Optimizing pregnancy outcomes: Lessons in a nutshell
By Debra Guinn, MD
In the United States, 50 percent of pregnancies are unplanned. Therefore, it is critically important that all women of reproductive age are prepared to bring a healthy newborn into the world – whether expected, hoped for or unplanned. What we do prior to pregnancy and during pregnancy influences the future for both mother and baby. Research has clearly shown that in utero (during pregnancy) exposures predispose us to long-term health complications. For example, babies born small for gestational age are at higher risk of hypertension and early-onset heart disease and stroke. Babies born too big are at higher risk of obesity and diabetes.
What happens during pregnancy influences the future health of both mother and child. By the time a woman misses her first period or shows signs or symptoms of pregnancy, the fetus has already gone through crucial stages of development. The brain, heart, abdominal wall and genitalia are already forming. So get in for care with an obstetrical (OB) provider as soon as possible.
One of the most important decisions you will make when you start planning for a pregnancy or realize you are pregnant is choosing your OB provider. There are many types of OB providers available, such as certified nurse midwives, family practitioners, general OB/GYNs and specialists in high-risk pregnancy (perinatologists or maternal fetal medicine specialists like myself). The right provider is out there for you. You can find providers through other medical professionals, hospital websites, or friends and family. If you have special needs, it is important that you choose a provider at a hospital who can support you. You can schedule to meet any provider and decide if he or she is the right fit for you. Ask questions! Practices are structured in different ways. Your OB provider may not be your delivery provider. It is important to realize that this is a safety issue. Babies are born at all times of the day and night, and you want your OB provider to be at his or her best when you deliver. It is also important to realize that if you develop complications during pregnancy, you may have your pregnancy co-managed with an obstetrician or a perinatologist. In most cases your OB provider will perform your delivery. Regardless of who your provider is, we all have a common goal. We want you to have the best experience possible, to modify any risk behaviors, and to intervene when appropriate to secure your health and your baby’s health.
It is possible to reduce the risk of pregnancy loss, birth defects, premature deliveries, stillbirths and cesareans by planning pregnancies and optimizing health before conceiving. It’s never too late. Even if you find yourself pregnant, you can affect the outcome by seeking early prenatal care and working with your OB provider to make the best plan for you and your family.
If you are considering pregnancy or find yourself pregnant, the following will increase your chances of a successful pregnancy and a healthy baby:
Eat a healthy diet including all food groups (complex carbohydrates, protein and fat).
Take a prenatal vitamin with folic acid (minimum of 800 mcg).
Try to achieve your ideal body weight. This is not solely about your weight. Women who are overweight have higher risks of all pregnancy complications. Even a 10 percent reduction in weight prior to conceiving will improve your odds of having a healthy pregnancy, avoiding diabetes and preventing cesareans. Make realistic changes in your lifestyle. Losing weight and maintaining weight loss does not happen overnight. There are lots of resources to help. Talk to your care provider for suggestions. At your first prenatal visit, your provider will discuss optimal weight gain goals for your pregnancy depending on your weight, height and exercise regimen. It is important to gain weight but not to indulge yourself. Women tend to retain weight after delivery, which increases your risk for complications in future pregnancies and lifelong. We are what we eat!
Quit smoking. Smoking puts you at higher risk for preterm delivery, small babies and placental problems. It also increases risks to your baby including sudden infant death syndrome. We know it is very hard to quit, but your baby and your family need you to do it. The Montana Quitline is an excellent resource. Behavioral and medical therapies are available. E-cigarettes and vapes are not much better than cigarettes and, for all we know, could be worse than smoking. The answer is to quit altogether and find a healthy substitute. You can do it!
Alcohol consumption, whether it is beer, wine or hard liquor, also is a danger. Even women who rarely drink but then get drunk at a party are putting their fetus at risk. There is no established safe amount of alcohol to consume during pregnancy. It is better to just say no. If you are having trouble with this, consult your OB provider or primary care provider, who can help you.
All illicit drugs are a problem. Whether it is marijuana, methamphetamines, crack cocaine or heroin, bad things can happen. As more and more women have access to marijuana, the data is increasing that marijuana use, whether recreational or for medicinal purposes, carries risks. Stop if you can and reach out for help if you need it. Your OB providers will try to help you. They have no interest in punishing you. They want the best for you and your baby, so share this information with them and work out a plan so that you will be successful.
Oral or injected narcotics, including hydrocodone, oxycodone, fentanyl and methadone, are all highly addictive. It is crucial that you report to your OB provider if you are using these medications, whether or not they are prescribed by a doctor. If you are using these medications for pain or for drug addiction, your OB provider can refer you to specialists who can help develop a plan of care that satisfies your needs and protects your baby. Subutex and methadone are both good options depending on your particular circumstances. Your OB provider and pediatrician need to know about narcotic use to best protect your baby from withdrawal and neonatal abstinence syndrome. It’s important to remember that your health care team wants the best for you and your baby. You are equally important.
There are certain medications to avoid. Most commonly used in pregnancy are the nonsteroidal inflammatory products such as ibuprofen, Advil, Motrin, Aleve, etc. Occasional use outside of the third trimester is okay, but chronic use can result in serious problems for your fetus. Consult your OB provider about any medications you are taking on a regular basis.
Herbal products are increasingly being promoted to address physical ailments and promote health. Despite their popularity and increasing use, there is very limited data in pregnancy regarding the majority of commonly ingested herbal products. There are real safety issues. Some of the herbal remedies may cause miscarriage and others may potentially cause birth defects. Some would argue that this may be true of “traditional medications.” Fair enough. The difference is that medications produced by a pharmaceutical company undergo quality control far in excess of what is available through your local nutritional center. Be careful, research your choices and talk to your OB provider.
Avoid infections if possible. We live in a world full of viruses, bacteria and parasites. Use common sense. Wash your hands frequently. Avoid sick children with fever and rashes. Stay current on your vaccinations. If you are pregnant, you should receive a flu shot and Tdap to protect yourself, your newborn and your family. If you own an outdoor cat, avoid cleaning the litter box. It’s time for your partner to help.
As part of your pregnancy evaluation, your OB provider should test you for sexually transmitted infections. This is routine and meant to protect everyone. If you have risk factors for acquiring a sexually transmitted disease, your OB provider should retest you prior to delivery. Half of all women in Montana and the United States with HIV acquire it from their male partners and are first diagnosed during pregnancy. Many of these women are in serious relationships and are unaware of their partner’s at-risk behavior. If diagnosed with HIV, treatment is available during pregnancy and can reduce the risk of transmission to your unborn child to less than 1 percent, not to mention save your life.
If you have medical problems, address them. The most common medical problems encountered in pregnancy are obesity, diabetes, prediabetes, thyroid issues and hypertension. All of these are treatable conditions where medical therapy is readily available and safe in pregnancy for both you and your unborn baby. Optimizing your care before conception is ideal, but addressing it as soon as possible will still have a big impact. Do not just stop taking your medication when you find out you are pregnant. The internet is a poor source of information regarding the safety of your medications in pregnancy. It is very important to weigh the risks of your medical issues relative to the risk of medical therapy.
Depression and anxiety are incredibly common issues for women. Pregnancy is a particularly dangerous time for women with psychiatric issues. Medical therapy can be safe and essential depending on your history. Talk to your provider as soon as possible and develop a plan of care. Even women who have never had a psychiatric issue in the past can develop problems during pregnancy, particularly postpartum depression. Untreated, this can cause longstanding issues with parenting and bonding. Seek treatment as needed – the sooner the better.
If you have other chronic medical conditions like lupus, Crohn’s disease, ulcerative colitis or other issues, make sure you are doing all that you can to keep your disease under control. That will increase your chance for a good pregnancy outcome.
There are a number of obstetrical complications in prior pregnancy that can be prevented through optimal prenatal care. For women with prior preterm delivery, progesterone therapy can reduce your risk of recurrence. For women with history of preeclampsia, a simple baby aspirin a day may reduce your risk. For women with more complex histories, consultation with a perinatologist (high-risk OB specialist) can help to develop a plan of care to minimize your risk.
For women with a prior cesarean, timing of pregnancy is especially important. Women should wait a minimum of one year before another pregnancy to allow their womb to heal and develop a stronger scar prior to exposing them to the risk of another pregnancy. Depending on your obstetrical history, the majority of women planning a trial of labor have a low risk of complications (less than 1 in 100 risk of ruptured uterus and less than 1 in 1,000 risk of permanent neurologic injury). If appropriate, hospital personnel are available in case of suspected uterine rupture. Both a trial of labor and repeat cesarean incur risk. Ultimately, only your provider and you can develop the best plan of care for you depending on your health, reason for cesarean and your family planning goals. Different hospital systems are available to support vaginal trials of labor. You will need to explore these options in your local community prior to picking your OB provider.
All women should consider prenatal diagnosis (ultrasound and/or blood tests) or genetic screening. Genetic counselors partnered with perinatologists can provide the most accurate up-to-date information regarding the different tests available to allow you to make an informed decision. Some women will say that testing is irrelevant. “What difference does it make? I am going to love my baby no matter what.” In fact, it makes a huge difference. In order to optimize your baby’s outcome, the more information obtained prenatally by ultrasound and genetic testing, the better the chance the perinatologist, your pediatrician and pediatric subspecialists can tailor a plan to help your baby. The more special the baby’s needs, the more important it is to be prepared and know your providers. It can empower you and protect your baby.
Despite all of our best efforts, pregnancies do not all result in a healthy baby. Sadly, about one third of pregnancies are lost in the first trimester. The majority of these early losses are due to chromosomal abnormalities. These events are out of our control and no one’s fault. The risk for chromosomal abnormalities and infertility increases gradually as we age.
It is important to keep this in mind when deciding when we want to have our families. It is common now for women to wait until they are older and establish their careers before having children, for a variety of reasons. The majority will be successful, but others will find the journey more difficult. Stillbirths are less common, occurring in one out of every 260 pregnancies. While heart-wrenching, the reason for these later losses vary, and finding the cause may be difficult. All women who sustain a loss, and their families, need our support. There are multiple resources locally and nationally for women in need.
Ultimately, pregnancy is an incredible experience. Thankfully most women will have a good outcome. It is up to you to ask a lot of questions and participate in your care. We are all here to support you regardless of your concerns or past medical or obstetrical history. Your willingness to work with your providers and ask questions will lead to the most satisfactory outcome. Remember, how you care for yourself during pregnancy will influence your family for generations to come.
First published in Montana Woman Magazine, November 2015