1. Preconception Care in the Context of Maternal Mortality Ashlesha K. Dayal, MD Assistant Professor Obstetrics and Gynecology and Women’s Health Albert Einstein College of Medicine/ Montefiore Medical Center Bronx, NY How to Save a Life

2. Renal Transplant 29 y/o P0 presents to MFM for 1 st PNV at 15 wks SLE, renal failure, dialysis 1998 Renal transplant from sister –Failed after 6 days, secondary to thrombosis 1998 2 nd 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

3. 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

4. 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

5. 2007 The State of Maternal Mortality……..

6. Daily Death Toll: during pregnancy & in childbirth WORLDWIDE

8. Lifetime risk of Maternal Death Africa 1 in 20 Asia 1 in 94 Latin America/Caribbean 1 in 160 Australia1 in 83 Developed Regions 1 in 2800

9. Source: JAMWA 2001 MMR Industrialized Nations, 1990-1994

11. 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.

12. Maternal Mortality: Nationally and in New York State Healthy People 2010 Goal: 3.3 Per 100,000 livebirths

13. Maternal Mortality Ratios 1987 - 1996 National: 7.7 / 100,000 (1987-1996)

14. Maternal Mortality Ratios for White Women:1987-1996 Note: The colors on these maps show the states divided into three terciles based on their MMR.

15. Maternal Mortality Ratios for Black Women 1987-1996 Source: NCHS, Vital statistics

16. 15.9 in NYS A Regional Look at Maternal Mortality Rates* for the Year 2000 *Per 100,000 livebirths 9.5 in Upstate New York 23.1 in NYC

17. Trends in Maternal Mortality Ratio by Race/Ethnicity:NYC OVS, 1993-2002 Source: NYC DOHMH Office of Vital Statistics

18. Comparing Leading Causes of Death (%) CauseInternationalPRMR* National PRMR N=4200** NYC PRMR N=119 EmbolismNegligible20%7% Hypertensive Disorders 12%16%10% Hemorrhage25%17%32% Infection/Sep sis 15%13%7% Other Obstructed Labor 8% Unsafe Ab 13% Cardiomyopathy 8% CVA 5.0% Anesthesia 2% Cardiomyopat hy 8% Anesthesia 7% *International WHO 1993, JAMWA 2002 **National MMWR 2003 ***NYC BMIRH 1998-2000

19. 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

20. Preconception Care What is preconception care? –Risk assessment for a future pregnancy –Assessment of broad range of risk factors –Timing of this risk assessment

21. Preconception Care Identifies reducible or reversible risks Maximizes maternal health Intervenes to achieve optimal outcomes From March of Dimes Preconception Curriculum

22. Preconception Care Reframes Issues Adds an anticipatory element Focuses on the impact of pregnancy From March of Dimes Preconception Curriculum

23. 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

24. Components to Preconception Care Medical History Pychosocial Issues Physical Exam Laboratory tests Family History Nutritional Assessment

25. Components to Preconception Care Medical history –Particular medical conditions that lend themselves to Pre-pregnancy management DiabetesHypertension Seizure disorder Cardiac diseases Lupus, sickle cell disease, renal disease

26. 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

27. 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

28. Components to preconception care Immunization History –Rubella, Varicella Physical exam Laboratory tests –In patients with particular histories, antiphospholipid screens best done prior to pregnancy

29. 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

30. 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

31. 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

32. 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

33. 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

34. Drug use and Preconception CocaineHeroinMethadone Congenital anomalies, placental abruption, LBW Newborn withdrawl, LBW Newborn withdrawl

35. “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

36. Maternal Mortality Ratios per 100,000 Live Births, 2000 WHO, United Nations