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PRE-CONCEPTION CARE AND COUNSELING
INTRODUCTION
 Concept of preconception care has evolved over the last several decades
 J.W. Ballantyne - originated concept of prenatal care
 Preconception and prenatal care are forms of primary care and prevention
 Opportunities exist in many settings
 Should target all women of reproductive age
 Education and preparation are key
 Worldwide maternal mortality approaches one million women annually
 Risk of maternal death in the is 1 in 10,000 live births
 Unintended pregnancy rate approaches 40% annually
COMPONENTS OF PRECONCEPTION CARE
 Risk assessment
 Education
 Intervention or modification
 Counseling
GOALS OF PRECONCEPTION CARE
 To identify pre-existing conditions that may affect an anticipated pregnancy
 This may allow for intervention(s) that could lead to more favorable outcome
 Goal should be realistic
 Identification process involves mother and fetus
CONTRACEPTION
 Good preconception care begins with appropriate contraception!!
 Should be addressed at each visit, including primary care visits, emergency room
visits, and well woman appointments
 Should be appropriate as regards patient’s lifestyle and medical condition
MATERNAL RISK ASSESSMENT
 Family and genetic history (maternal and paternal)
 Medical history
 Medication use
 Environmental exposures (home and work)
 Obstetric and reproductive history
 Domestic abuse
 Emotional preparedness
 Infectious disease
 HIV
 Immunization history
 Sexually transmitted diseases
REPRODUCTIVE HISTORY
 Conditions with recurrence risk:
 Premature delivery
 Preeclampsia/eclampsia
 Placenta previa/abruption
 Gestational diabetes
 Preterm premature rupture of membranes
 Certain birth defects/genetic disorders
 Prior uterine surgery or anomalies
 Good time to discuss trial of labor
 Prior pregnancy losses
 Habitual abortion
 Must also deal with associated emotional issues
FAMILY HISTORY
 Coagulation disorders
 Mental retardation
 Other conditions (congenital adrenal hyperplasia, neurofibromatosis, inborn errors of
metabolism)
 Anueploidy Risk
 Risk of any type of aneuploidy increases with maternal age
 Offer genetics consultation
 Important to obtain family pedigree
 Risk increases with increasing maternal age
 Risk of Trisomy 21 at age 35 is 1/378 and that of all aneuploidy is 1/192
 Risk increases to 1/30 and 1/21 respectively, at age 45
 Risk with increased paternal age probably small
RISK ASSESSMENT - MEDICAL HISTORY
 Possible effects of pregnancy on disease
 Possible effects of disease on pregnancy, mother and fetus
 Evaluate for any possible interventions
 Assess for possibility of teratogenic effects of medications
 Evaluate for presence of microvascular disease and level of glucose control
 Frequency of malformations 6-10 %
 Periconceptual control can significantly decrease malformation rate
 Hemoglobin A1C crude marker of glucose control/ ? Association with anomaly rate
 Hypertension - assess for microvascular disease, severity, underlying etiology
 Hyperthyroidism
 Hypothyroidism
 Previous treatment for cancer
 History of organ transplantation
RISK ASSESSMENT - MEDICAL HISTORY
 Connective tissue disorder
 Inflammatory bowel disease
 Asthma
 Neurological and psychiatric disorders
SPECIAL RISKS
 Primary Pulmonary Hypertension
 Chronic Renal Disease
 Complicated coarctation of the aorta
 Sever mitral or aortic stenosis
 Vasculitis syndromes
RISK ASSESSMENT - IMMUNIZATIONS
 Rubella - should wait 3 months before conceiving
 Hepatitis B
 Tetanus
 Mantoux skin test
 Influenza, pneumovax as indicated
 Varicella
RISK ASSESSMENT - STD’S
 Assess for high risk behaviors and counsel appropriately
 HIV - treatment can decrease transmission to fetus from 30% to 8%
 Gonorrhea
 Chlamydia
 Trichomonas
 Bacterial Vaginosis - presence associated with increased risk of premature labor and
delivery
 Group B beta streptococcus - ?
 HPV - human papillomavirus/PAP/possible colposcopy in select cases/neonatal
infection possible
 HSV - as indicated
 congenital syphilis can occur at any stage of maternal disease
 Toxoplasmosis - cat owners or if handle raw meat
 Cytomegalovirus
SOCIAL HISTORY
 Illicit substance use and abuse major public health problem
 Alcohol
 Most common preventable cause of mental retardation
 No proven safe level of ingestion
 Tobacco use
 Associated with numerous pregnancy complications
 One of most common preventable cause of fetal growth restriction
 Increased risk of other health problems
 Illicit drug use
 Usually associated with other high risk behaviors
 Possible teratogen
 Increased pregnancy complications
 Associated with sudden death, infarction, hypertension
 Prescription drug dependency
 Evaluate for life stressors that may predispose to substance abuse
 Encourage counseling and rehabilitation prior to pregnancy
 May have co-existing psychological disorders
 Seen in all social classes
DOMESTIC VIOLENCE
 Incidence of abuse increases during pregnancy
 Physicians do a poor job of screening
 Look for: vague complaints; substance abuse; insomnia; injuries to central body areas;
multiple ER visits
 Develop emergency plan/referral numbers
TERATOGENS
 Evaluate home environment
 Work exposure (plastics, vinyl monomers, heavy metals, viral agents)
 Medication or drug use
 Alcohol - fetal alcohol syndrome
 ACE - inhibitors - fetal renal dysfunction
 Coumarin derivatives - effects seen in up to 25% exposed
 Tegretol - craniofacial abnormalities; limb defects; growth and mental retardation
 Dilantin - fetal hydantoin syndrome
 Valproic acid - neural tube defects (1-2%)
 Lithium – congenital anomaly
 Tetracycline - deposition in fetal long bones
 Vitamin A derivatives - associated with numerous severe defects;
 X-Rays/radioactive isotopes
 DES - reproductive tract abnormalities
 Folic acid antagonists
 Thalidomide - limb defects
 Should consult specialist, poison control center or teratogen centers
 Some medications have different safety periods between cessation and conception
NUTRITIONAL ASSESSMENT
 Assess optimal nutritional needs
 Risk factors
 Low income
 Substance abuse
 Fad dieting/vegans
 Depression/mental illness
 Gastrointestinal disease
 Chronic disorders
 Must also assess for existence of eating disorders
 Folic acid supplementation beginning one month prior to conception can greatly
reduce incidence of neural tube defects
 Utilize nutritionist for full evaluation
 Obesity
 Adolescence
 Pre-existing conditions - iron deficiency anemia, hyperlipidemia
 Evaluate exercise regimen
FINANCIAL AND EMOTIONAL CONCERNS
 Couples should be aware of maternity coverage provided by their insurance
 Leave benefits
 Stress importance of good family support
 May consult social services
 Emotional issues addressed
SUMMARY
 Thorough history taking
 Complete physical exam
 Necessary consultations
 Counseling
 Instruct on accurate menstrual history and on contraception
 Necessary laboratory evaluation
 Adequate preconception counseling can decrease risk of pregnancy complications
 Education can lead to healthy habits and realistic expectations
 Can lead to more efficient and less costly pregnancy care
REFERENCES
1. Adams EM, Bruce C, Shulman MS et al: The PRAMS Working Group: pregnancy
planning and preconception counseling. Obstet Gynecol 82:955, 1993.
2. Moos MK, Cefalo RC: Preconceptional health promotion : A focus for obstetric
care. Am J Perinatol 4:63, 1987.
3. MRC Vitamin Study research Group : Prevention of neural tube defects: results of the
Medical Research Council Vitamin Study. Lancet 338:131, 1991.
4. Resources: Reproductive Toxicology Center; Obstetrical textbooks

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PRECONCEPTION CARE/ COUNSELLING

  • 1. PRE-CONCEPTION CARE AND COUNSELING INTRODUCTION  Concept of preconception care has evolved over the last several decades  J.W. Ballantyne - originated concept of prenatal care  Preconception and prenatal care are forms of primary care and prevention  Opportunities exist in many settings  Should target all women of reproductive age  Education and preparation are key  Worldwide maternal mortality approaches one million women annually  Risk of maternal death in the is 1 in 10,000 live births  Unintended pregnancy rate approaches 40% annually COMPONENTS OF PRECONCEPTION CARE  Risk assessment  Education  Intervention or modification  Counseling GOALS OF PRECONCEPTION CARE  To identify pre-existing conditions that may affect an anticipated pregnancy  This may allow for intervention(s) that could lead to more favorable outcome  Goal should be realistic  Identification process involves mother and fetus CONTRACEPTION  Good preconception care begins with appropriate contraception!!  Should be addressed at each visit, including primary care visits, emergency room visits, and well woman appointments  Should be appropriate as regards patient’s lifestyle and medical condition
  • 2. MATERNAL RISK ASSESSMENT  Family and genetic history (maternal and paternal)  Medical history  Medication use  Environmental exposures (home and work)  Obstetric and reproductive history  Domestic abuse  Emotional preparedness  Infectious disease  HIV  Immunization history  Sexually transmitted diseases REPRODUCTIVE HISTORY  Conditions with recurrence risk:  Premature delivery  Preeclampsia/eclampsia  Placenta previa/abruption  Gestational diabetes  Preterm premature rupture of membranes  Certain birth defects/genetic disorders  Prior uterine surgery or anomalies  Good time to discuss trial of labor  Prior pregnancy losses  Habitual abortion  Must also deal with associated emotional issues FAMILY HISTORY  Coagulation disorders  Mental retardation  Other conditions (congenital adrenal hyperplasia, neurofibromatosis, inborn errors of metabolism)
  • 3.  Anueploidy Risk  Risk of any type of aneuploidy increases with maternal age  Offer genetics consultation  Important to obtain family pedigree  Risk increases with increasing maternal age  Risk of Trisomy 21 at age 35 is 1/378 and that of all aneuploidy is 1/192  Risk increases to 1/30 and 1/21 respectively, at age 45  Risk with increased paternal age probably small RISK ASSESSMENT - MEDICAL HISTORY  Possible effects of pregnancy on disease  Possible effects of disease on pregnancy, mother and fetus  Evaluate for any possible interventions  Assess for possibility of teratogenic effects of medications  Evaluate for presence of microvascular disease and level of glucose control  Frequency of malformations 6-10 %  Periconceptual control can significantly decrease malformation rate  Hemoglobin A1C crude marker of glucose control/ ? Association with anomaly rate  Hypertension - assess for microvascular disease, severity, underlying etiology  Hyperthyroidism  Hypothyroidism  Previous treatment for cancer  History of organ transplantation RISK ASSESSMENT - MEDICAL HISTORY  Connective tissue disorder  Inflammatory bowel disease  Asthma  Neurological and psychiatric disorders SPECIAL RISKS  Primary Pulmonary Hypertension
  • 4.  Chronic Renal Disease  Complicated coarctation of the aorta  Sever mitral or aortic stenosis  Vasculitis syndromes RISK ASSESSMENT - IMMUNIZATIONS  Rubella - should wait 3 months before conceiving  Hepatitis B  Tetanus  Mantoux skin test  Influenza, pneumovax as indicated  Varicella RISK ASSESSMENT - STD’S  Assess for high risk behaviors and counsel appropriately  HIV - treatment can decrease transmission to fetus from 30% to 8%  Gonorrhea  Chlamydia  Trichomonas  Bacterial Vaginosis - presence associated with increased risk of premature labor and delivery  Group B beta streptococcus - ?  HPV - human papillomavirus/PAP/possible colposcopy in select cases/neonatal infection possible  HSV - as indicated  congenital syphilis can occur at any stage of maternal disease  Toxoplasmosis - cat owners or if handle raw meat  Cytomegalovirus SOCIAL HISTORY  Illicit substance use and abuse major public health problem  Alcohol  Most common preventable cause of mental retardation
  • 5.  No proven safe level of ingestion  Tobacco use  Associated with numerous pregnancy complications  One of most common preventable cause of fetal growth restriction  Increased risk of other health problems  Illicit drug use  Usually associated with other high risk behaviors  Possible teratogen  Increased pregnancy complications  Associated with sudden death, infarction, hypertension  Prescription drug dependency  Evaluate for life stressors that may predispose to substance abuse  Encourage counseling and rehabilitation prior to pregnancy  May have co-existing psychological disorders  Seen in all social classes DOMESTIC VIOLENCE  Incidence of abuse increases during pregnancy  Physicians do a poor job of screening  Look for: vague complaints; substance abuse; insomnia; injuries to central body areas; multiple ER visits  Develop emergency plan/referral numbers TERATOGENS  Evaluate home environment  Work exposure (plastics, vinyl monomers, heavy metals, viral agents)  Medication or drug use  Alcohol - fetal alcohol syndrome  ACE - inhibitors - fetal renal dysfunction  Coumarin derivatives - effects seen in up to 25% exposed  Tegretol - craniofacial abnormalities; limb defects; growth and mental retardation  Dilantin - fetal hydantoin syndrome  Valproic acid - neural tube defects (1-2%)  Lithium – congenital anomaly  Tetracycline - deposition in fetal long bones
  • 6.  Vitamin A derivatives - associated with numerous severe defects;  X-Rays/radioactive isotopes  DES - reproductive tract abnormalities  Folic acid antagonists  Thalidomide - limb defects  Should consult specialist, poison control center or teratogen centers  Some medications have different safety periods between cessation and conception NUTRITIONAL ASSESSMENT  Assess optimal nutritional needs  Risk factors  Low income  Substance abuse  Fad dieting/vegans  Depression/mental illness  Gastrointestinal disease  Chronic disorders  Must also assess for existence of eating disorders  Folic acid supplementation beginning one month prior to conception can greatly reduce incidence of neural tube defects  Utilize nutritionist for full evaluation  Obesity  Adolescence  Pre-existing conditions - iron deficiency anemia, hyperlipidemia  Evaluate exercise regimen FINANCIAL AND EMOTIONAL CONCERNS  Couples should be aware of maternity coverage provided by their insurance  Leave benefits  Stress importance of good family support  May consult social services  Emotional issues addressed
  • 7. SUMMARY  Thorough history taking  Complete physical exam  Necessary consultations  Counseling  Instruct on accurate menstrual history and on contraception  Necessary laboratory evaluation  Adequate preconception counseling can decrease risk of pregnancy complications  Education can lead to healthy habits and realistic expectations  Can lead to more efficient and less costly pregnancy care REFERENCES 1. Adams EM, Bruce C, Shulman MS et al: The PRAMS Working Group: pregnancy planning and preconception counseling. Obstet Gynecol 82:955, 1993. 2. Moos MK, Cefalo RC: Preconceptional health promotion : A focus for obstetric care. Am J Perinatol 4:63, 1987. 3. MRC Vitamin Study research Group : Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet 338:131, 1991. 4. Resources: Reproductive Toxicology Center; Obstetrical textbooks