Current Updates in Prematurity Prevention2017
5.5% - Proposed US Preterm Birth Rate
Goal For 2030 By March Of Dimes
Fighting for the Next Generation:
US Prematurity in 2030
Edward R.B. McCabe, Gerard E. Carrino, Rebecca
B. Russell and Jennifer L. Howse
Pediatrics; originally published online
November 3, 2014
Preterm birth rates
*2015 data are preliminary. L MP=gestational age based on date of mother’s last menstrual periodOE=gestational age based on obstetric estimate.2020 and 2030 goals based on OE gestational age.Preterm is less than 37 weeks gestation. So urce: National Center for Health Statistics, 1990-2014 final and 2015 preliminary natality data.Prepared by March of Dimes Perinatal Data Center, June 2016.
United States, 1990, 1995, 2000, 2005-2015*
Harris County Preterm Birth Rate
Source: www.dshs.state.tx.us
2010-2014
Birth Statistics for Harris
Year
2010 2011 2012 2013 2014 2010&2011&2012&
2013&2014
Indicator Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate
Prematu
re 9,095 13.7 8,539 13.4 8,289 12.8 8,042 12.2 8,611 12.6 42,576 12.9
All
Births 68,166 100.0 65,956 100.0 67,354 100.0 68,292 100.0 71,395 100.0 341,163 100.0
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FootnoteRates Per 100
Additional Footnotes
Premature - less than 37 known weeks gestation.
Denominator - Births with known length of pregnancy
Harris County Preterm Birthrate by Race
Source: www.dshs.state.tx.us
2010-2014
Birth Statistics for Harris
Indicator: Premature
Year
2010 2011 2012 2013 2014 2010&2011&2012&2013&
2014
Race Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate
White 1,921 12.4 1,813 11.9 1,665 11.0 1,641 10.6 1,796 11.1 8,836 11.4
Black 2,173 18.2 2,058 17.9 2,010 17.2 1,829 15.4 1,988 16.0 10,058 16.9
Hispanic 4,468 12.9 4,189 12.8 4,048 12.5 4,008 12.1 4,191 12.4 20,904 12.5
Other 533 12.3 479 10.9 566 10.4 564 10.5 636 10.4 2,778 10.8
All Races 9,095 13.7 8,539 13.4 8,289 12.8 8,042 12.2 8,611 12.6 42,576 12.9
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FootnoteRates Per 100
Additional Footnotes
Premature - less than 37 known weeks gestation.
Denominator - Births with known length of pregnancy
Preterm Birth Prevention – Current
Updates
1. Optimizing Birth Spacing or Interpregnancy
Interval (IPI)
2. Low-dose aspirin prophylaxis to reduce pre-eclampsia
3. Progesterone supplementation to reduce preterm birth
recurrence
Optimizing Birth Spacing or Interpregnancy Interval
Time between one live birth and
conception of next pregnancy.
Birth spacing of less than 18
months increases the risk of
preterm birth, low birthweight, and
small for gestational age.
33.1% of U.S. births have a short IPI (<18 months).
Risks increase as birth interval decreases, with birth spacing of less than
6 months having the highest risk.
For each month that birth spacing was less than 18
months,
Preterm births increased 1.9%
Low birthweight increased 3.3%
Poor intrauterine growth increased 1.5%
Conde-Agudelo JAMA 2006 295(15) 1809-23.
Possible reasons short IPI might contribute
to adverse outcomes
• Maternal nutritional depletion hypothesis
• Inadequate time to restore folate levels
• Inflammatory mediators / Intrauterine inflammatory milieu
– endometritis, PPROM
• Postpartum changes in vaginal microbiome
Conde-Agudelo JAMA 2006 295(15) 1809-23.
IPI exercises independent influence on
outcomes
Controlling for socioeconomic status, use of health care
services, tobacco, alcohol and other exposures does not
alter the finding that interpregnancy intervals exercise an
independent influence on poor pregnancy outcomes.
Conde-Agudelo JAMA 2006 295(15) 1809-23.
18 Months: HP 2020 Goal, ACOG
Recommendation
Healthy People 2020 birth spacing goal: reduce the
proportion of pregnancies conceived within 18 months of a
previous birth by 10%, to 29.8%.
ACOG recommends that “women wait at least 18 months
after having a baby before trying to get pregnant
again in order to have the best health outcomes
for both mom and baby.”
ACOG Committee Opinion. 2015. Your Pregnancy and Childbirth Month to Month.
Sixth Edition. pp. 585-586
ACOG Committee Opinion on Reproductive
Life Planning
ACOG “encourages obstetrician-gynecologists
and other health care providers
to use every patient encounter as an
opportunity to talk with patients about
their pregnancy intentions and to support
initiatives that promote access to and
availability of all effective contraceptive
methods.”
ACOG Committee Opinion, February 2016, Reproductive Life Planning to Reduce
Unintended Pregnancy
One Key Question® Initiative: Recommended in
ACOG Committee Opinion
This campaign promotes direct screening for women’s
pregnancy intentions by asking the following question ……
“Would you like to become pregnant in the next year?”
If the answer is “no,” discuss pregnancy prevention, including
education and counseling on all available contraceptive options.
If the response is “yes,” provide preconception counseling and discuss
evidence-based lifestyle modifications to optimize health status in
preparation for future pregnancies.
ACOG Committee Opinion, February 2016, Reproductive Life Planning to Reduce
Unintended Pregnancy
Tested messages for women
Preterm Birth Prevention – Current
Updates
1. Optimizing Birth Spacing or Interpregnancy Interval (IPI)
2. Low-dose aspirin prophylaxis to reduce pre-
eclampsia
3. Progesterone supplementation to reduce preterm birth
recurrence
Preeclampsia
Affected 3.8% of U.S. deliveries in
2010
Accounts for 12% - 16% of maternal
deaths
15% of preterm births are related to
preeclampsia
Jillian T Henderson, et. al., Ann. Intern. Med., 2014; 160: 695-703
Perinatal Outcomes of Preeclampsia
Leading cause of:
Fetal growth restriction
Indicated preterm delivery
Maternal and perinatal death and morbidity
Jillian T Henderson, et. al., Ann. Intern. Med., 2014; 160: 695-703
Clinical Risk Factors for Preeclampia
• Primiparity
• Previous preeclamptic pregnancy (especially if
severe) - 7 fold increase
• Chronic hypertension, chronic renal disease, or
both
• History of thrombophilia
• Multifetal pregnancy
• In vitro fertilization
• Family history of preeclampsia - 2-4 fold increase
• Diabetes mellitus
• Obesity
• Systemic lupus erythematosus
• Advanced maternal age (> 40 years)
ACOG, Hypertension in Pregnancy 2013 (Box 3.1, p22)
Poor Placentation
Placental Dysfunction
Vascular Dysfunction
PREECLAMPSIA
Pathophysiology of Preeclampsia
Efficacy of Aspirin
Reviewed 59 RCTs (37,560 women) to determine
benefits of aspirin:
• 17% reduced risk of preeclampsia with low dose
aspirin
• 14% reduced risk of stillbirth
• 8% reduced risk of preterm birth
Conclusion
• Antiplatelet agents have moderate benefits when
used for prevention of preeclampsia
Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004659
For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation
statement, and supporting documents, please go to www.uspreventiveservicestaskforce.org. IUGR = intrauterine
growth restriction.
Ann Intern Med. 2014;161(11):819-826. doi:10.7326/M14-1884
Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: U.S.
Preventive Services Task Force Recommendation Statement
USPSTF Recommendations, 2014
high risk women
USPTF – women with several moderate
risk factorsWomen with several moderate risk factors also may benefit from
low-dose aspirin, but evidence is less certain for this approach.
Clinicians should use clinical judgment in assessing the risk for
preeclampsia and talk with their patients about benefits and harms
of low-dose aspirin use. Consider low-dose aspirin if the patient
has several of these moderate-risk factors:
–Nulliparity
–Obesity
–Family history of preeclampsia (mother or sister)
–Sociodemographic characteristics (African American Race, low
socioeconomic status)
–Age > 35 years
–Personal history factors (e.g. low birthweight or small for gestational age, previous adverse outcome, >10 year pregnancy interval)
ACOG affirms USPTF high-risk factors,
July 2016
“Based on evidence supporting a broader
list of risk factors of preeclampsia for which
low-dose aspirin may provide benefit and
based on more recent, evolving expert
consensus, ACOG supports the
recommendation to consider the use of low-
dose aspirin (81 mg/day), initiated between
12 and 28 weeks of gestation, for the
prevention of preeclampsia, and
recommends using the high-risk factors as
recommended by the USPSTF ….”
ACOG, Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia:
Updated Recommendations. July 11, 2016
ACOG on moderate risk factors, July 2016
“The USPSTF review also identified “moderate” risk
factors, for which low-dose aspirin might be considered if
several moderate risk factors are present, although the
evidence to support low-dose aspirin in the setting of
moderate risk factors is uncertain. It is important to
recognize that other organizations recommend
consideration of low-dose aspirin in women at risk for
preeclampsia, although the risk-factor criteria may vary
somewhat.”
ACOG, Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia:
Updated Recommendations. July 11, 2016
Preterm Birth Prevention – Current
Updates
1. Optimizing Birth Spacing or Interpregnancy Interval (IPI)
2. Low-dose aspirin prophylaxis to reduce pre-eclampsia
3. Progesterone supplementation to reduce
preterm birth recurrence
17 alpha-hydroxyprogesterone caproate
(17P)
ACOG Practice Bulletin, October 2012
One of the strongest clinical risk factors for
preterm birth is a prior preterm birth.
Maternal history of preterm birth confers a 1.5-
fold to 2.0-fold increased risk in a subsequent
pregnancy
17P
Synthetic form of progesterone given by injection in the gluteus muscle or anterior thigh
Reduces a woman’s risk of recurrent preterm
birth by 33%
ACOG Committee Opinion, October 2012, Prediction & Prevention of preterm birth.
Progesterone trial for the prevention
of preterm delivery in high-risk
women
Meis et al, N Engl J M, 2003
NICHD Maternal Fetal Medicine Units (MFMU) Network
NICHD: MFMU Progesterone
Trial
• Aim: To establish if weekly progesterone injections in women with prior spontaneous
preterm delivery (sPTD) reduces the risk of PTD
• Design: double-masked, placebo-controlled trial
• Eligibility criteria: singleton pregnancy 16-20 wkswith documented previous sPTD
• Intervention: progesterone or placebo
• Primary outcome: delivery at < 37 weeks’
• Sample: 463 pregnant women
Meis et al, N Engl J Med 2003
Progesterone: Rates of Preterm
Birth
0%
10%
20%
30%
40%
50%
60%
< 37 <35 <32
P<0.0001 P<0.0165 P<0.0180
17 P
17 P
17 P
Placebo
Placebo
Placebo
Meis et al, N Engl J Med 2003
Progesterone Results: Ethnic
Group
0%
10%
20%
30%
40%
50%
60%
70%
African American p=0.0103 Non African American p=0.0044
PlaceboPlacebo
17 P 17 P
P=0.0103 P=0.0044
Meis et al, N Engl J Med 2003
Progesterone prevents neonatal
complications
0%
2%
4%
6%
8%
10%
12%
14%
16%
neonatal
death
RDS BPD IVH* NEC*
17 P
17 P17 P 17 P
Placebo
Placebo
Placebo
Placebo
Placebo
Meis et al, N Engl J Med 2003
Progesterone prevents recurrent
preterm delivery
Weekly injections of progesterone prevented
recurrent preterm birth and improved the
neonatal outcome for pregnancies at risk
Effective in preventing very early as well as
later preterm birth
Effective in both African American and
Non-African American women
Meis et al, N Engl J Med 2003
Protocol for 17P Use
History of a previous singleton spontaneous preterm birth (200 to 366 weeks)
Current singleton pregnancy
Initiate treatment between 160 - 216 weeks gestation*
Receive 17P injections weekly until 366 weeks gestation or she delivers
Women who delivered multiple infants preterm and/or who are pregnant with multiples are not eligible for
treatment
47% of eligible women in North Carolina receive 17P
7% of eligible women who are Medicaid recipients
received 17P in Louisiana in 2013
“Medicaid health plans have covered 17P for many years.
However, under-utilization is still broadly acknowledged.”Medicaid Health Plans of America Report, 2014
Underutilization of 17P – available
estimates
Stringer et al. 17OHP-C coverage among women delivering at 2 North Carolina hospitals. Am J Obstet Gynecol
2016. ajog.org OBSTETRICS Original Research JULY 2016
Orsulak et al. 17P Access in the Lousiana Medicaid Population, Clinical Therapeutics, November 2015.
Medicaid Health Plans of America (November, 2014) Preterm Birth Prevention: Evidence-Based Use of
Progesterone Treatment: Issue Brief and Action Steps for Medicaid Health Plans.
Optimal Prenatal Care
Session Overview
Session 9: Graduation
Participants celebrate their completion of Becoming a
Mom/Comenzando bien.
Key Message:
Participants can be proud of completing Becoming a
Mom/Comenzando bien.
Depression
Screening
and
Pregnancy
Grade Definition Suggestions for Practice
BThe USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
Offer or provide this service.
Depression in Adults: Screening. January 2016. U.S. Preventive Services Task Force..
From ACOG
• The totality of the evidence supports the
benefits of screening in pregnant and
postpartum and general adult populations,
• Although definitive evidence of benefit is
limited, the College recommends that
clinicians screen at least once during the
perinatal period for depression and anxiety
symptoms using a standardized, validated
tool.
ACOG Committee Opinion No. 630, May 2015. Screening for Perinatal Depression
Depression Screening Tools
ACOG Committee Opinion No. 630, May 2015. Screening for Perinatal Depression
Safer
Medication
Use
Medication Use in Pregnancy:
A Public Health Concern
• Medication use has surged to 9 out of 10 pregnant women. About 7 out
of 10 take at least one prescription medicine. Over the last 30 years, use
of prescription medicine during the first trimester of pregnancy has
increased more than 60%.1
• Fewer than 10% of medications have enough information to determine
their safety for use in pregnancy.2
• Taking certain medications, such as isotretinoin (also known as
Accutane®), during pregnancy can cause serious birth defects or poor
pregnancy outcomes.
1. Mitchell AA, et al. National Birth Defects Prevention Study. Am J Obstet Gynecol. 2011;205:51.e1-8
2. Adam MP, Polifka JE, Friedman JM. Am J Med Genet Part C. 2011;157:175-82.
CDC: Treating for Two. Available at:www.cdc.gov/pregnancy/meds/treatingfortwo/facts.html
Opioid Use in Pregnancy: A
Public Health Concern
• Some studies have shown an association of
opioid use with stillbirth, poor fetal growth,
pre-term delivery, and birth defects
• Before initiating opioid therapy for
reproductive-age women, clinicians should
discuss family planning and how long-term
opioid use might affect any future pregnancy.
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
• For pregnant women already receiving opioids, avoiding
or stopping medication use during pregnancy may be
more harmful than taking a medication.
• Clinicians should access appropriate expertise if
considering tapering opioids because of possible risk to
the pregnant patient and to the fetus if the patient goes
into withdrawal.
• For pregnant women with opioid use disorder,
medication-assisted therapy with buprenorphine or
methadone has been associated with improved maternal
outcomes and should be offered.
Opioid Use in Pregnancy
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
Pregnancy and
Oral Health
Pregnant women should have
oral healthcare
…Evidence shows that oral health care during
pregnancy is safe and should be recommended
to improve the oral and general health of the
woman.
ACOG Committee Opinion No. 569. Oral Health Care During Pregnancy and Through the
Lifespan. (August 2013, reaffirmed 2015). Obstet Gynecol. 2013;122(2 Pt 1):417-22.
1. Discuss oral health with all patients, including
those who are pregnant or in the postpartum
period.
2. Advise women that oral health care improves
a woman’s general health through her lifespan
and may also reduce the transmission of
potentially caries-producing oral bacteria from
mothers to their infants.
3. Conduct an oral health assessment during the
first prenatal visit.
ACOG Recommendations
ACOG Committee Opinion No. 569. Oral Health Care During Pregnancy and Through the Lifespan. (August
2013, reaffirmed 2015). Obstet Gynecol. 2013;122(2 Pt 1):417-22.
4. Reassure patients that prevention, diagnosis, and
treatment of oral conditions, including dental X-rays
(with shielding of the abdomen and thyroid) and local
anesthesia (lidocaine with or without epinephrine), are
safe during pregnancy.
5. Inform women that conditions that require immediate
treatment, such as extractions, root canals, and
restoration (amalgam or composite) of untreated caries,
may be managed at any time during pregnancy.
Delaying treatment may result in more complex
problems.
ACOG Recommendations
ACOG Committee Opinion No. 569. Oral Health Care During Pregnancy and Through the Lifespan. (August
2013, reaffirmed 2015). Obstet Gynecol. 2013;122(2 Pt 1):417-22.
Additional ResourcesDepression:
NICHD, NCMHEP
www.nichd.nih.gov/ncmhep
U.S. Preventive Services Task Force:
www.uspreventiveservicestaskforce.org
IMPLICIT (Interventions to Minimize Preterm and Low birthweight Infants through
Continuous Improvement Techniques) Toolkit Now Available!
www.prematurityprevention.org
Medication Use
Treating for Two: http://www.cdc.gov/pregnancy/meds/treatingfortwo/
Oral Health
ACOG Oral HealthCare During Pregnancy: A National Consensus Statement, 2012
http://mchoralhealth.org/PDFs/OralHealthPregnancyConsensus.pdf
Thank you