Transcript FAME course

Preconceptional care (PCC)
(The Critical role of Primary Care Physician)
Introduction to Primary Care
a course of the Center of Post Graduate Studies
in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
Content of this session
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Overview
Rational of PCC.
Objectives of PCC.
PCC implementation at PHC centers.
Physicians' role - delivering PCC.
Obstacles of PCC.
Premarital check-up.
Woman’s role.
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Birth Rate
 United State
13.82 births/1000 population
 Saudi Arabia
28.55 births/1000 population
country comparison to the world 52
 Egypt
21.70 births/1000 population
 United Arab Emirates
16.02 births/1000 population
 Japan
7.64 births/1000 population
Prematurity & Infant Mortality
 United State
7 deaths/1000 live births.
 Saudi Arabia
11.7 deaths / 1000 live births
 United Arab Emirates
12.70 deaths / 1000 live births

Egypt
27.26 deaths / 1000 live births
 Japan
2.4 deaths / 1000 live births
Central Intelligence Agency, The WORLD FACTBOOK
Factors Leading to Infant Mortality
 Maternal health problems
 Smoking
 Age <20 or > 40
 Late entry into prenatal care
 Education
 Marital status
 Inter-pregnancy interval
Potentially all related to
Maternal Health Prior to Pregnancy
(Preconception)
Key Factors

Health status overall
1.
Nutrition
2. Exercise habits
3. Infection risk (immunization)

Specific health risks
1. Chronic medical conditions
2. Medication
3. Tobacco use
Preconception Care: A window of opportunity
• All women of child-bearing yrs : pre- screened for
health & risk potentials Before attempting to be pregnant.
• Optimum: 3- 6 ms before conceiving attempt
This time frame allows:
1- Successful conception & pregnancy
2-  any within control health risks.
Rational of PCC
 PCC has been advocated as a measure to improve pregnancy
outcome.
 Its components parallel those of prenatal care : risk
assessment, health promotion and medical & physiological
interventions.
 Physician’ s role : providing PCC.
 Woman’s role : ….
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Objectives of PCC
Screening tool for physicians to assess
women’s health
In one sense, PCC can be compared to:
Will Baby Clinic visit
a baby is screened for Normal health, Normal Development to
identify emerging unnoticed problems in an infant.
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Objectives of PCC
For a Woman: PCC assess Normal health of a child-bearing
woman, to identify: 1. Existing or emerging illness or disease which may have
gone undetected before.
2. Existing risks for the woman who may become
pregnant.
3. Existing risks which may affect a fetus if the woman
does become pregnant.
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PCC at PHC centers
PCC can be provided most effectively as part of
ongoing primary care.
Physicians can deliver PCC during visits for
• Routine health maintenance,
• During examinations for school or work,
• At premarital or family planning visits,
• After a negative pregnancy test or
• During well-child care for another family member.
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Components of PCC
• Comprehensive check-lists.
• Assessments – History & examination.
• Screening: Investigations.
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What is involved in PCC?
Prescreening check-lists :
1. Reproductive & non- reproductive systems. Covers physical
& psychological aspects.
2. Woman's lifestyle
3. Family history information.
 Begins with basic information then in-depth,
especially if there is previous disease/operation.
 Pre-screening assessments: a Questionnaire filled by
women generally before seeing the physician with a
nurse.
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Assess & screen for:
1. Medical conditions.
2. Genetic counseling.
3. Immunization.
4. Lifestyle changes.
5. STDs (STI)
6.
Medications.
7. Occupational exposures.
8. Domestic violence.
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Medical conditions:
1. DM:
• Screen for DM and pre-diabetes.
• If already diabetic --- shift to insulin Rx.
Congenital anomalies: 2- 6x > offspring of DM.
 PCC care & good DM control  their rate
 Recent meta analysis: lower rate among PCC recipients (2.1%)
vs non-recipients (6.5%).
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Medical conditions:
2. Hypertension.
3. UTI & Renal problems.
4. Obesity .
5. Cardiac / pulmonary problems.
6.
Epilepsy .
7. Psychological disorders.
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Premarital couselling
Genetic counseling in PCC is ideal time:
Before a couple attempts to conceive especially if the
history reveals : Advanced maternal age,
 Previously affected pregnancy,
 Consanguinity or FH of genetic disease.
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Examples Genetic counseling
1. Blood conditions caries/ disease:
o Sickle cell anemia, thalasemia, G6PD
2. Cystic fibrosis.
3. Mental retardation condition:
Screen women with a known FH of fragile X syndrome or
FH of unexplained mental retardation or for women who
have learning disabilities or mental retardation.
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Immunization
PCC is ideal time:
Screen
for rubella
immunity.
Immunization:
 Rubella
Hepatitis A
Hepatitis B
Tetanus
Chickenpox?
Check : EIP complete? women <18 yrs.
EIP = Expanded Immunization Program)
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Lifestyle changes
Caffeine:
1 cup coffee : ~ 120 mg caffeine.
1 cup tea : ~ 40 mg caffeine.
12- oz soft drinks (cola) : ~ 45 mg caffeine.
Caffeine metabolism  during pregnancy
especially with cigarette smoking.
 Several studies: caffeine intake ± associated with
 fertility
 abortion
 birth wt.
  5-6 mg/kg/day spread on day + no smoke + no alcohol :
NO  reproductive risk.
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Lifestyle changes
Tobacco :
 Smoking women during pregnancy : subjects themselves &
their infants to a no. of adverse health effects.
 women contemplating pregnancy should quit smoking
prior to conception.
 Nicotine replacement could then be prescribed.
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Lifestyle changes
Tobacco : Smoking cessation before / early pregnancy : associated with
improvement in maternal airway function & at infant birth wt vs
among nonsmoking pregnant women.
Alcohol & illicit drugs
 Both a major health problem in USA.
 Both harm fetus.
 1981- USA : women abstain drinking alcohol during pregnancy
& when plan pregnancy.
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Sexually Transmitted Infection (STI = STD)
& medications
STI : PCC is a good opportunity to screen for genital infections
such as Chlamydia, gonorrhea, syphilis and HIV.
Medications : therapeutic regimens for chronic illnesses are
best modified, if possible, in PC period to include the drugs
that have been used the longest & have been determined to
pose the lowest risk.
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Medications
Antihypertensives: Diuretics & angiotensin-converting enzyme
should be avoided
drug of choice: methyldopa- proven maternal & fetal safety.
Anticoagulants:
Warfarin ContraIndidated Switch to heparin
Oral hypoglycemic:
Switch to insulin before pregnancy.
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Occupational exposures
Worldwide: women entry to workforce.
Most women are in reproductive age
Three most common occupational hazards reported to affect
pregnancy are:
 Radiation Exposure
 Organic solvents
 Lead
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Domestic violence
Is increasingly recognized as a major public health issue.
It crosses all racial, religious & educational boundaries.
Physical abuse during pregnancy :
significant Risk Factor low birth wt & maternal complications.
Physicians should assess the victims
& refer to local community resources.
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Obstacles of PPC
1) Pregnancies are still unplanned.
2) Women do not know, realize, or understand the benefits
of visiting their physician before become pregnant.
3) The lack of health insurance.
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PCC in Saudi Arabia
Premarital check up :
Mandatory For limited inherited risks.
It could be provided to the married women at the center by: health education of the patient at Pre-Natal Care
Well baby clinic , Chronic disease clinic ….etc
 Let the patient be aware of its importance
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Woman’s role
 A woman may need to adjust certain aspects of her
health and well-being which are in her control.
 These usually include aspects of lifestyle, drug and
alcohol use, exercise, rest and stress reduction.
 In addition, she may need to discontinue certain herbs or
over-the-counter medications as recommended by the
physician.
 Many physicians will also recommend pre-natal vitamins
before a woman actually conceives in order to boost her
overall health.
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‫تم بحمد هللا‬
‫‪Thank you‬‬
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MCQ
1) Birth rate is
a)
Annual number of births during one year/ 1000
population.
b)
Crude birth rate.
c)
Usually determine the rate of population growths.
d)
All of the above.
2) Infant mortality rate
a)
Number of infant deaths in one year/1000 live birth
in same year.
b)
Include total death rate.
c)
It indicate the level of health in a community.
d)
All of the above.
3) Factors leading to infant mortality include all EXCEPT
a) Maternal health problems.
b) Smoking.
c) Age >20 or < 40
d) Late entry into prenatal care.
4) Drugs that need to be changed for safe motherhood are
all EXCEPT
a)
Diuretics
b)
Warfarin
c)
Insulin
d)
Angiotensin-Converting Enzyme Inhibitors