A Preconception Care Health Strategy Addressing STIs and Other Infections

Julia Lange Kessler, CM, MSM Maternal Fetal Medicine Outreach Coordinator Maria Fareri Children’s Hospital at Westchester Medical Center

What is preconception health care?

 Health care for women and

men

that takes place prior to pregnancy.

  Prevention infant mortalities and morbidities Prevention of maternal mortalities and morbidities  AAP and ACOG classified the main components of PCC:  Physical assessment, risk screening, vaccinations and counseling.

The origins of Preconception Care:

  Late 1980s -the Public Health Service convened a multi-disciplinary group of experts in maternal and child health. This lead to a report “Caring for our Future: The Content of Prenatal Care”  Public Health Service, US DOH. Caring for our Future: the content of prenatal care (a report of the Public Health Service Expert Panel on the Content of Prenatal Care). Washington (DC): US Government Printing Office, 1989.

What we learned :

 Preconception Care should be in integral part of primary care services.

How did that concept evolve?

Radiation Exposure → childhood –leukemia DES Thalidomide

Thalidomide → Phocomelia

1962 legislation was passed so that the FDA could scrutinize drugs more carefully and from that a drug classification system evolved that for pregnancy and lactation.

Pregnancy Drug Classification System:

A: Controlled studies in ♀- no risk to fetus or newborn B: Animal studies – no risk but studies in ♀ have not been done C: Animal studies indicate adverse effects but there are no studies in ♀ - give only when the risks outweigh the benefits D: There is + risk to the human fetus. Use only in life threatening situations X: Studies have shown abnormalities in fetus.

Preconception considerations when planning a pregnancy:

 When to discontinue a family planning method  OC’s – wait one cycle before attempting pregnancy – optimized dating   Long term hormonal- make take several months to a year. Irregular menses-Basel Body Temperature or ovulation predictor  12 months of unprotected intercourse → infertility

Nutrition

 BMI  Pica   Eating disorders CDC: ≤ 1 gram Folic Acid  Good nutritional status: protein for brain and cell development “In one study, the reduced overall health status (including poorer physical and emotional health) of women with low income during the month before pregnancy was associated with and increase risk for preterm labor.” Haas JS, et al. Outcomes and health status of socially disadvantaged women during pregnancy. J Womens Health Gender Based Med 1999;8:547-53.

 Genetic screening  Dental care  Cardiac risk  Consider Previous OB complications:  PTB         GDM Hypertensive disorders Previa Low Birth Weight Incompetent cervix Fibroids Pre eclampsia Advanced maternal age

Preconception Issues for Men:

 50% of all infertility is male related  Medications or environmental factors can alter sperm shape, motility, count and sexual performance.  Some studies indicate male smoking may be linked to heart defects     Alcohol and marijuana impacts sperm quality Deficiencies in zinc lowers sperm count Heat (cycling, hot tubs, etc.) lowers sperm quantity. STIs affect pregnancy

The issue that remains is the

unplanned pregnancy

 ~ 50% of all pregnancies are unintended.

 Unintended pregnancies are associated with perinatal morbidity and very low birth weight

Early prenatal care is too late.

Organogensis occurs between days 17- 56 days before a ♀ may know that she is pregnant.

By the time a ♀ misses menses and the urine is + for HcG:

 The fetal heart is formed and functioning  The spinal canal has closed  Eyes are formed  Limbs are moving

The time to prevent complications:

 Before a woman conceives  This needs to become our “Standard of Care” :  Age appropriate preconception care and counseling by a majority of primary care providers    

Created by the CDCs Select Panel on Preconception Care: Prevention of pregnancy for adolescents Changes in life sytle prior to conception Assessment of Reproductive risks for all persons (male and female)

Preconception risk factors as a % of total risks at the time of negative pregnancy test.

Brian, J. et al. The Journal of Family Practice.47(1), July 1998, p. 33-8.

Preconception Care Works

Risk Factors for Adverse Pregnancy Outcomes:               Folic acid Rubella seronegativity Diabetes (preconception) Hypothyroidism HIV/AIDS Maternal phenylketonurea (PKU) Oral anticoagulant Antiepiletic drugs Isotretinoins (Accutane) Smoking Alcohol misuse Obesity Hepatitis B STIs Atrash HK, Johnson K, Adams MM, Cordero JF, Howse J. reconception Care for Improving Perinatal Outcomes: The Time to Act. Matern Child Health J. 2006 Jun 14.

Sexually Transmitted Infections

STIs can be devastating to a woman’s reproductive health

 Intense physical discomfort  Pain  Mental anguish  Mortality from an ectopic pregnancy (PID)  Cervical cancer  HIV/AIDS

March 2008: A CDC study estimates that one in four (26 percent) young women between the ages of 14 and 19 in the United States – or 3.2 million teenage girls – is infected with at least one of the most common sexually transmitted diseases (human papillomavirus [HPV] 18%, chlamydia 4%, herpes simplex virus, and trichomoniasis).

March 11, 2008 – Press Release – CDC.

Why are women more vulnerable?

 More biologically susceptible  More apt to acquire an STI from a man than vice versa  More apt to be asymtomatic  STI complications are more severe  Powerlessness in abusive situations  Practice of douching

Trichomoniasis

Pregnancy and trich:

 Vaginal trichomoniasis has been associated with adverse pregnancy outcomes :    premature rupture of the membranes preterm delivery low birth weight

Trichomoniasis  Trichomoniasis is caused by the protozoan parasite:

T. vaginalis

.   7.4 million new cases occur each year (CDC) 124,000 pregnant ♀ per year  Most men who are infected with

T. vaginalis

do not have symptoms.

Symptoms in ♀:

 Many infected women have symptoms characterized by a diffuse, malodorous, yellow green discharge with vulvar irritation. 5-28 days after exposure.  However, some women have minimal or no symptoms.

Diagnosis of vaginal trichomoniasis

  Is usually performed by microscopy of vaginal secretions, but this method has a sensitivity of only about 60% –70%. Culture is the most sensitive commercially available method of diagnosis.

Recommended Regimen



Metronidazole

2 g orally in a single dose.

Alternative Regimen:



Metronidazole

500 mg twice a day for 7 days.

Management of Sex Partners

 Sex partners of patients with

T. vaginalis

should be treated.

 Patients should be instructed to avoid sex until they and their sex partners are cured (i.e., when therapy has been completed and patient and partner(s) are asymptomatic [in the absence of a microbiologic test of cure]).

Gonorrhea

Untreated Gonorrhea in pregnancy:

 Stillbirth  low birth weight  Conjunctivitis  Miscarriage  PTL  PROM  Pneumonia  neonatal sepsis  neurologic damage  blindness  deafness  acute hepatitis, meningitis, chronic liver disease, and cirrhosis.

Untreated

 Women: gonorrhea is a major cause of PID, which can lead to chronic pelvic pain, ectopic pregnancy, infertility and HIV.  Men: untreated gonorrhea can cause epididymitis, a painful infection in the tissue surrounding the testicles that can result in infertility.

 http://www.cdc.gov/STD/STATS/trends2006.htm

Gonorrhea

 Gonorrhea is caused by

Neisseria gonorrhoeae

, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract, including the cervix , uterus , and fallopian tubes in women, and in the urethra in women and men. The bacterium can also grow in the mouth, throat, eyes, and anus.

 http://www.cdc.gov/std/Gonorrhea/default.htm

Symptoms (within 10 days)

 Pain or burning when passing urine  Vaginal discharge that is yellow or sometimes bloody  Bleeding between menstrual periods  Heavy bleeding with periods  Pain during sex  http://www.4woman.gov/faq/stdgonor.htm

Transmission: Oral, anal, or vaginal sex

  In 2005, the national rate (115.6 cases per 100,000 population) increased for the first time since 1999 13,200 pregnant ♀ per year

Antibiotic Resistant Gonorrhea

 Fluoroquinolone-resistant strains of

N. gonorrhoeae

have also been reported in the United States and Canada. The proportion of gonococcal isolates in Hawaii that are fluoroquinolone-resistant currently exceeds 10% and increasing numbers of resistant strains have been identified in the continental United States.

 http://www.cdc.gov/std/Gonorrhea/arg/default.htm



New Treatment-April 2007



Ceftriaxone

125 mg IM in a single dose

OR Cefixime*

400 mg orally in a single dose or 400 mg by suspension (200 mg/5ml)

PLUS

TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT * These regimens are recommended for all adult and adolescent patients, regardless of travel history or sexual behavior.

† The tablet formulation of cefixime is currently not available in the United States http://www.cdc.gov/STD/treatment/2006/updated-regimens.htm

Chlamydia

Untreated Chlamydia

 PID: 40% which can cause permanent damage:    fallopian tubes uterus surrounding tissues.  The damage can lead to chronic pelvic pain, infertility, and potentially fatal ectopic pregnancy.  Women infected with chlamydia are up to five times more likely to become infected with HIV, if exposed.

Chlamydia

  Caused by the bacterium,

Chlamydia trachomatis

, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. (75% ♀ and 50% ♂) 100,000 pregnant ♀ per year  http://www.cdc.gov/STD/chlamydia/default.htm

Symptoms:

 Any genital symptoms such as an unusual sore, discharge with odor, burning during urination, or bleeding between menstrual cycles  50-75% are asymptomatic

Treatment for both partners:

 A single dose of azithromycin -2 grams  Doxycycline 100 mg. BID  No sex until treatment for both (all) partners is complete.

Other STIs – Facts:

 CDC’s baseline HIV drug-resistant surveillance data from 11 states in 2007 revealed that about 10.4 percent of HIV infected persons have HIV drug-resistant mutations.  http://www.cdc.gov/nchhstp/docs/NCHHSTP2007AnnualReport_final-c.pdf

Candidiasis and Bacterial Vaginosis

Two vaginal/cervical infections that may NOT be sexually transmitted

 Candidiasis  Bacterial vaginosis

Candidiasis-Typical Symptoms:

 pruritus and vaginal discharge.  Other symptoms include:  vaginal soreness,    vulvar burning, dyspareunia, external dysuria.

Predisposing factors:

       Pregnancy (2X) Antibiotic therapy DM Obesity Corticosteroids Immunosuppressant agents Exogenous hormones  OCPs    HIV Diets high in sugar Diets high in dairy

Vulvovaginal Candidiasis (Yeast)

 usually is caused by

C. albicans

but occasionally is caused by other types of

Candida

.  Most common of vaginal infections  PO meds contraindicated during pregnancy

PRECONCEPTION: NOTE:

The creams and suppositories used to treat candiasis are oil based and may weaken latex condoms and diaphragms.

Effects on pregnancy:

 Most practitioners do not treat if pt. is asymtomatic  Harm to baby: possibility of baby developing thrush at time of delivery during an NSVD  More effective to use long term vaginal preparations during pregnancy at bedtime  Pelvic Rest during treatment

Bacterial Vaginosis (BV)

 It is the most commonly diagnosed cause of infectious vaginal discharge  BV is a clinical syndrome resulting from replacement of the normal

Lactobacillus

sp. in the vagina with high concentrations of anaerobic bacteria (e.g.,

Prevotella

sp. and

Mobiluncus

sp.),

G. vaginalis

, and

Mycoplasma hominis

.

BV

BV is associated with having multiple sex partners, douching; it is unclear whether BV results from acquisition of a sexually transmitted pathogen.  1,080,000 ♀ per year.

 Women who have never been sexually active are rarely affected.  Treatment of the male sex partner has not been beneficial in preventing the recurrence of BV.

 BV is the most prevalent cause of vaginal discharge or malodor; however, up to 50% of women with BV may not report symptoms of BV.

BV in the non pregnant ♀:

The established benefits of therapy for BV in non pregnant women are to:  relieve vaginal symptoms and signs of infection  reduce the risk for infectious complications after abortion or hysterectomy.  Other potential benefits include the reduction of other infectious complications (e.g., HIV and other STDs PID, endometritis, infertility). All women who have symptomatic disease require treatment.

BV during pregnancy

is associated with adverse pregnancy outcomes, including:  premature rupture of the membranes  preterm labor  preterm birth  amnionitis  postpartum endometritis  post cesarean wound infections

“Effective oral treatment of BV during pregnancy reduces the rate of preterm birth by 30% to 50%.” http://www.midwife.org/display.cfm?id=586

Treatment:



Metronidazole

500 mg orally twice a day for 7 days, (Demonstrated effective to reduce PTB)

OR



Metronidazole gel

0.75%, one full applicator (5 g) intravaginally, once a day for 5 days

OR



Clindamycin

300mg PO TID X 7 days(1 st Δ) 

Clindamycin cream

2%, one full applicator (5 g)intravaginally at bedtime for 7 days.

How do we correct or prevent adverse outcomes?



Preconception Care



Everywhere at every visit

The CDC strategy:

 The CDC has ten recommendations (with action steps) for improving preconception health through changes in:     Consumer knowledge Clinical practice Public health programs Health-care financing  Data and research activities

What are the building blocks of the solution?

1. Individual Responsibility Across the Lifespan.

 Focus individual attention on reproductive health in the same way that people are encouraged to watch their cholesterol or blood pressure.  A lifespan approach can be used to focus individual attention on reproductive health.

2. Consumer Awareness

 ↑ public awareness of the importance of preconception health behaviors and services.  Tag reproductive health messages onto other campaigns such as    Reduction of smoking Alcohol Obesity

3. Preventive Visits

 Integrate preconception components into primary care visits   Provide risk assessment Education and health promotion to all ♀ of childbearing age

4. Interventions for Identified Risks

 ↑ F/U for women needing interventions (as identified during risk screening)  Example: DM affects 1.85 million (21 per 1,000)

♀

in the US. (ages 18-44)  DM management has the potential to reduce the risk of loss and congenital malformation for approximately 113,000 births per year  www.cdc.gov/mmwR/preview/mmwrhtml/rr5506a1.htm

5. Interconception Care

 Use the interconception period to provide additional intensive intervention to women who have had a previous pregnancy that ended in an adverse outcome (low birth weight, preterm birth, infant death, fetal loss, birth defects)

6. Pre Pregnancy Check Up

 Offer as a component of maternity care for couples or women (or men who used to be women) that are planning a pregnancy.

   Risk assessment Health promotion Specific interventions depending on circumstances.

7. Health Insurance for ♀ w↓$

 Improve access to preventive women’s health, preconception and interconception care.

8. Public Health Programs

 Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception     Title X Family Planning Title V Maternal and Child Health Services WIC Healthy Start

9. Research

 Effectiveness of interventions  Increase the evidence base  Promote the use of evidence to improve preconception health

10. Monitoring Improvement

 Maximize public health surveillance and related research mechanisms to monitor preconception health.

 Maintain data collection

Summing up: Implementation

 Increase reproductive awareness  Reproductive life plan  Increase the number of planned and intended pregnancies  Health care coverage for all of childbearing age  Screening for women before pregnancy  Access to interconception care

Thank you for your attention!

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