Transcript A Preconception Care Health Strategy Addressing STIs and

A Preconception Care
Health Strategy
Addressing STIs and
Other Infections
Julia Lange Kessler, CM, MSM
Maternal Fetal Medicine
Outreach Coordinator
Maria Fareri Children’s Hospital
at Westchester Medical Center
What is preconception health
care?
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Health care for women and men that takes
place prior to pregnancy.
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Prevention infant mortalities and morbidities
Prevention of maternal mortalities and morbidities
AAP and ACOG classified the main
components of PCC:
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Physical assessment, risk screening, vaccinations
and counseling.
The origins of Preconception
Care:
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Late 1980s -the Public Health Service
convened a multi-disciplinary group of
experts in maternal and child health.
This lead to a report “Caring for our Future:
The Content of Prenatal Care”
Public Health Service, US DOH. Caring for our Future: the content of prenatal care (a report of the Public Health Service Expert Panel on
the Content of Prenatal Care). Washington (DC): US Government Printing Office, 1989.
What we learned :
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Preconception Care should be in integral part
of primary care services.
How did that concept evolve?
Radiation Exposure→
childhood–leukemia
DES
Thalidomide
Thalidomide → Phocomelia
1962 legislation was passed so that the FDA
could scrutinize drugs more carefully and
from that a drug classification system evolved
that for pregnancy and lactation.
Pregnancy Drug Classification
System:
A: Controlled studies in ♀- no risk to fetus or
newborn
B: Animal studies – no risk but studies in ♀
have not been done
C: Animal studies indicate adverse effects but
there are no studies in ♀ - give only when the
risks outweigh the benefits
D: There is + risk to the human fetus. Use only
in life threatening situations
X: Studies have shown abnormalities in fetus.
Preconception considerations
when planning a pregnancy:
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When to discontinue a family planning
method
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OC’s – wait one cycle before attempting
pregnancy – optimized dating
Long term hormonal- make take several months
to a year.
Irregular menses-Basel Body Temperature or
ovulation predictor
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12 months of unprotected intercourse → infertility
Nutrition
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BMI
Pica
Eating disorders
CDC: ≤ 1 gram Folic
Acid
Good nutritional
status: protein for
brain and cell
development
“In one study, the
reduced overall health
status (including poorer
physical and emotional health)
of women with low income
during the month before
pregnancy was associated
with and increase risk for
preterm labor.”
Haas JS, et al. Outcomes and health status of socially disadvantaged women
during pregnancy. J Womens Health Gender Based Med 1999;8:547-53.
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Consider Previous
OB complications:
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Genetic screening
Dental care
Cardiac risk
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PTB
GDM
Hypertensive disorders
Previa
Low Birth Weight
Incompetent cervix
Fibroids
Pre eclampsia
Advanced maternal
age
Preconception Issues for Men:
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50% of all infertility is male related
Medications or environmental factors can
alter sperm shape, motility, count and sexual
performance.
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Some studies indicate male smoking may be
linked to heart defects
Alcohol and marijuana impacts sperm quality
Deficiencies in zinc lowers sperm count
Heat (cycling, hot tubs, etc.) lowers sperm
quantity.
STIs affect pregnancy
The issue that remains is the
unplanned pregnancy
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~ 50% of all pregnancies are unintended.
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Unintended pregnancies are associated with
perinatal morbidity and very low birth weight
Early prenatal care is too late.
Organogensis occurs between
days 17- 56 days before a ♀
may know that she is
pregnant.
By the time a ♀ misses
menses and the urine is + for
HcG:
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The fetal heart is formed and functioning
The spinal canal has closed
Eyes are formed
Limbs are moving
The time to prevent
complications:
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Before a woman conceives
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This needs to become our “Standard of Care” :
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Age appropriate preconception care and
counseling by a majority of primary care
providers
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Created by the CDCs Select Panel on Preconception Care:
 Prevention of pregnancy for adolescents
 Changes in life sytle prior to conception
 Assessment of Reproductive risks for all persons (male
and female)
Preconception risk factors as a % of total risks at the time of negative pregnancy test.
Brian, J. et al. The Journal of Family Practice.47(1), July 1998, p. 33-8.
Preconception Care Works
Risk Factors for Adverse Pregnancy Outcomes:
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Folic acid
Rubella seronegativity
Diabetes (preconception)
Hypothyroidism
HIV/AIDS
Maternal phenylketonurea (PKU)
Oral anticoagulant
Antiepiletic drugs
Isotretinoins (Accutane)
Smoking
Alcohol misuse
Obesity
Hepatitis B
STIs
Atrash HK, Johnson K, Adams MM, Cordero JF, Howse J. reconception Care for Improving
Perinatal Outcomes: The Time to Act. Matern Child Health J. 2006 Jun 14.
Sexually Transmitted
Infections
STIs can be devastating to a
woman’s reproductive health
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Intense physical discomfort
Pain
Mental anguish
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Mortality from an ectopic pregnancy (PID)
 Cervical cancer
 HIV/AIDS
March 2008: A CDC study estimates that one in
four (26 percent) young women between the
ages of 14 and 19 in the United States – or
3.2 million teenage girls – is infected with at
least one of the most common sexually
transmitted diseases (human papillomavirus
[HPV] 18%, chlamydia 4%, herpes simplex
virus, and trichomoniasis).
March 11, 2008 – Press Release – CDC.
Why are women more
vulnerable?
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More biologically susceptible
More apt to acquire an STI from a man than
vice versa
More apt to be asymtomatic
STI complications are more severe
Powerlessness in abusive situations
Practice of douching
Trichomoniasis
Pregnancy and trich:
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Vaginal trichomoniasis has been associated
with adverse pregnancy outcomes :
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premature rupture of the membranes
preterm delivery
low birth weight
Trichomoniasis
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Trichomoniasis is caused by the protozoan
parasite: T. vaginalis.
7.4 million new cases occur each year (CDC)
124,000 pregnant ♀ per year
Most men who are infected with T. vaginalis do
not have symptoms.
Symptoms in ♀:
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Many infected women have symptoms
characterized by a diffuse, malodorous, yellowgreen discharge with vulvar irritation. 5-28 days
after exposure.
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However, some women have minimal or no
symptoms.
Diagnosis of vaginal
trichomoniasis
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Is usually performed by microscopy of vaginal
secretions, but this method has a sensitivity of
only about 60%–70%.
Culture is the most sensitive commercially
available method of diagnosis.
Recommended Regimen
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Metronidazole 2 g orally in a single dose.
Alternative Regimen:
 Metronidazole 500 mg twice a day for 7
days.
Management of Sex Partners
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Sex partners of patients with T. vaginalis
should be treated.
Patients should be instructed to avoid sex
until they and their sex partners are cured
(i.e., when therapy has been completed and
patient and partner(s) are asymptomatic [in
the absence of a microbiologic test of cure]).
Gonorrhea
Untreated Gonorrhea in
 Stillbirth
pregnancy:
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Miscarriage
PTL
PROM
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low birth weight
Conjunctivitis
Pneumonia
neonatal sepsis
neurologic damage
blindness
deafness
acute hepatitis,
meningitis, chronic
liver disease, and
cirrhosis.
Untreated
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Women: gonorrhea is a major cause of PID,
which can lead to chronic pelvic pain, ectopic
pregnancy, infertility and HIV.
Men: untreated gonorrhea can cause
epididymitis, a painful infection in the tissue
surrounding the testicles that can result in
infertility.
http://www.cdc.gov/STD/STATS/trends2006.htm
Gonorrhea
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Gonorrhea is caused by Neisseria
gonorrhoeae, a bacterium that can grow and
multiply easily in the warm, moist areas of the
reproductive tract, including the cervix ,
uterus , and fallopian tubes in women, and in
the urethra in women and men. The
bacterium can also grow in the mouth, throat,
eyes, and anus.
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http://www.cdc.gov/std/Gonorrhea/default.htm
Symptoms (within 10 days)
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Pain or burning when passing urine
Vaginal discharge that is yellow or sometimes
bloody
Bleeding between menstrual periods
Heavy bleeding with periods
Pain during sex
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http://www.4woman.gov/faq/stdgonor.htm
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Transmission: Oral, anal, or
vaginal sex
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In 2005, the national rate (115.6 cases per
100,000 population) increased for the first time
since 1999
13,200 pregnant ♀ per year
Antibiotic Resistant Gonorrhea
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Fluoroquinolone-resistant strains of N.
gonorrhoeae have also been reported in the
United States and Canada. The proportion of
gonococcal isolates in Hawaii that are
fluoroquinolone-resistant currently exceeds
10% and increasing numbers of resistant
strains have been identified in the continental
United States.
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http://www.cdc.gov/std/Gonorrhea/arg/default.htm
New Treatment-April 2007
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Ceftriaxone 125 mg IM in a single dose
OR
Cefixime*400 mg orally in a single dose or
400 mg by suspension (200 mg/5ml)
PLUS
TREATMENT FOR CHLAMYDIA IF
CHLAMYDIAL INFECTION IS NOT RULED
OUT * These regimens are recommended for
all adult and adolescent patients, regardless
of travel history or sexual behavior.
† The tablet formulation of cefixime is
currently not available in the United States
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http://www.cdc.gov/STD/treatment/2006/updated-regimens.htm
Chlamydia
Untreated Chlamydia
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PID: 40% which can cause permanent
damage:
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fallopian tubes
uterus
surrounding tissues.
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The damage can lead to chronic pelvic pain, infertility,
and potentially fatal ectopic pregnancy.
Women infected with chlamydia are up to five times
more likely to become infected with HIV, if exposed.
Chlamydia
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Caused by the bacterium, Chlamydia
trachomatis, which can damage a woman's
reproductive organs. Even though symptoms
of chlamydia are usually mild or absent,
serious complications that cause irreversible
damage, including infertility, can occur
"silently" before a woman ever recognizes a
problem. (75% ♀ and 50% ♂)
100,000 pregnant ♀ per year
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http://www.cdc.gov/STD/chlamydia/default.htm
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Symptoms:
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Any genital symptoms such as an unusual
sore, discharge with odor, burning during
urination, or bleeding between menstrual
cycles
50-75% are asymptomatic
Treatment for both partners:
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A single dose of azithromycin -2 grams
Doxycycline 100 mg. BID
No sex until treatment for both (all) partners
is complete.
Other STIs – Facts:
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CDC’s baseline HIV drug-resistant
surveillance data from 11 states in 2007
revealed that about 10.4 percent of HIVinfected persons have HIV drug-resistant
mutations.
http://www.cdc.gov/nchhstp/docs/NCHHSTP2007AnnualReport_final-c.pdf
Candidiasis and
Bacterial Vaginosis
Two vaginal/cervical infections
that may NOT be sexually
transmitted
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Candidiasis
Bacterial vaginosis
Candidiasis-Typical
Symptoms:
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pruritus and vaginal discharge.
Other symptoms include:
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vaginal soreness,
vulvar burning,
dyspareunia,
external dysuria.
Predisposing factors:
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Pregnancy (2X)
Antibiotic therapy
DM
Obesity
Corticosteroids
Immunosuppressant
agents
Exogenous hormones
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OCPs
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HIV
Diets high in sugar
Diets high in dairy
Vulvovaginal Candidiasis
(Yeast)
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usually is caused by C. albicans but
occasionally is caused by other types of
Candida.
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Most common of vaginal infections
PO meds contraindicated during pregnancy
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PRECONCEPTION:
NOTE: The creams and suppositories used to
treat candiasis are oil based and may weaken
latex condoms and diaphragms.
Effects on pregnancy:
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Most practitioners do not treat if pt. is
asymtomatic
Harm to baby: possibility of baby developing
thrush at time of delivery during an NSVD
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More effective to use long term vaginal
preparations during pregnancy at bedtime
Pelvic Rest during treatment
Bacterial Vaginosis (BV)
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It is the most commonly diagnosed cause of
infectious vaginal discharge
BV is a clinical syndrome resulting from
replacement of the normal Lactobacillus sp.
in the vagina with high concentrations of
anaerobic bacteria (e.g., Prevotella sp. and
Mobiluncus sp.), G. vaginalis, and
Mycoplasma hominis.
BV
BV is associated with having multiple sex
partners, douching; it is unclear whether BV
results from acquisition of a sexually
transmitted pathogen.
 1,080,000 ♀ per year.
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Women who have never been sexually
active are rarely affected.
Treatment of the male sex partner has not
been beneficial in preventing the recurrence
of BV.
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BV is the most
prevalent cause of
vaginal discharge or
malodor; however, up
to 50% of women with
BV may not report
symptoms of BV.
BV in the non pregnant ♀:
The established benefits of therapy for BV in nonpregnant women are to:
 relieve vaginal symptoms and signs of infection
 reduce the risk for infectious complications after
abortion or hysterectomy.
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Other potential benefits include the reduction of other
infectious complications (e.g., HIV and other STDsPID, endometritis, infertility). All women who have
symptomatic disease require treatment.
BV during pregnancy
is associated with adverse pregnancy
outcomes, including:
 premature rupture of the membranes
 preterm labor
 preterm birth
 amnionitis
 postpartum endometritis
 post cesarean wound infections
“Effective oral treatment of BV
during pregnancy reduces the
rate of preterm birth by 30% to
50%.”
http://www.midwife.org/display.cfm?id=586
Treatment:
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Metronidazole 500 mg orally twice a day for
7 days, (Demonstrated effective to reduce
PTB) OR
Metronidazole gel 0.75%, one full applicator
(5 g) intravaginally, once a day for 5 days OR
Clindamycin 300mg PO TID X 7 days(1st Δ)
Clindamycin cream 2%, one full applicator
(5 g)intravaginally at bedtime for 7 days.
How do we correct or prevent
adverse outcomes?
Preconception
 Everywhere
Care
at every visit
The CDC strategy:
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The CDC has ten recommendations (with
action steps) for improving preconception
health through changes in:
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Consumer knowledge
Clinical practice
Public health programs
Health-care financing
Data and research activities
What are the building blocks
of the solution?
1. Individual Responsibility
Across the Lifespan.
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Focus individual attention on reproductive
health in the same way that people are
encouraged to watch their cholesterol or
blood pressure.
A lifespan approach can be used to focus
individual attention on reproductive health.
2. Consumer Awareness
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↑ public awareness of the importance of
preconception health behaviors and services.
Tag reproductive health messages onto other
campaigns such as
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Reduction of smoking
Alcohol
Obesity
3. Preventive Visits
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Integrate preconception components into
primary care visits
Provide risk assessment
Education and health promotion to all ♀ of
childbearing age
4. Interventions for Identified
Risks
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↑ F/U for women needing interventions (as
identified during risk screening)
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Example: DM affects 1.85 million (21 per 1,000) ♀
in the US. (ages 18-44)
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DM management has the potential to reduce the risk
of loss and congenital malformation for approximately
113,000 births per year
www.cdc.gov/mmwR/preview/mmwrhtml/rr5506a1.htm
5. Interconception Care
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Use the interconception period to provide
additional intensive intervention to women
who have had a previous pregnancy that
ended in an adverse outcome (low birth
weight, preterm birth, infant death, fetal loss,
birth defects)
6. Pre Pregnancy Check Up
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Offer as a component of maternity care for
couples or women (or men who used to be
women) that are planning a pregnancy.
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Risk assessment
Health promotion
Specific interventions depending on
circumstances.
7. Health Insurance for ♀ w↓$
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Improve access to preventive women’s
health, preconception and interconception
care.
8. Public Health Programs
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Integrate components of preconception
health into existing local public health and
related programs, including emphasis on
interconception
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Title X Family Planning
Title V Maternal and Child Health Services
WIC
Healthy Start
9. Research
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Effectiveness of interventions
Increase the evidence base
Promote the use of evidence to improve
preconception health
10. Monitoring Improvement
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Maximize public health surveillance and
related research mechanisms to monitor
preconception health.
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Maintain data collection
Summing up: Implementation
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Increase reproductive awareness
Reproductive life plan
Increase the number of planned and intended
pregnancies
Health care coverage for all of childbearing
age
Screening for women before pregnancy
Access to interconception care
Thank you for your attention!
Be on the lookout for…
even more solutions!