Previous Pregnancy Outcomes At Risk/Unsure

[symple_toggle title="Scope of Problem" state="closed"]

• While most pregnancies in the U.S. end without casualty, the risks to a woman and her fetus/infant are still substantial:
  • Approximately 1 in 5 diagnosed pregnancies ends in a spontaneous miscarriage, generally very early in gestation.
  • The infant mortality rate in the U.S. is 6.1/1000 live births (2010) http://www.marchofdimes.com/Peristats. This rate represents approximately 25,472  infants who do not live to their first birthday every year.
    • Infant mortality is the death of a live born infant within the first year of life
    • This rate compares unfavorably with other nations
    • The leading causes of infant mortality in this country are: http://www.marchofdimes.org/Peristats/ViewSubtopic.aspx?reg=99&top=6&stop=112&lev=1&slev=1&obj=1:
      • Congenital anomalies (20.3% of all deaths)
      • Prematurity and low birthweight (17.1% of all deaths)
      • Sudden Infant Death Syndrome (8.4% of all deaths)
      • Maternal pregnancy complications (6.1% of all deaths)
• Another major poor outcome in the U.S. is stillbirths.
  • A fetus that dies before birth at or beyond 20 weeks of gestation is classified as a stillbirth.
  • The nation’s stillbirth rate is 6.1 per 1,000 live born infants plus fetal deaths;
  • This rate means that nearly as many babies die in-utero after 20 weeks of gestation as die in the first year of life.
  • The annual number of fetal deaths in this country is approximately 26,000.
• A fourth poor outcome of special preconception/interconception interest relates to the woman, herself. Maternal complications are common and can have life long implications–for instance:
  • A woman diagnosed with gestational diabetes has a 50% risk of developing T2DM within the next 5 years.
  • A woman who had preeclampsia/eclampsia has a relative risk of 1.4-3.98 for developing chronic hypertension.

[/symple_toggle][symple_toggle title="Preconception Significance" state="closed"]

• Adverse pregnancy outcomes are common and of significant preconception/interconception importance because a previous poor outcome is associated with subsequent poor outcomes. For instance:
  • Recurrence risk for prematurity:
    • One prior preterm birth ~ 16% recurrence risk
    • Three prior preterm births ~ 67% recurrence risk
  • Recurrence risk for intrauterine growth restriction ~ 20%
  • Recurrence risk for fetal death ~ 1.5-3 times the background risk.
  • Recurrence risk for isolated open neural tube defect
    • One previous pregnancy complicated by an ONTD (~ 3-5%)
    • Two previous pregnancies complicated by an ONTD (~6-9%)
• In addition, many maternal complications predict the development of chronic diseases in the future which, beyond impacting the health of the woman, may impact the health of her future pregnancies and offspring. Examples include:
  • Gestational diabetes
  • Preeclampsia

[/symple_toggle][symple_toggle title="Risk Identification Strategies" state="closed"]

• The period after delivery is the best time to determine what happened and to obtain prenatal records, discharge summaries, operative notes, pathology reports, autopsy findings, lab results, and interview the patient. However, it is very possible that the primary care provider is not the person who cared for the patient during the index pregnancy (ies) or conducted the postpartum visit.
• The obstetric history should be reviewed and updated annually; this should easily identify most adverse pregnancy outcomes. Adverse conditions considered in this page are:
  • Spontaneous abortion
  • Prior Stillbirth
  • Preterm birth
  • Fetal growth restriction/SGA
  • Prior infant with congenital anomalies or genetic disorder
  • Preeclampsia
  • Uterine anomalies (mullerian anomalies)
  • Cesarean birth
    • Cesarean delivery (now ~ 30% of all births) may not always be considered an adverse pregnancy outcome but it represents increased risks in subsequent pregnancies, especially if the woman has had several cesarean deliveries.

[/symple_toggle][symple_toggle title="Risk Reduction Strategies" state="closed"]

• Evaluations of potential contributors to the poor outcome and strategies to reduce the specific risk are best undertaken during the interconception period. Examples include:
  • Achieving healthiest pregravid weight possible
  • Smoking cessation
  • Alcohol and other drug use
  • Medication exposures
  • Chronic disease control
  • Genetics evaluation
• The rest of the clinical toolkit provides guidance on these and other topics.
• If the clinician is not an obstetrician, referrals to obstetricians or maternal-fetal medicine specialists should be offered to the woman (couple) in advance of their decision to conceive to:
  • Educate about the risks for a subsequent poor pregnancy outcome;
  • Undertake additional testing
  • Educate about the likely pregnancy course should pregnancy occur;
  • Appreciate the importance of early prenatal care.
• Referral to genetic specialists should be offered to women whose poor pregnancy outcome involved either a congenital anomaly or a genetic disorder.
• Some women/couples may benefit from grief or other counseling before undertaking a subsequent pregnancy
• Women/couples should be aware of the advantages of deliberate decisions about if and when to become pregnant again.
• Appropriate birth spacing is associated with reductions in low birth weight and preterm births delivery in subsequent pregnancies.
  • When discussing ideal pregnancy spacing, it is essential to consider woman’s (couple’s) specific circumstances such as advancing maternal age, chronic diseases, etc.

[/symple_toggle][symple_toggle title="Important Talking Points" state="closed"]

• Specifically exploring a woman’s (couple’s) desires and fears about another pregnancy provides an opening to counsel on recurrence risks, prevention opportunities and the benefits of actively planning for pregnancy.
• Based on the patient’s interests offer referrals to gain additional information (e.g. genetics, maternal-fetal medicine specialists, etc.)
• Adverse pregnancy outcomes can stress a couple and can result in prolonged grief. Referral to couples’ counseling and/or to individual counseling is appropriate.
• A woman’s reproductive life plan after experiencing an adverse pregnancy outcome can range from never considering another pregnancy to actively desiring a short interpregnancy interval.
  • These plans are dynamic and subject to change;
  • Women should be encouraged to contact your office if her plans change and she either now desires contraception or now desires to become pregnant.
• If pregnancy is desired, the optimal timing should be discussed.
  • While the ideal interpregnancy interval is 18-59 months, counseling should start with the patient’s own desires and should take into consideration fertility issues and age;
  • All women should be advised that interpregnancy intervals < 6 months should be avoided as they are highly correlated with poor outcomes.

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For EVERY woman who is ambivalent or at risk:

• Because unintended pregnancy is a risk factor for poor pregnancy outcomes, stress the advantages of planning if and when to become pregnant.
• Because short interpregnancy intervals are a risk factor for poor pregnancy outcomes, educate on appropriate IPIs;
• Follow-up and monitoring for T2DM and chronic hypertension following pregnancies complicated by gestational diabetes or pregnancy-induced hypertension should be undertaken.

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[symple_toggle title="Spontaneous Abortion: Miscarriage" state="closed"]

• Definition: Pregnancy loss before 20 weeks of gestation.
• Incidence: Up to 15% of diagnosed pregnancies (many more occur before the pregnancy is recognized).
• Recurrent pregnancy loss is defined as two or more miscarriages.
• Recurrence risk: Approximately 65% of women who have had 2 or more spontaneous abortions will subsequently have a successful pregnancy outcome.

The majority of women who have experienced a spontaneous abortion will subsequently have normal pregnancies and outcomes. The primary care practitioner should:

• Acknowledge grief and anxiety
  • Offer reassurance and support
  • If does not desire pregnancy in near future assist with contraception decisions and accessing desired method. (note: ovulation can resume within very few weeks after miscarriage).
• Approximately 65% of women who have had recurrent losses (> 2) will subsequently have a successful pregnancy even if the cause of the repeated losses is not uncovered. None-the-less, they should be offered the above plus:
  • Referral to an OB/GYN or maternal-fetal medicine specialist for appropriate work-up which may include:
    • Complete history and PE
    • Pelvic ultrasound
    • Laboratory testing
    • Referral to geneticist
• Provide access to contraception until future pregnancy desires are solidified, Timing of future pregnancy should allow recovery from grieving and workup, especially if recurrent losses. Based on a single study some recommend an interpregnancy interval of 6 months following a pregnancy loss before 20 weeks of gestation

RESOURCES

Report of a WHO Technical Consultation on Birth Spacing (2005, p3) at:http://whqlibdoc.who.int/hq/2007/WHO_RHR_07.1_eng.pdf.

[/symple_toggle][symple_toggle title="Prior Stillbirth: aka Fetal Death" state="closed"]

• Definition: There is lack of uniformity in definition but ACOG and others support a definition of no signs of life at or beyond 20 weeks gestational age or, if gestational age unknown, a fetal weight > 350 gms.
• Incidence: 6.1/1000 live births (plus fetal deaths)
• Recurrence risk: History of stillbirth may increase risk 1.5-3 times; varies by cause: for low risk women with unexplained etiology the risk is: 7.8-10.5/1,000 live births plus fetal deaths.
• The majority of women/couples who have experienced a stillbirth will be devastated: The primary care practitioner should:
  • Acknowledge grief, fear and anxiety
  • Offer support
  • Assess for depression and other mental health issues. When indicated, offer referral to:
    • Bereavement counselor
    • Religious leader
    • Peer support group
    • Mental health professional
  • Encourage use of contraception until future pregnancy desires are solidified.
  • Encourage an interpregnancy interval of 18-59 months individualized to maternal age, gestational age at fetal death, etiology of the stillbirth and sufficient time for grieving and workup.
  • Preconception care for women/couples who have had a stillbirth is most efficiently managed by an OB/GYN or maternal-fetal medicine specialist; advise woman/couple of advantages of not conceiving before seeing specialist and offer referral.

RESOURCES

Greater detail on caring for women with a history of stillbirth is available through:

American College of Obstetricians and Gynecologists (2009) Management of Stillbirth. ACOG Practice Bulletin No. 102 Obstetrics & Gynecology, 113(3), 748-761.

[/symple_toggle][symple_toggle title="Spontaneous Preterm Birth" state="closed"]

• Definition: Births before 37 completed weeks of gestation excluding those that were induced for maternal or fetal indications.
• Incidence: 12% of all births (2010)
• Recurrence risk: (significantly impacted by number of prior preterm births and gestational age at those births). These recurrence risks offer a broad estimate:
  • 16% if one previous preterm birth
  • 41% if two previous preterm births
  • 67% if three previous preterm births.
• Assure the woman that while her risks for another preterm birth are higher than a woman who has not had a spontaneous preterm birth, there are opportunities to reduce the risks.
• The causes of spontaneous preterm births are multifactorial and potentially synergistic. Many contributors are common issues in primary care and are addressed elsewhere in this toolkit:
  • Tobacco, drug, alcohol use
  • Underweight
  • Short interpregnancy intervals
  • Urogenital infections
• Encourage use of contraception until future pregnancy desires are solidified.
• Encourage an interpregnancy interval of 18-59 months individualized to maternal age, fertility concerns and sufficient time for grieving and to minimize risks for recurrence.
• Women with a history of spontaneous preterm birth should be referred to an OB/GYN or maternal-fetal medicine specialists prior to attempting conception:
  • For specific evaluation based on the woman’s history (e.g. cervical incompetence, uterine anomalies, etc.)
  • To learn about opportunities following conception to decrease the risk of recurrence such as progesterone supplementation starting around 16 weeks gestation.

RESOURCES

Greater detail on caring for women with a history of preterm birth is available through:

American College of Obstetricians and Gynecologists (2012). Prediction and prevention of preterm birth. ACOG Practice Bulletin. No. 130. Obstetrics & Gynecology, 120(4), 964-973.

[/symple_toggle][symple_toggle title="Fetal Growth Restriction/Small for Gestational Age" state="closed"]

• Definition: Weight for gestational age < 10th percentile; < 3rd percentile considered severe and more likely to be associated with pathology.
• Incidence: 10%.
• Recurrence risk: 20%
• Attempt to determine the cause. Causes can be subdivided into:
  • Maternal: e.g. weight (underweight, poor weight gain in pregnancy); maternal age (older/younger); substance use; chronic diseases (HTN, DM, vascular, renal disease); preeclampsia; short interpregnancy interval; malaria in areas where prevalent;
  • Fetal: e.g. congenital anomalies & infection; multiple gestation; genetic syndromes;
  • Placental: e.g. chronic abruption; placent previa; placental infarctions; placental villitis; small placenta.
• Specific interventions in the interconception period:
  • Women with a history of spontaneous preterm birth should be referred to gynecologists or maternal-fetal medicine specialists:
    • For specific evaluations based on the woman’s history.
    • To learn about prevention strategies before and during the next pregnancy.
  • Manage risks (e.g. weight, substance use, etc.)/diseases identified by the history.
  • Stress the importance of early prenatal care for gestation age assessment and the need for subsequent growth ultrasounds.
  • Encourage use of contraception until future pregnancy desires are solidified.
  • Encourage an interpregnancy interval of 18-59 months individualized to maternal age, fertility concerns, and sufficient time for grieving and to minimize risks for recurrence.

RESOURCES

Greater detail on caring for women with a history of fetal growth restriction/small for gestational age (SGA) is available through:

American College of Obstetricians and Gynecology (2013). Fetal growth restriction. ACOG Practice Bulletin No. 134. Obstetrics & Gynecology, 212(5), 1122-33.

[/symple_toggle][symple_toggle title="Prior Cesarean Delivery" state="closed"]

• Prevalence: up to 30% of all births
• Recurrence risk: highly variable 20% if trial of labor to 100% if planned repeat cesarean
• If not already achieved, gather relevant information such as:
  • Number of prior cesarean deliveries;
  • Woman’s attitudes about future trial of labor after cesarean (TOLAC) — currently considered acceptable with 1 (and sometimes with 2) prior cesarean deliveries.
  • Operative note to document uterine incision type and number of layers of uterine incision closure;
    • Document circumstances of the cesarean section (s) and scars for counseling regarding likely success of a trial of labor.
  • Specific interventions in the interconception period:
    • If classical or T-incision:
      • Education patient about need for repeat cesarean delivery with subsequent pregnancy
      • Document need for repeat cesarean delivery and conversation with patient
      • Encourage highly effective form of family planning if pregnancy is not desired.
    • Encourage at least an 18 month interpregnancy interval to allow for uterine scar healing.
    • If there are multiple c-sections, risks increase with increasing number as shown in the table.
    • Encourage use of contraception until future pregnancy desires are solidified.
    • Encourage an interpregnancy interval of 18-59 months individualized to maternal age, fertility concerns and sufficient time for grieving and to minimize risks for recurrence.

RESOURCES

Greater detail on caring for women with a history of cesarean delivery is available through:

American College of Obstetricians and Gynecology (2010). Vaginal Birth After Previous Cesarean Delivery. ACOG Practice Bulletin No. 115. Obstetrics & Gynecology, 115 (2 Pt 1), 450-63.

[/symple_toggle][symple_toggle title="Hypertensive Disorders of Pregnancy" state="closed"]

• Definition: elevation of blood pressure after 20 weeks of gestation. Categorized as preeclampsia with or without severe features, chronic hypertension with superimposed preeclampsia, and gestational hypertension.
• Prevalence: complicates 10% of pregnancies
• Recurrence risk: depends of gestational age of onset and severity of disease and presence of chronic hypertension.
• Assess history of the hypertensive disorder, categorization, gestational age and disease severity to assess recurrence risk:
  • Two case series provide guidance:
    • If severe disease in the 2nd trimester, recurrence risk was 65% (1/3 del < 28 wks; 1/3 28-36 wks; 1/3 37+)
    • If delivery at
  • Those with HELLP in the index pregnancy are more at risk for recurrent preeclampsia (25%) than recurrent HELLP (2-6%)
• Specific interventions in the interconception period:
  • Check blood pressure at least 6 weeks after delivery, if elevated then patient has chronic hypertension and will need appropriate primary care
    • Counsel regarding long term risks of chronic hypertension; manage as needed.
    • Assess for other cardiovascular disease, renal disease, obesity, diabetes mellitus, acquired thrombophilia, and connective tissue disease.
    • Obtain baseline laboratory evaluation including CBC, metabolic profile, and urinalysis.
  • Counsel about benefits of weight loss if overweight/obese. Consider bariatric surgery if patient is a candidate and has access to the surgery.
  • Encourage use of contraception until future pregnancy desires are solidified.
  • Encourage an interpregnancy interval of 18-59 months individualized to maternal age, and fertility concerns.
  • If not choosing an effective method of contraception counsel about:
    • Importance of early prenatal care (especially important if patient is a candidate for low dose aspirin for prevention of recurrent preeclampsia which is generally initiated prior to second trimester)

RESOURCES

Greater detail on caring for women with a history of hypertensive disorders of pregnancy is available through:

American College of Obstetricians and Gynecology (2013). Hypertension in pregnancy: report on the task force on hypertension in pregnancy: Executive summary. Obstetrics & Gynecology, 122(5), 1122-31.

[/symple_toggle][symple_toggle title="Prior Child with Anomalies" state="closed"]

• May range from minor anatomic defects with no long term consequences to major malformations not compatible with life.
• Prevalence of major anomalies: occur in 1 in 33 births
• Recurrence risk: may be near baseline risk for non-recurrent causes to 50% with autosomal dominant conditions.
• Acknowledge grief and anxiety:
  • Parents of infants with anomalies often feel guilty for having caused the problem.
• Offer reassurance and support.
• Assess for depression and other mental health issues. When indicated, offer referral to:
  • Bereavement counselor
  • Religious leader
  • Peer support group
  • Mental health professional
• Information to obtain:
  • What is the diagnosis?
  • When/how was it diagnosed?
  • Were chromosome studies done?
  • Was an autopsy performed (if infant death)?
  • What were the parents told about recurrence risk?
• Specific interventions in the interconception period:
  • If patients have questions or concerns about recurrence risks suggest/arrange referral to genetics specialist.
  • When appropriate, advise patient of prenatal diagnosis options and refer to maternal fetal medicine specialist for patient (couple) to learn more about options.
  • Emphasize the importance of early prenatal care, early dating ultrasound, and mention the likely course of pregnancy care.
  • If anomaly associated with a teratogenic drug exposure, refer to disease specialist/maternal fetal medicine specialist regarding need for medication or possible alternative.
  • Women with a previous pregnancy complicated by a neural tube defect should take a high dose of folic acid:
    • The precise dose required to reduce the risk of NTDs in high risk women is unknown but the most consistent recommendation is 4 mg starting one month prior to attempting pregnancy and continued through the first 3 months of gestation.
    • This amount of folic acid requires a prescription and should not be recommended for women who are not likely to become pregnant in the near future.
  • Encourage use of contraception until future pregnancy desires are solidified.
  • Encourage an interpregnancy interval of 18-59 months individualized to maternal age, fertility concerns and sufficient time for grieving.

[/symple_toggle][symple_toggle title="Gestational Diabetes" state="closed"]

• Definition: Diabetes mellitus first diagnosed in pregnancy.
• Prevalence: 6-7% of pregnancies
• Recurrence risk: reported to be 40% in one study*
• Up to 50% of women will develop type 2 diabetes in the 20 to 30 years following pregnancy with the greatest increased risk within the first 5 years postpartum
• Screening postpartum with a 2 hour GTT is the preferred method
  • Those with normal testing should be rescreened every 3 years
  • Those with impaired glucose tolerance should undergo lifestyle modification
    • If the fasting value is elevated, then metformin therapy may be considered
  • Those diagnosed with type 2 diabetes should be managed by their primary care provider (see chronic disease section)
• Encourage use of contraception until future pregnancy desires are solidified.

RESOURCES

Greater detail on caring for women with a history of gestation diabetes is available through:

American College of Obstetricians and Gynecologists (2013). Gestational diabetes mellitus ACOG Practice Bulletin No 137. Obstetrics & Gynecology 122(2 Pt 1) 406-16.

* Getahun, D., Fassett, M., J., Jacobsen, S.J. (2010) Gestational diabetes: risk of recurrence in subsequent pregnancies. American Journal of Obstetrics and Gynecology 203(5), 467 e1-6.

[/symple_toggle]

CDC: Preconception Clinical Care for Women: Personal History (2013)
http://www.cdc.gov/preconception/careforwomen/history.html.

UNC Center for Maternal and Infant Health: 17P Information for Providers (2012)
http://www.mombaby.org/index.php?c=2&s=58&p=340.

NIH Consensus Conference Statement on Vaginal Birth After Cesarean Delivery (2010)

http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf

Recurrent Pregnancy Loss: Etiology, Diagnosis, and Therapy (2009) –
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709325/.

ACOG: Patient FAQs on Repeated Miscarriages (2013)
http://www.acog.org/~/media/For%20Patients/faq100.pdf?dmc=1&ts=20130530T1545542088

March of Dimes: Pregnancy Loss (2010)
http://www.marchofdimes.com/loss/stillbirth.aspx

March of Dimes: Neonatal Loss (2010)
http://www.marchofdimes.com/loss/neonatal-death.aspx.

UNC Center for Maternal and Infant Health: 17P Resources for Patients (2013).
http://www.mombaby.org/index.php?c=2&s=58&p=756

Conde-Agudelo, A., Rosas-Bermundez, A., and Kafury-Goeta, A. (2006). Birth spacing and risk of adverse perinatal outcomes: A meta-analysis. Journal of the American Medical Association 295 (15), 1809-1823.

Report of a WHO Technical Consultation on Birth Spacing (2005, p3) at:http://whqlibdoc.who.int/hq/2007/WHO_RHR_07.1_eng.pdf.

Stubblefield, P.G., Coonrod, D.V., Reddy, U. M. et al. (2008). The clinical content of preconception care: reproductive history. American Journal of Obstetrics and Gynecology 199(6B), S373-384.

American College of Obstetricians and Gynecologists (2009) Management of Stillbirth. ACOG Practice Bulletin No. 102 Obstetrics & Gynecology, 113(3), 748-761.

American College of Obstetricians and Gynecologists (2012). Prediction and prevention of preterm birth. ACOG Practice Bulletin. No. 130. Obstetrics & Gynecology, 120(4), 964-973.

American College of Obstetricians and Gynecology (2013). Fetal growth restriction. ACOG Practice Bulletin No. 134. Obstetrics & Gynecology, 212(5), 1122-33.

American College of Obstetricians and Gynecology (2010). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 115. Obstetrics & Gynecology, 115 (2 Pt 1), 450-63.

American College of Obstetricians and Gynecology (2013). Hypertension in pregnancy: report on the task force on hypertension in pregnancy: Executive summary. Obstetrics & Gynecology, 122(5), 1122-31.

American College of Obstetricians and Gynecologists (2013). Gestational diabetes mellitus ACOG Practice Bulletin No 137. Obstetrics & Gynecology 122(2 Pt 1) 406-16.

Getahun, D., Fassett, M., J., Jacobsen, S.J. (2010) Gestational diabetes: risk of recurrence in subsequent pregnancies. American Journal of Obstetrics and Gynecology 203(5), 467 e1-6.