Preconception and Interconception Care by Obstetrician-Gynecologists

Duration of pregnancy is no longer “nine” months, it’s “twelve” months Both ACOG and AAP suggest that prenatal care begin before conception Preconception care has been called the most important element of prenatal care. (U.S. PHS Task Force on the Content of Prenatal Care, 1989) Health during pregnancy depends on a woman’s general health, nutrition and other factors before conception, as well as the amount and quality of prenatal care. For example, women with collagen vascular diseases, such as SLE, general have improved outcomes of pregnancy if the pregnancy is conceived during a quiescent period of the disease. The traditional access point for information relative to the prevention of poor reproductive outcomes is the first prenatal visit. In many cases, this is too late. Many compromised pregnancy outcomes are determined before women have had an opportunity to initiate prenatal care.

Goals of Preconception Care Optimize the woman’s health Minimize risks to her and the fetus and improve pregnancy outcome Provide information necessary to make informed decisions about future reproduction

Elements of Preconception Care Risk assessment Education and health promotion Medical and psychosocial interventions Preconception care does not follow the usual and customary medical disease model. It is an example of primary prevention service that OB/GYN’s can offer to their patients using a thorough and systematic approach. Systematic identification of preconception risks through assessment of medical, reproductive and family histories, nutritional status, drug exposures and social concerns of all women in the childbearing age. Once risks identified provisions of education based on these risks. Interventions -- if appropriate and desired.

Recommended Components of Preconception Care Reproductive awareness Family planning Medical conditions Infectious diseases Immunizations Teratogens and environmental toxicants Genetic issues Nutritional issues Domestic violence Substance abuse, alcohol & tobacco use Psychosocial issues Financial issues Since less than half of pregnancies in the U.S. are planned, this suggests a need for family planning spacing (Henshaw, 1998). Every encounter with the health care system should be viewed an an opportunity to reinforce reproductive awareness in women of childbearing age. Short intervals correlated with SGA and preterm birth (Hobcraft, 1984; Alam, 1995; & Rawlings 1995). MD’s should stay current with the explosion of new knowledge in the field of genetics and be able to appreciate that the list of genetic diseases that lend itself to prenatal diagnosis is growing rapidly, e.g., Fragile X, Tay Sachs, etc. Other components discussed in detail in the first hour of the curriculum.

Why Should Ob/Gyns be Concerned with Preconception Care? Prenatal care begins before conception OB/GYN’s have the most frequent contact with women of childbearing are We are aware of prior poor pregnancy outcomes It is to our advantage to improve pregnancy outcomes We already have the knowledge and are applying it Preconception risk reduction activities have been practiced for many years, in one form or the other (e.g., .general counseling, testing for rubella and syphilis, family planning, genetic screening and counseling etc.) It’s only in the last 2 decades that the concept has emerged of an organized comprehensive program.

How Preconception Care can be Integrated into Ob/Gyn Practice Annual gynecological visit Episodic visit for any common complaints Routine postpartum visit Negative pregnancy test - an opportunity for preconception care Family planning encounter Infertility evaluation Following a poor pregnancy outcome Given that 49% of pregnancies in the U.S. are unintended (Henshaw, 1998), preconception care must be introduced into health care settings that: - are convenient for the women - can reach as many women as possible Although preconception care should not be thought of as one more thing to do in the limited time we have for each patient visit, it is, in fact, a part of what most of us are already doing.

Barriers to Preconception Care Physician Aspect Feeling of having inadequate knowledge Perception of preconception care being time-consuming Concern about insurance reimbursement. Lack of awareness of how to integrate preconception care into ongoing primary care In addition, the lack of existing CPT coding for preconception care.

Barriers to Preconception Care Patient Aspect High rate of unintended pregnancies Ignorance about importance of good health habits prior to conception Limited access to health services in general For examples, good health habits include: Avoidance of tobacco & alcohol Folic acid supplementation Good nutrition

Case Study 33 year -old woman comes in for routine gynecologic visit. She has 3 children - 9, 5 and 1 year of age. She and her husband would like one more child, but she wants to finish her last year at school. The following cases demonstrate the integration of preconception care into good primary care.

Routine Health Maintenance for Women 1. Screening for her health status and physical activity 2. Dietary/nutritional assessment 3. Screening for tobacco, alcohol and other drugs 4. Screening for abuse and neglect 5. Thorough physical exam, including STD screening 6. Age and risk appropriate laboratory testing These recommendations come from Guidelines for Women’s Health Care. ACOG, 1996. This reference provides a standard screening tool for routine health maintenance.

Routine Well Woman Counseling Contraceptive options Importance of planned pregnancies and birth spacing STD prevention Dietary and nutritional advice Exercise and physical activity Breast self-examination Advice on injury prevention Specific counseling if - domestic violence/ substance abuse/depression identified through history Refer to ACOG’s Guideline s for Women’s Health Care, 1996.

Immunizations Tetanus-diphtheria booster (every 10 years) High-risk groups: MMR vaccine Hepatitis B vaccine Influenza vaccine Pneumococcal vaccine This patient does not fall in the high risk group.

Recommended Components of Preconception Care Every encounter with the health care system viewed as an opportunity to reinforce reproductive awareness in women of childbearing age Women should be assessed for underlying medical conditions and possible effects of pregnancy discussed Given that less than half of pregnancies in the U.S. are planned, suggests the need for family planning.

Specific Preconception Care Issues Advice about daily multivitamins containing at least 0.4 mg of folic acid Case emphasizes that good routine primary care encompasses most components of preconception care and points out how easily it can be integrated into Ob/Gyn care Need for preconception visit when planning next pregnancy. HIV testing at that visit.

Preconception Care For Women With Medical Diseases Advances in medical therapeutics have made more pregnancies possible in women with pre-existing medical conditions In some conditions, medical care and interventions prior to conception can have a tremendous impact on pregnancy outcomes - Examples of preexisting medical conditions: 1) older pregnant women: hypertension, diabetes, heart disease, pulmonary embolism, stroke 2) better treatment for underlying disease:cystic fibosis, renal transplants, heart valve replacements, prior cancer, HIV infection 3) better prenatal treatment leading to improved outcome: lupus, diabetes, sickle cell anemia - Preconception care in women with diabetes particularly has been shown to reduce the incidence of birth defects. (Kitzmiller, 1991)

Preconception Care For Women With Medical Diseases Points to consider - Effect of medical disease and its current or past therapeutic regimens on the intrauterine environment and fetal development - Effect of medical disease on the woman’s health and survival - Effect of pregnancy on the disease process - Examples of medical diseases & drug exposures with potential adverse effects: ACE inhibitors and fetal renal failure Poor control of diabetes and congenital anomalies Accutane and multiple congenital anomalies - Examples of medical diseases with poor prognosis HIV infection Advanced cancer - Examples of adverse effects of pregnancy on maternal disease (high maternal mortality rates): Eisenmengers syndrome Marfan’s syndrome with aortic root involvement Coronary artery disease

Preconception Care For Women With Medical Diseases Preconception care must be a multidisciplinary team approach Preconception counseling: - allows decision to attempt/avoid a pregnancy - influences on timing of conception - optimizes woman’s condition before conception Interdisciplinary team should include: obstetrician, maternal-fetal medicine specialist, obstetric anesthesiologist, sub-specialist in specific field of patients medical illness and obstetric nursing. Counseling to attempt pregnancy early in disease course prior to time related complications, e.g. diabetes, lupus, renal disease Avoid pregnancy in conditions with high maternal mortality, e.g. certain cardiac conditions. Conception during the quienence state in lupus yields the best maternal and perinatal outcomes. (Petri, 1991)

Some Medical Conditions Amenable to Preconception Care Diabetes Mellitus Hypertensive Disorders Cardiac Disease Thyroid Disorders Epilepsy Asthma HIV Infection Systemic Lupus Thromboembolic Disease Renal Disease Hemoglobinopathies Cancers As the list of medical conditions is extensive, discussion limited to 2-3 conditions.

Case Study: Diabetes 38 year old school principal with Type 2 Diabetes Mellitus for 13 years. Married for 10 years; deferred childbearing, but now wants to conceive. She is on Glyburide for diabetes control and on ACE inhibitor for microalbuminuria noted 3 years ago.

Background of Preconception Care and Diabetes Carbohydrate intolerance affects approximately 1.5 million women of reproductive age in the US Diabetes mellitus is the most common serious disease to affect the maternal-fetal dyad Maternal and perinatal mortality associated with diabetes has decreased In 1940’s the perinatal mortality rate was approximately 33%. Over last five decades, the perinatal mortality rate has dropped to 0-5%. (Garner, 1995)

Background of Preconception Care and Diabetes The incidence of congenital malformation in infants of diabetic mothers remains 2 to 3 times that of infants of non diabetic mothers Malformations associated with diabetes mellitus are the leading cause of perinatal death in this population Reduction in rate of malformations has been possible by achieving strict glucose control in the preconception period and maintaining control throughout organogenesis and pregnancy Many of the data supporting the benefits of preconception care came from the experiences of women with IDDM. However, despite the reduction in perinatal mortality, congenital malformations remain a serious morbidity.

Goals of Preconception Care in Diabetes To reduce the occurrence of obstetric and diabetic complications To decrease the incidence of congenital abnormalities Reduce risk of spontaneous abortions The possibility of a future pregnancy takes on a whole new meaning for the care of the diabetic woman.

How to Accomplish These Goals? Education about need to change diabetes medication regimen ie substitute insulin for oral hypoglycemics Optimal glycemic control achieved by home monitoring, multiple daily injections, adjustment of insulin, close supervision and education Postpone conception until control is achieved Reassess modifiable risks before conception by assessing end organ damage, retina, kidney, vasculature, heart, nervous system The cornerstone of management for pregestational diabetic patients is appropriate metabolic control and that is achieved by aggressive insulin therapy. Newer research of newer oral hypoglycemic agents (which are non-placenta crossing) are under investigation.

How to Accomplish These Goals Attention to lipids, hypertension, screening for urinary tract infections, and its prevention Preparation for demanding prenatal care, testing, frequent visits, etc Stop the ACE inhibitor ACE Inhibitors -- associated with fetal renal dysfunction, oliguria, renal failure and even fetal death.

Case Study: Seizure Disorder 22 year old woman misses her period. Pregnancy test in the office is “negative”. She expresses a desire to have a baby. On Dilantin since age 2. No seizures for past 5 years.

Background of Preconception Care and Seizure Disorders Epilepsy is the most common, serious neurologic problem seen in pregnancy All anticonvulsants are potentially teratogenic Increased incidence of congenital malformations in offsprings of mothers with a seizure disorder (independent of anticonvulsant use) Prepregnancy period could be an optimal time to review the diagnosis and classification of the patient’s seizure disorder and also the need and effectiveness of current therapeutic regimens Reference for malformations in offspring of women with seizure disorders: Kelly, 1984.

Goals of Preconception Care In Women with Seizure Disorders To keep the woman seizure-free To decrease the incidence of congenital abnormalities in her offspring Balance maternal seizure control with minimal fetal effects

Goals Achieved By: Thorough evaluation of patients’ past and present history, her treatment regimen and its effectiveness Collaborate with the neurologist for a pre-pregnancy workup including EEG, CT Scan, etc Discussion of effects of epilepsy on pregnancy and offspring Consider weaning the patient from anticonvulsants if appropriate candidate, in consultation with her neurologist, prior to pregnancy

Goals Achieved By: Consider monotherapy as far as possible Educate about risks of abrupt discontinuation Discuss risks associated with the medications used Folic acid supplementation Effective contraception until seizure-free Risk of congenital malformation is greater for infants whose mothers have epilepsy, irrespective of fetal exposure to anticonvulsant therapy, cardiac malformation -- two-fold increase in cleft lip; 8-fold increase in cleft palate. Skeletal, CNS, GI and urogenital abnormalities also increased. All anticonvulsants associated with congenital anomalies. Examples: Valproic Acid - 1-2% chance of NTD as well as other craniofacial abnormalities. Phenytoin -- fetal hydantoin syndrome, craniofacial anomalies, hypoplastic nails, microencephaly, etc. Carbamazepine -- minor craniofacial anomalies, fingernail hypoplasia, developmental delays. Folic acd supplementation is recommended because there is some evidence that such supplementation may reduce the incidence or the severity of congenital malformation. Recommended dose (0.4 - 4 mg/day).

Case Study: Medication Management 22 year old woman seen in the office for symptoms of urinary tract infection. In the course of history taking she says she is quite happy about the results of new medication (Accutane) her dermatologist prescribed for her acne. She is sexually active and uses condoms inconsistently. - Isotretinoin (Accutane) is a proven potent human teratogen. (Category X) causes craniofacial defects, CVS and CNS malformations, and defects of the thymus. Pregnancy must be excluded and prevented before Isotretinoin is prescribed. Preconception counseling includes: - information about risk of teratogenicity - need for reliable contraception

Recurrent Pregnancy Loss 31 year old woman and her husband come to your office wanting to know if they can ever have a live baby. She has been pregnant four times so far and all pregnancies resulted in miscarriages between 8 to 14 weeks. She is in good health and does not smoking, use alcohol or drugs. One of the primary reasons that couples seek preconceptional counseling is a previous poor reproductive outcome. Other reasons - prior fetal death, congenital anomalies, IUGR infants, NICU admissions, etc.

Goals of Preconceptional Counseling in Prior Pregnancy Loss To investigate the factors that may have contributed to the previous outcome To assuage guilt and resolve grief To provide recommendations that may prevent the recurrence of such a loss To inform patients realistically regarding their likelihood of successful childbearing Factors such as uterine malformations, maternal autoimmune diseases, endocrine abnormalities and genital infections lend themselves to diagnoses and possible therapies. Thrombophilia work-up Chromosome analysis for recurrent spontaneous abortions.

Techniques For Providing Preconception Care Self-administered Reproductive Health Screen Waiting room posters and magazines Pamphlets from the March of Dimes, ACOG, AAP, etc. Community and School Interventions Referral to Maternal-Fetal Medicine specialists.

Men Have Babies Too! Male issues in preconceptional health not to be forgotten Encourage cooperation and support between prospective father and mother Identify male exposures that could adversely affect reproduction eg. occupational exposures, alcohol, tobacco, drug exposure, HIV and STD Identify male genetic issues

Think Preconception Care At the next visit, the woman could be potentially pregnant. Hence, all women of childbearing age are appropriate candidates for preconception care.