1. Where it all begins: Optimizing Fetal Health Paul Dassow, MD, MSPH & A. Stevens Wrightson, M.D. 11/29/2006

2. 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?

3. 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

4. Determinants of Fetal Health “Environmental”/ External/Other factors –Maternal health –Maternal past medical history –Reproductive history –Family history –Social issues and preparedness for pregnancy (and parenthood) –Drug exposure –Infection exposure/risks

5. 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

6. Problems as Seen by Healthy People 2010 U. S. Ranks 25 th 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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)

14. 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)

15. 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

16. 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

17. 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

18. 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

19. Congenital Anomalies 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)

20. Teratogens Thalidomide-limb defects Valproic acid-neural tube defects Tetracycline-teeth and bone mal- development Warfarin-nasal hypoplasia and bone mal- development Accutane-craniofacial and cardiac defects

21. 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)

22. 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)

23. Complications of the Placenta, Cord, or Membranes Abnormal placental location or insertion Cord prolapse Premature rupture of the membranes

24. 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)

25. 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

26. 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

27. 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

28. 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?

29. 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: –LBW –Mental retardation –Microcephaly and other birth defects –Behavioral disturbances

30. 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%

31. 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 extra- uterine), preterm delivery, premature rupture of the membranes, increased meconium-stained fluid, perinatal death

32. 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

33. Nutrition and Fetal Health 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

34. Safety and Fetal Health Injury and violence –Seatbelts in pregnancy –Screen for alcohol and other drugs –Screen for violence –Preventive services

35. 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

36. 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

37. 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 well- being of women, infants, children, and families

38. 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)

39. Successes Decrease in infant mortality and low birth weight due to? –Decrease in teen birth rate (26.2% decline from 1991- 2001) –Early prenatal care –“Back to Sleep” education –Folate education –Others Why the increase in 2002?

40. Case 1 JM is a 28 year old 2 nd 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.

41. Case 1 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

42. Positive influences Preparation for pregnancy Healthy lifestyle Family history Social support

43. Negative influences Lack of folic acid supplementation

44. Interventions Add folic acid Screening –Immunizations –STD’s –Safety –Inherited disorders

45. 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.

46. 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.

47. 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.

48. Positive influences Patient is otherwise healthy Not engaged in risky behaviors, except sexual activity Supportive home environment Family history negative Early diagnosis

49. Negative influences Unplanned Teen pregnancy Drug exposure Lack of folic acid

50. Interventions Screening –STD’s –Abuse –Substance use Folic acid Frequent follow-up/Prenatal care –Education –Preparation for parenting –Stay in school

51. Fetal Health Continuum Woman’s health/Family health Preconception Periconception Embryologic development Fetal growth and maturation Birth Child’s health/Family health/Community health

52. References 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.