Search for tag: "high risk pregnancy"

Interviewer: We're with Dr. Stephen Fenton. He is the founder and director of the Utah Fetal Center at Primary Children's Hospital. And it is for women who have high-risk pregnancies due to a congenital anomaly with the child. There is kind of a way things used to be done. And now there's a way things are done at the Utah Fetal Center, Primary Children's Hospital, which is a much better way. Dr. Fenton, first of all, you're the founder and the director. You came in and you said, "I want to start this center."Why did you say that?

Dr. Fenton: I don't want anyone to ever think or believe that what was happening before wasn't being done to the best of its ability because it certainly was. All of these conditions were being cared for before. But the reality is it was kind of done in what I would term a physician-centered approach. So oftentimes that would require multiple clinic visits because they were separate clinics in each of the physician's clinics. And you can imagine how frustrating and how hard that must have been for that mom to kind of shoulder that burden all on her own.

Interviewer: It was a very stressful time.

Dr. Fenton: Very stressful time.

Interviewer: Just to coordinate her care kind of.

Dr. Fenton: I mean, and during all that time, of course, worried about her unborn child. And so what we've done is we've kind of shifted it from this physician-centered care to what I term patient-centered care with a multidisciplinary approach. So we, over the last five years, have put together a multidisciplinary team of all of these specialists that care for the child and for the anomaly. In addition, we've added adult specialists, so maternal fetal medicine or high-risk OBs that care for the mom, all in one place. We didn't have adult providers at the Children's Hospital. Now we have these adult MFM providers who help care for these moms. We also added a coordinator. We've added nurse coordinators that actually help the mom wade through all of this, and ancillary staff, such as a social worker, who can also help with the non-clinical aspects. We are now all in the same place. Instead of being in our individual silos, if you will, we're all located together where we can look at the images together, where we can talk about it, and where we can come up with a care plan not only for the mom until baby is delivered, but also for the child after delivery.

Interviewer: What is the objective of the center?

Dr. Fenton: We want to make sure mom and baby first have the right diagnosis. It's much easier to help the parent learn what the condition is and start understanding what the treatment, if any, will entail before the child is born. Now that's one aspect. The other aspect is some of these kids need intervention before they're born. And in order to do that, it's very specialized. It requires a team and it requires being able to take the mom to proper diagnosis and from diagnosis to intervention, and then from intervention to delivery safely. And you can't do that without proper infrastructure, and the Utah Fetal Center is that infrastructure.

Interviewer: Can you give me an example of a couple of the common conditions that you would require that would require this multidisciplinary team?

Dr. Fenton: Congenital diaphragmatic hernia is one that comes to mind, myelomeningocele, that's another word for spinal bifida, CPAM or congenital pulmonary airway malformation also known as congenital lung lesion, atresias, intestinal atresias, omphalocele, gastroschisis. These are all things that are surgical too. We oftentimes see kids that don't necessarily require surgery. So some of the genetic disorders like trisomy 21. We also see kids that have neurologic issues, so brain malformations that won't necessarily require intervention, but will require a coordinated care with multiple providers.

Interviewer: What does that initial consultation entail when they come to you? What does that look like?

Dr. Fenton: In the morning, they oftentimes will undergo an ultrasound and consultation with one of the maternal-fetal medicine physicians that work at the Utah Fetal Center. Dependent on what the original diagnosis is, and oftentimes we have already received outside imaging from the referring providers and reviewed it, they might also undergo a fetal MRI, and that fetal MRI will give us even more detail, especially when we can compare it to the ultrasound that happens on that same day. It's read by the fetal radiologists that work in the center. And then usually we give them a little bit of a break. They go to lunch, etc., and then come back in the afternoon or early afternoon, and there, they will see the specialist, the sub-specialist that will ultimately care for their child.

Interviewer: If a patient wasn't referred and they believe that the Utah Fetal Center is the place that they would like to go, are they able to call?

Dr. Fenton: Absolutely. They can go to our website, utahfetalcenter.org and self-refer. We really want to help these parents get through this very, very difficult time. We understand that there are a lot of providers out there that are doing a portion of this, and we certainly appreciate all that they are doing. We are not looking to just assume all care of these moms because we know that a lot of their care can be delivered close to home, but we do feel like it's very, very beneficial to start that coordination of care early so that we can help the parents understand what is happening, obtain expectations on the treatment plan, as well as understand the treatments involved and then initiate that plan early, and in the long run we know that doing so with the help of the many providers, not only here at the University of Utah and Primary Children's Hospital, but across the state will allow us to do that.

Dr. Jones: The modern intensive care nursery is a medical miracle. Over the past 30 years, our ability to help very premature babies survive has increased dramatically, but we haven't made any headway in preventing preterm births. Why? And what can we do about it? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care, and this is The Scope.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: The U.S. leads the developed world in rates of premature births. In Europe, the rates are about 8% to 10%. In the U.S., 12% to 13% of births are premature. So let's say 1 in 10 of babies are born prematurely. That's a big number.

Premature birth is defined as birth before 37 weeks. Of course, a baby born at 37 weeks minus 1 day is a pretty big baby that does usually quite well. Babies born at 34 to 36 weeks are called late preterm. Although they do pretty well, they can still have some difficulties. There have been big efforts in the U.S. to decrease the rates of late preterm births. The most successful of those efforts are to make sure that the moms and their doctors are careful about electively delivering babies early, meaning, don't deliver them early either by caesarean section or by inducing labor just because it's convenient.

Babies born at 32 to 34 weeks are called moderately preterm. Babies born 28 to 32 weeks are said to have severe prematurity. And babies born before 28 weeks are said to have extreme prematurity. Neonatal nursery costs for a baby born before 28 weeks can be about a quarter of a million dollars compared to less than $1,000 for a baby born at term.

I must say, in my professional life, I've contributed to the rate of preterm births in Utah. As a specialist in infertility who does in-vitro fertilization, I have contributed to the creation of my share of twins and triplets, and a couple sets of quadruplets. Part of the increased rate of prematurity in the U.S. is the way we do in-vitro fertilization. In many countries in Europe, IVF is paid for by national health insurance. But the rules are that only one embryo is transferred in young women who are likely to get pregnant. In the U.S., we have guidelines, but there are no legal rules about how many embryos to be transferred.

We all remember the octo-mom who gave birth to eight babies from IVF. We tried very hard to encourage our couples to transfer only one embryo because of the risk of twins. But many couples really want to become pregnant and they think that twins would be just fine. We do try to educate and convince, but often, couples want two. And with the young couples, putting two embryos back that are good quality puts the risk of twins at about 50%. And about 50% of twins are delivered prematurely. Okay, I got that off my chest and offered full disclosure.

Now, let's think about some other causes of prematurity. The number one risk of prematurity is having had a previous premature birth. Women know that risk before they get pregnant again so we should make sure that the next baby doesn't come too soon. About two to three years from the last pregnancy gives the best chance for the best baby. For women who have had a preterm birth that wasn't because of multiples, we can offer a natural hormone called progesterone during the next pregnancy that can decrease the risk of the next baby being premature.

There are a number of conditions in the mother that can increase the risk of prematurity. Cigarette smoking, excessive use of alcohol and other drugs of abuse, can increase the risk of prematurity. Obesity, social instability and intimate partner violence are also a few conditions that increase the chance of having a premature baby. With this in mind, we should give women all the opportunities to have babies when they have good health habits, a healthy weight and social stability. This means offering counseling and contraception for women whose babies would be healthier if their moms were a little healthier.

There are health conditions that can cause problems with pregnancy and with health, the mom, that can increase the chance that a mom might need to be delivered early. Diabetes and hypertension are two. Women with medical problems can seek pre-conceptual counseling so they can get their illnesses under control and be on medications that don't harm a baby.

There are structural conditions that can lead to premature birth. Structural problems with the uterus, such as uterine fibroids that push on the uterine cavity where the baby grows. Or women who were born with an abnormally shaped uterus. Women who have had operations on their cervix to treat an abnormal pap smear may be at an increased risk for having a preterm birth. Women with cervical or vaginal infections, such as chlamydia or bacterial vaginosis, may be at increased risk for a preterm birth. Many of these conditions can be treated or improved prior to getting pregnant.

Lastly, sometimes we just don't know why babies come early. We do our best as obstetricians to slow preterm labor and to give moms medications that can help their preterm baby's lungs be stronger. If we know that a woman has had a previous preterm birth for no good reason, we can try progesterone. But still, we depend every day on that miracle I call the neonatal intensive care unit to do their magic and grow our little, tiny babies when our moms can't. Thanks for joining us on The Scope.

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Dr. Kirtly Parker Jones: Preeclampsia or toxemia of pregnancy. What is that? For all of you Downton Abbey fans, it's what killed Lady Sybil Crawley at the end of her first and only pregnancy, and you all got to see it misdiagnosed and untreated on TV. What is preeclampsia? Who gets it? How can we prevent it? This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care and this is The Scope about preeclampsia.

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Dr. Kirtly Parker Jones: Toxemia is such an old fashioned term but it refers to a common condition of pregnancy, associated with high blood pressure, kidney problems, and possible seizures called eclampsia. The term toxemia came from the fact we didn't know what caused it but thought it was some sort of pregnancy toxin, and we knew it was cured by delivery. Preeclampsia is the condition before it gets to the stage of seizures. Today on The Scope we're going to talk about how it's diagnosed, who gets it, and some very recent recommendations, just this week, about how we might prevent it.
So toxemia, preeclampsia, pregnancy induced hypertension, these are all terms used for a condition in the pregnancy that causes high blood pressure and kidney problems and swelling that can progress to seizures, stroke and organ failure. It happens in about 5 to 10% of pregnancies, or about 1 in 15, so it's common and it's treated by delivery and resolves within several weeks after delivery, sometimes within hours after delivery. It's a major cause of premature delivery, because if the mom gets pretty sick and is only going to get sicker and sometimes is very dangerously sick, we have to get her delivered, even if the baby isn't ready.
We don't have great treatments, other than treating the blood pressure problem at the core of the disease, and that doesn't always work, so doctors have been looking for a prevention. It's hard to know a prevention when we barely even know the cause of this ancient and common disease of pregnancy.
So who can get it? Any woman who is pregnant can get and it usually shows up in the second half of pregnancy, mostly in the third trimester. It's more common in first moms and older moms. It's more common in African American moms. It's most common in woman with underlying medical conditions like high blood pressure, diabetes, clotting problems and auto immune disease. It's also more common in women with more than one baby on board or diabetes in pregnancy.
Many preventative treatments have been tried over the years; calcium supplements, low salt diets, blood letting. Didn't they try that on Lady Sybil? Vitamins, none have worked. Recently however, there have been enough studies of low dose aspirin to start at the beginning of pregnancy, to make the suggestion that all women who are at risk of preeclampsia take low dose aspirin after 12 weeks. The U.S. Preventative Services Task Force, the scientific group for all things about medical preventions, has made this recommendation for low dose aspirin, 81 mg, in women at risk, and studies show it decreases the risk of preeclampsia by about 25%. Now that's not perfect, but it's good and it's not risky for the pregnancy, the mom, or the baby or the baby later.

So if all women are at risk and you don't know if you're going to get it until after you've got it, who should start their pregnancy with low dose aspirin? Well women who've had preeclampsia before, women with more than one baby on board, women who have diabetes or blood pressure at conception. Other groups of women may also benefit and those are women with a family history of preeclampsia, women who are obese, women over 35 and African American women.
This is a little bit of good news, and important news. Preeclampsia can be very dangerous for Mom and baby. Keep your OB appointments, they check for this condition every visit with blood pressure check and a urine check. And if you think you're at risk, ask you doctor about low dose aspirin. Thanks for joining us on The Scope.