Presentation on theme: "Preconception and Interconception Care by Obstetrician-Gynecologists."— Presentation transcript:
Preconception and Interconception Care by Obstetrician-Gynecologists
Duration of pregnancy is no longer “nine” months, it’s “twelve” months Both ACOG and AAP suggest that prenatal care begin before conception
Goals of Preconception Care Optimize the woman’s health Minimize risks to her and the fetus and improve pregnancy outcome Provide information necessary to make informed decisions about future reproduction
Elements of Preconception Care Risk assessment Education and health promotion Medical and psychosocial interventions
Recommended Components of Preconception Care Reproductive awareness Family planning Medical conditions Infectious diseases Immunizations Teratogens and environmental toxicants Genetic issues Nutritional issues Domestic violence Substance abuse, alcohol & tobacco use Psychosocial issues Financial issues
Why Should Ob/Gyns be Concerned with Preconception Care? Prenatal care begins before conception OB/GYN’s have the most frequent contact with women of childbearing are We are aware of prior poor pregnancy outcomes It is to our advantage to improve pregnancy outcomes We already have the knowledge and are applying it
How Preconception Care can be Integrated into Ob/Gyn Practice Annual gynecological visit Episodic visit for any common complaints Routine postpartum visit Negative pregnancy test - an opportunity for preconception care Family planning encounter Infertility evaluation Following a poor pregnancy outcome
Barriers to Preconception Care Physician Aspect Feeling of having inadequate knowledge Perception of preconception care being time-consuming Concern about insurance reimbursement. Lack of awareness of how to integrate preconception care into ongoing primary care
Barriers to Preconception Care Patient Aspect High rate of unintended pregnancies Ignorance about importance of good health habits prior to conception Limited access to health services in general
Case Study 33 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.
Routine Health Maintenance for Women 1. Screening for her health status and physical activity 2. Dietary/nutritional assessment 3. Screening for tobacco, alcohol and other drugs 4. Screening for abuse and neglect 5. Thorough physical exam, including STD screening 6. Age and risk appropriate laboratory testing
Routine Well Woman Counseling Contraceptive options Importance of planned pregnancies and birth spacing STD prevention Dietary and nutritional advice Exercise and physical activity Breast self-examination Advice on injury prevention Specific counseling if - domestic violence/ substance abuse/depression identified through history
Recommended Components of Preconception Care Every encounter with the health care system viewed as an opportunity to reinforce reproductive awareness in women of childbearing age Women should be assessed for underlying medical conditions and possible effects of pregnancy discussed
Specific Preconception Care Issues Advice about daily multivitamins containing at least 0.4 mg of folic acid Case emphasizes that good routine primary care encompasses most components of preconception care and points out how easily it can be integrated into Ob/Gyn care
Preconception Care For Women With Medical Diseases Advances in medical therapeutics have made more pregnancies possible in women with pre-existing medical conditions In some conditions, medical care and interventions prior to conception can have a tremendous impact on pregnancy outcomes
Preconception 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
Preconception Care For Women With Medical Diseases Preconception care must be a multidisciplinary team approach Preconception counseling: - allows decision to attempt/avoid a pregnancy - influences on timing of conception - optimizes woman’s condition before conception
Some Medical Conditions Amenable to Preconception Care Diabetes Mellitus Hypertensive Disorders Cardiac Disease Thyroid Disorders Epilepsy Asthma HIV Infection Systemic Lupus Thromboembolic Disease Renal Disease Hemoglobinopathies Cancers
Case Study: Diabetes 38 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.
Background of Preconception Care and Diabetes Carbohydrate intolerance affects approximately 1.5 million women of reproductive age in the US Diabetes mellitus is the most common serious disease to affect the maternal-fetal dyad Maternal and perinatal mortality associated with diabetes has decreased
Background 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 mothers Malformations associated with diabetes mellitus are the leading cause of perinatal death in this population Reduction in rate of malformations has been possible by achieving strict glucose control in the preconception period and maintaining control throughout organogenesis and pregnancy
Goals of Preconception Care in Diabetes To reduce the occurrence of obstetric and diabetic complications To decrease the incidence of congenital abnormalities Reduce risk of spontaneous abortions
How to Accomplish These Goals? Education about need to change diabetes medication regimen ie substitute insulin for oral hypoglycemics Optimal glycemic control achieved by home monitoring, multiple daily injections, adjustment of insulin, close supervision and education Postpone conception until control is achieved Reassess modifiable risks before conception by assessing end organ damage, retina, kidney, vasculature, heart, nervous system
How to Accomplish These Goals Attention to lipids, hypertension, screening for urinary tract infections, and its prevention Preparation for demanding prenatal care, testing, frequent visits, etc Stop the ACE inhibitor
Case 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.
Background of Preconception Care and Seizure Disorders Epilepsy is the most common, serious neurologic problem seen in pregnancy All anticonvulsants are potentially teratogenic Increased 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 regimens
Goals of Preconception Care In Women with Seizure Disorders To keep the woman seizure-free To decrease the incidence of congenital abnormalities in her offspring Balance maternal seizure control with minimal fetal effects
Goals Achieved By: Thorough evaluation of patients’ past and present history, her treatment regimen and its effectiveness Collaborate with the neurologist for a pre- pregnancy workup including EEG, CT Scan, etc Discussion of effects of epilepsy on pregnancy and offspring Consider weaning the patient from anticonvulsants if appropriate candidate, in consultation with her neurologist, prior to pregnancy
Goals Achieved By: Consider monotherapy as far as possible Educate about risks of abrupt discontinuation Discuss risks associated with the medications used Folic acid supplementation Effective contraception until seizure-free
Case 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. -
Recurrent 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.
Goals of Preconceptional Counseling in Prior Pregnancy Loss To investigate the factors that may have contributed to the previous outcome To assuage guilt and resolve grief To provide recommendations that may prevent the recurrence of such a loss To inform patients realistically regarding their likelihood of successful childbearing
Techniques For Providing Preconception Care Self-administered Reproductive Health Screen Waiting room posters and magazines Pamphlets from the March of Dimes, ACOG, AAP, etc. Community and School Interventions Referral to Maternal-Fetal Medicine specialists.
Men Have Babies Too! Male issues in preconceptional health not to be forgotten Encourage cooperation and support between prospective father and mother Identify male exposures that could adversely affect reproduction eg. occupational exposures, alcohol, tobacco, drug exposure, HIV and STD Identify male genetic issues