Pediatric Annals

EDITORIAL 

A Pediatrician's View: Prevention of Prematurity: Important and Difficult

William A Altemeier, III, MD

Abstract

What role does the pediatrician have in prenatal care? None, right? If the obstetrician is the physician for the mother, he or she will take care of the baby until handing it to you in the delivery room or normal nursery. If the baby is delivered by family practice, that physician usually will keep the baby. Incidentally, family practice seems to have an inherent advantage in managed care. As gatekeepers for the whole family, they are in position to provide obstetrical care for their mothers and keep the newborn if they wish.

But anyway, for those families who do bring their children to you, what role can you play in prenatal care? You often will be the first physician to know a mother is pregnant or trying to get that way. Some will volunteer this or you may notice signs of pregnancy in your office such as weight gain (especially in the right places), the "mask of pregnancy," a mood change, or a sudden interruption with a Vx)It for the bathroom. Can you ask about weight gain, a prominent lower abdomen, or mask of pregnancy? Not if you want to keep that family in your practice. But an indirect question can give you an answer. "Let's see, Mrs Jones, how many children do you have now?" Or: "How large a family do you want?" It is interesting how frequently your "diagnosis" will be confirmed if you are alert and probe.

Of course, there is another situation when you will be the first physician to know a mother is pregnant - when the expectant mother is your adolescent patient. You have more direct responsibility for vigilance here because the mother is your patient, and there are greater health and social consequences of teen births. Actually, there is some good news about adolescent pregnancy.1 After rising until 1991, birth rates to 15- to 19-year-old girls have leveled off or fallen, and abortion rates have declined even more, indicating pregnancies must be dropping. There is some evidence that the proportion of adolescents who are sexually experienced has leveled off and those who are experienced are using contraception more. We should continue to help teens who don't want pregnancy (boys and girls) be successful.

So what should you do when you come across pregnancy in your practice? Start with some basics:

* "Are you taking vitamins that include folie acid?" Half to three quarters of spina bifida and anencephaly can be prevented by folie acid supplementation.2 However, these detects occur very early in pregnancy, before most women know they are pregnant or get prenatal care, so the US Public Health Service recommends that all women capable of becoming pregnant to take 0.4 mg of folte acid per day.2 Women who have delivered a baby with spina bifida or anencephaly should probably take 10 times this dose.3

* "Do you smoke or drink?" It can't hurt to remind mothers about the effects of these on the fetus.

* "Are you getting prenatal care?" If not, encourage this, and it should happen soon if the mother has medical problems that could impact the pregnancy - today or tomorrow if she is having complications of the pregnancy.

So you can get some mothers into prenatal care earlier. Will this decrease the most important predictor of neonatal mortality - low birthweight? The answer is: only to a limited extent because of the following

Low birthweight can be due to intrauterine growth retardation or shortened gestation. In developed countries like the US, the latter is most important while the former is a more common cause of small babies in…

What role does the pediatrician have in prenatal care? None, right? If the obstetrician is the physician for the mother, he or she will take care of the baby until handing it to you in the delivery room or normal nursery. If the baby is delivered by family practice, that physician usually will keep the baby. Incidentally, family practice seems to have an inherent advantage in managed care. As gatekeepers for the whole family, they are in position to provide obstetrical care for their mothers and keep the newborn if they wish.

But anyway, for those families who do bring their children to you, what role can you play in prenatal care? You often will be the first physician to know a mother is pregnant or trying to get that way. Some will volunteer this or you may notice signs of pregnancy in your office such as weight gain (especially in the right places), the "mask of pregnancy," a mood change, or a sudden interruption with a Vx)It for the bathroom. Can you ask about weight gain, a prominent lower abdomen, or mask of pregnancy? Not if you want to keep that family in your practice. But an indirect question can give you an answer. "Let's see, Mrs Jones, how many children do you have now?" Or: "How large a family do you want?" It is interesting how frequently your "diagnosis" will be confirmed if you are alert and probe.

Of course, there is another situation when you will be the first physician to know a mother is pregnant - when the expectant mother is your adolescent patient. You have more direct responsibility for vigilance here because the mother is your patient, and there are greater health and social consequences of teen births. Actually, there is some good news about adolescent pregnancy.1 After rising until 1991, birth rates to 15- to 19-year-old girls have leveled off or fallen, and abortion rates have declined even more, indicating pregnancies must be dropping. There is some evidence that the proportion of adolescents who are sexually experienced has leveled off and those who are experienced are using contraception more. We should continue to help teens who don't want pregnancy (boys and girls) be successful.

So what should you do when you come across pregnancy in your practice? Start with some basics:

* "Are you taking vitamins that include folie acid?" Half to three quarters of spina bifida and anencephaly can be prevented by folie acid supplementation.2 However, these detects occur very early in pregnancy, before most women know they are pregnant or get prenatal care, so the US Public Health Service recommends that all women capable of becoming pregnant to take 0.4 mg of folte acid per day.2 Women who have delivered a baby with spina bifida or anencephaly should probably take 10 times this dose.3

* "Do you smoke or drink?" It can't hurt to remind mothers about the effects of these on the fetus.

* "Are you getting prenatal care?" If not, encourage this, and it should happen soon if the mother has medical problems that could impact the pregnancy - today or tomorrow if she is having complications of the pregnancy.

So you can get some mothers into prenatal care earlier. Will this decrease the most important predictor of neonatal mortality - low birthweight? The answer is: only to a limited extent because of the following

Low birthweight can be due to intrauterine growth retardation or shortened gestation. In developed countries like the US, the latter is most important while the former is a more common cause of small babies in developing countries. The causes of intrauterine growth retardation are largely known, and, for the most part, are subject to prevention by prenatal care. The causes of prematurity are largely unknown. The factor most strongly associated with both premature and small-for-date deliveries has been cigarette smoking,4 It is encouraging that smoking rates during pregnancy have dropped from 20% in 1989 to 17% in 1992 and 16% in 1995.1 The message is getting through.

Not knowing what causes prematurity makes it hard to prevent this. Although it is logical that prenatal care should reduce prematurity, and data from France suggest that it does,5 the bottom line is that rates of premature birth in the United States have changed little during the past 50 years6 while prenatal care has increased. Hack and Merkatz6 state, "To date, the various programs undertaken specifically to prevent preteriti birth and low birthweight - including social support for pregnant women, early prenatal care, education to increase awareness of the signs of preterm labor, and the use of tocolytic therapy to suppress intrauterine contractions - have been largely unsuccessful." Besides reducing smoking in pregnant mothers, control of infection has the most potential for reducing prematurity. Infections of the genital tract are estimated to contribute to up to 40% of preterm births,6 and recently Hauth et al7 published exciting results through treating bacterial vaginosis. In a double-blind study, they randomized 624 pregnant women at high risk for prematurity into 433 who received metronidazole and erythromycin while 191 received placebos. Bacterial vaginosis was identified in 258 women, and within this subgroup, treatment with these antibiotics reduced preterm delivery from 49% (in the placebo group) to 31% (P=.006). The antibiotics did not change the prematurity rate in those without bacterial vaginosis, but the effects of treatment were still apparent (P= .01) in the total group. Bacterial vaginosis is overgrowth of the lactobacilli that constitute the normal vaginal flora by other organisms including Chiamydia tracHomatis, Trichomonas vaginaUs, group B streptococci, V urecdyticum, and candida. Although this sounds promising, one must remember that the study was done in a very high-risk group, and although it is critically important to identify and treat medical conditions, they play only a limited part among factors determining the preterm delivery of infants with low birthweight.6

Unfortunately, many of the determinates of prematurity that we know about are constitutional or genetic and thus cannot be changed easily.4"6 The mother who was low birthweight herself or who delivered another low birthweight child or who is constitutionally small or of black race is more likely to deliver a premature child. So although it is important to reduce smoking and alcohol and other substance abuse in pregnancy and to treat infections and maternal hypertension, the effect on prematurity will be limited, and we will continue to need neonatologists.

Pediatricians make a couple of other contributions to the care of the pregnant mother and her baby. The routine prenatal visit is one. The Academy of Pediatrics recently released their recommendations about this and emphasized four goals8:

* establish a physician/parent relationship,

* gather basic information about parental concerns, family history, and parental background and knowledge,

* provide information and advice about circumcision, breast-feeding, etc, and

* build parent skills.

Finally, the pediatrician should be tuned in to the high association between depression and pregnancy. About 10% of pregnant women will meet diagnostic criteria for major depression, and all types of psychiatric illnesses are increased during the postpartum period - especially during the first 30 days.9 The least serious is postpartum blues. This usually peaks around the fifth day and rapidly diminishes thereafter. Postpartum psychosis is most serious and occurs in one to four of every 1000 deliveries: major depression dominates although symptoms resembling organic brain syndrome may be seen. Postpartum depression is midway between these and occurs in 10% to 15% of new mothers. It usually begins within 2 weeks of delivery but can occur any time for the next several months. Prior depression and psychosocial Stressors increase the chances for postpartum depression. Hormonal variations are thought to contribute to all of these conditions.9 Be alert to them, and while postpartum blues usually require only support and time, mothers with postpartum depression should be assisted in getting help.

REFERENCES

1. Guyer B, Strobino DM, Ventura Sl, Síngh GK. Annual summary of vital statistics- 1994. Pediatrics. 1 995 ;96: 102 9- 1039.

2. Oakley CP, Enekson JD, Ada ins MJ. Urgent need to Increase folie acid consumption, JAMA. I995;274:1717-1718. Editorial

3. DaIy LE, Kirke PN, Molloy A, Weir DG. Scott TM. Folate levels and neural tube defects: implications for prevention J AMA. 1995;Z74:1698-1702.

4. Kramet MS. Intrauterine growth and gestational duration determinants Pediatrics. 1987:80:502-511.

5. Cole CH- Prevention of prematurity: can we do it in America! Pediatrici. YEAR! 76:310-312.

6. Hack M, Merkatz IR. Preterm delivery and low birth weight - a dire legacy, N Engi iMei I995;333:1772-1774. Editorial.

7. Hauth JC. Goldenberg RL, Andrews WW, DuBard MB, Cupper RL. Reduced incidence of preterm delivery with roetranidaiole and erythromycin in women with bacterial vaginosis. N Engl J Med. 1995:333:1732-1736.

8. Committee on Psychosocial Aspects of Child and Family Health. The prenatal visit. Pediatrics. 1996;97:141-142.

9. Weissman MM, Olfeon M. Depression in women: implications tor health care research. Science. 269:799-801.

10.3928/0090-4481-19960401-04

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