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PRECONCEPTION COUNSELING A “BEST” BUT UNCOMMON PRACTICE INTENDEDNESS 2002 DATA: 30.8% ALL WOMEN AGE 15-44 HAVE EXPERIENCED AN UNINTENDED BIRTH ESTIMATE THAT 49.2% ALL PREGNANCIES UNININTENDE (nsfg) ORGANOGENSIS DAYS 17-56 POST CONCEPTION FIRST DAY OF “MISSED” PERIOD IS DAY 14 POST-CONCEPTION DAY 56 IS ABOUT 6 WEEKS ALL ORGANS FORMED BY WEEK 9 Prevention, in order to be truly preventive, must be antenatal J. W. Ballantyne in 1902 Maternal Mortality per 100,000 live births 800 700 600 500 400 300 200 100 0 1900 1960 1980 2000 Rate Increase from 1980-2000 30% 25% 20% 15% 10% 5% 0% Preterm Very Preterm LBW VLBW Infant Deaths per 1000 Live Births 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 1960 1980 2000 1960: Maternal complications of pregnancy not on top 10 list of leading causes of infant mortality 1980: Number 5 2001: Number 3 2002: 46% of infant mortality related to congenital anomalies, LBW, Preterm Delivery and Maternal complications 2004 Behavioral Risk Factor Surveillance System Phone survey of Americans > 18 years of age Median response rate >52% Content varies by state Defined as preconceptional if: Wanted a baby in next 12 months, not using contraception, not sterile and not already pregnant A on su m D o N o pl an da y ei gh t 5/ a he al th no te at O ve rw Pregnant O be si ty pt C io ur n re nt S m ok N in ot g on fo lic ac H IV id e R is k B eh av io r lc oh ol C BRFSS 2004 Preconceptional 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Amongst reproductive aged women 6.1% asthma 11.4% smoke 5% obese 54.9% consume alcohol 3.4% cardiac dz 80% dental caries &other oral diseases PRENATAL CARE IS TOO 3% hypertension 9.3% diabetes 1.4% thyroid disease Maternal-Child Health J 2006 10:s3-s11 LATE Spartan Preconception Recommendations a la Plutarch “ordered the maidens to exercise themselves with wrestling, running, throwing the quoit and casting the dart, to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth” Preventing Low Birthweight Institute of Medicine 1985 “…one of the best protections available against low birth weight and other poor pregnancy outcomes is to have a woman actively plan for pregnancy, enter pregnancy in good health with as few risk factors as possible, and be fully informed about her reproductive and general health” IOM-1985 Family planning services essential to preconception initiatives Reproductive health/family planning must introduce concept of prepregnancy wellness Developed concept of preconception consultation Expert Panel on the Content of Prenatal Care: 1989 “Rosen Report” Preconception visit may be the single most important health care visit with respect to impact on pregnancy outcome Preconception counseling most likely to be effective when provided in context of general preventive care OR primary care visits Concept of “Opportunistic Care” ROSEN REPORT Risk Assessment Health Promotion Intervention Follow up Healthy People 2000 Increase to at least 60% the proportion of primary care providers who provide age-appropriate preconception care and counseling Deleted in 2010 Healthy People as not measurable Toward Improving Outcome of Pregnancy: The 90’s and Beyond MOD 1993 Concept of “reproductive awareness” Called for a new strategy to reach each woman of child-bearing age with reproductive awareness messages at every health encounter ACOG 1995: First technical bulletin on Preconception Care Thorough & Systematic ID of risks Provision of education individualized to patient needs Initiation of desired interventions 2002: Guidelines for Perinatal Care AAP/ACOG Emphasized integration of preconceptional health into ALL health encounters in reproductive age women Average woman of childbearing has 6.4 visits to MD’s per year Healthy People 2010 No global comment “Increase the proportion of pregnancies begun with an optimum folate level” (target 80%) HALLMARKS OF PRECONCEPTION CARE REYNOLDS PROVIDES WOMEN & FAMILIES INFORMATION AND OPPORTUNITIES TO MODIFY UNHEALTHY BEHAVIORS AND THUS POTENTIALLY IMPROVE THE QUALITY OF THEIR LIVES INCREASE REPRODUCTIVE CHOICES, POSSIBLY DECREASED UNINTENDED & UNWANTED PREGNANCIES HALLMARKS, cont’d IMPROVE PREGNANCY OUTCOME BY DECREASING INFANT MORTALITY & MORBIDITY REDUCES THE PROBABILITY OF DAMAGE DURING ORGANOGENESIS Which women most likely to get preconception care? Older Married or stable relationship Non Hispanic White Income >$20,000/year Non-smokers Private medical insurance Positive bond with pre-pregnancy health care provider NEGATIVE PREGNANCY TEST POPULATION OF ABOUT 100 WOMEN AT FAMILY PLANNING CLINIC WITH NEG. PREGNANCY TEST ALL HAD ASSESSMENTS DONE USING PRECONCEPTION RISK SURVEY INSTRUMENT ½ HAD RESULTS REPORTED TO DOC NEGATIVE PREGNANCY TEST AVERAGE WOMAN HAD 9 IDENTIFIED ISSUES 21% PSYCHIATRIC/BEHAVIORAL 12% FETAL EXPOSURE 7 – 10%: FAMILY PLANNING, NUTRITION, GENETIC, MEDICAL, BARRIERS TO CARE, DV, SEXUAL VIOLENCE 2-6%:REPRODUCTIVE HISTORY, STD’S Best Evidence Focus on a single intervention Not in the context of improving pregnancy outcomes PROMOTION OF LIFELONG WELLNESS PROMOTION OF HEALTHY AND DESIRED PREGNANCIES PROMOTION OF HEALTHY FUTURE INFANTS PREGNANCY FAMILY PLANNING/ PRECONCEPTIONAL CHILDBIRTH MENARCHE FAMILY PLANNING INTERCONCEPTIONAL MENOPAUSE PREVENTING PREMATURITY SPACING OF PREGNANCIES LOWEST RATE VERY/MODERATELY PREMATURE INFANTS 18 to 59 MONTHS BETWEEN PREGNANCIES DISCONTINUE SMOKING PRECONCEPTIONALLY What We Know: Tobacco Use Tobacco And Women’s Health: Implicated the leading causes of death for women: Heart disease (1) Stroke (2) Lung cancer (3) Lung disease (4) Tobacco and Reproductive Outcomes: Leading preventable cause of infant mortality Preventable cause of low birth weight and prematurity Associated with placental abnormalities SMOKING ECTOPIC PREGNANCY PLACENTA PREVIA UNDER-DEVELOPMENT OF PLACENTA MAY INCREASE RISK OF PREMATURITY AND BABIES TOO SMALL 15% and 29% of pregnant women smoke during pregnancy If smoking during pregnancy eliminated, estimated: 10% reduction in perinatal mortality 11% reduction in the incidence of low birth weight SMOKING:Evidence based counseling Ask every patient about tobacco use Advise them to quit Assess willingness to quit Assist them in quitting Pharmocotherapies and additional counseling each DOUBLE quit rate Arrange follow up 305.10 ICD-10 Code for tobacco dependence Effectiveness of smoking cessation programs 25-30% quit rates in general population Many women spontaneously quit when pregnancy 11-28% publically insured 40-65% privately insured ACOG COMMITTEE OPINION October 2006 # 316 Smoking is one of the most important modifiable causes of poor pregnancy outcomes in the United States. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment has been proved to increase quit rates. For pregnant women who are light to moderate smokers, a short counseling session with pregnancy-specific educational materials often is an effective intervention for smoking cessation. The 5 A's is an office-based intervention developed for use by trained practitioners. Techniques for smoking reduction, pharmacotherapy, and health care support systems can help smokers quit. What We Know: Alcohol Use Alcohol and Women’s Health Risk for MV and other accidents Risk for unintended pregnancy Risk for addiction Risk for nutritional depletions and inadequacies Alcohol and Reproductive Outcomes Delayed fertility Increased SABs FAS and FAE ALCOHOL 2002: 8% of American women 18-44 years of age were sexually active, fertile, not contracepting. Women age 18-24: 20% binge drink FAS 0.3-2 per 1000 live births Project CHOICES CDC sponsored trial Population at high risk of alcoholexposed pregnancy (12% binge) Focused on reducing risk drinking AND postponing pregnancy 4 brief motivational visits and Family Planning provider visit 68% at reduced risk at 6 months What We Know: Obesity Obesity and Women’s Obesity and Pregnancy: Health: Glucose intolerance of Diabetes pregnancy Hypertension Pregnancy induced hypertension Cardiovascular disease Thrombophlebitis Disabilities Neural tube defects Prematurity Higher rates of difficult births OBESITY Increased rates of: infertility, gestational diabetes, pre-existing diabetes, hypertension, preeclampsia, stillbirth, birth defects, LGA, cesarean sections, long dysfunctional labors, CPD, post partum anemia Fat is not inert What can we do about it? Weight loss programs Tsai and Wadden:, 2005 Weight Watcher least costly, maintenance of 3.2% of initial weight at 2 years Very Low Calorie Commercial Diet: Greatest initial weight loss; high costs; high attrition Internet based and organized self-help: minimal weight loss Low income obese women receiving 5 email messages in pregnancy around maintaining normal weight gain less likely to gain excessive weight Interconception period important if woman retained a lot of pregnancy weight What we know: FOLATE Peri conceptional supplementation with 400 micrograms of folate (folic acid) from 3 months preconceptionally to 8 weeks postconceptionally Decreases rate of spina bifida by 50-70% Decreases rate of cleft lip Decreases rate of heart disease Generally good health habit for adult cardiovascular health Probably decreases placental problems EPILEPSY MEDICATIONS ASSOCIATION WITH SOME MEDICATIONS WITH SOME BIRTH DEFECTS SOME WOMEN ON ANTI-SEIZURE MEDICATIONS FOR YEARS AFTER A SEIZURE AND MIGHT BE ABLE TO DISCONTINUE LOWEST POSSIBLE EFFECTIVE DOSE SINGLE DRUG VERSUS MULTIPLE DRUGS DIABETES GENERAL POPULATION 2-3% RISK OF SEVERE BIRTH DEFECTS DIABETICS PRIOR TO PREGNANCY POORLY CONTROLLED [Hgb A1c>7] RISK INCREASES TO 6-9% HEART DISEASE, SPINA BIFIDA, OTHER WELL CONTROLLED PRECONCEPTIONALLY BACK TO BASELINE RATE IN THE GENERAL POPULATION! INFECTIONS HEPATITIS B 90% CHRONIC CARRIERS ARE WITHOUT SYMPTOMS PREGNANCY DOESN’T ALTER COURSE OF DISEASE IDENTIFY NEONATES FOR FULL VACCINATION AND PROPHYLAXIS HIGH RISK WOMEN WHO ARE HEP. NEG CAN BE VACCINATED HIV HELPS INFECTED WOMEN MAKE INFORMED REPRODUCTIVE DECISIONS BEGIN MATERNAL CARE PROGRAM HIGH RISK WOMEN CAN BE COUNSELED RE: RISK REDUCTION TOXOPLASMOSIS 85% US WOMEN NON-IMMUNE (NHANES) 400-4000 CASES OF CONGENITAL TOXO/YR IN US PRENATAL TESTING VERY DIFFICULT TREATMENT IF KNOWN PRENATAL SEROCONVERSION PRECONCEPTION TESTING CAN ALTER BEHAVIOR AVOID FECES IN LITTERBOX/GARDEN AVOID RAW OR UNDERCOOKED MEAT DISPOSE OF CAT LITTER DAILY AND DISINFECT BOX;USE GLOVES PEEL OR WASH FRUITS AND VEGETABLES CMV 0.6-1.5% ALL BIRTHS IN US ADULTS USUALLY ASYMPTOMATIC, MONO LIKE ILLNESS LATENT STATE AFTER INFECTION MOST COMMON SOURCE OF PRIMARY INFECTION: TODDLERS MOST EFFECTIVE PREVENTION: HAND WASHING (URINE, SALIVA) OTHER INFECTIONS STD’S APPROPRIATE TREATMENT DEAL WITH MONOGAMY ISSUES VARICELLA AND RUBELLA: IF NEGATIVE ANTIBODY, CAN IMMUNIZE WAIT THREE MONTHS PRIOR TO CONCEPTION WWW.IHEALTHRECORD.ORG CDC, other federal agencies, and medical societies have developed emailbased education programs that are offered through the Interactive Health Record (iHealthRecord Learn what you need to know now to have a safe pregnancy and healthy baby. CDC has a new online education program available for women who are planning to get pregnant. Health information via email every other week for 3 months as you prepare for pregnancy. You can sign up for CDC’s pregnancy-planning education program by 1. Logging onto WWW.IHEALTHRECORD.ORG 2. Signing up for a free iHealthRecord. 3. Going to the "Education Programs" page. 4. Checking the box next to “Pregnancy Planning: What To Know About Your Health Before You Get Pregnant”. AAP/ACOG:Components of PCC Physical assessment Risk Screening Reproductive awareness Environmental toxins/teratogens Nutrition/folate Genetics Substance use Medical conditions/medications Infections/vaccinations Psychosocial concerns Vaccinations Counseling Preconception Risk Factors with Developed Clinical Practice Guidelines Folic Acid Rubella seronegativity Diabetes Hypothyroidism HIV/AIDS PKU Oral Anticoagulant Anti-epileptic drugs Isotretinoins Smoking Alcohol misuse Obesity STD Hepatitis B MMWR: April 21, 2006 Recommendations to Improve Preconception Health and Health Care-US Summary Preconception care “Opportunistic” Rolled into routine health encounters for reproductive aged women Needs to be proactive Clinical practice guidelines are available MMWR April 12, 2006