Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.

Sharon T. Phelan, MD


	More than a half million women in the United States are estimated to be dealing with spinal cord traumatic injury or disease. Individuals who survive the first year after such an event have an overall life expectancy that is almost normal (90%). Clearly, those women need ongoing reproductive health care that is comprehensive, consistent with the recommendations of the American College of Obstetricians and Gynecologists, and affirms their dignity. Having said that, there are a number of potential barriers and issues that can impair optimal care for this patient population.

The following is a Top 8 list of ways to optimize an outpatient visit for reproductive health care for women with spinal cord injury or disease. The recommendations are based on observations of a patient, Cody Unser, and suggestions from 

 Editorial Board Member Sharon T. Phelan, MD. Ms. Unser has been a paraplegic at a T4 level since age 12, when she experienced transverse myelitis.  She has been a strong advocate regarding women’s health care issues for wheelchair-dependent women. In this article, Ms. Unser discusses many of the challenges she has had when interfacing with medical offices, especially ob/gyn offices. Dr. Phelan offers her suggestions for how best to accommodate such patients and address some common issues that may arise during their exams. 

1. Making an appointment with the ob/gyn provider

 As a young woman living with paralysis, navigating the concrete world has its challenges. I have learned the hard way that no matter where I go, preparation is key in order for me to fully engage with life’s many activities. One of the biggest lessons I’ve learned is to never assume that just because you are going to a medical or health care office, the clinic is wheel-chair accessible. 

 As more patients require accommodations at their visits, it is increasingly important for the office staff to be more proactive by asking patients whether they need any accommodations at their appointments. This could mean a sign language interpreter, availability of a particular exam room or wheelchair access.  For returning patients, it’s important to have a system that clearly notes that unique services are needed. 

This is particularly important if the accommodation requires special scheduling of a particular exam room (e.g. one with electric height adjusting table, wheelchair accessible) or support personnel. If the handicapped parking area is not clearly evident, instructions as to where to park should be offered to patients. Otherwise, they may have to be rescheduled, which can be an inconvenience for all.  

2. Mobility and access through the office

: How a patient is treated from the very start of such a personal appointment impacts her impressions of the rest of the visit. I am proud of my independence and want do the things I can do by myself, but I will ask for help when I can’t do something. Being able to drive myself to my ob/gyn appointment and get around the clinic in my wheelchair is one of those things that empowers me to do more to take care of myself.

In my experience, reception desks are typically too high. A sense of being welcomed and treated with respect and dignity begins at the reception desk, where patients share information about their personal lives, insurance, and contact information. For women living with paralysis, shouting answers to the receptionist’s questions can be intrusive and may often leave them feeling like they don’t matter.

I particularly need bars next to the toilet because I can spasm on it when I transfer. Being able to grab onto the bars helps keep me from falling on the floor.  Also, exam rooms are usually too small to negotiate a wheelchair.

: Access throughout the building in which your practice is located may present barriers to a wheelchair-dependent patient. Is it compliant with the Americans With Disabilities Act (ADA)? Does the entrance door have an automatic opener? Is a ramp or elevator available as an alternative to any stairs? If your office entrance is off a hallway, does the door to the hallway have an automatic opener? If not, installing a doorbell and posting a simple sign to ring for assistance can be helpful, both to patients with disabilities and those who are elderly. is helpful 

Ideally, the check-in location should be either at a desk or window low enough to allow eye-to-eye contact between a patient and the receptionist. If that’s not possible, the receptionist should come out to a patient to check her in. Maintaining patient privacy per the Health Insurance Portability and Privacy ACT (HIPAA) is critical but preserving a patient’s dignity and demonstrating sensitivity to her needs is also important.   

Although ADA compliance may not be a problem in newer physical facilities, it is something that needs to be checked. Can a person in a wheelchair access your hallways, doorways and bathrooms are there “assist” bars in the bathrooms? Are the openings wide enough for larger wheelchairs used by obese individuals? If your answer about accessibility is no, you may need to see if there is a way to make at least one exam room, consult room, and bathroom wheelchair-accessible from the reception area.  Tax incentives are available to businesses that incur expenses to increase accessibility for individuals with disabilities. The “Tax Deduction to Remove Architectural and Transportation Barriers to People with Disabilities and Elderly Individuals” (Title 26, Internal Revenue Code, Section 190) allows a deduction for “qualified architectural barrier removal expenses not to exceed $15,000 for any taxable year.

: When I discussing my medical history with the nurse and ob/gyn, I explain why I am paralyzed. I have learned to express my goals for an appointment and volunteer any question or concern I have about my sexual and reproductive health. However, many women are not as confident as I am, and may not advocate for their own health. I would prefer a candid discussion with my provider regarding my needs. Communication is key between patient and doctor. As a woman living with paralysis, I encourage all women who value wheels more so than shoes to express concerns about their bodies openly and freely with their ob/gyns. 

: Many people have a tendency to see individuals with disabilities as ”broken.” A provider who has that bias may assume that a patient in a wheelchair is not sexually active or at risk of having a sexually transmitted infection (STIs) or becoming pregnant, or that she wouldn’t have sexual complaints. Ob/gyns should be proactive about discussing reproductive health issues with all patients of reproductive age. 

women need to be given the same opportunity to share their issues and concerns regarding sexual activity as other patients their age. This includes all routine screening recommended for women in their age range, such as for STIs. Don’t forget to screen for victimization and abuse. It is just as prevalent in women with disabilities as in the non-disabled population.

: Women living with paralysis and other disabling conditions can have loving sexual lives and successful pregnancies. When it comes to family planning, having a comprehensive healthcare team is vital because we are often seen as at high risk. The mechanics of my body are somewhat different in the bedroom and there are times when my bladder and bowels release involuntarily. I take medication that helps with bladder incontinence but it has side effects of dry mouth and decreased vaginal lubrication. I need to be able to discuss those and similar issues openly with my provider. Just like every other woman, I want intimacy and to be loved. I have yet to experience being pregnant and and I don’t know how my paralysis will impact my experience in creating a family, but I want to be able to discuss that with my provider when the time comes. 

: Misconceptions about sexual interest and activity in women with physical disabilities are commonplace among both the public and health care professionals. Women with disabilities have a similar level of sexual desire as their non-disabled peers. Therefore, they have the same concerns and questions regarding childbearing and contraception. Depending on their desires and limitations, these women need the same discussions as other patients their age. In fact, it may be more important because the medications they are using or the activities they engage in may place them at greater risk of side effects or complications. 

Depending on the degree and source of a patient’s disability, a provider may face unique challenges and issues in identifying the best contraceptive options for her. Women with limited mobility may be at increased risk of deep venous thrombosis or osteoporosis. Preconceptive counseling can be critical to the safety of mother and infant. Pregnancy in a woman who is wheelchair-dependent has unique risks and challenges that may best be addressed by a maternal-fetal medicine specialist. 

: Before my annual exam, I always outline what works best for me in order for the exam to go smoothly. The exam table is probably the biggest structural barrier in an ob/gyn clinic for women living with some form of paralysis. Ironically, it is where the most vulnerable and personal part of the annual exam takes place and yet it is the one thing that strips women with paralysis of their dignity and their independence. If the exam table is too high for me to transfer onto by myself, I either have to bring someone with me or ask one of the medical staff members to pick me up and place me onto the table. 

Because I am paralyzed and my legs will spasm, I don’t need the stirrups. I hold my legs up myself, with a nurse or someone standing by my side in case I start to roll off the table.

: A woman with a disability should be interviewed before they get unrobed for an exam. Ask specifically if there are any particular issues she has during pelvic exams and listen to her recommendations as how best to overcome those challenges. By listening and not assuming that you know what is best, the examination will proceed much more smoothly. Many women are well informed about their disability and the best way to approach transfer and exams. Scheduling patients with disabilities for an exam room that has an electric exam/procedure table can be a real help. By positioning the table very low (the patient can guide you on the level) many patients can make the transfer themselves or with minimal assistance. If that is not possible, let the patient give you guidance on the best way to accomplish the transfer safely. 

If a pelvic exam isn’t necessary-which may be the case in an asymptomatic patient who doesn’t require a Pap smear-consider doing a physical exam with her in her chair. The one consideration may be to examine for decubitus ulcers in the pelvic region if the patient doesn’t have another provider who is doing so. 

In this exchange, Dr. Phelan first offers a concise explanation of AD, then Ms. Unser discusses how it impacts her. 

: Ob/gyns should be aware that autonomic dysreflexia can occur in patients whose spinal insult is at the T6 level or above. It is due to loss of hypothalamic control over sympathetic spinal reflexes. Autonomic dysreflexia is an uninhibited or exaggerated sympathetic response to a noxious stimuli below the level of the injury, which leads to diffuse vasoconstriction and hypertension. A reflex parasympathetic response produces bradycardia and vasodilation above the level of the lesion. Many things can trigger a dysreflexia event in these patients, including pressure on the pelvic structure, uterine contractions, sexual activity, and infection. Even a transvaginal ultrasound (U/S), pelvic exam or labor can trigger an event. Physical signs include sweating, nausea, nasal congestion, hypertension or hypotension, bradycardia or tachycardia and blurred vision. The severity of the attacks can range from asymptomatic hypertension to hypertensive crisis complicated by bradycardia resulting in cardiac arrest or seizures.

: Autonomic dysreflexia is my body’s way of signaling to me that something is happening and may be wrong below the level of my T4 paralysis. Knowing my triggers and symptoms helps me to understand how to best manage autonomic dysreflexia. The key is knowing my baseline blood pressure. So during my annual exam, I request that my blood pressure be taken before and after the speculum has been inserted. If there is a significant difference in the readings, then I consider my next steps so it doesn’t get worse and require further medical response. During the pelvic exam, I get flushed in the face, start to sweat, and get goose bumps on my arms. Most medical professionals are unfamiliar with autonomic dysreflexia. Any temporary activity that involves the lower half of my body, like the pelvic exam or sexual intercourse, can trigger autonomic dysreflexia symptoms, but for me, they typically subside after about 1 hour. 

: Although I don’t have any motor function in my legs nor do I have “normal” sensation, they do respond involuntarily by spasming every time I move my body or transfer to another surface. Some people with paralysis take medication to subdue their spasms, but other people like me use them and the tightness in the legs to help with transfers by stabilizing them. 

: Inadequate support of legs or marked flexion may elicit a muscle spasm. A quick passive movement of a limb can be a trigger. A spasm may be the result of disruption of descending inhibitory modulation of the alpha motor neurons, producing hyperexcitability that is manifested as increased muscle tone and spasms. Ask a patient what activities provoke her spasms and how best to prevent them or support her when they occur. You may need another person standing at the side of the exam table to prevent the patient from rolling off during spasms. 

: Bladder and bowel dysfunction is a common secondary condition that those of us living with paralysis deal with on a daily basis. I always tell the nurse and doctor that before I get onto the exam table, I will need to catheterize to completely empty my bladder. Despite this, I have had a bladder accident during the pelvic exam.

: Urinary and/or fecal incontinence during the exam is likely in patients who are confined to a wheelchair. Do not be startled if this happens. If a patient can empty her bowels and bladder prior to the exam, that may minimize an event. It is useful to have appropriate drapes placed.

Optimizing the ob/gyn office experience for a woman with spinal cord injury/lesion is a team effort. Each aspect of the patient’s encounter with the health care provider can either welcome and empower her or make her feel unimportant and worthless. The suggestions offered here are designed to help your clinic staff provide reproductive health services to this special population of women who are commonly underserved or even ignored. 

References
	1. Committee on Health Care for the Underserved Woman.  Special Issues in Women’s Health.   December 2017. American College of Obstetricians and Gynecologists. Washington DC

2. Abrams GM and Wakasa M. Chronic Complications of Spinal Cord injury and disease.  Up-To Date. Last revised August 19, 2019.  Accessed on Oct 24, 2019 at 

https://www.uptodate.com/contents/chronic-complications-of-spinal-cord-injury-and-disease?search=autonomic%20dysreflexia&source=search_result&selectedTitle=1~31&usage_type=default&display_rank=1

Articles

These recommendations, based on the observations of a patient, is a Top 8 list of ways to optimize an outpatient visit for reproductive health care for women with spinal cord injury or disease.

Eight tips to improve outpatient visits for spinal cord injury patients

"  target="_blank">In 2018, maternal mortality is a major topic of discussion in obstetrical, public health and political circles. 

has dedicated a great deal of editorial space this year to articles and commentary on causes and consequences of these deaths. There clearly are many issues to explore about death of US mothers during pregnancy and the puerperium, including who is dying and why, and what can be done about it. 

Disparities in care received by certain patients and populations have been the focus of strong pushes for solutions from multiple sources. With health disparities, the focus typically is on race/ethnicity and socioeconomic factors as they relate to access to and quality of care. But an often forgotten disparity is geographic location. Earlier this year, an article in 

discussed the challenges of improving rural health care,

addressed general aspects of care, especially for rural hospitals and the current reimbursement system. 

The American College of Obstetricians and Gynecologists (ACOG) describes rural America as representing 75% of the national landmass and being home to 22.8% of US women aged 18 and older, with substantial variance in ethnic and racial composition.

ACOG Committee Opinion #586 outlines health disparities for rural women. Significantly, it notes that data describing both health and outcomes for these patients are limited overall, although risks related to level of rurality are evident. Clearly the challenges for a state such as Pennsylvania (reported to have the third largest rural population in the United States) will be different than those for states such as Montana or Alaska, which have smaller absolute numbers of rural residents spread over a much larger geographic area. But some statistics stand out. 

Overall, rural women are less likely to receive any preventative health care and screenings. Fewer than half of rural women live within a 30-minute drive to a hospital with perinatal services, and over 10% have a drive of 100 miles or more. Some states, such as Wyoming, have no tertiary care centers for pregnant women at all.

And because overall health outcomes generally are worse in rural communities due to increased incidences of obesity, cancer, cardiovascular disease, opioid use, and violent deaths, it would seem reasonable to assume that these outcomes would be echoed in the maternal death rates seen in rural communities.

Nationally, rural health care availability is under attack with closure of hospitals and lack of medical personnel in communities, as described by Dr. Lockwood in this month’s 

. ACOG reports that in 2010, 49% of the nation’s counties lacked an obstetrician-gynecologist, leaving over 10 million women-or 8% of those in our country-without that service. The challenge is even greater when one looks at hospital-based obstetrical services (or lack of) and birth outcomes in rural communities.

Clearly, the impact of closing a maternity ward in a rural hospital where the next nearest obstetrical unit is 100 miles away would be very different than in an urban community with another center of care less than 10 miles away. 

It is possible that pregnancy-associated deaths, rather than pregnancy-related deaths, may provide a unique window into the socioeconomic and cultural challenges faced by rural communities. Teasing out the possible differences, however, is not possible with our current system of state-collected data. State and national statistics, therefore, are inevitably dominated by the cause of maternal deaths in population centers simply due to sample size. To begin to address this problem, policy makers need to look at aggregate rural-based data to see if the causes of mortality and morbidity there are similar to those in urban settings and determine if interventions for urban patients can be applied to those in rural settings. 

For example, maternal deaths from motor vehicle accidents may be more common in remote rural settings due to the long distances at high speeds that rural women travel on a regular basis to obtain care. In that setting, seat belt education may be more important than it would be in a metropolitan area. Postpartum hemorrhage (PPH) deaths may be more preventable if tranexamic acid and cryoprecipitate were available as well as six to eight units of total blood products in the hospital blood bank, together with streamlined procedures for obtaining those products in emergency situations. Or interventions in a rural setting may focus on early recognition of risk of PPH or active blood loss, basic stabilization techniques and prompt transport rather than a detailed mass transfusion protocol. 

In addressing any health care disparity, accurate data are critical to identifying specific problems and tailoring interventions to address actual issues rather than issues “perceived” by “outsiders.” Because the absolute numbers of maternal deaths are small in rural states given their overall lower populations and birth rates, it is impossible for a single state to have numbers sufficient to accurately interpret data without aggregation of five or more years of information. With current published state reports, it is also impossible to aggregate data across states because they use different definitions and presentations for their aggregate state data. Until recently, that has stood in the way of accurate data collection and management across the nation.   

Working toward solutions: ACOG maternal mortality task force

In 2017, to help address these challenges and better identify sources of health care disparities in rural settings, ACOG District VIII launched a Maternal Mortality Task Force. District VIII is uniquely situated to collect data on rural maternity care and deaths. District VIII is made up of 12 states as well as Guam, American Samoa, Alberta, British Columbia, and Central America. Those states alone make up over 50% of the land mass of the United States but only about 15% of the US population resides in those areas. Much of the population in the 12 states is concentrated in one or two urban settings (e.g., Alaska with Anchorage and Juno). Using data standards developed by the Centers for Disease Control (CDC) and the Association of Maternal and Child Health Programs (AMCHP) and employed by the national Maternal Mortality Review Information Application (or MMRIA) database, it is possible to capture information about the distance from the woman’s home to where she delivered as well as the level of maternity care available where the delivery occurred. The data collected also include details of a patient’s circumstances, building an extensive narrative that covers all aspects of her experience of pregnancy and then presenting those facts in standardized format for examination and analysis.  

The ACOG District VIII Task Force hopes to be able to aggregate the data over the 12 states using the structure of the MMRIA database. Without specifying state or county, data will be combined across the region, using references of distance from hospitals and levels of care as the standard. That, in turn, will produce samples sizes large enough to allow examination of rural vs urban causes of death on an annual or biannual basis. This larger data pool would also allow for quicker identification of unique evolving issues (Hantavirus, suicides or motor vehicle accidents) and evaluation of intervention strategies. Because the 12 states have some of the largest populations of indigenous people, a detailed data collection of this type may also be of great assistance in documenting data for increased maternal morbidity and mortality associated with this particular group and guiding interventions. 

To accomplish this ambitious goal, the sections in District VIII are working with their respective departments of health to enact legislation as needed to support MMRCs and to encourage and empower individual departments of health to provide their data through MMRIA to the CDC. As more states enter data into the CDC database, the task force will look at the reports, identify issues to address, identify already established interventions a state may have that can be exported to other states in the region and continue to educate our district providers as to steps they can take to decrease our unacceptable national maternal mortality statistics and disparities. 

Iglehart JK.  The Challenging Quest to Improve Rural Health Care – Health Policy report. N Engl J Med. 2018;378:473-479.

Murphy KM, Hughes LS, Conway P. A path to sustain rural hospitals. JAMA. 2018;319(12):1193-1194.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 586:  Health disparities in rural women.  2014 Feb;(2 Pt 1):384-388.

Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S.  Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the US. JAMA. 2018;319(12):1239-1247.

Shah NT. Eroding access and quality of childbirth care in rural US counties. JAMA. 2018;319(12):1203-1204.

Wetzel LM. Maternal mortality statistics; data collection methods improving but still a challenge. Contemp OB/GYN. 2018:63(1):24-27.

Women who give birth in rural areas face unique challenges because of geography but state-based data collection hampers efforts to understand and address the factors that place them at particular risk for morbidity and mortality.

Maternal death  in rural America

COMMITTEE ON PRACTICE BULLETINS-Gynecology

Practice Bulletin #164: Diagnosis and Management of Benign Breast Disorders. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e141-56. Full text of Practice Bulletin #164 is available to ACOG members at 

https://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Diagnosis-and-Management-of-Benign-Breast-Disorders

Diagnosis and management of benign breast disorders

 Breast-related symptoms are among the most common reasons women present to obstetrician–gynecologists. Obstetrician–gynecologists are in a favorable position to diagnose benign breast disease in their patients. The purpose of a thorough understanding of benign breast disease is threefold: 1) to alleviate, when possible, symptoms attributable to benign breast disease, 2) to distinguish benign from malignant breast disease, and 3) to identify patients with an increased risk of breast cancer so that increased surveillance or preventive therapy can be initiated. Obstetrician–gynecologists may perform diagnostic procedures when indicated or may make referrals to physicians who specialize in the diagnosis and treatment of breast disease. The purpose of this Practice Bulletin is to outline common benign breast disease symptoms in women who are not pregnant or lactating and discuss appropriate evaluation and management. The obstetrician–gynecologist’s role in the screening and management of breast cancer is beyond the scope of this document and is addressed in other publications of the American College of Obstetricians and Gynecologists (1–3).

Used with permission. Copyright the American College of Obstetricians and Gynecologists.

ACOG Practice Bulletin #164 on benign breast disorders is a comprehensive summary of various benign and pre-malignant breast pathologies that may cause signs or symptoms prompting a woman to seek guidance from her ob/gyn.

 Evaluation and management of breast complaints is complex. The most obvious clinical challenge is that breast complaints may represent problems that are endocrinologic, dermatologic, musculoskeletal, pharmaceutical or neurologic in origin and not just simply breast-related. Given the broad differential diagnoses that must be considered, it is important to approach any breast complaint in a logical and systematic manner.    

The first step is to always get a comprehensive history that includes the 7 dimensions of the current complaint (issues around onset, frequency, quality and quantity of pain/discharge/mass, associated symptoms, prior history of similar complaint and so on). It is also important to get a history of medications (source of galactorrhea), physical activity (trauma or stimulation due to poorly fitted bra), family history (evaluate for genetic risks of breast pathology and possible cancer), reproductive history (contraceptive use, pregnancies, and breastfeeding) and detailed review of systems looking for evidence of endocrine, trauma or other sources of the concern. The physical exam needs to determine if the breast complaint is the primary manifestation of a breast problem (e.g., fibroadenoma) or a secondary manifestation of a more systemic process, such as a pituitary adenoma or autoimmune disease with marked eczema. Findings need to be carefully described and documented for follow-up assessments of growth, change or resolution. Typically, if a finding is bilateral, it is more likely to be physiologically normal or manifestation of a more systemic issue (e.g. prolactinoma or fibrocystic changes). The bulletin helps with this process by presenting clear logical algorithms to guide a provider in a systematic cost-effective process to make a diagnosis.

A palpable breast mass is the most common finding of symptomatic breast cancer. Evaluation of a breast mass begins with a detailed history, assessment of breast cancer risk, and physical examination and requires age-appropriate breast imaging. Breast masses are common and typically benign. Certain qualities of a mass (e.g. mobile, unattached to surrounding tissue, discrete, smooth surface) are reassuring to the provider that a mass in a young woman is benign. Based on the history and physical exam, the provider can often make the right diagnosis of benign or malignant but not necessarily to the degree that is reassuring for the provider and/or the patient.

 Cyst aspiration and cytology of the fluid is used in a more limited fashion and primarily only for larger, bothersome simple cysts. If aspiration is done, the fluid is non-bloody and the mass is gone, simple close follow-up is acceptable. If the mass does not totally resolve, recurs or the fluid is bloody with aspiration, a tissue biopsy is indicated. In the setting of a mass seen as solid on ultrasound, further imaging and likely biopsy may be merited. When imaging is ordered in the setting of a breast complaint, it should be diagnostic and not screening. Depending on the imaging unit, they may immediately proceed without additional orders to secondary imaging and even biopsy as indicated by the classification of the initial images. Providers should be aware of the reporting and diagnostic steps of the imaging group and ensure that subsequent reports are tracked and follow-up is performed. A system similar to that for Pap smear tracking may be used. Once the diagnosis is determined the treatment recommendations are nicely outlined in the bulletin.  

Nipple discharge can be alarming to a woman. The algorithm in the practice bulletin helps to divide this presentation into 4 groups that guide diagnostic steps. These are based on the nipple discharge being associated with: 1) a breast mass (evaluate per mass algorithm); 2) spontaneous unilateral discharge (needs imaging and biopsy); 3) bilateral milky discharge (likely endocrine); or 4) non-spontaneous, multi-ductal discharge (probably trauma or self-expression). The role of color, consistency, and presence of blood in the discharge, uniductal vs. multiductal will help direct evaluation and management.   

Breast pain and skin lesions are commonly manifestations of systemic dermatologic issues (e.g. eczema, monilia, hidradenitis suppurativa), trauma, inflammation and endocrine pathologies. The history and physical exam should specifically explore for these possibilities. Because these lesions may represent an underlying malignancy, recurrent skin lesions, persistent edema, peau d’orange appearance, ulcerations or erythema warrant imaging and tissue confirmation of the diagnosis. 

The correct diagnosis for any breast complaint is clearly important for determining correct management, be it simply reassurance or excisional surgery. Another very important aspect of diagnosing a breast pathology is evaluating the patient for her level of risk for breast cancer. As the practice bulletin stresses, there are “benign” pathologies that are associated with moderate to marked risk of eventually developing breast cancer. When an atypical hyperplastic lesion or multiple papillomas are identified on a biopsy prompted by the presence of a breast mass or a mammographic finding, more aggressive treatment and a proactive cancer screening approach are indicated. A unilateral spontaneous nipple discharge also merits a tissue biopsy due to a significant risk of malignancy in the sample. Recent developments with imaging modalities and the current social media hype about celebrities encouraging mastectomies are confusing to patients and provider. Consultation with a breast specialist may be indicated for patients in the higher-risk groups to review the most current ongoing screening, diagnostic and/or treatment options with them. 

Finally-and just as important-make this visit an opportunity to screen for risk factors for breast cancer such as obesity, family history of breast cancer (especially if BRCA 1 or 2), tallness, menopausal exogenous hormones, nulliparity, increased age at first pregnancy, and exposure to therapeutic ionizing radiation. There are protective factors that may reduce risk, such as breastfeeding. Although most of the risk factors are not modifiable there are behavioral changes a woman can make to minimize certain risks, such as weight loss, exercise, not smoking, minimizing alcohol intake, and possibly adopting a diet that is lower in fat and stresses vegetables and fruit.

 Based on her risk factors, a woman may benefit from additional screening, such as BRCA or earlier imaging. The psychology of cancer screening is challenging. Depending on a woman’s culture, fear of cancer, and anxiety level, she may or may not participate in a regular screening program as typically recommended. With the resolution of her breast complaint may come a window of opportunity to educate a woman on the role of breast cancer screening for her as an individual.

1.   Hereditary   breast   and   ovarian   cancer   syndrome. ACOG Practice Bulletin No. 103. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:957–66. (Level III)

2.   Breast cancer screening. Practice Bulletin No. 122. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:372–82. (Level III)

3.   Management of gynecologic issues in women with breast cancer. ACOG Practice Bulletin No. 126. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:666 – 82. (Level III)

1.    Committee on Practice Bulletins-Gynecology. Diagnosis and management of benign breast disorders. Practice Bulletin No. 164. American College of Obstetricians and Gynecologists. 

2.    Sabel MS. Clinical Manifestations and diagnosis of a palpable breast mass. 

3.    Port DR. Your breasts are not a ticking time bomb. Glamour. November 2010. Accessed on Oct 7, 2017 at 

https://www.glamour.com/story/your-breasts-are-not-a-ticking-time-bomb

4.    Consedine ND, Magai C, Krivoshekova YS et al.  Fear, anxiety, worry and breast cancer screening behavior: a critical review.  

Expert commentary on Practice Bulletin #164: Diagnosis and Management of Benign Breast Disorders.

ACOG Guidelines at a Glance: Diagnosis and management of benign breast disorders

Although pregnant women say they would trust information from their doctor about food safety in pregnancy, surveys of patients and clinicians alike find that the topic is often not discussed.

  Consider that your pregnant patients are typically exposed to contradictory information and much freely offered advice regarding food safety. The expectant mother may be warned to not eat specific foods or to avoid entire food categories. Yet if she tries to follow all the advice, she may have very few food options left. What is she to do?  Our goal in this two-part series is to address some key concerns about eating during pregnancy. Part 1 helps you guide patients on how to eat safely to avoid food-borne infection. (Part 2, which focuses on toxins, will be published in the December issue of 

By CDC estimates, 5,000 Americans die from the 76 million cases of food-borne illness in the United States each year.

  Compare this to 5,915 Americans who die on the job annually and 42,000 who die in motor vehicle accidents.

  Most susceptible are the very young, the very old, the immunocompromised, and those exposed to large doses of a food-borne pathogen.

  Although historically, animal products and contaminated water have been the major sources of food-borne contaminants in the United States, the importance of fresh produce as a source of food-borne illness is on the rise.

A few food-borne pathogens merit extra attention because they affect pregnant women far more than the general population. Although it's killed by pasteurization and cooking, 

 (LM)-because it can be airborne-can contaminate treated foods.

  Unlike most bacteria, it's also able to grow inside a refrigerator.

  Among foods most often contaminated are unpasteurized milk products and refrigerated and ready-to-eat products (dairy, meats, poultry, seafood), including deli products. Overall prevalence in high-risk food categories is 1.82% (range, 0.17–4.7%), with a higher prevalence in in-store packaged products compared to manufacturer-packaged lunch meats, deli salads, and seafood salads.

 The risk of infection is small, even if one eats a contaminated food,

  and typically causes only low-grade gastroenteritis or mild, flu-like symptoms (fever, headache, myalgia).

  Symptoms of a more serious listeriosis infection are nausea, vomiting, abdominal pain, diarrhea with fever, and possibly meningitis, septicemia, and encephalitis. "However, the relationship between the number of 

[organisms] consumed (the dose) and the likelihood of illness occurring (response) in combination with the severity of the illness resulting from that dose is not well understood," according to the Cneter for Food Safety and Applied Nutrition (CFSAN).

Fortunately, LM is not a common pathogen. FoodNet data for 2007 found an LM infection incidence of 0.27 cases per 100,000 population (versus 14.92 per 100,000 

  The case rate for those aged 5 to 49 years is 0.07/100,000, and newest prevalence estimates are 2,000 cases, with 420 deaths per year.

Pregnant women appear to be more likely to develop listeriosis, and one-third of all cases occur during pregnancy.

  A pregnant patient's presenting symptoms may be similar to influenza or pyelonephritis, and even if symptoms are few or very mild, LM may cross the placenta and infect the fetus.

Deli salads are another area likely to cause confusion. On one hand, the US Department of Agriculture (USDA) includes them as worthy of caution.

  On the other hand, the FDA's most recent publications don't even list them.

 According to the 2003 FDA study of risk, the most common source of infections (with >5 cases per billion servings) was 1,600 cases per year associated with deli meats.

Heating sandwich meats to steaming is recommended. Canned salmon, chicken, and tuna will not cause LM contamination.   

Sharon T. Phelan, MD

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