Pregnancy and Birth Sourcebook Part 21

* Gestational diabetes mellitus Gestational diabetes mellitus (or gestational diabetes) is a type of diabetes that only pregnant women get. If a woman gets diabetes when she is pregnant, but never had it before, then she has gestational diabetes. Many women with gestational diabetes have healthy pregnancies and healthy babies because they follow a treatment plan from their health care provider. (or gestational diabetes) is a type of diabetes that only pregnant women get. If a woman gets diabetes when she is pregnant, but never had it before, then she has gestational diabetes. Many women with gestational diabetes have healthy pregnancies and healthy babies because they follow a treatment plan from their health care provider.

* HIV/AIDS HIV/AIDS (acquired immunodeficiency syndrome) kills or damages cells of the body's immune system, progressively destroying the body's ability to fight infections and certain cancers. The term AIDS applies to the most advanced stages of HIV infection. Women can give HIV to their babies during pregnancy, while giving birth, or through breastfeeding. But, there are effective ways to prevent the spread of mother-to-infant transmission of HIV. (acquired immunodeficiency syndrome) kills or damages cells of the body's immune system, progressively destroying the body's ability to fight infections and certain cancers. The term AIDS applies to the most advanced stages of HIV infection. Women can give HIV to their babies during pregnancy, while giving birth, or through breastfeeding. But, there are effective ways to prevent the spread of mother-to-infant transmission of HIV.

* Preterm labor Preterm labor is labor that begins before 37 weeks of pregnancy. is labor that begins before 37 weeks of pregnancy.

Because the baby is not fully grown at this time, it may not be able to survive outside the womb. Health care providers will often take steps to try to stop labor if it occurs before this time. Although there is no way to know which women will experience preterm labor or birth, there are factors that place women at higher risk, such as certain infections, a shortened cervix, or previous preterm birth.

* Other medical conditions Other medical conditions like high blood pressure, diabetes, or heart, breathing, or kidney problems can become more serious during a woman's pregnancy. Regular prenatal care can help ensure a healthier pregnancy for a woman and her baby. like high blood pressure, diabetes, or heart, breathing, or kidney problems can become more serious during a woman's pregnancy. Regular prenatal care can help ensure a healthier pregnancy for a woman and her baby.

What can a woman do to promote a healthy pregnancy?

Many health care providers recommend that a woman who is thinking about becoming pregnant see a health care provider to ensure she is in good preconception health.

During pregnancy, there are also steps a woman can take to reduce the risk of certain problems, such as: * getting at least 400 micrograms of folic acid every day if she thinks she could become pregnant, and continuing folic acid when she does get pregnant; * getting proper immunizations; * maintaining a healthy weight and diet, getting regular physical activity, and avoiding smoking, alcohol, or drug use; and * starting prenatal care appointments early in pregnancy.

267.

Pregnancy and Birth Sourcebook, Third Edition Section 30.2 Teen Pregnancy "Teen Pregnancy and Other Health Issues,"

2009 National Campaign to Prevent Teen and Unplanned Pregnancy (www.thenationalcampaign.org). Reprinted with permission.

Teen pregnancy can have negative health implications for both the mother and child. Of course, the health and health-related behavior of teen mothers before, during, and after pregnancy affects the health of the baby. Evidence suggests that babies born to teen mothers are at increased risk for specific health problems compared to babies born to older mothers. In addition to these personal costs, there are considerable costs to taxpayers a.s.sociated with the public health care expenses of teen childbearing. Reducing teen pregnancy will not only improve the health of teens and their future children, it will also reduce some of the costs of public health services.

* Infants born to teen mothers are at increased risk of being born prematurely and at a low birthweight. This puts newborns at greater risk for infant death, respiratory distress syndrome, bleeding in the brain, vision loss, and serious intestinal problems.1,2 * Teen mothers are also more likely than mothers over the age of 25 to smoke during pregnancy, and often teen mothers are not at adequate pre-pregnancy weight and/or do not gain the appropriate amount of weight while pregnant.1 * Compared to older pregnant women, pregnant teens are far less likely to receive timely and consistent prenatal care.1 * Recent research indicates that while there is little difference in their child's health status as reported by teen mothers or by older mothers, the children of teen mothers are less likely to visit a medical care provider.3 Teen mothers are also slightly more likely than similarly situated older mothers to report that their child has a chronic health condition.3 * The children of teen mothers are more likely to depend on publicly provided health care than the children of older mothers. In 268 What Is a High-Risk Pregnancy?

fact, 84 percent of health care expenses for children (ages 01) of teen mothers aged 1819 are provided through public programs. Three quarters of health care expenses for pre-school children of teen mothers 17 and younger are provided through public programs. This is compared to about half of the expenses for children born to mothers who were aged 20 or 21.3 * Despite their lower utilization of health care resources, the costs a.s.sociated with providing health and medical care (primarily Medicaid and SCHIP [State Children's Health Insurance Program]) to the children of teen mothers is nearly $2 billion each year.3 * Furthermore, approximately 72 percent of teen births in the United States are financed by Medicaid.4 Early pregnancy not only has health implications for the children of young mothers, it has implications for the teens as well. Helping more teens to avoid or reduce risky s.e.xual behavior (by either delaying s.e.x or using contraception effectively) will help prevent teen pregnancy and s.e.xually transmitted diseases (STDs) including HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome).

* Even though young people aged 1524 represent 25 percent of the s.e.xually active population, they account for about half of all new cases of STDs.5 * The rate of reported chlamydia cases among teens age 1519 increased 20 percent between 2000 and 2004-the second highest rate among all age groups and nearly five times the overall rate.6 * Although the rate of reported gonorrhea cases decreased slightly between 2000 and 2004, the rate among teens remains second only to young adults aged 2024 years and is almost four times the overall rate.6 * Between 2001 and 2005, the estimated number of HIV/AIDS cases increased among teens aged 1519. By the end of 2005, there were more than 6,300 reported AIDS cases among teens aged 1319 in the United States.7 In addition, in the 33 areas with confidential HIV infection reporting, an estimated 5,300 teenagers were reported to be living with HIV/AIDS in 2005.

* Approximately half of all new HIV infections occur among young people aged 1524 annually.8 269.

Pregnancy and Birth Sourcebook, Third Edition Sources March of Dimes, Teenage Pregnancy, in Quick Reference and Fact Sheets. 2004.

Martin, J.A., Hamilton, B.E., Ventura, S.J., Menacker, F. and Kirmeyer, S., Births: Final Data for 2004. Births: Final Data for 2004. National Vital Statistics Reports, 2006. 55(1). National Vital Statistics Reports, 2006. 55(1).

Hoffman, S.D., By the Numbers: The Public Costs of Adolescent By the Numbers: The Public Costs of Adolescent Childbearing. Childbearing. 2006, The National Campaign to Prevent Teen Pregnancy Was.h.i.+ngton, DC. 2006, The National Campaign to Prevent Teen Pregnancy Was.h.i.+ngton, DC.

National Campaign a.n.a.lysis of, National Survey of Family National Survey of Family Growth, 2002. Growth, 2002. 2005, National Campaign to Prevent Teen Pregnancy: Was.h.i.+ngton, DC. 2005, National Campaign to Prevent Teen Pregnancy: Was.h.i.+ngton, DC.

Weinstock, H., Berman, S., and Cates, W., s.e.xually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates. Perspectives on s.e.xual and Reproductive Health, Perspectives on s.e.xual and Reproductive Health, 2004. 36(1): p. 610. 2004. 36(1): p. 610.

Centers for Disease Control and Prevention, s.e.xually Transmitted Disease Surveillance, 2004. s.e.xually Transmitted Disease Surveillance, 2004. 2005, U.S. Department of Health and Human Services: Atlanta, GA. 2005, U.S. Department of Health and Human Services: Atlanta, GA.

Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, HIV/AIDS Surveillance Report, 2005. 2006, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention: Atlanta, GA. 2005. 2006, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention: Atlanta, GA.

Guttmacher Inst.i.tute, Facts on American Teens' s.e.xual and Reproductive Health in In Brief. In Brief. 2006, Guttmacher Inst.i.tute: New York, NY. 2006, Guttmacher Inst.i.tute: New York, NY.

270.

What Is a High-Risk Pregnancy?

Section 30.3 Pregnancy after Age 35 "Pregnancy After 35," 2008 University of Pittsburgh Medical Center (www.upmc.com). Reprinted with permission.

Today, many women are waiting until their mid-30s or later before having their first child.

Women over age 35 can have normal pregnancies and deliver healthy babies. But 35 is the age often used to measure an increased risk of problems with pregnancy.

A woman's chance of having problems during pregnancy goes up a little each year after a woman is in her early 20s. These problems usually fall into 2 categories: a decrease in fertility (a woman's ability to become pregnant) and genetic conditions that may affect the baby.

Decline in Fertility As you get older, it is harder to become pregnant. This is because your body does not release eggs (ovulate) as often. Even though you may have regular menstrual periods, your body may not be releasing eggs every month. There is less chance that your partner's sperm will fertilize the eggs that are released. Fertilized eggs are less likely to attach to your uterus.

Some physical conditions, such as a blocked fallopian tube or endometriosis, also may decrease your chance of becoming pregnant.

These problems are more common in women over age 35.

Also, if you and your partner have been together for a long time, chances are you may be having s.e.x less often. Any of these factors may make it difficult for you to become pregnant. If you and your partner have s.e.x without using birth control for 6 months without your getting pregnant, you should make an appointment with your doctor for a fertility test.

Genetic Conditions The most common genetic problem in babies born to women older than 35 is Down syndrome. Down syndrome causes birth defects such 271 Pregnancy and Birth Sourcebook, Third Edition as mental r.e.t.a.r.dation and heart problems, among others. Children born to women of any age can have Down syndrome. But the older the mother is, the greater the risk.

Prenatal testing can detect a pregnancy with Down syndrome. Two tests-chorionic villi sampling and amniocentesis are invasive and have some risk. The most serious risk is losing the baby (miscarriage).

At age 35, the risk of having a child with a birth defect is about the same as the risk from the test. For this reason, prenatal testing is routinely offered to pregnant women who are 35 or older.

Another test is the multiple marker screen. It is a simple blood test that measures the amount of a certain substance in the mother's blood.

This test can tell if there is a greater risk of having a baby with Down syndrome or other birth defects like spina bifida and anencephaly. It is important to remember that these are screening tests and are not 100 percent accurate. Also, they cannot identify all birth defects or genetic conditions.

Genetic counseling can help you and your partner estimate your chances of having a child with a birth defect. If you or your partner has a family history of birth defects or genetic problems, you should have genetic counseling before you become pregnant.

Other Considerations If you are over 35 and planning to become pregnant, you also need to consider that chronic health problems, such as diabetes or high blood pressure, often develop with age. Miscarriage and stillbirth (the birth of a baby who has died before delivery) rates also are higher in women over age 35. By staying in good physical health, you can avoid many of these possible problems.

Preparing for Pregnancy One of the best things you and your partner can do is prepare for pregnancy, both physically and emotionally. Even though you may feel your "biological clock" speeding up, you should not become pregnant unless you and your partner are ready for the responsibilities and changes that come with having a baby.

When you and your partner decide you are ready to have a child, you should make an appointment with your doctor to discuss your prepregnancy care. The father-to-be may want to come to this appointment.

Early and regular care is important to having a healthy pregnancy.

Your doctor may recommend that you take prenatal vitamins, especially 272 What Is a High-Risk Pregnancy?

folic acid (also known as folate), before getting pregnant to help reduce the risks of some birth defects. Always check with your doctor before you take any medicine or vitamins.

Section 30.4 Multiple Pregnancy: Twins, Triplets, and Beyond "Multiples: Twins, Triplets and Beyond," 2006 March of Dimes Birth Defects Foundation. All rights reserved. For additional information, contact the March of Dimes at their website www.marchofdimes.com.

When a woman is carrying two or more babies (fetuses), it is called a multiple pregnancy. In the past two decades, the number of multiple births in the United States has jumped dramatically. Between 1980 and 2003, the number of twin births increased by two-thirds (66 percent), and the number of higher-order multiples (triplets or more) increased four-fold, according to the National Center for Health Statistics.1 Today, more than 3 percent of babies in this country are born in sets of two, three or more, and about 94 percent of these multiple births are twins.1 The rising number of multiple pregnancies is a concern because women who are expecting more than one baby are at increased risk of certain pregnancy complications, including preterm delivery (before 37 completed weeks of pregnancy). Premature babies are at risk of serious health problems during the newborn period, as well as lasting disabilities and death.

Some of the complications a.s.sociated with multiple pregnancy can be minimized or prevented when they are diagnosed early. There are a number of steps a pregnant woman and her health care provider can take to help improve the chances that her babies will be born healthy.

Why are multiple pregnancies increasing?

About one-third of the increase in multiple pregnancies is due to the fact that more women over age 30 are having babies.2 Women in 273 Pregnancy and Birth Sourcebook, Third Edition this age group are more likely than younger women to conceive multiples.

The remainder of the increase is due to the use of fertility-stimulating drugs and a.s.sisted reproductive techniques (ART), such as in vitro fertilization (IVF). In IVF, eggs are removed from the mother, fertilized in a laboratory dish and then transferred to the uterus.

About 45 percent of ART pregnancies result in twins and about 7 percent in triplets or more.3 Doctors now monitor fertility treatments carefully so that women will have fewer, but healthier, babies. This involves limiting the number of embryos transferred during IVF.

In 2004, the American Society for Reproductive Medicine and the Society for a.s.sisted Reproductive Technology issued guidelines on the best number of embryos to transfer, depending on a woman's age and other factors.4 For example, the guidelines recommend that doctors transfer no more than two embryos for women under age 35, and consider transferring only one embryo for women in this age group who are considered most likely to become pregnant.

Doctors monitor women taking certain fertility drugs with ultrasound. If ultrasound shows that a large number of eggs could be released during that treatment cycle, the doctor will stop the treatment. In fact, the rate of higher-order multiple births has remained stable since 1999.1 A woman has a higher-than-average chance of conceiving twins if she has a personal or family history of fraternal (non-identical) twins or if she is obese or tall.2,5 African-American women are more likely to have twins than Caucasian women, and Asian women are the least likely to have twins.5 What is the difference between identical and fraternal twins?

Identical twins (also called monozygotic twins) occur when one fertilized egg splits and develops into two (or occasionally more) fetuses.

The fetuses usually share one placenta. Identical twins have the same chromosomes, so they generally look alike and are the same s.e.x.

Fraternal twins (also called dizygotic twins) develop when two separate eggs are fertilized by two different sperm. Each twin usually has its own placenta. Fraternal twins (like other siblings) share about 50 percent of their chromosomes, so they can be different s.e.xes.

They generally do not look any more alike than brothers or sisters born from different pregnancies. Fraternal twins are more common than identical twins.

274.

What Is a High-Risk Pregnancy?

Triplets and other higher-order multiples can result from three or more eggs being fertilized, one egg splitting twice (or more) or a combination of both. A set of higher-order multiples may contain all fraternal siblings or a combination of identical and fraternal siblings.

How are multiple pregnancies diagnosed?

Although previous generations often were surprised by the delivery of twins (or other multiples), today most parents-to-be learn the news fairly early. An ultrasound examination can detect most multiples by the beginning of the second trimester.

(Sometimes a twin pregnancy that is identified very early is later found to have only one fetus. This is called "vanis.h.i.+ng twin syndrome,"

and its cause is not well understood. The surviving twin generally is not harmed.) Other factors can alert a health care provider that a woman may be expecting twins or more. These include: * abnormal results on a blood test done around 16 weeks of pregnancy to screen for certain birth defects; * more than one heartbeat heard by a provider using a hand-held ultrasound device (Doppler); * rapid weight gain during the first trimester; * larger uterus than expected; * severe pregnancy-related nausea and vomiting (morning sickness); * more fetal movement than experienced by the woman in a previous singleton pregnancy.

When a health care provider suspects a multiple pregnancy, he will likely recommend an ultrasound examination to find out for sure.

What complications occur more frequently in a multiple pregnancy?

Women who are expecting more than one baby are at increased risk of a number of pregnancy complications. The more babies a woman is carrying at once, the greater her risk. Common complications include: * Premature birth: Premature birth: More than 50 percent of twins, more than 90 More than 50 percent of twins, more than 90 percent of triplets, and virtually all quadruplets and higher 275 Pregnancy and Birth Sourcebook, Third Edition multiples are born preterm.6 The length of pregnancy decreases with each additional baby. On average, most singleton pregnancies last 39 weeks; for twins, 35 weeks; for triplets, 33 weeks; and for quadruplets, 29 weeks.5 * Low birthweight (LBW): Low birthweight (LBW): About half of twins and almost all higher order multiples are born with low birthweight (less than 5 1/2 pounds or 2,500 grams).3 LBW can result from preterm birth and/or poor fetal growth. Both are common in multiple pregnancies. Low-birthweight babies, especially those born before about 32 weeks gestation and/or weighing less than 3 1/3 About half of twins and almost all higher order multiples are born with low birthweight (less than 5 1/2 pounds or 2,500 grams).3 LBW can result from preterm birth and/or poor fetal growth. Both are common in multiple pregnancies. Low-birthweight babies, especially those born before about 32 weeks gestation and/or weighing less than 3 1/3 pounds (1,500 grams), are at increased risk of health problems in the newborn period as well as lasting disabilities, such as mental r.e.t.a.r.dation, cerebral palsy and vision and hearing loss.

While advances in health care have brightened the outlook for these tiny babies, chances remain slim that all infants in a set of s.e.xtuplets or more will survive and thrive.

* Twin-twin transfusion syndrome: Twin-twin transfusion syndrome: About 20 percent of identical twins who share a placenta develop this complication.7 It occurs when a connection between the two babies' blood vessels in the placenta results in one baby getting too much blood flow and the other too little. Until recently, severe cases often resulted in the loss of both babies. Recent studies, though, suggest that the use of amniocentesis to drain off excess fluid can save up to 64 percent of affected babies.7 Removing the excess fluid appears to improve blood flow in the placenta and reduces the risk of preterm labor. Studies also suggest that using laser surgery to seal off the connection between the blood vessels may save a similar number of babies.7 An advantage of laser surgery is that only one treatment is needed, while amniocentesis generally must be repeated more than once. About 20 percent of identical twins who share a placenta develop this complication.7 It occurs when a connection between the two babies' blood vessels in the placenta results in one baby getting too much blood flow and the other too little. Until recently, severe cases often resulted in the loss of both babies. Recent studies, though, suggest that the use of amniocentesis to drain off excess fluid can save up to 64 percent of affected babies.7 Removing the excess fluid appears to improve blood flow in the placenta and reduces the risk of preterm labor. Studies also suggest that using laser surgery to seal off the connection between the blood vessels may save a similar number of babies.7 An advantage of laser surgery is that only one treatment is needed, while amniocentesis generally must be repeated more than once.

* Preeclampsia: Preeclampsia: Women expecting twins are more than twice as likely as women with a singleton pregnancy to develop this complication, characterized by high blood pressure and protein in the urine.8 Severe cases can be dangerous for mother and baby. Women expecting twins are more than twice as likely as women with a singleton pregnancy to develop this complication, characterized by high blood pressure and protein in the urine.8 Severe cases can be dangerous for mother and baby.

In some cases, the baby must be delivered early to prevent serious complications.

* Gestational diabetes: Gestational diabetes: Women carrying multiples are at increased risk of this pregnancy-related form of diabetes (high blood sugar).8 This condition can cause the baby to grow especially large, increasing the risk of injuries during v.a.g.i.n.al delivery. Babies 276 Women carrying multiples are at increased risk of this pregnancy-related form of diabetes (high blood sugar).8 This condition can cause the baby to grow especially large, increasing the risk of injuries during v.a.g.i.n.al delivery. Babies 276 What Is a High-Risk Pregnancy?

born to women with gestational diabetes also may have breathing and other problems during the newborn period.

Early diagnosis and management of these complications can help protect mother and babies.

What special care is needed in a multiple gestation?

Women who are expecting multiples generally need to visit their health care providers more frequently than women expecting one baby to help prevent, detect, and treat the complications that develop more often in a multiple pregnancy. Health care providers may recommend twice-monthly visits during the second trimester and weekly (or more frequent) visits during the third trimester.

Starting around the 20th week of pregnancy, a health care provider will monitor the pregnant woman carefully for signs of preterm labor. She may do an internal exam or recommend a v.a.g.i.n.al ultrasound examination to see if the woman's cervix is shortening (a possible sign that labor may begin soon).

If a woman develops preterm labor, her provider may recommend bed rest in the hospital and, possibly, treatment with drugs that may postpone labor. If the provider believes the babies are likely to be born before 34 weeks gestation, she will probably recommend that the pregnant woman be treated with drugs called corticosteroids. These drugs help speed fetal lung development and reduce the likelihood and severity of breathing and other problems during the newborn period.

Even if a woman pregnant with multiples has no signs of preterm labor, her provider may recommend cutting back on activities sometime between the 20th and 24th weeks of pregnancy. She may be advised to cut back on activities even sooner and to rest several times a day if she is expecting more than two babies.

As a multiple gestation progresses, the health care provider will regularly check the pregnant woman's blood pressure for preeclampsia. The provider also may recommend regular ultrasound examinations starting around 20 weeks of pregnancy to check that all babies are growing at about the same rate.

During the third trimester, the provider may recommend tests of fetal well-being. These include the non-stress test, which measures fetal heart rate when the baby is moving, and the biophysical profile, which combines the non-stress test with a special ultrasound examination.

277.

Pregnancy and Birth Sourcebook, Third Edition Should a woman expecting multiples gain extra weight?

Eating right and gaining the recommended amount of weight reduces the risk of having a premature or low-birthweight baby in singleton, as well as multiple, gestations. A healthy weight gain is especially important if a woman is pregnant with twins or more, as multiples have a higher risk of preterm birth and low birthweight than singletons.

Women who begin pregnancy at a normal weight and who are expecting one baby usually should gain 25 to 35 pounds over 9 months.

Women pregnant with multiples should discuss their weight-gain goals with their health care provider. Women of normal weight who are expecting twins usually should gain 35 to 45 pounds.9 This breaks down to about 1 pound per week in the first half of pregnancy, and a little more than a pound a week for the remainder of pregnancy.

Women pregnant with triplets or more may need to gain more.

The American College of Obstetricians and Gynecologists recommends that women with multiple pregnancies consume about 500 more calories a day than usual (a total of about 2,700 calories a day).9 Women pregnant with multiples should discuss with their health care providers the number of extra calories they should eat.

Women who are carrying more than one baby should take a prenatal vitamin that is recommended by their health care provider and that contains at least 30 milligrams of iron. Iron-deficiency anemia is common in multiple gestations, and it can increase the risk of preterm delivery.

Can a woman expecting multiples deliver v.a.g.i.n.ally?

The chance of a cesarean delivery is higher in twin than in singleton births. However, a pregnant woman has a good chance of having a normal v.a.g.i.n.al delivery if both babies are in a head-down position and there are no other complications. When a woman is carrying three or more babies, a cesarean delivery is usually recommended because it is safer for the babies.

Does the March of Dimes support research relevant to mul- tiple gestation?

The March of Dimes supports a number of grants aimed at improving understanding of the causes of preterm delivery. Although these studies generally focus on singleton pregnancies, the largely unknown mechanisms leading to preterm delivery of singletons and of multiples 278 What Is a High-Risk Pregnancy?

may be much the same. One grantee is studying the causes of con-joined ("Siamese") twinning, with the ultimate goal of learning how to prevent this severe complication of twinning.

For More Information The Fetal Hope Foundation [http://www.fetalhope.org] provides support and information about twin-to-twin transfusion syndrome.

References Martin, J.A., et al. Births: Final Data for 2003. National Vital Statistics Reports, volume 54, number 2, September 8, 2005.

Reddy, U.M., et al. Relations.h.i.+p of Maternal Body Ma.s.s Index and Height to Twinning. Obstetrics and Gynecology, Obstetrics and Gynecology, volume 105, number 3, March 2005, pages 593597. volume 105, number 3, March 2005, pages 593597.

Wright, V.C., et al. a.s.sisted Reproductive Technology Surveillance-2003. Morbidity and Mortality Weekly Report, Morbidity and Mortality Weekly Report, volume 55 (SS04), May 26, 2006. volume 55 (SS04), May 26, 2006.