preconception care in the context of maternal mortality ashlesha k. dayal, md assistant professor...
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Preconception Care in the Preconception Care in the Context of Maternal Context of Maternal
MortalityMortality
Ashlesha K. Dayal, MDAshlesha K. Dayal, MDAssistant Professor Obstetrics and Gynecology and Assistant Professor Obstetrics and Gynecology and
Women’s HealthWomen’s Health
Albert Einstein College of Medicine/ Montefiore Albert Einstein College of Medicine/ Montefiore Medical CenterMedical Center
Bronx, NYBronx, NY
How to Save a Life
Renal TransplantRenal Transplant29 y/o P0 presents to MFM for 129 y/o P0 presents to MFM for 1stst PNV at 15 wks PNV at 15 wksSLE, renal failure, dialysisSLE, renal failure, dialysis1998 Renal transplant from sister 1998 Renal transplant from sister – Failed after 6 days, secondary to thrombosisFailed after 6 days, secondary to thrombosis
1998 21998 2ndnd renal transplant from husband renal transplant from husband – – stable on immunosuppresive meds for 6 yearsstable on immunosuppresive meds for 6 years
Nephrologist stops meds at 7 wks of pregNephrologist stops meds at 7 wks of pregAbnormal u/a & inc creatinine – 10 wksAbnormal u/a & inc creatinine – 10 wksRenal bx in pregnancy to r/o rejection – 10 wksRenal bx in pregnancy to r/o rejection – 10 wksHemorrhage from bx – nephrectomyHemorrhage from bx – nephrectomy
Renal TransplantRenal Transplant
Pregnancy on dialysis since 10 wksPregnancy on dialysis since 10 wks
Uncontrollable HTN, seizures at 23 wks, pt Uncontrollable HTN, seizures at 23 wks, pt declines TOP despite risk of maternal declines TOP despite risk of maternal deathdeath
Fetus IUGR (280gm at 24 wks) – IUFDFetus IUGR (280gm at 24 wks) – IUFD
Patient anephric on dialysis, awaits Patient anephric on dialysis, awaits transplanttransplant
Renal TransplantRenal Transplant Preconception Counseling & Preconception Counseling &
RecommendationsRecommendations
Evaluate length of time without rejectionEvaluate length of time without rejection
Continue immunosuppressive medicationsContinue immunosuppressive medications– Benefit of controlling rejection outweighs Benefit of controlling rejection outweighs
theoretical risks of medicationstheoretical risks of medications
Obtain baseline renal functionObtain baseline renal function
Folic acidFolic acid
20072007
The State of Maternal The State of Maternal Mortality……..Mortality……..
Daily Death Toll: during pregnancy & in childbirthduring pregnancy & in childbirth
WORLDWIDE
Lifetime risk of Maternal Death Lifetime risk of Maternal Death
Africa Africa 1 in 201 in 20
Asia Asia 1 in 941 in 94
Latin America/Caribbean 1 in 160Latin America/Caribbean 1 in 160
AustraliaAustralia 1 in 831 in 83
Developed Regions Developed Regions 1 in 28001 in 2800
Source: JAMWA 2001
MMR Industrialized Nations, 1990-1994
ACOG/CDC DefinitionsACOG/CDC DefinitionsPregnancy-associated death.Pregnancy-associated death.
The death of a women while The death of a women while pregnant or within one year pregnant or within one year of termination of pregnancy, irrespective of causeof termination of pregnancy, irrespective of cause..
Pregnancy-related death.Pregnancy-related death.The death of a women while pregnant or within one year of The death of a women while pregnant or within one year of termination of pregnancy, irrespective of the duration & site termination of pregnancy, irrespective of the duration & site of the pregnancy, of the pregnancy, from any cause related to or from any cause related to or aggravated by her pregnancy or its managementaggravated by her pregnancy or its management, but not , but not from accidental or incidental causes.from accidental or incidental causes.
Not-pregnancy-related death.Not-pregnancy-related death.The death of a women while pregnant or within one year of The death of a women while pregnant or within one year of termination of pregnancy, due to a cause termination of pregnancy, due to a cause unrelated to unrelated to pregnancypregnancy..
Source: Berg, Atrash, Zane, Barlett. Strategies to reduce pregnancy-related deaths: From identification and review to action. Atlanta: Center for Disease Control and Prevention 2001.
Maternal Mortality: Maternal Mortality: Nationally Nationally
and in and in New York StateNew York StateHealthy People 2010 Goal:
3.3 Per 100,000 livebirths
Maternal Mortality Ratios Maternal Mortality Ratios 1987 - 19961987 - 1996
9.7
11.7
3.8
11.7
9.1
5.37.5
12.3
7.4
7.7
11.9
3.8
6.44.3
6.3
6.4
9.1
5.3
9.5
4.6
5.95.1
4.3
6.3
3.4
6.9
3.6
4.6
1.9
5.9
3.5
3.7
8.1
3.3
6.1
7.7
6.2 6.2
5.8
6.3
6.7
8.2
10.710.8
7.5 4.56.9
Source: NCHS, Vital statistics
12.03.1
22.8 (D.C.)5.2
> 7.4
5.3 - 7.4< 5.3
National: 7.7 / 100,000 (1987-1996)
Maternal Mortality Ratios for Maternal Mortality Ratios for White Women:1987-1996White Women:1987-1996
5.3
6.2
3.4
6.7
9.2
5.03.6
5.1
5.8
6.3
6.3
3.9
5.2
5.9
6.1
3.9
7.0
3.6
5.64.5
3.2
6.5 5.76.9
3.0
6.7
6.1
4.6 4.1
3.8
4.5
7.0
4.9
5.56.6
4.3 4.03.9
Source: NCHS, Vital statistics
7.62.7
4.0
> 7.45.3 - 7.4< 5.3unable to calculate reliably
Note: The colors on these maps show the states divided into three terciles based on their MMR.
Maternal Mortality Ratios for Maternal Mortality Ratios for Black Women 1987-1996Black Women 1987-1996
24.8
18.9
21.1
22.6
20.5
15.3
17.4
21.2
20.5
27.3 15.9
16.2
17.9
18.4 12.4
12.0
16.8
19.5
20.317.4
21.313.319.0
28.78.7
25.7 (D.C.)
> 7.47.4 - 5.3< 5.3unable to calculate reliably
Source: NCHS, Vital statistics
15.9 in NYS15.9 in NYS
A Regional Look at Maternal A Regional Look at Maternal Mortality Rates* for the Mortality Rates* for the
Year 2000Year 2000
*Per 100,000 livebirths
9.5 in Upstate New York9.5 in Upstate New York
23.1 in NYC23.1 in NYC
Trends in Maternal Mortality Ratio by Race/Ethnicity:NYC OVS, 1993-2002
0
10
20
30
40
50
60
70
80
90
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Pe
r 1
00
,00
0 L
ive
Bir
ths
Black non-Hispanic White non-Hispanic Puerto Rican
Other Hispanic Asian/Pacific Islander
Source: NYC DOHMH Office of Vital Statistics
Comparing Leading Causes of Death Comparing Leading Causes of Death (%)(%)
CauseCauseInternationalInternational
PRMR*PRMR*
National PRMR National PRMR
N=4200**N=4200**
NYC PRMR NYC PRMR
N=119N=119
EmbolismEmbolism NegligibleNegligible 20%20% 7%7%
Hypertensive Hypertensive DisordersDisorders 12%12% 16%16% 10%10%
HemorrhageHemorrhage 25%25% 17%17% 32%32%
Infection/Infection/SepsisSepsis 15%15% 13%13% 7%7%
OtherOtherObstructed Obstructed Labor 8%Labor 8%
Unsafe Ab 13%Unsafe Ab 13%
Cardiomyopathy Cardiomyopathy 8%8%
CVA 5.0%CVA 5.0%
Anesthesia 2%Anesthesia 2%
CardiomyopatCardiomyopathy 8%hy 8%
Anesthesia 7%Anesthesia 7%
*International WHO 1993, JAMWA 2002
**National MMWR 2003
***NYC BMIRH 1998-2000
Preconception BackgroundPreconception Background
In 2000, 4.1 million women aged 18-44 In 2000, 4.1 million women aged 18-44 made visits to family physiciansmade visits to family physicians
Opportune times for preconception Opportune times for preconception discussions—well woman visit, discussions—well woman visit, negative pregnancy test, follow up negative pregnancy test, follow up visits after spontaneous or voluntary visits after spontaneous or voluntary abortionsabortions
Preconception CarePreconception Care
What is preconception care?What is preconception care?– Risk assessment for a future pregnancyRisk assessment for a future pregnancy– Assessment of broad range of risk factorsAssessment of broad range of risk factors– Timing of this risk assessmentTiming of this risk assessment
Preconception CarePreconception Care
Identifies reducible or reversible risksIdentifies reducible or reversible risks
Maximizes maternal healthMaximizes maternal health
Intervenes to achieve optimal Intervenes to achieve optimal outcomesoutcomes
From March of Dimes Preconception Curriculum
Preconception CarePreconception Care
Reframes IssuesReframes Issues
Adds an anticipatory elementAdds an anticipatory element
Focuses on the impact of pregnancyFocuses on the impact of pregnancy
From March of DimesPreconception Curriculum
Elements of Preconception CareElements of Preconception Care
Focuses on elements which must be Focuses on elements which must be accomplished prior to conception or accomplished prior to conception or weeks thereafter to be effectiveweeks thereafter to be effective– Risk assessmentRisk assessment– Health promotionHealth promotion– Medical and psychosocial interventionsMedical and psychosocial interventions
From March of DimesPreconception Curriculum
Components to Preconception Components to Preconception CareCare
Medical HistoryMedical History
Pychosocial IssuesPychosocial Issues
Physical ExamPhysical Exam
Laboratory testsLaboratory tests
Family HistoryFamily History
Nutritional AssessmentNutritional Assessment
Components to Preconception Components to Preconception CareCare
Medical historyMedical history– Particular medical conditions that lend Particular medical conditions that lend
themselves to Pre-pregnancy managementthemselves to Pre-pregnancy managementDiabetesDiabetes
HypertensionHypertension
Seizure disorderSeizure disorder
Cardiac diseasesCardiac diseases
Lupus, sickle cell disease, renal diseaseLupus, sickle cell disease, renal disease
Components to Preconception Components to Preconception CareCare
Obstetrical HistoryObstetrical History– Risk factor assessment for Preterm Risk factor assessment for Preterm
DeliveryDeliveryPrevious preterm delivery—most important risk Previous preterm delivery—most important risk factorfactor
History of fetal loss—what gestational age?History of fetal loss—what gestational age?
Interpregnancy interval--<18 monthsInterpregnancy interval--<18 months
Obstetrical conditions at high risk---Obstetrical conditions at high risk---incompetent cervix, history of premature incompetent cervix, history of premature rupture of membranes, uterine malformationsrupture of membranes, uterine malformations
Components to Preconception Components to Preconception CareCare
Pychosocial IssuesPychosocial Issues– Screening for Depression—discussion of Screening for Depression—discussion of
medication, therapy and PP depression risk medication, therapy and PP depression risk – Emotional or Physical Abuse--offer confidential, Emotional or Physical Abuse--offer confidential,
safe screening and discussion safe screening and discussion Assess safetyAssess safety
One third of women reporting violence report escalation One third of women reporting violence report escalation in pregnancyin pregnancy
Role of health care providerRole of health care provider
Components to preconception Components to preconception carecare
Immunization HistoryImmunization History– Rubella, VaricellaRubella, Varicella
Physical examPhysical exam
Laboratory testsLaboratory tests– In patients with particular histories, In patients with particular histories,
antiphospholipid screens best done prior antiphospholipid screens best done prior to pregnancyto pregnancy
Components to Preconception Components to Preconception CareCare
Family HistoryFamily History– Genetic historyGenetic history– Discussion of age-related risksDiscussion of age-related risks– Discussion of disease related risksDiscussion of disease related risks– Carrier screeningCarrier screening– Potential for egg or sperm donation or Potential for egg or sperm donation or
early genetic screeningearly genetic screening
Components to Preconception Components to Preconception CareCare
Nutritional AssessmentNutritional Assessment– Folic Acid for Everyone!! Modifies risk for neural Folic Acid for Everyone!! Modifies risk for neural
tube defect—0.4 mg everydaytube defect—0.4 mg everyday– BMI Assessment: underweight, overweightBMI Assessment: underweight, overweight– Identifiying particular nutritional targets: iron Identifiying particular nutritional targets: iron
deficiency, vitamin excess (A and D)deficiency, vitamin excess (A and D)– Pica screeningPica screening
Lifestyle Risk AssessmentLifestyle Risk Assessment
Effects of various substance use on Effects of various substance use on pregnancy and fetuspregnancy and fetus
Screening for use and abuseScreening for use and abuse
Referral for treatment Referral for treatment options/programsoptions/programs
Emphasize using pregnancy as Emphasize using pregnancy as motivation for changemotivation for change
Tobacco and PreconceptionTobacco and Preconception
Tobacco: most preventable cause of Tobacco: most preventable cause of LBWLBW– Associations with abruption, placenta Associations with abruption, placenta
previa, preterm deliveryprevia, preterm delivery– Cessation at any time in pregnancy Cessation at any time in pregnancy
improves risksimproves risks– How to offer help with cessationHow to offer help with cessation
Alcohol and PreconceptionAlcohol and Preconception
Most preventable cause of Mental Most preventable cause of Mental Retardation---fetal alcohol syndromeRetardation---fetal alcohol syndromeMost common teratogen exposureMost common teratogen exposureDose related effects---worst outcomes Dose related effects---worst outcomes with “binge drinking”with “binge drinking”Effects can be seen at all stages of Effects can be seen at all stages of pregnancypregnancy
Drug use and PreconceptionDrug use and Preconception
Cocaine Cocaine
Heroin Heroin
Methadone Methadone
Congenital anomalies, Congenital anomalies, placental abruption, LBWplacental abruption, LBW
Newborn withdrawl, LBWNewborn withdrawl, LBW
Newborn withdrawlNewborn withdrawl
““The failure to address preventable The failure to address preventable maternal disability and death represents maternal disability and death represents one of the greatest social injustices of our one of the greatest social injustices of our times….Women’s reproductive health risks times….Women’s reproductive health risks are are notnot mere misfortunes and unavoidable mere misfortunes and unavoidable disadvantages of pregnancy, but rather, disadvantages of pregnancy, but rather, injustices that societies are able and injustices that societies are able and obliged to remedy…”obliged to remedy…”
Rebecca J. Cook, Bernard M. Dickens, WHO, 2001
Maternal Mortality Ratios per 100,000 Live Births, 2000WHO, United Nations