Preconception Care: What Should a Reproductive Healthcare Provider Do? Jody Steinauer, MD, MAS Dept. Ob/Gyn & Reproductive Sciences University of California, San Francisco Disclosures • I have no relevant financial disclosures. Acknowledgements • Michael Policar and Beth Harleman
Objectives • Define preconception care • List medical conditions that increase adverse outcomes in pregnancy • Review the Reproductive Life Plan • Describe recommended preconception care practices
Why Preconception Care? • Since 1996, progress in the US to improve pregnancy outcomes has slowed, in part, because of inconsistent implementation of interventions before pregnancy to detect, treat, and help women modify behaviors, health conditions, and risk factors that contribute to adverse maternal and infant outcomes CDC, MMWR 2006;55(No. RR ‐ 6): 1 ‐ 23 Why Does Prenatal Care Have Limited Effect on Outcomes? • Most problems exist before onset of PNC • Small improvements are hard to detect • PNC limited effect on women who have not changed their behaviors due to pregnancy • PNC has limited impact on – Prematurity – Congenital anomalies: – Critical period of teratogenesis – Day 17 to Day 56
Infant Deaths by Cause; US 2002 9 % NN Deaths 6 % Inf. Deaths National Center for Health Statistics, period linked birth/infant death data. www.marchofdimes.com/peristats. Infant Deaths: Maternal Complications of Pregnancy National Center for Health Statistics, period linked birth/infant death data. www.marchofdimes.com/peristats.
Infant Deaths due to Maternal Complications of Pregnancy, U.S. Cause of death for 1996 ‐ 1998 is based on the Ninth Revision, International Classification of Diseases (ICD ‐ 9); cause of death for after 1998 is based on the Tenth Revision, International Classification of Diseases (ICD ‐ 10). Data after 2001 are impacted by cause of death coding changes for maternal complications of pregnancy and not comparable to earlier years Source: National Center for Health Statistics, period linked birth/infant death data. Retrieved June 27, 2014, from www.marchofdimes.com/peristats. Infant Deaths due to Prematurity Low Birthweight, US National Center for Health Statistics, period linked birth/infant death data. www.marchofdimes.com/peristats.
Infant Deaths due to Prematurity Low Birthweight, U.S. Cause of death for 1996 ‐ 1998 is based on the Ninth Revision, International Classification of Diseases (ICD ‐ 9); cause of death for after 1998 is based on the Tenth Revision, International Classification of Diseases (ICD ‐ 10). Source: National Center for Health Statistics, period linked birth/infant death data. Retrieved June 27, 2014, from www.marchofdimes.com/peristats. Many Maternal Health Conditions Cause Adverse Birth Outcomes • Diabetes, hypertension, obesity • Depression • Sexually transmitted infections • Alcohol, tobacco, prescription medications, illicit drugs
US Birth Rates by Selected Age of Mother, 1990 ‐ 2011 Hypertension • 8% of women ages 20 ‐ 44 have HTN, 28% have prehypertension • Rate of increase in women 2x that of men • African Americans have highest rates • Obesity associated with 4x increased risk • HTN in pregnancy: low ‐ birth weight, IUGR, abruption, PTD, perinatal mortality NHANES 2011-2012
Figure 1. Prevalence of hypertension by body mass index (BMI)and for reproductive aged women, 20–44, United States, National Health and Nutrition Examination Survey, 1999–2008 Bateman BT, Shaw KM, Kuklina EV, Callaghan WM, et al. (2012) Hypertension in Women of Reproductive Age in the United States: NHANES 1999-2008. PLoS ONE 7(4): e36171. doi:10.1371/journal.pone.0036171 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036171 Age ‐ adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Centers for Disease Control and Prevention: National Diabetes Surveillance System http://www.cdc.gov/diabetes/statistics
Diabetes Rates by Age of Mother Preconception Care 101 • 2002 : Systematic review of 21 trials – Need to promote readiness for pregnancy • 2005: First National Summit on Preconception Care and CDC select panel • 2006: CDC recommendations (in MMWR) for PCHC – 10 recommendations and key action steps • Preconception Health and Health Care Initiative – Clinical workgroup published report in 2008 – Assessment of evidence
2006: CDC recommendations for PCHHC
Definition of Preconception Care • Preconception care is comprised of interventions that aim to identify and modify biomedical, behavioral, and social risks to a pregnancy outcome through prevention and management, emphasizing those that must be acted on before conception or early in pregnancy to have maximal impact • It is more than a single visit. It includes care before a first pregnancy or between pregnancies (interconception care.) CDC, MMWR 2006;55(No. RR ‐ 6): 1 ‐ 23
Effect of Short Inter ‐ pregnancy Intervals Obstetric Outcomes 3 2.54 2.5 1.73 1.72 2 1.33 1.3 1.5 1 0.5 0 3rd Tri VB PPROM PP Anemia Maternal Endometritis Death Odds Ratio at pregnancy intervals of <6 months vs. 18 ‐ 23 months N=500,000 Conde ‐ Agudelo et al. BMJ 2000 Effect of Short Inter ‐ pregnancy Intervals Neonatal Outcomes 2.5 2.01 1.8 1.95 1.88 2 1.49 1.54 1.3 1.5 1 0.5 0 early fetal *low very low *PTD <37 PTD *SGA neonatal death brith wt birth wt wks <32wks (<10%) death (<2500g) (<1500g) Odds Ratio at pregnancy intervals of <6 months vs. 18 ‐ 23 months N=1.2 million Conde ‐ Agudelo et al. Ob/Gyne 2005
CDC 2006: Four Goals for Preconception Health • Improve knowledge, attitudes, and behaviors of men and women • Assure that all women of childbearing age receive preconception care services • Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period; and • Reduce the disparities in adverse pregnancy outcomes. 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 Can be reduced from ~10% to 2 ‐ 3% control of mother (including sacral through glycemic control of the agenesis, cardiac defects and neural woman before organogenesis tube defects) The National Preconception Curriculum and Resources Guide for Clinicians
Examples of Primary Prevention Opportunities: Congenital Anomalies The Opportunity: The Potential Benefit: Minimize a prospective mother’s Teratogenic substances interfere contact with teratogenic exposures with normal organ development such as prescribed medications, primarily during the period of environmental exposures and organogenesis alcohol The National Preconception Curriculum and Resources Guide for Clinicians What are Components of Preconception Care? Assess Risk Health, pregnancy intention, contraception • Give Protection • Folic acid, immunizations Manage Conditions Diabetes, Obesity, Hypothyroidism, STI • Avoid Harmful Exposures • Medications, alcohol, tobacco
Reframe Clinical Visits as Preparation for Possible Pregnancy • Identify risk factors for herself and potential pregnancies • Counsel about strategies to reduce risk • Includes well ‐ woman visits, family planning encounters, chronic disease visits, postpartum Assess Risk Pregnancy Intendedness • Recommendation: S creen women for their intentions to become or not become pregnant in the short ‐ and long ‐ term and their risk of conceiving a pregnancy • Educate patients about how the reproductive life plan impacts contraceptive and decision ‐ making • Every woman should receive information and counseling about all forms of contraception and emergency contraception Assess Risk
Screen for Risk of Pregnancy Women who use less ‐ effective contraceptives • Relatively high risk of method failure • Many women with method failure will continue pregnancy to term • Study of 172 PCPs • Underestimated unintended pregnancy risk • Underestimated failure rate of pills, condoms • How do we promote effective contraception with a message to prepare for a healthy pregnancy? Assess Risk Paris, Contraception, 2012. Reproductive Life Plan Questions • Do you hope to have (any more) children? • How long do you plan to wait? • How much space between pregnancies? • What do you plan to do until you are ready to become pregnant? • What can I do today to help you achieve your plan? A Assess Risk
Assess Risk: History • Reproductive history (PTB, CD, losses) • Environmental hazards and toxins • Medications that are known teratogens • Nutrition, folic acid intake, weight management • Genetic conditions and family history • Substance use, including tobacco and alcohol • Chronic medical conditions (DM, HTN) • Infectious diseases and vaccination • Family planning • Psychosocial concerns (depression or violence) Assess Risk Assess Risk: Infectious Disease Screening • HIV Screening (A) – Once for all adults then based on risk • Chlamydia Screening (A) • HPV/cytology screening (A) • For high ‐ risk women – HCV (C), TB (B), GC (B), Syphilis (A) • Question – BV for h/o PTB (C) • Counseling (C) – CMV (high ‐ risk women), Listeria Assess Risk A= good support; B = fair support; C= insufficient
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