Definition Definition Pre-conception Care Pre-conception Care for Primary Care for Primary Care Providers Providers • Biomedical & behavioral interventions that identify and address reversible risks to a woman s health that must be acted on woman’s health that must be acted on before conception to maximize the impact Cynthia S. Shellhaas, MD, MPH on birth outcomes improvement. Associate Professor Division of Maternal-Fetal Medicine The Ohio State University College of Medicine MMWR April 21, 2006, Volume 55 Goal of Pre- Goal of Pre- Objectives Objectives Conception Care Conception Care • Review the rationale for pre-conception care • Correlate women’s health with pregnancy • To promote the health of women of outcomes reproductive age before conception so p g p as to: • Promote every encounter with a woman of childbearing age as an opportunity for health � Improve pregnancy-related outcomes promotion and disease prevention. � Reduce morbidity and mortality in • Provide examples of medical conditions and women their potential impact on pregnancy outcome 1
What is pre- What is pre- Preconception Care Preconception Care conception care? conception care? Risk Assessment: Genetics, overall health status, substance abuse, domestic violence, Influencing reproductive awareness • Comprehensive well woman care is factors: preconception care for women who p p Health Promotion: • Psychosocial Psychosocial may become pregnant. Some Nutrition, physical activity, environmental safety, social support, • Environment women may need more than routine socio-economic, life decision-making • Medical well woman care but no woman Conditions Intervention: needs less. • Behavioral Family Planning, immunizations, smoking cessation, treatment of infectious disease and medical conditions www.mombaby.org Interventions That Work Interventions That Work Who needs pre-conception care? Who needs pre-conception care? • Primary prevention � Folic acid • Women who are intending to become pregnant in the near future � Immunizations • Women who have a chronic medical condition • Avoid teratogens • Women with a prior pregnancy affected by: W ith i ff t d b � Alcohol � Preterm or LBW birth � Anti-epileptic medications � Fetal or infant death � Oral anticoagulants � Congenital anomalies • Manage maternal medical conditions • All women with reproductive capacity � Diabetes mellitus � Phenylketonuria 2
Reproductive Health Care Reproductive Health Care Reproductive Health Care Reproductive Health Care Across the Lifespan Across the Lifespan Across the Lifespan Across the Lifespan Early Adolescence Young Midlife Menopause Early Adolescence Young Midlife Menopause Childhood Adult Childhood Adult Pre- Menarche Conception Pre- Menarche Conception reproduction reproduction reproduction reproduction Early Early childbearing childbearing Pre-conception Pre-conception Delayed childbearing Delayed childbearing Phase Phase Late Childbearing Late Childbearing = Interconception = Interconception No Childbearing No Childbearing Reproductive Health Care Reproductive Health Care Opportunities to Incorporate Opportunities to Incorporate Across the Lifespan Across the Lifespan “Every Woman, Every Time” “Every Woman, Every Time” Early Adolescence Young Midlife Menopause Childhood Adult • Well woman visits Pre- Menarche Conception • Annual exams Annual exams reproduction reproduction Early • Family planning encounters childbearing Pre-conception Delayed childbearing • Chronic disease visits Phase • Postpartum exams Late Childbearing = Interconception No Childbearing 3
Example 1 Example 1 Recurrence Risk Recurrence Risk • 33-67% of women with GDM in one pregnancy will • 29 year old AA female G3P2012 have GDM in a subsequent pregnancy � Hx A2 GDM � Older maternal age � BMI—29 � Increased parity � Increased parity � OB Hx � Greater inter-pregnancy weight gain • Term, 4300 gram BW, A1 GDM � C/S � Higher infant birth weight in index pregnancy • Sab � Higher maternal pre-pregnancy weight • Term, 4600 grams BW, A2 GDM � C/S Gestational Diabetes Gestational Diabetes Long-Term Consequences Long-Term Consequences • Definition: Glucose intolerance that first occurs or is identified during pregnancy � Type 2 Diabetes • Prevalence in United States: 1-14% � Impaired glucose tolerance/Impaired fasting glucose • 33% will have abnormal post-partum � Intermediate stage between normal glucose homeostasis screening and diabetes d di b t • 50% will develop diabetes in the future � Many individuals are euglycemic in daily life and have • Risks for offspring normal glycohemoglobin levels � Macrosomia � All women with this diagnosis should be tested early in � Shoulder dystocia pregnancy for the diagnosis of gestational diabetes � Birth trauma � Hyperbilirubinemia 4
Interventions Interventions Post-partum screening Post-partum screening • Timing: 6-12 weeks post-partum • Post-partum lifestyle modifications • Type of screening � Healthy diet � Fasting plasma glucose test � Exercise � E • Easier to perform i • Lacks sensitivity for detection of other � Weight loss abnormal glucose metabolism � Breastfeeding � 75 gram, 2 hour glucose tolerance test � If normal post-partum test, repeat q 3 years Diagnostic Criteria: Abnormal Glucose Diagnostic Criteria: Abnormal Glucose Example 2 Example 2 Metabolism Metabolism Test Diabetes Impaired Impaired • 36 year old white female G2P0202 Fasting Glucose Glucose Tolerance � Chronic hypertension (diuretic) X 8 years Fasting Plasma Greater or Fasting value NA � Hx Pre-eclampsia—both pregnancies equal to 126 is 100-125 Glucose G ucose � BMI—33 75 g, 2 hr oral Fasting is Fasting value 2-hr glucose is GTT greater or is 100-125 140-199 � OB Hx equal to 126 OR 2 hr • 35 weeks, pre-eclampsia, failed induction of labor � c/s plasma • 31 weeks, pre-eclampsia, repeat c/s glucose greater or equal to 200 5
Pre-pregnancy Pre-pregnancy Hypertension Hypertension Evaluation Evaluation • Definition: Systolic blood pressure > 140 mmHg • Blood pressure control and/or diastolic blood pressure > 90 mmHg • Medication change if needed • Risks for adverse pregnancy outcomes • EKG EKG � Mild pre-existing hypertension • Echocardiogram • Super-imposed pre-eclampsia: 10-25% • Renal evaluation • Abruptio placentae: 0.7-1.5% � 24 hour urine for creatinine clearance • Preterm birth (< 37 weeks): 12-34% and protein • Fetal growth restriction: 8-16% • Baseline pre-eclampsia studies Hypertension Hypertension Anti-hypertensive therapy Anti-hypertensive therapy • Contra-indicated: ACE inhibitors & angiotensin • Risks for adverse pregnancy outcomes receptor antagonists � Severe pre-existing hypertension (1 st • Diuretic trimester) • Calcium channel blockers • Calcium channel blockers • Super-imposed pre-eclampsia: 50% • Beta-blockers • Abruptio placentae: 5-10% � Atenolol • Preterm birth (< 37 weeks): 62-70% • Labetolol • Fetal growth restriction: 31-40% • Methyldopa 6
Reproductive Life Plan Reproductive Life Plan Post-partum Hypertension Post-partum Hypertension • Do you plan to have any (more) children? • Pre-eclampsia related HTN • How many children do you hope to have? • How long do you plan to wait until you (next) � Most resolves in few weeks become pregnant? p g � Almost always gone in 12 weeks • How much space do you plan to have between � Rarely may be seen up to six months your future pregnancies? post-partum • What do you plan to do to avoid pregnancy until you are ready to become pregnant? • What can I do today to help you achieve your plan? Barriers to Pre- Barriers to Pre- PCC Prescription PCC Prescription Conception Care Conception Care • Provider Factors � Physician knowledge � Time � Lack of reimbursement � Inability to promote change in patient behaviors • Patient Factors � High rate of unintended pregnancy � Limited access to health services overall � Ignorance of importance of good health habits � Difficulty in promoting behavior change 7
www.mombaby.org www.mombaby.org Routine Pregnancy Care for Routine Pregnancy Care for Primary Care Providers Primary Care Providers Melissa Goist M.D. Clinical Assistant Professor The Ohio State University Medical Center Obstetrics and Gynecologic Consultants Routine Prenatal Care Routine Prenatal Care Goals and Objectives Goals and Objectives • Early and accurate gestational age determination • Ongoing evaluation of maternal and or fetal O i l ti f t l d f t l medical problems � Pre-conception counseling � Early intervention • Patient education and communication www.cdc.gov/ncbddd/preconception 8
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