Preconception care: Aboubakr Elnashar

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1 Preconception Care Aboubakr Elnashar Prof Obs Gyn, Benha University Hospital, Egypt Aboubakr Elnashar

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Transcript of Preconception care: Aboubakr Elnashar

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Preconception Care Aboubakr Elnashar

Prof Obs Gyn, Benha University Hospital, Egypt

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• Duration of pregnancy is no longer “9” months, it’s

“12” months

ACOG& AAP: prenatal care before conception

• PCC: Concept has evolved over the last several decades Form of primary care& prevention

12 NOT 9

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Outline

• Definition& Goals

• Why Do We Need PCC?

• Components

• Scientific Evidence

• Current Recommendations

• Barriers

• Implementation

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Goal

• Goal should be realistic

Identify pre-existing conditions

that may affect an anticipated

pregnancy

Intervention(s) that could lead to

more favorable outcome

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Currently: Poor pregnancy outcomes Women enter pregnancy “at risk” for

adverse outcomes We intervene too late There is consensus that: Intervening before pregnancy:

improve outcomes

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Early ANC is too late

1. To Prevent Some Birth Defects

Critical period of teratogenesis: D17 to D56 Heart: begins to beat at 22 ds after conception

Neural tube: closes by 28 ds after conception

Palate: fuses at 56 ds after conception

2. To Prevent Implantation Errors

3. To restore allostasis: Maintain stability through change An important objective of PCC is to restore allostasis to women’s health before pregnancy

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Critical Periods of Development Critical Periods of Development

4 5 6 7 8 9 10 11 12

Weeks gestation

from LMP

Central Nervous System Central Nervous System

Heart Heart

Arms Arms

Eyes Eyes

Legs Legs

Teeth Teeth

Palate Palate

External genitalia External genitalia

Ear Ear

Missed Period Mean Entry into ANC

Most susceptible

time for major

malformation

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Components CDC, 2007

I. Risk Assessment

II. Health promotion

III. Interventions

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A. Risk assessment I. Reproductive life plan: If she plans to have children? How long she plans to wait until she becomes pregnant? Plan, based on: her values& resources, to achieve those goals

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II. History 1. Reproductive history:

Previous adverse outcomes:

infant death, fetal loss,

birth defects, low birth weight, PTL 2. Medical history: Rheumatic heart disease Thromboembolism Autoimmune diseases Hypertension Diabetes

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3. Medication use:

Current medication

Avoid FDA

Category X: Estrogen, androgens,Aminopterin, isotretinoin,Thalidomide

Category D: Phenytoin, valporic acid, diazepam, Imipramine, captopril, thiazides, Spironolactone, coumarine, chlorpropamide, Progestins, tetracyclin, streptomycin, Quinine, methotrexate, vinblastin, Azathioprine.

unless maternal benefits outweigh fetal risks;

Over-the-counter medications, herbs& supplements

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4. Substance abuse: Tobacco Alcohol Drug use 5.Toxins& teratogenic agents: At home, in the neighborhood, in the workplace: heavy metals, solvents, pesticides, endocrine disruptors, allergens

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II. Physical examination: 1. Nutritional assessment: Assess the ABCDs of nutrition: anthropometric factors (e.g., BMI) biochemical factors (e.g., anemia) clinical factors dietary risks 2. Focus on

Periodontal,

thyroid, heart,

breast,

pelvic examination

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III. Screening 1. Infections &immunizations:

Screen for periodontal, urogenital & STD as indicated;

Update immunization with hepatitis B, rubella, varicella,

Tdap,HPV& influenza vaccines as needed

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2. Genetic screening:

Based on:

family history

ethnic background

age

Offer cystic fibrosis& other carrier screening as indicated

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3. Psychosocial: Screen for depression, anxiety, domestic violence major psychosocial stressors

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4. Laboratory testing:

Testing should include

CBC;

urinalysis;

blood type& screen

When indicated screen for

Rubella, syphilis, hepatitis B,HIV, gonorrhea, chlamydia

Diabetes

Thyroid Dysfunction

Cervical cytology

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B. Health promotion 1. Family planning:

Based on the patient’s reproductive life plan

Effective contraceptive use

Discuss emergency contraception

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2. Healthy weight & nutrition:

Ideal BMI: 20 to 26.0 kg/m2

Exercise

Nutrition

Macro& micronutrients:

Getting “five a-day”: 2 servings of

fruit +3 servings of vegetables

Daily multivitamin that contains

folic acid

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3. Healthy behaviors: Nutrition

Exercise,

Safe sex

Effective contraceptive use

Dental flossing

Preventive health services

Discourage risky behaviors:

Douching

Not wearing a seatbelt,

Smoking:

use the five A’s [Ask, Advise, Assess, Assist, Arrange] for smoking cessation Alcohol

Substance abuse

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4. Healthy environments:

Discuss household, neighborhood& occupational

exposures to heavy metals, organic solvents, pesticides,

endocrine disruptors& allergens;

Give practical tips such as how to avoid exposures

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5. Stress resilience: Promote nutrition, exercise, sufficient sleep, and relaxation techniques; Address ongoing stressors (e.g., domestic violence) Identify resources to help the patient develop problem solving and conflict-resolution skills, positive mental health, and strong relationships 6. Interconception care: Promote breastfeeding, placing infants on their backs to sleep to reduce the risk of sudden infant death syndrome, positive parenting behaviors, and the reduction of ongoing biobehavioral risks

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C. Interventions

1. Folic acid supplementation

Reduces NTD by two thirds.

2. Rubella vaccination

protection against congenital rubella syndrome.

3. Hepatitis B vaccination for at risk women:

Prevents transmission of infection to infants

Eliminates the risks to the women of hepatic failure, liver

carcinoma, age cirrhosis& death due to HBV infection.

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4. Diabetes management: reduces birth defects among infants of diabetic women.

5. Hypothyroidism: protects proper neurological development.

6. HIV/AIDS screening: Allows for timely treatment Provides women (or couples) with additional information

that can influence the timing of pregnancy& treatment.

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7. STD screening& TT Reduces the risk of ectopic pregnancy, infertility, chronic

pelvic pain associated with Ct& NG

Reduces risk to a fetus of fetal death or physical&

developmental disabilities, including mental retardation&

blindness.

8. Maternal PKU management: Prevents babies from being born with PKU-related

mental retardation.

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9. Switching women off Oral anticoagulant: avoids harmful exposure.

10. Antiepileptic drug: Changing to a less teratogenic tt reduces harmful

exposure.

11. Accutane (isotretinoin) use management: Preventing pregnancy for women who use OR

Stop before conception

:eliminates harmful exposure.

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12. Smoking cessation: Prevent:

PTL

low birth weight

other adverse perinatal outcomes.

13. Eliminating alcohol use Prevents fetal alcohol syndrome

other alcohol-related birth defects.

14. Obesity control: Reduces the risks of

NTD, PTL, DM, CS, Hypertension

Thromboembolic disease Aboubakr Elnashar

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PPC for men • Alcohol

May be associated with physical& emotional abuse

May decrease fertility

• Genetic Counseling

• Occupational Exposure

- lead

• STD

– Syphilis, herpes, HIV

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Scientific Evidence

Does PCC work?

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There is evidence that individual components of PCC work:

• Rubella vaccination

• HIV/AIDS screening

• Management and control of:

– Diabetes

– Hypothyroidism

– PKU

– Obesity

• Folic Acid supplements

(level 2)

• Avoiding teratogens:

– Smoking

– Alcohol (level 2)

– Oral anticoagulants

– Accutane

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Clinical Practice Guidelines

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Clinical practice guidelines for PCC of specific maternal health conditions have been developed by professional organizations:

• American Diabetes Association (Diabetes -2004)

• American Association of Clinical Endocrinologists (Hypothyroidism – 1999)

• American Academy of Neurology (Anti-epileptic drugs)

• American Heart Association/American College of

Cardiologists (Anti-epileptic drugs - 2003)

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ACOG/AAP (2002)

All health encounters during a woman’s reproductive

years, particularly those that are a part of PCC

should include counseling on appropriate medical

care and behavior to optimize pregnancy outcomes.

ACOG/AAP Guidelines for perinatal care, 5th edition, 2002

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USPHS

“Every woman (and, when possible, her partner)

contemplating pregnancy within one year should consult

a prenatal care provider. Because many pregnancies

are not planned, providers should include preconception

counseling, when appropriate, in contacts with women

and men of

reproductive age….Such care should be integrated into

primary care services.”

USPHS Expert Panel on the Content of Prenatal Care, 1989

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Barriers

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I. Patient Aspects

• High rate of unintended pregnancies

• Ignorance about importance of good health habits prior to

conception

• Limited access to health services in general.

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II. Provider Aspects

• Feeling of having inadequate

knowledge

• Perception of PCC being time

consuming

• Lack of awareness of how to

integrate PCC into practice

• Concern about insurance reimbursement.

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III. Other barriers:

• Availability of contraceptives

• Health Insurance Coverage

• Out of Pocket Expenses.

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Who Should Get PCC? • PCC should be provided to all reproductive age

individuals

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WHO TO PROVIDE?

– OB-GYNs

– Pediatricians, Family Medicine, Internists,

– Nurses

– Genetic Counselors

– Health Educators

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Why Should Ob/Gyns be Concerned with

PCC?

• OB/GYN’s

have the most frequent contact with women

of childbearing age

are aware of prior poor pregnancy outcomes

Responsible for ANC

already have the knowledge& are applying it

advantage to improve pregnancy outcomes

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How PCC can be Integrated into Practice? I. OB-GYNs 1. WHC:

- Our best opportunity

- Single or multiple visits

- Ask about reproductive life plan

- If she plans to have child in next 1-2 yrs: she& husband should return for full visit.

2. Negative pregnancy test: an opportunity for PCC

3. Family planning encounter

4. Infertility evaluation

5. Following a poor pregnancy outcome

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Thank you

CONCLUSION “PCC is the cornerstone of healthy infants, children, families& communities

Yhank you

Aboubakr Elnashar