred by smaller airways predisposes women to develop airflow limitation predominantly through the airway phenotype. All airway remodeling changes were associated with more dyspnea, worse respiratory quality of life, and lower functional capacity in women than in men. The smaller airways in women can result in higher airway resistance and more turbulent airflow, and thus place a higher ventilatory constraint during exertion. Alteration in each airway measure was also associated with worse survival in women than in men, partially explaining the comparable mortality between the sexes for COPD despite the differing degrees of emphysema.”

“I think these findings highlight underappreciated sex differences in the natural history of COPD,” Mohsen Sadatsafavi, MD, PhD, associate professor, faculty of pharmaceutical sciences, at the University of British Columbia, Vancouver, said in an interview. “To me, first and foremost, the Bhatt et al. findings highlight how the ‘one size fits all’ approach to COPD management of using exacerbation history alone to guide preventive therapies is incorrect. These findings have the potential to change the management paradigm of COPD in the long term, but before getting there, I think we need to relate these findings to clinically relevant and patient-reported outcomes.”

Noting study limitations, the authors stated that a higher proportion of men were active smokers, compared with women, and despite adjustments for smoking status, some of the airway wall differences may be from the impact of active cigarette smoking on airway wall thickness.

Five study authors reported receiving support from various government and industry sources and disclosed conflicts of interest based on relationships with industry. The rest reported no conflicts of interest.

A study aimed at determining whether behind some of the sex differences in chronic obstructive airway disease (COPD) prevalence and clinical outcomes lie structural differences in airways found that airway lumen sizes quantified through chest CT were smaller in women than in men.

The findings, published in Radiology, took into account height and lung size. The lower baseline airway lumen sizes in women conferred lower reserves against respiratory morbidity and mortality for equivalent changes, compared with men.

Alfred Pasieka/Science Source

Among key findings in a secondary analysis of consecutive participants (9,363 ever-smokers and 420 never-smokers) enrolled in the Genetic Epidemiology of COPD (COPDGene) study, airway lumen dimensions were lower in never-smoker women than in men (segmental lumen diameter, 8.1 mm vs. 9.1 mm; P < .001). Also, ever-smoker women had narrower segmental lumen diameter (7.8 mm ± 0.05 vs. 8.7 mm ± 0.04; P < .001). The investigators found also that a unit change in wall thickness or lumen area resulted in more severe airflow obstruction, more dyspnea, worse respiratory quality of life, lower 6-minute walk distance, and worse survival in women, compared with men.

While COPD is diagnosed more often in men than women, changes in smoking behavior and increasing urbanization have led to COPD prevalence in women fast approaching the rate in men. Although age-adjusted rates for COPD-related deaths have continued to decline in men, in women they have not. Indeed, never-smoking women accounted for two-thirds of COPD in a population-based study.

COPDGene, a prospective, multicenter, observational cohort study, enrolled current and former smokers, as well as never-smokers, aged 45-80 years at 21 clinical centers across the United States from January 2008 to June 2011 with longitudinal follow-up until November 2020. The investigators quantified airway disease through CT imaging using the following metrics: airway wall thickness of segmental airways, wall area percent of segmental airways, the square root of the wall area of a hypothetical airway with 10-mm internal perimeter, total airway count, lumen diameter of segmental airways, airway volume, and airway fractal dimension.

“Not all sex differences in prevalence of COPD have been explained, and structural differences may explain some of these differences. Our findings may have implications for patient selection for clinical trials,” corresponding author Surya P. Bhatt, MD, associate professor of medicine and director of the University of Alabama Imaging Core at Birmingham, said in an interview.

The investigators wrote: “Our findings have implications for airflow limitation and the consequent clinical outcomes. ... We confirmed that men have more emphysema than women with equivalent smoking burden, and our results suggest that the lower reserve conferred by smaller airways predisposes women to develop airflow limitation predominantly through the airway phenotype. All airway remodeling changes were associated with more dyspnea, worse respiratory quality of life, and lower functional capacity in women than in men. The smaller airways in women can result in higher airway resistance and more turbulent airflow, and thus place a higher ventilatory constraint during exertion. Alteration in each airway measure was also associated with worse survival in women than in men, partially explaining the comparable mortality between the sexes for COPD despite the differing degrees of emphysema.”

“I think these findings highlight underappreciated sex differences in the natural history of COPD,” Mohsen Sadatsafavi, MD, PhD, associate professor, faculty of pharmaceutical sciences, at the University of British Columbia, Vancouver, said in an interview. “To me, first and foremost, the Bhatt et al. findings highlight how the ‘one size fits all’ approach to COPD management of using exacerbation history alone to guide preventive therapies is incorrect. These findings have the potential to change the management paradigm of COPD in the long term, but before getting there, I think we need to relate these findings to clinically relevant and patient-reported outcomes.”

Noting study limitations, the authors stated that a higher proportion of men were active smokers, compared with women, and despite adjustments for smoking status, some of the airway wall differences may be from the impact of active cigarette smoking on airway wall thickness.

Five study authors reported receiving support from various government and industry sources and disclosed conflicts of interest based on relationships with industry. The rest reported no conflicts of interest.

A prenatal test can accurately detect an incorrect number of chromosomes more quickly and at about one-tenth the cost of current clinical genetic tests, new data suggest.

Aneuploid pregnancies are a major cause of pregnancy loss, developmental delays, and fetal structural abnormalities, so there is high interest in screening options.

Study leader Zev Williams, MD, PhD, professor of women’s health and chief of the division of reproductive endocrinology and infertility at Columbia University, New York, and colleagues, describe a test they have developed and validated in a letter to the editor published in the New England Journal of Medicine.

The new test is called STORK (Short-Read Transpore Rapid Karyotyping) and can be used in doctors’ offices. The test uses a palm-sized, nanopore-based DNA sequencer to examine tissue from miscarriages or from a biopsy of the placenta or in vitro fertilization (IVF) embryo to determine if it has a normal count of chromosomes.

Results can be delivered in 2 hours, the researchers said. Sequencing times and costs range from 10 minutes and $200 for a single sample to 2 hours and less than $50 per sample when 10 samples are tested simultaneously.

The currently available tests and results cost thousands of dollars and results take days to weeks.

”What’s so exciting is that STORK can be used to rapidly assess chromosomal health across all reproductive tissue types,” Dr. Williams said in a press release.

“For those patients who are trying to get pregnant through IVF, the test gives the ability to conceive sooner,“ he said.

IVF embryos are typically biopsied for chromosomal testing on day 5 or 6 and are frozen for weeks until they can be implanted in a woman’s uterus. Freezing may not be necessary with rapid tests, as embryos found normal could be transferred immediately.

Dr. Williams added: “For those who are already pregnant, it gives more time to make important family-planning decisions. For those who have had a miscarriage, it can show why the loss happened so that steps can be taken to prevent future pregnancy losses.”

Existing tests include two main approaches. One is a rapid and target approach, which tests only a limited number of chromosomes and the other is a whole-genome approach, which takes days or weeks to get results and requires sending samples to specialized laboratories.

”The affordability of this [STORK] test also means that individuals who have suffered a miscarriage do not have to wait until a second or third loss before insurance will cover expensive lab tests, leaving many women in the dark and often blaming themselves,” Dr. Williams said.

The researchers used STORK to perform blinded testing using 218 specimens from miscarriage tissue, placenta samples, amniotic fluid, and biopsy specimens from embryos undergoing preimplantation genetic tests for aneuploidy (PGT-A).

They compared the results from STORK with those obtained using standard clinical testing,

For miscarriage tissue samples and placenta and amniotic-fluid samples, STORK results calculated the number of chromosomes “with 100% accuracy (95% confidence intervals, 94.3%-100%, 93.2%-100%, and 92.9%-100%, respectively),” the authors wrote.

For PGT-A samples, STORK results were 98.1% matched (95% CI, 89.7%-100%) with the clinical diagnosis of the embryos, they report.

According to the Columbia University press release, the researchers are waiting for authorization from the New York State Department of Health before the test can be offered to Columbia patients.

Sarah Wernimont, MD, PhD, a maternal-fetal physician with the University of Minnesota, Minneapolis, who was not part of the study, said in an interview she found the results “exciting.”

“For patients I care for who have abnormal screening results, there’s the potential to receive diagnostic testing in a much faster way that can help parents make serious decisions about pregnancy care in a more timely fashion,” she said.

She said the quickest test they use in her practice for detection of aneuploidy, the fluorescence in situ hybridization test, takes 3 days to get results and tests only a few chromosomes.

The STORK test, she noted, has the potential to test all the chromosomes.

She said the sample size is small and she would like to see more external validation in a larger population, but “their sensitivity and specificity compared to the current standard seems to be excellent.”

The study was supported by the National Institutes of Health, the Biomedical Engineering Technology Accelerator at Columbia University and the Wendy and John Havens Innovation fund. Dr. Williams and one study coauthor are inventors on patents filed related to this work. Dr. Wernimont declared no relevant financial relationships.

A prenatal test can accurately detect an incorrect number of chromosomes more quickly and at about one-tenth the cost of current clinical genetic tests, new data suggest.

Aneuploid pregnancies are a major cause of pregnancy loss, developmental delays, and fetal structural abnormalities, so there is high interest in screening options.

Study leader Zev Williams, MD, PhD, professor of women’s health and chief of the division of reproductive endocrinology and infertility at Columbia University, New York, and colleagues, describe a test they have developed and validated in a letter to the editor published in the New England Journal of Medicine.

The new test is called STORK (Short-Read Transpore Rapid Karyotyping) and can be used in doctors’ offices. The test uses a palm-sized, nanopore-based DNA sequencer to examine tissue from miscarriages or from a biopsy of the placenta or in vitro fertilization (IVF) embryo to determine if it has a normal count of chromosomes.

Results can be delivered in 2 hours, the researchers said. Sequencing times and costs range from 10 minutes and $200 for a single sample to 2 hours and less than $50 per sample when 10 samples are tested simultaneously.

The currently available tests and results cost thousands of dollars and results take days to weeks.

”What’s so exciting is that STORK can be used to rapidly assess chromosomal health across all reproductive tissue types,” Dr. Williams said in a press release.

“For those patients who are trying to get pregnant through IVF, the test gives the ability to conceive sooner,“ he said.

IVF embryos are typically biopsied for chromosomal testing on day 5 or 6 and are frozen for weeks until they can be implanted in a woman’s uterus. Freezing may not be necessary with rapid tests, as embryos found normal could be transferred immediately.

Dr. Williams added: “For those who are already pregnant, it gives more time to make important family-planning decisions. For those who have had a miscarriage, it can show why the loss happened so that steps can be taken to prevent future pregnancy losses.”

Existing tests include two main approaches. One is a rapid and target approach, which tests only a limited number of chromosomes and the other is a whole-genome approach, which takes days or weeks to get results and requires sending samples to specialized laboratories.

”The affordability of this [STORK] test also means that individuals who have suffered a miscarriage do not have to wait until a second or third loss before insurance will cover expensive lab tests, leaving many women in the dark and often blaming themselves,” Dr. Williams said.

The researchers used STORK to perform blinded testing using 218 specimens from miscarriage tissue, placenta samples, amniotic fluid, and biopsy specimens from embryos undergoing preimplantation genetic tests for aneuploidy (PGT-A).

They compared the results from STORK with those obtained using standard clinical testing,

For miscarriage tissue samples and placenta and amniotic-fluid samples, STORK results calculated the number of chromosomes “with 100% accuracy (95% confidence intervals, 94.3%-100%, 93.2%-100%, and 92.9%-100%, respectively),” the authors wrote.

For PGT-A samples, STORK results were 98.1% matched (95% CI, 89.7%-100%) with the clinical diagnosis of the embryos, they report.

According to the Columbia University press release, the researchers are waiting for authorization from the New York State Department of Health before the test can be offered to Columbia patients.

Sarah Wernimont, MD, PhD, a maternal-fetal physician with the University of Minnesota, Minneapolis, who was not part of the study, said in an interview she found the results “exciting.”

“For patients I care for who have abnormal screening results, there’s the potential to receive diagnostic testing in a much faster way that can help parents make serious decisions about pregnancy care in a more timely fashion,” she said.

She said the quickest test they use in her practice for detection of aneuploidy, the fluorescence in situ hybridization test, takes 3 days to get results and tests only a few chromosomes.

The STORK test, she noted, has the potential to test all the chromosomes.

She said the sample size is small and she would like to see more external validation in a larger population, but “their sensitivity and specificity compared to the current standard seems to be excellent.”

The study was supported by the National Institutes of Health, the Biomedical Engineering Technology Accelerator at Columbia University and the Wendy and John Havens Innovation fund. Dr. Williams and one study coauthor are inventors on patents filed related to this work. Dr. Wernimont declared no relevant financial relationships.

A prenatal test can accurately detect an incorrect number of chromosomes more quickly and at about one-tenth the cost of current clinical genetic tests, new data suggest.

Aneuploid pregnancies are a major cause of pregnancy loss, developmental delays, and fetal structural abnormalities, so there is high interest in screening options.

Study leader Zev Williams, MD, PhD, professor of women’s health and chief of the division of reproductive endocrinology and infertility at Columbia University, New York, and colleagues, describe a test they have developed and validated in a letter to the editor published in the New England Journal of Medicine.

The new test is called STORK (Short-Read Transpore Rapid Karyotyping) and can be used in doctors’ offices. The test uses a palm-sized, nanopore-based DNA sequencer to examine tissue from miscarriages or from a biopsy of the placenta or in vitro fertilization (IVF) embryo to determine if it has a normal count of chromosomes.

Results can be delivered in 2 hours, the researchers said. Sequencing times and costs range from 10 minutes and $200 for a single sample to 2 hours and less than $50 per sample when 10 samples are tested simultaneously.

The currently available tests and results cost thousands of dollars and results take days to weeks.

”What’s so exciting is that STORK can be used to rapidly assess chromosomal health across all reproductive tissue types,” Dr. Williams said in a press release.

“For those patients who are trying to get pregnant through IVF, the test gives the ability to conceive sooner,“ he said.

IVF embryos are typically biopsied for chromosomal testing on day 5 or 6 and are frozen for weeks until they can be implanted in a woman’s uterus. Freezing may not be necessary with rapid tests, as embryos found normal could be transferred immediately.

Dr. Williams added: “For those who are already pregnant, it gives more time to make important family-planning decisions. For those who have had a miscarriage, it can show why the loss happened so that steps can be taken to prevent future pregnancy losses.”

Existing tests include two main approaches. One is a rapid and target approach, which tests only a limited number of chromosomes and the other is a whole-genome approach, which takes days or weeks to get results and requires sending samples to specialized laboratories.

”The affordability of this [STORK] test also means that individuals who have suffered a miscarriage do not have to wait until a second or third loss before insurance will cover expensive lab tests, leaving many women in the dark and often blaming themselves,” Dr. Williams said.

The researchers used STORK to perform blinded testing using 218 specimens from miscarriage tissue, placenta samples, amniotic fluid, and biopsy specimens from embryos undergoing preimplantation genetic tests for aneuploidy (PGT-A).

They compared the results from STORK with those obtained using standard clinical testing,

For miscarriage tissue samples and placenta and amniotic-fluid samples, STORK results calculated the number of chromosomes “with 100% accuracy (95% confidence intervals, 94.3%-100%, 93.2%-100%, and 92.9%-100%, respectively),” the authors wrote.

For PGT-A samples, STORK results were 98.1% matched (95% CI, 89.7%-100%) with the clinical diagnosis of the embryos, they report.

According to the Columbia University press release, the researchers are waiting for authorization from the New York State Department of Health before the test can be offered to Columbia patients.

Sarah Wernimont, MD, PhD, a maternal-fetal physician with the University of Minnesota, Minneapolis, who was not part of the study, said in an interview she found the results “exciting.”

“For patients I care for who have abnormal screening results, there’s the potential to receive diagnostic testing in a much faster way that can help parents make serious decisions about pregnancy care in a more timely fashion,” she said.

She said the quickest test they use in her practice for detection of aneuploidy, the fluorescence in situ hybridization test, takes 3 days to get results and tests only a few chromosomes.

The STORK test, she noted, has the potential to test all the chromosomes.

She said the sample size is small and she would like to see more external validation in a larger population, but “their sensitivity and specificity compared to the current standard seems to be excellent.”

The study was supported by the National Institutes of Health, the Biomedical Engineering Technology Accelerator at Columbia University and the Wendy and John Havens Innovation fund. Dr. Williams and one study coauthor are inventors on patents filed related to this work. Dr. Wernimont declared no relevant financial relationships.

Mothers who have a family history of any psychiatric disorder have almost two times the risk of postpartum depression as do mothers without such history, according to a new study.

Mette-Marie Zacher Kjeldsen, MSc, with the National Centre for Register-based Research at Aarhus (Denmark) University, led the study, a meta-analysis that included 26 studies with information on 100,877 women.

Findings were published online in JAMA Psychiatry.

When mothers had a family history of psychiatric disorders, the odds ratio for PPD was 2.08 (95% confidence interval, 1.67-2.59). That corresponds to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population.
 

Not doomed to develop PPD

Polina Teslyar, MD, a perinatal psychiatrist at Brigham and Women’s Hospital in Boston told this news organization it’s important to point out that though the risk is higher, women with a family psychiatric history should not feel as though they are destined to develop PPD.

“You are still more likely to not have postpartum depression, but it is important to be aware of personal risk factors so that if a person is experiencing that, they ask for help quickly rather than suffering and not knowing something is amiss,” she emphasized. Dr. Teslyar says she does see the higher risk for PPD, which is preventable and treatable, in her own practice when women have had a family history of psychiatric disorders.

The association makes sense, but literature on why that is has been varied, she said, and likely involves both genetics and socioeconomic factors. It’s difficult to tease apart how big a part each plays.

In her perinatal practice she sees women even before they are pregnant to discuss risk factors for PPD so she does ask about family history of psychiatric disorders, specifically about history of PPD and anxiety.

The researchers suggest routine perinatal care should include an easy low-cost, two-part question about both personal and family history of psychiatric disorders.

“As the assessment is possible even prior to conception, this would leave time for planning preventive efforts, such as psychosocial and psychological interventions targeting these at-risk women,” the authors write.
 

Asking about family history a challenge

Dr. Teslyar noted though that one of the challenges in asking about family history is that families may not have openly shared psychiatric history details with offspring. Family members may also report conditions they suspect a family member had rather than having a documented diagnosis.

In places where there is universal health care, she noted, finding documented diagnoses is easier, but otherwise “you’re really taking a subjective interpretation.”

The researchers found that subgroup, sensitivity, and meta–regression analyses aligned with the primary findings. The overall certainty of evidence was graded as moderate.

This study was not able to make clear how the specific diagnoses of family members affect the risk of developing PPD because much of the data from the studies came from self-report and questions were not consistent across the studies.

For instance, only 7 studies asked specifically about first-degree family members and 10 asked about specific diagnoses. Diagnoses ranged from mild affective disorders to more intrusive disorders, such as schizophrenia.

And while this study doesn’t seek to determine why the family history and risk of PPD appear to be connected, the authors offer some possible explanations.

“Growing up in an environment with parents struggling with mental health problems potentially influences the social support received from these parents when going into motherhood,” the authors write. “This particular explanation is supported by umbrella reviews concluding that lack of social support is a significant PPD risk factor.”

Screening, extraction, and assessment of studies included was done independently by two reviewers, increasing validity, the authors note.

The authors state that approximately 10%-15% of new mothers experience PPD, but Dr. Teslyar points out the numbers in the United States are typically quoted at up to 20%-30%. PPD ranges from mild to severe episodes and includes symptoms like those for major depression outside the postpartum period.

Study authors received funding from The Lundbeck Foundation and the European Union’s Horizon 2020 Research and Innovation Programme. A coauthor, Vibe G. Frokjaer, MD, PhD, has served as consultant and lecturer for H. Lundbeck and Sage Therapeutics. No other disclosures were reported. Dr. Teslyar reports no relevant financial relationships.

Mothers who have a family history of any psychiatric disorder have almost two times the risk of postpartum depression as do mothers without such history, according to a new study.

Mette-Marie Zacher Kjeldsen, MSc, with the National Centre for Register-based Research at Aarhus (Denmark) University, led the study, a meta-analysis that included 26 studies with information on 100,877 women.

Findings were published online in JAMA Psychiatry.

When mothers had a family history of psychiatric disorders, the odds ratio for PPD was 2.08 (95% confidence interval, 1.67-2.59). That corresponds to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population.
 

Not doomed to develop PPD

Polina Teslyar, MD, a perinatal psychiatrist at Brigham and Women’s Hospital in Boston told this news organization it’s important to point out that though the risk is higher, women with a family psychiatric history should not feel as though they are destined to develop PPD.

“You are still more likely to not have postpartum depression, but it is important to be aware of personal risk factors so that if a person is experiencing that, they ask for help quickly rather than suffering and not knowing something is amiss,” she emphasized. Dr. Teslyar says she does see the higher risk for PPD, which is preventable and treatable, in her own practice when women have had a family history of psychiatric disorders.

The association makes sense, but literature on why that is has been varied, she said, and likely involves both genetics and socioeconomic factors. It’s difficult to tease apart how big a part each plays.

In her perinatal practice she sees women even before they are pregnant to discuss risk factors for PPD so she does ask about family history of psychiatric disorders, specifically about history of PPD and anxiety.

The researchers suggest routine perinatal care should include an easy low-cost, two-part question about both personal and family history of psychiatric disorders.

“As the assessment is possible even prior to conception, this would leave time for planning preventive efforts, such as psychosocial and psychological interventions targeting these at-risk women,” the authors write.
 

Asking about family history a challenge

Dr. Teslyar noted though that one of the challenges in asking about family history is that families may not have openly shared psychiatric history details with offspring. Family members may also report conditions they suspect a family member had rather than having a documented diagnosis.

In places where there is universal health care, she noted, finding documented diagnoses is easier, but otherwise “you’re really taking a subjective interpretation.”

The researchers found that subgroup, sensitivity, and meta–regression analyses aligned with the primary findings. The overall certainty of evidence was graded as moderate.

This study was not able to make clear how the specific diagnoses of family members affect the risk of developing PPD because much of the data from the studies came from self-report and questions were not consistent across the studies.

For instance, only 7 studies asked specifically about first-degree family members and 10 asked about specific diagnoses. Diagnoses ranged from mild affective disorders to more intrusive disorders, such as schizophrenia.

And while this study doesn’t seek to determine why the family history and risk of PPD appear to be connected, the authors offer some possible explanations.

“Growing up in an environment with parents struggling with mental health problems potentially influences the social support received from these parents when going into motherhood,” the authors write. “This particular explanation is supported by umbrella reviews concluding that lack of social support is a significant PPD risk factor.”

Screening, extraction, and assessment of studies included was done independently by two reviewers, increasing validity, the authors note.

The authors state that approximately 10%-15% of new mothers experience PPD, but Dr. Teslyar points out the numbers in the United States are typically quoted at up to 20%-30%. PPD ranges from mild to severe episodes and includes symptoms like those for major depression outside the postpartum period.

Study authors received funding from The Lundbeck Foundation and the European Union’s Horizon 2020 Research and Innovation Programme. A coauthor, Vibe G. Frokjaer, MD, PhD, has served as consultant and lecturer for H. Lundbeck and Sage Therapeutics. No other disclosures were reported. Dr. Teslyar reports no relevant financial relationships.

Mothers who have a family history of any psychiatric disorder have almost two times the risk of postpartum depression as do mothers without such history, according to a new study.

Mette-Marie Zacher Kjeldsen, MSc, with the National Centre for Register-based Research at Aarhus (Denmark) University, led the study, a meta-analysis that included 26 studies with information on 100,877 women.

Findings were published online in JAMA Psychiatry.

When mothers had a family history of psychiatric disorders, the odds ratio for PPD was 2.08 (95% confidence interval, 1.67-2.59). That corresponds to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population.
 

Not doomed to develop PPD

Polina Teslyar, MD, a perinatal psychiatrist at Brigham and Women’s Hospital in Boston told this news organization it’s important to point out that though the risk is higher, women with a family psychiatric history should not feel as though they are destined to develop PPD.

“You are still more likely to not have postpartum depression, but it is important to be aware of personal risk factors so that if a person is experiencing that, they ask for help quickly rather than suffering and not knowing something is amiss,” she emphasized. Dr. Teslyar says she does see the higher risk for PPD, which is preventable and treatable, in her own practice when women have had a family history of psychiatric disorders.

The association makes sense, but literature on why that is has been varied, she said, and likely involves both genetics and socioeconomic factors. It’s difficult to tease apart how big a part each plays.

In her perinatal practice she sees women even before they are pregnant to discuss risk factors for PPD so she does ask about family history of psychiatric disorders, specifically about history of PPD and anxiety.

The researchers suggest routine perinatal care should include an easy low-cost, two-part question about both personal and family history of psychiatric disorders.

“As the assessment is possible even prior to conception, this would leave time for planning preventive efforts, such as psychosocial and psychological interventions targeting these at-risk women,” the authors write.
 

Asking about family history a challenge

Dr. Teslyar noted though that one of the challenges in asking about family history is that families may not have openly shared psychiatric history details with offspring. Family members may also report conditions they suspect a family member had rather than having a documented diagnosis.

In places where there is universal health care, she noted, finding documented diagnoses is easier, but otherwise “you’re really taking a subjective interpretation.”

The researchers found that subgroup, sensitivity, and meta–regression analyses aligned with the primary findings. The overall certainty of evidence was graded as moderate.

This study was not able to make clear how the specific diagnoses of family members affect the risk of developing PPD because much of the data from the studies came from self-report and questions were not consistent across the studies.

For instance, only 7 studies asked specifically about first-degree family members and 10 asked about specific diagnoses. Diagnoses ranged from mild affective disorders to more intrusive disorders, such as schizophrenia.

And while this study doesn’t seek to determine why the family history and risk of PPD appear to be connected, the authors offer some possible explanations.

“Growing up in an environment with parents struggling with mental health problems potentially influences the social support received from these parents when going into motherhood,” the authors write. “This particular explanation is supported by umbrella reviews concluding that lack of social support is a significant PPD risk factor.”

Screening, extraction, and assessment of studies included was done independently by two reviewers, increasing validity, the authors note.

The authors state that approximately 10%-15% of new mothers experience PPD, but Dr. Teslyar points out the numbers in the United States are typically quoted at up to 20%-30%. PPD ranges from mild to severe episodes and includes symptoms like those for major depression outside the postpartum period.

Study authors received funding from The Lundbeck Foundation and the European Union’s Horizon 2020 Research and Innovation Programme. A coauthor, Vibe G. Frokjaer, MD, PhD, has served as consultant and lecturer for H. Lundbeck and Sage Therapeutics. No other disclosures were reported. Dr. Teslyar reports no relevant financial relationships.

After New York–based yoga instructor Erin Conley’s two sisters gave birth, Ms. Conley suggested a few advanced poses to help strengthen their pelvic floor.

“With one of my sisters, she said, ‘Honestly right now, I just can’t even stand up,’ ” she recalled.

Ms. Conley’s other sister could do slightly more advanced poses – leading Ms. Conley to recognize that after delivery, women’s ability to practice yoga varied widely.

“Post-birth is certainly a progression for each woman,” she said. “You can’t just go into these advance postures.”

Ms. Conley tailored a slow sequence of 30-second poses that each sister could start with, and they eventually reported an improvement of pelvic floor issues. Ms. Conley’s suggestions to her sisters are backed by a small but growing body of research. One study published in August in the journal Urology suggests that yoga may be a way to help treat multiple types of pelvic floor disorders.

More than 1 in 4 women in the United States experience pelvic floor disorders such as bowel or urinary incontinence or pelvic organ prolapse, many as a result of giving birth. But less than 15% of these women seek medical treatment for their symptoms, according to Hari Tunuguntla, MD, associate professor of urologic surgery at Rutgers University’s Robert Wood Johnson Medical School, New Brunswick.

For those who do seek medical help, many patients have trouble complying with initial lifestyle-based recommendations, such as refraining from drinking caffeinated and carbonated beverages, Dr. Tunuguntla said.

“It requires a lot of persistence and knowledge and compliance,” he said.

Medication and physical therapy are routes doctors can order before considering surgery, but some patients find clinical-based interventions to be costly. The cost of the interventions can add up depending on what a person’s insurance policy covers, Dr. Tunuguntla said.

With those struggles in mind, he and his colleagues set out to study the efficacy of the mobile app Yoga of Immortals, which offers a holistic form of yoga that includes postures, breathing exercises, sound therapy, and meditation.

“It includes sound therapy, summative breathing exercise,” Dr. Tunuguntla said. “These are useful not just for the condition but for general well-being.”

For the study, Dr. Tunuguntla and his colleagues emailed surveys to 420 people between ages 18 and 74 years in 23 countries who reported having any type of urinary incontinence, regardless of severity. The participants, most of whom were women, used the yoga app for 30 minutes a day for 8 weeks.

More than three-quarters of participants reported that the frequency and severity of their incontinence improved after 8 weeks of practice, compared with when they started, without having to visit their health care provider. Most participants also said that they felt “very much better” after 8 weeks, compared with when they began the yoga regimen, the researchers found.

The study did not compare the effectiveness of the approach with other standard treatments for incontinence, like physical therapy, medication, or surgery.

Ms. Conley, an instructor since 2010, said that one of the benefits of yoga is building strength and flexibility slowly and simultaneously. She uses yoga poses that focus less on movement and more on holding positions for longer periods of time.

“I’ll do sequences of a mountain pose with a block to activate the core in the most basic ways and really focus on the breathing,” she said.

Another benefit of slower forms of yoga is that they can help participants become more aware of the structures of their pelvic floor, according to Alison Huang, MD, professor of medicine, urology and epidemiology, and biostatistics at University of California, San Francisco.

“In some ways we can think of it as a complementary substitute for rehabilitation therapy,” Dr. Huang said.

Dr. Huang and her colleagues published a short report recently in The Journal of Integrative and Complementary Medicine, showing that even telehealth-based yoga programs for older women with urinary incontinence can offer an accessible way for women of any background to take advantage of yoga’s benefits.

An estimated 93% of 66 participants who practiced yoga through planned telehealth appointments reported feeling “very or moderately satisfied” with their practice. Dr. Huang said that the study is not yet complete but offers a glimpse into some of the advantages of yoga for women with urinary incontinence.

“Any kind of treatment that relies on intensive one-on-one visits with specialists is going to be harder to access for some women,” Dr. Huang told this news organization. “Yoga is typically practiced in a community setting, outside of traditional health care settings.”

The accessibility of yoga and its community-based practice may help eliminate any obstacles to care and compliance that clinicians like she and Dr. Tunuguntla at times experience. Mounting studies have also indicated that yoga may help improve overall wellness, manage stress, promote healthier eating, and benefit a person’s mental and emotional health.

Despite emerging research on the link between yoga and pelvic floor disorders, Dr. Huang said that it’s still early for clinicians to recommend the exercise form for every patient.

“We just don’t have the [solid] evidence to show your pelvic floor will improve,” she said.

“For any woman who is starting out more sedentary, I think there are benefits to practic[ing] yoga for overall health,” Dr. Huang said. “Most clinicians would say there are opportunities to practice yoga regularly in a way that is safe, with a knowledgeable instructor.”

According to Ms. Conley, yoga is only as beneficial as a person’s level of consistency in the practice.

“The dedication to yoga is your willingness to showing up,” she said. “I think depending on your commitment to the practice, if you’re really committed to the practice – just like you show up to physical therapy every day – you will improve,” said Ms. Conley.

“Being gentle and patient with the process is important too,” she said.

Dr. Tunuguntla and coauthors report no relevant financial relationships. 

A version of this article first appeared on Medscape.com.

After New York–based yoga instructor Erin Conley’s two sisters gave birth, Ms. Conley suggested a few advanced poses to help strengthen their pelvic floor.

“With one of my sisters, she said, ‘Honestly right now, I just can’t even stand up,’ ” she recalled.

Ms. Conley’s other sister could do slightly more advanced poses – leading Ms. Conley to recognize that after delivery, women’s ability to practice yoga varied widely.

“Post-birth is certainly a progression for each woman,” she said. “You can’t just go into these advance postures.”

Ms. Conley tailored a slow sequence of 30-second poses that each sister could start with, and they eventually reported an improvement of pelvic floor issues. Ms. Conley’s suggestions to her sisters are backed by a small but growing body of research. One study published in August in the journal Urology suggests that yoga may be a way to help treat multiple types of pelvic floor disorders.

More than 1 in 4 women in the United States experience pelvic floor disorders such as bowel or urinary incontinence or pelvic organ prolapse, many as a result of giving birth. But less than 15% of these women seek medical treatment for their symptoms, according to Hari Tunuguntla, MD, associate professor of urologic surgery at Rutgers University’s Robert Wood Johnson Medical School, New Brunswick.

For those who do seek medical help, many patients have trouble complying with initial lifestyle-based recommendations, such as refraining from drinking caffeinated and carbonated beverages, Dr. Tunuguntla said.

“It requires a lot of persistence and knowledge and compliance,” he said.

Medication and physical therapy are routes doctors can order before considering surgery, but some patients find clinical-based interventions to be costly. The cost of the interventions can add up depending on what a person’s insurance policy covers, Dr. Tunuguntla said.

With those struggles in mind, he and his colleagues set out to study the efficacy of the mobile app Yoga of Immortals, which offers a holistic form of yoga that includes postures, breathing exercises, sound therapy, and meditation.

“It includes sound therapy, summative breathing exercise,” Dr. Tunuguntla said. “These are useful not just for the condition but for general well-being.”

For the study, Dr. Tunuguntla and his colleagues emailed surveys to 420 people between ages 18 and 74 years in 23 countries who reported having any type of urinary incontinence, regardless of severity. The participants, most of whom were women, used the yoga app for 30 minutes a day for 8 weeks.

More than three-quarters of participants reported that the frequency and severity of their incontinence improved after 8 weeks of practice, compared with when they started, without having to visit their health care provider. Most participants also said that they felt “very much better” after 8 weeks, compared with when they began the yoga regimen, the researchers found.

The study did not compare the effectiveness of the approach with other standard treatments for incontinence, like physical therapy, medication, or surgery.

Ms. Conley, an instructor since 2010, said that one of the benefits of yoga is building strength and flexibility slowly and simultaneously. She uses yoga poses that focus less on movement and more on holding positions for longer periods of time.

“I’ll do sequences of a mountain pose with a block to activate the core in the most basic ways and really focus on the breathing,” she said.

Another benefit of slower forms of yoga is that they can help participants become more aware of the structures of their pelvic floor, according to Alison Huang, MD, professor of medicine, urology and epidemiology, and biostatistics at University of California, San Francisco.

“In some ways we can think of it as a complementary substitute for rehabilitation therapy,” Dr. Huang said.

Dr. Huang and her colleagues published a short report recently in The Journal of Integrative and Complementary Medicine, showing that even telehealth-based yoga programs for older women with urinary incontinence can offer an accessible way for women of any background to take advantage of yoga’s benefits.

An estimated 93% of 66 participants who practiced yoga through planned telehealth appointments reported feeling “very or moderately satisfied” with their practice. Dr. Huang said that the study is not yet complete but offers a glimpse into some of the advantages of yoga for women with urinary incontinence.

“Any kind of treatment that relies on intensive one-on-one visits with specialists is going to be harder to access for some women,” Dr. Huang told this news organization. “Yoga is typically practiced in a community setting, outside of traditional health care settings.”

The accessibility of yoga and its community-based practice may help eliminate any obstacles to care and compliance that clinicians like she and Dr. Tunuguntla at times experience. Mounting studies have also indicated that yoga may help improve overall wellness, manage stress, promote healthier eating, and benefit a person’s mental and emotional health.

Despite emerging research on the link between yoga and pelvic floor disorders, Dr. Huang said that it’s still early for clinicians to recommend the exercise form for every patient.

“We just don’t have the [solid] evidence to show your pelvic floor will improve,” she said.

“For any woman who is starting out more sedentary, I think there are benefits to practic[ing] yoga for overall health,” Dr. Huang said. “Most clinicians would say there are opportunities to practice yoga regularly in a way that is safe, with a knowledgeable instructor.”

According to Ms. Conley, yoga is only as beneficial as a person’s level of consistency in the practice.

“The dedication to yoga is your willingness to showing up,” she said. “I think depending on your commitment to the practice, if you’re really committed to the practice – just like you show up to physical therapy every day – you will improve,” said Ms. Conley.

“Being gentle and patient with the process is important too,” she said.

Dr. Tunuguntla and coauthors report no relevant financial relationships. 

A version of this article first appeared on Medscape.com.

After New York–based yoga instructor Erin Conley’s two sisters gave birth, Ms. Conley suggested a few advanced poses to help strengthen their pelvic floor.

“With one of my sisters, she said, ‘Honestly right now, I just can’t even stand up,’ ” she recalled.

Ms. Conley’s other sister could do slightly more advanced poses – leading Ms. Conley to recognize that after delivery, women’s ability to practice yoga varied widely.

“Post-birth is certainly a progression for each woman,” she said. “You can’t just go into these advance postures.”

Ms. Conley tailored a slow sequence of 30-second poses that each sister could start with, and they eventually reported an improvement of pelvic floor issues. Ms. Conley’s suggestions to her sisters are backed by a small but growing body of research. One study published in August in the journal Urology suggests that yoga may be a way to help treat multiple types of pelvic floor disorders.

More than 1 in 4 women in the United States experience pelvic floor disorders such as bowel or urinary incontinence or pelvic organ prolapse, many as a result of giving birth. But less than 15% of these women seek medical treatment for their symptoms, according to Hari Tunuguntla, MD, associate professor of urologic surgery at Rutgers University’s Robert Wood Johnson Medical School, New Brunswick.

For those who do seek medical help, many patients have trouble complying with initial lifestyle-based recommendations, such as refraining from drinking caffeinated and carbonated beverages, Dr. Tunuguntla said.

“It requires a lot of persistence and knowledge and compliance,” he said.

Medication and physical therapy are routes doctors can order before considering surgery, but some patients find clinical-based interventions to be costly. The cost of the interventions can add up depending on what a person’s insurance policy covers, Dr. Tunuguntla said.

With those struggles in mind, he and his colleagues set out to study the efficacy of the mobile app Yoga of Immortals, which offers a holistic form of yoga that includes postures, breathing exercises, sound therapy, and meditation.

“It includes sound therapy, summative breathing exercise,” Dr. Tunuguntla said. “These are useful not just for the condition but for general well-being.”

For the study, Dr. Tunuguntla and his colleagues emailed surveys to 420 people between ages 18 and 74 years in 23 countries who reported having any type of urinary incontinence, regardless of severity. The participants, most of whom were women, used the yoga app for 30 minutes a day for 8 weeks.

More than three-quarters of participants reported that the frequency and severity of their incontinence improved after 8 weeks of practice, compared with when they started, without having to visit their health care provider. Most participants also said that they felt “very much better” after 8 weeks, compared with when they began the yoga regimen, the researchers found.

The study did not compare the effectiveness of the approach with other standard treatments for incontinence, like physical therapy, medication, or surgery.

Ms. Conley, an instructor since 2010, said that one of the benefits of yoga is building strength and flexibility slowly and simultaneously. She uses yoga poses that focus less on movement and more on holding positions for longer periods of time.

“I’ll do sequences of a mountain pose with a block to activate the core in the most basic ways and really focus on the breathing,” she said.

Another benefit of slower forms of yoga is that they can help participants become more aware of the structures of their pelvic floor, according to Alison Huang, MD, professor of medicine, urology and epidemiology, and biostatistics at University of California, San Francisco.

“In some ways we can think of it as a complementary substitute for rehabilitation therapy,” Dr. Huang said.

Dr. Huang and her colleagues published a short report recently in The Journal of Integrative and Complementary Medicine, showing that even telehealth-based yoga programs for older women with urinary incontinence can offer an accessible way for women of any background to take advantage of yoga’s benefits.

An estimated 93% of 66 participants who practiced yoga through planned telehealth appointments reported feeling “very or moderately satisfied” with their practice. Dr. Huang said that the study is not yet complete but offers a glimpse into some of the advantages of yoga for women with urinary incontinence.

“Any kind of treatment that relies on intensive one-on-one visits with specialists is going to be harder to access for some women,” Dr. Huang told this news organization. “Yoga is typically practiced in a community setting, outside of traditional health care settings.”

The accessibility of yoga and its community-based practice may help eliminate any obstacles to care and compliance that clinicians like she and Dr. Tunuguntla at times experience. Mounting studies have also indicated that yoga may help improve overall wellness, manage stress, promote healthier eating, and benefit a person’s mental and emotional health.

Despite emerging research on the link between yoga and pelvic floor disorders, Dr. Huang said that it’s still early for clinicians to recommend the exercise form for every patient.

“We just don’t have the [solid] evidence to show your pelvic floor will improve,” she said.

“For any woman who is starting out more sedentary, I think there are benefits to practic[ing] yoga for overall health,” Dr. Huang said. “Most clinicians would say there are opportunities to practice yoga regularly in a way that is safe, with a knowledgeable instructor.”

According to Ms. Conley, yoga is only as beneficial as a person’s level of consistency in the practice.

“The dedication to yoga is your willingness to showing up,” she said. “I think depending on your commitment to the practice, if you’re really committed to the practice – just like you show up to physical therapy every day – you will improve,” said Ms. Conley.

“Being gentle and patient with the process is important too,” she said.

Dr. Tunuguntla and coauthors report no relevant financial relationships. 

A version of this article first appeared on Medscape.com.

In the United States, uterine cancer is the fourth most common cancer among women, behind breast, lung/bronchus, and colorectal cancer. There are expected to be almost 66,000 new cases of uterine cancer in 2022.¹ The majority of uterine cancers are endometrioid in histology and tend to be low grade, diagnosed at an early stage, and have a good prognosis. While our molecular understanding of endometrial cancers (EC) has changed significantly in recent years, low-grade endometrioid adenocarcinomas have historically been described as type 1 ECs. Type 1 ECs are typically caused by excess estrogen exposure (often unopposed or lacking progesterone protection) and are preceded by endometrial hyperplasia. Excess estrogen can come from exogenous sources (such as unopposed estrogen replacement therapy or tamoxifen, a commonly used treatment in estrogen receptor–positive breast cancer that acts as an estrogen agonist in the endometrium in postmenopausal patients) or endogenous ones (such as obesity).

Peripheral adipose tissue converts androgens into estrogens; paired with the decreased levels of sex hormone–binding globulin seen in obesity, there is more unbound or free serum estrogen (specifically estradiol) in obese women. Estrogen acts on the endometrium to cause proliferation and, if unopposed or imbalanced in relation to progesterone exposure, can ultimately lead to hyperplasia and malignancy.

Footnote: vaginal estrogen therapy

There are no randomized trials assessing the safety of vaginal estrogen preparations or their effect on oncologic outcomes in EC survivors. Observational data from the Women’s Health Initiative showed no increased risk of endometrial cancer in patients who used vaginal estrogen with an intact uterus.⁴ A recently published retrospective study among 244 gynecologic cancer survivors found low rates of disease recurrence and adverse outcomes among women who used vaginal estrogen for genitourinary symptoms.⁵ Among EC survivors, the incidence of recurrence was 2.4% for patients with stage I/II disease and 4.3% for stage III/IV disease, with a median follow-up of 80.2 months. While there appears to be some systemic absorption with vaginal estrogen use, this can be quite challenging to measure because of the current sensitivity of serum estradiol and estrone assays. Given the significantly lower serum levels with vaginal estrogen preparations compared with ERT, vaginal estrogen use appears to be safe in EC survivors.

Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.

References

1. Cancer Stat Facts: Uterine Cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Accessed 12 Aug. 2022. https://seer.cancer.gov/statfacts/html/corp.html.

2. Barakat RR et al. J Clin Oncol. 2006;24(4):587-92.

3. Shim SH et al. Eur J Cancer. 2014;50(9):1628-37.

4. Crandall CJ et al. Menopause. 2018 Jan;25(1):11-20.

5. Chambers LM et al. Int J Gynecol Cancer. 2020 Apr;30(4):515-24.

In the United States, uterine cancer is the fourth most common cancer among women, behind breast, lung/bronchus, and colorectal cancer. There are expected to be almost 66,000 new cases of uterine cancer in 2022.¹ The majority of uterine cancers are endometrioid in histology and tend to be low grade, diagnosed at an early stage, and have a good prognosis. While our molecular understanding of endometrial cancers (EC) has changed significantly in recent years, low-grade endometrioid adenocarcinomas have historically been described as type 1 ECs. Type 1 ECs are typically caused by excess estrogen exposure (often unopposed or lacking progesterone protection) and are preceded by endometrial hyperplasia. Excess estrogen can come from exogenous sources (such as unopposed estrogen replacement therapy or tamoxifen, a commonly used treatment in estrogen receptor–positive breast cancer that acts as an estrogen agonist in the endometrium in postmenopausal patients) or endogenous ones (such as obesity).

Peripheral adipose tissue converts androgens into estrogens; paired with the decreased levels of sex hormone–binding globulin seen in obesity, there is more unbound or free serum estrogen (specifically estradiol) in obese women. Estrogen acts on the endometrium to cause proliferation and, if unopposed or imbalanced in relation to progesterone exposure, can ultimately lead to hyperplasia and malignancy.

Footnote: vaginal estrogen therapy

There are no randomized trials assessing the safety of vaginal estrogen preparations or their effect on oncologic outcomes in EC survivors. Observational data from the Women’s Health Initiative showed no increased risk of endometrial cancer in patients who used vaginal estrogen with an intact uterus.⁴ A recently published retrospective study among 244 gynecologic cancer survivors found low rates of disease recurrence and adverse outcomes among women who used vaginal estrogen for genitourinary symptoms.⁵ Among EC survivors, the incidence of recurrence was 2.4% for patients with stage I/II disease and 4.3% for stage III/IV disease, with a median follow-up of 80.2 months. While there appears to be some systemic absorption with vaginal estrogen use, this can be quite challenging to measure because of the current sensitivity of serum estradiol and estrone assays. Given the significantly lower serum levels with vaginal estrogen preparations compared with ERT, vaginal estrogen use appears to be safe in EC survivors.

Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.

References

1. Cancer Stat Facts: Uterine Cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Accessed 12 Aug. 2022. https://seer.cancer.gov/statfacts/html/corp.html.

2. Barakat RR et al. J Clin Oncol. 2006;24(4):587-92.

3. Shim SH et al. Eur J Cancer. 2014;50(9):1628-37.

4. Crandall CJ et al. Menopause. 2018 Jan;25(1):11-20.

5. Chambers LM et al. Int J Gynecol Cancer. 2020 Apr;30(4):515-24.

In the United States, uterine cancer is the fourth most common cancer among women, behind breast, lung/bronchus, and colorectal cancer. There are expected to be almost 66,000 new cases of uterine cancer in 2022.¹ The majority of uterine cancers are endometrioid in histology and tend to be low grade, diagnosed at an early stage, and have a good prognosis. While our molecular understanding of endometrial cancers (EC) has changed significantly in recent years, low-grade endometrioid adenocarcinomas have historically been described as type 1 ECs. Type 1 ECs are typically caused by excess estrogen exposure (often unopposed or lacking progesterone protection) and are preceded by endometrial hyperplasia. Excess estrogen can come from exogenous sources (such as unopposed estrogen replacement therapy or tamoxifen, a commonly used treatment in estrogen receptor–positive breast cancer that acts as an estrogen agonist in the endometrium in postmenopausal patients) or endogenous ones (such as obesity).

Peripheral adipose tissue converts androgens into estrogens; paired with the decreased levels of sex hormone–binding globulin seen in obesity, there is more unbound or free serum estrogen (specifically estradiol) in obese women. Estrogen acts on the endometrium to cause proliferation and, if unopposed or imbalanced in relation to progesterone exposure, can ultimately lead to hyperplasia and malignancy.

Footnote: vaginal estrogen therapy

There are no randomized trials assessing the safety of vaginal estrogen preparations or their effect on oncologic outcomes in EC survivors. Observational data from the Women’s Health Initiative showed no increased risk of endometrial cancer in patients who used vaginal estrogen with an intact uterus.⁴ A recently published retrospective study among 244 gynecologic cancer survivors found low rates of disease recurrence and adverse outcomes among women who used vaginal estrogen for genitourinary symptoms.⁵ Among EC survivors, the incidence of recurrence was 2.4% for patients with stage I/II disease and 4.3% for stage III/IV disease, with a median follow-up of 80.2 months. While there appears to be some systemic absorption with vaginal estrogen use, this can be quite challenging to measure because of the current sensitivity of serum estradiol and estrone assays. Given the significantly lower serum levels with vaginal estrogen preparations compared with ERT, vaginal estrogen use appears to be safe in EC survivors.

Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.

References

1. Cancer Stat Facts: Uterine Cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Accessed 12 Aug. 2022. https://seer.cancer.gov/statfacts/html/corp.html.

2. Barakat RR et al. J Clin Oncol. 2006;24(4):587-92.

3. Shim SH et al. Eur J Cancer. 2014;50(9):1628-37.

4. Crandall CJ et al. Menopause. 2018 Jan;25(1):11-20.

5. Chambers LM et al. Int J Gynecol Cancer. 2020 Apr;30(4):515-24.

The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That’s exceedingly welcome given the morbidity and potential mortality associated with postpartum psychiatric disorders across the country.

From small community hospitals to major academic centers, screening for postpartum depression is part of the clinical fabric of routine obstetrical care. There is a growing appreciation for the complexity of perinatal psychiatric illness, particularly with respect to the commingling of both mood and anxiety disorders during the postpartum period. However, willingness to treat and appreciation of the urgency to treat with both pharmacologic and nonpharmacologic interventions can vary. For women who suffer from postpartum depression and their families, there are real-world implications of both treating and failing to treat this illness, and there is an urgent need to really help these women “climb out of the darkness” that is and defines postpartum depression.

Less common but of great clinical importance is postpartum psychosis, which occurs in approximately 1 in 1,000-2,000 women based on estimates from several studies. As noted in previous columns, the presentation is a dramatic one, with the typical onset of psychotic symptoms in the first days to weeks post partum. The disorder typically has a mood component and is not an exacerbation of underlying chronic psychotic illness. While there have been few systematic treatment studies, the clinical consensus is treatment usually includes hospitalization to ensure the safety of both the patient and infant. Use of medications, including mood stabilizers, antipsychotics, and benzodiazepines may be appropriate when expeditious treatment is needed.

Appropriate treatment by informed clinical staff is essential, as untreated or incompletely treated postpartum psychosis with its attendant morbidity and potential mortality is a very real concern. As I speak with women across the country with histories of postpartum psychosis, I’m often told of the difficult exchanges that women and their partners have at EDs in various clinical settings where diagnosis was delayed, or treatment was incomplete because of staff without expertise in postpartum psychosis management.

Another dilemma that patients and clinicians face after acute treatment is treatment duration, which is derived from how we conceptualize the illness. Even for experts in the area, there is not a consensus on whether postpartum psychosis should be considered as bipolar disorder or whether it is a circumscribed diagnostic entity. This issue has been hotly debated for many years and is one of the reasons why the illness is not included in the DSM classification system.

At Massachusetts General Hospital, we are systematically studying a large cohort of women with histories of postpartum psychosis as part of the MGH Postpartum Psychosis Project to better understand the phenomenology of postpartum psychosis, and also to understand the possible genomic underpinning of the illness. Most recently, we are conducting a neuroimaging study of women with histories of postpartum psychosis, compared with women in a healthy control group. We hope the results of this novel investigation will help to answer whether there is a neural signature identifiable with neuroimaging techniques such as functional MRI, if those findings are similar to other findings of neural circuitry we see in other forms of psychotic illness, or if the illness has a more distinct neural signature.

A question patients and colleagues often ask is what is the long-term nature of postpartum psychosis. If one considers it clearly to be bipolar disorder, the most intuitive approach would be long-term treatment with mood stabilizers. We now have a growing amount of data on the longitudinal course of postpartum psychosis. In one meta-analysis, 64% of women who had an episode of postpartum psychosis developed episodes of recurrent psychiatric disorder mostly consistent with bipolar illness. However, 36% of women appear to have more circumscribed illness without recurrence. In those women with recurrent disease, the presumption was those patients who had bipolar disorder and their presentation postpartum was simply their index episode of bipolar illness. However, there were other women who looked as if they had developed subsequent illness over the 11-26 years of follow-up, and those women did not receive long-term treatment.

A more recent prospective study of 106 women with postpartum psychosis who had their medication tapered and discontinued showed that 32% of women went on to have recurrent disease with a median time to illness of 20.3 months, and those patients presented primarily with illness that looked like bipolar disorder.

These accumulating data support the impression we’ve had for years that there’s a very strong relationship between bipolar disorder and postpartum psychiatric illness. Regardless of what side of the debate you fall on, the acute treatment is really the same. The real question for the clinician is what to do over the long term. Frequently, patients feel very strongly about a taper and discontinuation of medicine, and even the data show between 30% and 45% of women seem to have relatively circumscribed disease. There may be an issue in terms of prophylaxis if a patient gets pregnant and delivers another child, but that’s a separate issue. The issue is really whether there is a way to “thread the clinical needle” and meet patients where they are who do not want to continue long-term treatment.

I think we are at a point where we could argue the clinical treatment algorithm for patients who present with a new-onset manic-like psychosis postpartum is clear: initial treatment to stabilize, and then treatment with mood stabilizers for at least 12 months to follow is indicated. However, it may also be reasonable to taper treatment at 12-18 months, particularly for patients who have discussed this option with their clinician and who have been totally well for a year. (Women with previously documented bipolar disorder who have episodes of postpartum psychosis should obviously be treated with longer-term treatment aimed at maintenance of euthymia, as discontinuation of mood stabilizer is well known to be associated with risk for relapse.)

It should be noted that the longitudinal course and the treatment implications for women with postpartum psychosis are not etched in stone absent a clear evidence base driving care guidelines. Treatment must still be individualized. Women with underlying mood diatheses will typically declare themselves over time, and others may do well if they discontinue treatment, particularly if they are followed closely and instructed to present to a clinician at the earliest symptoms of mood dysregulation. The good news is we’ve seen an evolution of both interest and expertise in acute management of postpartum psychosis and a richer appreciation of the potential heterogeneity of this sample of women. There may be some variability in terms of long-term course requiring personalized treatment and obviously close follow-up of these women.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That’s exceedingly welcome given the morbidity and potential mortality associated with postpartum psychiatric disorders across the country.

From small community hospitals to major academic centers, screening for postpartum depression is part of the clinical fabric of routine obstetrical care. There is a growing appreciation for the complexity of perinatal psychiatric illness, particularly with respect to the commingling of both mood and anxiety disorders during the postpartum period. However, willingness to treat and appreciation of the urgency to treat with both pharmacologic and nonpharmacologic interventions can vary. For women who suffer from postpartum depression and their families, there are real-world implications of both treating and failing to treat this illness, and there is an urgent need to really help these women “climb out of the darkness” that is and defines postpartum depression.

Less common but of great clinical importance is postpartum psychosis, which occurs in approximately 1 in 1,000-2,000 women based on estimates from several studies. As noted in previous columns, the presentation is a dramatic one, with the typical onset of psychotic symptoms in the first days to weeks post partum. The disorder typically has a mood component and is not an exacerbation of underlying chronic psychotic illness. While there have been few systematic treatment studies, the clinical consensus is treatment usually includes hospitalization to ensure the safety of both the patient and infant. Use of medications, including mood stabilizers, antipsychotics, and benzodiazepines may be appropriate when expeditious treatment is needed.

Appropriate treatment by informed clinical staff is essential, as untreated or incompletely treated postpartum psychosis with its attendant morbidity and potential mortality is a very real concern. As I speak with women across the country with histories of postpartum psychosis, I’m often told of the difficult exchanges that women and their partners have at EDs in various clinical settings where diagnosis was delayed, or treatment was incomplete because of staff without expertise in postpartum psychosis management.

Another dilemma that patients and clinicians face after acute treatment is treatment duration, which is derived from how we conceptualize the illness. Even for experts in the area, there is not a consensus on whether postpartum psychosis should be considered as bipolar disorder or whether it is a circumscribed diagnostic entity. This issue has been hotly debated for many years and is one of the reasons why the illness is not included in the DSM classification system.

At Massachusetts General Hospital, we are systematically studying a large cohort of women with histories of postpartum psychosis as part of the MGH Postpartum Psychosis Project to better understand the phenomenology of postpartum psychosis, and also to understand the possible genomic underpinning of the illness. Most recently, we are conducting a neuroimaging study of women with histories of postpartum psychosis, compared with women in a healthy control group. We hope the results of this novel investigation will help to answer whether there is a neural signature identifiable with neuroimaging techniques such as functional MRI, if those findings are similar to other findings of neural circuitry we see in other forms of psychotic illness, or if the illness has a more distinct neural signature.

A question patients and colleagues often ask is what is the long-term nature of postpartum psychosis. If one considers it clearly to be bipolar disorder, the most intuitive approach would be long-term treatment with mood stabilizers. We now have a growing amount of data on the longitudinal course of postpartum psychosis. In one meta-analysis, 64% of women who had an episode of postpartum psychosis developed episodes of recurrent psychiatric disorder mostly consistent with bipolar illness. However, 36% of women appear to have more circumscribed illness without recurrence. In those women with recurrent disease, the presumption was those patients who had bipolar disorder and their presentation postpartum was simply their index episode of bipolar illness. However, there were other women who looked as if they had developed subsequent illness over the 11-26 years of follow-up, and those women did not receive long-term treatment.

A more recent prospective study of 106 women with postpartum psychosis who had their medication tapered and discontinued showed that 32% of women went on to have recurrent disease with a median time to illness of 20.3 months, and those patients presented primarily with illness that looked like bipolar disorder.

These accumulating data support the impression we’ve had for years that there’s a very strong relationship between bipolar disorder and postpartum psychiatric illness. Regardless of what side of the debate you fall on, the acute treatment is really the same. The real question for the clinician is what to do over the long term. Frequently, patients feel very strongly about a taper and discontinuation of medicine, and even the data show between 30% and 45% of women seem to have relatively circumscribed disease. There may be an issue in terms of prophylaxis if a patient gets pregnant and delivers another child, but that’s a separate issue. The issue is really whether there is a way to “thread the clinical needle” and meet patients where they are who do not want to continue long-term treatment.

I think we are at a point where we could argue the clinical treatment algorithm for patients who present with a new-onset manic-like psychosis postpartum is clear: initial treatment to stabilize, and then treatment with mood stabilizers for at least 12 months to follow is indicated. However, it may also be reasonable to taper treatment at 12-18 months, particularly for patients who have discussed this option with their clinician and who have been totally well for a year. (Women with previously documented bipolar disorder who have episodes of postpartum psychosis should obviously be treated with longer-term treatment aimed at maintenance of euthymia, as discontinuation of mood stabilizer is well known to be associated with risk for relapse.)

It should be noted that the longitudinal course and the treatment implications for women with postpartum psychosis are not etched in stone absent a clear evidence base driving care guidelines. Treatment must still be individualized. Women with underlying mood diatheses will typically declare themselves over time, and others may do well if they discontinue treatment, particularly if they are followed closely and instructed to present to a clinician at the earliest symptoms of mood dysregulation. The good news is we’ve seen an evolution of both interest and expertise in acute management of postpartum psychosis and a richer appreciation of the potential heterogeneity of this sample of women. There may be some variability in terms of long-term course requiring personalized treatment and obviously close follow-up of these women.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That’s exceedingly welcome given the morbidity and potential mortality associated with postpartum psychiatric disorders across the country.

From small community hospitals to major academic centers, screening for postpartum depression is part of the clinical fabric of routine obstetrical care. There is a growing appreciation for the complexity of perinatal psychiatric illness, particularly with respect to the commingling of both mood and anxiety disorders during the postpartum period. However, willingness to treat and appreciation of the urgency to treat with both pharmacologic and nonpharmacologic interventions can vary. For women who suffer from postpartum depression and their families, there are real-world implications of both treating and failing to treat this illness, and there is an urgent need to really help these women “climb out of the darkness” that is and defines postpartum depression.

Less common but of great clinical importance is postpartum psychosis, which occurs in approximately 1 in 1,000-2,000 women based on estimates from several studies. As noted in previous columns, the presentation is a dramatic one, with the typical onset of psychotic symptoms in the first days to weeks post partum. The disorder typically has a mood component and is not an exacerbation of underlying chronic psychotic illness. While there have been few systematic treatment studies, the clinical consensus is treatment usually includes hospitalization to ensure the safety of both the patient and infant. Use of medications, including mood stabilizers, antipsychotics, and benzodiazepines may be appropriate when expeditious treatment is needed.

Appropriate treatment by informed clinical staff is essential, as untreated or incompletely treated postpartum psychosis with its attendant morbidity and potential mortality is a very real concern. As I speak with women across the country with histories of postpartum psychosis, I’m often told of the difficult exchanges that women and their partners have at EDs in various clinical settings where diagnosis was delayed, or treatment was incomplete because of staff without expertise in postpartum psychosis management.

Another dilemma that patients and clinicians face after acute treatment is treatment duration, which is derived from how we conceptualize the illness. Even for experts in the area, there is not a consensus on whether postpartum psychosis should be considered as bipolar disorder or whether it is a circumscribed diagnostic entity. This issue has been hotly debated for many years and is one of the reasons why the illness is not included in the DSM classification system.

At Massachusetts General Hospital, we are systematically studying a large cohort of women with histories of postpartum psychosis as part of the MGH Postpartum Psychosis Project to better understand the phenomenology of postpartum psychosis, and also to understand the possible genomic underpinning of the illness. Most recently, we are conducting a neuroimaging study of women with histories of postpartum psychosis, compared with women in a healthy control group. We hope the results of this novel investigation will help to answer whether there is a neural signature identifiable with neuroimaging techniques such as functional MRI, if those findings are similar to other findings of neural circuitry we see in other forms of psychotic illness, or if the illness has a more distinct neural signature.

A question patients and colleagues often ask is what is the long-term nature of postpartum psychosis. If one considers it clearly to be bipolar disorder, the most intuitive approach would be long-term treatment with mood stabilizers. We now have a growing amount of data on the longitudinal course of postpartum psychosis. In one meta-analysis, 64% of women who had an episode of postpartum psychosis developed episodes of recurrent psychiatric disorder mostly consistent with bipolar illness. However, 36% of women appear to have more circumscribed illness without recurrence. In those women with recurrent disease, the presumption was those patients who had bipolar disorder and their presentation postpartum was simply their index episode of bipolar illness. However, there were other women who looked as if they had developed subsequent illness over the 11-26 years of follow-up, and those women did not receive long-term treatment.

A more recent prospective study of 106 women with postpartum psychosis who had their medication tapered and discontinued showed that 32% of women went on to have recurrent disease with a median time to illness of 20.3 months, and those patients presented primarily with illness that looked like bipolar disorder.

These accumulating data support the impression we’ve had for years that there’s a very strong relationship between bipolar disorder and postpartum psychiatric illness. Regardless of what side of the debate you fall on, the acute treatment is really the same. The real question for the clinician is what to do over the long term. Frequently, patients feel very strongly about a taper and discontinuation of medicine, and even the data show between 30% and 45% of women seem to have relatively circumscribed disease. There may be an issue in terms of prophylaxis if a patient gets pregnant and delivers another child, but that’s a separate issue. The issue is really whether there is a way to “thread the clinical needle” and meet patients where they are who do not want to continue long-term treatment.

I think we are at a point where we could argue the clinical treatment algorithm for patients who present with a new-onset manic-like psychosis postpartum is clear: initial treatment to stabilize, and then treatment with mood stabilizers for at least 12 months to follow is indicated. However, it may also be reasonable to taper treatment at 12-18 months, particularly for patients who have discussed this option with their clinician and who have been totally well for a year. (Women with previously documented bipolar disorder who have episodes of postpartum psychosis should obviously be treated with longer-term treatment aimed at maintenance of euthymia, as discontinuation of mood stabilizer is well known to be associated with risk for relapse.)

It should be noted that the longitudinal course and the treatment implications for women with postpartum psychosis are not etched in stone absent a clear evidence base driving care guidelines. Treatment must still be individualized. Women with underlying mood diatheses will typically declare themselves over time, and others may do well if they discontinue treatment, particularly if they are followed closely and instructed to present to a clinician at the earliest symptoms of mood dysregulation. The good news is we’ve seen an evolution of both interest and expertise in acute management of postpartum psychosis and a richer appreciation of the potential heterogeneity of this sample of women. There may be some variability in terms of long-term course requiring personalized treatment and obviously close follow-up of these women.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].