preconception counseling for women dr,b.khani questions what is preconception care? what is the role...
TRANSCRIPT
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
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
Typical Patient Visit
Chief Complaint History of Present Illness Past Medical History
Immunizations Infections Previous Pregnancies Chronic Diseases
Medications Family History
Social History Physical Exam Assessment and Plan
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
Typical Patient Visit
Chief Complaint History of Present Illness Past Medical History
Immunizations Infections Previous Pregnancies Chronic Diseases
Medications Family History
Social History Physical Exam Assessment and Plan
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
Typical Patient Visit
Chief Complaint History of Present Illness Past Medical History
Immunizations Infections Previous Pregnancies Chronic Diseases
Medications Family History
Social History Physical Exam Assessment and Plan
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
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
Typical Patient Visit
Chief Complaint History of Present Illness Past Medical History
Immunizations Infections Previous Pregnancies Chronic Diseases
Medications Family History
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- 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.
Typical Patient Visit
Chief Complaint History of Present Illness Past Medical History
Immunizations Infections Previous Pregnancies Chronic Diseases
Medications Family History
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
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