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Download Laura Tatpati, MD KUMC - Wichita Dept of Obstetrics and Gynecology
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Preconception care Laura Tatpati, MD KUMC - Wichita Dept of Obstetrics and Gynecology No disclosures Objectives Understand the general importance of preconception care Discuss the concept of a Reproductive Life Plan Be able to define areas of concern for preconception care Health promotion Nutrition Exposures Substance abuse Environmental Medical/Psychiatric conditions & medication Reproductive History Family & Genetic History Vaccination counseling ID Psychosocial risk Special populations 1/2 of all pregnancies are unintended The challenge of preconception care lies not only in addressing pregnancy planning for women who seek medical care and consultation specifically in anticipation of a planned pregnancy but also in educating and screening all reproductively capable women on an ongoing basis to identify potential maternal and fetal risks and hazards to pregnancy before and between pregnancies ACOG Committee Opinion Number 313, September 2005, reaffirmed 2012 Timing is everything Vulnerability Begins from 17-56d post-conception Goals Screen for risks Recommend intervention Promote health & provide education (the non-judgemental) Reproductive Life Plan Do you plan to have any (more) children at any time in your future? How many children would you like to have? How long would you like to wait? <6 mo btwn birth and conception assoc w/ LBW, PT & SGA; > 60mo incr PT & Very SGA What family planning method do you plan to use until you are ready? Unintended: Method failure (5%); imperfect use (43%); no contraception Preconception care topics Health promotion Weight Status Physical Activity Nutrient Intake Folate Substance Use STIs Exposures Weight status & Physical Activity Weight Status Near-normal BMI is ideal Address disordered eating and variants Malnutrition with obesity and anorexia Counsel obesity risks: difficulty with conception, birth defects, GDM, C/S, Htn disorders, thromboembolic event, preterm delivery Physical Activity Advise for uncomplicated 30min daily exercise most days of week Review for healthy behaviors Insulin resistance - increasing evidence for enhanced benefit peri-prandially Health promotion Nutrition Eating disorders are more likely if: Hx of eating disorder, body distortion endorsement, unusual eating habits Substance abuse hx Hx pica in prior pregnancy High parity Mental illness Bariatric surgery hx - vitamin absorption and B12 production issues Health promotion Vitamins & Supplements Folic acid 400mcg daily routine & 4mg daily for high risk groups Initiate 1 mo prior to conception NTD risk reduction; Cong heart disease and cleft lip/palate Vitamin over-usage What is the single day dose for their brand? No “mega-dose” vitamins (particularly KADE) Dietary Supplements - avoidance Suggest consideration of intake of calcium, iron, Vit D, Vit A, Vit B12 and note that Vit C enhances the absorption of iron Health promotion Substance Use/Abuse Tobacco 5-A tool Ask about use, Advise to quit, Assess willingness, Assist, Arrange f/u & support 1-877-44U-QUIT Pharmacotherapy/Refer back to PCP Alcohol Address use/misuse & unintended usage during pregnancy Recreational and Prescription Drug Use/Abuse Health promotion Exposures Environmental/Hobbies Paucity of screening tools and interventions that are rigorously evaluted Discuss food safety & toxin exposure avoidance Medications Lowest effective dose of only necessary medications Address known teratogens and lack of safety data Health promotion Personal & Family Medical History Reproductive Prior Cesarean Delivery Prior Miscarriage Prior Preterm Birth Known Genetic Conditions (self, child or close family member) Pre-pregnancy screening coverage??? Consideration of PGD for FH single gene defects Prior Stillbirth FH MR/Autism/FXTAS Uterine Anomalies Ethnic based Hemoglobinopathies Ashkenazi Jewish panel Cystic fibrosis Personal & Family Medical History Infectious Diseases STI including HIV Chlamydia - annually prior to 25 and p.r.n. in at-risk > 25 Hepatitis A Hepatitis B (if high risk) Rubella (confirm immunity or document MMR) Varicella (history of illness or vaccination) Hep C Cytomegalovirus Herpes Simplex Virus Listeriosis Malaria Syphilis Toxoplasmosis Tuberculosis Personal & Family Medical History Immunizations Avoid conception x 1 mo post-live virus vaccination Ideal to complete others prior as well to avoid exposures, although no documented issues Flu: Inactivated flu vaccine (no mist) Tdap: Offer vaccination (this will be repeated in pregnancy) Rubella - screen for IgG (some do not convert) Varicella - Historical screen At risk populations - Hepatitis screen/vaccinate; Meningococcus, Pneumococcus HPV - if not completed, recommend; hold completion until after pregnancy prn Personal & Family Medical History Medical conditions Conditions and fetal and maternal risks of pregnancy Medications and risks of teratogenicity or pregnancy associated complications Action plan for pregnancy for exacerbation or monitoring Consideration of MFM &/or IM specialist pre-pregnancy consultation Hx of Bariatric Surgery Cardiovascular Disease Diabetes Mellitus Eating Disorders Hypertension Lupus Morbid Obesity PKU - low phenylalanine diet Psychiatric Conditions Renal Disease Rheumatoid Arthritis Seizure Disorders Thrombophilia Thyroid Disease Asthma Personal & Family Medical History Psychosocial Risks Access to Care Inadequate Financial Resources (transportation/housing) Safety (domestic violence assessment) Special populations Disability Immigrant and Refugee Populations Survivors of Cancer Resources http://www.acog.org/Resources-AndPublications/Guidelines-for-Perinatal-Care cdc.gov - preconception care
