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• Duration of pregnancy is no longer “9” months, it’s “12” monthsACOG & AAP: prenatal care before conception• PCC:Concept has evolved over the last several decadesForm of primary care & prevention
12 NOT 9
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Outline
• Definition & Goals• Why Do We Need PCC?• Components • Scientific Evidence • Current Recommendations• Barriers• Implementation
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DefinitionA set of interventions that
aim to identify & modify (biomedical, identify & modify (biomedical, behavioral & social) risksbehavioral & social) risks to a woman’s health or pregnancy outcome
through prevention & managementprevention & management (CDC, 2006)
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Goal
• Goal should be realistic To identify pre-existing conditions
that may affect an anticipated pregnancy
Identification process involves mother& fetus
This may allow for intervention(s) that could lead to more favorable outcome
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Currently: Poor pregnancy outcomes Women enter pregnancy “at risk” for
adverse outcomes We intervene too late There is consensus that: Intervening before pregnancy will
help improve outcomes
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Early ANC is too late 1. To Prevent Some Birth Defects The heart begins to beat at 22 days after conception The neural tube closes by 28 days after conception The palate fuses at 56 days after conception Critical period of teratogenesis – D17 to D562. To Prevent Implantation Errors3. To restore allostasis: Maintain stability through changeAn important objective of PCC is to restore allostasis to women’s health before pregnancy
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Critical Periods of DevelopmentCritical Periods of Development
4 5 6 7 8 9 10 11 12Weeks gestation from LMP
Central Nervous SystemCentral Nervous System
HeartHeart
ArmsArms
EyesEyes
LegsLegs
TeethTeeth
PalatePalate
External genitaliaExternal genitalia
EarEar
Missed Period Mean Entry into ANC
Most susceptible time for major malformation
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From Anticipation & Management to Health Promotion& Prevention
From Healthy Mothers Healthy Babies to Healthy Women Healthy Mothers Healthy Babies
Paradigm Shift
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ComponentsCDC, 2007
I. Risk Assessment
II. Health promotion
III.Interventions
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A. Risk Assessment
I.Reproductive life plan:
If she plans to have children?How long she plans to wait until she becomes pregnant?
Plan based on: her values & resources, to achieve those goals
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II. History
1. Reproductive history:
Previous adverse outcomes:infant death, fetal loss, birth defects, low birth weight, PTL
2. Medical history:
Rheumatic heart diseaseThromboembolismAutoimmune diseasesHypertensionDiabetes
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3. Medication use:
Current medicationAvoid FDA Category X:Estrogen, androgens, Aminopterin, isotretinoin, Thalidomide
Category D: Phenytoin, valporic acid, diazepam, Imipramine, captopril, thiazides, Spironolactone, coumarine, chlorpropamide, Progestins, tetracyclin,streptomycin, Quinine, methotrexate, vinblastin, Azathioprine.
unless maternal benefits outweigh fetal risks; Over-the-counter medications, herbs & supplements
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4. Substance abuse:
TobaccoAlcoholdrug use
5.Toxins & teratogenic agents: At home, in the neighborhood, in the workplace:heavy metals,solvents,pesticides, endocrine disruptors, allergens
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II. Physical examination:
1. Nutritional assessment: Assess the ABCDs of nutrition:
anthropometric factors (e.g., BMI) biochemical factors (e.g., anemia) clinical factorsdietary risks
2. Focus on
Periodontal, thyroid, heart, breast, pelvic examination
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III. Screening
1. Infections &immunizations: Screen for periodontal, urogenital & STD as indicated; Update immunization with hepatitis B, rubella, varicella, Tdap, HPV & influenza vaccines as needed
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2. Genetic screening:
Based on: family history ethnic backgroundAge
Offer cystic fibrosis & other carrier screening as indicated
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3. Psychosocial concerns:
Screen for depression, anxiety, domestic violencemajor psychosocial stressors
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4. Laboratory testing:
Testing should includeCBC; urinalysis; blood type & screen
When indicated screen for Rubella, Syphilis, Hepatitis B,HIV, Gonorrhea, ChlamydiaDiabetesThyroid DysfunctionCervical cytology
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B. Health Promotion1.Family planning: Based on the patient’s reproductive life planEffective contraceptive use Discuss emergency contraception
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2. Healthy weight and nutrition:
Ideal BMI: 20 to 26.0 kg/m2 ExerciseNutrition
Macro & micronutrients:Getting “five a-day”: 2 servings of fruit +3 servings of vegetables Daily multivitamin that contains folic acid
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3. Healthy behaviors: NutritionExerciseSafe sexEffective contraceptive useDental flossingPreventive health services Discourage risky behaviors: DouchingNot wearing a seatbelt, Smoking: use the five A’s [Ask, Advise, Assess, Assist, Arrange] for smoking cessationAlcoholSubstance abuse
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4. Healthy Environments:
Discuss household, neighborhood & occupational exposures to heavy metals, organic solvents, pesticides, endocrine disruptors & allergens
Give practical tips such as how to avoid exposures
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5. Stress resilience: Promote nutrition, exercise, sufficient sleep, and relaxation techniques; Address ongoing stressors (e.g., domestic violence)Identify resources to help the patient develop problem solving and conflict-resolution skills, positive mental health, and strong relationships6. Interconception care: Promote breastfeeding, placing infants on their backs to sleep to reduce the risk of sudden infant death syndrome, positive parenting behaviors, and the reduction of ongoing biobehavioral risks
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C. Interventions
1. Folic acid supplementation Reduces NTD by two thirds.
2. Rubella vaccination protection against congenital rubella syndrome.
3. Hepatitis B vaccination for at risk women: Prevents transmission of infection to infantsEliminates the risks to the women of hepatic failure, liver
carcinoma, age cirrhosis & death due to HBV infection.
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4. Diabetes management: reduces birth defects among infants of diabetic women.
5. Hypothyroidism: protects proper neurological development.
6. HIV/AIDS screening: Allows for timely treatment Provides women (or couples) with additional information
that can influence the timing of pregnancy & treatment.
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7. STD screening& TT
Reduces the risk of ectopic pregnancy, infertility, chronic pelvic pain associated with Ct & NG
Reduces risk to a fetus of fetal death or physical & developmental disabilities, including mental retardation & blindness.
8. Maternal PKU management: Prevents babies from being born with PKU-related mental
retardation.
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9. Switching women off Oral anticoagulant: avoids harmful exposure.
10. Antiepileptic drug: Changing to a less teratogenic tt reduces harmful exposure.
11. Accutane (isotretinoin) use management: Preventing pregnancy for women who use ORStop before conceptioneliminates harmful exposure.
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12. Smoking cessation: Prevent: PTLlow birth weightother adverse perinatal outcomes.
13. Eliminating alcohol usePrevents fetal alcohol syndromeother alcohol-related birth defects.
14. Obesity control: Reduces the risks of NTD, PTL, DM, CS, HypertensionThromboembolic disease
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PPC for men• Alcohol
May be associated with physical & emotional abuse
May decrease fertility• Genetic Counseling• Occupational Exposure - lead• STD
– Syphilis, herpes, HIV
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Scientific EvidenceDoes PCC work?
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There is evidence that individual components of PCC work:
• Rubella vaccination• HIV/AIDS screening• Management and
control of:– Diabetes– Hypothyroidism– PKU– Obesity
• Folic Acid supplements (level 2)
• Avoiding teratogens:– Smoking – Alcohol (level 2)
– Oral anticoagulants– Accutane
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Clinical Practice Guidelines
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Clinical practice guidelines for PCC of specific maternal health conditions have been developed by professional organizations:
• American Diabetes Association (Diabetes -2004)
• American Association of Clinical Endocrinologists (Hypothyroidism – 1999)
• American Academy of Neurology (Anti-epileptic drugs)
• American Heart Association/American College of Cardiologists (Anti-epileptic drugs - 2003)
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ACOG/AAP (2002)
All health encounters during a woman’s reproductive
years, particularly those that are a part of PCC
should include counseling on appropriate medical
care and behavior to optimize pregnancy outcomes.ACOG/AAP Guidelines for perinatal care, 5th edition, 2002
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USPHS
“Every woman (and, when possible, her partner) contemplating pregnancy within one year should consult a prenatal care provider. Because many pregnancies are not planned, providers should include preconception counseling, when appropriate, in contacts with women and men of
reproductive age….Such care should be integrated into primary care services.”
USPHS Expert Panel on the Content of Prenatal Care, 1989
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Barriers
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I. Patient Aspects• High rate of unintended pregnancies• Ignorance about importance of good health habits prior to
conception• Limited access to health services in general.
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II. Provider Aspects
• Feeling of having inadequate knowledge
• Perception of PCC being time consuming
• Lack of awareness of how to integrate PCC into practice
• Concern about insurance reimbursement.
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III. Other Barriers:
• Availability of contraceptives• Health Insurance Coverage• Out of Pocket Expenses.
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Implementation
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Who Should Get PCC? • PCC should be provided to all reproductive age
individuals
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WHO TO PROVIDE? – OB-GYNs– Pediatricians, Family Medicine, Internists,– Nurses– Genetic Counselors– Health Educators
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Why Should Ob/Gyns be Concerned with PCC?
• OB/GYN’s have the most frequent contact with women
of childbearing age are aware of prior poor pregnancy outcomes Responsible for ANC already have the knowledge & are applying it advantage to improve pregnancy outcomes
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How PCC can be Integrated into Practice?I. OB-GYNs
1. WHC:- Our best opportunity - Single or multiple visits- Ask about reproductive life plan- If she plans to have child in next 1-2 yrs: she & husband
should return for full visit.
2. Negative pregnancy test: an opportunity for PCC
3. Family planning encounter
4. Infertility evaluation
5. Following a poor pregnancy outcome
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CONCLUSION“PCC is the cornerstone of healthy infants,
children, families & communities”
Thank you