fetal morbidity

Mamas on Bedrest: Who is Ban Ki-Moon?

March 9th, 2012

International Women’s Day was yesterday, March 8, 2012. International Women’s Day, helps to culminate The United Nation’s Commission on the Status of Women (CSW), 2 weeks of meetings during which world leaders come together to discuss the status of women and girls around the world. The meetings are wrapping up this week.

The head of the UN is Secretary General, Ban Ki-moon. To mark the occasion of International Women’s Day, the Secretary General noted gender equality and the empowerment of women are gaining ground worldwide, but urged governments, civil society and the private sector to continue to commit to gender equality and the empowerment of women as a fundamental human right and a force for the benefit of all in his statement to the UN counsel and partners.

I have only recently began to study Mr. Ban and I am heartily impressed. This man is a staunch advocate for women’s rights and well being. One of his primary initiatives as Secretary General is empowering women. Here is what he has done during his tenure as Secretary General:

The Secretary-General pressed successfully for the creation of UN Women, a major new agency that consolidates the UN’s work in this area. His advocacy for women’s rights and gender equality has also included the “Unite to End Violence against Women” campaign, the “Stop Rape Now” initiative, the creation of a “Network of Men Leaders” and the establishment of a new Special Representative on Sexual Violence in Conflict. Within the UN itself, the Secretary-General has increased the number of women in senior management positions by more than 40 per cent, reaching the highest level in the Organization’s history.

How fantastic is it that a man with such global power has such a heart for the health and well being of the world’s women? One could argue that Mr. Ban is inspired by his wife, Madam Yoo (Ban) Soon-taek. Since 2007, Mrs. Ban has devoted her attention to women’s and children’s health, including autism, the elimination of violence against women, and the campaign to prevent mother-to-child transmission of HIV/AIDS.  So maybe his interest stems from her interest, her “whispering sweet nothings in his ear”?

That is not the impression that I get. In his own words, Mr. Ban says, “I grew up in war” (Mr. Ban was born in the Republic of Korea (South Korea)) and he knows first hand the destruction and hardship people often endure. He also knows the importance of global help in order to rebuild a nation and its people. But even more key, Mr. Ban recognizes that for a nation to be strong  a nation must tend to the care of all of its people and when one or more segments of the population are not thriving, the nation and subsequently the world, cannot thrive.

I am thrilled that I am learning about his plans for global women’s empowerment. I think that it behooves all of us to learn more about the United Nations’ initiatives on women’s empowerment and to see what we each can do to help move these initiatives forward-after all, they will impact us all in one way or another. There is something for everyone to do. For some of us, it will be making financial donations. For others, it may mean becoming involved with one of the many partnering organizations. I think most of us will work in our immediate neighborhoods, towns, cities, states and nations to effect change. There is nothing wrong with that. We are not all called to perform on the global stage as Mr. Ban does, but we are all called to serve.

Mamas on Bedrest: Soothing Belly Itches During Pregnancy

February 27th, 2012

As your pregnancy progresses, your belly will begin to itch. This is really no surprise. As your belly expands, your skin stretches and it is this stretching that causes the itching.

There are a variety of salves, lotions and antihistamine creams available on the market to relieve belly itching, many touting that they are “specifically formulated” to relieve the itching associated with pregnancy. Don’t be fooled. Most of the belly itching associated with pregnancy is not so specific that it requires any specialized type of cream or salve. Many products, readily available on the general retail market are sufficient to provide relief. Emollient creams, creams containing shea butter, cocoa butter, aloe vera or oatmeal and sometimes creams or lotions containing 0.5% or 1.0% hydrocortisone cream are effective in providing relief. Typically, keeping the skin on you belly well moisturized (applying creams or lotions 2-3 times daily or more as needed for itching. Be sure to consult with your health care provider if you are using cortisone creams and do not apply more frequently than the manufacturer or your health care provider recommends. ) and avoiding harsh chemicals, constricting clothing or clothing that rubs against your belly will provide relief. There are a few skin eruptions that cause itching specifically during pregnancy that may require more specific care and attention. They are described below.

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPPs)

Pruritic Urticarial Papules and Plaques of Pregnancy or PUPPPs is a common, intensely itchy skin condition that occurs typically late in the third trimester of pregnancy. PUPPP’s is characterized by red papular (bumpy) lesions on the belly, often around stretchmarks, that become so widespread that the bumps become grouped into large red patches on the belly, usually centered around the belly button. The patches often spread to include the thighs and buttocks and will occasionally spread to the arms and legs but this is less common. Seeing PUPPPs on or above the breasts is rare. The patches are extremely itchy and many women report that they can’t sleep due to the itching.

PUPPPs typically spontaneously resolves within days after delivery. For the intense itching, many health care providers prescribe low dose corticosteroid creams (0.5-1.0% hydrocortisone cream) to be applied 5-6 times daily. In some cases, patients are prescribed mild oral antihistamines for relief and to allow them to sleep. In rare cases, patients have to be prescribed a short taper of oral corticosteroids, but again, this is extremely rare.

Impetigo Herpetiformis

Impetigo Herpetiformis is a rare  form of pustular psoriasis which occurs during pregnancy and may be life threatening. While it has been documented in all trimesters, Impetigo Herpetiformis usually occurs during the last trimester and resolves shortly after delivery. However, it is crucial the impetigo herpetiformis be accurately diagnosed and treated as it can lead to placental insufficiency, stillbirth and increases in complications and even death for mothers and babies. Impetigo Herpetiformis is associated with low levels of calcium and women with hypoparathyroidism are at particular risk for developing the disorder.

Impetigo Herpetiformis begins as pus-filled bumps on reddened skin of the inner thighs and groin. The pustules join and spread to the trunk and extremities. The rash typically spares the face, hands, and feet but can spread to inside the mouth and into the nail beds.  Interestingly, the pustules are not filled with bacteria, but can become infected as the rash progresses. Some women will also experience generalized viral symptoms such as fatigue, nausea, vomiting, diarrhea, fever and chills. Treatment for Impetigo Herpetiformis is oral corticosteroids such as prednisone.

Intrahepatic Cholestasis of Pregnancy (ICP)

Intrahepatic Cholestasis of Pregnancy occurs when bile secretion in the liver is impaired. As the bile backs up in the liver, the level of bile acids increases in the bloodstream. These “backed up” bile acids are then deposited in the skin causing the intense itching.  The itching ranges from annoying to severe and tends to be worse at night. The itching typically begins on the palms of the hands and soles of the feet and them spreads to the rest of the body. Rash develops as a result of scratching. Jaundice occurs in 10% to 15% of cases and typically develops 2 to 4 weeks after the itching starts. All symptoms spontaneously resolve shortly after delivery.

Intrahepatic Cholestasis is rare and occurs in 0.3-5% of pregnancies overall. It is more common in women who have a family history of ICP,  and women who develop the disorder in a first pregnancy tend to develop it in subsequent pregnancies.  While the exact etiology of ICP is unknown, it has been determined that the increase in estrogen and progesterone during pregnancy play a major role. Estrogen interferes with bile clearance from the liver and progesterone interferes with estrogen removal from the liver.

The most important side effects of ICP on infants are preterm delivery, meconium staining (stool changes) at birth and still birth because the fetal liver cannot manage the additional bile salts from the maternal circulation. Treatment of ICP is aimed at lowering the bile salt levels and preserving the livers and health of both mother and baby.

ICP is diagnosed based on history and  blood tests showing elevated levels of bile acids and certain liver enzymes. There is rarely a need for a liver biopsy. Treatment consists of ursodeoxycholic acid (10–20 mg/kg/d) as well as antihistamines, Questran for elevated cholesterol and in severe cases of itching, phenobarbital. In some cases, high doses of oral steroids are needed to relieve the itching. Most mothers with ICP are delivered between 37 and 38 weeks once fetal lung maturity has been established.

Resources

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPPs)

MedScape

About.com

BabyCenter.com

Impetigo Herpetiformis

About.com

Intrahepatic Cholestasis of Pregnancy

Dr. Mona Ridgeway, MD The Austin Gastroenterology Clinic, Austin, TX

Itchy Moms

About.com

MedScape

Please share your experiences with itching during pregnancy below. You can also contact us on Facebook and on Twitter, @mamasonbedrest.

Mamas on Bedrest: Pregnancy Spacing Improves Long Term Health Of Mamas and Babies

September 23rd, 2011

According to a February 1999 New England Journal of Medicine article, separating pregnancies by 18-23 months is optimum to ensure the health of both mamas and babies.

The authors,  Bao-Ping Zhu and colleagues found that incidences of adverse pregnancy outcomes such as premature birth and low birth weight were less likely to occur in pregnancies in which conception occurred 18-23 months after a prior pregnancy and delivery. They also found that there were lower incidences of pregnancy complications, such as pre-eclampsia, in pregnancies which occurred 18-23 months after a previous pregnancy and delivery. Interestingly, rates of complications went up when the pregnancy intervals were longer than 23 months between pregnancy and subsequent conception. The authors admitted that while this was a first assessment, there may be likely confounding variables such as maternal age, socioeconomic status, reproductive history and others that may exert an influence on pregnancy outcome.

As you can imagine, this has not always been well received. Many people simply balk at the notion of “planning” pregnancies and feel like pregnancies occur when they are supposed to occur. Others contend that the failures of contraception account for most of the pregnancy failures and that this cannot be helped as not contraceptive method, except for abstinence, is 100% effective at preventing pregnancy.

At the 2011 Association of Reproductive Health Professions Annual Meeting, this topic was discussed and the position of the Reproductive Health professionals present is to recommend long acting contraception (LARC) to women, especially those in the highest risk groups. Robert Hatcher, MD, MPH reviewed the currently available forms of reversible contraception.

  1. Depro Provera Injection
  2. Paragard IUD
  3. Mirena IUS
  4. Implanon implants

The recommendation for LARC comes as unintended pregnancies in the United States account for approximately half of all pregnancies annually. 60% of unintended pregnancies are what is called “Mistimed Pregnancies” meaning women admit that they would have had (another) child, just not at the time of this particular pregnancy. Most women cited contraceptive failure as the primary reason for unintended pregnancy. But a closer look at contraceptive use habits revealed some interesting statistics.

James Trussell, PhD, Office of Population Research at Princeton University and The Hull York Medical School shared statistics that showed that while the rates of unintended pregnancy has dropped amongst teens, the rates have increased in women in their 20’s. Women of lower education and lower socioeconomic status account for the greatest numbers of unintended pregnancies and African American and Latina Women have the highest rates of unintended pregnancies.

What was even more alarming is that in 2001, 52% of unintended pregnancies were to women who were using no method of birth control. Further, when interviewed for a study between 2006 and 2008, 10.6% of women at risk for unintended pregnancy weren’t using any contraceptive method.

Contraceptive problems arise mostly from “typical use”. What this means is how women typically use the contraceptive method vs. “Perfect use” i.e. how the method is intended to be used. Below is a table taken from the 2011 Contraceptive Technology Handbook outlining the failure rates of contraceptives with “typical use” and “perfect use”.

Method      Typical Use      Perfect Use

Chance 85%                   85%   (Percentages are effective rates)

Condom                     18%                      2%

Pill, Patch, Ring        9%                     0.3%

Depo Provera            6%                     0.2%

Paragard IUD         0.8%                   0.6%

Mirena IUS            0.2%                    0.2%

Implanon               0.05%                0.05%

What this table shows is that methods that require consistent (daily) use have a significant failure rate and significant difference between “typical use” and “perfect use”. However, the more “reliable” methods provide no protection against sexually transmitted infections (STI’s).

Anita Nelson, MD, Professor at the David Geffen School of Medicine at Harbor-UCLA Medical Center in Manhattan Beach, CA looked specifically at the oral contraceptives or birth control pills. What she shared both from the research and from her years in clinical practice is that in a 12 month cycle, women rarely take their pills as prescribed. Women on average miss 3 pills a month and as many as 60 pills a year. Even if they take a pill when they remember, for many women, this is days later and they are already at risk for unintended pregnancy.

Nelson also reiterated a little known fact amongst many women. Pregnancy is more dangerous to a woman’s health than hypertension, blood clots in the legs or diabetes and yet pregnancy increases the risk of all of these conditions occurring and persisting throughout a woman’s life.  Pregnancy related mortality (death) in the United States between 1998 and 2005 has been higher than at any other time in the previous 20 years. 14.5 women die annually for every 100, 00o births and the rates for African American women is 3-4 times higher. Unintended pregnancy also has a higher risk of “sicker babies”.  Nelson and other researchers advocate continuous (or long acting) oral contraceptives and condoms as a way for,

  • Women to control their fertility
  • Pregnancy to occur when desired, lowering risk for complications
  • Unwanted fertility to be eliminated

Family Planning is seen by the US Centers for Disease Control and Prevention as one of the top 10 most important contributions to public health in the 20th century.

Family Planning is also seen as an important global health issue asserts Willard Cates, Jr., MD, MPH of Family Health International and The UNC Gillings School of Global Public Health. Cates presented data and information from the United Nations Population Fund, an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. Sharing statistics from the Guttmacher Institute, family planning averts 187 million unintended pregnancies and in turn prevents:
• 54 million unplanned births
• 112 million induced abortions
• 1.2 million infant deaths
• 230,000 maternal deaths
• 71 million DALYs saved

(WHO Definition of DALY’s: DALYs = Disability Adjusted Life Years. The sum of years of potential life lost due to prematuremortality and the years of productive life lost due to disability)

Cates reiterated that Family Planning contributes to the Millinium Development Goals for the world which are:

1. End Poverty and Hunger
2. Universal Education
3. Gender Equality
4. Child Health
5. Maternal Health
6. Combat HIV/AIDS
7. Environmental Sustainability
8. Global Partnerships

Cates makes the case that only with widely available, long acting reversible family planning will the world’s goals of economic equality for women, increased educational opportunities for women, improved health and mortality for women and babies, reduced unintended pregnancy rates, reduced abortion rates, increased economic growth and stability for all nations.

What are your thoughts on contraception and unintended pregnancy? Would you ever use a long acting reversible contraceptive (LARC)? Share your comments below.