Transcript Preconception Care
Preconception Care
Greater New York Chapter of the March of Dimes Preconception Care Curriculum Working Group Albert Einstein College of Medicine/Montefiore Medical Center Peter Bernstein, MD, MPH Associate Professor of Clinical Obstetrics & Gynecology and Women’s Health
Preconception Care
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May be the most important part of prenatal care
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US Public Health Service, 1989 Only 20-50% of primary care provider routinely provide preconception care
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Healthy People 2000 Report
Preconception Care 1. The Case for Preconception Care 2. What is Preconception Care?
3. How to incorporate Preconception Care into clinical practice
Preconception Care 1. The Case for Preconception Care
The Need for Preconception Care
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Kempe, 1992 (NEJM): Racial disparities in low birth weight rates may partially be the result of maternal conditions that should be addressed prior to conception Haas, 1993 (JAMA): Additional access to prenatal care only in Massachusetts did not impact rates of adverse birth outcomes
The Need for Preconception Care
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More than 40% increase in utilization of prenatal care by African-American Women since the 1970’s No improvement in rates of very low birth weight infants Minimal improvement in rates of low birth weight infants
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National Center for Health Statistics 1975, 1984, 1994
Preconception Care 1. The Case for Preconception Care 2. What is Preconception Care?
Preconception Care
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Identifies reducible or reversible risks Maximizes maternal health Intervenes to achieve optimal outcomes Provide health education
Preconception Care
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Reframes issues Adds an anticipatory element Focuses on the impact of pregnancy
Elements of Preconception Care
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Focus on elements which must be accomplished prior to conception or within weeks thereafter to be effective
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Risk assessment
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Health promotion
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Medical and pyschosocial interventions
Components of Preconception Care
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Medical history Psychosocial issues Physical exam Laboratory tests Family history Nutrition assessment
Examples of Components of Preconception Care
– Family planning and pregnancy spacing – Family history – Genetic history (maternal and paternal) – Medical, surgical, pulmonary and neurologic history – Current medications (prescription and OTC) – Substance use, including alcohol, tobacco and illicit drugs – Nutrition – Domestic abuse and violence – Environmental and occupational exposures – Immunity and immunization status – Risk factors for STDs – Obstetric history – Gynecologic history – General physical exam – Assessment of Socioeconomic, educational, and cultural context
Pregnant or gave birth Prevalence of Risk Factors Smoked during pregnancy Consumed alcohol in pregnancy (55% at risk of pregnancy) At risk of getting pregnant Had preexisting medical conditions Rubella seronegative HIV/AIDS Received inadequate prenatal Care Cardiac Disease Hypertension Asthma Dental caries or oral disease (women 20-39) Diabetic On teratogenic drugs Overweight or Obese Not taking Folic Acid 11.0% 10.1% 4.1% 7.1% 0.2% 15.9% 3% 3% 6% >80% 9% 2.6% 50% 69.0%
Conditions Addressed by Preconception Care
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Those that need time to correct prior to conception Interventions not usually undertaken in pregnancy Interventions considered only because a pregnancy is planned
Conditions Addressed by Preconception Care (cont)
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Conditions that might change the choice or timing to conceive Conditions that would require early post conception prenatal care
Family Planning
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A short pregnancy interval may be associated with:
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birth of an SGA infant in a subsequent pregnancy
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Lieberman 1989, Zhu 1999
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preterm birth in a subsequent pregnancy
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Basso 1998, Zhu 1999
Preconception Genetic Counseling and Screening
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Family history of genetic diseases Discussion of age-related risks Discussion of disease-related risks Carrier screening Potential options of donor egg or sperm or early genetic testing
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Discussion of exposure to teratogens
Weeks gestation from LMP
Most susceptible time for major malformation
4 5 6 7 8 9 10 11 12
Missed Period Mean Entry into Prenatal Care
Substance Use and Preconception Care
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Patient education as to effects of substances on fetus Screening for use/abuse Referral for treatment program Pregnancy may be a strong motivator for change
Alcohol
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Leading preventable cause of mental retardation
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Most common teratogen to which fetuses are exposed
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Effects related to dose No threshold has been identified for “safe” use in pregnancy
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Effects at all stages of pregnancy
Tobacco
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Leading preventable cause of low birthweight
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For every 10 cigarettes smoked each day the risk of delivering an SGA infant increases by a factor of 1.5
Associated with placental abruption, preterm delivery, placenta previa, miscarriage Smoking cessation results in increased birth weight
Substance Use and Consequences
Cocaine congenital anomalies low birth weight abruptio placenta
Heroin low birth weight newborn withdrawal
Methadone newborn withdrawal
Environmental Teratogens
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Exposures
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Home, workplace, environment
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Physical/chemical hazards
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ionizing radiation, lead, mercury, hyperthermia, herbicides, pesticides
Physical and Emotional Abuse in Pregnancy
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Two million women each year are abused by a partner No correlation with ethnicity, socio economic status, or education 29% of abused women report escalation of abuse during pregnancy
Role of the Health Care Provider
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Be open to the subject Provide a private, confidential setting for visit Use a standardized screen Ask every woman Know local resources for referral
Nutritional Risks
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Underweight (BMI < 19.8 prepregnant)
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Increased risk for: low birthweight, fetal death, mental retardation Overweight (BMI 26.1-29.0) and Obese (BMI >29.0)
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Increased risk for: diabetes, hypertension, thromboembolic disease, macrosomia, birth trauma, abnormal labor, cesarean delivery
Nutritional Risks Vitamins and Minerals
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Folic acid - modifies risk of neural tube defects
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Iron - increased risk of preterm delivery, LBW
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Oversupplementation of Vitamins A & D increase in congenital anomalies
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Pica - iron deficiency, lead poisoning
Prevention of Neural Tube Defects
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Supplementation for all women of childbearing potential with folic acid
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No history of NTD: 0.4 mg. qd
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Prior infant with NTD: 4.0 mg. qd
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Woman with NTD: 4.0 mg. qd
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Nutritional sources often inadequate
Immunizations
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Women of childbearing age in the US should be immune to measles, mumps, rubella, varicella, tetanus, diptheria, and poliomyelitis through childhood immunizations If immunity is determined to be lacking, proper immunization should be provided Need for immunizations according to age group of women and occupational or lifestyle risks
Rubella Vaccination
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Determine rubella immunity prior to conception Vaccinate susceptible nonpregnant women Congenital rubella syndrome may result from infection during pregnancy (microcephaly, fetal growth restriction, cardiac malformations, etc)
Preconception Care for Men
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Alcohol
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may be associated with physical and emotional abuse
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may decrease fertility
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Genetic Counseling Occupational exposure
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lead
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Sexually transmitted diseases
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syphilis, herpes, HIV
Preparedness for Parenthood
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Pyschological Financial Life plans
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education
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career
Preconception Care 1. The Case for Preconception Care 2. What is Preconception Care?
3. How to incorporate Preconception Care into clinical practice
Epidemiology of Unintended Pregnancy
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49% of pregnancies in the US are unintended (unwanted or mistimed)
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Henshaw, 1998
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Preconception care should be provided to all reproductive age individuals
Barriers to Preconception Care
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Unintended pregnancy “Planned” pregnancies are seldom planned with a health care provider
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Unpreparedness of health care providers
When should preconception care be offered?
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As part of routine health maintenance care At a defined preconception visit For women with chronic illness At one visit v. several visits
Incorporating Preconception Care into Routine Primary Care
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Encourage all women to have a “Reproductive Life Plan” Chart stamp:
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LMP, BP, Weight, Height, BMI
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“Plan to become pregnant in the next year?”
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Family Planning Method
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Tobacco use
Bernstein, Merkatz J Repro Med, 2000
Medical Record #: Patient name: Family Planning
Pregnancy planning and spacing Pregnancy prevention
Preconception Health Screening/Counseling Date Done Pending Action Comments/Provider’s Initials Social History
Social support (safety, resources) Alcohol use Tobacco use Illicit drug use Exercise Teratogen exposure (e.g. lead, chemicals at work)
Nutrition History
Special diet Eating disorder Adequate vitamin/mineral intake (e.g.
Ca, folate)
Medical History
Diabetes Thyroid disease Asthma Cardiovascular Disease Hypertension Deep Venous Thrombosis Kidney Disease Autoimmune Disease Neurologic Disease Hemoglobinopathy Other medical or surgical problems
Infectious Disease History
STD’s including HIV Hepatitis B (immunize if at high risk) Rubella (test, if nonimmune, immunize) Toxoplasmosis
Medications
Over the counter medications Prescription medications
Reproductive History
Uterine abnormalities 2 or more first trimester SAb’s One or more 2nd trimester losses Any fetal deaths Preterm deliveries Any infants admitted to NICU
Family History
Birth defects Hemoglobinopathies Mental retardation Cystic fibrosis Tay-Sachs disease Consanguinous marriage