preconception counseling
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PRECONCEPTION COUNSELING. A “BEST” BUT UNCOMMON PRACTICE. INTENDEDNESS. 2002 DATA: 30.8% ALL WOMEN AGE 15-44 HAVE EXPERIENCED AN UNINTENDED BIRTH ESTIMATE THAT 49.2% ALL PREGNANCIES UNININTENDE (nsfg). ORGANOGENSIS. DAYS 17-56 POST CONCEPTION - PowerPoint PPT PresentationTRANSCRIPT
PRECONCEPTION COUNSELING
A “BEST” BUT UNCOMMON PRACTICE
INTENDEDNESS 2002 DATA: 30.8% ALL WOMEN
AGE 15-44 HAVE EXPERIENCED AN UNINTENDED BIRTH
ESTIMATE THAT 49.2% ALL PREGNANCIES UNININTENDE (nsfg)
ORGANOGENSIS DAYS 17-56 POST CONCEPTION
FIRST DAY OF “MISSED” PERIOD IS DAY 14 POST-CONCEPTION
DAY 56 IS ABOUT 6 WEEKS ALL ORGANS FORMED BY WEEK 9
Prevention, in order to be truly preventive, must be antenatal
J. W. Ballantyne in 1902
Maternal Mortality per 100,000 live births
0
100
200
300
400
500
600
700
800
1900 1960 1980 2000
Rate Increase from 1980-2000
0%
5%
10%
15%
20%
25%
30%
Preterm Very Preterm LBW VLBW
Infant Deaths per 1000 Live Births
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
1960 1980 2000
1960: Maternal complications of pregnancy not on top 10 list of leading causes of infant mortality1980: Number 52001: Number 3
2002: 46% of infant mortality related to congenital anomalies, LBW, Preterm Delivery and Maternal complications
2004 Behavioral Risk Factor Surveillance System Phone survey of Americans > 18
years of age Median response rate >52% Content varies by state Defined as preconceptional if:
Wanted a baby in next 12 months, not using contraception, not sterile and not already pregnant
BRFSS 2004
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Pregnant Preconceptional
Amongst reproductive aged women
6.1% asthma 11.4% smoke
5% obese 54.9% consume alcohol
3.4% cardiac dz 80% dental caries &other oral diseases
3% hypertension PRENATAL CARE IS TOO
9.3% diabetes LATE
1.4% thyroid diseaseMaternal-Child Health J 2006 10:s3-s11
Spartan Preconception Recommendations a la Plutarch
“ordered the maidens to exercise themselves with wrestling, running, throwing the quoit and casting the dart, to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth”
Preventing Low BirthweightInstitute of Medicine 1985
“…one of the best protections available against low birth weight and other poor pregnancy outcomes is to have a woman actively plan for pregnancy, enter pregnancy in good health with as few risk factors as possible, and be fully informed about her reproductive and general health”
IOM-1985 Family planning services essential
to preconception initiatives Reproductive health/family
planning must introduce concept of pre-pregnancy wellness
Developed concept of preconception consultation
Expert Panel on the Content of Prenatal Care: 1989 “Rosen Report”
Preconception visit may be the single most important health care visit with respect to impact on pregnancy outcome
Preconception counseling most likely to be effective when provided in context of general preventive care OR primary care visits Concept of “Opportunistic Care”
ROSEN REPORT Risk Assessment Health Promotion Intervention Follow up
Healthy People 2000 Increase to at least 60% the
proportion of primary care providers who provide age-appropriate preconception care and counseling
Deleted in 2010 Healthy People as not measurable
Toward Improving Outcome of Pregnancy: The 90’s and BeyondMOD 1993
Concept of “reproductive awareness”
Called for a new strategy to reach each woman of child-bearing age with reproductive awareness messages at every health encounter
ACOG 1995: First technical bulletin on Preconception Care
Thorough & Systematic ID of risks Provision of education
individualized to patient needs Initiation of desired interventions
2002: Guidelines for Perinatal Care AAP/ACOG
Emphasized integration of pre-conceptional health into ALL health encounters in reproductive age women
Average woman of childbearing has 6.4 visits to MD’s per year
Healthy People 2010 No global comment “Increase the proportion of
pregnancies begun with an optimum folate level” (target 80%)
HALLMARKS OF PRECONCEPTION CARE REYNOLDS
PROVIDES WOMEN & FAMILIES INFORMATION AND OPPORTUNITIES TO MODIFY UNHEALTHY BEHAVIORS AND THUS POTENTIALLY IMPROVE THE QUALITY OF THEIR LIVES
INCREASE REPRODUCTIVE CHOICES, POSSIBLY DECREASED UNINTENDED & UNWANTED PREGNANCIES
HALLMARKS, cont’d IMPROVE PREGNANCY OUTCOME
BY DECREASING INFANT MORTALITY & MORBIDITY
REDUCES THE PROBABILITY OF DAMAGE DURING ORGANOGENESIS
Which women most likely to get preconception care?
Older Married or stable relationship Non Hispanic White Income >$20,000/year Non-smokers Private medical insurance Positive bond with pre-pregnancy
health care provider
NEGATIVE PREGNANCY TEST POPULATION OF ABOUT 100 WOMEN
AT FAMILY PLANNING CLINIC WITH NEG. PREGNANCY TEST
ALL HAD ASSESSMENTS DONE USING PRECONCEPTION RISK SURVEY INSTRUMENT
½ HAD RESULTS REPORTED TO DOC
NEGATIVE PREGNANCY TEST AVERAGE WOMAN HAD 9 IDENTIFIED
ISSUES 21% PSYCHIATRIC/BEHAVIORAL 12% FETAL EXPOSURE 7 – 10%: FAMILY PLANNING, NUTRITION,
GENETIC, MEDICAL, BARRIERS TO CARE, DV, SEXUAL VIOLENCE
2-6%:REPRODUCTIVE HISTORY, STD’S
Best Evidence Focus on a single intervention Not in the context of improving
pregnancy outcomes
PROMOTION OFHEALTHY FUTURE
INFANTS
PROMOTION OFLIFELONGWELLNESS
PROMOTION OFHEALTHY AND
DESIRED PREGNANCIES
PREGNANCY
FAMILY PLANNING/PRECONCEPTIONAL
FAMILY PLANNINGINTERCONCEPTIONAL
CHILDBIRTH
MENOPAUSE
MENARCHE
PREVENTING PREMATURITY SPACING OF PREGNANCIES
LOWEST RATE VERY/MODERATELY PREMATURE INFANTS
18 to 59 MONTHS BETWEEN PREGNANCIES
DISCONTINUE SMOKING PRECONCEPTIONALLY
MODERATE EXERCISE
What We Know: Tobacco Use
Tobacco And Women’s Health: Implicated the
leading causes of death for women:
Heart disease (1) Stroke (2) Lung cancer (3) Lung disease (4)
Tobacco and Reproductive Outcomes: Leading preventable
cause of infant mortality
Preventable cause of low birth weight and prematurity
Associated with placental abnormalities
SMOKING ECTOPIC PREGNANCY PLACENTA PREVIA UNDER-DEVELOPMENT OF
PLACENTA MAY INCREASE RISK OF PREMATURITY
AND BABIES TOO SMALL
15% and 29% of pregnant women smoke during pregnancy
If smoking during pregnancy eliminated, estimated: 10% reduction in perinatal mortality
11% reduction in the incidence of low birth weight
SMOKING:Evidence based counseling
Ask every patient about tobacco use Advise them to quit Assess willingness to quit Assist them in quitting
Pharmocotherapies and additional counseling each DOUBLE quit rate
Arrange follow up 305.10 ICD-10 Code for tobacco
dependence
Effectiveness of smoking cessation programs
25-30% quit rates in general population
Many women spontaneously quit when pregnancy 11-28% publically insured 40-65% privately insured
ACOG COMMITTEE OPINIONOctober 2006 # 316
Smoking is one of the most important modifiable causes of poor pregnancy outcomes in the United States. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment has been proved to increase quit rates. For pregnant women who are light to moderate smokers, a short counseling session with pregnancy-specific educational materials often is an effective intervention for smoking cessation. The 5 A's is an office-based intervention developed for use by trained practitioners. Techniques for smoking reduction, pharmacotherapy, and health care support systems can help smokers quit.
What We Know: Alcohol Use
Alcohol and Women’s Health Risk for MV and other
accidents Risk for unintended
pregnancy Risk for addiction Risk for nutritional
depletions and inadequacies
Alcohol and Reproductive Outcomes Delayed fertility Increased SABs FAS and FAE
ALCOHOL 2002: 8% of American women 18-
44 years of age were sexually active, fertile, not contracepting.
Women age 18-24: 20% binge drink
FAS 0.3-2 per 1000 live births
Project CHOICES CDC sponsored trial Population at high risk of alcohol-
exposed pregnancy (12% binge) Focused on reducing risk drinking
AND postponing pregnancy 4 brief motivational visits and
Family Planning provider visit 68% at reduced risk at 6 months
What We Know: Obesity
Obesity and Women’s Health: Diabetes Hypertension Cardiovascular
disease Disabilities
Obesity and Pregnancy: Glucose intolerance of
pregnancy Pregnancy induced
hypertension Thrombophlebitis Neural tube defects Prematurity Higher rates of difficult births Fetal injury from birth difficulty
OBESITY Increased rates of: infertility,
gestational diabetes, pre-existing diabetes, hypertension, preeclampsia, stillbirth, birth defects, LGA, cesarean sections, long dysfunctional labors, CPD, post partum anemia
Fat is not inert
What can we do about it? Weight loss programs
Tsai and Wadden:, 2005 Weight Watcher least costly, maintenance of 3.2% of initial
weight at 2 years Very Low Calorie Commercial Diet:
Greatest initial weight loss; high costs; high attrition Internet based and organized self-help: minimal weight loss
Low income obese women receiving 5 email messages in pregnancy around maintaining normal weight gain less likely to gain excessive weight
Interconception period important if woman retained a lot of pregnancy weight
What we know: FOLATE Peri conceptional supplementation with 400
micrograms of folate (folic acid) from 3 months preconceptionally to 8 weeks postconceptionally
Decreases rate of spina bifida by 50-70% Decreases rate of cleft lip Decreases rate of heart disease Generally good health habit for adult
cardiovascular health Probably decreases placental problems
EPILEPSY MEDICATIONS
ASSOCIATION WITH SOME MEDICATIONS WITH SOME BIRTH DEFECTS
SOME WOMEN ON ANTI-SEIZURE MEDICATIONS FOR YEARS AFTER A SEIZURE AND MIGHT BE ABLE TO DISCONTINUE
LOWEST POSSIBLE EFFECTIVE DOSE SINGLE DRUG VERSUS MULTIPLE DRUGS
DIABETES GENERAL POPULATION
2-3% RISK OF SEVERE BIRTH DEFECTS DIABETICS PRIOR TO PREGNANCY
POORLY CONTROLLED [Hgb A1c>7] RISK INCREASES TO 6-9% HEART DISEASE, SPINA BIFIDA, OTHER
WELL CONTROLLED PRECONCEPTIONALLY BACK TO BASELINE RATE IN THE GENERAL
POPULATION!
INFECTIONS HEPATITIS B
90% CHRONIC CARRIERS ARE WITHOUT SYMPTOMS
PREGNANCY DOESN’T ALTER COURSE OF DISEASE
IDENTIFY NEONATES FOR FULL VACCINATION AND PROPHYLAXIS
HIGH RISK WOMEN WHO ARE HEP. NEG CAN BE VACCINATED
HIV HELPS INFECTED WOMEN MAKE
INFORMED REPRODUCTIVE DECISIONS
BEGIN MATERNAL CARE PROGRAM HIGH RISK WOMEN CAN BE
COUNSELED RE: RISK REDUCTION
TOXOPLASMOSIS 85% US WOMEN NON-IMMUNE (NHANES) 400-4000 CASES OF CONGENITAL TOXO/YR IN US PRENATAL TESTING VERY DIFFICULT TREATMENT IF KNOWN PRENATAL
SEROCONVERSION PRECONCEPTION TESTING CAN ALTER BEHAVIOR
AVOID FECES IN LITTERBOX/GARDEN AVOID RAW OR UNDERCOOKED MEAT DISPOSE OF CAT LITTER DAILY AND DISINFECT BOX;USE
GLOVES PEEL OR WASH FRUITS AND VEGETABLES
CMV 0.6-1.5% ALL BIRTHS IN US ADULTS USUALLY ASYMPTOMATIC,
MONO LIKE ILLNESS LATENT STATE AFTER INFECTION MOST COMMON SOURCE OF
PRIMARY INFECTION: TODDLERS MOST EFFECTIVE PREVENTION:
HAND WASHING (URINE, SALIVA)
OTHER INFECTIONS STD’S
APPROPRIATE TREATMENT DEAL WITH MONOGAMY ISSUES
VARICELLA AND RUBELLA: IF NEGATIVE ANTIBODY, CAN
IMMUNIZE WAIT THREE MONTHS PRIOR TO
CONCEPTION
WWW.IHEALTHRECORD.ORGCDC, other federal agencies, and medical societies have developed email-based education programs that are offered through the Interactive Health Record (iHealthRecord
Learn what you need to know now to have a safe pregnancy and healthy baby. CDC has a new online education program available for women who are planning to get pregnant.
Health information via email every other week for 3 months as you prepare for pregnancy. You can sign up for CDC’s pregnancy-planning education program by 1. Logging onto WWW.IHEALTHRECORD.ORG2. Signing up for a free iHealthRecord.3. Going to the "Education Programs" page.4. Checking the box next to “Pregnancy Planning: What To Know About Your Health Before You Get Pregnant”.
AAP/ACOG:Components of PCC Physical assessment Risk Screening
Reproductive awareness Environmental toxins/teratogens Nutrition/folate Genetics Substance use Medical conditions/medications Infections/vaccinations Psychosocial concerns
Vaccinations Counseling
Preconception Risk Factors with Developed Clinical Practice Guidelines
Folic Acid Rubella
seronegativity Diabetes Hypothyroidism HIV/AIDS PKU Oral Anticoagulant
Anti-epileptic drugs
Isotretinoins Smoking Alcohol misuse Obesity STD Hepatitis B
MMWR: April 21, 2006 Recommendations to ImprovePreconception Health and Health Care-US
Summary Preconception care
“Opportunistic” Rolled into routine health encounters
for reproductive aged women Needs to be proactive Clinical practice guidelines are
available MMWR April 12, 2006