We had problems with our We had problems with our last baby – now what?last baby – now what?

Kim M. Puterbaugh, MDKim M. Puterbaugh, MDClinical Assistant ProfessorClinical Assistant Professor

Associate Residency DirectorAssociate Residency DirectorAurora Sinai/UW Aurora Sinai/UW

Things to do between Things to do between pregnanciespregnancies

• Determine the cause (if possible) of the Determine the cause (if possible) of the complications last timecomplications last time

• Improve the mother’s chronic illness, if Improve the mother’s chronic illness, if possiblepossible

• Assess the mother’s medications, if Assess the mother’s medications, if appropriate for pregnancyappropriate for pregnancy

• Choose an appropriate form of birth Choose an appropriate form of birth control for the couple and discuss birth control for the couple and discuss birth spacing and timing of next pregnancyspacing and timing of next pregnancy

Previous Pregnancy Previous Pregnancy complicationscomplications

Determine the cause of the complication Determine the cause of the complication if possible: if possible:

1.1. Hypertension Hypertension 2.2. DiabetesDiabetes3.3. Premature deliveryPremature delivery4.4. Congenital anomaly, such as spina Congenital anomaly, such as spina

bifida bifida 5.5. Drug exposure (tobacco, alcohol, Drug exposure (tobacco, alcohol,

cocaine)cocaine)

Is this problem likely to Is this problem likely to recur?recur?• Was it a rare, sporadic event that probably Was it a rare, sporadic event that probably

won’t happen again?won’t happen again?• Is there a genetic component? Is there a genetic component?

- Meet with a genetic counselor to discuss - Meet with a genetic counselor to discuss likelihood of recurrence, get family likelihood of recurrence, get family members tested.members tested.

• Is there a way to lower the recurrence Is there a way to lower the recurrence risk? (improving the mother’s health, risk? (improving the mother’s health, changing medications)changing medications)

Address any medical problems Address any medical problems you can between pregnanciesyou can between pregnancies• Get hypertension under better control, if Get hypertension under better control, if

necessarynecessary• Get diabetes under control – elevated HgA1C is Get diabetes under control – elevated HgA1C is

directly associated with increasing risk of directly associated with increasing risk of congenital anomaliescongenital anomalies

• Determine if the mom needs Progesterone (17-Determine if the mom needs Progesterone (17-OHP) or cerclage (for cervical insufficiency) next OHP) or cerclage (for cervical insufficiency) next pregnancy to try to prevent another preterm birth. pregnancy to try to prevent another preterm birth. Be sure the mother knows your Be sure the mother knows your recommendations.recommendations.

• High dose Folic Acid supplementation for mothers High dose Folic Acid supplementation for mothers with a child with spina bifidawith a child with spina bifida

Improve the mother’s chronic Improve the mother’s chronic illness, if possibleillness, if possible

• Waiting until the next pregnancy to make Waiting until the next pregnancy to make healthy lifestyle changes is healthy lifestyle changes is TOO LATETOO LATE..

1. Get exercising1. Get exercising 2. Eat a healthy diet (for you and your 2. Eat a healthy diet (for you and your

family)family) 3. Quit smoking3. Quit smoking

• Start and optimize medications Start and optimize medications (antihypertensives, diabetes drugs, (antihypertensives, diabetes drugs, asthma medications that are safe for asthma medications that are safe for pregnancy)pregnancy)

Have a frank discussion with Have a frank discussion with mothers about the risks to mothers about the risks to themselves and their childrenthemselves and their children• Mother’s with pulmonary hypertension, Mother’s with pulmonary hypertension,

Marfan’s syndrome or congestive heart Marfan’s syndrome or congestive heart failure may not survive another pregnancyfailure may not survive another pregnancy– Have you thought about what would happen if Have you thought about what would happen if

you leave your children without a mother?you leave your children without a mother?– Do you have a condition you could pass on to Do you have a condition you could pass on to

your child?your child?

It is not our place to judge, just It is not our place to judge, just inform and help patients think inform and help patients think through the possibilitiesthrough the possibilities

Review MedicationsReview Medications

• Make sure medications are safe in Make sure medications are safe in pregnancy, or that patient is aware that pregnancy, or that patient is aware that they are not and should avoid they are not and should avoid pregnancy for a period of time (e.g. pregnancy for a period of time (e.g. Coumadin)Coumadin)

• Let patients know what will happen to Let patients know what will happen to their medications when they become their medications when they become pregnant (many people quit pregnant (many people quit “everything” right away)“everything” right away)

Birth SpacingBirth Spacing

• Infant mortality is higher in women Infant mortality is higher in women who deliver within 12 months of their who deliver within 12 months of their previous deliveryprevious delivery

• Women who have a C-section should Women who have a C-section should wait at least 18 months between wait at least 18 months between pregnancies for their scar to pregnancies for their scar to completely healcompletely heal

Birth ControlBirth Control

• HALFHALF of all pregnancies in the U.S. of all pregnancies in the U.S. are unplannedare unplanned

• Even in married couples…Even in married couples…• High risk women need effective High risk women need effective

contraceptioncontraception• Physicians worry about the risks of Physicians worry about the risks of

birth control, when pregnancy is a birth control, when pregnancy is a much greater riskmuch greater risk

Discuss the optionsDiscuss the options

• Progesterone only – pills, Progesterone only – pills, DepoProvera, Implanon and Mirena DepoProvera, Implanon and Mirena IUD (For women who cannot take IUD (For women who cannot take estrogen)estrogen)

• No hormones – condoms (not most No hormones – condoms (not most effective) and Paraguard IUDeffective) and Paraguard IUD

• Discuss permanent sterilization Discuss permanent sterilization (INCLUDING (INCLUDING VASECTOMYVASECTOMY))

Don’t forget the basicsDon’t forget the basics

• All women of reproductive age need All women of reproductive age need to be up-to-date on their vaccines to be up-to-date on their vaccines prior to pregnancy (Rubella, prior to pregnancy (Rubella, varicella)varicella)

• Correct anemiaCorrect anemia

• Prenatal vitamins are great for Prenatal vitamins are great for everyone!everyone!

A final thought:A final thought:

• The desire to have a child is primal The desire to have a child is primal and almost universal.and almost universal.

• Our role is to respect each woman Our role is to respect each woman and her decisions and help her have and her decisions and help her have the healthiest pregnancy she can.the healthiest pregnancy she can.