reproductive health early pregnancy and preconception care€¦ · • at least 1 dental visit...

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DOS CME Course 2012

DOS CME Course 20122 DOS CME Course 20112 Oxtober 20102Confidential

Reproductive Health

Early Pregnancy and Preconception Care

Cynthia Cover CNM, MSNDirector, Midwife Services

Womens Health Institute Cleveland Clinic

Elliot H. Philipson, MD MBA Professor, CCLCMChairman, Department of Ob/Gyn at Hillcrest Hospital Division of Maternal-Fetal MedicineWomens Health Institute Cleveland Clinic

© Cleveland Clinic 2012

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Preconception Care

• ~ 50% of all pregnancies in US are unplanned/unintended

• Preconception counseling needs to be an integral part of primary care and incorporated into all health encounters for reproductive age women

• Safe motherhood begins before conception with proper nutrition and a healthy lifestyle

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• Use a checklist to cover essential topics

• Med / Surg hx

• Ob / Gyn hx

• Genetic and family medical history

• Immunization status: varicella, rubella, hepatitis B

• Lifestyle Issues: nutrition, exercise, avoidance of teratogens, oral hygiene, hazards in the workplace and occupational exposure to teratogens

• Prenatal vitamin, Folic acid, DHA

• Consider screening for STDs, anemia, pap

• Health insurance coverage

Preconception Visit


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• H2O soluble B Vitamin so need daily

• Minimum 400 mcg/d reduces neural tube defects by 70%

• Prescription prenatal vitamins contain 1 mg; OTC prenatal vitamins contain 800 mcg; OTC multivitamins contain 400 mcg

• If on seizure meds or if previous hxneural tube defect, ↑ FA dose to 4mg/d, start before conception, and take thru 1st trimester, consider synthetic folate

• Latinas have a 1.5-2x risk of NTDs: “enriched” corn meal important as dietary source of folic acid (advise to choose corn over flour tortillas)

Folic Acid To Prevent Spina Bifida, Anencephaly, Cleft Lip/Palate And Some Heart Defects

Ideal to start folic acid 1 to 3 months before conception


www.kabiassi.com/advice/index-63.html

• Decreased fertility

• Increased– miscarriage, ectopic, low birth

weight, SIDS, preterm birth, placenta previa, premature rupture of membranes, placental abruption

• Environmental tobacco smoke– Smaller birth weight, risk for IUGR

Tobacco Adverse Effects


Kiwipolemicist.files.wordpress.com/

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Tobacco Use : A Smoking Intervention Proven Effective For Pregnant Women

5 step counseling

• Asking every pt. about tobacco use

• Advising them to quit

• Assessing willingness to quit within the next 30 days

• Assisting them in quitting

• Arranging follow-up

Pharmacotherapy (nicotine patch, gum or Chantix) not sufficiently tested for efficacy or safety in pregnancy

ACOG Committee Opinion, Sept 2011


www.gidos.org

Alcohol in Pregnancy

• ~20% of pregnant women worldwide consume ETOH

• > 7 drinks/week ↑ risk disabilities in infant but no “safe” amount has been determined

• Fetal Alcohol Spectrum Disorders– Fetal Alcohol Syndrome is the severest form with

abnormal facial features, CNS problems, learning disabilities, smaller height/weight

– Alcohol-Related Neurodevelopmental Disorder: behavior & learning problems

– Alcohol-Related Birth Defects: heart, kidneys, bones, hearing

www.hhs.gov/surgeongeneral


www.dailymail.co.uk

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• Thin upper lip

• Smooth ridge between nose and upper lip (philtrum)

• Small head circumference

• Epicanthal folds

• Short palpebral fissures

• Flat nasal bridge

• Upturned nose

Fetal Alcohol Syndrome Facial Features

Am Fam Physician 2005; 72(2):279-285


• Tolerance– How many drinks does it take to make you feel high?– >2 drinks = 2 points

• Annoyed– Have people annoyed you by criticizing your drinking?– Yes = 1 point

• Cut down– Have you ever thought you should cut down on your drinking? – Yes = 1 point

• Eye-opener– Have you ever had a drink first thing in the morning to steady your

nerves or get rid of a hangover?– Yes = 1 point

• Total score of > 2 points indicates at-risk drinking

TACE Questions for Screening Pregnant Women for Alcohol Misuse

Sokol et al. Am J Ob/Gyn 1989;160:863-8


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Prenatal Lab Tests


Routine 1st visit

• Type & screen

• CBC / platelets

• Rubella IGG

• HepB sAg

• HIV

• Hemoglobin (sickle)

• Syphilis

• Gonorrhea / Chlamydia

• Urinalysis

If indicated

• Pap

• TSH

• HgbA1C

• Hemoglobinopathies (sickle or thalassemias

25-28 weeks

• 1 hr 50g GTT

• Hgb

• Repeat T&S if Rh neg

36-40 weeks

• Group B beta strep recto/vag culture

• Repeat Gc/CT if indicated

Cytomegalovirus (CMV) Screening

• Most common cause of perinatal infection in US

• Ubiquitous DNA herpes virus

• Majority of infections asymptomatic; mono-like illness

• Higher socioeconomic groups are more susceptable

• Primary infection - highest risk of transmission to the fetus (40%)

• Recurrent infection has a low risk of transmission (<1%)

• Do Not recommend routine serologic screening!

• Perinatal infection suspected when U/S shows IUGR, microcephaly,cerebral calcifications

• Diagnose with CMV IgG 4 fold rise in paired specimens but gold standard is CMV viral cultures

• Management: minimize exposure, good handwashing; currently no vaccine


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Prenatal Genetic Screening and Testing

Initial Visit

• Cystic fibrosis mutation

11-13 weeks

• Nuchal translucency screen for trisomy 21, 18

15-19 weeks

• Quad test for trisomy 21,18 and NTD

• AFP for NTD if did sequential screen

Fetal Chromosome karyotype

• 11 weeks Chorionic villi test

• > 15 weeks amniocentesis

Anatomy U/S @ 18-20 weeks

Fetal Echo @ 20-22 weeks prn


Early 1st Trimester Ultrasound

5-6 weeks fetal cardiac activity

Yolk sac

Crown-rump length


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1st Trimester Ultrasound Twins


www.brooksidepress.org

Prenatal visit schedule

• Monthly thru 28 weeks then every 2 weeks until 36 weeks then weekly until delivery

Recommended Weight Gain

• 25-35# if normal weight

• 28-40# if underweight

• 15-25# if overweight

• 11-20# if obeseInstitute of Medicine 2009


Fetal Heart Tones first ausculated at 10-11wks with doppler and 20 weeks with fetoscope

Begin measuring fundal height with measuring tape at 20 weeks

www.crozerkeystone.org

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• Better iron assessment– Transferrin and Soluble Transferrin Receptor (TfR)

• Treat Hgb <10g/dl with qd to tid Fe

• Ferrous Sulfate, Gluconate, Fumarate– Capsules, tablets, solution, liquid– Add vitamin C, take ~30min before meals for better absorption– Supplementation 30- 60 mg/day– Change formulas– Try slow release variety

• Iron-polysaccharide– Nu-Iron, Niferex

• Diet high in iron-containing foods

• Common Side Effects– Constipation, black stools, N/V– GI absorption

• Ideal for all women of reproductive age– Multivit + Folic acid + Fe

Iron (Fe) in Pregnancy

DOS CME Course 201217

• Infants of obese mothers tend to be heavier at birth and 9x more prone to obesity in adulthood

• High gestational weight gain assoc. with 2-3 x increased risk of becoming overweight after delivery

• Only 1 in 10 women were counseled regarding appropriate pregnancy weight gain

Excessive Weight Gain and Obesity In Pregnancy

Amer J OB/GYN 10/2011


www.surebaby.com

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• Caffeine intake < 200mg/d (8-16 oz coffee) OK– ACOG Committee Opinion August 2010

• Hair dyes OK but often don’t recommend in 1st trimester

• Air travel– Commercial airlines restrict travel after 36 weeks– Promote circulation to avoid VTE, drink fluids– take copy of prenatal chart – ACOG Committee Opinion October 2009

• At least 1 dental visit– OK for dental work and x-rays– Women with periodontitis are 7x more likely to deliver prematurely

• Avoid hot tubs in 1st 4 to 6 weeks of pregnancy– Risk of hyperthermia could cause miscarriage or neural tube defects – Limit time to <10min later in pregnancy

Pregnancy Recommendations


• Omega 3 fatty acids EPA and DHA

• Improves visual acuity and cognitive development during pregnancy & lactation

• Rec at least 250 mg/d DHA– Twins need more

– No specifics on EPA

• Other benefits– Boosts immune system, improves

depression, prolongs pregnancy, prevents prematurity

Docosahexanoic Acid (DHA) and Fetal Brain Development

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www.dietaryguidelines.gov

www.infiniteunknown.net/2009/11/19

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• Vitamin D– Optimal serum levels in pregnancy have not been established

– >30 to 80 ng/ml = optimal in nonpregnant

– 1,000 to 2,000 IU per day of vitamin D3 considered safe

• Prenatal Vitamin with Folic Acid (some contain DHA)– Chewables available

• Avoid herbs that may cause contractions or bleeding– Angelica, birthwort, black or blue cohosh, cotton root, feverfew,

goldenseal, horehound, juniper, licorice, lovage, motherwort, mugwort, pennyroyal, rue, sassafras, shepherds purse, squill, tansy, wild yam, wormwood

– See www.pregnancy.org for complete list

Pregancy Recommendations


• Seafood high in mercury: swordfish, shark, King mackerel, tilefish

• OK for max of 12oz fish (2 meals)/week: shrimp, crab, canned light tuna (limit albacore to 6oz/week), salmon,pollock,catfish, cod, tilapia source: FDA and EPA

• Avoid raw fish, undercooked poultry, meat and eggs

• Avoid unpasteurized foods: soft cheese made from unpasteurized milk

• Avoid unwashed fruits and vegetables esp. raw sprouts due to listeria outbreaks (turkey deli meat, hot dogs, meat paté, cantalopes); listeriosis can cause preterm labor, stillbirth and neonatal sepsis

Foods to Avoid in Pregnancy


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Exercise in Pregnancy


Exercise in Pregnancy ACOG Guidelines (2005)

Benefits of exercise in pregnancy:

• ↓ backache; improved posture

• ↓ constipation

• ↑ energy level, strength and endurance

• Improved sleep

• Improved ability to cope with pain of labor

• Improved glucose tolerance and may prevent gestational diabetes

• Enhances placental volume and function


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• ACOG recommends > 30 min/d of moderate exercise with max heart rate ~140-160 bpm

• Abdominal exercises OK

• Hydration important: 1 pint before exercise + 1 cup q 20 min during; 300 additional calories/d

Exercise Contraindications

• Severe pregnancy induced hypertension (PIH)– May be beneficial in mild PIH or chronic HTN

• Preterm labor or preterm rupture of membranes, incompetent cervix

• Vaginal bleeding; placenta previa

• Intrauterine growth restriction

Exercise In Pregnancy


• Round ligaments function to maintain anteversion, a position where the fundus leans ventrally during pregnancy

• Attach to either side of uterus just below and in front of insertion of the fallopian tubes

• Round ligaments insert in the upper portion of the labia majora on either side of the perineum

• Composed of smooth muscle tissue which hypertrophies in pregnancy allowing the ligaments to increase in length as the uterus rises high into the abdomen

Round Ligament Pain in Pregnancy


www.wellsphere.com/wellpage/round-ligament

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• As the uterus grows, the round ligaments stretch and spasm causing pain

• Brief sharp stabbing pain or a longer-lasting dull ache felt on one or both sides of inguinal area

• Starts in early 2nd trimester as the uterus rises out of the pelvis to become an abdominal organ

• May lessen in 3rd trimester

• Frequently felt when changing positions or getting up

• Round ligament pain is a normal physiologic pain but not every pregnant woman experiences it

Round Ligament Pain


• Comfort Measures:– Warm bath or heating pad

– Tylenol

– Bend toward the pain to ease stretch on the ligaments

– Lie on opposite side of pain in “fetal position”–Knees flexed with pillow between knees

– Avoiding sudden movements may decrease the spasms

– Wearing a maternity abdominal support or girdle

Round Ligament Pain


www.askamum.co.uk

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Sciatica in Pregnancy

• Pain, tingling, numbness radiates from the buttock down the leg to the foot

• Causes– increased relaxin, weak

abdominals, poor posture, spinal alignment problems, increased weight/obesity, prolonged sitting

• Treatments– Manipulation by skilled

chiropractor, physical therapy, steroid injection, analgesics, hot/cold packs, pillow between knees when sleeping


CenteringPregnancy ® Group Prenatal Care

• Emerging model of prenatal care

• 8-12 women at ~ same gestational age

• Ten 90 min sessions with educational component (videos, guest speakers, in-depth discussions, “dancing”)

• OB provider performs exams in nearby room or area blocked off for privacy

www.centeringpregnancy.org


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DOS CME Course 201231 DOS CME Course 201131

reproductive health early pregnancy and preconception care€¦ · • at least 1 dental visit...

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