Transcript Pre-Conception Counselling

Preconception Care
• Dr. Julie Jenner
• Dr. Kristine Whitehead
• 2015
• What is the purpose of
preconception counselling?
Goals of counselling
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Screen for conditions which may impact fertility, fetal
development or mother’s ability to adapt to pregnancy
Institute preventative measures before pregnancy eg.
Vaccination, prenatal vitamins
Educate couples regarding risks to pregnancy and
strategies to minimize the risks eg. Excess weight, smoking,
alcohol
Safeguard fertility – incidence of infertility is 11-16%
Optimize the health of those with chronic medical
conditions prior to conception
Improved outcomes
• prevent preterm births
• improve birth weight
• prevent congenital anomalies, including
neural tube defects
• reduce infant morbidity and mortality
• reduce maternal morbidity and mortality
Healthy eating, physical activity, immunization
status, reproductive life planning, substance use,
chronic medical conditions, and exposure to
environmental toxins. Addressing these issues at
the first prenatal visit is often too late
Ideally we should encourage couples to plan
pregnancy
This care often needs to be opportunistic
Ontario initiative: Best Start Resource Centre,
preconception health
The Hard Reality
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In Ontario, about 60-70% of pregnancies
are planned*
Women in Canada are delaying childbirth
The average pregnant woman is older,
heavier and less fit than 20 years ago
Woman of childbearing age have
increasing rates of HTN, NIDDM, and
obesity
*Best Start 2008
The advice
• Considering discussing pregnancy
timing during a CPX/PHE
• Treat all woman as if they could have
an unplanned pregnancy
• Lifestyle counseling is important to
optimize pregnancy and so much more
• Counsel men as well
Preconception Health Care
Tool
• For primary care
• Available online and on V-drive
• Over a series of visits
• Bill K013, counselling
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Centre for Effective Practice, Barrett R, Telner D.
Preconception health care tool. 2015 Jan. Available
from: www.effectivepractice.org/preconception
Vaccines
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Rubella (MMR), varicella – check for
immunity by bloodwork/history, give prior
to conception
Avoid live and live-attenuated vaccines in
pregnancy and delayed conception for at
least 4 weeks (theoretical risk to fetus)
Pertussis (TdP) - advisable
Influenza – advisable
Hepatitis B – check for immunity
Kristin
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34 year old married woman here for CPX
Hx of migraine headaches, Imitrex prn
Non smoker, BP 135/82, 5’4” 150lbs (BMI 26)
Executive for Canadian Tire, 60 hour work week,
frequent travel to Asia
Plays hockey once per week
Family History Greek/English
Both parents overweight , 2 sisters - 2 kids each
When should women
conceive?
• Women over 35 now account for 14% of
deliveries
• With age comes wisdom…
• BUT…
- Infertility rises with age
- Chromosomal abnormalities increase
- Miscarriage rates increase
- Medical complication rate increases
- Surgical intervention increases
- Ectopic pregnancy, placental abnormalities
increase
- Congenital malformations, neonatal
complications, maternal death, stillbirth
increases
Chance of infertility
• Research based on age of marriage,
before good access to contraception
• Age 20 6%
• Age 30-34 15%
• Age 35-39 30%
• Age 40-44 64%
Fecundity per cycle
• Age 19 - 50%
• Age 30 - 40%
• Age 37 - 30%
Maternal Mortality
• Rates are low in North America
• Rates do increase 5X after age 40
• 25-29 - 9/100,000
• 30-34 - 21/100,000
• above 40 - 46/100,000 = 1/2175
Kristin #2
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Kristin wants to have children some day
She is career focused right now
Her sisters had their children at 20 and 25 “a
big mistake”
She agrees she is a little heavy due to
demands of work and travel
Drinks scotch only, 2 per week
Thinks diabetes runs in her dad’s family
Advanced Maternal Age
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Given information about the risks to fertility
with age, woman may choose to plan
pregnancy sooner
Other women may feel new reproductive
technologies like egg freezing or IVF solves
the problem of AMA – note complications
Don’t assume that all women want children –
ask them
Social egg freezing: risk, benefits and other considerations CMAJ
June 16, 2015 187:666-669
NIDDM
• Risk of gestational diabetes is 3%
overall
• Age >40: rate is 7 – 12%
• Moderate obesity increases ODDs ratio
for NIDDM by 2.3
• Increases risk of macrosomia, perinatal
death, infant hypoglycemia, maternal
PIH
Obesity
• Obesity is associated with infertility
• Obesity is also a risk factor for PIH,
gestational diabetes, congenital
anomalies
• Childhood obesity is positively
associated with maternal obesity and
maternal weight gain
Hypertension
• Essential HTN is a risk factor for
abruption, PIH, IUGR
• Disproportionately higher risk to woman
and child when combined with smoking
or metabolic syndrome
• PIH overall rate is 3-4%
• PIH rate for women >40 increases to 510%
Intrapartum risks of
advanced maternal age
• Older woman have increased risk of
induction
• Increased risk of stillbirth
• Increased risk of dystocia
• Increased risk of Cesarean Section
Kristin #3
• What does preconception counselling
look like for Kristin?
• Share info for her consideration
Marcy
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20 yo female
Presents for meds renewal (Celexa 20mg, Epival
1000 mg)
Dx of dysthymia, borderline personality disorder,
substance abuse disorder
Not currently under psychiatric care
Just enrolled in high school upgrading
New “perfect” boyfriend of 4 weeks duration at
Narcotics Anonymous
They are “being careful” to avoid pregnancy
AHHHH!!!
• Please don’t get pregnant
Substance Abuse
• Cigarette smoking is common in women
of child bearing age
• Pregnancy is a powerful incentive to try
to quit
• Smoking increases preterm labor, low
birth weight, miscarriage
• Marijuana risks are unclear - perhaps
affects cognitive development
Tobacco Use
1.Advise all women of childbearing age
to quit smoking
2.Provide support ie. referral to group,
advice re. patches, Rx for
Zyban/champix
Alcohol
• Multiple effects are noted
• Spontaneous abortion
• Facial deformity
• Growth restriction
• Neurobehavioural
• Counsel not to drink during any month
when not using contraception
Marcy #2
• Marcy smokes 20 cigarettes per day
• She drinks on the weekends, 5-7 drinks
• She uses marijuana occasionally
• She uses condoms or withdrawal
• G2P0, TA at age 17 and 19
• Marcy says she has never felt this good
before
Marcy #3
• “What would you do if you got
pregnant?”
• Marcy says she would never have
another abortion
• Would quit drinking
• Would try to quit smoking
• Would stop her prescription meds
Prescription Drugs
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Women and physicians fear use of
prescription drugs in pregnancy
Most prescription drugs are safer to take
than consequences of non treatment in
pregnancy
Some women perceive untested herbal
products (ie echinacea) as safer than well
tested prescription drugs (ie Diclectin)
THE BLACK LIST
• Drugs known to be teratogenic
AVOID THESE
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Accutane
Chemotherapy
Valproic Acid, Carbamazepine, Septra
(the folate inhibitors)
Methotrexate
Misoprostol
Warfarin
ACE inhibitors
Risk vs Benefit
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SSRIs
NSAIDs
Antimalarials
Live attenuated vaccines (ie yellow fever)
Oral Steroids
Colchicine
Benzodiazepines
Gadolinium
Medication Safety in pregnancy
and breastfeeding
• Motherisk.org
• Lactmed
Marcy #4
• How should we counsel Marcy?
• Reliable contraception like IUD or depoprovera advisable, MAP prn
• Educate about risks of unplanned
pregnancy, especially in light of her
meds
Easy Patient
• 27 year old Sally presents with her
supportive partner of 1 year
• They are ready to start a family and
want the best advice available
• No meds, healthy weight
• No medical issues, no genetic issues on
either side
• No drugs or alcohol
Bloodwork
• Rubella titre
• Varicella titre
• HIV, HepB sAg, VDRL
• CBC
• Ferritin
Consider
• Hemoglobin electrophoresis – if at risk
• Toxoplasmosis, CMV titre
• Hep C if from endemic area
• Fasting glucose (eg. Obesity)
• TB testing – if at risk
Counselling
• Pre-conception prenatal vitamin
• Avoid toxins and medications
• Maintain healthy weight
• Healthy diet and regular exercise for
both her and her partner