Download Preconception Care for the Primary Care Provider

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
• May be the most important part of
prenatal care
– US Public Health Service, 1989
• Only 20-50% of primary care provider
routinely provide preconception care
– 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
• 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
• 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
– 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
• Reframes issues
• Adds an anticipatory element
• Focuses on the impact of pregnancy
Elements of
Preconception Care
• Focus on elements which must be
accomplished prior to conception or
within weeks thereafter to be effective
– Risk assessment
– Health promotion
– 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
Prevalence of Risk Factors
Pregnant
or
gave birth
Smoked during pregnancy
11.0%
Consumed alcohol in pregnancy (55% at risk of pregnancy)
10.1%
Had preexisting medical conditions
4.1%
Rubella seronegative
7.1%
HIV/AIDS
0.2%
Received inadequate prenatal Care
At risk of
getting
pregnant
15.9%
Cardiac Disease
3%
Hypertension
3%
Asthma
6%
Dental caries or oral disease (women 20-39)
Diabetic
>80%
9%
On teratogenic drugs
2.6%
Overweight or Obese
50%
Not taking Folic Acid
69.0%
Conditions Addressed by
Preconception Care
• 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)
• Conditions that might change the choice
or timing to conceive
• Conditions that would require early postconception prenatal care
Family Planning
• A short pregnancy interval may be
associated with:
– birth of an SGA infant in a subsequent
pregnancy
– Lieberman 1989, Zhu 1999
– preterm birth in a subsequent pregnancy
– 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
• Discussion of exposure to teratogens
Critical
Periods
of Development
Critical Periods
of Development
Weeks gestation
from LMP
Most susceptible
time for major
malformation
4
5
6
7
8
9
10
11
12
Central
Central Nervous
Nervous System
System
Heart
Heart
Arms
Arms
Eyes
Eyes
Legs
Legs
Teeth
Teeth
Palate
Palate
External
External genitalia
genitalia
Ear
Ear
Missed Period
Mean Entry into Prenatal Care
Substance Use and Preconception Care
• 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
• Leading preventable cause of mental
retardation
• Most common teratogen to which fetuses
are exposed
• Effects related to dose
• No threshold has been identified for
“safe” use in pregnancy
• Effects at all stages of pregnancy
Tobacco
• Leading preventable cause of low birthweight
– 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
• Exposures
– Home, workplace, environment
• Physical/chemical hazards
– ionizing radiation, lead, mercury,
hyperthermia, herbicides, pesticides
Physical and Emotional Abuse in
Pregnancy
• Two million women each year are abused
by a partner
• No correlation with ethnicity, socioeconomic status, or education
• 29% of abused women report escalation
of abuse during pregnancy
Role of the Health Care Provider
• 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
• Underweight (BMI < 19.8 prepregnant)
– Increased risk for: low birthweight, fetal
death, mental retardation
• Overweight (BMI 26.1-29.0) and Obese
(BMI >29.0)
– Increased risk for: diabetes, hypertension,
thromboembolic disease, macrosomia, birth
trauma, abnormal labor, cesarean delivery
Nutritional Risks
Vitamins and Minerals
• Folic acid - modifies risk of neural tube
defects
• Iron - increased risk of preterm delivery,
LBW
• Oversupplementation of Vitamins A & D increase in congenital anomalies
• Pica - iron deficiency, lead poisoning
Prevention of Neural Tube Defects
• Supplementation for all women of
childbearing potential with folic acid
– No history of NTD: 0.4 mg. qd
– Prior infant with NTD: 4.0 mg. qd
– Woman with NTD: 4.0 mg. qd
• Nutritional sources often inadequate
Immunizations
• 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
• 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
• Alcohol
– may be associated with physical and emotional
abuse
– may decrease fertility
• Genetic Counseling
• Occupational exposure
– lead
• Sexually transmitted diseases
– syphilis, herpes, HIV
Preparedness for Parenthood
• Pyschological
• Financial
• Life plans
– education
– 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
• 49% of pregnancies in the US are
unintended (unwanted or mistimed)
– Henshaw, 1998
• Preconception care should be provided to
all reproductive age individuals
Barriers to Preconception Care
• Unintended pregnancy
• “Planned” pregnancies are seldom
planned with a health care provider
• Unpreparedness of health care providers
When should preconception care
be offered?
• 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
• Encourage all women to have a
“Reproductive Life Plan”
• Chart stamp:
– LMP, BP, Weight, Height, BMI
– “Plan to become pregnant in the next year?”
– Family Planning Method
– Tobacco use
Medical Record #:
Patient name:
Preconception Health Screening/Counseling
Date
Done
Family Planning
Pregnancy planning and spacing
Pregnancy prevention
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
Bernstein, Merkatz
J Repro Med, 2000
Birth defects
Hemoglobinopathies
Mental retardation
Cystic fibrosis
Tay-Sachs disease
Consanguinous marriage
Pending Action
Comments/Provider’s Initials
Since so few pregnancies are
planned, preconception care
issues must be addressed at all
encounters with reproductiveaged individuals
Thank You