Preconception Care

Greater New York Chapter of the March of Dimes

Preconception Care Curriculum Working GroupAlbert Einstein College of Medicine/Montefiore Medical Center

Peter Bernstein, MD, MPH

Associate Professor of Clinical Obstetrics & Gynecology and Women’s Health

Preconception Care

• May be the most important part of prenatal care

– US Public Health Service, 1989

• Only 20-50% of primary care provider routinely provide preconception care

– Healthy People 2000 Report

Preconception Care

1. The Case for Preconception Care

2. What is Preconception Care?

3. How to incorporate Preconception Care into clinical practice

Preconception Care

1. The Case for Preconception Care

The Need for Preconception Care

• Kempe, 1992 (NEJM): Racial disparities in low birth weight rates may partially be the result of maternal conditions that should be addressed prior to conception

• Haas, 1993 (JAMA): Additional access to prenatal care only in Massachusetts did not impact rates of adverse birth outcomes

The Need for Preconception Care

• More than 40% increase in utilization of prenatal care by African-American Women since the 1970’s

• No improvement in rates of very low birth weight infants

• Minimal improvement in rates of low birth weight infants

– National Center for Health Statistics 1975, 1984, 1994

Preconception Care

1. The Case for Preconception Care

2. What is Preconception Care?

Preconception Care

• Identifies reducible or reversible risks

• Maximizes maternal health

• Intervenes to achieve optimal outcomes

• Provide health education

Preconception Care

• Reframes issues

• Adds an anticipatory element

• Focuses on the impact of pregnancy

Elements of Preconception Care

• Focus on elements which must be accomplished prior to conception or within weeks thereafter to be effective

– Risk assessment

– Health promotion

– Medical and pyschosocial interventions

Components of Preconception Care

• Medical history• Psychosocial issues• Physical exam• Laboratory tests• Family history• Nutrition assessment

Examples of Components of Preconception Care

– Family planning and pregnancy spacing

– Family history– Genetic history (maternal and

paternal)– Medical, surgical, pulmonary

and neurologic history– Current medications

(prescription and OTC)– Substance use, including

alcohol, tobacco and illicit drugs

– Nutrition

– Domestic abuse and violence– Environmental and

occupational exposures– Immunity and immunization

status– Risk factors for STDs– Obstetric history– Gynecologic history– General physical exam– Assessment of

Socioeconomic, educational, and cultural context

Prevalence of Risk Factors Pregnant orgave birth

Smoked during pregnancy 11.0%

Consumed alcohol in pregnancy (55% at risk of pregnancy) 10.1%

Had preexisting medical conditions 4.1%

Rubella seronegative 7.1%

HIV/AIDS 0.2%

Received inadequate prenatal Care 15.9%

At risk of getting pregnant

Cardiac Disease 3%

Hypertension 3%

Asthma 6%

Dental caries or oral disease (women 20-39) >80%

Diabetic 9%

On teratogenic drugs 2.6%

Overweight or Obese 50%

Not taking Folic Acid 69.0%

Conditions Addressed by Preconception Care

• Those that need time to correct prior to conception

• Interventions not usually undertaken in pregnancy

• Interventions considered only because a pregnancy is planned

Conditions Addressed by Preconception Care (cont)

• Conditions that might change the choice or timing to conceive

• Conditions that would require early post-conception prenatal care

Family Planning

• A short pregnancy interval may be associated with:– birth of an SGA infant in a subsequent

pregnancy – Lieberman 1989, Zhu 1999

– preterm birth in a subsequent pregnancy – Basso 1998, Zhu 1999

Preconception Genetic Counseling and Screening

• Family history of genetic diseases

• Discussion of age-related risks

• Discussion of disease-related risks

• Carrier screening

• Potential options of donor egg or sperm or early genetic testing

• Discussion of exposure to teratogens

Critical Periods of DevelopmentCritical Periods of Development

4 5 6 7 8 9 10 11 12Weeks gestation from LMP

Central Nervous SystemCentral Nervous System

HeartHeart

ArmsArms

EyesEyes

LegsLegs

TeethTeeth

PalatePalate

External genitaliaExternal genitalia

EarEar

Missed Period Mean Entry into Prenatal Care

Most susceptible time for major malformation

Substance Use and Preconception Care

• Patient education as to effects of substances on fetus

• Screening for use/abuse

• Referral for treatment program

• Pregnancy may be a strong motivator for change

Alcohol

• Leading preventable cause of mental retardation

• Most common teratogen to which fetuses are exposed

• Effects related to dose

• No threshold has been identified for “safe” use in pregnancy

• Effects at all stages of pregnancy

Tobacco

• Leading preventable cause of low birthweight– For every 10 cigarettes smoked each day the

risk of delivering an SGA infant increases by a factor of 1.5

• Associated with placental abruption, preterm delivery, placenta previa, miscarriage

• Smoking cessation results in increased birth weight

Substance Use and Consequences

Cocaine congenital anomalieslow birth weightabruptio placenta

Heroin low birth weightnewborn withdrawal

Methadone newborn withdrawal

Environmental Teratogens

• Exposures

– Home, workplace, environment

• Physical/chemical hazards

– ionizing radiation, lead, mercury, hyperthermia, herbicides, pesticides

Physical and Emotional Abuse in Pregnancy

• Two million women each year are abused by a partner

• No correlation with ethnicity, socio-economic status, or education

• 29% of abused women report escalation of abuse during pregnancy

Role of the Health Care Provider

• Be open to the subject

• Provide a private, confidential setting for visit

• Use a standardized screen

• Ask every woman

• Know local resources for referral

Nutritional Risks

• Underweight (BMI < 19.8 prepregnant)– Increased risk for: low birthweight, fetal

death, mental retardation

• Overweight (BMI 26.1-29.0) and Obese (BMI >29.0)– Increased risk for: diabetes, hypertension,

thromboembolic disease, macrosomia, birth trauma, abnormal labor, cesarean delivery

Nutritional RisksVitamins and Minerals

• Folic acid - modifies risk of neural tube defects

• Iron - increased risk of preterm delivery, LBW

• Oversupplementation of Vitamins A & D - increase in congenital anomalies

• Pica - iron deficiency, lead poisoning

Prevention of Neural Tube Defects

• Supplementation for all women of childbearing potential with folic acid

– No history of NTD: 0.4 mg. qd

– Prior infant with NTD: 4.0 mg. qd

– Woman with NTD: 4.0 mg. qd

• Nutritional sources often inadequate

Immunizations

• Women of childbearing age in the US should be immune to measles, mumps, rubella, varicella, tetanus, diptheria, and poliomyelitis through childhood immunizations

• If immunity is determined to be lacking, proper immunization should be provided

• Need for immunizations according to age group of women and occupational or lifestyle risks

Rubella Vaccination

• Determine rubella immunity prior to conception• Vaccinate susceptible nonpregnant women• Congenital rubella syndrome may result from

infection during pregnancy (microcephaly, fetal growth restriction, cardiac malformations, etc)

Preconception Care for Men

• Alcohol– may be associated with physical and emotional

abuse– may decrease fertility

• Genetic Counseling

• Occupational exposure– lead

• Sexually transmitted diseases– syphilis, herpes, HIV

Preparedness for Parenthood

• Pyschological

• Financial

• Life plans

– education

– career

Preconception Care

1. The Case for Preconception Care

2. What is Preconception Care?

3. How to incorporate Preconception Care into clinical practice

Epidemiology of Unintended Pregnancy

• 49% of pregnancies in the US are unintended (unwanted or mistimed)– Henshaw, 1998

• Preconception care should be provided to all reproductive age individuals

Barriers to Preconception Care

• Unintended pregnancy

• “Planned” pregnancies are seldom planned with a health care provider

• Unpreparedness of health care providers

When should preconception carebe offered?

• As part of routine health maintenance care

• At a defined preconception visit

• For women with chronic illness

• At one visit v. several visits

Incorporating Preconception Care into Routine Primary Care

• Encourage all women to have a “Reproductive Life Plan”

• Chart stamp:– LMP, BP, Weight, Height, BMI– “Plan to become pregnant in the next year?” – Family Planning Method– Tobacco use

Medical Record #:Patient name:

Preconception Health Screening/Counseling

DateDone

Pending Action Comments/Provider’s Initials

Family PlanningPregnancy planning and spacingPregnancy prevention

Social HistorySocial support (safety, resources)Alcohol useTobacco useIllicit drug useExerciseTeratogen exposure (e.g. lead,

chemicals at work)

Nutrition HistorySpecial dietEating disorderAdequate vitamin/mineral intake (e.g.

Ca, folate)

Medical HistoryDiabetesThyroid diseaseAsthmaCardiovascular DiseaseHypertensionDeep Venous ThrombosisKidney DiseaseAutoimmune DiseaseNeurologic DiseaseHemoglobinopathyOther medical or surgical problems

Infectious Disease HistorySTD’s including HIVHepatitis B (immunize if at high risk)Rubella (test, if nonimmune,

immunize)Toxoplasmosis

MedicationsOver the counter medicationsPrescription medications

Reproductive HistoryUterine abnormalities2 or more first trimester SAb’sOne or more 2nd trimester lossesAny fetal deathsPreterm deliveriesAny infants admitted to NICU

Family HistoryBirth defectsHemoglobinopathiesMental retardationCystic fibrosisTay-Sachs diseaseConsanguinous marriage

Bernstein, Merkatz J Repro Med, 2000

Since so few pregnancies are planned, preconception care issues must be addressed at all encounters with reproductive-aged individuals

Thank You