BEFORE THE PREGNANCY – H OW M AT E R N A L FAC TO R S I N F LU E N C E P R E G N A N C Y O U TC O M E

Tracy Papa, D.O., FACOOG Fort Worth Perinatal Associates DrTracyPapa.com Twitter: @DrTracyPapa

INFANT MORTALITY BY REGION, PER 1000 LIVE BIRTHS, 2011 Area Rate World 57 Developed Countries 8 Less Developed Countries 63 Africa 88 Sierra Leone 157 Western Sahara 150 Liberia 139 Asia 56 Afghanistan 150 East Timor 143 Hong Kong 3.2 Europe 9 Iceland 2.6 Sweden 3.5 Albania 22 Romania 20.5 Latin America (and the Caribbean) 35 North America (U.S. and Canada) 7 SOURCE : Population Reference Bureau. 2001 World Population Data Sheet. Washington, DC: Population Reference Bureau, 2001.

Read more: http://www.deathreference.com/Me-Nu/Mortality-Infant.html#ixzz2dHAJJBZB

INFANT MORTALITY RATES (PER 1,000 LIVE BIRTHS) AND RANKINGS FOR OECD AND OTHER SELECTED COUNTRIES, 2008 Country IMR Rank

Luxembourg 1.8 1

Slovenia 2.1 2

Iceland 2.5 3

Sweden 2.5 3

Japan 2.6 5

Finland 2.6 5

Norway 2.7 7

Greece 2.7 7

Czech Republic 2.8 9

Ireland 3.0 10

Portugal 3.3 11

Belgium 3.4 12

Germany 3.5 13

Spain 3.5 13

Austria 3.7 15

Italy 3.7 15

France 3.8 17

Israel 3.8 17

Netherlands 3.8 17

Denmark 4.0 20

Switzerland 4.0 20

Australia 4.1 22

OECD Average 4.6 —

Korea 4.7 23

United Kingdom 4.7 23

New Zealand 4.9 25

Estonia 5.0 26

Hungary 5.6 27

Poland 5.6 27

Canada 5.7 29

Slovak Republic 5.9 30

United States 6.6 31

Chile 7.0 32

Mexico 15.2 33

Turkey 17.0 34

SOURCE: ADAPTED FROM ORGANIZATION FOR ECONOMIC COOPERATION AND DEVELOPMENT, OECD HEALTH DATA, 2010

FACTORS THAT MAY CONTRIBUTE TO RELATIVELY HIGH U.S. IMR

Inconsistent recording of live births

Different rates of low birth weight and preterm births

Racial and ethnic IMR disparities

SOURCE: ADAPTED FROM ORGANIZATION FOR ECONOMIC COOPERATION AND DEVELOPMENT, OECD HEALTH DATA, 2010

PREMATURITY AND LOW BIRTH WEIGHT IN U.S.

Preterm birth much more common in U.S. than in Europe Double that of Scandinavian countries

If U.S. had same rate of preterm birth as Sweden, CDC estimates that our IMR would be 3.9

Reducing preterm birth/low birth weight in U.S. would lower IMR

OECD suggests that the increasing rate of preterm/LBW infants may explain stagnation in U.S. IMR

BEHIND INTERNATIONAL RANKINGS OF INFANT MORTALITY: HOW THE UNITED STATES COMPARES WITH EUROPE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES: CENTERS FOR DISEASE CONTROL AND PREVENTION: NATIONAL CENTER FOR HEALTH STATISTICS, NCHS DATA BRIEF NO.23, HYATTSVILLE, MD, NOVEMBER 2009

EFFECT OF RACIAL DISPARITIES ON U.S. IMR

IMR for infants of black mothers - 12.7

IMR for infants of white mothers - 5.5

Black mothers have 16% of infants in U.S., but 30% of infant deaths

Eliminating racial disparity differences would lower IMR, but we would still be higher than the OECD average of 4.6

GEOGRAPHIC INFLUENCES – U.S. IMR (PER 1,000 LIVE BIRTHS), BY STATE, 2008

SOURCE: ADAPTED BY CRS FROM ARIADI M. MININO, ET AL., NATIONAL VITAL STATICS REPORTS: DEATHS: FINAL DATA FOR 2008, NATIONAL CENTER FOR HEALTH STATISTICS, VOL. 59, NO. 10, HYATTSVILLE, MD, DECEMBER 7, 2011.

TEXAS 2008

2478 infant deaths – 6 per 1000 live births Black 10 per 1000 White 6 per 1000 Hispanic 5.4 per 1000

U.S. rate 6.8 per 1000

FROM TEXAS DEPARTMENT OF STATE HEALTH SERVICES, 2011

TEXAS

FROM TEXAS DEPARTMENT OF STATE HEALTH SERVICES, 2011

INFANT MORTALITY RATES FOR TEN LEADING CAUSES OF DEATH, U.S. 2005

PER 100,000 LIVE BIRTHS, FROM CDC

FACTORS INFLUENCING PERINATAL OUTCOME

Income

Race

Ethnicity

Age

Preconception health

SOURCE: CDC

Age Preconception health Maternal obesity Maternal diabetes

TEEN PREGNANCY

BIRTH RATES IN U.S. FOR TEENS AGED 15-19

SOURCE: CDC

BIRTH RATE IN TEENS AGED 15-19 BY STATE, 2009

Overall teen birth rate has declined

Texas ranks third in teen pregnancies – 60 per 1000 population (national average 39 per 1000)

Texas ranks highest in REPEAT teen births – 22% of teen births here are repeat births

MATERNAL OBESITY

OBESITY RATES U.S.

• Normal weight – BMI 18.5 – 24.9 • Overweight – BMI 25 – 29.9 • Obese – BMI ≥ 30

• Class I – BMI 30 – 34.9 • Class II – BMI 35 – 39.9 • Class III (extreme) – BMI ≥ 40

NIH/WHO DEFINITIONS BMI = KG/M²

ECONOMICS OF OBESITY IN PREGNANCY

0

2

4

6

8

10

12

14

Relativecost

• Increased complications

• Increased hospitalization costs – more days, more readmissions

• Increased cesarean deliveries

Gestational diabetes

Preeclampsia

Cesarean delivery Increased surgical and anesthesia risks Increased operative time and blood loss

Babies have increased risk of: Neural tube defects Stillbirth Prematurity Macrosomia

COMPLICATIONS OF OBESITY

Maternal Risks BMI Class 1 (Odds Ratio)

BMI Classes 2 and 3 (Odds Ratio)

Preeclampsia 1.4–2.0 2.4–3.3

Hypertension 6.0 15.0

Diabetes mellitus 2.3 7.0

Gestational diabetes 1.6–2.6 3.6–4.0

Cardiac disease 1.4–3.4 3.4–5.6

Deep vein thrombosis 2.7 4.1

INCREASED RISKS OF OBESITY IN PREGNANCY

AJR 2011; 196:311-319

Information Review risks and outcomes for obesity

Intervention Weight loss/exercise counseling Bariatric surgery Folate supplementation

Screening for comorbid conditions Hypertension Diabetes Thyroid disease

PRECONCEPTION COUNSELING IN OBESITY

Reduce BMI prior to pregnancy, avoid weight loss attempts during pregnancy

Ideally, women should have BMI <25-30 prior to pregnancy

Minimal weight gain improves pregnancy outcome

Initial goal – reduce total weight by 5-10% over 6 months

Exercise 30 minutes/day, increase tolerance to 60 minutes daily

PRECONCEPTION GOALS

Prepregnancy BMI

BMI kg/m²

Total weight gain (lbs)

Rate of weight gain 2nd/3rd trimester (lbs/week)

Underweight <18.5 28-40 1 (1-1.3)

Normal weight 18.5-24.9 25-35 1 (0.8-1)

Overweight 25-29.9 15-25 0.6 (0.5-0.7)

Obese >30 11-20 0.5 (0.4-0.6)

INSTITUTE OF MEDICINE 2009 RECOMMENDATIONS FOR WEIGHT GAIN IN PREGNANCY

First and second trimester serum screens affected by maternal obesity

Screens depend on serum analytes to determine risk of aneuploidy

Plasma markers adjusted upward for obesity (increased plasma volume)

MSAFP adjusted up to maternal weight of 200 lbs. Higher weights have lower MoM and increased risk of positive Down syndrome screen

EFFECT OF OBESITY ON PRENATAL SCREENING

EFFECT OF MATERNAL OBESITY ON THE ULTRASOUND DETECTION OF ANOMALOUS FETUSES

Dashe. Obesity and Anomaly Detection. Obstet Gynecol 2009.

Note: Anomaly detection lower among women with pregestational diabetes than in those with other high-risk indications, 38%compared with 88% respectively

COPYRIGHT © 2012 OBSTETRICS & GYNECOLOGY. PUBLISHED BY LIPPINCOTT WILLIAMS & WILKINS. 31

COPYRIGHT © 2012 OBSTETRICS & GYNECOLOGY. PUBLISHED BY LIPPINCOTT WILLIAMS & WILKINS. 32

Neural tube defects OR 1.87

Spina bifida OR 2.24 Cardiovascular anomalies OR 1.30

Septal anomalies OR 1.20

Cleft lip/palate OR 1.23 Anorectal atresia OR 1.48

Hydrocephaly OR 1.68

Limb reduction anomalies OR 1.34 Gastroschisis OR 0.17

ODDS RATIOS FOR ANOMALIES IN OVERWEIGHT AND OBESE PATIENTS

JAMA 2009; 301(6);636-650

Increased rate of stillbirth BMI 25-29.9 kg/m2 – OR 1.9-2.7 (12-15/1000) BMI > 30 kg/m2 – OR 2.1-2.8 (13-18/1000) Present even after correction for smoking, diabetes, preeclampsia

Risk appears to be greatest at later gestational ages.

Hazard ratio for stillbirth: 2.0 at 30 weeks to 4.0 at term

No ACOG recommendations regarding antepartum testing

Obstet Gynecol 2009; 113:748–61.

Am J Obstet Gynecol 2005; 193:1923-35.

Obstet Gynecol 2005;106:250–9

ANTEPARTUM SURVEILLANCE IN OBESITY

RISK OF C/S WITH INCREASED PREPREGNANCY BMI

External fetal monitoring relies on ultrasound signal

Increased rate of internal monitoring with obesity

Small studies are evaluating fetal ECG as alternative to external ultrasound monitoring

Consider anesthesia consult to evaluate anesthetic risk

Obese pregnancy increases risk of VTE Consider thromboprophylaxis based on comorbidities

INTRAPARTUM FETAL MONITORING

HOVERMATT

Relative to normal BMI women undergoing VBAC: 5 X increase in uterine rupture/dehiscence 2 X risk maternal morbidity 5 X risk in neonatal injury (fracture, brachial plexus injury, laceration) 3 X increase in 5-minute APGAR < 7

VBAC RISKS IN OBESITY

OBSTET GYNECOL 2006; 108:125-133

At Duke University, most hospital readmissions are due to wound infections related to morbid obesity.

Cost up to $60,000 per patient to treat

Centers for Medicare and Medicaid Services (CMS) have adopted payment rules that will deny reimbursement for some complications

HOSPITAL READMISSION

—Schematic of metabolic syndrome and effects on fetal and childhood development.

Maxwell C , Glanc P AJR 2011;196:311-319

©2011 by American Roentgen Ray Society

110 patients followed to delivery 57 intervention (30 nl weight, 27 overweight) 53 controls (31 nl weight, 22 overweight)

Intervention group received education about weight gain, healthy eating, and exercise and individual graphs of their weight gain. Those exceeding weight gain goals were given more intensive intervention.

Overall, no difference between groups in wt gain

Significant reduction in fat intake by most patients, not related to intervention

Intervention was associated with more activity

No effect of treatment group on PP wt loss

Polley et al, Int J Obesity, 2002

WEIGHT CONTROL IN PREGNANCY PITTSBURGH PA

Polley et al, Int J Obesity, 2002

WEIGHT CONTROL IN PREGNANCY PITTSBURGH PA

DIETARY RESOURCES FOR OBESE PREGNANCIES CHOOSEMYPLATE.GOV

Traditionally, 35 kcal/kg/day recommended Example: 250 lb woman = 3,977 calories/day

Counseling should be individualized

Patients may be unaware that concept of “eating for two” is outdated

Allowances for level of activity

Portion Control Learn serving sizes for different foods Limits even on “good” foods—fruits and vegetables, dairy Use 24 hour recall diaries

DIETARY COUNSELING

NIH criteria for surgery: BMI > 40 BMI > 35 + comorbid illness

Restrictive surgery – restricts total intake, limiting calories obtained Roux-en-Y gastric bypass Laparoscopic adjustable banding

Malabsorptive – limits absorption of calories Roux-en-Y Biliopancreatic diversion/duodenal switch

BARIATRIC SURGERY

PREGNANCY OUTCOME AFTER LAPBAND

0

5

10

15

20

25

30

Gestationaldiabetes

Preeclampsia

PreLapBandPostLapBandObese Controls

79 pregnancies after surgery compared to 40 prior in same patients vs. 79 obese controls

No difference in birth weight

Weight gain less in banded pregnancies

Rapid weight loss phase 6-24 months

Ideally, delay pregnancy 2 years, or 1 year after stable weight – yeah, right…

Possible nutritional deficiencies following bariatric surgery, especially in 1st year B12 B6 Folate Iron Vitamin K

DIETARY COUNSELING POST BARIATRIC SURGERY

B12 Common after 1 year post-surgery Up to 70% of patients affected Decreased gastric acid prevents binding

Folate 20% of patients deficient after 1 year post-surgery

Iron Absorbed in proximal intestine 50-60% deficient after 1 year post-surgery Replace with IV/IM iron – limited absorption orally

VITAMIN DEFICIENCIES

All patients should have some level of nutritional counseling, ideally before pregnancy

All pregnant women should know recommendations for total weight gain

For obese patients, caloric goal based on ideal body weight

Screen obese patients for comorbid conditions

Screen post-bariatric surgery patients for vitamin deficiencies and supplement as needed

SUMMARY

DIABETES IN PREGNANCY

DIABETES IN PREGNANCY

Birth injury 2X

Fetal macrosomia 10X

Birth defects 3-4X

Cesarean delivery 3X

NICU admission 4X

CONTRAINDICATIONS TO PREGNANCY

Ischemic heart disease

Creatinine clearance < 50

Serum creatinine > 2

24 hr urine protein > 2 grams

Hypertension >140/90 despite medication

Gastroenteropathy

Untreated retinopathy

RISK OF ANOMALIES WITH IDDM

Anomaly Rate/1000 RR Caudal regression 0.7 175 All vertebral 1.5 50 Cardiac 10.0 4.3 Anencephaly 3.0 3.3 NTD 4.6 1.9 Spina bifida 2.0 1.4 All anomalies 47.9 2.9

Kucera J, J Repro Med 1971;7:61

WILL MY CHILD BE DIABETIC?

If mom < age 25:

Risk of IDDM in child 6% If mom > age 25:

Risk of IDDM in child 0.7%

Bottom Line – If mom is > age 25, her child has a very low risk of developing IDDM, almost as low as nondiabetic parents

Warram JH et al., Diabetes 1991; 40:1679-1684

RE-EDUCATING DIABETIC PATIENTS

Glucoses checked at least QID

Insulin regimen may need to be updated

Follow up with endocrinologist or MFM

Dietary consult

GLUCOSE METABOLISM IN PREGNANCY

Lower fasting glucoses

Placental steroid hormones rise

Insulin less effective in pregnancy – more insulin required

Fetal glucose about 80% of maternal glucose

RISK FACTORS FOR GDM

Previous infant >4000 grams

Previous stillbirth

Maternal obesity or weight gain

Multiple gestation

Previous gestational diabetes

GLUCOSE SCREENING IN PREGNANCY

Screen at 24-28 weeks

If risk factors - screen on entry

50 gram 1 hour GTT

Positive screen > 140 mg/dl

If screen positive - 3 hour GTT

2 or more abnormal values = GDM

METFORMIN IN PREGNANCY

Metformin given increasingly to women with PCOS-related infertility

Reduces incidence of first trimester pregnancy loss in women with PCOS

Decreases development of gestational diabetes in women with PCOS 3% with metformin 31% without metformin

ORAL HYPOGLYCEMICS

In Oct 2000 NEJM, Langer compared glyburide and insulin in gestational diabetics

No difference in macrosomia, lung complications, NICU admissions, or fetal anomalies

Cord insulin levels similar

No glyburide detected in cord blood

PRE-PREGNANCY COUNSELING - WHY?

Establishes working relationship with your doctor

Obtain optimal glucose and weight control before conception

Begin folic acid supplementation

Address smoking, obesity, alcohol use