2. Preconception and Interconception Health Every Child Deserves a Healthy Start Patricia A. Brownlee, B.S.N., A.R.N.P. Hendry / Glades County Health Department

3. Public Health Perspective Preconceptual and Interconceptional Education and Counseling for women of childbearing age has the potential to favorably impact rates of: Preconceptual and Interconceptional Education and Counseling for women of childbearing age has the potential to favorably impact rates of: Infant mortality and morbidity Infant mortality and morbidity Maternal mortality and morbidity Maternal mortality and morbidity Moms and Babies survive and do well. Moms and Babies survive and do well.

4. Goals To increase awareness of the optimal health status needed by any sexually active woman to improve the birth outcome of a potential pregnancy. To increase awareness of the optimal health status needed by any sexually active woman to improve the birth outcome of a potential pregnancy. To identify reversible risks to a woman’s health or pregnancy outcome, emphasizing those factors which must be acted on before conception. To identify reversible risks to a woman’s health or pregnancy outcome, emphasizing those factors which must be acted on before conception.

5. Strategies Risk Identification, Reduction, and Elimination Risk Identification, Reduction, and Elimination Appropriate intervention, treatment and/or referral Appropriate intervention, treatment and/or referral Ongoing education, counseling and support Ongoing education, counseling and support Prevention of Unplanned Pregnancy Prevention of Unplanned Pregnancy

6. Unplanned Pregnancy Incidence of unplanned pregnancy is 50%. Incidence of unplanned pregnancy is 50%. Usual entry into prenatal care is in the 3 rd month after the Last Menstrual Period. Usual entry into prenatal care is in the 3 rd month after the Last Menstrual Period. Preconception counseling needs to be provided to all reproductive age individuals. Preconception counseling needs to be provided to all reproductive age individuals.

7. Baby Spacing A short pregnancy interval may be associated with: A short pregnancy interval may be associated with: Birth of a Small For Gestational Age (SGA) infant in a subsequent pregnancy (Lieberman 1989, Zhu 1999) Birth of a Small For Gestational Age (SGA) infant in a subsequent pregnancy (Lieberman 1989, Zhu 1999) Preterm birth in a subsequent pregnancy (Basso 1998, Zhu 1999) Preterm birth in a subsequent pregnancy (Basso 1998, Zhu 1999)

8. Health Care Provider Review medical history and immunizations Review medical history and immunizations Review family history for genetic disorders (such as Tay-Sachs, Thalassemia, Cystic Fibrosis, Sickle Cell disease) Review family history for genetic disorders (such as Tay-Sachs, Thalassemia, Cystic Fibrosis, Sickle Cell disease) Laboratory testing and screening for infectious diseases Laboratory testing and screening for infectious diseases Medical assessment and management Medical assessment and management Lifestyle assessment/intervention Lifestyle assessment/intervention Recommend Folic Acid, immunize and counsel Recommend Folic Acid, immunize and counsel Review contraceptive options Review contraceptive options

9. Common Conditions Amenable to Preconception Care Diabetes Diabetes Hypertension Hypertension Cardiac Conditions Cardiac Conditions Seizure Disorder Seizure Disorder Thyroid Disorder Thyroid Disorder Thrombo-embolic disease Thrombo-embolic disease Hemoglobin disorders Hemoglobin disorders STDs/HIV Infection Depression Eating Disorders Alcohol, tobacco and other drug use Domestic Violence Poor nutrition

10. Conditions that Need Time to Correct Prior to Conception Optimal Weight Optimal Weight Dental Health Dental Health Choice and Use of Medications Choice and Use of Medications Substance Use and Abuse: Substance Use and Abuse: ~Illicit Drugs ~Alcohol~Tobacco

11. Nutritional Risks UNDERWEIGHT: Increased risk for low birth weight, fetal death and mental retardation. UNDERWEIGHT: Increased risk for low birth weight, fetal death and mental retardation. OVERWEIGHT AND OBESE: Increased risk for diabetes, hypertension, thrombo- embolic disease, birth trauma, abnormal labor, cesarean delivery. OVERWEIGHT AND OBESE: Increased risk for diabetes, hypertension, thrombo- embolic disease, birth trauma, abnormal labor, cesarean delivery.

12. Nutritional Alerts Over supplementation of Vitamins A (limit to 3,000 IU /day) & D (limit to 400 IU/day) - Associated with an increase in congenital anomalies Over supplementation of Vitamins A (limit to 3,000 IU /day) & D (limit to 400 IU/day) - Associated with an increase in congenital anomalies Pica - Associated with iron deficiency and lead poisoning Pica - Associated with iron deficiency and lead poisoning Iron Deficiency – Associated with increased risk of preterm delivery and low birth weight Iron Deficiency – Associated with increased risk of preterm delivery and low birth weight Milk Intolerance or Calcium Deficiency Milk Intolerance or Calcium Deficiency

13. Physical Activity and Nutrition Exercise at least 30 minutes 3 times / week. Exercise at least 30 minutes 3 times / week. Eat a balanced meal from the Food Pyramid. Eat a balanced meal from the Food Pyramid. Don’t eat uncooked or undercooked meats or fish. Don’t eat uncooked or undercooked meats or fish. Limit or eliminate caffeine intake from coffee, tea, sodas, medications and chocolates. Limit or eliminate caffeine intake from coffee, tea, sodas, medications and chocolates.

14. Dental Health Research suggests that the bacteria that cause inflammation in the gums can actually get into the bloodstream and target the fetus, potentially leading to premature labor and low birth weight babies. (Offenbacher 1996) Research suggests that the bacteria that cause inflammation in the gums can actually get into the bloodstream and target the fetus, potentially leading to premature labor and low birth weight babies. (Offenbacher 1996) Women who have gum disease are more than twice as likely as other women to give birth to a premature baby. (Jeffcoat 2000) Women who have gum disease are more than twice as likely as other women to give birth to a premature baby. (Jeffcoat 2000) Encourage routine dental health care. Encourage routine dental health care.

15. Medications Not all medications are safe while trying to conceive and during pregnancy. Not all medications are safe while trying to conceive and during pregnancy. Over-the-Counter Over-the-Counter Prescription Prescription Vitamins and Supplements Vitamins and Supplements Pregnancy Risk Categories for Meds Pregnancy Risk Categories for Meds Review all medications with a health care provider. Review all medications with a health care provider.

16. Substance Use / Abuse Birth Defects and Learning Defects Birth Defects and Learning Defects Safety Issues impacting the ability to properly care for an infant Safety Issues impacting the ability to properly care for an infant Family Dysfunction Family Dysfunction Financial Stress Financial Stress Potential for Law Enforcement Involvement Potential for Law Enforcement Involvement Pregnancy may be a strong motivator for change. Pregnancy may be a strong motivator for change. Refer for Substance Abuse Evaluation/Counseling Refer for Substance Abuse Evaluation/Counseling

17. Alcohol Intake Fetal Alcohol Syndrome is a leading cause of preventable mental retardation. Fetal Alcohol Syndrome is a leading cause of preventable mental retardation. No level of alcohol is considered “safe”. No level of alcohol is considered “safe”. Advise to abstain when attempting to conceive and during pregnancy. Advise to abstain when attempting to conceive and during pregnancy. Refer for evaluation and treatment. Refer for evaluation and treatment.

18. Tobacco Exposure Smoking in pregnancy is associated with preterm delivery and low birth weight infants. Smoking in pregnancy is associated with preterm delivery and low birth weight infants. Smoking in the household is associated with Sudden Infant Death Syndrome, childhood respiratory illness, asthma, and otitis media. Smoking in the household is associated with Sudden Infant Death Syndrome, childhood respiratory illness, asthma, and otitis media. Promote Smoking Cessation. Promote Smoking Cessation.

19. Environmental Hazards Chemical: Lead, Mercury, Herbicides & Pesticides Chemical: Lead, Mercury, Herbicides & Pesticides Physical: Hyperthermia Physical: Hyperthermia Radiation: X-Ray Radiation: X-Ray Infectious: Live Vaccines, STD’s, Toxoplasmosis, Cytomegalovirus, Parvovirus B19 (Fifth Disease) Infectious: Live Vaccines, STD’s, Toxoplasmosis, Cytomegalovirus, Parvovirus B19 (Fifth Disease) Exposures at home, workplace and environment Exposures at home, workplace and environment Cultural considerations Cultural considerations

20. Environmental Counseling Avoid hot tubs, saunas, and x-rays. Avoid hot tubs, saunas, and x-rays. Stay away from toxic chemicals like insecticides, solvents, mercury and lead. Stay away from toxic chemicals like insecticides, solvents, mercury and lead. Avoid cat litter, garden soil and raw meat. Avoid cat litter, garden soil and raw meat. Frequent hand washing Frequent hand washing Universal Precautions for child care and health care Universal Precautions for child care and health care Cultural Practices Cultural Practices

21. Life Cycle Issues Psychological Concerns Psychological Concerns Social Concerns Social Concerns Screen for Domestic Violence Screen for Domestic Violence Readiness for parenthood Readiness for parenthood Financial readiness Financial readiness Life Plans (Education or Career) Life Plans (Education or Career) Stress Stress Teens Teens

22. Neural Tube Defects Anacephaly - born without brain Anacephaly - born without brain Spina Bifida -exposure of tube along spine Spina Bifida -exposure of tube along spine Encephalocele - hernia of the brain Encephalocele - hernia of the brain Estimated 4000 affected pregnancies /year in U.S. Estimated 4000 affected pregnancies /year in U.S. NTD form in the first 28 days of pregnancy NTD form in the first 28 days of pregnancy

23. Increased Risk of NTD Ethnicity (Hispanic mothers) Ethnicity (Hispanic mothers) Maternal Conditions Maternal Conditions Medications taken during pregnancy Medications taken during pregnancy Previous NTD Previous NTD Low socio-economic status Low socio-economic status Genetics/environment Genetics/environment

24. What is Folic Acid? Water soluble B vitamin also known as folate, folacin or pteroylmonoglutamic acid. Water soluble B vitamin also known as folate, folacin or pteroylmonoglutamic acid. Helps to synthesize DNA required for all rapidly growing cells. Helps to synthesize DNA required for all rapidly growing cells. The need for folate rises whenever cells are multiplying. The need for folate rises whenever cells are multiplying. Only about half of dietary folate is available for use in the body Only about half of dietary folate is available for use in the body

25. Folic Acid Modifies risk of neural tube defects (NTD) Modifies risk of neural tube defects (NTD) Supplementation for all women of childbearing potential Supplementation for all women of childbearing potential No history of NTD: 0.4 mg daily No history of NTD: 0.4 mg daily Prior infant with NTD: 4.0 mg daily Prior infant with NTD: 4.0 mg daily Woman with NTD: 4.0 mg daily Woman with NTD: 4.0 mg daily Nutritional sources often inadequate Nutritional sources often inadequate

26. Food High in Folic Acid Orange Juice and Oranges Orange Juice and Oranges Bananas Bananas Spinach Spinach Dried Navy Beans Dried Navy Beans Peanuts Peanuts Broccoli Broccoli Asparagus Asparagus Peas and lentils Peas and lentils Food with added Folic Acid: Flour Rice Spaghetti Bread Cereals Check food label for folate

27. Ongoing Support and Involvement Lifestyle Choices Lifestyle Choices Community Resources Community Resources Promote routine women’s health care versus increased attention and care of women while pregnant. Promote routine women’s health care versus increased attention and care of women while pregnant. Personalize the message Personalize the message

28. www.healthystartflorida.com www.marchofdimes.com “Funded by a Community Grant from the March of Dimes. “This material is for information purposes only and does not constitute medical advice.. The opinions expressed in this material are those of the author(s) and do not necessarily reflect the views of the March of Dimes.”