New Paradigms for Prenatal Care: Preconception Care Peter Bernstein, MD, MPH Associate Professor of Clinical Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine Montefiore Medical Center

History of Prenatal Care 1843: J.C. Lever notes that albuminuria is associated with eclampsia 1858: Sinclair founds the first prenatal clinic in Dublin resulting fewer cases of eclampsia 1915: Williams in Baltimore notes prenatal care results in fewer fetal deaths due to detection of syphilis

History of Prenatal Care 1925: US Children’s Bureau publishes Prenatal Care –Sets the standards of the medical and educational components of prenatal care 1989: US Public Health Service publishes Caring for Our Future: The Content of Prenatal Care

Prenatal Care for the Pregnant Woman To increase her well-being before, during, and after pregnancy and to improve her self-image and self-care To reduce maternal mortality and morbidity, fetal loss, and unnecessary pregnancy interventions To reduce the risks to her health prior to subsequent pregnancies and beyond childbearing years To promote the development of parenting skills US Public Health Task Force, 1989

Prenatal Care for the Fetus/Infant To increase well-being To reduce preterm birth, intrauterine growth restriction, congenital anomalies, and failure to thrive To promote healthy growth and development, immunizations, and health supervision To reduce neurologic, developmental, and other morbidities To reduce child abuse and neglect, injuries, preventable acute and chronic illness, and the need for extended hospitalization after birth US Public Health Task Force, 1989

Prenatal Care for the Family To promote family development, and positive parent-infant interaction To reduce unintended pregnancies To identify for treatment behavior disorders leading to child neglect and family violence US Public Health Task Force, 1989

Goals of Prenatal Care Foster the well-being of the fetus and pregnant woman to ensure a healthy outcome for both

Failures of Prenatal Care More than 40% increase in utilization of prenatal care by African-American Women since the 1970’s No improvement in rates of very low birth weight infants Minimal improvement in rates of low birth weight infants –National Center for Health Statistics 1975, 1984, 1994

Failures of Prenatal Care Haas, 1993 (JAMA): –Compared all births in 1984 and 1987 in Massachusetts Approx 60,000 births in each cohort –Decline in rates of satisfactory prenatal care from 96.4% to 93.8% (p < 0.001) –No change in rates of adverse birth outcomes

New Paradigms for Prenatal Care Improved Preconception Care Group Prenatal Care Perinatal Information Systems

Preconception Care Greater New York Chapter of the March of Dimes Preconception Care Curriculum Working Group Albert Einstein College of Medicine/Montefiore Medical Center

Preconception Care May be the most important component of prenatal care –US Public Health Service, 1989

How are we doing on Preconception Care? Only 20-50% of all primary care providers routinely offer appropriate preconception care Healthy People 2000 goal: 60% of providers will routinely provide preconception care –Healthy People 2000 Report

Preconception Care 1. The Case for Preconception Care 2. What is Preconception Care? 3. How to incorporate Preconception Care into clinical practice

Preconception Care 1. The Case for Preconception Care

The Need for Preconception Care Kempe, 1992 (NEJM): Racial disparities in low birth weight rates may partially be the result of maternal conditions that should be addressed prior to conception

The Need for Preconception Care Adams, 1993: –Utilized the PRAMS database (survey of 9535 women in 4 states) –Indications for preconception counseling Tobacco or alcohol use, underweight, or delayed enrollment into prenatal care –Of those with planned pregnancies, 38% could have used preconception counseling –Those with unplanned pregnancies (40% of respondents) were more likely to have an indication for preconception counseling

Critical Periods of Development Weeks gestation from LMP Central Nervous System Heart Arms Eyes Legs Teeth Palate External genitalia Ear Missed Period Mean Entry into Prenatal Care Most susceptible time for major malformation

Preconception Care 1. The Case for Preconception Care 2. What is Preconception Care?

Preconception Care Similar to routine care: Identifies reducible or reversible risks Maximizes maternal health Intervenes to achieve optimal outcomes

Preconception Care Differences from routine care: –Reframes issues –Adds an anticipatory element –Focuses on the impact of pregnancy –Emphasizes factors which must be acted upon before conception or early in pregnancy to have maximum impact

Components of Preconception Care Medical history Psychosocial issues Physical exam Laboratory tests Family history Nutrition assessment

Conditions Addressed by Preconception Care Those that need time to correct prior to conception Interventions not usually undertaken in pregnancy Interventions considered only because a pregnancy is planned

Conditions Addressed by Preconception Care (cont) Conditions that might change the choice or timing to conceive Conditions that would require early post- conception prenatal care

Family Planning A short pregnancy interval may be associated with: –birth of an SGA infant in a subsequent pregnancy –Lieberman 1989, Zhu 1999 –preterm birth in a subsequent pregnancy –Basso 1998, Zhu 1999

Preconception Genetic Counseling and Screening Family history of genetic diseases Discussion of age-related risks Discussion of disease-related risks Carrier screening Potential options of donor egg or sperm or early genetic testing Discussion of exposure to teratogens

Critical Periods of Development Weeks gestation from LMP Central Nervous System Heart Arms Eyes Legs Teeth Palate External genitalia Ear Missed Period Mean Entry into Prenatal Care Most susceptible time for major malformation

Diabetes Mellitus 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

Substance Use and Preconception Care Patient education as to effects of substances on fetus Screening for use/abuse Referral for treatment program Pregnancy may be a strong motivator for change

Alcohol Leading preventable cause of mental retardation Most common teratogen to which fetuses are exposed Effects related to dose No threshold has been identified for “safe” use in pregnancy Effects at all stages of pregnancy Binge drinking associated with unintended pregnancy

Tobacco Leading preventable cause of low birthweight –For every 10 cigarettes smoked each day the risk of delivering an SGA infant increases by a factor of 1.5 Associated with placental abruption, preterm delivery, placenta previa, miscarriage Smoking cessation results in increased birth weight Neurobehaviorial differences in neonates exposed in utero to tobacco

Substance Use and Consequences

Environmental Teratogens Exposures –Home, workplace, environment Physical/chemical hazards –ionizing radiation, lead, mercury, hyperthermia, herbicides, pesticides

Physical and Emotional Abuse in Pregnancy Two million women each year are abused by a partner No correlation with ethnicity, socio- economic status, or education 29% of abused women report escalation of abuse during pregnancy

Role of the Health Care Provider Be open to the subject Provide a private, confidential setting for visit Use a standardized screen Ask every woman Know local resources for referral

Nutritional Risks Underweight (BMI < 19.8 prepregnant) –Increased risk for: low birthweight, fetal death, mental retardation Overweight (BMI ) and Obese (BMI >29.0) –Increased risk for: diabetes, hypertension, thromboembolic disease, macrosomia, birth trauma, abnormal labor, cesarean delivery, birth defects

Nutritional Risks Vitamins and Minerals Folic acid - modifies risk of neural tube defects Iron - increased risk of preterm delivery, LBW Oversupplementation of Vitamins A & D - increase in congenital anomalies Pica - iron deficiency, lead poisoning

Prevention of Neural Tube Defects Supplementation for all women of childbearing potential with folic acid –No history of NTD: 0.4 mg. qd –Prior infant with NTD: 4.0 mg. qd –Woman with NTD: 4.0 mg. qd Nutritional sources often inadequate Women with unintended pregnancies less likely to taking folic acid supplementation

Rubella Vaccination Determine rubella immunity prior to conception Vaccinate susceptible nonpregnant women Congenital rubella syndrome may result from infection during pregnancy (microcephaly, fetal growth restriction, cardiac malformations, etc)

Immunizations Women of childbearing age in the US should be immune to measles, mumps, rubella, varicella, tetanus, diptheria, and poliomyelitis through childhood immunizations If immunity is determined to be lacking, proper immunization should be provided Need for immunizations according to age group of women and occupational or lifestyle risks

Preconception Care for Men Alcohol –may be associated with physical and emotional abuse –may decrease fertility Genetic Counseling Occupational exposure –lead Sexually transmitted diseases –syphilis, herpes, HIV

Preparedness for Parenthood Pyschological Financial Life plans –education –career

Preconception Care 1. The Case for Preconception Care 2. What is Preconception Care? 3. How to incorporate Preconception Care into clinical practice

Epidemiology of Unintended Pregnancy 49% of pregnancies in the US are unintended (unwanted or mistimed) –Henshaw, 1998 Preconception care should be provided to all reproductive age individuals

Barriers to Preconception Care Unintended pregnancy “Planned” pregnancies are seldom planned with a health care provider Unpreparedness of health care providers

When should preconception care be offered? As part of routine health maintenance care At a defined preconception visit For women with chronic illness

Improving the Delivery of Preconception Care Use of chart insert checklists –Physician completed Bernstein 2000 –Patient Completed Available from the March of Dimes

Bernstein, J Reprod Med, 2000

Since so few pregnancies are planned, preconception care issues must be addressed at all encounters with reproductive- aged individuals

Thank You