1. Preconception Care Greater New York Chapter of the March of Dimes Preconception Care Curriculum Working Group Albert Einstein College of Medicine/Montefiore Medical Center Peter Bernstein, MD, MPH Associate Professor of Clinical Obstetrics & Gynecology and Women’s Health

2. Preconception Care May be the most important part of prenatal care –US Public Health Service, 1989 Only 20-50% of primary care provider routinely provide preconception care –Healthy People 2000 Report

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

4. Preconception Care 1. The Case for Preconception Care

5. 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 Haas, 1993 (JAMA): Additional access to prenatal care only in Massachusetts did not impact rates of adverse birth outcomes

6. The Need for Preconception 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

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

13. Preconception Care Identifies reducible or reversible risks Maximizes maternal health Intervenes to achieve optimal outcomes Provide health education

14. Preconception Care Reframes issues Adds an anticipatory element Focuses on the impact of pregnancy

15. Elements of Preconception Care Focus on elements which must be accomplished prior to conception or within weeks thereafter to be effective –Risk assessment –Health promotion –Medical and pyschosocial interventions

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

17. Examples of Components of Preconception Care –Family planning and pregnancy spacing –Family history –Genetic history (maternal and paternal) –Medical, surgical, pulmonary and neurologic history –Current medications (prescription and OTC) –Substance use, including alcohol, tobacco and illicit drugs –Nutrition –Domestic abuse and violence –Environmental and occupational exposures –Immunity and immunization status –Risk factors for STDs –Obstetric history –Gynecologic history –General physical exam –Assessment of Socioeconomic, educational, and cultural context

18. Prevalence of Risk Factors Pregnant or gave birth Smoked during pregnancy11.0% Consumed alcohol in pregnancy (55% at risk of pregnancy)10.1% Had preexisting medical conditions4.1% Rubella seronegative7.1% HIV/AIDS0.2% Received inadequate prenatal Care15.9% At risk of getting pregnant Cardiac Disease3% Hypertension3% Asthma6% Dental caries or oral disease (women 20-39)>80% Diabetic9% On teratogenic drugs2.6% Overweight or Obese50% Not taking Folic Acid69.0%

19. 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

20. 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

21. 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

22. 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

24. Critical Periods of Development 4 5 6 7 8 9 10 11 12 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

27. 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

29. 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

30. 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

31. Substance Use and Consequences

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

33. 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

34. 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

35. Nutritional Risks Underweight (BMI < 19.8 prepregnant) –Increased risk for: low birthweight, fetal death, mental retardation Overweight (BMI 26.1-29.0) and Obese (BMI >29.0) –Increased risk for: diabetes, hypertension, thromboembolic disease, macrosomia, birth trauma, abnormal labor, cesarean delivery

37. 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

39. 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

40. 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

42. 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)

44. 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

45. Preparedness for Parenthood Pyschological Financial Life plans –education –career

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

48. 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

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

50. When should preconception care be offered? As part of routine health maintenance care At a defined preconception visit For women with chronic illness At one visit v. several visits

51. Incorporating Preconception Care into Routine Primary Care Encourage all women to have a “Reproductive Life Plan” Chart stamp: –LMP, BP, Weight, Height, BMI –“Plan to become pregnant in the next year?” –Family Planning Method –Tobacco use

52. Bernstein, Merkatz J Repro Med, 2000

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

54. Thank You