New Paradigms for Prenatal Care: Preconception Care

Peter Bernstein, MD, MPH

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

Albert Einstein College of Medicine

Montefiore Medical Center

History of Prenatal Care

• 1843: J.C. Lever notes that albuminuria is associated with eclampsia

• 1858: Sinclair founds the first prenatal clinic in Dublin resulting fewer cases of eclampsia

• 1915: Williams in Baltimore notes prenatal care results in fewer fetal deaths due to detection of syphilis

History of Prenatal Care

• 1925: US Children’s Bureau publishes Prenatal Care– Sets the standards of the medical and

educational components of prenatal care

• 1989: US Public Health Service publishes Caring for Our Future: The Content of Prenatal Care

Prenatal Care for the Pregnant Woman

• To increase her well-being before, during, and after pregnancy and to improve her self-image and self-care

• To reduce maternal mortality and morbidity, fetal loss, and unnecessary pregnancy interventions

• To reduce the risks to her health prior to subsequent pregnancies and beyond childbearing years

• To promote the development of parenting skills

US Public Health Task Force, 1989

Prenatal Care for the Fetus/Infant• To increase well-being• To reduce preterm birth, intrauterine growth restriction,

congenital anomalies, and failure to thrive• To promote healthy growth and development,

immunizations, and health supervision• To reduce neurologic, developmental, and other

morbidities• To reduce child abuse and neglect, injuries, preventable

acute and chronic illness, and the need for extended hospitalization after birth

US Public Health Task Force, 1989

Prenatal Care for the Family

• To promote family development, and positive parent-infant interaction

• To reduce unintended pregnancies• To identify for treatment behavior disorders

leading to child neglect and family violence

US Public Health Task Force, 1989

Goals of Prenatal Care

Foster the well-being of the fetus and pregnant woman to ensure a healthy

outcome for both

Failures of Prenatal 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

Failures of Prenatal Care

• Haas, 1993 (JAMA): – Compared all births in 1984 and 1987 in

Massachusetts • Approx 60,000 births in each cohort

– Decline in rates of satisfactory prenatal care from 96.4% to 93.8% (p < 0.001)

– No change in rates of adverse birth outcomes

New Paradigms for Prenatal Care

• Improved Preconception Care

• Group Prenatal Care

• Perinatal Information Systems

Preconception Care

Greater New York Chapter of the March of DimesPreconception Care Curriculum Working GroupAlbert Einstein College of Medicine/Montefiore Medical

Center

Preconception Care

May be the most important component of prenatal care

– US Public Health Service, 1989

How are we doing on Preconception Care?

• Only 20-50% of all primary care providers routinely offer appropriate preconception care

• Healthy People 2000 goal: 60% of providers will 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

The Need for Preconception Care

• Adams, 1993:– Utilized the PRAMS database (survey of 9535 women

in 4 states)– Indications for preconception counseling

• Tobacco or alcohol use, underweight, or delayed enrollment into prenatal care

– Of those with planned pregnancies, 38% could have used preconception counseling

– Those with unplanned pregnancies (40% of respondents) were more likely to have an indication for preconception counseling

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

Preconception Care

1. The Case for Preconception Care

2. What is Preconception Care?

Preconception Care

• Similar to routine care:• Identifies reducible or reversible risks

• Maximizes maternal health

• Intervenes to achieve optimal outcomes

Preconception Care

• Differences from routine care:– Reframes issues– Adds an anticipatory element– Focuses on the impact of pregnancy– Emphasizes factors which must be acted

upon before conception or early in pregnancy to have maximum impact

Components of Preconception Care

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

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

Diabetes Mellitus

• 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

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• Binge drinking associated with unintended

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

• Neurobehaviorial differences in neonates exposed in utero to tobacco

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, birth defects

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• Women with unintended pregnancies less likely

to taking folic acid supplementation

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)

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

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

Improving the Delivery of Preconception Care

• Use of chart insert checklists– Physician completed

• Bernstein 2000

– Patient Completed• Available from the March of Dimes

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, J Reprod Med, 2000

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

Thank You