Recent data shows 20-50% of maternal mortality cases are preventable. Dr Joanne Stone, a maternal fetal medicine (MFM) speaks about how moms-to-be can prevent the preventable during pregnancy.
Georgie Kovacs: What does a maternal fetal medicine specialist do?
Dr Joanne Stone: A maternal fetal medicine specialist (MFM) is somebody that specializes in the care of high risk pregnancies. In the United States, it requires a four year residency in obstetrics and gynecology and then another three years. We cover a gamut of medical, maternal medical conditions, fetal conditions, and things that might develop during pregnancy.
We take care of women who have underlying medical disorders such as:
Coronary artery artery disease
Long standing diabetes
Lupus, you know
It can also be that we're taking care of fetuses that have problems such as complicated twin pregnancies. We also do a lot of, depending on where you train, prenatal diagnostic procedures such as those to diagnose genetic abnormalities like a chorionic villus sampling, amniocentesis, or fetal therapies. The latter is for patients at risk for fetal anemia where we can identify that the fetus is anemic and go in and do an integral blood transfusion.
Georgie Kovacs: Before we dive into some of the conditions, would you say that there's an overall theme where, once a woman is carrying a child, regardless of some of these preventable conditions?
Dr Joanne Stone: The majority of pregnancies tend to be uncomplicated, but there's also that assumption that pregnancy is that nothing can ever go wrong. I think women should understand that complications can arise during pregnancy, but without being scared about it. One of the things that some women do, which is more common in patients who have had a poor pregnancy outcome or have maternal medical conditions, where, before pregnancy, they will meet with the MFM.
It's really a great idea for anybody to do this. As a little example, obesity is becoming an epidemic in the United States. Understanding what the risks are of obesity during pregnancy, and what you can do, and you can prepare for it. We can do a work up and help you get yourself into the best possible shape before you get pregnant.
Georgie Kovacs: Is there a priority list of women who should consider at least that one consult?
Dr Joanne Stone: It’s best to see a doctor before you try to get pregnant and they can guide you on whether you need a MFM consultation. You definitely need to visit a MFM if you have an underlying condition, however.
Our Medicaid system is really difficult because people who are uninsured don't necessarily have that access. It's only once they become pregnant that they get Medicaid, so there's a disparity already in the care between those insured and uninsured populations.
Georgie Kovacs: Yes, the healthcare disparities are very sad, and I am looking into covering this topic on the podcast.
Now let's talk about some of these conditions. What are the risks of preterm labor and how can pregnant women be proactive?
Dr Joanne Stone: Preterm labor can be due to a whole lot of different causes, anything from a multiple gestation to a genetic predisposition to a medically indicated preterm birth or spontaneous preterm birth that might result from infection or inflammation.
One of the highest risk groups for spontaneous preterm birth is somebody that has a history of a spontaneous preterm birth. So if you went into labor at 32 or 34 weeks in a prior pregnancy, you’re at risk for another preterm birth, and it can be the same gestational age, it could be even earlier. We do have progesterone, which can help prevent that preterm birth. It doesn't prevent all of it, but it can greatly reduce the chance of preterm birth happening again.
Progesterone was one of the first things published back in 2003 that showed, in the United States population, a tremendous reduction in recurrent preterm birth and received authorization from the FDA. However, they had to repeat they had to redo the study as part of FDA regulations. It was very hard to redo the study in the United States, because here, you had a therapy that was successful. So it was done, mainly outside the US in a very different patient population.
The first study had somewhere over 50% rate of recurrent preterm birth in the placebo group and maybe 35% or so in the progesterone group. In this new study, it was 10 and 11%, and didn't show a difference. Very different, much lower rate of preterm birth, very different patient population. And the FDA has not come out with whether or not they're going to take it off the market or not. But there's a recent meta analysis published that looked at both vaginal progesterone and IM progesterone, both showing pretty much a benefit and vaginal certainly might even be better than injection But either way, either one is worthwhile.
Georgie Kovacs: What about over-the-counter progesterone? I know it is not as effective in such situations. Can you validate?
Dr Joanne Stone: That’s correct. Over the counter progesterone would not be ideal for preventing preterm labor.
There's another utility of progesterone that's been found effective, where it's in combination with an ultrasound that measures the cervical lane, and it is part of the routine anatomy scan. Usually, pregnant individuals get ultrasound for anatomy at 20 weeks. So if you do a vaginal ultrasound and measure the cervical length, a shortened cervix is a predictor of preterm birth. And if you give vaginal progesterone for shortened cervix, you can reduce that rate of preterm birth.
Georgie Kovacs: In some cases, for diagnostic procedures like HPV, doctors have to freeze the tip of your cervix off. Does that create a shortened cervix?
Dr Joanne Stone It's a good question. There are, infrequently, causes due to some kind of surgery in the cervix, but not the freezing so much. There is something called a LEEP or a cone biopsy where they're removing some of the cervical tissue, but the chances of the shortened surface from that are still not very high, but it can be caused and other ones we don't know. Maybe there's some kind of natural process that's already starting to occur such as inflammation leading to a shortened cervix.
The shortened cervix can be a finding on a routine exam that you treat with progesterone to decrease the occurrence of spontaneous preterm birth. Another procedure is a cerclage, which is a stitch that's placed into the cervix to help keep it closed. There's very specific indications for it. For example, a history-indicated cerclage is for those with evidence of multiple second trimester miscarriages and in those patients that had a prior preterm birth. So they delivered, let's say, at 30 weeks, they go for that 20 week ultrasound, and their cervix is short, that's a reason to put that in. Alternatively, if during the physical exam, you see a dilated cervix at around that same time period, 18 to 20 to 23 weeks, for whatever reason, and there's no evidence of infection, a cerclage can help to prolong that pregnancy.
This is all important because preterm birth is one of the leading causes of perinatal morbidity and mortality.
Georgie Kovacs: If those who've already had preterm labor are at high risk of having it again, how do you know, with the first kid, if you can have it, and what can you do to be proactive?
Dr Joanne Stone: Good question. There was a multi-center study published about a year ago that actually showed that a baby aspirin can help reduce the rate of preterm birth. It wasn't a huge reduction, but it was a reduction for anybody. We say, “When is it going to be part of a prenatal vitamin? Almost everybody's going to be on baby aspirin.”
There are other things as well, and this is why at an early appointment with your OB or a preconception visit, you can change a certain lifestyle to minimize this risk. Those at higher risk include:
Illicit drug use
Modifying some lifestyle changes to be as healthy as possible during pregnancy is also something that an individual can do.
Georgie Kovacs: Next on the list is cervical insufficiency. What did we not cover earlier in the conversation?
Dr Joanne Stone: I have a patient who had a first pregnancy, full term delivery, very rapid labor for a first pregnancy. I didn't take care of her then, but she had a 16 week loss the day after an ultrasound. The doctors didn't do a vaginal ultrasound but took a picture of what they thought was the cervix abdominally, and it looked okay. The next day, she presented with some spotting and pressure and ruptured membranes and delivered really rapidly. Very unusual to have a full time delivery and then this.
Was it a really cervical insufficiency is unclear. I went and looked at the picture of the ultrasound that was done the day before. It was no fault of the person that did it, but I suspect the bladder was super full and it was the vagina, not the cervix, being measured, so they did not pick up the funneling of the cervix. Of course, I had the benefit of knowing what happened.
We talked about either following with cervical lanes or putting a cerclage in, and we decided to put this sort of closure in for cervical insufficiency. At the time of this cerclage, done around 12-13 weeks, her cervix looked a little bit dilated already.
It’s important to understand that much of this is not black and white, so it is important to advocate for yourself and sometimes talking to a specialist can be helpful.
Georgie Kovacs: What would be the ideal proactive approach for women? Should they routinely ask for the transvaginal ultrasound?
Dr Joanne Stone: There's some controversy around there, but I do believe in universal transvaginal ultrasound screening at the time of the routine 20 week scan for the otherwise uncomplicated patient. Not all societies make that recommendation. There are programs that teach you how to properly measure that cervical lane, which is important.
Georgie Kovacs: So if I were to be a proactive patient, I would add the transvaginal ultrasound to my 20-week scan and then I would verify that the person is certified?
Dr Joanne Stone: Not all insurance covers it either. They have to pay separately or if the center wants to write it off, they just do the procedure and write it off.
Georgie Kovacs: That is incredibly challenging and frustrating. Let’s talk about recurrent miscarriages.
Dr Joanne Stone: This fits into the idea that we were talking about in terms of advocacy. Recurrent miscarriages, defined as two or more (used to be three or more) spontaneous miscarriages. The majority of early (first trimester) miscarriages are due to chromosomal abnormalities or potentially structural defects. It's almost like nature's way of not continuing with an abnormal pregnancy.
I think that patients who have even the first miscarriage, if they go in for their eight week ultrasound, and there's no heartbeat, and they end up needing to have a DNC, then I recommend very strongly they ask their doctor to send off the tissue for genetic testing. If they don't do that, and a lot of people don't have that done, if you have another miscarriage, you don't know whether that first one was genetically abnormal. It's really important to know this.
Now, you can take a pill to empty the uterus. However, collecting that tissue can be challenging.
Georgie Kovacs: Let's assume genetic testing is done. What can be learned from genetic testing and how does that impact care for future pregnancies?
Dr Joanne Stone: One thing they may carry is what's called a balanced translocation, where they can pass on to the fetus, a genetic material that leads to miscarriage. It’s important to check the couple’s chromosomes.
Then there's looking for other causes like thyroid disease or undiagnosed diabetes. There's something that's more associated with miscarriages that 10 weeks or later called antiphospholipid antibody syndrome, where they have certain antibodies that cause increased risk for clotting, which can lead to miscarriages. Sometimes it can be due to underlying infection. Uterine abnormalities are a bit more common for later miscarriages.
There are different things that you have to, in the workup, check the box off to see if you can identify a cause, and then know how to treat it.
Georgie Kovacs: Would you recommend that, if you have a miscarriage, women need to see some kind of a specialist and if so, what kind?
Dr Joanne Stone: A general OB GYN, who has done a full residency but hasn't done any extra training after that, can usually handle that miscarriage workup. It becomes more of an issue of, when you don't find anything, you don't know what to do.
There's a little bit of a crossover between Maternal Fetal Medicine specialists and reproductive endocrinologists (REI), who do the fertility work. Both of us often deal with patients with recurrent miscarriage. So it may be in some places, the MFM that does it and other places, the infertility specialists that do it.
There are some people that have developed a real interest in recurrent pregnancy loss that they may not be either, but they've done a lot of research in that area and might be somebody else to see.
Georgie Kovacs: Next is preeclampsia. How can women be proactive and preventative?
Dr Joanne Stone: Preeclampsia is one of the most fascinating diseases. We're getting closer to gaining somewhat of an understanding, but it's quite complicated. Preeclampsia is high blood pressure that develops after 20 weeks of pregnancy, and in a patient without prior high blood pressure. It can be just blood pressure alone, which is hypertensive disorder pregnancy, or gestational hypertension can be associated with certain abnormalities in the urine and the blood.
It has a lot of possible underlying causes. It can be related to somebody's genetics. So we know that family history is really important. Even if a patient's partner had another partner who had preeclampsia, they're at a higher risk. Other risks include:
People having the first baby
Those who have underlying diabetes
Women having multiples, like twins or triplets
Women over 40
Knowing these risk factors is important.
It does seem there's a bit of a difference in the underlying etiology, if they develop it early and severe, like less than 34 weeks, or they develop it closer to term. That’s become evident over the last few years. In general, there's a thought that this has involved a sort of abnormal placentation. This means the placenta implants abnormally very early in the pregnancy and the manifestations don't really occur until later.
There's a lot of research being done and looking at different markers called sFlt-1 and placental growth factor, that can be measured that can be somewhat predictive of preeclampsia. In the UK, they've done a lot of work, where they do a test at like 11 to 12 weeks, and they measure the mother's blood pressure, take a history, and send off these markers. It's a whole combination, and it can be very predictive of that early onset preeclampsia.
There was a randomized trial of 150 milligram dose of aspirin versus placebo and showed a significant reduction in that early onset preeclampsia, since it's very specific for that. They also measured blood flow in the uterine arteries, the arteries that flow to the uterus. So that's very compelling for early onset. The aspirin didn't have that same effect. But the later onset of preeclampsia is so likely a slightly different etiology, that the aspirin is targeting that early onset.
In the US, right now, we don't have the sFlt-1 marker available. But there is research that is being done even measuring at 20 weeks as a marker along with a lot measuring a difference in other markers.
I think people should know, if you're at risk for it, have the discussion. There are patients that need to be on a baby aspirin from 12 weeks onward, or even start at 16 weeks. Here in the US, we use an 81 milligram dose of baby aspirin. The American College of OB GYN has a specific criteria. You have to have one of the more severe risk factors or two of the moderate risk factors and you should be on baby aspirin. I will tell patients who are really at high risk, to monitor the blood pressure at home after 24 weeks.
So there are things that you can do to help prevent it, or delay the onset, or identify it early. That can improve outcomes.
Georgie Kovacs Let’s discuss PPH, or postpartum hemorrhage and how that can be preventable.
Dr Joanne Stone: One of the things to understand is whether you are at risk for postpartum hemorrhage and then be prepared. If you are pregnant with triplets, there's about a 10% chance that you're going to need a blood transfusion at delivery because the uterus is so over distended, it’s hard for it to contract down. So having the conversation, “What are going to be the plans, are there medications in the room to help the uterus contract down?” Things like that.
Patients who have had multiple cesarean deliveries are at a higher risk for the placenta to grow into the uterus itself, especially if they've had three c-sections, and then become pregnant with a placenta that's over the scar. That's a much bigger risk factor.
These are things that you can be prepared for and have the doctors have a multidisciplinary approach to taking care of these patients. So you meet you bring in the obstetrician, the Maternal Fetal Medicine Specialist, maybe the surgical specialist. Some places, the GYN oncologist, who are excellent surgeons, are involved, the anesthesia team, the nursing team, Everybody gets involved to form the best plan to take care of this patient. We even have the blood bank involved so that they know there might be a massive transfusion. We need to have all that blood ready and products.
This planning can help save lives.
Georgie Kovacs: What is your greatest hope for women's health?
Dr Joanne Stone: Besides my world in obstetrics, you hear a lot about women who have cardiac complaints, which we don't typically think of women as having heart attacks. There is a need to listen to women and their complaints and take them quite seriously. We need to get better. There's so many efforts underway to help with that.
Reproductive justice is also incredibly important, that we have to make sure that women continue to have choice in this, especially for people who have underlying conditions that don't have access. That's a huge problem. It can increase their risk of dying.
Reducing the disparities that we see is really important.
Addressing all these issues, making sure women stay safe and healthy and mean, pregnancy is supposed to end and that result is not always going to happen. We can't prevent everything from happening. But we can make it as healthy as possible.