Download Fetal Health - Dassow - 11-29

Where it all begins:
Optimizing Fetal Health
Paul Dassow, MD, MSPH &
A. Stevens Wrightson, M.D.
11/29/2006
Questions?
• What are the “factors” that contribute to the
health of a fetus?
• What are some threats to fetal health?
• What is the healthcare provider’s role in
discussing the health of the expectant mother
and her fetus?
• How are we doing locally and nationally in
maintaining/improving fetal health?
Determinants of Fetal Health
• Fetal factors
– Genetics
• Female or male
• Blue or brown eyes
• Sickle cell anemia, phenylketonuria, galactosemia
– Healthy/not healthy
• 50% or more of pregnancies end in spontaneous
abortion, half of which are due to major
chromosomal abnormalities
Determinants of Fetal Health
• “Environmental”/ External/Other factors
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Maternal health
Maternal past medical history
Reproductive history
Family history
Social issues and preparedness for pregnancy (and
parenthood)
– Drug exposure
– Infection exposure/risks
Healthy People 2010
• Incorporates a broad, cross-section of experts
from a large number of local, state and federal
agencies
• Represents a blueprint for healthcare and
progress for this decade
– Goal 1: Increase quality and years of healthy life
– Goal 2: Eliminate health disparities
• 10 Leading health indicators
• 28 focus areas
– Focus area 16: Improve the health and well-being of
women, infants, children, and families
Problems as Seen by
Healthy People 2010
• U. S. Ranks 25th in infant mortality among
industrialized nations
• Cases of low birth weight and very low
birth weight have increased in the U. S. in
the last 10 years
• There exists a significant disparity in infant
mortality between whites and other ethnic
groups
Other Problems
• 50% of pregnancies in the United States are
unintended
• 80% of teen pregnancies are unintended
– Teen birth rate/1000: 43 (U.S.), 51 (Ky., 15th)
• Resulting in:
– Delay in prenatal care
– Increase adverse birth outcomes
– Loss of the ability to intervene to improve the health
of the mother and her baby
What to do?
• Reproductive health counseling
– Identify and reduce risks
– Improve overall health
– Prepare for/prevent pregnancy
• Prenatal care
– Medical risk factor surveillance
– Psychosocial assessment-hopes, fears, expectations
• Preventive care for both the mother and her
child and family after delivery
What I will cover
• The 5 major causes of infant and neonatal
death
• The difference between low birth weight,
very low birth weight and short gestation
and some of the associated risk factors
and consequences
• Some of the implications of tobacco,
alcohol and illegal drug use on fetal health
What I will cover
• The recommended nutritional requirements for
healthy fetal growth, specifically folic acid
• Safety recommendations
• The impact of intimate partner violence on fetal
health
• The disparities between whites and other ethnic
groups as they pertain to fetal health
Pregnancy Definitions
• Last menstrual period (LMP) – generally
occurs 2 weeks before conception
• Conception – fertilization of the human
egg 14 days after the onset of LMP
• Expected date of delivery (EDD) – 40
weeks after the LMP or 38 weeks after
conception.
Milestones
• Week 2 after LMP - fertilization has occurred
• Week 3 – implantation occurs, human chorionic
gonadotropin (HCG) begins to rise
• Weeks 4 or 5 – the first missed period
• Weeks 4 to 10 – major organogenesis is
occurring
Implications for Fetal Health
• Fetal organogenesis often has begun before a
woman knows she is pregnant
• Maternal healthful habits should begin prior to
conception
• Due to the unplanned nature of many
pregnancies, these habits should begin once a
woman reaches child-bearing potential
(adolescence)
• Men’s health has an impact as well (drug use,
history of violence, economic support)
Infant Mortality
• Infant death
– Death prior to one year of age
– Incidence in the U. S.- 7.0/1000 (first increase since
1950’s)
– Incidence in Ky.- 5.9/1000
• Neonatal death
– Death prior to 28 days
– Incidence – 4.7/1000 (accounts for most of the
increase)
Causes
• Congenital anomalies
• Disorders due to short gestation or low
birth weight
• Sudden infant death syndrome
• Maternal complications of pregnancy
• Complications of the placenta, cord, or
membranes
Fetal Death
• Death prior to birth, after 20 weeks EGA
• Incidence – 6.8-7.5/1000
• Causes:
– Problems with amniotic fluid levels
– Maternal blood disorders
– Maternal complications of pregnancy
Birth Weight vs. Gestational Age
• Low birth weight (LBW) – less than 2500
gm
• Premature birth (short gestation) - birth
prior to 37 weeks
• Very low birth weight (VLBW) – less than
1500 gm
• Extremely low birth weight (ELBW) – less
than 1000 gm
Implications of Low Birth Weight
• Long term disabilities
– Cerebral palsy
– Autism
– Mental retardation
– Vision and hearing deficits
• Costs
– $1900 for normal newborn care
– $6200 for care of LBW child
Congenital Anomalies
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3% overall incidence
Often genetic and unpreventable (70%)
Cause of 20% of infant deaths
At least 30% are preventable
– Folic acid
– Alcohol
– Other drugs (teratogens)
Teratogens
• Thalidomide-limb defects
• Valproic acid-neural tube defects
• Tetracycline-teeth and bone maldevelopment
• Warfarin-nasal hypoplasia and bone maldevelopment
• Accutane-craniofacial and cardiac defects
Sudden Infant Death Syndrome
(SIDS)
• Cause is unknown
• Higher in certain ethnic groups
– African Americans
– Native Americans
• Higher in households of smokers
• Higher in households with lower education
• Higher in certain sleeping positions
– “Back to Sleep” campaign (China)
Maternal Complications of
Pregnancy
• Diabetes, before and during pregnancy
– HgB A1C values >10 vs. <8
– Controlled vs. uncontrolled diabetes
– Screen those at risk-Obese and overweight
• Hypertension, before and during pregnancy
• Infections
– Sexually transmitted diseases (Syphilis, HIV)
– Viral or bacterial diseases (Varicella, Group B Strep)
• Blood disorders (anemia, Rh sensitization)
Complications of the Placenta,
Cord, or Membranes
• Abnormal placental location or insertion
• Cord prolapse
• Premature rupture of the membranes
Trends and Associations
• Blacks had high rates of infant mortality
(14.4/1000) and neonatal mortality
(9.5/1000)
• Hispanic subgroups had wide variations,
for example, between Puerto Rican infants
(8.5/1000) and Cuban infants (4.2/1000)
Trends and Associations
• Rate of infant mortality highest in the south
(Mississippi 10.3/1000)
• Lowest in the west and northeast
(Massachusetts 4.9/1000)
• District of Columbia had highest rate
(11.3/1000) similar to other big cities with a
concentration of high risk women
Trends and Associations
• Male sex
• Multiple births
• Maternal age
– Teens and advanced maternal age(>40) at
risk
• Low birth weight and short gestation are
the 2 most important predictors of infant
mortality, long term and short term
disability
Tobacco and Fetal Health
• Tobacco use
– Increases the risk of placental abruption or previa,
pregnancy-induced hypertension, short gestation,
LBW and SIDS
– Cost is $1.4-2.0 billion a year due to complicated
births
– Simple advice to quit has a small but significant
impact in reducing smoking
– Smoking bans and tobacco taxes decreases smoking
rates, particularly in teens
Alcohol and Fetal Health
• Alcohol use
– 34% of U.S. women drink alcohol during
pregnancy
– Mild intake can cause subtle abnormalities
– There is no known safe threshold
– Reasonable recommendation?
Alcohol Abuse
• Fetal alcohol syndrome is characterized by
congenital malformations and mental retardation
• Leading known environmental cause of mental
retardation in the western world
• 4000 to 12000 newborns a year affected
• Fetal Alcohol Syndrome causes:
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LBW
Mental retardation
Microcephaly and other birth defects
Behavioral disturbances
Drug Use and Fetal Health
• Substance Abuse
– Short gestation and LBW
– Increases risks of infection
• Hepatitis B and C
• HIV
• Other STD’s
– Self reported use– 3-15%
Kentucky Drugs
• Methamphetamine
– Abortion, congenital anomalies (heart, biliary
atresia?), depression of interactive behavior, growth
restriction, placental abruption, congenital stroke,
withdrawal, fetal death
• Abused prescription drugs/narcotics
– Growth restriction, withdrawal (intra- and extrauterine), preterm delivery, premature rupture of the
membranes, increased meconium-stained fluid,
perinatal death
Nutrition and Fetal Health
• Folic acid supplementation reduces the risk of
neural tube defects at first delivery
• Children affected by NTD each year: 4000
• Reduction with folate: 50%
• Dosage:
– 400mcg if no past history of child with NTD
– 4000mcg if history of previous child with NTD
– Over-the-counter multivitamins typically have 400mcg
of folate
Nutrition and Fetal Health
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Calcium requirements – 1200mg
Iron supplementation – 30mg Fe
Calorie intake – 2500 to 2600
Weight gain
– Normal BMI – 25-35 pounds
– Low BMI – 28-40 pounds
– High BMI – 15-25 pounds
Safety and Fetal Health
• Injury and violence
– Seatbelts in pregnancy
– Screen for alcohol and other drugs
– Screen for violence
– Preventive services
Intimate Partner Violence and
Fetal Health
• Injury and violence
– Affects 4-17% of pregnancies
– Affects 35% of women who have been
abused in the past
– Risks include drug and alcohol use,
depression or anxiety, inadequate prenatal
care, and homelessness
Intimate Partner Violence
• Complications include placental abruption,
short gestation and LBW, and fetal injury
or death from blunt or penetrating trauma
• Maternal mortality estimates – 13-35%
due to intimate partner violence
Healthy People 2010
• Goal 1: Increase quality and years of
healthy life
• Goal 2: Eliminate health disparities
• Leading health indicators
– Focus area 16: Improve the health and wellbeing of women, infants, children, and
families
Disparities in Fetal Health
• In 2001 mortality in African American infants was
2.5 times that of whites
– In Ky. Infant death rate/1000 is 5.6 for whites, 9.7 for
African-Americans, 5.9 overall
• LBW in African Americans, though declining, is
twice that of whites (13% to 6.5%)
• Fetal alcohol syndrome disproportionately
affects Native, Alaskan, and African-Americans
• Socioeconomic status continues to impact fetal
health (LBW, short gestation, drug use)
Successes
• Decrease in infant mortality and low birth weight
due to?
– Decrease in teen birth rate (26.2% decline from 19912001)
– Early prenatal care
– “Back to Sleep” education
– Folate education
– Others
• Why the increase in 2002?
Case 1
• JM is a 28 year old 2nd grade teacher. She
goes to see her gynecologist for her
“annual” and tells him that she and her
husband of 4 years would like to start their
family. She has never been pregnant and
wonders if there is anything she should do
to prepare.
Case 1
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JM is in excellent health
Good nutrition and exercise habits
Takes oral contraceptives
No other medicines, vitamins or herbals
No risky behaviors
No family history of inherited or congenital
disorders
Positive influences
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Preparation for pregnancy
Healthy lifestyle
Family history
Social support
Negative influences
• Lack of folic acid supplementation
Interventions
• Add folic acid
• Screening
– Immunizations
– STD’s
– Safety
– Inherited disorders
Case 2
• MW is a 16 year old female who comes in
to discuss contraception with her family
physician. She has just initiated sexual
activity with her boyfriend and, having
discussed this with her mother, wants to
start something to prevent pregnancy. She
decides upon long acting progesterone
injections.
Case 2
• As is clinic policy, she undergoes a
pregnancy test which is negative prior to
receiving the injection. She is also
counseled and screened for STD’s. As a
regular patient to the clinic, she has
previously been updated on immunizations
and counseled about tobacco, alcohol,
and drug use. She denies using any
substances.
Case 2
• She returns 4 weeks later having missed a
period and experienced some nausea. A
pregnancy test at home was positive and
is confirmed in the office. A dating
ultrasound would indicate she probably
was 7 to 10 days pregnant at the time she
received her progesterone injection.
Positive influences
• Patient is otherwise healthy
• Not engaged in risky behaviors, except
sexual activity
• Supportive home environment
• Family history negative
• Early diagnosis
Negative influences
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Unplanned
Teen pregnancy
Drug exposure
Lack of folic acid
Interventions
• Screening
– STD’s
– Abuse
– Substance use
• Folic acid
• Frequent follow-up/Prenatal care
– Education
– Preparation for parenting
– Stay in school
Fetal Health Continuum
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Woman’s health/Family health
Preconception
Periconception
Embryologic development
Fetal growth and maturation
Birth
Child’s health/Family health/Community health
References
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Healthy People 2010
Behavior and Medicine
http://www.cdc.gov/nchs/hus.htm
http://www.statehealthfacts.kff.org/
National Vital Statistics Report; Births, vol. 52 no. 10,
Dec 2003.
• National Vital Statistics Report; Deaths, vol.53, no. 5,
Oct 2004.
• Rayburn WF, Pharmacotherapy for pregnant women with
addiction. American Journal of ObGYN:191;6, Dec 2004.