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Patient is (PIC)turing Pregnancy - Previous Pregnancy Outcomes

Background

  • Scope: Ohio presents many areas of concern related to infant deaths and other adverse pregnancy outcomes:

  • Miscarriages: About 1 in 5, usually very early in pregnancy.

  • Infant mortality rate 2011 – 2013 of 23 per 1,000 live births in some counties, black infant mortality at 13.6 per 1,000 live births (March of Dimes PeriStats: http://www.marchofdimes.org/Peristats/ViewSubtopic.aspx?reg=39&top=6&stop=94&lev=1&slev=4&obj=1)

    • Leading causes of death for Ohio (2013) infants include:

      • Birth defects (148.3 per 100,000 live births)

      • Premature/Low birth weight (139.2 per 100,000 live births)

      • SIDS (63.7 per 100,000 live births)

      • Respiratory Distress Syndrome (11.7 per 100,000 live births)

      • Maternal pregnancy complications (50.6 per 100,000 live births)

  • Still Birth Outcomes for Ohio:

    • Perinatal mortality (2006): 7.4 per 1,000 live births and fetal deaths

    • Late fetal mortality (2006): 3.0 per 1,000 live births and fetal deaths

  • Women’s heath complications pose very significant risks to the pregnancy and infant, as well as life-long illness. For example, a woman with preeclampsia/eclampsia, has a 1.4 -3.98 risk of developing chronic hypertension after pregnancy.

  • Preconception Significance: Adverse pregnancy outcomes are of significance because adverse previous pregnancy outcomes are directly related to subsequent pregnancy outcomes.

Maternal complications can predict the development of chronic illness that could impact her health, future pregnancies, and children.

  • Risk Identification Strategies: Postpartum is the best time to determine risk factors: obtain prenatal records, discharge summaries, operative notes, pathology reports, autopsy findings, lab results, and patient interviews. NOTE: primary care provider may not be patient’s provider during pregnancy or conducting postpartum visits.

  • Review obstetric history annually in order to easily spot adverse conditions and pregnancy outcomes including:

  • Spontaneous abortions

  • Prior stillbirth

  • Preterm birth

  • Fetal growth restriction

  • Prior infant congenital abnormalities or genetic disorders

  • Preeclampsia

  • Uterine anomalies

  • Cesarean births (mainly if woman has had several caesarean sections)

Clinician Guide

  • Acknowledge her fears and assure her that a healthy pregnancy is more likely than she fears.

  • Educate her on her specific risks for a poor pregnancy outcome.

  • Encourage contraception until she has achieved a healthy state and has completed consultations.

  • Stress the importance of the interconception period of at least 18 months before the next pregnancy (modify if necessary based on maternal age, fertility issues, etc.).

  • Stress the importance of the multivitamin with 400 mcg of folic acid daily.

Miscarriage

  • Incidence: Up to 15 percent of diagnosed pregnancies in U.S.

  • Recurrent pregnancy loss: 2+ miscarriages

  • Recurrence risk: About 65 percent of those who have had 2 or more miscarriages will have a successful subsequent pregnancy. Offer these women reassurance and support, and a referral to an OB/Gyn or maternal fetal medicine specialist for a work-up. Timing for another pregnancy should allow for grieving (an interval of 6 months is recommended).

Stillbirth

  • Incidence: 6.1/1,000 live births in U.S. (includes fetal death)

  • Recurrent risk: 1.5-3 times the risk if patient has history of still birth. Provider should offer reassurance and support, assess for depression and mental health and refer to appropriate support personnel (religious leader, support group, mental health professional, etc.). Encourage an interconception period of 18-59 months (modify if necessary based on maternal age, gestational age at fetal death, grieving time, etc.). Advise women to conceive only after visiting OB/Gyn or maternal fetal medicine specialist.

Preterm Birth

  • Incidence: 12 percent of all births in U.S. (2010)

  • Recurrence risk: 16 percent if one previous preterm, 41 percent if two previous preterm, 67 percent if three previous preterm. Encourage that despite risk percentages, there are opportunities to reduce risks. Stress the importance of the interconception period of 18 - 59 months before the next pregnancy (modify if necessary based on maternal age, fertility issues, etc.). Refer women to an OB/Gyn or maternal fetal medicine specialist before attempting conception again for evaluation of history and risk reduction strategies.

Hypertensive Disorders (Preeclampsia/Eclampsia)

  • Prevalence: About 10 percent of pregnancies.

  • Recurrence risk: Depends of gestational age of onset, severity, and presence of chronic hypertension illness. Asses hypertensive history, categorization, gestational age, and severity to find recurrence risk.

  • Interconception period intervention: Check blood pressure at least 6 weeks after delivery for raised levels. If elevated, patient has chronic hypertension. Provider should counsel on long term risks and management with certain medications that are teratogenic. Also assess for cardiovascular disease, obesity, diabetes mellitus, connective tissue disease, acquired thrombophilia, and renal disease. Obtain a baseline laboratory evaluation. Counsel on weight loss if overweight/obese. Stress the importance of the interconception period of 18-59 months before the next pregnancy (modify if necessary based on maternal age, fertility issues, etc.).

Infant Death

  • Incidence: 6.0 per 1,000 live births (2003-2013)

  • Recurrence risk: Dependent upon the nature of the infant death (ex. depending on whether due to premature birth, birth defects, low birth weight, SIDS, etc.) Premature birth and low birth weight cause about 1 in 4 of neonatal deaths, while birth defects cause about 1 in 5 neonatal deaths. Provider should offer reassurance and support, assess for depression and mental health and refer to appropriate support personnel (religious leader, support group, mental health professional, etc.). Encourage that despite risk percentages, there are opportunities to reduce risks for next pregnancy. Stress the importance of the interconception period of 18 - 59 months before the next pregnancy (modify if necessary based on maternal age, fertility issues, grieving time, etc.). Refer women to an OB/Gyn or maternal fetal medicine specialist before attempting conception again for evaluation of history and risk reduction strategies. http://www.marchofdimes.org/complications/neonatal-death.aspx

Low Birth Weight

  • Incidence: 8 percent of babies in the U.S. (2014) (Very low birthweight – 1.4% in 2014)

  • Recurrent Risk: Depends on medical and behavioral risk factors of mother. Medical: chronic illnesses, infections, previous low birth weight baby, congenital anomalies, problems with placenta, or not gaining enough weight during pregnancy. Behavioral: smoking, drinking alcohol, using street drugs, and prescription drug abuse. NOTE: Black women in the U.S. are more likely to have a low birth weight baby (more than 13 percent). Stress prenatal care for gestational age assessment and ultrasounds. Stress the importance of the interconception period of 18 - 59 months before the next pregnancy (modify if necessary based on maternal age, fertility issues, etc.). Refer women to an OB/Gyn or maternal fetal medicine specialist before attempting conception again for evaluation of history and risk reduction strategies.

    http://www.marchofdimes.org/complications/low-birthweight.aspx

Gestational Diabetes

  • Prevalence: 6-7 percent of pregnancies in the U.S.

  • Recurrence Risk: Up to 50 percent of women with gestational diabetes will have type 2 diabetes 20-30 years following pregnancy, most risky period in the first 5 years after pregnancy. Provider should screen after pregnancy with 2 hour GTT and rescreen every 3 years. Women showing impaired glucose tolerance will need healthy lifestyle changes or metformin if fasting value is elated. Refer woman to primary care provider. Advise appropriate interval interpregnancy period with stable glucose levels before next attempt to conceive.  


Page Updated: 8/15/2017