Preconception Counseling for women Dr,B.Khani Questions What is preconception care? What is the role of the ob&gyn in providing preconception care? What

IN THE NAME OF GOD

Preconception Counseling for

women

Dr,B.Khani

Questions

What is preconception care? What is the role of the ob&gyn in

providing preconception care? What are risks of pregnancy in

patients with chronic medical problems?

Opportunities for preconception counseling occur ;

Premarital examination and testing Contraception counseling Evaluation for sexually transmitted

disease or vaginal infection After a negative pregnancy test Presents for a periodic health

examination

Barriers to preconception counseling Unplanned pregnancy Risk factors for adverse outcome

that cannot be modified(maternal age or genetic history)

Financial issues Inadequate training of health care

providers and long waiting times for appointments

Typical Patient Visit

Chief Complaint History of Present Illness Past Medical History Medications Family History

Social History Physical Exam Assessment and Plan

Chief Complaint/HPI

Ask about reproductive life plan ½ pregnancies in the US are

unintended Remember that any one who is

menstruating and having sex can get pregnant.

Help patients and partners develop a plan, and help them implement it

Past Medical History

Infections Immunizations Previous Pregnancies Chronic Diseases

Infection History TORCHES

Toxoplasmosis: increased risk with handling raw meats, cat litter

Other: Listeria, Coxsackie virus, ParvovirusRubellaCMV: seroconversion highest risk for day

care workers caring for 12-36 month old children

Hepatitis B, HIV, Herpes virusesSyphilis

Immunizations

TORCHES: Rubella, Hepatitis B, Varicella

Tetanus Pertussis Flu: If woman expects to be at least

3 months pregnant during flu season

Reproductive History

Pregnancies Outcome Perinatal difficulties Control of chronic diseases during

pregnancy

Chronic Hypertension-Maternal Morbidity

Preeclampsia: 25% of women with chronic HTN 40% with severe HTN Renal failure, HELLP syndrome,

Eclampsia Peripartum cardiomyopathy

Exacerbated by increased blood volume, decreased oncotic pressure

Chronic Hypertension-Neonatal Morbidity

2/3 Preterm delivery 1/3 Small for Gestational Age Mortality

2-4 times above baseline rate for population

Other complications Placental Abruption Cesarean Delivery Intrauterine Growth Restriction

Glycemic Changes during Pregnancy

ENHANCED insulin sensitivity- late first trimester More hypoglycemia, especially with coexistent

vomiting Increased caloric requirements- 300kcal/day

REDUCED insulin sensitivity- throughout pregnancy Allows for continuous glucose delivery to

fetus, even at fasting state Increased cortisol, placental growth factor,

progesterone, prolactin, human placental lactogen, others

Diabetes-Maternal Morbidity

Ketoacidosis Develops more rapidly with less severe

hyperglycemia than non pregnant patients

Risk factors: new onset DM, infection, poor compliance, antenatal corticosteroids and tocolytics

Preeclampsia Up to 50% of pts with Diabetes and

Nephropathy

Diabetes- Maternal Morbidity

Retinopathy PROGRESSION of retinopathy due to

tight glucose control Long term risk is not altered by

pregnancy Nephropathy

Risk Factors: baseline creatinine >1.5mg/dL, severe proteinuria

Diabetes-Congenital Malformations

• Risk of malformation proportional to HbA1c

• Overall double the risk compared to infants born to non-diabetics

• 5% risk if HbA1c is 7%

• 23% risk if HbA1c is 8.6%

Diabetes-Congenital Malformations

Cardiac: Transposition of great vessels, VSD, Coarctation, Patent Ductus Arteriosis, Situs Inversus

Renal: Ureteral Duplication, Agenesis

Neurologic: Anencephaly, Microcephaly, Neural tube defects

Gastrointestinal: Duodenal atresia, imperforate anus, anorectal atresia

Skeletal: Caudal Regression Syndrome

Diabetes- Neonatal Morbidity

Neonatal hypoglycemia Transient fetal hyperglycemia leads to

β-cell hyperplasia and hyperinsulinemia Macrosomia

Increased risk shoulder dystocia at delivery

Higher rates of primary cesarean delivery


Chief Complaint History of Present Illness Past Medical History

Immunizations Infections Previous Pregnancies Chronic Diseases

Medications Family History


Medications

Up To Date 15.3, 2007

Analgesic Drugs

• NSAIDS• Acetaminophen is class B, throughout

pregnancy

• Ibuprofen, Naproxen, Diclofenac are class B, in first and second trimesters

• All NSAIDS are class D in third trimester

• Narcotics: Class C

Antidepressants/Anxiolytics

SSRIs, Mirtazepine, Trazodone, Venlafexine: Class C

Tricyclics: Class D Buspirone, Zolpidem: Class B Benzodiazepines: Class D Lithium: Class D

Antimicrobials

Penicillins, Cephalosporins, Clindamycin, Metronidazole, Macrolides: Class B

Sulfonamides: Class B first and second trimester, Class D third trimester

Quinolones, Trimethoprim, Vancomycin: Class C

Tetracyclines: Class D Nystatin: Class B Fluconazole: Class D first trimester, Class

C second and third trimesters

Allergy Treatments

Diphenhydramine, Loratadine, Cetirizine : Class B

Fexofenadine, Bromphenphiramine : Class C

Pseudoephedrine: class C in second and third trimesters

Guaifenesin: class C

GI Medications

Ranitidine, Lansoprazole, Sulcrafate: Class B

Omeprazole: Class C Metoclopromide, Dimenhydrinate

(Dramamine): Class B Promethazine, Prochlorperazine:

Class C Bismuth subsalicylate: Class D

Others

Nicotine replacement: Patches, nasal spray, inhaler are Class D, gum is Class X

Isotretinoin(Accutane): Class X

Chronic Hypertension- Treatment

No data that treatment of Mild Hypertension will improve maternal/fetal outcomes

Consider stopping/reducing RX in women who become pregnant. Restart for women with SBP>150-160

or DBP>100-110

1 Ferrer et al. Obst Gynecol 2000

Chronic Hypertension-Treatment

Safe Agents: Class C Methyldopa Labetalol Nifedipine

Some Risk: Class D Diuretics Selective beta blockers, during second and

third trimesters Avoid: Class D

ACE-Inhibitors/ARBs

Diabetes-Treatment

Good control BEFORE conception During Pregnancy

Diet, Exercise, and Insulin therapy Close Monitoring

Goals: fasting glucose <95mg/dL nighttime glucose >60mg/dL Hemoglobin A1c <6%

Diabetes-Treatment

Insulin therapy Range from .7-1.2 U/kg/day

Oral Agents: Glyburide: Class C, but does not cross

placenta, comparable to insulin in improving control without evidence of complications

Metformin: Class B TZDs: Not well studied, Class C






Carrier Screening by Ethnicity

Caucasian: Cystic Fibrosis Black: Sickle cell, Beta-Thalassemia European Jewish: Tay-Sachs French Canadian: Tay-Sachs Mediterranean: Alpha-, Beta-

Thalassemia Southeast Asian: Alpha-, Beta-

Thalassemia Indian, Middle Eastern: Sickle Cell,

Alpha-, Beta-Thalassemia






Social History

Environmental Exposures Diet Social Stressors Substance abuse

Environmental Toxins

Organic solvents (paint, cleaning fluids, pesticides)

Anesthetic gases Radiation Heavy Metals

Diet vegetarians may need supplements Fish: Limit to 12oz of safe fish per week.

Unsafe fish: Shark, swordfish, king mackerel, tile fish, tuna Canned tuna (<2 cans per week) is OK

Caffeine Associated with increased risk of miscarriage

in one study: 12.5% nonusers, 15% users of <200mg/day, 25%

users >200mg/day

Folic Acid intake: Recommended 400mcg/dayWeng, X; Odolui, R; Li, DK. Am J of Obstetrics and Gynecology, 2008

Social Stressors

Emotional abuse Physical abuse

Substance Abuse

Alcohol consumption: even small amounts can cause persistent neurobehavioral deficits.

Tobacco: preeclampsia, placental abruption, low birthweight

Illicit drug use: wide variety of effects





Social History Environmental exposures Diet Substances Social Stressors

Physical Exam Assessment and Plan

Physical Exam

Screening for/ evaluation of Chronic diseases Pulse, blood pressure Thyroid disease Hypoxemia

Weight Oral Care

Obesity

Obesity is defined as BMI of 30-35 kg/m2

Morbid Obesity is BMI > 35 kg/m2

Obesity- Maternal Morbidity

Gestational diabetes (GDM) NYC study: women 200-300+ lbs were 4

to 5 times more likely to develop GDM Preeclampsia Placental abruption Cesarean delivery

Even when controlling for macrosomia Endometritis and wound infections

Rosenberg et al. Obstet Gynecol 2003

Obesity-Neonatal Morbidity

Macrosomia Mount Sinai Study: mean birth weight

83 g (3 ounces) heavier Increased even when controlling for

GDM Significant increase risk among

morbidly obese women who gained >25 lbs during pregnancy

Increased risk NICU stayBianco, Et al. Obstet Gynecol

1998

Periodontal Disease Perhaps related to preterm birth Multiple studies, varying

designs/quality 3 studies: Treatment lead to significant

reduction in preterm low birthweight infants, no significant difference in total preterm births

800 women randomized to tx during pregnancy vs tx postpartum: No difference in preterm birth, low birthweight

Thought to be a marker for excessive local response to bacteria

Xiong, X et al.. BJOG 2006; 113:135.





Social History Environmental exposures Diet Substances Social Stressors

Physical Exam BMI Oral Care Sign of chronic illness

Assessment and Plan

Reproductive Life Plan

Encourage her to talk with partner, develop a plan for more children.

Offer contraception Consider IUDs, contraceptive implants

Infections/Immunizations

Screen for Rubella immunity Syphilis, HIV, Hepatitis B

Vaccinate Routine: Pneumovax, Flu, Tetanus,

Pertussis Consider Hepatitis B, HPV if risk

factors

Chronic Diseases

Screen for Anemia Hypothyroidism Cervical dysplasia

Treat known diseases HTN DM Obesity

Hypertension Treatment

Change Class D/X drugs before pregnancy, Consider Class C Change ACE-I to labetalol, methyldopa,

thiazide, calcium channel blocker Remember that BP may drop early in

pregnancy, pt may need to stop medications initially

Diabetes Treatment

Delay pregnancy until good control achieved

Educate regarding risks to fetus/patient

Consider change to better studied agent Insulin Metformin, Glyburide

Obesity Treatment

Diet and Exercise Goal to get to at least “overweight” BMI

Surgical Treatment Less likely to develop GDM,

hypertension, and macrosomia Avoid pregnancy during 12-18 months

after surgery Fertility may be enhanced in some

women after weight loss Nutritional supplements

Family History

Specific questioning Consider genetic testing in certain

groups

Environmental Exposures

Collect material data safety sheets from employer

Discuss safe practices: mask, clothing, etc

Consider contraception/duty change if pt around potential hazards

Diet

Folic Acid: 400mcg/day all women of reproductive age Prevents Neural Tube Defects May decrease preterm birth

38,000 women, self reported Folic Acid intake

Those with one year of prenatal Folic Acid intake

70% decrease in very early preterm delivery (20-28 WGA)

50% decrease in early preterm delivery (28-32 WGA) March of Dimes Foundation, Feb 2008

Diet

Reduce/eliminate caffeine Reduce fish, especially cold water,

denser fish Consider supplementation for

specific populations Vegan, vegetarian Post Bariatric Surgery

Substances

Smoking cessation Nicotine replacements may be

dangerous in early pregnancy Limit alcohol Avoid illicit substances

Take Home Points

Preconception counseling fits in to every phase of the patient visit

Discuss a Reproductive Life Plan with every patient of childbearing potential

Consider perinatal risk when managing chronic disease

Folic Acid 400mcg/ day for ALL Reproductive age Women

References Kaaja RJ, Greer IA. Manifestations of Chronic Disease During Pregnancy. JAMA 2005;

294(21):2751-57. Lu, MC. Recommendations for Preconception Care. Am Family Physician. 2007; 76:397-400 Frey KA. Preconception Care by the Nonobstetrical Provider. Mayo Clin Proc 2002; 77:469-73 Brundage, SC. Preconception Health Care. Am Family Physician. 2002; 2507-14 American College of Obstetrics and Gynecology. Clinical Management Guidelines for Obstetrician-

Gynecologists- Chronic Hypertension in Pregnancy. ACOG Practice Bulletin 2005; 29. Gregg AR. Hypertension in Pregnancy. Obstet Gynecol Clin. 2004;31(2):223-41. Obstetric Analgesia and Anesthesia: 1980 Bonica JJ. World Federation of Anaesthesiologists,

Amsterdam, from http://homepages.ed.ac.uk/asb/SHOA2/chpt1.htm Rosenn B, Miodovnik M, Kranias G, et al. Progression of diabetic retinopathy in pregnancy:

association with hypertension in pregnancy. AM J Obstet Gynecol 1992;13:34-40. Jovanovic, L. Pre-pregnancy counseling in women with diabetes mellitus. Up To Date 15.3 Ferrer RL, Sibai BM, Mulrow CD, et al. Management of mild chronic hypertension during

pregnancy; a review. Obstet Gynecol. 2000; 96: 849-860 Driul L, Cacciaguerra G, Citossi A. Prepregnancy BMI and adverse pregnancy outcomes. Arch

Gynecol Obstet. 2007 Bianco AT, Smilen SW, Davis Y, Lopez S, Lapinski R, Lockwood CJ. Pregnancy outcome and weight

gain Recommendations for the morbidly obese. Obstet Gynecol. 1998;91:97-102 Rosenberg TJ, Garbers S, Chavkin W, Chiasson MA. Prepregnancy weight and adverse perinatal

outcomes in an ethnically diverse population. Obstet Gyneco. 2003;102:1022-7. Xiong, X, Buekens, P, Fraser, WD, et al. Periodontal disease and adverse pregnancy outcomes: a

systematic review. BJOG 2006; 113:135. March of Dimes Foundation. Huge Drop in Preterm Birth Risk among Women. 2008 February 1 Weng, X; Odoluli, R; Li, DK. Maternal caffeine consumption during pregnancy and the risk of

miscarriage: a prospective cohort study. Am J Obstet Gynecol. 2008; 198:279 Oncken C; Dornelas E; Green J; et al. Nicotine gum for pregnant smokers: a randomized controlled

trial. Obstet Gynecol. 2008; 112:859-67

Documents

Preconception Counseling for women Dr,B.Khani Questions What is preconception care? What is the role of the ob&gyn in providing preconception care? What