Current Updates in Prematurity Prevention2017

5.5% - Proposed US Preterm Birth Rate

Goal For 2030 By March Of Dimes

Fighting for the Next Generation:

US Prematurity in 2030

Edward R.B. McCabe, Gerard E. Carrino, Rebecca

B. Russell and Jennifer L. Howse

Pediatrics; originally published online

November 3, 2014

Preterm birth rates

*2015 data are preliminary. L MP=gestational age based on date of mother’s last menstrual periodOE=gestational age based on obstetric estimate.2020 and 2030 goals based on OE gestational age.Preterm is less than 37 weeks gestation. So urce: National Center for Health Statistics, 1990-2014 final and 2015 preliminary natality data.Prepared by March of Dimes Perinatal Data Center, June 2016.

United States, 1990, 1995, 2000, 2005-2015*

Harris County Preterm Birth Rate

Source: www.dshs.state.tx.us

2010-2014

Birth Statistics for Harris

Year

2010 2011 2012 2013 2014 2010&2011&2012&

2013&2014

Indicator Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate

Prematu

re 9,095 13.7 8,539 13.4 8,289 12.8 8,042 12.2 8,611 12.6 42,576 12.9

All

Births 68,166 100.0 65,956 100.0 67,354 100.0 68,292 100.0 71,395 100.0 341,163 100.0

Rotate Download

FootnoteRates Per 100

Additional Footnotes

Premature - less than 37 known weeks gestation.

Denominator - Births with known length of pregnancy

Harris County Preterm Birthrate by Race

Source: www.dshs.state.tx.us

2010-2014

Birth Statistics for Harris

Indicator: Premature

Year

2010 2011 2012 2013 2014 2010&2011&2012&2013&

2014

Race Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate

White 1,921 12.4 1,813 11.9 1,665 11.0 1,641 10.6 1,796 11.1 8,836 11.4

Black 2,173 18.2 2,058 17.9 2,010 17.2 1,829 15.4 1,988 16.0 10,058 16.9

Hispanic 4,468 12.9 4,189 12.8 4,048 12.5 4,008 12.1 4,191 12.4 20,904 12.5

Other 533 12.3 479 10.9 566 10.4 564 10.5 636 10.4 2,778 10.8

All Races 9,095 13.7 8,539 13.4 8,289 12.8 8,042 12.2 8,611 12.6 42,576 12.9

Rotate Download

FootnoteRates Per 100

Additional Footnotes

Premature - less than 37 known weeks gestation.

Denominator - Births with known length of pregnancy

Preterm Birth Prevention – Current

Updates

1. Optimizing Birth Spacing or Interpregnancy

Interval (IPI)

2. Low-dose aspirin prophylaxis to reduce pre-eclampsia

3. Progesterone supplementation to reduce preterm birth

recurrence

Optimizing Birth Spacing or Interpregnancy Interval

Time between one live birth and

conception of next pregnancy.

Birth spacing of less than 18

months increases the risk of

preterm birth, low birthweight, and

small for gestational age.

33.1% of U.S. births have a short IPI (<18 months).

Risks increase as birth interval decreases, with birth spacing of less than

6 months having the highest risk.

For each month that birth spacing was less than 18

months,

Preterm births increased 1.9%

Low birthweight increased 3.3%

Poor intrauterine growth increased 1.5%

Conde-Agudelo JAMA 2006 295(15) 1809-23.

Possible reasons short IPI might contribute

to adverse outcomes

• Maternal nutritional depletion hypothesis

• Inadequate time to restore folate levels

• Inflammatory mediators / Intrauterine inflammatory milieu

– endometritis, PPROM

• Postpartum changes in vaginal microbiome

Conde-Agudelo JAMA 2006 295(15) 1809-23.

IPI exercises independent influence on

outcomes

Controlling for socioeconomic status, use of health care

services, tobacco, alcohol and other exposures does not

alter the finding that interpregnancy intervals exercise an

independent influence on poor pregnancy outcomes.

Conde-Agudelo JAMA 2006 295(15) 1809-23.

18 Months: HP 2020 Goal, ACOG

Recommendation

Healthy People 2020 birth spacing goal: reduce the

proportion of pregnancies conceived within 18 months of a

previous birth by 10%, to 29.8%.

ACOG recommends that “women wait at least 18 months

after having a baby before trying to get pregnant

again in order to have the best health outcomes

for both mom and baby.”

ACOG Committee Opinion. 2015. Your Pregnancy and Childbirth Month to Month.

Sixth Edition. pp. 585-586

ACOG Committee Opinion on Reproductive

Life Planning

ACOG “encourages obstetrician-gynecologists

and other health care providers

to use every patient encounter as an

opportunity to talk with patients about

their pregnancy intentions and to support

initiatives that promote access to and

availability of all effective contraceptive

methods.”

ACOG Committee Opinion, February 2016, Reproductive Life Planning to Reduce

Unintended Pregnancy

One Key Question® Initiative: Recommended in

ACOG Committee Opinion

This campaign promotes direct screening for women’s

pregnancy intentions by asking the following question ……

“Would you like to become pregnant in the next year?”

If the answer is “no,” discuss pregnancy prevention, including

education and counseling on all available contraceptive options.

If the response is “yes,” provide preconception counseling and discuss

evidence-based lifestyle modifications to optimize health status in

preparation for future pregnancies.

ACOG Committee Opinion, February 2016, Reproductive Life Planning to Reduce

Unintended Pregnancy

Tested messages for women

Preterm Birth Prevention – Current

Updates

1. Optimizing Birth Spacing or Interpregnancy Interval (IPI)

2. Low-dose aspirin prophylaxis to reduce pre-

eclampsia

3. Progesterone supplementation to reduce preterm birth

recurrence

Preeclampsia

Affected 3.8% of U.S. deliveries in

2010

Accounts for 12% - 16% of maternal

deaths

15% of preterm births are related to

preeclampsia

Jillian T Henderson, et. al., Ann. Intern. Med., 2014; 160: 695-703

Perinatal Outcomes of Preeclampsia

Leading cause of:

Fetal growth restriction

Indicated preterm delivery

Maternal and perinatal death and morbidity

Jillian T Henderson, et. al., Ann. Intern. Med., 2014; 160: 695-703

Clinical Risk Factors for Preeclampia

• Primiparity

• Previous preeclamptic pregnancy (especially if

severe) - 7 fold increase

• Chronic hypertension, chronic renal disease, or

both

• History of thrombophilia

• Multifetal pregnancy

• In vitro fertilization

• Family history of preeclampsia - 2-4 fold increase

• Diabetes mellitus

• Obesity

• Systemic lupus erythematosus

• Advanced maternal age (> 40 years)

ACOG, Hypertension in Pregnancy 2013 (Box 3.1, p22)

Poor Placentation

Placental Dysfunction

Vascular Dysfunction

PREECLAMPSIA

Pathophysiology of Preeclampsia

Efficacy of Aspirin

Reviewed 59 RCTs (37,560 women) to determine

benefits of aspirin:

• 17% reduced risk of preeclampsia with low dose

aspirin

• 14% reduced risk of stillbirth

• 8% reduced risk of preterm birth

Conclusion

• Antiplatelet agents have moderate benefits when

used for prevention of preeclampsia

Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004659

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation

statement, and supporting documents, please go to www.uspreventiveservicestaskforce.org. IUGR = intrauterine

growth restriction.

Ann Intern Med. 2014;161(11):819-826. doi:10.7326/M14-1884

Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: U.S.

Preventive Services Task Force Recommendation Statement

USPSTF Recommendations, 2014

high risk women

USPTF – women with several moderate

risk factorsWomen with several moderate risk factors also may benefit from

low-dose aspirin, but evidence is less certain for this approach.

Clinicians should use clinical judgment in assessing the risk for

preeclampsia and talk with their patients about benefits and harms

of low-dose aspirin use. Consider low-dose aspirin if the patient

has several of these moderate-risk factors:

–Nulliparity

–Obesity

–Family history of preeclampsia (mother or sister)

–Sociodemographic characteristics (African American Race, low

socioeconomic status)

–Age > 35 years

–Personal history factors (e.g. low birthweight or small for gestational age, previous adverse outcome, >10 year pregnancy interval)

ACOG affirms USPTF high-risk factors,

July 2016

“Based on evidence supporting a broader

list of risk factors of preeclampsia for which

low-dose aspirin may provide benefit and

based on more recent, evolving expert

consensus, ACOG supports the

recommendation to consider the use of low-

dose aspirin (81 mg/day), initiated between

12 and 28 weeks of gestation, for the

prevention of preeclampsia, and

recommends using the high-risk factors as

recommended by the USPSTF ….”

ACOG, Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia:

Updated Recommendations. July 11, 2016

ACOG on moderate risk factors, July 2016

“The USPSTF review also identified “moderate” risk

factors, for which low-dose aspirin might be considered if

several moderate risk factors are present, although the

evidence to support low-dose aspirin in the setting of

moderate risk factors is uncertain. It is important to

recognize that other organizations recommend

consideration of low-dose aspirin in women at risk for

preeclampsia, although the risk-factor criteria may vary

somewhat.”

ACOG, Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia:

Updated Recommendations. July 11, 2016

Preterm Birth Prevention – Current

Updates

1. Optimizing Birth Spacing or Interpregnancy Interval (IPI)

2. Low-dose aspirin prophylaxis to reduce pre-eclampsia

3. Progesterone supplementation to reduce

preterm birth recurrence

17 alpha-hydroxyprogesterone caproate

(17P)

ACOG Practice Bulletin, October 2012

One of the strongest clinical risk factors for

preterm birth is a prior preterm birth.

Maternal history of preterm birth confers a 1.5-

fold to 2.0-fold increased risk in a subsequent

pregnancy

17P

Synthetic form of progesterone given by injection in the gluteus muscle or anterior thigh

Reduces a woman’s risk of recurrent preterm

birth by 33%

ACOG Committee Opinion, October 2012, Prediction & Prevention of preterm birth.

Progesterone trial for the prevention

of preterm delivery in high-risk

women

Meis et al, N Engl J M, 2003

NICHD Maternal Fetal Medicine Units (MFMU) Network

NICHD: MFMU Progesterone

Trial

• Aim: To establish if weekly progesterone injections in women with prior spontaneous

preterm delivery (sPTD) reduces the risk of PTD

• Design: double-masked, placebo-controlled trial

• Eligibility criteria: singleton pregnancy 16-20 wkswith documented previous sPTD

• Intervention: progesterone or placebo

• Primary outcome: delivery at < 37 weeks’

• Sample: 463 pregnant women

Meis et al, N Engl J Med 2003

Progesterone: Rates of Preterm

Birth

0%

10%

20%

30%

40%

50%

60%

< 37 <35 <32

P<0.0001 P<0.0165 P<0.0180

17 P

17 P

17 P

Placebo

Placebo

Placebo

Meis et al, N Engl J Med 2003

Progesterone Results: Ethnic

Group

0%

10%

20%

30%

40%

50%

60%

70%

African American p=0.0103 Non African American p=0.0044

PlaceboPlacebo

17 P 17 P

P=0.0103 P=0.0044

Meis et al, N Engl J Med 2003

Progesterone prevents neonatal

complications

0%

2%

4%

6%

8%

10%

12%

14%

16%

neonatal

death

RDS BPD IVH* NEC*

17 P

17 P17 P 17 P

Placebo

Placebo

Placebo

Placebo

Placebo

Meis et al, N Engl J Med 2003

Progesterone prevents recurrent

preterm delivery

Weekly injections of progesterone prevented

recurrent preterm birth and improved the

neonatal outcome for pregnancies at risk

Effective in preventing very early as well as

later preterm birth

Effective in both African American and

Non-African American women

Meis et al, N Engl J Med 2003

Protocol for 17P Use

History of a previous singleton spontaneous preterm birth (200 to 366 weeks)

Current singleton pregnancy

Initiate treatment between 160 - 216 weeks gestation*

Receive 17P injections weekly until 366 weeks gestation or she delivers

Women who delivered multiple infants preterm and/or who are pregnant with multiples are not eligible for

treatment

47% of eligible women in North Carolina receive 17P

7% of eligible women who are Medicaid recipients

received 17P in Louisiana in 2013

“Medicaid health plans have covered 17P for many years.

However, under-utilization is still broadly acknowledged.”Medicaid Health Plans of America Report, 2014

Underutilization of 17P – available

estimates

Stringer et al. 17OHP-C coverage among women delivering at 2 North Carolina hospitals. Am J Obstet Gynecol

2016. ajog.org OBSTETRICS Original Research JULY 2016

Orsulak et al. 17P Access in the Lousiana Medicaid Population, Clinical Therapeutics, November 2015.

Medicaid Health Plans of America (November, 2014) Preterm Birth Prevention: Evidence-Based Use of

Progesterone Treatment: Issue Brief and Action Steps for Medicaid Health Plans.

Optimal Prenatal Care

Session Overview

Session 9: Graduation

Participants celebrate their completion of Becoming a

Mom/Comenzando bien.

Key Message:

Participants can be proud of completing Becoming a

Mom/Comenzando bien.

Depression

Screening

and

Pregnancy

Grade Definition Suggestions for Practice

BThe USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer or provide this service.

Depression in Adults: Screening. January 2016. U.S. Preventive Services Task Force..

From ACOG

• The totality of the evidence supports the

benefits of screening in pregnant and

postpartum and general adult populations,

• Although definitive evidence of benefit is

limited, the College recommends that

clinicians screen at least once during the

perinatal period for depression and anxiety

symptoms using a standardized, validated

tool.

ACOG Committee Opinion No. 630, May 2015. Screening for Perinatal Depression

Depression Screening Tools

ACOG Committee Opinion No. 630, May 2015. Screening for Perinatal Depression

Safer

Medication

Use

Medication Use in Pregnancy:

A Public Health Concern

• Medication use has surged to 9 out of 10 pregnant women. About 7 out

of 10 take at least one prescription medicine. Over the last 30 years, use

of prescription medicine during the first trimester of pregnancy has

increased more than 60%.1

• Fewer than 10% of medications have enough information to determine

their safety for use in pregnancy.2

• Taking certain medications, such as isotretinoin (also known as

Accutane®), during pregnancy can cause serious birth defects or poor

pregnancy outcomes.

1. Mitchell AA, et al. National Birth Defects Prevention Study. Am J Obstet Gynecol. 2011;205:51.e1-8

2. Adam MP, Polifka JE, Friedman JM. Am J Med Genet Part C. 2011;157:175-82.

CDC: Treating for Two. Available at:www.cdc.gov/pregnancy/meds/treatingfortwo/facts.html

Opioid Use in Pregnancy: A

Public Health Concern

• Some studies have shown an association of

opioid use with stillbirth, poor fetal growth,

pre-term delivery, and birth defects

• Before initiating opioid therapy for

reproductive-age women, clinicians should

discuss family planning and how long-term

opioid use might affect any future pregnancy.

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

• For pregnant women already receiving opioids, avoiding

or stopping medication use during pregnancy may be

more harmful than taking a medication.

• Clinicians should access appropriate expertise if

considering tapering opioids because of possible risk to

the pregnant patient and to the fetus if the patient goes

into withdrawal.

• For pregnant women with opioid use disorder,

medication-assisted therapy with buprenorphine or

methadone has been associated with improved maternal

outcomes and should be offered.

Opioid Use in Pregnancy

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.

Pregnancy and

Oral Health

Pregnant women should have

oral healthcare

…Evidence shows that oral health care during

pregnancy is safe and should be recommended

to improve the oral and general health of the

woman.

ACOG Committee Opinion No. 569. Oral Health Care During Pregnancy and Through the

Lifespan. (August 2013, reaffirmed 2015). Obstet Gynecol. 2013;122(2 Pt 1):417-22.

1. Discuss oral health with all patients, including

those who are pregnant or in the postpartum

period.

2. Advise women that oral health care improves

a woman’s general health through her lifespan

and may also reduce the transmission of

potentially caries-producing oral bacteria from

mothers to their infants.

3. Conduct an oral health assessment during the

first prenatal visit.

ACOG Recommendations

ACOG Committee Opinion No. 569. Oral Health Care During Pregnancy and Through the Lifespan. (August

2013, reaffirmed 2015). Obstet Gynecol. 2013;122(2 Pt 1):417-22.

4. Reassure patients that prevention, diagnosis, and

treatment of oral conditions, including dental X-rays

(with shielding of the abdomen and thyroid) and local

anesthesia (lidocaine with or without epinephrine), are

safe during pregnancy.

5. Inform women that conditions that require immediate

treatment, such as extractions, root canals, and

restoration (amalgam or composite) of untreated caries,

may be managed at any time during pregnancy.

Delaying treatment may result in more complex

problems.

ACOG Recommendations

ACOG Committee Opinion No. 569. Oral Health Care During Pregnancy and Through the Lifespan. (August

2013, reaffirmed 2015). Obstet Gynecol. 2013;122(2 Pt 1):417-22.

Additional ResourcesDepression:

NICHD, NCMHEP

www.nichd.nih.gov/ncmhep

U.S. Preventive Services Task Force:

www.uspreventiveservicestaskforce.org

IMPLICIT (Interventions to Minimize Preterm and Low birthweight Infants through

Continuous Improvement Techniques) Toolkit Now Available!

www.prematurityprevention.org

Medication Use

Treating for Two: http://www.cdc.gov/pregnancy/meds/treatingfortwo/

Oral Health

ACOG Oral HealthCare During Pregnancy: A National Consensus Statement, 2012

http://mchoralhealth.org/PDFs/OralHealthPregnancyConsensus.pdf

Thank you