Transcript 9:45 AM Preconception Counseling

PRECONCEPTION
COUNSELING
A “BEST” BUT UNCOMMON
PRACTICE
INTENDEDNESS
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2002 DATA: 30.8% ALL WOMEN AGE
15-44 HAVE EXPERIENCED AN
UNINTENDED BIRTH
ESTIMATE THAT 49.2% ALL
PREGNANCIES UNININTENDE (nsfg)
ORGANOGENSIS
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DAYS 17-56 POST CONCEPTION
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FIRST DAY OF “MISSED” PERIOD IS DAY
14 POST-CONCEPTION
DAY 56 IS ABOUT 6 WEEKS
ALL ORGANS FORMED BY WEEK 9
Prevention, in order to be
truly preventive, must be
antenatal
J. W. Ballantyne in 1902
Maternal Mortality per 100,000 live births
800
700
600
500
400
300
200
100
0
1900
1960
1980
2000
Rate Increase from 1980-2000
30%
25%
20%
15%
10%
5%
0%
Preterm
Very Preterm
LBW
VLBW
Infant Deaths per 1000 Live Births
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
1960
1980
2000
1960: Maternal complications of pregnancy not on top
10 list of leading causes of infant mortality
1980: Number 5
2001: Number 3
2002: 46% of infant mortality related to congenital anomalies,
LBW, Preterm Delivery and Maternal complications
2004 Behavioral Risk Factor
Surveillance System
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Phone survey of Americans > 18 years
of age
Median response rate >52%
Content varies by state
Defined as preconceptional if:
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Wanted a baby in next 12 months, not
using contraception, not sterile and not
already pregnant
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BRFSS 2004
Preconceptional
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Amongst reproductive aged
women
6.1% asthma
11.4% smoke
5% obese
54.9% consume alcohol
3.4% cardiac dz
80% dental caries
&other oral diseases
PRENATAL CARE IS TOO
3% hypertension
9.3% diabetes
1.4% thyroid disease
Maternal-Child Health J 2006 10:s3-s11
LATE
Spartan Preconception
Recommendations a la Plutarch
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“ordered the maidens to exercise
themselves with wrestling, running,
throwing the quoit and casting the dart,
to the end that the fruit they conceived
might, in strong and healthy bodies,
take firmer root and find better growth”
Preventing Low Birthweight
Institute of Medicine 1985
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“…one of the best protections available
against low birth weight and other poor
pregnancy outcomes is to have a
woman actively plan for pregnancy,
enter pregnancy in good health with as
few risk factors as possible, and be fully
informed about her reproductive and
general health”
IOM-1985
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Family planning services essential to
preconception initiatives
Reproductive health/family planning
must introduce concept of prepregnancy wellness
Developed concept of preconception
consultation
Expert Panel on the Content of
Prenatal Care: 1989 “Rosen
Report”
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Preconception visit may be the single most
important health care visit with respect to
impact on pregnancy outcome
Preconception counseling most likely to be
effective when provided in context of
general preventive care OR primary care
visits
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Concept of “Opportunistic Care”
ROSEN REPORT
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Risk Assessment
Health Promotion
Intervention
Follow up
Healthy People 2000
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Increase to at least 60% the proportion
of primary care providers who provide
age-appropriate preconception care and
counseling
Deleted in 2010 Healthy People as not
measurable
Toward Improving Outcome of
Pregnancy: The 90’s and Beyond
MOD
1993
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Concept of “reproductive awareness”
Called for a new strategy to reach each
woman of child-bearing age with
reproductive awareness messages at
every health encounter
ACOG 1995: First technical
bulletin on Preconception Care
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Thorough & Systematic ID of risks
Provision of education individualized to
patient needs
Initiation of desired interventions
2002: Guidelines for Perinatal
Care AAP/ACOG
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Emphasized integration of preconceptional health into ALL health
encounters in reproductive age women
Average woman of childbearing has 6.4
visits to MD’s per year
Healthy People 2010
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No global comment
“Increase the proportion of pregnancies
begun with an optimum folate level”
(target 80%)
HALLMARKS OF
PRECONCEPTION CARE
REYNOLDS
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PROVIDES WOMEN & FAMILIES
INFORMATION AND OPPORTUNITIES
TO MODIFY UNHEALTHY BEHAVIORS
AND THUS POTENTIALLY IMPROVE THE
QUALITY OF THEIR LIVES
INCREASE REPRODUCTIVE CHOICES,
POSSIBLY DECREASED UNINTENDED &
UNWANTED PREGNANCIES
HALLMARKS, cont’d
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IMPROVE PREGNANCY OUTCOME BY
DECREASING INFANT MORTALITY &
MORBIDITY
REDUCES THE PROBABILITY OF
DAMAGE DURING ORGANOGENESIS
Which women most likely to get
preconception care?
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Older
Married or stable relationship
Non Hispanic White
Income >$20,000/year
Non-smokers
Private medical insurance
Positive bond with pre-pregnancy health
care provider
NEGATIVE PREGNANCY TEST
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POPULATION OF ABOUT 100 WOMEN
AT FAMILY PLANNING CLINIC WITH
NEG. PREGNANCY TEST
ALL HAD ASSESSMENTS DONE USING
PRECONCEPTION RISK SURVEY
INSTRUMENT
½ HAD RESULTS REPORTED TO DOC
NEGATIVE PREGNANCY TEST
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AVERAGE WOMAN HAD 9 IDENTIFIED
ISSUES
21% PSYCHIATRIC/BEHAVIORAL
12% FETAL EXPOSURE
7 – 10%: FAMILY PLANNING, NUTRITION,
GENETIC, MEDICAL, BARRIERS TO CARE, DV,
SEXUAL VIOLENCE
2-6%:REPRODUCTIVE HISTORY, STD’S
Best Evidence
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Focus on a single intervention
Not in the context of improving
pregnancy outcomes
PROMOTION OF
LIFELONG
WELLNESS
PROMOTION OF
HEALTHY AND
DESIRED
PREGNANCIES
PROMOTION OF
HEALTHY FUTURE
INFANTS
PREGNANCY
FAMILY PLANNING/
PRECONCEPTIONAL
CHILDBIRTH
MENARCHE
FAMILY PLANNING
INTERCONCEPTIONAL
MENOPAUSE
PREVENTING PREMATURITY
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SPACING OF PREGNANCIES
 LOWEST RATE
VERY/MODERATELY PREMATURE
INFANTS
 18 to 59 MONTHS BETWEEN
PREGNANCIES
DISCONTINUE SMOKING
PRECONCEPTIONALLY
What We Know: Tobacco Use
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Tobacco And Women’s
Health:
 Implicated the leading
causes of death for
women:
 Heart disease (1)
 Stroke (2)
 Lung cancer (3)
 Lung disease (4)
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Tobacco and
Reproductive Outcomes:
 Leading preventable
cause of infant
mortality
 Preventable cause of
low birth weight and
prematurity
 Associated with
placental
abnormalities
SMOKING
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
ECTOPIC PREGNANCY
PLACENTA PREVIA
UNDER-DEVELOPMENT OF PLACENTA
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MAY INCREASE RISK OF PREMATURITY
AND BABIES TOO SMALL
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15% and 29% of pregnant women
smoke during pregnancy
If smoking during pregnancy
eliminated, estimated:
 10% reduction in perinatal
mortality
 11% reduction in the incidence of
low birth weight
SMOKING:Evidence based
counseling
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Ask every patient about tobacco use
Advise them to quit
Assess willingness to quit
Assist them in quitting
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Pharmocotherapies and additional counseling each
DOUBLE quit rate
Arrange follow up
305.10 ICD-10 Code for tobacco dependence
Effectiveness of smoking
cessation programs
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25-30% quit rates in general population
Many women spontaneously quit when
pregnancy
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11-28% publically insured
40-65% privately insured
ACOG COMMITTEE OPINION
October 2006 # 316
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Smoking is one of the most important modifiable
causes of poor pregnancy outcomes in the United
States. An office-based protocol that systematically
identifies pregnant women who smoke and offers
treatment has been proved to increase quit rates. For
pregnant women who are light to moderate smokers, a
short counseling session with pregnancy-specific
educational materials often is an effective intervention
for smoking cessation. The 5 A's is an office-based
intervention developed for use by trained practitioners.
Techniques for smoking reduction, pharmacotherapy,
and health care support systems can help smokers
quit.
What We Know: Alcohol Use
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Alcohol and Women’s
Health
 Risk for MV and other
accidents
 Risk for unintended
pregnancy
 Risk for addiction
 Risk for nutritional
depletions and
inadequacies
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Alcohol and
Reproductive Outcomes
 Delayed fertility
 Increased SABs
 FAS and FAE
ALCOHOL
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2002: 8% of American women 18-44
years of age were sexually active,
fertile, not contracepting.
Women age 18-24: 20% binge drink
FAS 0.3-2 per 1000 live births
Project CHOICES
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CDC sponsored trial
Population at high risk of alcoholexposed pregnancy (12% binge)
Focused on reducing risk drinking AND
postponing pregnancy
4 brief motivational visits and Family
Planning provider visit
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68% at reduced risk at 6 months
What We Know: Obesity
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Obesity and Women’s  Obesity and Pregnancy:
Health:
 Glucose intolerance of
 Diabetes
pregnancy
 Hypertension
 Pregnancy induced
hypertension
 Cardiovascular
disease
 Thrombophlebitis
 Disabilities
 Neural tube defects
 Prematurity
 Higher rates of difficult
births
OBESITY
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Increased rates of: infertility,
gestational diabetes, pre-existing
diabetes, hypertension, preeclampsia,
stillbirth, birth defects, LGA, cesarean
sections, long dysfunctional labors,
CPD, post partum anemia
Fat is not inert
What can we do about it?
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Weight loss programs
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Tsai and Wadden:, 2005
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Weight Watcher least costly, maintenance of 3.2% of initial
weight at 2 years
Very Low Calorie Commercial Diet:
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Greatest initial weight loss; high costs; high attrition
Internet based and organized self-help: minimal weight loss
Low income obese women receiving 5 email
messages in pregnancy around maintaining normal
weight gain less likely to gain excessive weight
Interconception period important if woman retained a
lot of pregnancy weight
What we know: FOLATE
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Peri conceptional supplementation with 400
micrograms of folate (folic acid) from 3
months preconceptionally to 8 weeks
postconceptionally
Decreases rate of spina bifida by 50-70%
Decreases rate of cleft lip
Decreases rate of heart disease
Generally good health habit for adult
cardiovascular health
Probably decreases placental problems
EPILEPSY
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MEDICATIONS
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ASSOCIATION WITH SOME MEDICATIONS
WITH SOME BIRTH DEFECTS
SOME WOMEN ON ANTI-SEIZURE
MEDICATIONS FOR YEARS AFTER A
SEIZURE AND MIGHT BE ABLE TO
DISCONTINUE
LOWEST POSSIBLE EFFECTIVE DOSE
SINGLE DRUG VERSUS MULTIPLE DRUGS
DIABETES
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GENERAL POPULATION
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2-3% RISK OF SEVERE BIRTH DEFECTS
DIABETICS PRIOR TO PREGNANCY
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POORLY CONTROLLED [Hgb A1c>7]
RISK INCREASES TO 6-9%
HEART DISEASE, SPINA BIFIDA, OTHER
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WELL CONTROLLED PRECONCEPTIONALLY
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BACK TO BASELINE RATE IN THE GENERAL
POPULATION!
INFECTIONS
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HEPATITIS B
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90% CHRONIC CARRIERS ARE WITHOUT
SYMPTOMS
PREGNANCY DOESN’T ALTER COURSE OF
DISEASE
IDENTIFY NEONATES FOR FULL
VACCINATION AND PROPHYLAXIS
HIGH RISK WOMEN WHO ARE HEP. NEG
CAN BE VACCINATED
HIV
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HELPS INFECTED WOMEN MAKE
INFORMED REPRODUCTIVE DECISIONS
BEGIN MATERNAL CARE PROGRAM
HIGH RISK WOMEN CAN BE
COUNSELED RE: RISK REDUCTION
TOXOPLASMOSIS
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85% US WOMEN NON-IMMUNE (NHANES)
400-4000 CASES OF CONGENITAL TOXO/YR IN US
PRENATAL TESTING VERY DIFFICULT
TREATMENT IF KNOWN PRENATAL
SEROCONVERSION
PRECONCEPTION TESTING CAN ALTER BEHAVIOR
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AVOID FECES IN LITTERBOX/GARDEN
AVOID RAW OR UNDERCOOKED MEAT
DISPOSE OF CAT LITTER DAILY AND DISINFECT BOX;USE
GLOVES
PEEL OR WASH FRUITS AND VEGETABLES
CMV
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0.6-1.5% ALL BIRTHS IN US
ADULTS USUALLY ASYMPTOMATIC,
MONO LIKE ILLNESS
LATENT STATE AFTER INFECTION
MOST COMMON SOURCE OF PRIMARY
INFECTION: TODDLERS
MOST EFFECTIVE PREVENTION: HAND
WASHING (URINE, SALIVA)
OTHER INFECTIONS
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STD’S
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APPROPRIATE TREATMENT
DEAL WITH MONOGAMY ISSUES
VARICELLA AND RUBELLA:
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IF NEGATIVE ANTIBODY, CAN IMMUNIZE
WAIT THREE MONTHS PRIOR TO
CONCEPTION
WWW.IHEALTHRECORD.ORG
CDC, other federal agencies, and medical societies have developed emailbased education programs that are offered through the Interactive Health
Record (iHealthRecord
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Learn what you need to know now to have a safe pregnancy and healthy
baby. CDC has a new online education program available for women
who are planning to get pregnant.
Health information via email every other week for 3 months as you
prepare for pregnancy.
You can sign up for CDC’s pregnancy-planning education
program by
1. Logging onto WWW.IHEALTHRECORD.ORG
2. Signing up for a free iHealthRecord.
3. Going to the "Education Programs" page.
4. Checking the box next to “Pregnancy Planning: What To
Know About Your Health Before You Get Pregnant”.
AAP/ACOG:Components of PCC
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Physical assessment
Risk Screening
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Reproductive awareness
Environmental toxins/teratogens
Nutrition/folate
Genetics
Substance use
Medical conditions/medications
Infections/vaccinations
Psychosocial concerns
Vaccinations
Counseling
Preconception Risk Factors with
Developed Clinical Practice Guidelines
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Folic Acid
Rubella
seronegativity
Diabetes
Hypothyroidism
HIV/AIDS
PKU
Oral Anticoagulant
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Anti-epileptic drugs
Isotretinoins
Smoking
Alcohol misuse
Obesity
STD
Hepatitis B
MMWR: April 21, 2006 Recommendations to Improve
Preconception Health and Health Care-US
Summary
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Preconception care
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“Opportunistic”
Rolled into routine health encounters for
reproductive aged women
Needs to be proactive
Clinical practice guidelines are available
MMWR April 12, 2006