Preconception care

Laura Tatpati, MDKUMC - WichitaDept of Obstetrics and Gynecology

No disclosures

ObjectivesUnderstand the general importance of preconception careDiscuss the concept of a Reproductive Life Plan Be able to define areas of concern for preconception care

Health promotionNutritionExposures

Substance abuseEnvironmental

Medical/Psychiatric conditions & medicationReproductive HistoryFamily & Genetic History Vaccination counselingID

Psychosocial risk Special populations

The challenge of preconception care lies not only in addressing pregnancy planning for women who seek

medical care and consultation specifically in anticipation of a planned pregnancy but also in

educating and screening all reproductively capable women on an ongoing basis to identify potential

maternal and fetal risks and hazards to pregnancy before and between pregnancies

ACOG Committee Opinion Number 313, September 2005, reaffirmed 2012

1/2 of all pregnancies are unintended

Timing is everything

Vulnerability Begins from 17-56d post-conception

Goals

Screen for risks

Recommend intervention

Promote health & provide education

(the non-judgemental)Reproductive Life Plan

Do you plan to have any (more) children at any time in your future? How many children would you like to have?How long would you like to wait?

<6 mo btwn birth and conception assoc w/ LBW, PT & SGA; > 60mo incr PT & Very SGA

What family planning method do you plan to use until you are ready?

Unintended: Method failure (5%); imperfect use (43%); no contraception

Preconception care topics

Health promotion

Weight Status

Physical Activity

Nutrient Intake

Folate

Substance Use

STIs

Exposures

Weight status & Physical Activity

Weight Status

Near-normal BMI is ideal

Address disordered eating and variants

Malnutrition with obesity and anorexia

Counsel obesity risks: difficulty with conception, birth defects, GDM, C/S, Htn disorders, thromboembolic event, preterm delivery

Physical Activity

Advise for uncomplicated 30min daily exercise most days of week

Review for healthy behaviors

Insulin resistance - increasing evidence for enhanced benefit peri-prandially

Health promotion

Nutrition

Eating disorders are more likely if:

Hx of eating disorder, body distortion endorsement, unusual eating habits

Substance abuse hx

Hx pica in prior pregnancy

High parity

Mental illness

Bariatric surgery hx - vitamin absorption and B12 production issues

Health promotion

Vitamins & Supplements

Folic acid400mcg daily routine & 4mg daily for high risk groupsInitiate 1 mo prior to conceptionNTD risk reduction; Cong heart disease and cleft lip/palate

Vitamin over-usage

What is the single day dose for their brand?

No “mega-dose” vitamins (particularly KADE)

Dietary Supplements - avoidance

Suggest consideration of intake of calcium, iron, Vit D, Vit A, Vit B12 and note that Vit C enhances the absorption of iron

Health promotion

Substance Use/Abuse

Tobacco

5-A tool

Ask about use, Advise to quit, Assess willingness, Assist, Arrange f/u & support

1-877-44U-QUIT

Pharmacotherapy/Refer back to PCP

Alcohol

Address use/misuse & unintended usage during pregnancy

Recreational and Prescription Drug Use/Abuse

Health promotion

Exposures

Environmental/HobbiesPaucity of screening tools and interventions that are rigorously evalutedDiscuss food safety & toxin exposure avoidance

Medications

Lowest effective dose of only necessary medications

Address known teratogens and lack of safety data

Health promotion

Personal & Family Medical History

Reproductive

Prior Cesarean Delivery

Prior Miscarriage

Prior Preterm Birth

Prior Stillbirth

Uterine Anomalies

Known Genetic Conditions (self, child or close family member)

Pre-pregnancy screening coverage???

Consideration of PGD for FH single gene defects

FH MR/Autism/FXTAS

Ethnic based

Hemoglobinopathies

Ashkenazi Jewish panel

Cystic fibrosis

Personal & Family Medical History

Infectious Diseases

STI including HIV Chlamydia - annually prior to 25 and p.r.n. in at-risk > 25

Hepatitis AHepatitis B (if high risk)Rubella (confirm immunity or document MMR)Varicella (history of illness or vaccination)

Hep CCytomegalovirusHerpes Simplex VirusListeriosisMalariaSyphilisToxoplasmosisTuberculosis

Personal & Family Medical History

Immunizations

Avoid conception x 1 mo post-live virus vaccination

Ideal to complete others prior as well to avoid exposures, although no documented issues

Flu: Inactivated flu vaccine (no mist)

Tdap: Offer vaccination (this will be repeated in pregnancy)

Rubella - screen for IgG (some do not convert)

Varicella - Historical screen

At risk populations - Hepatitis screen/vaccinate; Meningococcus, Pneumococcus

HPV - if not completed, recommend; hold completion until after pregnancy prn

Personal & Family Medical History

Medical conditions

Conditions and fetal and maternal risks of pregnancyMedications and risks of teratogenicity or pregnancy associated complicationsAction plan for pregnancy for exacerbation or monitoring

Consideration of MFM &/or IM specialist pre-pregnancy consultation

Asthma

Hx of Bariatric SurgeryCardiovascular DiseaseDiabetes MellitusEating DisordersHypertensionLupusMorbid ObesityPKU - low phenylalanine dietPsychiatric ConditionsRenal DiseaseRheumatoid ArthritisSeizure DisordersThrombophiliaThyroid Disease

Personal & Family Medical History

Psychosocial Risks

Access to Care

Inadequate Financial Resources (transportation/housing)

Safety (domestic violence assessment)

Special populations

Disability

Immigrant and Refugee Populations

Survivors of Cancer

Resources

http://www.acog.org/Resources-And-Publications/Guidelines-for-Perinatal-Care

cdc.gov - preconception care