Dr. Rochelson: Pregnancy is normal. I think it is really important that we realize I am not standing up here talking about a disease state. Pregnancy is a normal state. Women were meant to be pregnant and it is a very normal physiologic occurrence. I also want to emphasize that you don’t have to be perfect, none of us are in the conduct of a pregnancy, and thank God most pregnancies work out very well even without us being perfect. And I think that is important because I think in today’s day and age, there is a lot of guilt associated with pregnancy and I don’t think we need to be quite as guilty as a lot of us feel. I think the take-home message from this talk is that preconceptional visits really help. That is important if you have a problem to come to see us before your get pregnant so you can be in the best possible shape when the pregnancy begins. So what is the definition of high-risk pregnancy? And the answer is I do not know. When you go on the website and you look for in the internet and you look for the definition of high-risk pregnancy you are going to have 15 different explanations what a high-risk pregnancy is. And so, it is really to a large degree in the eye of the beholder but I think if you stratify it, if you separate it out into these three categories, you will cover most high risk pregnancies and that is there are maternal indications problems with the mother, problems with the fetus and problems with the pregnancy itself. The facts are concerning the incidence of premature delivery in this country is about 12% and 8% of all babies are low birth weight which is defined as under 5 pounds, 11% of women still smoke in pregnancy and 10 drink during pregnancy. And remarkably and we will talk about this in greater detail. About 2/3 of women still don’t take folic acid supplements. About 1/3 of women today are obese when they conceive their pregnancy and a fair number have pre-existing medical conditions and even those without about a third of pregnancies end up with complications before the delivery. We have done dramatically better over the last 40 years in reducing the incidence of maternal death and infant mortality. As you can see, the graph starts in 1960 and goes down to 2002 and fortunately we are doing much, much better in terms of losing both mothers and babies. The top two reasons for babies dying in this country are birth defects and prematurity. It is important that you realize that both of these issues, congenital malformations and preterm delivery maybe reduced by the mother seeing an obstetrician or a perinatologist prior to conception and starting the pregnancy particularly if she is a high risk to begin with, such as a diabetic or woman with hypertension and so on. Despite the improvement in infant mortality and maternal mortality, the incidence of low birth weight and prematurity is essentially the same as it was for the past 25 years. And what does this mean. It means that we are still not doing as good a job as we would like to in terms of reducing the incidence of prematurity despite all the medications and hospitalizations and surgical procedures, we still have an acceptably high incidence of preterm delivery. The majority of women in this country gets some prenatal care but about 13% only start in the second trimester and there are still almost 4% of women in this country that get very late or no prenatal care. And this significantly impacts on the outcome in the pregnancy. This is a long list of complications that the mother can have which will influence both her health and the health of the baby. The number two problems that we see in the high-risk pregnancies are diabetes and high blood pressure although the list is really endless. Any kind of maternal disease can have an impact on the pregnancy. I would add particularly in a family that wants to have a lot of children that a previous caesarian delivery, I would list as a high risk condition. I am going to stop for just a couple of seconds now. If any body has any questions that they want to ask me, please feel free to jump in. We can make this a dialogue if you like.
Okay, so as I mentioned it is very important to have a preconceptional care as part of the disciplinary team approach. What this means is that we have internists, cardiologists, and endocrinologists, whatever the medical problem is, participate in the counseling of the patient. This is going to help us do primarily is this gets the mother in the optimal shape prior to beginning the pregnancy because, really an ounce of prevention is worth a pound of cure in this regard. I just want to take one second to thank Rabbi Shteinman and Rabbi Jacobo who I think has an honorary medical degree for really being so gracious in inviting me to give this talk. So thank you. Thank you very much.
So what happens if you have these medical problems? Aside from the effects on the mother, all of these medical conditions can result in a very low birth weight baby. And low-birth weight babies are with a lot of complications in terms of development and nutrition and further development and sometimes mental retardation and cerebral palsy and so on, which makes it really, really critical to get these moms in the best shape possible prior to pregnancy. I want to just mention one thing here, you will see on the slide, Thrombophilius. Thrombophilius is an interesting condition. Thrombus is clot and phili means love, it means the blood loves to clot and in some conditions, when blood loves to clot it results in clotting in the placenta and it affects blood flow to the fetus and results as you can see in the picture of a very low-birth weight baby. I want to use diabetes as an illustration; women with diabetes have a much higher incidence of having babies with birth defects. Any chemical or drug that causes birth defect is called a teratogen and glucose by itself, sugar, is a major teratogen. And if the diabetes is uncontrolled, about 40% of babies will have major birth defects. However, if you control the mother’s sugar prior to the pregnancy, you can reduce the incidence of birth defects to that of the normal population. So for example, in this community and I was talking to Rabbi Jacobo that is about this and I know from my own patient population that you do a lot of genetic testing even prior to marriage. I think part of that, once you think of control of hypertension and control of diabetes to optimize the optimal outcome for your children to be. Mothers with diabetes can have a variety of medical complications such as cardiac disease and kidney disease, eye disease and so on and so it is important to get all the appropriate consultations prior to the mom becoming pregnant. In women with hypertension, you want to be in the best blood pressure shape possible prior to pregnancy. Some medications are extremely dangerous in pregnancy. For example, there is a class in medications called an ACE Inhibitor. It is very important if the mom is on any medications prior to pregnancy that she consult the obstetrician so she is sure that the medication that she is on is a safe one for the baby. There are certain conditions as I mentioned, there is maternal, there is fetal and there is pregnancy high-risk situations. There is something called preecclampsia which occurs in about 6% to 8% of women in which they get high blood pressure and protein in the urine and swelling. It is always better for the mother for the mother to deliver the baby. It is not always better for the baby because it may occur in a very premature state. But one of the basic principles, which I think is also, and you can correct me if I am wrong. I think it is also holistically correct that the mother comes first, the mother’s health is paramount, and it really is very logical as well because if the mother is not healthy then clearly the fetus is not going to be healthy either. But the basic principle of maternal fetal medicine which is why it is called maternal fetal medicine and not fetal maternal medicine is that the mother’s health always comes first.
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