Transcript Preconception Care and Maternal Mortality

Preconception Care in the
Context of Maternal
Mortality
How to Save a Life
Ashlesha K. Dayal, MD
Assistant Professor Obstetrics and Gynecology and
Women’s Health
Albert Einstein College of Medicine/ Montefiore
Medical Center
Bronx, NY
Renal Transplant
29 y/o P0 presents to MFM for 1st PNV at 15
wks
SLE, renal failure, dialysis
1998 Renal transplant from sister
– Failed after 6 days, secondary to thrombosis
1998 2nd renal transplant from husband
– stable on immunosuppresive meds for 6 years
Nephrologist stops meds at 7 wks of preg
Abnormal u/a & inc creatinine – 10 wks
Renal bx in pregnancy to r/o rejection – 10
wks
Hemorrhage from bx – nephrectomy
Renal Transplant
Pregnancy on dialysis since 10 wks
Uncontrollable HTN, seizures at 23 wks, pt
declines TOP despite risk of maternal
death
Fetus IUGR (280gm at 24 wks) – IUFD
Patient anephric on dialysis, awaits
transplant
Renal Transplant
Preconception Counseling &
Recommendations
Evaluate length of time without rejection
Continue immunosuppressive medications
– Benefit of controlling rejection outweighs
theoretical risks of medications
Obtain baseline renal function
Folic acid
2007
The State of Maternal
Mortality……..
WORLDWIDE
Daily Death Toll:
during pregnancy & in childbirth
Lifetime risk of Maternal Death
Africa
Asia
Latin America/Caribbean
Australia
Developed Regions
1 in 20
1 in 94
1 in 160
1 in 83
1 in 2800
MMR Industrialized Nations, 1990-1994
Source: JAMWA 2001
ACOG/CDC Definitions
Pregnancy-associated death.
The death of a women while pregnant or within one year
of termination of pregnancy, irrespective of cause.
Pregnancy-related death.
The death of a women while pregnant or within one year of
termination of pregnancy, irrespective of the duration & site
of the pregnancy, from any cause related to or
aggravated by her pregnancy or its management, but not
from accidental or incidental causes.
Not-pregnancy-related death.
The death of a women while pregnant or within one year of
termination of pregnancy, due to a cause unrelated to
pregnancy.
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:
Nationally
and in
New York State
Healthy People 2010 Goal:
3.3 Per 100,000 livebirths
Maternal Mortality Ratios
1987 - 1996
1
.
9
9
.
1
6
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3
3
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3
3
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5
7
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7
4
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6
3
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8
3
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1
5
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7
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0
5
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9
7
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5
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6
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4
3
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45
6
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4
6
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9
6
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3
4
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3
7
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5
4
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5
3
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8
6
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9
5
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9
5
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8
8
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1
6
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37
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4
9
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1
6
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7
1
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92
2
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8
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8
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5
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2
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26
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2
9
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5
1
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8
1
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7
1
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7
1
2
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3
National: 7.7 / 100,000
7
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7
(1987-1996)
1
1
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7
3
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6
6
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1
9
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7
4
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S
o
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>
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3
Maternal Mortality Ratios for
White Women:1987-1996
3
.
0
9
.
2
6
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1
3
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6
3
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4
2
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7
3
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9
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6
3
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0
5
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3
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9
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0
6
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8
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25
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8
6
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6
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3
4
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9
4
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0
4
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64
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1
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6
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5
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5
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S
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,
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a
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a
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Note: The colors on these maps show the states
divided into three terciles based on their MMR.
>
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<
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3
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Maternal Mortality Ratios for
Black Women 1987-1996
1
6
.
2
2
2
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6
1
7
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9
2
8
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7
2
0
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5
1
9
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0
6
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8
2
1
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31
1
3
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3
1
2
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0
2
7
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3
1
5
.
3
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9
2
1
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22
5
.
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1
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1
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4
1
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1
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2
0
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1
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1
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1
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4
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Source: NCHS, Vital statistics
8
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7
A Regional Look at Maternal
Mortality Rates* for the Year 2000
9.5 in Upstate New York
15.9 in NYS
*Per 100,000 livebirths
23.1 in NYC
Trends in Maternal Mortality Ratio by
Race/Ethnicity:NYC OVS, 1993-2002
90
80
Per 100,000 Live Births
70
60
50
40
30
20
10
0
1993
1994
1995
1996
1997
1998
1999
Black non-Hispanic
White non-Hispanic
Other Hispanic
Asian/Pacific Islander
Source: NYC DOHMH Office of Vital Statistics
2000
2001
Puerto Rican
2002
Comparing Leading Causes of Death
(%)
Cause
International
PRMR*
National PRMR
N=4200**
NYC PRMR
N=119
Embolism
Negligible
20%
7%
Hypertensive
Disorders
12%
16%
10%
Hemorrhage
25%
17%
32%
Infection/Sep
sis
15%
13%
7%
Other
Obstructed
Labor 8%
Unsafe Ab 13%
*International WHO 1993, JAMWA 2002
**National MMWR 2003
***NYC BMIRH 1998-2000
Cardiomyopathy Cardiomyopat
8%
hy 8%
CVA 5.0%
Anesthesia 7%
Anesthesia 2%
Preconception Background
In 2000, 4.1 million women aged 18-44
made visits to family physicians
Opportune times for preconception
discussions—well woman visit,
negative pregnancy test, follow up
visits after spontaneous or voluntary
abortions
Preconception Care
What is preconception care?
– Risk assessment for a future pregnancy
– Assessment of broad range of risk factors
– Timing of this risk assessment
Preconception Care
Identifies reducible or reversible risks
Maximizes maternal health
Intervenes to achieve optimal
outcomes
From March of Dimes
Preconception Curriculum
Preconception Care
Reframes Issues
Adds an anticipatory element
Focuses on the impact of pregnancy
From March of Dimes
Preconception Curriculum
Elements of Preconception Care
Focuses on elements which must be
accomplished prior to conception or
weeks thereafter to be effective
– Risk assessment
– Health promotion
– Medical and psychosocial interventions
From March of Dimes
Preconception Curriculum
Components to Preconception
Care
Medical History
Pychosocial Issues
Physical Exam
Laboratory tests
Family History
Nutritional Assessment
Components to Preconception
Care
Medical history
– Particular medical conditions that lend
themselves to Pre-pregnancy management
Diabetes
Hypertension
Seizure disorder
Cardiac diseases
Lupus, sickle cell disease, renal disease
Components to Preconception
Care
Obstetrical History
– Risk factor assessment for Preterm
Delivery
Previous preterm delivery—most important risk
factor
History of fetal loss—what gestational age?
Interpregnancy interval--<18 months
Obstetrical conditions at high risk--incompetent cervix, history of premature
rupture of membranes, uterine malformations
Components to Preconception
Care
Pychosocial Issues
– Screening for Depression—discussion of
medication, therapy and PP depression risk
– Emotional or Physical Abuse--offer confidential,
safe screening and discussion
Assess safety
One third of women reporting violence report escalation
in pregnancy
Role of health care provider
Components to preconception
care
Immunization History
– Rubella, Varicella
Physical exam
Laboratory tests
– In patients with particular histories,
antiphospholipid screens best done prior
to pregnancy
Components to Preconception
Care
Family History
– Genetic history
– Discussion of age-related risks
– Discussion of disease related risks
– Carrier screening
– Potential for egg or sperm donation or
early genetic screening
Components to Preconception
Care
Nutritional Assessment
– Folic Acid for Everyone!! Modifies risk for neural
tube defect—0.4 mg everyday
– BMI Assessment: underweight, overweight
– Identifiying particular nutritional targets: iron
deficiency, vitamin excess (A and D)
– Pica screening
Lifestyle Risk Assessment
Effects of various substance use on
pregnancy and fetus
Screening for use and abuse
Referral for treatment
options/programs
Emphasize using pregnancy as
motivation for change
Tobacco and Preconception
Tobacco: most preventable cause of
LBW
– Associations with abruption, placenta
previa, preterm delivery
– Cessation at any time in pregnancy
improves risks
– How to offer help with cessation
Alcohol and Preconception
Most preventable cause of Mental
Retardation---fetal alcohol syndrome
Most common teratogen exposure
Dose related effects---worst outcomes
with “binge drinking”
Effects can be seen at all stages of
pregnancy
Drug use and Preconception
Cocaine
Congenital anomalies,
placental abruption, LBW
Heroin
Newborn withdrawl, LBW
Methadone
Newborn withdrawl
“The failure to address preventable
maternal disability and death represents
one of the greatest social injustices of our
times….Women’s reproductive health risks
are not mere misfortunes and unavoidable
disadvantages of pregnancy, but rather,
injustices that societies are able and
obliged to remedy…”
Rebecca J. Cook, Bernard M. Dickens, WHO,
2001
Maternal Mortality Ratios per 100,000 Live Births, 2000
WHO, United Nations