75 - High Risk Pregnancies (Dr. Stephen Pedron)

Dr. Stephen Pedron, physician at UnityPoint Clinic Maternal Fetal Medicine, joins Dr. Arnold to discuss high-risk pregnancies.

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Transcript

Dr. Arnold:

This is LiveWell Talk On high risk pregnancy. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health-St. Luke's Hospital. There are many risk factors that contribute to high risk pregnancies. Here to dive deeper into this topic is Dr. Steven Pedron, physician at Unity Point Clinic Maternal Fetal Medicine. Thanks so much for stopping by.

Dr. Pedron:

It's a pleasure. Morning.

Dr. Arnold:

Good morning. What is considered advanced maternal age or high risk pregnancy?

Dr. Pedron:

Oh I was hoping you would ask that. I saw a patient this week who said that she had been tagged as a geriatric pregnancy. And I forgot that I wasn't an attorney and raised my hand and objected strenuously. And then I did some homework this week trying to figure out where that expression comes from. And looked up the word geriatric and that's old people and I thought, well that's me. I'm geriatric, but pregnant patients aren't. And his designation of advanced maternal age is arbitrary. It's a statistical consequence of the intersection of the curves for the risk of amniocentesis and the risk of down syndrome. It's just an old statistical convention and it really doesn't apply. Advanced maternal age is 35 and above, but it's much more about, should be much more about the suitability of mother to sustain a healthy pregnancy. Is she gonna make it home alive and well? If she's 45 and she has a good heart and good kidneys, she's going to do fine. And if she's 25 and she's got lupus or bad diabetes or hypertension or chronic kidney disease then she's older than she should be to sustain a healthy pregnancy. Then there are fetal issues associated with advanced maternal age and that's this increasing risk of down syndrome and other chromosome problems. But once again, that's arbitrary and there are so many noninvasive tests now to diagnose that problem, if you will. That it really doesn't have much meaning either. So this arbitrary cutoff of 35, it doesn't mean much to me now.

Dr. Arnold:

Back to the down syndrome, the trisomy 21, in a nonobstetric physician, that would be the answer to the question of risk for maternal age just because of historical. Do the other chromosome abnormalities also increase with maternal age?

Dr. Pedron:

Yes.

Dr. Arnold:

Okay. So not just downs, all of them do?

Dr. Pedron:

All of them that I'm aware of increase in equivalent fashion due to some good old fashioned genetics, non-disjunction. Those eggs are created when, as my wife would say, the woman was a baby in her mommy's tummy. They're created by 20 weeks and then they're suspended in state of disjunction, miosis, getting ready to be down to their haploid of chromosomes and forming eggs. And men are of course forming sperm and that all happens when women are themselves fetuses. That process degenerates over time, breaks down, as women age, then mishaps occur.

Dr. Arnold:

How about the man's age? The father's age? Is that a risk factor? I think I've read that before.

Dr. Pedron:

Yes, it is. It's a risk for other things and the data for this is murky. They are not at risk for nondisjunction because men are continually producing new sperm. They're continuously producing cells, gametes with half the number of chromosomes to combine with those eggs that have half the number of chromosomes. So their problem is a different one. They're at risk for autosomal dominant disorders, neurobehavioral disorders. Some people are saying autism now. So there's a whole different spectrum of increasing risk with increasing paternal age, which by the book is 40 years.

Dr. Arnold:

40 so 35 for women, 40 for men. What's the oldest age that you've cared for of a woman that had a baby?

Dr. Pedron:

Oh, I want to say 55 maybe. I have a couple of 49, 50 year old patients right now.

Dr. Arnold:

That is amazing.

Dr. Pedron:

Yes it is. And you might think too old and it might be for some reasons and we don't need to get into the ethics and societal implications of all of this, but as long as they have a good pump and good kidneys, they have good blood flow and chances are they'll do just fine.

Dr. Arnold:

Well in the Bible, wasn't Ruth like 84 or something like that?

Dr. Pedron:

She was old.

Dr. Arnold:

She pulled it off. You mentioned obesity, diabetes and hypertension as risks that increase with age or at any age they provide a higher risk pregnancy. What are some other medical conditions that commonly you see beyond those big three?

Dr. Pedron:

Lupus, chronic kidney disease, past history of malignancy. Really anything that a patient is seeing another provider for. Those are problems which have some impact on pregnancy. But the biggest, without having a podcast on social determinants, which I'm happy to do time. I think if you took substance abuse and societal problems out of the equation, if you took that, including cigarettes and obesity out of the equation, you could probably put me out of business.

Dr. Arnold:

I think there's a lot of subspecialties that would be part-time greeters at Walmart if we didn't have cigarettes and obesity.

Dr. Pedron:

Yes. Cigarettes and obesity. Take those two out of the equation and you would knock down my practice by a half, no exaggeration.

Dr. Arnold:

And you know, I think you've seen, I'm surprised at the number of young people I see smoking, you know, I think that's just anecdotally, I see more young people smoking then I think I did before. But the obesity just continues to climb as an epidemic.

Dr. Pedron:

Can't see that ever going the other direction.

Dr. Arnold:

No, you really can't. And I don't know if there was a projection, I don't know if I was listening to the radio or watching television of recent that you know it's a worldwide phenomenon. And as underdeveloped countries have become developed and have access to the luxuries as you will, that developed nations have that it's growing significantly, no pun intended there. It is commonly observed that women gain weight during pregnancy. What is too much weight? And what are the limitations to them losing that weight after they've delivered?

Dr. Pedron:

There are guidelines for this. First, the optimal weight to conceive is normal BMI 25 or less. 20 to 25 if we had that, we'd be home. The optimal weight gain during pregnancy is predicated upon your pre-pregnancy BMI, but roughly speaking, 25 to 35 pounds for a singleton pregnancy. For a multiple gestation again, roughly speaking about twice that. What's the impediment to losing weight? I don't know, habits, stress, life, childbearing, lack of motivation, poor dietary habits, lack of guidance. I think that that's one of the ways with our diabetic patients that we can really impact their longterm health is get them onto a good dietary habit. The whole family during pregnancy, and maybe some of that will carry over. But the strategy to lose weight is not very complex actually. You just knock out 500 calories a day and that's 3,500 calories a week and you will lose a pound a week, which is sustainable. It's wise and sustainable, but it's tough to do that. People love to eat I guess, and it's a part of our comfort.

Dr. Arnold:

It is. It's social, there's social emotional aspects to it. That is so true. I know when my wife was pregnant with both our daughters, I was so excited for her to have these cravings where she'd send me to Taco Bell in the middle of the night and that way I could eat taco bell middle of the night. She had none, zero, no cravings at all.

Dr. Pedron:

Oh shoot. I'm so sorry.

Dr. Arnold:

I really felt like I got cheated because I was just, you know, expecting being a big eater that I am, that yes, we're going to have pizza at two o'clock in the morning. This is gonna be awesome and nothing.

Dr. Pedron:

Oh that's tragic.

Dr. Arnold:

Yeah. I really do believe I was cheated. Now diabetes during pregnancy, obviously you can't use the oral agents. I'm assuming Metformin would be contraindicated, wouldn't it?

Dr. Pedron:

For the most part, yes.

Dr. Arnold:

So it's basically insulin?

Dr. Pedron:

Yes.

Dr. Arnold:

And do you have patients that are on oral agents conceive, go to insulin and then go back to oral agents? Or sometimes do you have type two diabetics that might be on pills, transition insulin and then they just stay on insulin?

Dr. Pedron:

All of it. I have plenty of patients who come in on oral hypoglycemic and that for now is contraindicated in pregnancy except for Metformin, which is wonderful for certain early pregnancy conditions such as polycystic ovarian syndrome,. Those patients are all transitioned to insulin. If I had my choice, they would all stay on insulin because far as I'm aware of, that's the best. That's the gold standard for treating diabetes. So my vote for those patients is that they stay on insulin as long as they need medication. Some of them will transition back to oral hypoglycemics. And that's in the hands of the folks that are managing their diabetes after the pregnancy.

Dr. Arnold:

That's so true, I think there is a time in medicine, and this is speaking from personal experience. You know, 25 years ago, where you held insulin over the patient's head as a metric that they'd failed. And now that, well, now you have to go on insulin and I've learned over time that that's not the attitude to have. Some patients try really hard and then despite that, they go on insulin and it's not their fault. But the sooner they're on insulin, other than the hyperinsulinemic state, you can see with some type twos. Which is usually a calorie problem, not an insulin problem. You're right. Insulin, better control, quite frankly, easier to manage. I know that needles scare some people, but you're absolutely right. Once you can get them on insulin, I think it's a better, outcome for the patient.

Dr. Pedron:

You nailed it. Patients and providers resist that and they resist it because they feel that they're a worst diabetic when they have to take it.

Dr. Arnold:

Yeah, I would say it becomes real. It becomes real. You know, taking a pill and you get your A1C checked every three to six months and you go see the doctor. But then once you have to start injecting insulin, it's real then. And that's a big emotional transition for the patient. But you see those patients a year later and they're like, why didn't we do this three years ago? You know what I mean? Because I feel better my A1Cs are better. And I think when you're on insulin, you check your blood sugars, right? And then you start to observe, wow, that sugar-coated breakfast cereal makes it go up X amount. And so they see this cause and effect and they start to put two and two together and start to avoid those foods.

Dr. Pedron:

Exactly, if patients will pay attention to this then they can actually become keen on the detail that they can get out of it just by following what happens in response to what they eat and how they treat themselves or a little bit of exercise after a meal. It's really kind of fun once they start to get into it and as I tell them, it's the way to get them old, watching their grandkids grow up. But that expression that it just became real. I think I might just use that.

Dr. Arnold:

Yeah, we call that nursing home prophylaxis, when people take care of themselves. In the internal medicine world we call it.

Dr. Pedron:

That's a great expression.

Dr. Arnold:

You mentioned singleton and multiple births. Should a family that's having twins or triplets, should they see the maternal fetal medicine specialist just by default because it's a multi? I mean that makes sense to me.

Dr. Pedron:

I think so yes, they should. For twins, the healthy twin pregnancy, maybe once just for a good close look at the pregnancy and a set of recommendations. For other higher risk twin pregnancies, shared placenta, multiple gestation. I should probably see those patients regularly. And there's a lot of patients that I could and should make a difference for but oftentimes that's just a one off. It's appraisal of both the mother and the fetus and it's a set of recommendations on the chart and after that it's call me if you need me.

Dr. Arnold:

Right, right. Well that's just good advice there. What are the common screenings if you're in a high risk pregnancy? I mean, not every patient gets an amniocentesis, do they?

Dr. Pedron:

No. In fact, in this day and age with all the other noninvasive tools that are out there, we do, I don't know maybe one a week, one a month. We're not doing that many amnios where I used to line them up and do them half a dozen a day. But there's so many other great screening tools, genetic screening tools that are out there now. Including nuchal translucency, first trimester screening, Sierra multi analyte screening, integrated screen, sequential screens, detailed ultrasound. These are all different strategies and schemes to screen for something, a genetic problem, a growth problem, a blood flow problem. There are a lot of tools out there for screening and then obstetrician, gynecologists all have their own subset of screening in early pregnancy for blood type and antibody and diabetes for obese patients. There's some pretty sophisticated strategies available.

Dr. Arnold:

So let me ask you this question, because I know this happens, I've had other guests and I have colleagues that I've heard these stories, no prenatal care whatsoever. They show up, they're pregnant. I mean they're delivering, if I was an obstetrician, can I still call you and say, "Hey, I have someone here that has high risk and it's go time. Is that still a time when the maternal fetal medicine specialist can help?

Dr. Pedron:

Absolutely. Okay. You can call me anytime day or night. Everybody has my cell phone. I'm always available at the drop of hat, so I'll come for anything. You name it. If it's a patient who needs something early in pregnancy, fine. If there's a crisis in labor and delivery, call me if you've got a patient in the ICU. I love the ICU, so I'm available for anything.

Dr. Arnold:

That's outstanding. This has been really great information today. I want to thank you for taking time, I know you have a busy schedule. This is, again, this is Dr. Steven Pedron, physician at UnityPoint Clinic Maternal Fetal Medicine. For more information, visit unitypoint.org. If you have a topic you'd like to suggest for our LiveWell Talk On podcast, shoot us an email at stlukescr@unionpoint.org and we encourage you to tell your family, friends, neighbors about our podcast. Until next time, be well.