All babies need extra care and attention, but premature babies need a helping hand more than most

 

 

Around one in 13 babies in the UK are born prematurely – before 37 weeks gestation – putting them at risk of death in infancy, disability and future long-term health problems.

The numbers are rising and it is increasingly important that women should be given evidence-based advice on how they can avoid the pregnancy complications that might put them at risk of giving birth prematurely.

Experts are unable to explain what causes many premature births. One-third are termed “unexplained” or “spontaneous”, a further 30 per cent are due to multiple pregnancies because twins or triplets are much more likely to come early, and up to a quarter are caused by factors such as infections or problems with the cervix.

The remaining births are elective where a baby will be delivered early due to a health complication, such as the mum developing pre-eclampsia or because the baby has suffered intrauterine growth restriction affecting his/her chance of survival.

“Because many premature births are still unexplained it’s difficult to pin down exactly why prematurity is increasing,” says Jacqui Clinton, health campaigns director at the baby charity, Tommy’s. “The rise in the overall birth rate is a factor. We’re also having babies later, and women over 35 years of age have an increased risk of premature birth. The increasing use of fertility treatments mean there are more multiple pregnancies too.

Women over 35 years of age have an increased risk of premature birth

“Lifestyle factors such as drinking and smoking also raise the risk of premature birth, along with mums-to-be experiencing health issues such as obesity, diabetes or hypertension.”

Pharmacists, she says, can play a key role in giving reliable advice to women, both before conception and during pregnancy. “If you have high blood pressure or hypertension before you fall pregnant, you are more likely to develop pre-eclampsia which, while rare, is a serious condition for both mother and baby and may result in a baby being delivered prematurely.

“A recent study⁽¹⁾ shows that mothers who are obese are more likely to go into spontaneous early labour, but they are also more likely to develop pre-eclampsia and gestational diabetes, where the baby may need to be delivered early.

“In the case of smoking, nicotine affects how the placenta works, restricting the blood flow to the baby, meaning the baby is getting less oxygen and nutrients. Babies can be smaller and more likely to be born too soon,” says Clinton.

Research is helping to advance treatment and detection of conditions which cause complications in pregnancy. For example a new rapid blood test that can accurately diagnose pre-eclampsia is set to revolutionise treatment².

Researchers at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London have discovered that testing the level of a protein called placental growth factor (PlGF) in pregnant women before 35 weeks can accurately diagnose pre-eclampsia.

Results of the study show that the PlGF blood test, which is done at the bedside and gives an accurate result in just 15 minutes, identifies 96 per cent of women who will need to be delivered within the next 14 days.

“This test means we can now decide with greater certainty if a mother should be closely monitored to see if her baby needs to be delivered early to save its life, or if it is safe to wait and allow the pregnancy to continue,” says Professor Andrew Shennan, consultant obstetrician at Guy’s and St Thomas’.

Gestational diabetes is very common, affecting up to 18 in 100 women during pregnancy and can increase the risk of complications if not carefully controlled. However there are differing opinions about how women should be screened. In the UK, NICE recommends that women should be screened only if they are at risk of developing gestational diabetes (i.e. if they have a body mass index of 30 or higher, have previously given birth to a large baby weighing 4.5kg or more, have had gestational diabetes before or have a parent, brother or sister with diabetes and their family origin is South Asian, Chinese, African-Caribbean or Middle Eastern³).

In America, however, a Government-backed panel of experts has recommended that screening for gestational diabetes should be conducted on all pregnant women at 24 weeks, even if they have no symptoms of the disease.

Women with diabetes prior to conception also need to take extra special care of themselves during pregnancy. Research shows that women with diabetes who monitor their blood glucose levels and take folic acid supplements before conception and during pregnancy have half the risk of a stillbirth or death during the first year of life⁴. “More must be done during pre-conception care, such as a health professional explaining to women about the need for folic acid and good diabetic control from conception,” the researchers concluded.

 

A healthy pregnancy

Leading a healthy lifestyle in the months prior to conception as well as during pregnancy is likely to reduce a woman’s risk of developing complications, a new study led by scientists at King’s College London has found⁵.

Researchers monitored over 5,000 first-time mothers to investigate factors leading to a normal pregnancy rather than factors that could have an adverse effect. They found that maintaining a healthy weight and blood pressure, eating a healthy diet both before and during pregnancy, and being in paid employment at 15 weeks’ gestation, were the key factors likely to boost a woman’s chances of having a healthy pregnancy.

“We have always known that a mother’s general health is important, but until now we did not know the specific factors that could be associated with a normal pregnancy,” says Dr Lucy Chappell from the Division of Women’s Health at King’s College London, who led the research.

Drinking

Media reports about drinking in pregnancy frequently send conflicting messages, but Dr Sarah Jarvis, London GP and adviser for the charity Drinkaware, says there is unequivocal evidence that women should avoid drinking alcohol altogether during the first trimester of pregnancy because it is a key time in the formation of the baby’s brain and neural tube.

“After that there is very little evidence that one or two units once or twice a week will cause significant harm but what we have seen in the research are some quite subtle possible changes in terms of babies’ developmental milestones up to the age of about four or five years. With that in mind the recommendation is that in an ideal world you shouldn’t drink, but if you are going to drink it shouldn’t be more than one or two units once or twice a week.”

She warns, however, that there is a huge misconception among the public about what a unit of alcohol is. “People assume that a glass of wine is one unit. It’s not – a standard glass of wine measuring 175ml is 2.2 units and a large wine glass is three units. What pharmacists can do is make sure that pregnant women really understand these limits.”

Smoking

Smoking during pregnancy causes up to 2,200 premature births, 5,000 miscarriages and 300 perinatal deaths every year in the UK. This is a key area where pharmacists can provide information, encouragement and tips on stopping.

Government figures show that smoking cessation advice is having an impact. In England in the 12 months to March 2013 there were fewer women smoking at the time of delivery (12.7 per cent) compared to the previous year (13.2 per cent) and considerably fewer than five years ago (14.4 per cent).

Exercise

Exercise should be encouraged during pregnancy as it helps to reduce complications. However a recent survey by Tommy’s found many mums-to-be were not exercising because they were concerned that it might cause a miscarriage or premature labour. The research also found that women do not routinely receive advice on exercise.

Pregnant women should be advised to do a minimum of 30 minutes five times a week. The benefits include less swelling of the hands and feet, less backache, breathlessness and general tiredness and fatigue, while strengthening muscles and improving fitness means that women are better able to cope with the weight of their growing baby. Meanwhile, babies receive improved blood flow to the placenta, which is needed for good growth and development.

Immunisations

It is important to check that pregnant women have had their flu jab. Research has shown that seasonal influenza vaccination can reduce the chance of having a pre-term birth or a low birth weight baby. The study of over 12,000 women in Nova Scotia, Canada, lends further support to the UK’s programme to vaccinate all pregnant women against flu, introduced in 2010. Pregnant women should also be vaccinated against whooping cough when they are 28-38 weeks pregnant to help protect their babies.

Vitamin supplements

Eating a healthy, varied diet in pregnancy will help women to get most of the vitamins and minerals they need. They should also take:

• 10mcg of vitamin D each day throughout pregnancy and during breastfeeding
• 400mcg of folic acid each day – this should be taken before a woman conceives and until she is 12 weeks pregnant.

Pregnant women should not take vitamin A supplements as too much retinol could harm the baby. Many pregnant women are short of iron and may be prescribed iron supplements by their GP.

Weight management

During pregnancy women should be advised that it is not necessary to “eat for two”, even if they are having twins or triplets. Too much weight gain increases the risk of developing problems later in the pregnancy. A weight gain of 10-14kg over the pregnancy is associated with the lowest risk of pregnancy complications.

Shaheen Bhatia, an independent pharmacist in Redbridge, who was shortlisted for the Asian Women of Achievement Award last year for her work in piloting local services in teenage pregnancy and sexual health, offers free pregnancy testing in her pharmacy.

She sees supporting women throughout their pregnancies as a key part of her role as a caring healthcare professional. “It also builds customer loyalty – this woman is likely to be your customer for life,” she explains.

“I guide mums-to-be through all aspects of staying healthy throughout pregnancy. I try not to put time limits on consultations. One of the biggest complaints I hear from my customers is that their GP doesn’t have time for them. Pregnant women always have a lot of questions, whether they have read everything under the sun on the internet or have literacy problems – so I always try to provide as much information as I can in one slot and give them leaflets to take away. Then I tell them that they can drop in whenever they like because the advantage of pharmacy is that we can offer open access,” says Bhatia.

 

 

References

1. Scott-Pillai R, Spence D, Cardwell CR, Hunter A, Holmes VA. The impact of body mass index on maternal and neonatal outcomes: A retrospective study in UK Obstetric population. BJOG 2013
2. Shennan A, Chappell CLucy C et al. Diagnostic Accuracy of Placental Growth Factor in Women with Suspected Preeclampsia: A Prospective Multicenter Study. Circulation. 2013; 128:2121-2131
3. Diabetes in pregnancy. NICE March 2008
4. Tennant P, Glinianaia S, Bbilous R et al. Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study. Diabetologia 2014: 57; 285-294
5. Exploration and confirmation of factors associated with uncomplicated pregnancy in nulliparous women: prospective cohort study. BMJ 2013.
6. Self Care Forum: Fever in Children factsheet.
7. Feverish illness in children: Assessment and initial management in children younger than 5 years. NICE May 2013.