MODELS OF PREVENTION AND INNOVATION

Women’s Reproductive Health:Preconception Care

Reproductive Life Planning

What defines YOUR care?

Reproductive Life Plan

Definitionhttp://www.marchofdimes.com/professionals/

professionals.htmlhttp://www.cdc.gov/preconception/

freematerials.htmlhttp://www.beforeandbeyond.org/?page=cme-

modulesWhat are the components?

RECENT HISTORY: 1990s

ACOG published its first technical bulletin on preconception care in 1995. In this bulletin, ACOG recommended that routine visits by women who may, at some time, become pregnant are important opportunities to emphasize the importance of prepregnancy health and habits and the advantages of planned pregnancies.

ACOG, Technical Bulletin #205, 1995

Preconception Care CDC National Summit on Preconception Care (2006)

• 4 GOALS– 1. Improve the knowledge and attitudes and behaviors

of men and women;– 2. Ensure all women of childbearing age in the U.S.

receive preconception care services;– 3. Reduce risks indicated by a previous adverse

pregnancy outcome during INTERCONCEPTION period to prevent or minimize future health problems for mom and children

– 4. Reduce the disparities in adverse pregnancy outcomes.

CDC National Summit on Preconception Care (2006): Clinical Guidelines

CDC National Summit on Preconception Care (2006): Clinical Guidelines

Every Woman Californiahttp://everywomancalifornia.org/

content_display.cfm?ContentID=404&

Interconception Care CA

http://www.everywomancalifornia.org/

Preconception Visit

The counseling priorities to optimize pregnancy outcomes are based on maternal assessments, including….

What are the key components of this visit?

Components of Preconception Visit

• (ACOG): – Family Planning and Spacing; – Family History; – Genetic History; – Med/Surg Psych and neurologic histories; – Current medications; – Substance use; – Domestic abuse and violence; – Nutrition;

Components of Preconception Visit

Environmental and occupational exposures; Immunity and immunization status; Risk factors for STIs; OB and GYN histories; PE; Assessment of socioeconomic, education, and culture;

Sexual History.

Examples of Primary Prevention Opportunities: Congenital Anomalies

The Opportunity: The Potential Benefit:

Prevention of neural tube defects 50-70% can be prevented if a woman has adequate levels of folic acid during earliest weeks of organogenesis—before she receives her prenatal vitamins

Birth Defects related to poor glycemic control of mother (including sacral agenesis, cardiac defects and neural tube defects)

Can be reduced from ~10% to 2-3% through glycemic control of the woman before organogenesis

Examples of Primary Prevention Opportunities: Congenital Anomalies

The Opportunity: The Potential Benefit:

Minimize a prospective mother’s contact with teratogenic exposures such as prescribed medications, environmental exposures and alcohol

Teratogenic substances interfere with normal organ development primarily during the period of organogenesis

Advise avoiding pregnancy within one month of receiving a live attenuated vaccine (Rubella).MMR (Measles, Mumps and

Rubella) Attenuated, live viruses: do not give to pregnant women and counsel to avoid pregnancy for 4 weeks after vaccination

Tetanus, Diphtheria, and Pertussis (Tdap); & Tetanus and Diphtheria (Td)

On October 24, 2012, the Advisory Committee on Immunization Practices voted to recommend Tdap during each pregnancy, preferably at 27 through 36 weeks gestation.

Vaccinations:

Varicella InfluenzaHepatitis B Assess for Travel Plans (immunization

review) http://www.cdc.gov/vaccines/pubs/preg-

guide.htm

http://www.cdc.gov/vaccines/pubs/preg-guide.htm

HIV Screening and Treatment

Clinical GuidelinesCDC Website for Primary Carehttp://www.cdc.gov/actagainstaids/provider/index.h

tml CDC recommends testing all patients ages 13-64 http://www.nccc.ucsf.edu/training_ta/

Review and teach safer sex to prevent HIV infection.

CDC STI TX Guidelines 2010http://www.cdc.gov/std/treatment/2010/

Screening and Treatment for STIs prior to pregnancyReview general screening protocols

http://www.cdc.gov/std/2010-ebook.htm

Mantoux test with purified protein derivative for TB

Medication Review

OCT, prescriptive and natural remedies

Medication Review and Teratogens Identified www.otispregnancy.org FDA Risk Factor Category NEW (no longer A,B,C,D,

X)

Genetic Diseases

Why Screen? Prevalence and Impact

Phenylketonuria (PKU)

Genetic History /Ethnic Assessment

• Sickle hemoglobinopathies (African Americans)

• Beta-thalassemia (Southeast Asia, Mediterranean dissent; African Americans)

• Alpha-thalassemia (Southeast Asia, Mediterranean dissent; African Americans)

• Tay-Sachs disease (Ashkenazi Jews, French Canadians, and Cajuns)

• Canavan disease and familial dysautonomia (Ashkenazi Jews)

Genetic History /Ethnic Assessment

Cystic Fibrosis Frequency of 1:25 Caucasian, Ashkenazi Jewish, and

Native Americans; 1:46 Hispanic Americans; 1:65 African Americans; 1:94 Asian Americans

Information about CF screening should be available to all clients

Screening for other genetic disorders on the basis of family history.

Nutrition and Genetic Assessment

• Neural-Tube Defects = Folic Acid supplementation overcomes specific mutations in genes.

• Folic Acid Supplementation– Need prior to pregnancy and first 12 weeks. – .4mg/day– If history, 4 mg/day

• Recommendation: All women of childbearing age should take a multivitamin supplement containing 0.4 mg of folic acid a day.

Controlling Chronic Medical Disorders

Research supports significantly better birth outcomes with preconceptional counseling (hypertension, renal disease, thyroid disease, asthma, or heart disease 80% normal outcomes vs. 40% without counseling.

Chronic Medical Disorders

• Diabetes Mellitus care = lowest hemoglobin A1c level possible– Hemoglobin A1c Measurement can be used to compute

risks for major anomalies (4.6-7.6 low fourfold increase in risk with 10-10.5)

• Seizure Disorder– Monotherapy recommended and medications

considered less teratogenic (lamotrigine mono)– Folic Acid supplementation important in this

population 4mg per day at least one month prior to conception.

Chronic Medical Disorders

Hypothyroidism. The dosages of Levothyroxine® required for

treatment of hypothyroidism increases in early pregnancy.

Levothyroxine® dosage needs to be adjusted for proper neurologic development.

Preconception Care

• TACE questions for Alcohol use assessment; non-judgemental questioning key

• Alcohol and Drug Use– Fetal toxicity is dose related; exposure time of

greatest risk in first trimester. – No established safe level of alcohol use during

pregnancy. – Drug Use: Ask, Listen, Refer to Treatment Program

• Smoking Cessation

Environmental Exposure

• Evaluate exposure to infectious organisms and chemicals. Assess work conditions, safety. – Encourage them to ask employers for Material Safety

Data Sheets– Consult databases for hazardous substances (Reprotox,

March of Dimes, OSHA) Refer if in doubt. – Identify ways to minimize exposure (safety precautions)

• Mercury in Fish: FDA and EPA guidelines.

NEW

Mental Health

Depression Screen and Treat Screen for symptoms of depression; Counsel for

treatment and high risk of exacerbation during pregnancy and postpartum

Domestic Abuse/Intimate Partner Violence (upcoming lecture) Pregnancy is a time of increased risk from an abusive

partner

Preconception Nutrition

• Obesity (BMI Measurements) control to reduce risks of HTN, gestational diabetes, surgical births, preeclampsia, postterm pregnancy, operative delivery; also structural fetal anomalies. – Reduce weight before pregnancy– Increase weight if underweight

• Nutrition Consult Key• Encourage Exercise

Preconception Nutrition

• Take a nutritionally oriented history (24 hour recall)

• Encourage healthy eating habits and balanced diet

• Evaluate eating disorders• Evaluate anemia status• Vegetarians: assess those without animal

proteins and consider referral/supplementation

• Discuss vitamins and minerals intake

Preconception to Prenatal Nutrition

How many extra calories for pregnant and breastfeeding women?

New Guidelines for weight gain from IOM. Cultural and International variables—ASK.Caffeine Intake Assessment. “My Pyramid Plan for Moms” USDA (

http://www.mypyramid.gov/mypyramidmoms).

Nutrition

Exercise: Assess activities past and present. Encourage regular exercise (enhance overall health and wellbeing)

WIC Program 9.3 million women, infants, and children (under 5)

each month http://www.fns.usda.gov/wic/