Presentation on theme: "Preconception and Interconception Care by Obstetrician-Gynecologists"— Presentation transcript:
1Preconception and Interconception Care by Obstetrician-Gynecologists
2Duration of pregnancy is no longer “nine” months, it’s “twelve” months Both ACOG and AAP suggest that prenatal care begin before conceptionPreconception care has been called the most important element of prenatal care. (U.S. PHS Task Force on the Content of Prenatal Care, 1989)Health during pregnancy depends on a woman’s general health, nutrition and other factors before conception, as well as the amount and quality of prenatal care. For example, women with collagen vascular diseases, such as SLE, general have improved outcomes of pregnancy if the pregnancy is conceived during a quiescent period of the disease.The traditional access point for information relative to the prevention of poor reproductive outcomes is the first prenatal visit. In many cases, this is too late. Many compromised pregnancy outcomes are determined before women have had an opportunity to initiate prenatal care.
3Goals of Preconception Care Optimize the woman’s healthMinimize risks to her and the fetus and improve pregnancy outcomeProvide information necessary to make informed decisions about future reproduction
4Elements of Preconception Care Risk assessmentEducation and health promotionMedical and psychosocial interventionsPreconception care does not follow the usual and customary medical disease model.It is an example of primary prevention service that OB/GYN’s can offer to their patients using a thorough and systematic approach.Systematic identification of preconception risks through assessment of medical, reproductive and family histories, nutritional status, drug exposures and social concerns of all women in the childbearing age.Once risks identified provisions of education based on these risks.Interventions -- if appropriate and desired.
5Recommended Components of Preconception Care Reproductive awarenessFamily planningMedical conditionsInfectious diseasesImmunizationsTeratogens and environmental toxicantsGenetic issuesNutritional issuesDomestic violenceSubstance abuse, alcohol & tobacco usePsychosocial issuesFinancial issuesSince less than half of pregnancies in the U.S. are planned, this suggests a need for family planning spacing (Henshaw, 1998).Every encounter with the health care system should be viewed an an opportunity to reinforce reproductive awareness in women of childbearing age.Short intervals correlated with SGA and preterm birth (Hobcraft, 1984; Alam, 1995; & Rawlings 1995).MD’s should stay current with the explosion of new knowledge in the field of genetics and be able to appreciate that the list of genetic diseases that lend itself to prenatal diagnosis is growing rapidly, e.g., Fragile X, Tay Sachs, etc.Other components discussed in detail in the first hour of the curriculum.
6Why Should Ob/Gyns be Concerned with Preconception Care? Prenatal care begins before conceptionOB/GYN’s have the most frequent contact with women of childbearing areWe are aware of prior poor pregnancy outcomesIt is to our advantage to improve pregnancy outcomesWe already have the knowledge and are applying itPreconception risk reduction activities have been practiced for many years, in one form or the other (e.g., .general counseling, testing for rubella and syphilis, family planning, genetic screening and counseling etc.) It’s only in the last 2 decades that the concept has emerged of an organized comprehensive program.
7How Preconception Care can be Integrated into Ob/Gyn Practice Annual gynecological visitEpisodic visit for any common complaintsRoutine postpartum visitNegative pregnancy test - an opportunity for preconception careFamily planning encounterInfertility evaluationFollowing a poor pregnancy outcomeGiven that 49% of pregnancies in the U.S. are unintended (Henshaw, 1998), preconception care must be introduced into health care settings that:- are convenient for the women- can reach as many women as possibleAlthough preconception care should not be thought of as one more thing to do in the limited time we have for each patient visit, it is, in fact, a part of what most of us are already doing.
8Barriers to Preconception Care Physician AspectFeeling of having inadequate knowledgePerception of preconception care being time-consumingConcern about insurance reimbursement.Lack of awareness of how to integrate preconception care into ongoing primary careIn addition, the lack of existing CPT coding for preconception care.
9Barriers to Preconception Care Patient AspectHigh rate of unintended pregnanciesIgnorance about importance of good health habits prior to conceptionLimited access to health services in generalFor examples, good health habits include:Avoidance of tobacco & alcoholFolic acid supplementationGood nutrition
10Case Study33 year -old woman comes in for routine gynecologic visit. She has 3 children - 9, 5 and 1 year of age. She and her husband would like one more child, but she wants to finish her last year at school.The following cases demonstrate the integration of preconception care into good primary care.
11Routine Health Maintenance for Women 1. Screening for her health status and physical activity2. Dietary/nutritional assessment3. Screening for tobacco, alcohol and other drugs4. Screening for abuse and neglect5. Thorough physical exam, including STD screening6. Age and risk appropriate laboratory testingThese recommendations come from Guidelines for Women’s Health Care. ACOG, This reference provides a standard screening tool for routine health maintenance.
12Routine Well Woman Counseling Contraceptive optionsImportance of planned pregnancies and birth spacingSTD preventionDietary and nutritional adviceExercise and physical activityBreast self-examinationAdvice on injury preventionSpecific counseling if - domestic violence/ substance abuse/depression identified through historyRefer to ACOG’s Guideline s for Women’s Health Care, 1996.
13Immunizations Tetanus-diphtheria booster (every 10 years) High-risk groups:MMR vaccineHepatitis B vaccineInfluenza vaccinePneumococcal vaccineThis patient does not fall in the high risk group.
14Recommended Components of Preconception Care Every encounter with the health care system viewed as an opportunity to reinforce reproductive awareness in women of childbearing ageWomen should be assessed for underlying medical conditions and possible effects of pregnancy discussedGiven that less than half of pregnancies in the U.S. are planned, suggests the need for family planning.
15Specific Preconception Care Issues Advice about daily multivitamins containing at least 0.4 mg of folic acidCase emphasizes that good routine primary care encompasses most components of preconception care and points out how easily it can be integrated into Ob/Gyn careNeed for preconception visit when planning next pregnancy.HIV testing at that visit.
16Preconception Care For Women With Medical Diseases Advances in medical therapeutics have made more pregnancies possible in women with pre-existing medical conditionsIn some conditions, medical care and interventions prior to conception can have a tremendous impact on pregnancy outcomes- Examples of preexisting medical conditions:1) older pregnant women: hypertension, diabetes, heart disease, pulmonary embolism, stroke2) better treatment for underlying disease:cystic fibosis, renal transplants,heart valve replacements, prior cancer, HIV infection3) better prenatal treatment leading to improved outcome: lupus, diabetes,sickle cell anemia- Preconception care in women with diabetes particularly has been shown to reduce the incidence of birth defects. (Kitzmiller, 1991)
17Preconception Care For Women With Medical Diseases Points to consider- Effect of medical disease and its current or past therapeutic regimens on the intrauterine environment and fetal development- Effect of medical disease on the woman’s health and survival- Effect of pregnancy on the disease process- Examples of medical diseases & drug exposures with potential adverse effects:ACE inhibitors and fetal renal failurePoor control of diabetes and congenital anomaliesAccutane and multiple congenital anomalies- Examples of medical diseases with poor prognosisHIV infectionAdvanced cancer- Examples of adverse effects of pregnancy on maternal disease (high maternal mortality rates):Eisenmengers syndromeMarfan’s syndrome with aortic root involvementCoronary artery disease
18Preconception Care For Women With Medical Diseases Preconception care must be a multidisciplinary team approachPreconception counseling:- allows decision to attempt/avoid a pregnancy- influences on timing of conception- optimizes woman’s condition before conceptionInterdisciplinary team should include: obstetrician, maternal-fetal medicine specialist, obstetric anesthesiologist, sub-specialist in specific field of patients medical illness and obstetric nursing.Counseling to attempt pregnancy early in disease course prior to time related complications, e.g. diabetes, lupus, renal diseaseAvoid pregnancy in conditions with high maternal mortality, e.g. certain cardiac conditions.Conception during the quienence state in lupus yields the best maternal and perinatal outcomes. (Petri, 1991)
19Some Medical Conditions Amenable to Preconception Care Diabetes MellitusHypertensive DisordersCardiac DiseaseThyroid DisordersEpilepsyAsthmaHIV InfectionSystemic LupusThromboembolic DiseaseRenal DiseaseHemoglobinopathiesCancersAs the list of medical conditions is extensive, discussion limited to 2-3 conditions.
20Case Study: Diabetes38 year old school principal with Type 2 Diabetes Mellitus for 13 years. Married for 10 years; deferred childbearing, but now wants to conceive. She is on Glyburide for diabetes control and on ACE inhibitor for microalbuminuria noted 3 years ago.
21Background of Preconception Care and Diabetes Carbohydrate intolerance affects approximately 1.5 million women of reproductive age in the USDiabetes mellitus is the most common serious disease to affect the maternal-fetal dyadMaternal and perinatal mortality associated with diabetes has decreasedIn 1940’s the perinatal mortality rate was approximately 33%.Over last five decades, the perinatal mortality rate has dropped to 0-5%. (Garner, 1995)
22Background of Preconception Care and Diabetes The incidence of congenital malformation in infants of diabetic mothers remains 2 to 3 times that of infants of non diabetic mothersMalformations associated with diabetes mellitus are the leading cause of perinatal death in this populationReduction in rate of malformations has been possible by achieving strict glucose control in the preconception period and maintaining control throughout organogenesis and pregnancyMany of the data supporting the benefits of preconception care came from the experiences of women with IDDM.However, despite the reduction in perinatal mortality, congenital malformations remain a serious morbidity.
23Goals of Preconception Care in Diabetes To reduce the occurrence of obstetric and diabetic complicationsTo decrease the incidence of congenital abnormalitiesReduce risk of spontaneous abortionsThe possibility of a future pregnancy takes on a whole new meaning for the care of the diabetic woman.
24How to Accomplish These Goals? Education about need to change diabetes medication regimen ie substitute insulin for oral hypoglycemicsOptimal glycemic control achieved by home monitoring, multiple daily injections, adjustment of insulin, close supervision and educationPostpone conception until control is achievedReassess modifiable risks before conception by assessing end organ damage, retina, kidney, vasculature, heart, nervous systemThe cornerstone of management for pregestational diabetic patients is appropriate metabolic control and that is achieved by aggressive insulin therapy.Newer research of newer oral hypoglycemic agents (which are non-placenta crossing) are under investigation.
25How to Accomplish These Goals Attention to lipids, hypertension, screening for urinary tract infections, and its preventionPreparation for demanding prenatal care, testing, frequent visits, etcStop the ACE inhibitorACE Inhibitors -- associated with fetal renal dysfunction, oliguria, renal failure and even fetal death.
26Case Study: Seizure Disorder 22 year old woman misses her period. Pregnancy test in the office is “negative”. She expresses a desire to have a baby. On Dilantin since age 2. No seizures for past 5 years.
27Background of Preconception Care and Seizure Disorders Epilepsy is the most common, serious neurologic problem seen in pregnancyAll anticonvulsants are potentially teratogenicIncreased incidence of congenital malformations in offsprings of mothers with a seizure disorder (independent of anticonvulsant use)Prepregnancy period could be an optimal time to review the diagnosis and classification of the patient’s seizure disorder and also the need and effectiveness of current therapeutic regimensReference for malformations in offspring of women with seizure disorders: Kelly, 1984.
28Goals of Preconception Care In Women with Seizure Disorders To keep the woman seizure-freeTo decrease the incidence of congenital abnormalities in her offspringBalance maternal seizure control with minimal fetal effects
29Goals Achieved By:Thorough evaluation of patients’ past and present history, her treatment regimen and its effectivenessCollaborate with the neurologist for a pre-pregnancy workup including EEG, CT Scan, etcDiscussion of effects of epilepsy on pregnancy and offspringConsider weaning the patient from anticonvulsants if appropriate candidate, in consultation with her neurologist, prior to pregnancy
30Goals Achieved By: Consider monotherapy as far as possible Educate about risks of abrupt discontinuationDiscuss risks associated with the medications usedFolic acid supplementationEffective contraception until seizure-freeRisk of congenital malformation is greater for infants whose mothers have epilepsy, irrespective of fetal exposure to anticonvulsant therapy, cardiac malformation -- two-fold increase in cleft lip; 8-fold increase in cleft palate. Skeletal, CNS, GI and urogenital abnormalities also increased.All anticonvulsants associated with congenital anomalies.Examples: Valproic Acid - 1-2% chance of NTD as well as other craniofacial abnormalities. Phenytoin -- fetal hydantoin syndrome, craniofacial anomalies, hypoplastic nails, microencephaly, etc. Carbamazepine -- minor craniofacial anomalies, fingernail hypoplasia, developmental delays.Folic acd supplementation is recommended because there is some evidence that such supplementation may reduce the incidence or the severity of congenital malformation. Recommended dose ( mg/day).
31Case Study: Medication Management 22 year old woman seen in the office for symptoms of urinary tract infection. In the course of history taking she says she is quite happy about the results of new medication (Accutane) her dermatologist prescribed for her acne. She is sexually active and uses condoms inconsistently.-Isotretinoin (Accutane) is a proven potent human teratogen. (Category X) causes craniofacial defects, CVS and CNS malformations, and defects of the thymus.Pregnancy must be excluded and prevented before Isotretinoin is prescribed.Preconception counseling includes:- information about risk of teratogenicity- need for reliable contraception
32Recurrent Pregnancy Loss 31 year old woman and her husband come to your office wanting to know if they can ever have a live baby. She has been pregnant four times so far and all pregnancies resulted in miscarriages between 8 to 14 weeks. She is in good health and does not smoking, use alcohol or drugs.One of the primary reasons that couples seek preconceptional counseling is a previous poor reproductive outcome.Other reasons - prior fetal death, congenital anomalies, IUGR infants, NICU admissions, etc.
33Goals of Preconceptional Counseling in Prior Pregnancy Loss To investigate the factors that may have contributed to the previous outcomeTo assuage guilt and resolve griefTo provide recommendations that may prevent the recurrence of such a lossTo inform patients realistically regarding their likelihood of successful childbearingFactors such as uterine malformations, maternal autoimmune diseases, endocrine abnormalities and genital infections lend themselves to diagnoses and possible therapies.Thrombophilia work-upChromosome analysis for recurrent spontaneous abortions.
34Techniques For Providing Preconception Care Self-administered Reproductive Health ScreenWaiting room posters and magazinesPamphlets from the March of Dimes, ACOG, AAP, etc.Community and School InterventionsReferral to Maternal-Fetal Medicine specialists.
35Men Have Babies Too!Male issues in preconceptional health not to be forgottenEncourage cooperation and support between prospective father and motherIdentify male exposures that could adversely affect reproduction eg. occupational exposures, alcohol, tobacco, drug exposure, HIV and STDIdentify male genetic issues
36Think Preconception Care At the next visit, the woman could be potentially pregnant. Hence, all women of childbearing age are appropriate candidates for preconception care.