Preconception Care: What Should a Reproductive Healthcare Provider - - PDF document

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
• utcomes in pregnancy
• Review the Reproductive Life Plan
• Describe recommended preconception care

practices

Why Preconception Care?

• Since 1996, progress in the US to improve pregnancy
• utcomes 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

National Center for Health Statistics, period linked birth/infant death data. www.marchofdimes.com/peristats.

9 % NN Deaths 6 % Inf. Deaths

Infant Deaths: Maternal Complications of Pregnancy

National Center for Health Statistics, period linked birth/infant death data. www.marchofdimes.com/peristats.

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 Maternal Complications of Pregnancy, U.S. Infant Deaths due to Prematurity Low Birthweight, US

National Center for Health Statistics, period linked birth/infant death data. www.marchofdimes.com/peristats.

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.

Infant Deaths due to Prematurity Low Birthweight, U.S. 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

0.5 1 1.5 2 2.5 3

3rd Tri VB PPROM PP Endometritis Anemia Maternal Death

1.73 1.72 1.33 1.3 2.54

Conde‐Agudelo et al. BMJ 2000

Odds Ratio at pregnancy intervals of <6 months vs. 18‐23 months

N=500,000

Obstetric Outcomes

Effect of Short Inter‐pregnancy Intervals

1.49 1.54 1.88 2.01 1.8 1.95 1.3

0.5 1 1.5 2 2.5

early neonatal death fetal death *low brith wt (<2500g) very low birth wt (<1500g) *PTD <37 wks PTD <32wks *SGA (<10%)

Conde‐Agudelo et al. Ob/Gyne 2005

Odds Ratio at pregnancy intervals of <6 months vs. 18‐23 months

N=1.2 million

Neonatal Outcomes

CDC 2006: Four Goals for Preconception Health

• Improve knowledge, attitudes, and behaviors
• f 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
• utcomes.

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

• rganogenesis—before she receives

her prenatal vitamins Birth Defects related to poor glycemic control of mother (including sacral agenesis, cardiac defects and neural tube defects) Can be reduced from ~10% to 2‐3% through glycemic control of the woman before organogenesis 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 contact with teratogenic exposures such as prescribed medications, environmental exposures and alcohol Teratogenic substances interfere with normal organ development primarily during the period of

• rganogenesis

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: Screen 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?

Assess Risk A

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

Give Protection: Take Folic Acid

• Folic acid supplementation reduces neural

tube defects by two thirds

• Recommendations

–All women of childbearing age should take a folic acid‐containing multivitamin supplement –All women should ingest 0.4 mg (400 mcg)

• f folic acid daily

–Start at least 3 months before conception Give Protection A

Give Protection: Vaccinations

• MMR (A) – screen first – contraindicated in preg
• TdaP (B) – now recommended in pregnancy
• Hepatitis B (A)
• Varicella (B) screen first – contraindicated in preg
• HPV (B)
• Influenza

– All pregnant women in flu season

Give Protection

Manage Conditions: Hypertension

• Stop ACE inhibitors

– Calcium channel blocker and/or diazide

• Lifestyle modifications
• Mild essential hypertension

– Consider stopping meds (short time period) – Goal in pregnancy is <160/100

• Severe HTN, multiple medications, end‐organ

– Control blood pressures – Early prenatal care – may be candidate for ASA end of first trimester

Manage Conditions A

Manage Conditions: Diabetes

• All women with diabetes should be counseled

about DM control before considering pregnancy – Maximize control with self‐glucose monitoring

• *Insulin if necessary

– Regular exercise program / weight control

• Before pregnancy goal: HgA1C <6 (5.5 if possible)

– Increased pregnancy loss at HgA1c>6 – Increased defects >8

• Poorly controlled DM – encourage effective birth

control until control

Manage Conditions A

Manage Conditions: Healthy Weight

• Annual BMI calculation
• BMI ≥ 25 kg/m2 should be counseled about

risks to future pregnancies, including infertility

– Offer specific strategies to decrease caloric intake and increase physical activity, such as structured weight loss programs – Exercise alone decreases risk

• Low BMI (<20 kg/m2) – counsel about risk;

screen for eating disorders Manage Conditions A

Manage Conditions: Thyroid Dz

• Hypothyroidism

– Women must continue to take levothyroxine if they become pregnant – Dosages increase during early pregnancy

• Should be seen immediately
• If not possible take 2 additional doses per week until

PNC

• In pregnancy goal TSH <2.5 first trimester and <3 2nd

and 3rd trimesters

Manage Conditions A

Manage Conditions: Thyroid Dz

• Ensure 150‐200 mcg/day iodine in PNC
• Hyperthyroidism – treated medically

– Recommend PTU in first trimester and Methimazole in 2nd and 3rd trimesters – PTU – hepatotoxicity later in pregnancy – Methimazole – scalp deformities in 1st trimester

Manage Conditions

Manage Conditions: Seizure Disorders

• Counsel about risks of increased seizures

during pregnancy and risks of medications

– Trial off meds in those without a recent seizure

• Contraception

– Many enzyme‐inducing meds make hormonal contraception less effective* – CHC also decreases efficacy of seizure meds: lamotrigine monotherapy and valproate

Manage Conditions A

*Carbamazepine, Felbamate, Oxcarbazepine, Phenobarbatol, Phenytoin, Topiramate

Manage Conditions: Seizure Disorders

• The least toxic anticonvulsant medication should be

initiated before pregnancy and adjusted for lowest effective range (avoid valproate, phenytoin)

• For women taking antiepileptic drugs who are

considering a pregnancy, folic acid supplementation 4 or 5 mg/day is recommended for 1 month prior to conception and until the end of the 1st trimester

Manage Conditions A

Avoid Exposures: Smoking

• Adverse perinatal outcomes can be prevented

if women stop smoking before pregnancy

• 11% prenatal smoking
• IUGR, PTD, LBW, SIDS
• Stopping smoking would deaths by 5%
• Only 20% of women successfully stop during

pregnancy

– Surgeon general’s website

Avoid Harmful Exposures A

Avoid Exposures: Alcohol

• 12% prenatal drinking and 3% binge
• IUGR, birth defects, FAS
• No established safe level of alcohol

– Many organizations ‐ 1‐2 units of alcohol 2 x/ wk

• Data on light drinking and obstetric outcomes

– No convincing evidence of harm but overall evidence is weak so hard to conclude safety – Binge drinking is bad.

• ACOG toolkit

Avoid Harmful Exposures

Patra, BJOG, 2011; McCarthy, Ob Gyn, 2013

A

Avoid Exposures: Limits of the FDA Classification

• Hard to remember
• NOT a gradation of risk
• May be misleading
• 60% of category X drugs have no human data
• No information on degree of risk
• No information on timing of administration
• A drug may end up in category X simply if it has no

utility in pregnancy

• Rarely updated

Avoid Harmful Exposures

Does the FDA Classification System Make Prescribing Safer?

• 50% of pregnant women taking meds receive

a category C, D or X drug

• 1 in 6 reproductive age women receive a

category D or X drug

• Women who received a D or X drug are no

more likely to have documentation of contraception than A or B drugs

Schwarz EB, Ann Int Med 2007, Sept 18; 147(6): 370-6

Avoid Harmful Exposures

Drugs to Avoid in Pregnancy

• ACE‐I: fetal renal failure and hypotension
• Tetracycline: abnormalities of bone and teeth
• Fluoroquinolones: abnl cartilage development
• Systemic retinoids: CNS, craniofacial, CV defects
• Warfarin: skeletal and CNS defects
• Anticonvulsants
• Valproic acid: neural tube defects and Phenytoin: syndrome
• Lamotrigine: (higher doses)? Carbamazepine?
• NSAIDS: bleeding, premature closure of the ductus

arteriosis

• Live vaccines (MMR, oral polio, varicella, yellow fever):

may cross placenta

• Aspirin: First trimester

Avoid Harmful Exposures A

Medication Resources

• Drugs in Pregnancy and Lactation, 2011.
• Medical Care of the Pregnant Patient, 2007,

www.acponline.org

• Reprotox (free for trainees)
• Uptodate
• NIH

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

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

Georgia Preconception Toolkit

• Study of 300 low‐income women
• 10‐minute targeted intervention
• Improved knowledge at 3 & 6

months

Dunlop, AJ Health Promotion, 2013

CDC Resources ACOG, CME

Summary

• All clinical interactions with women of

reproductive age should include assessment

• f pregnancy intention and risk.
• Interventions before pregnancy can positively

affect pregnancy outcomes.