Care of the Transgender Patient

Today we sit down with Dr. Beth Cronin, clinical associate professor and assistant program director at Brown / Women and Infants of Rhode Island. Dr. Cronin has become a national expert in the care of LGBTQ patients, and is a fixture at ACOG and other venues, and we are lucky enough today to have her break down the need-to-know essentials for the OB/Gyn.

Definitions are an excellent place to start, and set the stage for this conversation:

  • Sex is what we do in the delivery room - defining “male” or “female” based on the presence of external genitalia.

  • Gender is a social construct, comprising attitudes, feelings, or behaviors associated to “male” or “female” by a culture.

  • Gender identity is a person’s internal sense of their gender:

    • Cisgender the biological sex and gender identity align

    • Transgender the biological sex and gender identity are opposite:

      • Transgender woman biological sex male, identity female

      • Transgender man biological sex female, identify male

    • Gender should be viewed along a spectrum, with varying definitions for terms such as gender fluid, gender queer, or nonbinary.

About 1.4 million adults and 150,000 youth aged 13-17 are estimated to identify as transgender or gender non-binary in the United States. This population has much higher risks of experiencing discrimination, violence, and sexual assault. Additionally, these patients are likely to have poor experiences in healthcare settings. These patients really need access to care, and OB/Gyns are in perfect position to be safe and welcoming environments for the transgender/gender non-binary community.

For your office and daily practice, it is important to be inclusive, and there are myriad resources to get this started. Staff training and education to promote inclusivity is also important. Inclusive forms and medical record systems that elicit gender identity are important to make available, including documentation of preferred pronouns.

Dr. Cronin also took time today to discuss some clinical care aspects. UCSF and WPATH each have excellent protocols and guidelines for clinical care, including for initiating or maintaining transition care. Modifications of usual care, and care in the midst of hormonal transition, is discussed in great detail at these resources. ACOG also has excellent online modules for OB/Gyns for transgender healthcare, in addition to more primary reading at CO 512, CO 685, and additional ACOG-approved resources for clinicians.

Dr. Cronin easily explains it as “screen the parts that are present” per usual care guidelines, including with respect to things such as breast and cervical cancer screening, contraceptive methods, and pregnancy and abortion care.

Preterm Labor and PPROM

Today we talk about the routine management of PPROM and PTL. We’ve prepared a little chart that we hope is handy for both teaching and learning! Be sure to also check out ACOB PB 171 and PB 188. For some primary literature, check out the BEAM trial on magnesium sulfate, the most recent Cochrane review on steroid administration, the ALPS trial for Antenatal Late Preterm Steroid administration, and the RCT demonstrating benefit to latency antibiotics in PPROM.

(c) CREOGS over Coffee, 2019

We also use the podcast to highlight a number of controversies, differing practice patterns, or areas of new and active research in these clinical topics (with help from our friends at the ObG Project!)

  • Delivery timing: A 2017 Cochrane review suggested better neonatal outcomes with expectant management of PPROM to 37 weeks, convincing enough to have the Royal College of Obstetrics and Gynecology to change their clinical practice guideline to allow expectant management to 37’0.

  • Administration of Corticosteroids: The ObG Project gives a great summary on when to administer betamethasone. In summary:

    • Between 24-34 weeks in all cases of PPROM and in PTL if delivery is expected within 7 days.

    • A single rescue course should be administered if it has been > 14 days since the last course, and delivery is again expected within the subsequent 7 days.

    • Between 34-36’6 weeks if PPROM or PTL occurs, no prior steroids have been administered, and delivery is expected within the subsequent 7 days.

  • Periviability: The management of periviable PPROM is managed very differently by institution, as resources and optimal management strategies remain to be identified. Protocols and policies should be arranged in accordance with the individual obstetrics and neonatology departments. Ideally, counseling for patients experiencing periviable PTL and PPROM should be performed in an interdisciplinary fashion.

  • Outpatient Management of PPROM: There have a few retrospective studies, the most recent of which came from a large series out of France and received some press attention, suggesting that outpatient management may be appropriate in select candidates. That said, this is definitely NOT the standard of care at this time; inpatient management of PPROM is still the standard set forth by ACOG in the absence of larger, prospective studies.

Intimate Partner Violence and Gun Violence

Today we are spending some time on IPV/DV and gun violence. These are topics every OB/GYN should be familiar with; IPV accounts for 250,000 hospital visits, 2,000 deaths, and $8 billion in direct care costs annually on a conservative estimate. 1 in 3 American women is victimized by IPV during their lifetimes, and 1 in 5 report being the victim of sexual assault.

ACOG CO 518 serves as essential reading for our conversation today. Important points from the reading and today’s episode include:

Finally, check out ACOG’s stance and legislative priority list surrounding gun violence. Be active and get involved today — this is our lane!

Management of an Early Unlocated Pregnancy

Today we’re bringing back Dr. Erin Cleary one more time before she transitions to her new role as an MFM fellow at the Ohio State University! Dr. Cleary today talks with us on early pregnancy of unknown location - a common problem in the office or the emergency department/triage.

Women presenting to the ED with first trimester bleeding, pain, or both, have had a demonstrated prevalence rate of ectopic pregnancy up to 18% in some studies. Ruptured ectopic is a leading cause of pregnancy-related mortality in the first trimester, accounting for 2.7% of pregnancy-related deaths overall in 2011-2013. Proper identification and management of early, unlocated pregnancy is life-saving!

Dr. Cleary was kind enough to put together her high points from this episode for our blog post today:

H&P:

  • Any patient with an unlocated pregnancy should be considered to have a potential ectopic pregnancy.

    • Women with prior ectopic, regardless of method of treatment, are at risk for ectopic in a subsequent pregnancy (three- to eightfold higher compared with other pregnant women).

    • If pregnancy is present while IUD is in place, risk of ectopic is 1 in 2 pregnancies for the levonorgestrel IUD and 1 in 16 pregnancies for the copper IUD.

    • Women with a history of PID have an approximately threefold increased risk of ectopic pregnancy

  • Pelvic exam. THIS MUST BE DONE.

Beta-HCG

  • The threshold for a positive qualitative β-hcg test is 20-50 milli-int units, depending on test. For quantitative serum tests, the threshold is 5-10 milli-int units, and 1-2 milli-int units, for ultrasensitive tests.

  • The β-hcg concentration doubles every 29 to 53 hours during the first 30 days after implantation of a viable, intrauterine pregnancy.

  • When ectopic pregnancy is on the differential, a qualitative test is not sufficient. A serum quantitative value is essential to:

    • 1. Interpret imaging (“discriminatory zone”)

    • 2. Have a baseline in the event the β-hcg must be trended

The Discriminatory Zone

  • Definition: A concept that there is a quantitative β-hcg level above which the landmarks of a normal intrauterine pregnancy (yolk sac and embryo) should be visible on ultrasound.

    • Therefore, the absence of a gestational sac when β-hcg level is above the DZ is strongly suggestive of nonviable pregnancy, with 50-70% being ectopic.

  • Pelvic ultrasound is the gold standard first line imaging modality in early pregnancy and for evaluation of suspected ectopic pregnancy

  • Imaging results will fall into 1 of 5 main categories

    • IUP with normal adnexa. Normal pregnancy!

    • IUP with abnormal adnexa. Although rare, must evaluate for heterotopic pregnancy, or presence of both an intra and extra-uterine pregnancy.

    • No IUP, extra-uterine mass with YS/FP. Confirms ectopic pregnancy.

    • No IUP, adnexal mass without YS/FP. Suspicious for ectopic pregnancy

    • No IUP, normal adnexa. Differential includes normal but early IUP, failed IUP, or unidentified ectopic.

  • A patient with a confirmed ectopic requires evaluation and counseling by an OBGYN to evaluate candidacy for medical or surgical evaluation.

Management:

  • Expectant management: serial quantitative β-hcg level assessment ~q 48 hours, only for stable patients.

    • Scenario A: The β-hcg level rises appropriately (doubles approximately every 2 days).

    • Scenario B: The β-hcg level falls precipitously.

    • Scenario C: The β-hcg level neither rises appropriately nor drops precipitously. Now we should be MORE concerned about ectopic pregnancy, but abnormal IUP is also on the differential.

  • Repeat pelvic imaging is very helpful

  • Every patient who is stable and an appropriate candidate to trend β-hcg levels will eventually declare herself, with either a located IUP, a failed IUP/SAB, or a confirmed or presumed ectopic pregnancy.

We will cover ectopics for surgical and medical management in a future episode, so stay tuned!

Breastfeeding Part II: Facts and Myth-busting

Today we (finally!) sit down with Part II of our breastfeeding special with Dr. Erin Cleary to cover myths, facts, and advantages of breastfeeding.

There are only three main contraindications to breastfeeding:
1. In infants with galactosemia.
2. In mothers who are HIV+ in high-resource settings.
3. In mothers with human T-cell lymphoma virus.

There are a number of relative contraindications to breastfeeding:

  • In a mother with Hepatitis A until she receives gamma globulin.

  • In a mother with Hepatitis B until the infant receives HBIG and HepB vaccine.

  • In a mother with Hepatitis C if coinfections present, such as HIV.

  • In a mother with Varicella zoster (Chicken pox) while mother is infectious.

  • In a mother with Active TB until mother has received 2+ weeks treatment

  • In a mother with influenza

    • if the mother has been afebrile without antipyretics for >24 hours, and the mother is able to control her cough and respiratory secretions.

    • Oseltamivir or Tamiflu is poorly excreted in breastmilk

  • In patients abusing IV drugs.

  • In patients using marijuana:

    • (THC), the main compound in marijuana, is present in human milk up to eight times that of maternal plasma levels, and metabolites are found in infant feces, indicating that THC is absorbed and metabolized by the infant

    • Several preclinical studies highlight how even low to moderate doses during particular periods of brain development can have profound consequences for brain maturation, potentially leading to long-lasting alterations in cognitive functions and emotional behaviors

    • Breastfeeding mothers should be counseled to reduce or eliminate their use of marijuana to avoid exposing their infants to this substance and advised of the possible long-term neurobehavioral effects from continued use

Common Breastfeeding Myths/Misconceptions:

Infectious:

  • You should breastfeed if you have mastitis, emptying the breast prevents stasis of milk

You can breastfeed in setting of acute respiratory, urinary, GU infections, continuation of BF acceptable

Imaging Sudies

  • You can breastfeed if… You need medical imaging.

    • XRays do not affect milk

    • Mammograms may be harder to interpret when a patient is lactating, but this should not be a reason to defer recommended diagnostic imaging

    • CT/MRI with or without contrast do not impact breastmilk

    • XRays with contrast dye or imaging with radioactive material are also OK

    • Exception: thyroid scan using I-131

      • I-131 concentrates in breastmilk and at high levels can suppress baby’s thyroid function (or even destroy the thyroid) and increase risk of thyroid cancer.

      • Therefore it is important that breastfeeding be discontinued until breastmilk levels are safe (this depends upon the dose and ranges from 8 days to 106+ days). The half-life for I-131 is 8.1 days.

      • Hale recommends that when I-131 is used, breastmilk samples should be tested with a gamma (radiation) counter before breastfeeding is resumed to ensure that radiation in the milk has returned to safe levels.

  • You can breastfeed if… You are pregnant!  

    • Increasing progesterone will decrease supply and cause breast/nipple sensitivity.  

    • Mature milk will be replaced by colostrum in the 2nd trimester.

    • Tandem feeding includes breastfeeding a newborn and toddler

  • You can breastfeed if… You’ve had general anesthesia.  As soon as you are awake enough to hold the baby, the medication has metabolized and breastfeeding is safe.

  • You can breastfeed if… You are on maintenance medications such as methadone and buprenorphine

    • There is a reduction in severity and duration of treatment of NAS when mothers on these medications breastfeed

  • You can breastfeed if… You have an occasional alcoholic beverage

    • Alcohol concentration in the blood is in steady state with the milk, so delaying nursing or pumping until more alcohol is metabolized can limit exposure

  • If direct breastfeeding is interrupted due to temporary separation of mother and child for any reason, the breastfeeding mother should be encouraged and supported to regularly express her milk.

    • Expression and storage of milk allows the infant to continue to receive milk if appropriate, and prevents stasis of milk and mastitis

In the setting of infection, prior to expressing breast milk, mothers should wash their hands well with soap and water and, if using a pump, follow recommendations for proper cleaning.