September is Fetal Alcohol Spectrum Disorders Awareness Month

The below is written by NPWH Director of Publications, Beth Kelsey, EdD, APRN, WHNP-BC, FAANP

As nurse practitioners providing healthcare for women, we have the opportunity to be leaders and champions in a campaign to prevent alcohol use during pregnancy and fetal alcohol spectrum disorders (FASDs). Our patients trust us to provide client-centered care that includes providing facts, being respectful of their individual needs and concerns, and supporting them in making informed decisions that will promote healthy pregnancy outcomes. Sometimes the conversations we have with patients about alcohol use during pregnancy are easy, sometimes they are difficult. As nurse practitioners we are equipped to have the conversation whether easy or difficult.

Call to Action

According to CDC data, only 17 percent of pregnant women reported that their healthcare provider talked with them about alcohol use. We have to do better. Our role must go beyond individual patient care. Educate colleagues, offer to speak at community events on the topic of preventing alcohol use during pregnancy, and, if you teach NP students be sure they have the knowledge and skills to also be leaders and champions.

Let’s start by agreeing to set the record straight regarding the mixed messages women may receive from family, friends, and even other healthcare providers about whether it is safe to drink alcohol during pregnancy. There is no safe time, no safe amount, and no safe type of alcohol to drink during pregnancy.

Alcohol is a known teratogen that readily crosses the placenta. When a developing baby is exposed to alcohol it can lead to permanent conditions known as FASDs. A range of developmental, cognitive, and behavioral problems can occur, appear at any time during childhood, and last a lifetime. We don’t have a crystal ball to know who might be affected and how seriously. Genetics, environment, and other exposures may all contribute to outcomes. Every pregnancy is different so alcohol exposure can affect each developing baby differently even in the same woman.

The Facts

  • About 1 in 9 pregnant women reported drinking alcohol in the past 30 days and one third of pregnant women who reported consuming alcohol engaged in binge drinking.1
  • Drinking alcohol while pregnant can cause miscarriage, stillbirth, premature birth, and FASDs.
  • Alcohol-exposed pregnancies are a leading cause of preventable birth defects and neurodevelopmental abnormalities in the United States.
  • Based on National Institutes of Health-funded community studies, experts estimate that the full range of FASDs in the United States might number as high as 1 to 5 per 100 school children.2

There is no safe time to drink during pregnancy — Prenatal alcohol exposure at any time during pregnancy can cause developmental problems. Brain development occurs throughout gestation. Because alcohol exposure affects the developing baby through a variety of mechanisms and impacts different body systems, timing of the exposure can influence some of the potential effects. You can use a fetal development chart to facilitate discussion with your patients about developmental timing. The chart can help you to make the point that while it is best to stop drinking prior to becoming pregnant, it is never too late in pregnancy to stop drinking and lessen potential effects. The fetal development chart can also be used when you provide preconception counseling. Approximately half of pregnancies are unplanned, so women could potentially be drinking alcohol before they realize they are pregnant.

There is no safe amount of alcohol to drink during pregnancy – No amount of alcohol is currently deemed safe during pregnancy. This is true for most known teratogens. We don’t know a dose threshold for teratogenic effects. We do know that because alcohol readily crosses the placenta, a developing baby can be exposed to the same level of alcohol as the mother.

There is no safe type of alcohol to drink during pregnancy – all types of alcohol can be equally harmful to the developing fetus, including all wines and beer.

Are you ready to answer the call to action? Here are some useful resources.

The CDC and Collaborative for Alcohol-Free Pregnancy
Mother’s Womb: Baby’s First Environment Graphic

Fetal Development Chart 

Free online continuing education courses for healthcare providers on the prevention, identification, and management of FASDs

University of Pittsburgh School of Nursing
Fetal Alcohol Spectrum Disorders Toolkit for Nurse Champions

NPWH
Optimizing Preconception Health: Preventing Unexpected Teratogen Exposure in Reproductive Age Women is a series of seven taped webinars on different aspects of this topic.

The National Organization on Fetal Alcohol Syndrome (NOFAS) provides fact sheets, videos, and other resources for professionals and individuals impacted by FASDs.

References:

  1. Denny CH, Acero CS, Naimi Ts, Kim SY. Consumption of alcohol beverages and binge drinking among pregnant women aged 18-44 years – United States, 2015-2017. MMWR. 2019; 68:365-368.
  2. May PA, Chambers CD, Kalberg WO, et al. Prevalence of fetal alcohol spectrum disorders in 4 US communities. Journal of American Medical Association. 2018;319(5):474–482.

Ovarian Cancer Awareness Month

The below is written by Rachel Gorham, MSN, WHNP-BC, AGN-BC. Ms. Gorham is on the NPWH Board of Directors. 

Ovarian cancer is said to be a “silent killer,” but it’s a whisper that needs to be heard. The American Cancer Society estimates in 2019, 22,530 women will be diagnosed and approximately 13,980 will die from ovarian cancer. It ranks fifth in cancer deaths among women. As providers, we have an opportunity during Ovarian Cancer Awareness Month to help patients to better understand this gynecological cancer. I’d like to provide this overview of the basics we should all be well-versed in, and also let you know about some of the promising developments in screening and prevention.

Risk Factors

Ovarian cancer typically develops in older women. About half of women are 63 years or older at the time of diagnosis. This cancer develops more commonly in white women than African American women. Factors that can elevate a woman’s risk of developing ovarian cancer include:

  • Age: Risk increases with age, and typically develops after menopause.
  • Personal or family historyof breast cancer, ovarian cancer, uterine cancer, or colorectal cancer.
  • Hormone therapy, particularly for more than five years of estrogen-only therapy.
  • Inherited cancer syndromes, including BRCA gene mutations, hereditary nonpolyposis colorectal cancer (also known as HNPCC or Lynch syndrome), Peutz-Jeghers syndrome and MUTYH-associated polyposis.
  • Reproductive history:Women who had their first child after the age of 35 or who have never given birth.
  • Endometriosis is a condition in which uterine lining grows outside of the uterus.

Symptoms

Women who develop ovarian cancer generally have a poor outcome, with a survival rate of less than 35% over five years. Women who have ovarian cancer often present with advanced disease and staging, which is the most critical factor affecting disease outcome. Most have had symptoms for an extended period before the presentation, which often leads to delays between presentation and treatment. Ovarian cancer symptoms include:

  • Pelvic, abdominal or back pain
  • Bloating
  • Loss of appetite or feeling full quickly
  • Changes in bowel or bladder function, such as constipation, urinary frequency, or urinary urgency
  • Menstrual changes
  • Pain during sex
  • Fatigue

Screening

Currently, there are no societal guidelines that recommend routine screening for ovarian cancer since screenings have not shown to decrease mortality. Patients may require increased monitoring if found to be high-risk of developing ovarian cancer, which includes:

  • Family history and/or personal history of breast or ovarian cancer
  • Inherited pathogenic variant, such as BRCA gene mutations and Lynch syndrome
  • History of infertility or use of assisted reproductive therapies
  • Hormone replacement therapy
  • Endometriosis

Treatment Options

Surgery is the standard treatment option for patients with ovarian cancer, including:

  • Cytoreductive (debulking) surgeries, whichremove as much tumor as possible from the pelvic and abdominal areas. This can improve outcomes and reduce cancer recurrence.
  • Coordination with other surgical specialties such as urology, thoracic, hepatobiliary, and neurosurgeons, who can remove secondary tumors in other parts of the body.
  • Fertility-sparing surgeryfor early-stage germ cell or stromal tumors confined to one ovary, which can preserve the patient’s ability to have children.
  • HIPEC(heated intraoperative peritoneal chemotherapy), a procedure in which cancer-fighting drugs are circulated into the abdominal cavity immediately after surgery. This therapy of direct heated chemotherapy can help kill more cancer cells than chemotherapy given orally or intravenously.
  • Inherited cancer syndromesfor patients who are high-risk for developing ovarian cancer (such as BRCA gene mutation carriers), can undergo a risk-reducing surgery such as a bilateral salpingo-oophorectomy.

Recent Advancements in Screening

A good deal of the current research in ovarian cancer is focused on screening and early detection, as early diagnosis is key to a positive prognosis. Recent advancements in this area include a promising test from Queens University Belfast which may allow clinicians to diagnose patients up to two years sooner than current tests allow. 

Continued Support for Preventive Effects of OCP

In the last few years, we’ve continued to see evidence that oral contraceptives decrease both ovarian and endometrial cancer risk. Risk reduction is correlated with duration of use. Studies have shown up to 50% reduction in ovarian cancer seen with 15 years of OCP. Furthermore, this risk reduction carries over beyond the general population to higher risk groups, such as BRCA carriers and those with Lynch syndrome BRIP1RAD51C, or RAD51D mutations. The degree of risk reduction with 1 year of use has been estimated at 33-80% for BRCA1 and 58-63% for BRCA2 carriers.  Providers should consider recommending OCP use for all woman with increased risk factors for epithelial ovarian cancer.

There is plenty of work to be done when it comes to advancing screening, prevention, and treatment for ovarian cancer. But every day, Nurse Practitioners and other providers who care for women can work with patients to identify risks, catch symptoms early, and provide support throughout treatment.