1. We had problems with our last baby – now what? Kim M. Puterbaugh, MD Clinical Assistant Professor Associate Residency Director Aurora Sinai/UW

2. Things to do between pregnancies Determine the cause (if possible) of the complications last time Determine the cause (if possible) of the complications last time Improve the mothers chronic illness, if possible Improve the mothers chronic illness, if possible Assess the mothers medications, if appropriate for pregnancy Assess the mothers medications, if appropriate for pregnancy Choose an appropriate form of birth control for the couple and discuss birth spacing and timing of next pregnancy Choose an appropriate form of birth control for the couple and discuss birth spacing and timing of next pregnancy

3. Previous Pregnancy complications Determine the cause of the complication if possible: 1. Hypertension 2. Diabetes 3. Premature delivery 4. Congenital anomaly, such as spina bifida 5. Drug exposure (tobacco, alcohol, cocaine)

4. Is this problem likely to recur? Was it a rare, sporadic event that probably wont happen again? Was it a rare, sporadic event that probably wont happen again? Is there a genetic component? Is there a genetic component? - Meet with a genetic counselor to discuss likelihood of recurrence, get family members tested. Is there a way to lower the recurrence risk? (improving the mothers health, changing medications) Is there a way to lower the recurrence risk? (improving the mothers health, changing medications)

5. Address any medical problems you can between pregnancies Get hypertension under better control, if necessary Get hypertension under better control, if necessary Get diabetes under control – elevated HgA1C is directly associated with increasing risk of congenital anomalies Get diabetes under control – elevated HgA1C is directly associated with increasing risk of congenital anomalies Determine if the mom needs Progesterone (17- OHP) or cerclage (for cervical insufficiency) next pregnancy to try to prevent another preterm birth. Be sure the mother knows your recommendations. Determine if the mom needs Progesterone (17- OHP) or cerclage (for cervical insufficiency) next pregnancy to try to prevent another preterm birth. Be sure the mother knows your recommendations. High dose Folic Acid supplementation for mothers with a child with spina bifida High dose Folic Acid supplementation for mothers with a child with spina bifida

6. Improve the mothers chronic illness, if possible Waiting until the next pregnancy to make healthy lifestyle changes is TOO LATE. Waiting until the next pregnancy to make healthy lifestyle changes is TOO LATE. 1. Get exercising 2. Eat a healthy diet (for you and your 2. Eat a healthy diet (for you and your family) family) 3. Quit smoking 3. Quit smoking Start and optimize medications (antihypertensives, diabetes drugs, asthma medications that are safe for pregnancy) Start and optimize medications (antihypertensives, diabetes drugs, asthma medications that are safe for pregnancy)

7. Have a frank discussion with mothers about the risks to themselves and their children Mothers with pulmonary hypertension, Marfans syndrome or congestive heart failure may not survive another pregnancy Mothers with pulmonary hypertension, Marfans syndrome or congestive heart failure may not survive another pregnancy –Have you thought about what would happen if you leave your children without a mother? –Do you have a condition you could pass on to your child? It is not our place to judge, just inform and help patients think through the possibilities

8. Review Medications Make sure medications are safe in pregnancy, or that patient is aware that they are not and should avoid pregnancy for a period of time (e.g. Coumadin) Make sure medications are safe in pregnancy, or that patient is aware that they are not and should avoid pregnancy for a period of time (e.g. Coumadin) Let patients know what will happen to their medications when they become pregnant (many people quit everything right away) Let patients know what will happen to their medications when they become pregnant (many people quit everything right away)

9. Birth Spacing Infant mortality is higher in women who deliver within 12 months of their previous delivery Infant mortality is higher in women who deliver within 12 months of their previous delivery Women who have a C-section should wait at least 18 months between pregnancies for their scar to completely heal Women who have a C-section should wait at least 18 months between pregnancies for their scar to completely heal

10. Birth Control HALF of all pregnancies in the U.S. are unplanned HALF of all pregnancies in the U.S. are unplanned Even in married couples… Even in married couples… High risk women need effective contraception High risk women need effective contraception Physicians worry about the risks of birth control, when pregnancy is a much greater risk Physicians worry about the risks of birth control, when pregnancy is a much greater risk

11. Discuss the options Progesterone only – pills, DepoProvera, Implanon and Mirena IUD (For women who cannot take estrogen) Progesterone only – pills, DepoProvera, Implanon and Mirena IUD (For women who cannot take estrogen) No hormones – condoms (not most effective) and Paraguard IUD No hormones – condoms (not most effective) and Paraguard IUD Discuss permanent sterilization (INCLUDING VASECTOMY) Discuss permanent sterilization (INCLUDING VASECTOMY)

12. Dont forget the basics All women of reproductive age need to be up-to-date on their vaccines prior to pregnancy (Rubella, varicella) All women of reproductive age need to be up-to-date on their vaccines prior to pregnancy (Rubella, varicella) Correct anemia Correct anemia Prenatal vitamins are great for everyone! Prenatal vitamins are great for everyone!

13. A final thought: The desire to have a child is primal and almost universal. The desire to have a child is primal and almost universal. Our role is to respect each woman and her decisions and help her have the healthiest pregnancy she can. Our role is to respect each woman and her decisions and help her have the healthiest pregnancy she can.