When should my adolescent daughter come in for her first pap smear?

Actually, your daughter doesn't need a pap smear until she is 21 years old according to the American College of Obstetricians and Gynecologists (ACOG). However, ACOG does recommend a reproductive health care visit between the ages of 13-15. At this visit, mom and daughter will fill out a questionnaire that is very specific to the issues of adolescent girls. We will take a thorough social, sexual, and reproductive history. We will also discuss birth control methods and sexually transmitted infection prevention. This visit typically does not include a pelvic exam or pap smear. Screening for the most common sexually transmitted infections can be done from a urine specimen. At some point during the visit, we will want to talk to your daughter without a parent or guardian in the room. Information obtained during this part of the visit will be confidential.

Treating Depression: What do we recommend?

Dr. Gore and I believe that the benefits of treating depression during pregnancy far outweigh any risks caused by antidepressants. Depression can be accompanied by great risks to both the baby and the mother. These risks have been well documented in many scientific studies. The major risk of SSRIs (selective serotonin reuptake inhibitors) is neonatal adaptation syndrome a complication that is easily handled in a hospital setting. Other risks of SSRIs are not well documented across the scientific literature at this time.

Cognitive behavior therapy and EMDR are great adjuncts to treatment of depression and are done by a qualified therapist.

If you are suffering from depression during your pregnancy or after your baby is born, be sure to talk to us. We can carefully discuss which therapeutic modalities are acceptable to you and prescibe medicine or refer you to a therapist.

Treating Depression in Pregnancy: Are Antidepressants Safe?

The most successful modalities for treatment of depression and anxiety in pregnancy are a combination of therapy (cognitive behavior therapy, EMDR-eye movement desensitization and reprocessing) and medication (most commonly the SSRIs-selective serotonin reuptake inhibitors like Prozac, Zoloft, Celexa, etc.).

As we discussed before, not treating poses some significant risks. Many patients respond to therapy only and this is certainly the safest modality. However, there are many women who do not respond to therapy alone.

Every few months, another study is published in the medical literature linking SSRIs used during pregnancy to birth defects. First, it's important to have an understanding of medical research. Many researchers agree that in order for a drug to be considered a teratogen (causing birth defects), this finding must be consistent across many studies. This has not been the case with SSRIs.

The one side effect that has been consistent is the risk of "neonatal adaptation syndrome" - a transient jitteriness that occurs for a few hours after birth. I certainly consider this a real risk that happens in 20-25% of pregnancies. However, the important word here is transient. All of the babies in these studies were eventually rooming in and went home from the hospital with their moms on day of discharge.

With the use of electronic medical records, we can now collect information from large administrative databases like Medicaid or health maintenance organizations about prescriptions written during pregnancy and a host of obstetrical and neonatal outcomes data.. Dr. Lee Cohen writes in the Sept 2011 issue of OB/GYN News "Conclusions about a teratogenic outcome or adverse perinatal outcome are only as reliable as the quality of the data from which the conclusions are derived, and, unfortunately, some of the data from these databases have been profoundly lacking".

Kaiser Permanente Northern California published a study using such data in the Archives of General Psychiatry in July 2011. They reported an association between an increased risk for autism spectrum disorders (ASDs) in children whose mothers used SSRIs during pregnancy. The study received considerable attention from the media and led to substantial concern from patients. Dr. Cohen pointed out many limitations of the study: (1) a very small number of SSRI exposures in the autism and control groups (2) it failed to take into account exposure to illness during pregnancy as a variable (3) The study failed to confirm actual ingestion of the drug by women who were prescribed an antidepressant (4) No measure of psychiatric disorder during pregnancy or the history and severity of psychiatric disorder in the past.

The use of medication to treat depression and anxiety during pregnancy needs to be made on a case-by-case basis. Pregnant women and their health care providers need to give careful thought to the treatment of depression and anxiety during pregnancy. It's important to take into consideration the risks of not treating and balance this decision with the longer-term prospective data regarding fetal exposure to SSRIs.

Maternal blood test for fetal Down Syndrome

Thirty years ago when I first started private practice I spent my days off performing genetic amniocenteses at the Rose Hospital Genetics Center.  In those days virtually every woman over the age of 35 who was pregnant elected to have an amnio to rule out genetic, chromosomal abnormalities.  Initially the miscarriage rate was 1/100-200 after the procedure.  In the early 1980s , I began using continuous, real-time, ultrasound monitoring of the needle insertion to make the procedure safer and more efficient.  This lowered the miscarriage rate to 1/200-400.  In those days we had a dream, perhaps fantasy, that perhaps in the future a test would be developed that could sample fetal DNA from a maternal blood and avoid the pain and risks of miscarriage from an amniocentesis.

TODAY I can report that this dream has become a clinical reality.  In high risk patients, we can draw a sample of maternal blood any time after 10 weeks gestation and in 10 days know if the fetus does or does not have Trisomy 21 (Down Syndrome).  This is the most common chromosomal abnormality affecting the babies of women over the age of 35.  The test can also detect two other abnormalities, Trisomy 13 and 18.

I consider this test a true revolution in prenatal, genetic diagnosis and it will drastically change how we screen first and second trimester pregnancies in Obstetrics.  New paradigms for screening have developed over the past 15 years based on ultrasound and blood screening of specific substances.  These paradigms will be re-written over the next 5 years as we gain more experience with this exciting new technology.

If you have any questions about this new test, please call our office for a consultation and we will be happy to  discuss them with you.  

RB Gore

Depression and Pregnancy: What are the risks of not treating?

Anyone watching television lately has probably seen the ads by attorneys soliciting you to call if you've been on an antidepressant during your pregnancy. Many patients who are planning a pregnancy and taking anitidepressants have asked about the safety of these medications during pregnancy. This is a complex subject and those of you who know me are aware that I am rarely short on words. Therefore I will be dividing this subject into three posts: 1. What are the risks of not treating? 2. How should we treat depression during pregnancy/ Are antidepressants safe? 3. What do Dr. Gore, myself, and others recommend?

First, depression during pregnancy can be very serious. It can be life threatening if it gets to the place where a person is considering suicide. We must always remember this when treating patients. I believe that depression should always be treated during pregnancy, the questions is how?...to be continued Blog #2

It is estimated that 10-15% of pregnant women wil experience significant levels of depression during pregnancy and postpartum and it is frequently accompanied by anxiety. What are the risks of not treating? According to Dr. Jeffrey Newport of Emory Univesity School of Medicine in an "Update" publication from the American College of Obstetricians and Gynecologists, "depression, even of a less or moderate severity, has some signiciant adverse outcomes associated with it. Doubling to tripling of rates of preterm delivery, low birth weight, preeclampsia, neonatal intensive care admissions." There are the long-term adverse consequences as well: "Children whose mothers have been depressed or anxious during pregnancy are more likely to have an array of childhood developmental problems ranging from cognitive delay to behaviorql problems, and childhood anxiety". Wow. That's a big impact.

Sign up for Tex4baby

If you are pregnant or a new mom, there is a new free service called text4baby that can help keep you and your baby healthy. Text4baby will send 3 text messages each week to your cell phone with expert health tipsto help you through your pregnancy and your baby's first year. It's free to sign up and the messatges are free.

To sign up, text BABY to 511411. To sign up for tex4baby in Spanish, text BEBE to 511411. You can also sign up and find more at www.text4baby.org.

Text4baby is an educational service of the Naional Healthy Mothers, Healthy Babies Coalition.

In The Beginning

Hello and Welcome to our new blog.  Mindy our nurse practitioner had a wonderful idea to start a blog so that we can post up to date information on topics important to you our patients and to us your health care providers.  We will try to keep this activity going on a weekly basis and also respond to questions that you have.  Please write to us with topics you want to hear more about and any questions that you may have on our posts.  Our first post will be on a new blood test that can obviate the need for invasive amniocentesis or chorionic villus sampling in high-risk pregnancies.  Stay Tuned.  RB Gore, MD