By John C. Hobbins, MD
Professor, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora
Dr. Hobbins reports no financial relationships relevant to this field of study.
SYNOPSIS: This special feature addresses ways a woman can optimize outcomes in her next pregnancy by following specific preparatory activities during her interpregnancy interval.
Fortunately, most patients have happy endings to their pregnancies, and for these women, an early discussion of the “next” pregnancy may seem like a low priority. However, others may have had a difficult pregnancy or one complicated by serious fetal/infant abnormalities or even loss. These patients often will want information immediately about another pregnancy.
Regardless of the circumstances, optimizing the outcome of the next pregnancy depends on early preparation, and this should not wait until the first prenatal visit. This Special Feature provides a discussion of a preemptive approach for future pregnancies.
The timing of when to have “next pregnancy” discussions will vary, but for most patients the most pragmatic approach would be to discuss this subject at the six-week postpartum visit. However, some couples experiencing an adverse outcome will want timely answers, which can be discussed once all the pertinent information is available.
Recurrence Rates
When a disaster occurs, one of the first words from patients’ mouths is “Will this happen again?” Here is the condensed version of answers to address the most common problems.
Stillbirth. The largest study involved 3,000,412,079 pregnancies, and 24,541 (0.7%) ended in stillbirth; 14,000,606 (2.5%) occurred in those with previous stillbirth.1 So although there was a 4.8-fold increased risk of a recurrence, there is a > 97% chance that this disaster will not repeat.
Preterm Birth. The rates in the literature are skewed by ethnic and pregnancy complication statistics, but the authors of one of the largest studies cited a 14-15% risk of recurrent spontaneous preterm birth at < 37 weeks compared with 3% rate in those without this history.2
Gestational Diabetes. One might expect a very high likelihood of recurrence in patients who are predisposed to insulin resistance. However, in a large study from Massachusetts, the chances of a patient developing gestational diabetes again is 47%, with a 2-5% risk of the patient becoming a type 2 diabetic in a subsequent pregnancy.2 Seventeen percent will develop type 2 diabetes one year postpartum, and Hispanics, who are more prone to glucose intolerance, have a 50% risk of developing type 2 diabetes.
Preeclampsia. Preeclampsia comes in many varieties, the worst of which surfaces early and requires delivery prior to 34 weeks. Fortunately, most often, the condition becomes apparent late in pregnancy and is manageable. So when assessing recurrence rates, the severity of the initial pregnancy must be considered. One study showed an overall 14.7% chance of recurrence any time in pregnancy and a 6.4% rate of the second pregnancy ending before 34 weeks.4 Having two prior preeclampsias raises the recurrence risk to 32%. Ethnicity also plays a role. An Indian/Asian population is reported to have a 26% recurrence risk for preeclampsia.5
Hyperemesis Gravidarum. Experiencing severe nausea and vomiting in pregnancy leaves long-lasting memories. In one survey of 100 women with a history of hyperemesis gravidarum, 37% of responders said they would not attempt another pregnancy.6 Although the recurrence risk commonly is thought to be about 50%, a Norwegian study found that only 15% of patients with hyperemesis gravidarum had a recurrence severe enough to require temporary hospitalization.7
Fetal Anomalies. This complicated topic really deserves a separate discussion. Any patient delivering a child with an anomaly should have a genetic workup and receive counseling, and the postulated recurrence rate will depend heavily on this information. However, if a contemporary genetic workup is negative, the gross rates of recurrence of most of the common anomalies are as follows (references have been deleted for brevity):
a. Aqueductal stenosis: 4-5%
b. Neuronal migration disorder: < 1%
c. Dandy Walker complex: 1-5%
d. Cleft lip and palate: bilateral (4.6%), unilateral (2.5%)
e. Neural tube defect: 4%, but 1.5% with folic acid supplementation
f. Congenital heart disease: 2.8%, but 4.2% if congenital heart disease is in the immediate family
g. Diaphragmatic hernia: < 1%
h. Ventral wall defects: omphalocoele, 50% have a genetic origin, but once these are ruled out, the risk is < 1%; gastroschisis, < 1%
i. Clubfoot: bilateral (4.6%) and unilateral (2.5%)
Preemptive Approaches to Optimize Future Pregnancies
Customize the Interpregnancy Interval. Studies consistently have shown that the ideal window for optimal outcome is between 18 and 23 months from the end of a previous pregnancy to the end of the next pregnancy.8 Since the worst outcomes occur when conception happens within three months postpartum, this is a major reason to initiate a discussion of contraception before the patient leaves the hospital postpartum and to reemphasize at the six-week postpartum visit.
Weight Control. Every year, more people in the United States are classified as obese, with the latest figures showing an overall obesity rate (body mass index [BMI] > 30 kg/m2) of 35.7% and a combined rate of obesity and overweight (BMI 25-30 kg/m2) of 68.8%. The average weight gain in pregnancy is 32 pounds.9 One year later, 75% of women were heavier than their previous pre-pregnant weight, 47% were more than 10 pounds heavier, and 24.2% were more than 20 pounds heavier.
The immediate concern is the association between prepregnant weight and macrosomia, yielding to higher rates of birth injury and even later childhood obesity and metabolic syndrome. Fortunately, studies have shown that programs involving lifestyle changes (diet, habits, and exercise) between pregnancies can have a major beneficial effect on future pregnancies. One study in patients with gestational diabetes showed that 33% of patients attained their weight loss goal in 12 months with a prescribed program compared with only 8% of those randomized to usual care.10 Another review found a halting of the usual progression from gestational diabetes to type 2 diabetes with combinations of lifestyle modification and metformin.11 Also, adequate control of type 2 diabetes prior to pregnancy, by lowering hemoglobin A1c levels below 5%, will diminish the chances of diabetes-related anomalies to that of a nondiabetic.
Habits/Smoking/Alcohol
Smoking interferes in many ways with placental development and the delivery of nutrients and oxygen to the fetus, resulting in an increased rate of fetal growth restriction,12 preterm birth,13 and stillbirth.14 The impressive addictive power of cigarettes is well-demonstrated by the fact that so many women, despite awareness of the harmful effects on their fetuses, continue to smoke in pregnancy. About 11% of American women smoke during pregnancies, and in some states this rate is substantially higher (23% of patients in Ohio). Of those who smoke within three months of pregnancy, 54% quit when becoming pregnant and, unfortunately, 44% will start again after pregnancy ends, despite attempts at cessation.15 One study using an objective measure of cigarette fallout in the maternal circulation (cotinine) identified patients who had either stopped just before becoming pregnant or had been exposed to passive smoke.16 These women had higher rates of preeclampsia than non-smokers, suggesting that the best outcomes could be attained by cessation long before the start of pregnancy and by an adjustment to live in a smoke-free environment.
Various methods of smoking cessation using different nicotine replacement vehicles can be successful, but the least effective approach seems to be the “cold turkey” approach. Although a concern has been voiced recently about the effect on the fetal lung of nicotine alone, the full package of cigarette smoke and its relationship to maternal carboxyhemoglobin levels represents a greater risk.
Alcohol
Alcohol ingested in large amounts in the first trimester can be teratogenic (the fetal face and heart) and can affect the central nervous system later in pregnancy (fetal alcohol spectrum), but it always has been difficult to quantify how much is too much. Therefore, the American College of Obstetricians and Gynecologists’ committee opinion contains a conservative statement that women abstain from all alcohol before and during pregnancy.17 It is most important that women get corrective help before becoming pregnant so they will not have an overlap into early pregnancy during organogenesis. Also, binge drinking at any time should be discouraged strongly. That said, there is no evidence that having an occasional drink preconception (only) will have an adverse effect on pregnancy. Initiating contraceptive measures postpartum allows adequate time for recovery and preparation of the reproductive system and for patients to lose weight, make positive lifestyle changes with exercise and diet, and adjust habits while training for another pregnancy marathon.
Travel
The threat of the Zika virus looms large in areas in which the Aedes aegypti mosquito is indigenous. Women who are contemplating pregnancy should avoid traveling to these areas. If such a trip is unavoidable, then it is important for women and their partners to use anti-mosquito sprays or lotions (containing DEET) to exposed areas. Since the virus has a long lifespan in semen, a woman’s sexual partner traveling to these areas should use condoms for up to six months after returning. The absence of Zika virus symptoms does not preclude infection, since 80% of Zika-positive patients are asymptomatic. Information about danger areas can be accessed by visiting the CDC website at https://wwwnc.cdc.gov/travel/notices/.
Medications
Patients with intercurrent diseases, such as diabetes, heart disease, hypertension, hyperthyroidism, and neuropsychiatric abnormalities, should be followed by primary care physicians or appropriate medical specialists between pregnancies to prescribe and monitor the dosage of necessary medications. Among the most difficult conditions to manage are those involving chronic pain, like fibromyalgia, as well as neuropsychiatric disorders. The most problematic drugs used in pregnancy are antipsychotics (selective serotonin reuptake inhibitors, lithium, and newer drugs untested in pregnancy) and opiates. Yet, management generally will not suffer when creative substitution or readjustment of dosage is applied before and after conception. In most cases, the conditions for which the medications are prescribed represent a greater danger to the pregnancy than the medications themselves and, therefore, the motto should be “whatever it takes to control the condition.”
When to Schedule the First Prenatal Visit
Data suggest that the earlier in pregnancy a woman makes contact with her provider, the better the outcome. Yet, for various reasons, in a sampling of calls to 239 offices providing obstetrical care in Michigan, 50% of the time the mock-pregnant researchers were told to book their appointment within six weeks, 66% < 7 weeks, and 75% within eight weeks.18 Interestingly, only once was the researcher granted an appointment earlier (during organogenesis) than the recommended appointment date.
Cohen recommends asking a few simple, but important, questions at the time of the first phone call so that the first appointment can be tailor-made to the patient’s needs.19 This should increase the efficiency of care and allow early intervention for the few who need it. Most importantly, if plans for early pregnancy are customized long in advance, the pressure is removed from the front office scheduler to make these decisions.
REFERENCES
- Lamont R, Scott NW, Jones GT, Bhattacharya S. Risk of recurrent stillbirth: Systematic review and meta-analysis. BMJ 2015;350:h3080.
- Mazaki-Tovi S, Romero R, Kusanovic JP, et al. Recurrent preterm birth. Sem Perinatol 2007;31:142-158.
- England L, Kotelchuck M, Wilson HG, et al. Estimating recurrence rate of gestational diabetes mellitus (GDM) in Massachusetts 1998-2007: Methods and findings. Matern Child Health J 2015;19:2303-2313.
- Hernandez-Diaz, Tovi S, Cnattingius S. Risk of pre-eclampsia in first and subsequent pregnancies: Prospective cohort study. BMJ 2009;338:b2255.
- Surapaneni T, Bada VP, Nirmalan CP. Risk of recurrence of pre-eclampsia in the subsequent pregnancy. J Clin Diagn Res 2013;7:2889-2891.
- Fejzo MS, Macgibbon KW, Romero R, et al. Recurrence risk of hyperemesis gravidarum. J Midwifery Womens Health 2011;56:132-136.
- Trogstad LI, Stoltenberg C, Magnus P, et al. Recurrence risk in hyperemesis gravidarum. BJOG 2005;112:1641-1645.
- Zhu BP, Rolfs RT, Nangle BE, Horan JM. Effect of the interval between pregnancies on perinatal outcome. N Engl J Med 1999;340:589-594.
- Endres LK, Straub H, McKinney C, et al. Postpartum weight retention risk factors and relationship to obesity at 1 year. Obstet Gynecol 2015;125:144-152.
- Ratner PE. Prevention of type 2 diabetes in women with previous gestational diabetes. Diabetes Care 2007;30(Suppl 2):S242-245.
- Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
- Robinson JS, Moore VM, Owens JA, McMillan IC. Origins of fetal growth restriction. Eur J Obstet Gynecol Reprod Biol 2000;92:13-90.
- Shah NR, Bracken MR. A systematic review and meta-analysis of prospective studies on the association between maternal cigarette smoking and preterm delivery. Am J Obstet Gynecol 2000;182:465-472.
- Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol 2005;193:1923-1935.
- Jones M, Lewis S, Parrott S, et al. Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: A systematic review. Addiction 2016;111:981-990.
- Luo ZC, Julien P, Wei SQ, et al. Plasma cotinine indicates an increased risk of preeclampsia in passive smokers. Am J Obstet Gynecol 2014;210:232.eE1-5.
- American College of Obstetricians and Gynecologists. Committee on Health Care for Underserved Women. Committee opinion no. 496: At-risk drinking and alcohol dependence: Obstetric and gynecologic implications. Obstet Gynecol 2011;11(2 Pt 1):383-388.
- Nettleman MD, Brewer J, Stafford M. Scheduling the first prenatal visit: Office-based delays. Am J Obstet Gynecol 2010;203:207.e1-3.
- Cohen AW. Scheduling the first prenatal visit: A missed opportunity. Am J Obstet Gynecol 2010;203:192-193.
This special feature addresses ways a woman can optimize outcomes in her next pregnancy by following specific preparatory activities during her interpregnancy interval.
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