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Low birthweight is costly to sufferers and to society. Primary prevention gives benefits exceeding costs, but many plans to prevent low birthweight, for example improvement in antenatal care, have failed because the intervention is too late. Preconception care is generally necessary. Poor maternal nutrition and infection are the major causes of low birthweight.
Although ongoing study is required to winnow environmental ideology from scientific fact, existing evidence from recent research demonstrates a definitive link between chemical toxicants and potential health sequelae, including congenital affliction and gynaecological disorders. Amid media clamour of health risk and biological peril associated with various environmental toxicants, a spectrum of responses has emerged: some have embraced the environmental cause, some have summarily dismissed it as piffle and perhaps the majority has remained disinterested. Although journals devoted to toxicological and environmental health concerns have become prominent in academia with voluminous numbers of scientific reports being published, there has been limited exploration of the relationship between contemporary chemical exposure and reproductive medical issues in mainstream obstetrics and gynaecology literature. Providers of obstetrical and gynaecological health care need to acquire knowledge of taking an exposure history, instruction in details of precautionary avoidance, skills to provide preconception care and necessary tools to investigate and manage patients with toxicant exposure.
A 1991 study of 115 internal medicine and 28 family practice residents at a large inner-city public hospital finds that both groups would perform poorly in providing preconception counseling to women of reproductive age. More than 40% of residents failed to indicate that they would provide a healthy woman with information on rubella immunization and family planning or counseling on sexually transmitted diseases and safer sex. When counseling a diabetic woman seeking pregnancy, 74% would not have discussed congenital anomalies with her and 45% would not have considered discontinuing oral hypoglycemics if she became pregnant. Furthermore, 58% would have neglected to review or change hypertension medications in a newly diagnosed pregnant woman. Although both internal medicine and family practice residents had positive attitudes toward offering preconception care, family practice residents had significantly higher attitude scores. No clear improvement was found in patient management, attitude or knowledge scores as residents progressed from their first to their third year of training.
Diabetes of all types is a known complication of pregnancy and is a risk for mother and foetus. Despite significantly improved care of pregnancies complicated by diabetes the perinatological results are still somewhat worse than in the healthy population. Therefore in the further improvement of perinatological indicators preconception care participates as well as systematic compensation of insulin dependent diabetes, preventive admission on hospital and correct timing of termination of pregnancy in pregestational as well as in gestational diabetes. All care of these pregnancies is shared by the obstetrician and diabetologist.
Current classification, diagnostic and therapeutic guidelines of diabetes in pregnancy are briefly reviewed in this paper. Obstetricians mainly are confronted with the insulin-dependent diabetic (IDDM) prior to conception and during pregnancy. Intensive interdisciplinary co-operation is considered a prerequisite for treatment of the diabetic patient planning or carrying a pregnancy. The following subspecialties should work together in diabetic pregnant care: Reproductive Medicine incl. high-level endocrinological diagnostics, Diabetology with a teaching facility, and--within a perinatal center--an obstetric and neonatal department experienced in diabetic care. Preconceptional metabolic adjustment as well as surveillance of fetal and maternal condition during the first trimester of pregnancy are considered the mainstay in diabetic patient's care. Possible complications of diabetic pregnancy are described. Only in rare cases, pregnancy is contraindicated because of retino- or nephropathy. The screening program for gestational diabetes is based upon the patient's history, fasting-blood-glucose-levels, 50-g-oral-glucose-tolerance-test (OGTT) and a 24-h-blood-glucose-profile. Measurement of insulin levels in amniotic fluid are recommended for cases that remain yet undiagnosed.
OBJECTIVE: The incidence of major congenital malformations is approximately 6-9% in pregnancies complicated by diabetes mellitus. This incidence is 3-4-fold higher than that in the general population. Congenital malformations are now ranked as the leading cause of death in the offspring of women with diabetes. The precise mechanism(s) by which these anomalies are induced is unknown. It is also not clear what predisposes women to deliver malformed infants, which infants are at risk, and why some are spared even when exposed to presumably high risk conditions. The purpose of this report is to determine, from the literature, the primary etiologic factors associated with diabetes-induced embryopathy and its prevention. METHODS: A review of the current literature regarding malformations in diabetic pregnancies was conducted to elucidate dominant concepts in the pathogenic mechanism(s) of these anomalies and to discuss current and future strategies for their prevention. RESULTS: Numerous investigators have demonstrated that hyperglycemia has a teratogenic effect during organogenesis. However, the exact mechanisms involved have not been completely elucidated. Dietary supplementation of deficient substrates (arachidonic acid or myo-inositol), either in vitro or in vivo, has been shown to reduce the incidence of diabetes-related malformations in offspring of diabetic pregnant animals. In addition, free oxygen radical-scavenging enzymes and antioxidants aimed at reducing the excess load of radicals also result in a reduced malformation rate. Clinical evidence has demonstrated that the teratogenic effects of hyperglycemia may be obviated by maintaining euglycemia throughout organogenesis. Numerous studies have demonstrated that participation in a preconception care program can reduce the incidence of malformations in women with diabetes to the background rate. Unfortunately, less than 10% of women with diabetes currently enter these programs. CONCLUSIONS: Diabetic embryopathy remains the single most common lethal problem affecting diabetic pregnancies today. Although preconception planning and glycemic control can reduce the incidence of malformations, it is often difficult to get women to attend such programs and to achieve and maintain euglycemia. The use of dietary supplements, which presumably would override the teratogenic effects of aberrant metabolic fuels, holds great promise for the future as a prophylaxis against diabetic embryopathy.
For too long, the health care of women has separated childbearing from health promotion and management of chronic health problems. A critical dimension of an integrative science of women's health is bringing together childbearing with women's health during the life span. This integration is needed in areas such as preconception care, reproductive weight management, and gestational diabetes. An integrative science enhances research promoting women's health and patterns of care aimed at disease prevention.
The management of pregnancy in a woman with diabetes is directed toward insuring a normal outcome for the mother and her newborn baby. There is ample evidence from studies in both humans and animals that maintenance of a normal maternal metabolic environment, particularly blood glucose concentrations, can avoid or ameliorate the complications of pregnancy responsible for increased morbidity and mortality in the mother and her baby. It is essential that this metabolic normalcy be achieved preconceptionally if congenital malformations, the leading cause of death in IDMs, are to be avoided. Thus, preconceptional care, intensive regulation of maternal glucose metabolism and fetal surveillance throughout pregnancy are critical. The use of the multidisciplinary team to optimize care has led to significant reductions in maternal and perinatal morbidity/mortality in IDMs, and is thus essential to successful outcomes in pregnancies complicated by diabetes.
Although 90% of patients using anticonvulsant drugs can expect a favorable pregnancy result, this outcome can be maximized by careful preconceptional, antepartum, and postpartum management. There is no clearcut agreement that any one of the four major drugs used for the treatment of seizure disorders (phenytoin, phenobarbital, valproic acid, and carbamazepine) is more teratogenic than others. Patients should be counseled that the risk of adverse maternal and neonatal outcomes from recurrent seizures during pregnancy is greater than the risk of teratogenicity with anticonvulsant drugs. The lowest possible dose of one of the four front-line agents is recommended for seizure control in pregnancy. The interaction of epilepsy and pregnancy, as well as the possible mechanisms of anticonvulsant teratogenesis, are reviewed. The use and toxicity of individual, commonly used, anticonvulsant drugs are described. Detailed consensus recommendations for preconceptional, antenatal, intrapartum, and postpartum management of patients using anticonvulsant drugs are discussed.
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OBJECTIVES: To determine the feto-infant mortality rate for New York City, assess racial/ethnic variations and identify areas for intervention using the Perinatal Periods of Risk (PPOR) approach. METHODS: The PPOR model examines fetal and infant deaths by age at death (fetal, neonatal, postneonatal) and birthweight (500-1499, > or =1500 g). It groups age at death and birthweight into four categories to identify problems hypothesized to lead to the death: factors related to Maternal Health and Prematurity, Maternal Care, Newborn Care and Infant Health. The model was applied to fetal and infant deaths occurring in New York City using Vital Records data from 1996-2000. Analysis was completed for the entire city and by race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, Asians/Pacific Islander). RESULTS: The overall feto-infant mortality rate was 11.5/1,000 live births plus fetal deaths. This rate varied by race/ethnicity; black non-Hispanics had a higher rate than other racial/ethnic groups. Conditions related to maternal health and prematurity were the largest contributing factors to feto-infant mortality (5.9/1000) in New York City. Among blacks and Hispanics, problems related to maternal health and prematurity contributed a larger share than among whites and Asians/Pacific Islanders. CONCLUSION: The use of the PPOR approach shows that the racial/ethnic disparities in feto-infant mortality that exist in New York City are largely related to maternal health and prematurity. Interventions to reduce the feto-infant mortality rate should include preconception care and improvements in women's health.
To ascertain current practice trends among obstetricians and maternal-fetal subspecialists regarding the care of pregnancies complicated by diabetes mellitus, a questionnaire was sent to all members of the Society of Perinatal Obstetricians (SPO) and a randomly selected group of American College of Obstetricians and Gynecologists (ACOG) Fellows. A total of 273 of 356 SPO members (77%) and 198 of 504 ACOG Fellows (39%) responded. When divided according to years post-residency (ACOGa, less than 15 years; ACOGb, 15 years or more), significant differences in practice patterns were observed for ACOG Fellows. The SPO responses were similar among these subgroups. Despite current ACOG recommendations, most clinicians practice universal screening for gestational diabetes. Significant discrepancies appear to exist between ACOGb versus ACOGa and SPO with regard to methods of glucose surveillance and the threshold for initiating insulin therapy in gestational diabetes. Intensive fetal surveillance, elective delivery, and high cesarean rates are common in pregnancies complicated by insulin-dependent diabetes mellitus, which is most often managed by a perinatologist or by an obstetrician in consultation with an internist. Few insulin-dependent patients seek preconceptional care.
A tremendous amount of data suggest that near-normal glycemic control prevents or delays complications of diabetes, which has led to a dramatic increase in continuous subcutaneous insulin infusion (CSII) or insulin pump use. In this article, the data supporting CSII in type 1 diabetes is reviewed, and the advantages and disadvantages of CSII are analyzed. In addition, CSII use in specific situations is examined, including during childhood and pregnancy and while exercising. The published articles suggest that CSII provides better glycemic control than does conventional therapy and comparable to or slightly better control than multiple daily injections. The use of CSII may be especially indicated during pregnancy or for preconception care and for diabetes presenting in childhood or adolescence.
BACKGROUND: We conducted a study of a group of primary physicians in Puerto Rico to evaluate their knowledge about folic acid supplementation to prevent neural tube defects. METHOD: The study design was transverse-correlational. A total of 66 primary physicians in two hospitals (public and private) participated in the study. The sample was nonrandom and opportunistic, and only those physicians present in the hospitals at the moment of distribution of the questionnaires participated. A self-administered and anonymous questionnaire was used. Descriptive statistics and cross-tabular analysis were used to describe the results of this study. Inferential statistics were also used, including Chi square and t-tests to establish the associations/differences between physician knowledge and the independent variables. RESULTS: Of the participants, 87.9% demonstrated an inadequate knowledge about folic acid supplementation for the prevention of neural tube defects as part of preconception care and only 12.1% demonstrated adequate knowledge. Older physicians had greater knowledge about folic acid. Also, women demonstrated greater knowledge about folic acid than did men. Most of the physicians who always recommend supplementation to their patients demonstrated a greater knowledge about folic acid, and all participants with adequate knowledge came from the public hospital. CONCLUSIONS: Despite a concerted effort by the Health Department of Puerto Rico to provide education in the importance of folic acid supplementation to reduce the incidence of neural tube defects, primary physicians in two Puerto Rican hospitals generally have not availed themselves of this training and showed a lack of knowledge on this important clinical issue.
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Antimicrobial therapy can ameliorate infection and prevent long-term morbidity caused by several pathogens that infect the fetus and neonate. Ultimately, however, preventive strategies need to be developed and incorporated into routine preconceptional care. The future of prevention lies in immunizations, and if past and current successes with smallpox, polio, rubella, and measles vaccination programs are any indication, the future is bright for the developing fetus.
BACKGROUND: Periconceptional folic acid use reduces the risk of neural tube defects and possibly other birth defects. The effectiveness of two interventions to increase the use of multivitamins among women of childbearing ages was evaluated. METHODS: Quasi-experimental interrupted time series design with a nonequivalent control group. Participants included female members of Kaiser Foundation Health Plan aged 18 to 39 years residing in the three geographic service areas of California under study from 1998 through 2000. The central component of the direct mail/pharmacy information intervention was the mailing of "starter kits" of 100 multivitamins, while the provider education intervention used primary care providers to deliver the study message. Main outcomes included the use of multivitamins containing folic acid at least four times per week ("regularly"), intention to use multivitamins regularly, and knowledge and attitudes about multivitamins. Outcomes were measured via telephone interviews of nonpregnant women of childbearing age. RESULTS: A total of 3438 women were interviewed. There was a small but significant increase in the percentage of women using multivitamins in the direct mail/pharmacy information intervention group at the beginning of the intervention period (p =0.006), but this increase was not sustained after the interventions ended. No other significant change was observed. CONCLUSIONS: Despite our ability to reach many women of childbearing age with multiple messages about regularly using multivitamins, only a small temporary increase was found in the percentage of women using multivitamins who received the messages in the mail. Other interventions and further evaluation of the impact of food fortification with folic acid should be considered.