As we discussed last week, safety is a big issue, and some recommendations are summarily ignored. Why do we care so much about safety? Why do we push the bike helmets and childproofing homes and whatnot? Why do we have so many products aimed at safety? After all, 'when I was growing up, our parents didn't care about any of that stuff.'
Well, unintentional injury is the most common cause of death in children (aged 1-14). More than cancer, heart disease and every other disease children get, combined. The only reason it isn't so for the under 1 crowd is because we have a lot of babies born with various congenital conditions that lead to an early death.
Of course, those stats include all unintentional injuries, which covers a lot of things. What, specifically, causes death in children? Well, the CDC puts together that information for us too. The causes that are in the top 10 for all age groups through age 14 are:
1. Unintentional Suffocation (1117 deaths in 2012, differentiated from homicidal suffocation and undetermined suffocation)
2. Homicide (730 in 2012)
3. Drowning (725 in 2012)
4. Motor Vehicle Accidents (437 in 2012)
5. Burn (277 in 2012)
Others high on the list are those related to firearms (317 in 2012, but none in <1 year), pedestrian accidents (104) and environmental causes (89).
All of these are something that we're concerned about. Many of these can be prevented by simply educating parents about what to look for. For instance, unintentional suffocation is the most common cause of unintentional injury death in children less than 1 year of age. So, we as pediatricians recommend that the beds not be lined with bumper pads, remove large fluffy pillows from the couches, etc, and careful supervision of these children. The number of children dying from suffocation drops dramatically after age 1. I'll cover safe sleep and SIDS in another blog post.
For homicides, there isn't much we can tell the parents. Living in a bad neighborhood, violence at schools--these are things that are often beyond the parent's control. We deal with these as best we can.
Drowning is most common in the 1-4 age group, and while pools are a concern, most children actually die in bathtubs, dog bowls, etc. It only takes 3 inches of water to drown--enough to cover the nose and mouth. So, watching the child, especially in the bathtub, is key for preventing these injuries.
Motor vehicle accidents are very common, so we focus on making sure the kids are strapped in appropriately. This is likely a whole blog post in and of itself, but the gist is that children under age 2 need to be in a rear-facing seat, and should be in a car seat until they meet the weight recommendations for that seat. Then they should be in a booster seat until they can comfortably wear a seat belt (at about 4 ft 9 inches tall).
Burns are most commonly caused by hot water, and so we make the recommendation to keep water heaters set at 120 degrees F. Not because this is a safe temperature, but because it takes about 5 minutes at this temperature before a serious burn injury develops. Baths should be slightly warmer than body temperature, about 100 degrees F.
There are plenty more safety issues that can be discussed, from medications and poisonings to firearms to falls, but I feel this post is already long enough, so we'll save those for another time.
In the meantime, if you have any questions or comments, feel free to post in the comments below or use the 'contact me' form available as a tab at the top of the page.
Sunday, July 27, 2014
Sunday, July 20, 2014
Children and Heat Safety
Hopefully you've heard of some of the recent deaths after leaving children locked in a car on a hot day: Cooper Harris, Benjamin Seitz, and many others. Some of these stories are a little old, but these stories happen every summer. In fact, roughly 35 children die in hot cars every year. Thirty-five. Countless other pets and elderly individuals also die each year.
Why does this happen? It could be intentional. It could be an accident. It could be lack of awareness. I'm hoping for the latter two, and want to hopefully change thinking.
First and foremost, children should never be left in a car (or anywhere, really) unattended. There's a whole host of things that can go wrong, and without quick intervention, many of these can lead to serious injury or death.
Now, let's speak generally about what heat does to us.
Our bodies produce heat constantly. This leads to a body temperature around 98.6 degrees F (37 degrees C). Actually, your body temperature fluxuates during the day, and is lowest around 2-3 am. If your temperature drops below 36 degrees C (96.8 F), you are considered hypothermic. If your temperature is over 38 degrees C (100.4 F), you are considered to have an elevated temperature. If this is due to an infection or inflammation (a reset in the body's 'normal'), we call it a fever. If it is due to a breakdown in the body's ability to cool, we call it hyperthermia.
When the body's temperature is above it's normal set point (about 37 degrees C in children without a fever), the body responds by sweating. From experience, I'm sure you've noted that you start to sweat even in temperatures below your own body temperature. As I said before, the body produces its own heat, and has to get rid of this heat to the environment. This is fairly easy when the environment is 'room temperature', but as the temperature starts to climb (or there is more body heat to get rid of, as in exercise), it becomes more difficult to do so, and sweating is one way this is done. Sweating gets rid of excess body heat because the water takes the heat with it as it evaporates off the skin. (This is why wiping sweat off can actually make you feel hotter, and why a cool mist can make you feel cooler).
When it is hot outside (>90 degrees F/32 degrees C), and the humidity is high, it can impede the ability for sweat to evaporate, and thus the body to cool down. When the body temperature starts to go up, it means bad things for the person.
Heat exhaustion occurs when the core body temperature is still below 104 degrees F (40 degrees C), and the person is awake and alert. They may complain of dizziness/lightheadedness, headache, rapid heart rate, fast breathing, tiredness, and so forth. But, importantly, they are still able to appropriately answer questions. Heat exhaustion is considered the precursor to heat stroke. This person needs to be moved to a cool place, be given water, and allowed to rest. If symptoms do not improve in 20-30 minutes, they should be brought to the Emergency Department for further evaluation.
Heat stroke is characterized by a core body temperature greater than 104 degrees F (40 degrees C), and an abnormal level of consciousness--the person is not awake or is not able to appropriately answer questions. This is a medical emergency, as it can very rapidly result in multi-organ failure.
You'll notice that heat stroke is defined by the temperature. However, there is a difference between having a fever and being hyperthermic to the point where you are at risk for heat stroke. In fact, rapid cooling with ice packs, water, etc does not help in cases of fever, which is why they are given two separate terms (fever vs. hyperthermia), despite having the same characteristic (elevated core body temperature).
What a fever does to a child is raise the body's set point to higher than 98.6F. Thus, when they have a fever, they may not be sweating, because the body is trying to stay hot. It is when you 'break' the fever and they start to come down to their normal temperature that they start to sweat. People tend to get worried for 'high' fevers, up above 103 degrees F, but the body cannot really produce temperatures above 105 degrees F on its own, and children with fevers, even high fevers, do not have the same complications as children with heat stroke. The take home from this point is that if your child has a high fever, you should bring them to see the physician just in case it is not a fever and to make sure that you are treating the infection appropriately.
So, what can be done to prevent heat exhaustion and heat stroke?
Since most often, these occur when children are outside playing sports (exertional heat stroke), it is important to incorporate several breaks, and emphasize adequate hydration (with a sports drink solution, since sweat causes the loss of some important electrolytes) during play.
As for the origin of this article--the publicity of automotive heat deaths in children--you should not be leaving a child in a car during the warmer months. It can get very hot inside the vehicle, even if it is only left for a few minutes. If the vehicle is in the sun, it can get even warmer. Leaving the windows cracked is not enough to prevent this rise in temperature. Putting up a sunshade may delay the time for the temperature to rise slightly, but not enough to safely leave a child in the car.
Just don't do it. Take your child with you, even if they are sleeping. Especially if they are sleeping. I would rather your child annoy you in the store than for you to live with the devastation of losing your child.
Why does this happen? It could be intentional. It could be an accident. It could be lack of awareness. I'm hoping for the latter two, and want to hopefully change thinking.
First and foremost, children should never be left in a car (or anywhere, really) unattended. There's a whole host of things that can go wrong, and without quick intervention, many of these can lead to serious injury or death.
Now, let's speak generally about what heat does to us.
Our bodies produce heat constantly. This leads to a body temperature around 98.6 degrees F (37 degrees C). Actually, your body temperature fluxuates during the day, and is lowest around 2-3 am. If your temperature drops below 36 degrees C (96.8 F), you are considered hypothermic. If your temperature is over 38 degrees C (100.4 F), you are considered to have an elevated temperature. If this is due to an infection or inflammation (a reset in the body's 'normal'), we call it a fever. If it is due to a breakdown in the body's ability to cool, we call it hyperthermia.
When the body's temperature is above it's normal set point (about 37 degrees C in children without a fever), the body responds by sweating. From experience, I'm sure you've noted that you start to sweat even in temperatures below your own body temperature. As I said before, the body produces its own heat, and has to get rid of this heat to the environment. This is fairly easy when the environment is 'room temperature', but as the temperature starts to climb (or there is more body heat to get rid of, as in exercise), it becomes more difficult to do so, and sweating is one way this is done. Sweating gets rid of excess body heat because the water takes the heat with it as it evaporates off the skin. (This is why wiping sweat off can actually make you feel hotter, and why a cool mist can make you feel cooler).
When it is hot outside (>90 degrees F/32 degrees C), and the humidity is high, it can impede the ability for sweat to evaporate, and thus the body to cool down. When the body temperature starts to go up, it means bad things for the person.
Heat exhaustion occurs when the core body temperature is still below 104 degrees F (40 degrees C), and the person is awake and alert. They may complain of dizziness/lightheadedness, headache, rapid heart rate, fast breathing, tiredness, and so forth. But, importantly, they are still able to appropriately answer questions. Heat exhaustion is considered the precursor to heat stroke. This person needs to be moved to a cool place, be given water, and allowed to rest. If symptoms do not improve in 20-30 minutes, they should be brought to the Emergency Department for further evaluation.
Heat stroke is characterized by a core body temperature greater than 104 degrees F (40 degrees C), and an abnormal level of consciousness--the person is not awake or is not able to appropriately answer questions. This is a medical emergency, as it can very rapidly result in multi-organ failure.
You'll notice that heat stroke is defined by the temperature. However, there is a difference between having a fever and being hyperthermic to the point where you are at risk for heat stroke. In fact, rapid cooling with ice packs, water, etc does not help in cases of fever, which is why they are given two separate terms (fever vs. hyperthermia), despite having the same characteristic (elevated core body temperature).
What a fever does to a child is raise the body's set point to higher than 98.6F. Thus, when they have a fever, they may not be sweating, because the body is trying to stay hot. It is when you 'break' the fever and they start to come down to their normal temperature that they start to sweat. People tend to get worried for 'high' fevers, up above 103 degrees F, but the body cannot really produce temperatures above 105 degrees F on its own, and children with fevers, even high fevers, do not have the same complications as children with heat stroke. The take home from this point is that if your child has a high fever, you should bring them to see the physician just in case it is not a fever and to make sure that you are treating the infection appropriately.
So, what can be done to prevent heat exhaustion and heat stroke?
Since most often, these occur when children are outside playing sports (exertional heat stroke), it is important to incorporate several breaks, and emphasize adequate hydration (with a sports drink solution, since sweat causes the loss of some important electrolytes) during play.
As for the origin of this article--the publicity of automotive heat deaths in children--you should not be leaving a child in a car during the warmer months. It can get very hot inside the vehicle, even if it is only left for a few minutes. If the vehicle is in the sun, it can get even warmer. Leaving the windows cracked is not enough to prevent this rise in temperature. Putting up a sunshade may delay the time for the temperature to rise slightly, but not enough to safely leave a child in the car.
Just don't do it. Take your child with you, even if they are sleeping. Especially if they are sleeping. I would rather your child annoy you in the store than for you to live with the devastation of losing your child.
Sunday, July 13, 2014
Wet Bedsheets: When Nighttime 'Accidents' Become a Problem
One of the questions I've heard more than a couple times in clinic is: "Is my child's bed wetting a problem?" The answer? It depends.
Toilet training typically begins around age 2. Some kids show interest earlier, some later. Many things have to be in place before toilet training can be successful, ranging from the ability to sense the need to use the bathroom, to the ability to indicate that need to a caregiver, and finally to the ability to 'hold it' and control the muscles responsible for going. And, of course, the child must show interest, else attempts at getting them to use the bathroom are futile.
Nighttime bathroom use is generally the last stage of toilet training. At this point, children are usually able to use the bathroom appropriately during the day, but frequently have accidents at night. It is important to note that it is not their fault. Usually bed wetting is a result of deep sleep, when the signals of a full bladder are not processed to result in waking up to use the bathroom. It may take years after daytime training for nighttime training to be complete.
Importantly, if mom or dad (or both) were bed wetters as children, the child is more likely to take longer to achieve nighttime dryness. Boys are also more likely to wet the bed than girls, so don't use an older sister as a comparison.
If a child is still wetting the bed at age 5, it should be brought up to the pediatrician. In one study, most children had stopped bed wetting by age 41 months, or about 3 1/2 years old. However, at age 5, up to 25% of children are still wetting the bed, so it's not outside the realm of normal. The reason you should bring it up with your pediatrician is that it might be indicative of a developmental delay, so that possibility should be explored. It could also be an ongoing issue of constipation, as excessive stool may compress the bladder and lead to more accidents. However, it is not really considered 'abnormal' until the child is 7 years old or so.
There are some behavioral modifications you can do to help reduce your laundry load. This includes making sure the child stays well hydrated during the day (so they don't need to catch up on fluid intake at night), and reducing the amount of liquid at dinner time. The child should be asked to use the bathroom before bed, and even woken up when the parents go to bed to use the bathroom again. There are some sensors and alarms that can also be used to wake a child when they start wetting, but these tend not be very effective. Finally, there are some medications that can be used to decrease urine production during the night in extreme cases.
This is assuming the child has never had a period of dryness at night. I'm not talking about a day or two stretch here and there, but a period of consistent dryness lasting several weeks. If the child begins bed wetting again after this point, you should always bring it up to your pediatrician, because this is always abnormal.
In some cases, it will be due some sort of stress (divorce, new family member, etc), which can be treated with therapy. In others, though, it may signal another condition, such as diabetes (one of the early symptoms of diabetes is increased urination), a urinary tract infection, or even issues with sleep.
Bed wetting can be a stressful thing for both children and parents, but allow time to take its course and most of the time, it will resolve on its own.
Comments? Questions? Concerns? Comment below or send me a note through the Contact form located above!
Toilet training typically begins around age 2. Some kids show interest earlier, some later. Many things have to be in place before toilet training can be successful, ranging from the ability to sense the need to use the bathroom, to the ability to indicate that need to a caregiver, and finally to the ability to 'hold it' and control the muscles responsible for going. And, of course, the child must show interest, else attempts at getting them to use the bathroom are futile.
Nighttime bathroom use is generally the last stage of toilet training. At this point, children are usually able to use the bathroom appropriately during the day, but frequently have accidents at night. It is important to note that it is not their fault. Usually bed wetting is a result of deep sleep, when the signals of a full bladder are not processed to result in waking up to use the bathroom. It may take years after daytime training for nighttime training to be complete.
Importantly, if mom or dad (or both) were bed wetters as children, the child is more likely to take longer to achieve nighttime dryness. Boys are also more likely to wet the bed than girls, so don't use an older sister as a comparison.
If a child is still wetting the bed at age 5, it should be brought up to the pediatrician. In one study, most children had stopped bed wetting by age 41 months, or about 3 1/2 years old. However, at age 5, up to 25% of children are still wetting the bed, so it's not outside the realm of normal. The reason you should bring it up with your pediatrician is that it might be indicative of a developmental delay, so that possibility should be explored. It could also be an ongoing issue of constipation, as excessive stool may compress the bladder and lead to more accidents. However, it is not really considered 'abnormal' until the child is 7 years old or so.
There are some behavioral modifications you can do to help reduce your laundry load. This includes making sure the child stays well hydrated during the day (so they don't need to catch up on fluid intake at night), and reducing the amount of liquid at dinner time. The child should be asked to use the bathroom before bed, and even woken up when the parents go to bed to use the bathroom again. There are some sensors and alarms that can also be used to wake a child when they start wetting, but these tend not be very effective. Finally, there are some medications that can be used to decrease urine production during the night in extreme cases.
This is assuming the child has never had a period of dryness at night. I'm not talking about a day or two stretch here and there, but a period of consistent dryness lasting several weeks. If the child begins bed wetting again after this point, you should always bring it up to your pediatrician, because this is always abnormal.
In some cases, it will be due some sort of stress (divorce, new family member, etc), which can be treated with therapy. In others, though, it may signal another condition, such as diabetes (one of the early symptoms of diabetes is increased urination), a urinary tract infection, or even issues with sleep.
Bed wetting can be a stressful thing for both children and parents, but allow time to take its course and most of the time, it will resolve on its own.
Comments? Questions? Concerns? Comment below or send me a note through the Contact form located above!
Sunday, July 6, 2014
Contraceptives and Abortifacients
So, originally this week I was going to write about some of the developmental delays I've been seeing this past week in clinic. But after multiple Supreme Court rulings on the contraceptive mandate, I decided I really can't stay quiet about this.
For those of you who haven't heard of these rulings, allow me to summarize them for you.
First, we have Burwell vs. Hobby Lobby. Hobby Lobby is an arts and crafts store owned by the Green family, who are devout Christians. Their argument was that their corporation remains a family owned business, and they should be able to run that corporation in line with their religious beliefs. The particular argument was that the contraceptive mandate of the ACA (the section that required insurers to cover at no additional cost all 20 FDA approved contraceptives) violated their religious beliefs because 4 of the contraceptives covered (two forms of IUDs and two forms of 'emergency contraception') are abortifacients, that is, they have an action that may prevent implantation and thus result in 'abortion' of a fertilized egg.
A linked case, Conestoga vs. Burwell, had a similar argument. The Hahn family is the sole owner of the company and also believe that these four contraceptives are abortifacients.
In these cases, the Supreme Court voted 5-4 in favor of the companies. It should be noted that all three female justices voted against this decision.
Wheaton College vs. Burwell was not decided this week, but was allowed to abstain from the contraceptive mandate until they can gather arguments to go in front of the Supreme Court in the future.
I see multiple issues with these decisions, but for now am only going to focus on the medical aspect: Whether these contraceptives are abortifacients or not.
Before we get into how these contraceptives work, here's a crash course on what needs to happen for pregnancy.
First, there needs to be a viable egg. Each month, roughly, an egg is released from the ovary following a hormonal signal called the LH surge. This is referred to as ovulation. The egg then travels down the Fallopian tube towards the uterus (you can view of diagram of this here, if you're more of a visual person). Somewhere in this Fallopian tube, it is met by the sperm released after sex. The sperm fight to be the first inside the egg, and the now fertilized egg (soon to be an embryo) travels down to the uterus, where it implants in the rich lining and starts to form an actual baby. Progesterone, another hormone, is produced by the ovary following ovulation to promote the growth of the lining of the uterus until the placenta (the direct connection between baby and mama) forms and can produce this hormone on its own.
You'll note that I said the sperm meet the egg in the Fallopian tube. Sperm can live inside the female body for up to 5 days after sex. The egg can only survive without being fertilized for 24 hours or so after ovulation. So the most fertile time for women is actually having sex prior to ovulation so that the sperm can already be present when the egg is released.
When the embryo does not implant, there is obviously no development of a placenta, so after a period of time (usually 2 weeks), the ovary stops producing progesterone, and the uterine lining sheds, resulting in a period. Birth control pills work by supplying the body with a continuous dose of progesterone (and some estrogen, yet another hormone), so the body thinks its pregnant and doesn't release another egg. Thus, when you are on the placebo pill week, you have your period because you are not producing progesterone.
Onto the 'emergency contraceptives'. Plan B, Plan B One-Step, and Next Choice are levonorgestrel, a progesterone-like hormone. Thus, it acts like progesterone by preventing ovulation. As already described, progesterone is necessary to keep the uterine lining intact for the developing embryo. So, if this pill was taken after ovulation, the ovary would continue to produce progesterone, allowing the implantation of the embryo into the uterine lining. This is taken after sex, so it wouldn't prevent the sperm from getting into the Fallopian tube in the first place (as daily birth control pills might). The only way it would prevent pregnancy is if it prevents ovulation. So, not an abortifacient.
Now, an aside, taking the pill after ovulation doesn't mean you'll get pregnant. Everything else has to go right for that to happen. Successful implantation is estimated to occur in 15-30% of natural cycles. Many miscarriages are not realized because the body simply rejects the embryo before the woman knows she's pregnant. Most of the time, this is because there is some major genetic issue--an extra set of chromosomes, or something of that nature. Trust me, after studying genetics and embryology, I was amazed that this process worked at all.
There are some studies showing that there may be some changes in the uterine lining following administration of loveonorgestrel, but as far as I can tell, these studies were all done in the 80s, and much more recent studies have shown that there is little to no effect on the lining. Medications have also changed a great deal in that time.
Ella, ulipristal acetate, is another pill form of emergency contraception. It acts as a mixed progesterone receptor agonist and antagonist, which means it sometimes acts like progesterone and sometimes blocks the action of progesterone. Its effect is determined by the timing of the cycle. It can prevent the LH surge if given early enough, but can also block the effect of the LH surge (ovulation) if given after this hormonal signal. Essentially, it directly delays ovulation, ideally long enough so that the sperm are no longer viable. If given after ovulation, though, it diminishes the ability for the ovary to produce progresterone, thus affecting the uterine lining. Because of this action, I can see its potential for 'abortion', by preventing implantation. Ella is a relatively new contraceptive medication, so there are relatively few studies out there--it was difficult for me to pin down its exact mechanism of action.
Intrauterine Devices (IUDs) are implants placed by an OB/GYN or another clinician trained in the insertion that are used for long-term contraception. Historically, they were thought to have effects primarily in the post-fertilization phase of pregnancy, but other evidence now suggests otherwise.
There are two types available on the market today. First is the copper IUD. This one has been around forever. There is no hormonal effect to this contraceptive, and it is cited as an effective emergency contraception. It seems the effect is primarily toxic to the sperm as they move through the uterus, but it also produces an inflammatory response in the uterus which may affect implantation. So, potentially disrupts implantation.
The second type of IUD is the hormonal IUD, such as Mirena or Skylar. It is a small plastic device that contains progesterone, which acts in much the same way that the progesterone pills function. They are effective for about 3-5 years after insertion and prevent 99% of pregnancies. In theory, these can cause a foreign body reaction in the uterus that prevents implantation, but women can still get pregnant using this device, and it's not very effective as an emergency contraception, so it doesn't seem that this is an active issue. Therefore, I say it's not an abortifacient.
Conclusions: Hobby Lobby may have had a case. As I mentioned, I disagree with the decision on multiple fronts, and this was only the start of it. At minimum, they should not be permitted to object to Plan B and hormonal IUDs on the basis of them being abortifacients, because the science indicates that they are not, and thus it is a flawed argument. Ella and other similar oral emergency contraceptives need to be studied more before we determine for certain whether they result in decreased implantation of a viable embryo. Copper IUDs likely produce an environment that is hostile to life in general in the uterus, and thus potentially disrupt implantation.
There is some disagreement about the term 'abortifacient' as well, since by definition an abortion is the termination of a pregnancy, and a pregnancy can only occur if there is implantation of the embryo, but I chose not to get into this discussion for now.
Thoughts? Questions? Concerns? Feel free to comment or use the contact me form located at the top of the blog. See you next week!
For those of you who haven't heard of these rulings, allow me to summarize them for you.
First, we have Burwell vs. Hobby Lobby. Hobby Lobby is an arts and crafts store owned by the Green family, who are devout Christians. Their argument was that their corporation remains a family owned business, and they should be able to run that corporation in line with their religious beliefs. The particular argument was that the contraceptive mandate of the ACA (the section that required insurers to cover at no additional cost all 20 FDA approved contraceptives) violated their religious beliefs because 4 of the contraceptives covered (two forms of IUDs and two forms of 'emergency contraception') are abortifacients, that is, they have an action that may prevent implantation and thus result in 'abortion' of a fertilized egg.
A linked case, Conestoga vs. Burwell, had a similar argument. The Hahn family is the sole owner of the company and also believe that these four contraceptives are abortifacients.
In these cases, the Supreme Court voted 5-4 in favor of the companies. It should be noted that all three female justices voted against this decision.
Wheaton College vs. Burwell was not decided this week, but was allowed to abstain from the contraceptive mandate until they can gather arguments to go in front of the Supreme Court in the future.
I see multiple issues with these decisions, but for now am only going to focus on the medical aspect: Whether these contraceptives are abortifacients or not.
Before we get into how these contraceptives work, here's a crash course on what needs to happen for pregnancy.
First, there needs to be a viable egg. Each month, roughly, an egg is released from the ovary following a hormonal signal called the LH surge. This is referred to as ovulation. The egg then travels down the Fallopian tube towards the uterus (you can view of diagram of this here, if you're more of a visual person). Somewhere in this Fallopian tube, it is met by the sperm released after sex. The sperm fight to be the first inside the egg, and the now fertilized egg (soon to be an embryo) travels down to the uterus, where it implants in the rich lining and starts to form an actual baby. Progesterone, another hormone, is produced by the ovary following ovulation to promote the growth of the lining of the uterus until the placenta (the direct connection between baby and mama) forms and can produce this hormone on its own.
You'll note that I said the sperm meet the egg in the Fallopian tube. Sperm can live inside the female body for up to 5 days after sex. The egg can only survive without being fertilized for 24 hours or so after ovulation. So the most fertile time for women is actually having sex prior to ovulation so that the sperm can already be present when the egg is released.
When the embryo does not implant, there is obviously no development of a placenta, so after a period of time (usually 2 weeks), the ovary stops producing progesterone, and the uterine lining sheds, resulting in a period. Birth control pills work by supplying the body with a continuous dose of progesterone (and some estrogen, yet another hormone), so the body thinks its pregnant and doesn't release another egg. Thus, when you are on the placebo pill week, you have your period because you are not producing progesterone.
Onto the 'emergency contraceptives'. Plan B, Plan B One-Step, and Next Choice are levonorgestrel, a progesterone-like hormone. Thus, it acts like progesterone by preventing ovulation. As already described, progesterone is necessary to keep the uterine lining intact for the developing embryo. So, if this pill was taken after ovulation, the ovary would continue to produce progesterone, allowing the implantation of the embryo into the uterine lining. This is taken after sex, so it wouldn't prevent the sperm from getting into the Fallopian tube in the first place (as daily birth control pills might). The only way it would prevent pregnancy is if it prevents ovulation. So, not an abortifacient.
Now, an aside, taking the pill after ovulation doesn't mean you'll get pregnant. Everything else has to go right for that to happen. Successful implantation is estimated to occur in 15-30% of natural cycles. Many miscarriages are not realized because the body simply rejects the embryo before the woman knows she's pregnant. Most of the time, this is because there is some major genetic issue--an extra set of chromosomes, or something of that nature. Trust me, after studying genetics and embryology, I was amazed that this process worked at all.
There are some studies showing that there may be some changes in the uterine lining following administration of loveonorgestrel, but as far as I can tell, these studies were all done in the 80s, and much more recent studies have shown that there is little to no effect on the lining. Medications have also changed a great deal in that time.
Ella, ulipristal acetate, is another pill form of emergency contraception. It acts as a mixed progesterone receptor agonist and antagonist, which means it sometimes acts like progesterone and sometimes blocks the action of progesterone. Its effect is determined by the timing of the cycle. It can prevent the LH surge if given early enough, but can also block the effect of the LH surge (ovulation) if given after this hormonal signal. Essentially, it directly delays ovulation, ideally long enough so that the sperm are no longer viable. If given after ovulation, though, it diminishes the ability for the ovary to produce progresterone, thus affecting the uterine lining. Because of this action, I can see its potential for 'abortion', by preventing implantation. Ella is a relatively new contraceptive medication, so there are relatively few studies out there--it was difficult for me to pin down its exact mechanism of action.
Intrauterine Devices (IUDs) are implants placed by an OB/GYN or another clinician trained in the insertion that are used for long-term contraception. Historically, they were thought to have effects primarily in the post-fertilization phase of pregnancy, but other evidence now suggests otherwise.
There are two types available on the market today. First is the copper IUD. This one has been around forever. There is no hormonal effect to this contraceptive, and it is cited as an effective emergency contraception. It seems the effect is primarily toxic to the sperm as they move through the uterus, but it also produces an inflammatory response in the uterus which may affect implantation. So, potentially disrupts implantation.
The second type of IUD is the hormonal IUD, such as Mirena or Skylar. It is a small plastic device that contains progesterone, which acts in much the same way that the progesterone pills function. They are effective for about 3-5 years after insertion and prevent 99% of pregnancies. In theory, these can cause a foreign body reaction in the uterus that prevents implantation, but women can still get pregnant using this device, and it's not very effective as an emergency contraception, so it doesn't seem that this is an active issue. Therefore, I say it's not an abortifacient.
Conclusions: Hobby Lobby may have had a case. As I mentioned, I disagree with the decision on multiple fronts, and this was only the start of it. At minimum, they should not be permitted to object to Plan B and hormonal IUDs on the basis of them being abortifacients, because the science indicates that they are not, and thus it is a flawed argument. Ella and other similar oral emergency contraceptives need to be studied more before we determine for certain whether they result in decreased implantation of a viable embryo. Copper IUDs likely produce an environment that is hostile to life in general in the uterus, and thus potentially disrupt implantation.
There is some disagreement about the term 'abortifacient' as well, since by definition an abortion is the termination of a pregnancy, and a pregnancy can only occur if there is implantation of the embryo, but I chose not to get into this discussion for now.
Thoughts? Questions? Concerns? Feel free to comment or use the contact me form located at the top of the blog. See you next week!
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