Preconception Care: New Guidelines, New Opportunities

1. Preconception Care: New Guidelines, New Opportunities

2. 2 Michael C. Lu, MD, MPH Associate Professor Department of Obstetrics & Gynecology David Geffen School of Medicine at UCLA Department of Community Health Sciences UCLA School of Public Health June 30, 2008 PRECONCEPTION CARE: Promoting the Health of California�s Families Good morning, I�m honored to be invited to speak to the network of FamilyPACT providers today on a topic which I believe will be the next frontier for promoting the health of California�s families, and I�m especially honored to be doing this webcast with one of my greatest heroes in the field, Dr. Michael Policar. We are going to be talking about preconception care. Good morning, I�m honored to be invited to speak to the network of FamilyPACT providers today on a topic which I believe will be the next frontier for promoting the health of California�s families, and I�m especially honored to be doing this webcast with one of my greatest heroes in the field, Dr. Michael Policar. We are going to be talking about preconception care.

3. 3 Why Preconception Care? I�m going to be talking about why preconception care, and what does it have to do with family planning?I�m going to be talking about why preconception care, and what does it have to do with family planning?

4. 4 Why Preconception Care? Early prenatal care is too late. And the answer is because even early prenatal care may be too late. If you want to make smart and healthy babies who will grow up to be healthy women, you�ve got to start before pregnancy, by optimizing women�s health. Why is early prenatal care too late? First of all, we know that early prenatal care is too late to prevent a number of birth defects When does the heart begin to beat When does the neural tube closeAnd the answer is because even early prenatal care may be too late. If you want to make smart and healthy babies who will grow up to be healthy women, you�ve got to start before pregnancy, by optimizing women�s health. Why is early prenatal care too late? First of all, we know that early prenatal care is too late to prevent a number of birth defects When does the heart begin to beat When does the neural tube close

5. 5 Early Prenatal Care Is Too LateTo Prevent Some Birth Defects The heart begins to beat at 22 days after conception The neural tube closes by 28 days after conception The palate fuses at 56 days after conception Critical period of teratogenesis � Day 17 to Day 56 The heart begins to beat at 22 days after conception, and the neural tube closes by 28 days after conception. If you do the math, that�s 5 to 6 weeks after the last menstrual period for women with 28-day cycles. Most women haven�t started prenatal care yet, and many women aren�t even aware that they are pregnant, and yet some of the most vital organs are already formed. This is why early prenatal care is too late. By the time the woman comes in for prenatal care, there may not be much you can do about preventing some birth defects.The heart begins to beat at 22 days after conception, and the neural tube closes by 28 days after conception. If you do the math, that�s 5 to 6 weeks after the last menstrual period for women with 28-day cycles. Most women haven�t started prenatal care yet, and many women aren�t even aware that they are pregnant, and yet some of the most vital organs are already formed. This is why early prenatal care is too late. By the time the woman comes in for prenatal care, there may not be much you can do about preventing some birth defects.

6. 6 Early Prenatal Care Is Too LateTo Prevent Implantation Errors But the heart and neural tube aren�t even the first things to form. The placenta begins to form very early in pregnancy, beginning with implantation at 7 days after conception. This is important because we now know that many pregnancy complications that manifest late in pregnancy may have their origins early in pregnancy, right around the time of implantation and placentation. Take preeclampsia, as an example. One of the most consistent pathologic findings of preeclampsia is poor, shallow placentation; something went awry with trophoblastic invasion early in pregnancy, possibly as a result of some immunologic or inflammatory dysfunction or dysregulation, so that the placenta implants poorly onto the uterus; This poor, shallow placentation plays a major role in the pathogenic processes leading to preeclampsia, so that by the time you start prenatal care, it may be too late to reverse the implantation errors and alter the course of the pregnancy.But the heart and neural tube aren�t even the first things to form. The placenta begins to form very early in pregnancy, beginning with implantation at 7 days after conception. This is important because we now know that many pregnancy complications that manifest late in pregnancy may have their origins early in pregnancy, right around the time of implantation and placentation. Take preeclampsia, as an example. One of the most consistent pathologic findings of preeclampsia is poor, shallow placentation; something went awry with trophoblastic invasion early in pregnancy, possibly as a result of some immunologic or inflammatory dysfunction or dysregulation, so that the placenta implants poorly onto the uterus; This poor, shallow placentation plays a major role in the pathogenic processes leading to preeclampsia, so that by the time you start prenatal care, it may be too late to reverse the implantation errors and alter the course of the pregnancy.

7. 7 Allostasis: Maintain stability through change Early Prenatal Care Is Too LateTo Restore Allostasis Most importantly, early prenatal care may be too late to restore allostasis. Allostasis is an important concept which describes the body�s ability to maintain stability through change.Most importantly, early prenatal care may be too late to restore allostasis. Allostasis is an important concept which describes the body�s ability to maintain stability through change.

8. 8 Stress Response A good example of allostasis is your stress response. What happens when you are stressed? What happens when you see a saber tooth tiger? You run! Your body activates the fight-or-flight response -- the hypothalamic-pituitary-adrenal system and the sympatho-adrenal-medullary system -- to put out more stress hormones -- CRH and ACTH and cortisol and catecholamines -- to help you run faster. A good example of allostasis is your stress response. What happens when you are stressed? What happens when you see a saber tooth tiger? You run! Your body activates the fight-or-flight response -- the hypothalamic-pituitary-adrenal system and the sympatho-adrenal-medullary system -- to put out more stress hormones -- CRH and ACTH and cortisol and catecholamines -- to help you run faster.

9. 9 Allostasis But what happens after you got away? Your heart rate slows down, your blood pressure comes down, and you calm down. The amazing thing about the human body is that it is self-regulating; it knows to shut itself off once the stressor has been removed. This is called allostasis � maintaining stability through change. This works by a negative feedback mechanism, which is found common to many biological systems. It works very much like a thermostat. When the temperature falls below a preset point, it turns on the heat. Once the temperature reaches that preset point, the heat is turned off. In the stress response, the HPA axis produces cortisol. Cortisol, in turn, feeds back to the brain to shut off the HPA axis.But what happens after you got away? Your heart rate slows down, your blood pressure comes down, and you calm down. The amazing thing about the human body is that it is self-regulating; it knows to shut itself off once the stressor has been removed. This is called allostasis � maintaining stability through change. This works by a negative feedback mechanism, which is found common to many biological systems. It works very much like a thermostat. When the temperature falls below a preset point, it turns on the heat. Once the temperature reaches that preset point, the heat is turned off. In the stress response, the HPA axis produces cortisol. Cortisol, in turn, feeds back to the brain to shut off the HPA axis.

10. 10 Allostatic Load:Wear and Tear from Chronic Stress But what happens when there is no where to run? In the face of repeated or chronic stress, the body loses the ability for self-regulation so you can turn it on, but you can�t shut it off. Biologically speaking, tonically elevated levels of cortisol start to down-regulate the glucocorticoid receptors in the brain leading to the loss of negative feedback. So we find in animals and humans who are chronically stressed that they walk around with higher circulating levels of stress hormones, and if they were to be exposed to some natural or experimental stressors, they put out out much more CRH and cortisol than normal. This is referred to as allostatic load, which describes that wear and tear on your body�s allostatic systems from chronic stress. Over time the systems are going to get worn out so that you can turn them on, but you can�t shut them off. But what happens when there is no where to run? In the face of repeated or chronic stress, the body loses the ability for self-regulation so you can turn it on, but you can�t shut it off. Biologically speaking, tonically elevated levels of cortisol start to down-regulate the glucocorticoid receptors in the brain leading to the loss of negative feedback. So we find in animals and humans who are chronically stressed that they walk around with higher circulating levels of stress hormones, and if they were to be exposed to some natural or experimental stressors, they put out out much more CRH and cortisol than normal. This is referred to as allostatic load, which describes that wear and tear on your body�s allostatic systems from chronic stress. Over time the systems are going to get worn out so that you can turn them on, but you can�t shut them off.

11. 11 Stressed vs. Stressed Out Stressed Increased cardiac output Increased available glucose Enhanced immune functions Growth of neurons in hippocampus & prefrontal cortex Stressed Out Hypertension & cardiovascular diseases Glucose intolerance & insulin resistance Infection & inflammation Atrophy & death of neurons in hippocampus & prefrontal cortex This is when you go from being stressed to being stressed out. When you are stressed, your body activates a sympathetic response which leads to increased cardiac output. When you are stressed out, you can�t shut off the sympathetic response which in the long run leads to hypertension and cardiovascular diseases When you are stressed, your body activates the HPA axis to produce cortisol which increases blood glucose as fuel. When you are stressed out, your body can�t shut off the HPA axis which in the long run leads to glucose intolerance and insulin resistance. When you are stressed, your immune functions are actually enhanced. But when you are stressed out, as we talked about, you become more susceptible to infection and inflammation. When you are stressed, your hippocampus and prefrontal cortex actually grow in size. These are learning centers inside your brain that help you learn from your mistakes. But when you are stressed out, these neurons don�t grow; they atrophy and die. So acute stress helps you learn; that�s why we keep such vivid memories of a stressful event like when Kennedy was shot or 911. But chronic stress makes you forget and you start to lose your memory if you are under chronic stress.This is when you go from being stressed to being stressed out. When you are stressed, your body activates a sympathetic response which leads to increased cardiac output. When you are stressed out, you can�t shut off the sympathetic response which in the long run leads to hypertension and cardiovascular diseases When you are stressed, your body activates the HPA axis to produce cortisol which increases blood glucose as fuel. When you are stressed out, your body can�t shut off the HPA axis which in the long run leads to glucose intolerance and insulin resistance. When you are stressed, your immune functions are actually enhanced. But when you are stressed out, as we talked about, you become more susceptible to infection and inflammation. When you are stressed, your hippocampus and prefrontal cortex actually grow in size. These are learning centers inside your brain that help you learn from your mistakes. But when you are stressed out, these neurons don�t grow; they atrophy and die. So acute stress helps you learn; that�s why we keep such vivid memories of a stressful event like when Kennedy was shot or 911. But chronic stress makes you forget and you start to lose your memory if you are under chronic stress.

12. 12 Allostasis vs. Allostatic Load Bruce McEwen uses this diagram to illustrate the concepts of allostasis and allostatic load. The lower image is an picture of allostasis � maintaining stability through change. The upper image is one of allostatic load � if you put 2 500 kilo sumo wrestlers on a seesaw what is going to happen? It is going to break. Allostatic load is the consequences of all that wear and tear from chronic stress � both biological and psychological stress. Over time the systems are going to get worn out, get broken down. Bruce McEwen uses this diagram to illustrate the concepts of allostasis and allostatic load. The lower image is an picture of allostasis � maintaining stability through change. The upper image is one of allostatic load � if you put 2 500 kilo sumo wrestlers on a seesaw what is going to happen? It is going to break. Allostatic load is the consequences of all that wear and tear from chronic stress � both biological and psychological stress. Over time the systems are going to get worn out, get broken down.

13. 13 Preterm Birth:A Life Course Perspective And what�s going to happen if you enter the pregnancy with all that allostatic load? Let�s take preterm birth, as an example. We used to think the preterm birth is the consequence of some precipitating event such as an infection or a stressful life event, that occur around the time of the onset of labor. And what�s going to happen if you enter the pregnancy with all that allostatic load? Let�s take preterm birth, as an example. We used to think the preterm birth is the consequence of some precipitating event such as an infection or a stressful life event, that occur around the time of the onset of labor.

14. 14 Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course Preterm Birth:A Life Course Perspective The life course perspective posits that vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course. To prevent preterm birth, it�s not enough to just reduce stress or treat infection during pregnancy. From a life course perspective, we have to reduce allostatic load and restore allostasis in stress and immune response before pregnancy. The life course perspective posits that vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course. To prevent preterm birth, it�s not enough to just reduce stress or treat infection during pregnancy. From a life course perspective, we have to reduce allostatic load and restore allostasis in stress and immune response before pregnancy.

15. 15 An important objective of preconception care is to restore allostasis to women�s health before pregnancy

16. 16 Preterm Birth:A Life Course Perspective And just in case you think this is all about the baby, think again. The same allostatic load � the stress reactivity and immune-inflammatory dysregulation that lead to preterm birth will go on in the next 15-20 years to wreak havoc in mom�s blood vessels, heart, and other vital organs. In this study, women who had a preterm birth are significantly more likely to be hospitalized or die from a heart attack within the next 15 to 20 years, compared to women who had never had a term birth. Thus we can reframe preterm birth not only as a children�s health issue, but as a women�s health issue � that preterm birth may be an early sign of things to come � it may herald the development of hypertension, heart disease, and other chronic diseases mediated by stress and inflammation. And just in case you think this is all about the baby, think again. The same allostatic load � the stress reactivity and immune-inflammatory dysregulation that lead to preterm birth will go on in the next 15-20 years to wreak havoc in mom�s blood vessels, heart, and other vital organs. In this study, women who had a preterm birth are significantly more likely to be hospitalized or die from a heart attack within the next 15 to 20 years, compared to women who had never had a term birth. Thus we can reframe preterm birth not only as a children�s health issue, but as a women�s health issue � that preterm birth may be an early sign of things to come � it may herald the development of hypertension, heart disease, and other chronic diseases mediated by stress and inflammation.

17. 17 Why Preconception Care?Summary Early Prenatal Care Is Too Late To prevent some birth defects To prevent implantation errors To restore allostasis

18. 18 What Is Preconception Care?

19. 19 What is Preconception Care? A set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management.

20. 20 Definition of Preconception Care Preconception care is comprised of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman�s health or pregnancy outcome through prevention and management It is more than a single visit and less than all well-woman care. It includes care before a first pregnancy or between pregnancies (interconception care)

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24. 24 Content of Preconception Care Risk Assessment Health Promotion Medical and Psychosocial Interventions Several models of preconception care have been developed. Generally speaking, preconception care consists of 3 major components: risk assessment, health promotion, medical and psychosocial interventionsSeveral models of preconception care have been developed. Generally speaking, preconception care consists of 3 major components: risk assessment, health promotion, medical and psychosocial interventions

25. 25 Content of Preconception CareRisk Assessment Reproductive Life Plan A set of personal goals about having (or not having) children based on personal values and resources A plan to achieve those goals Risk assessment begins with an assessment of a woman�s reproductive life plan. As defined by the CDC, a reproductive life plan is a set of personal goals about having (or not having) children based on personal values and resources, and a plan to achieve those goals This means asking every woman of childbearing age at every visit if she plans to have any children or any more children, and how long she plans to wait until she becomes pregnant. Risk assessment begins with an assessment of a woman�s reproductive life plan. As defined by the CDC, a reproductive life plan is a set of personal goals about having (or not having) children based on personal values and resources, and a plan to achieve those goals This means asking every woman of childbearing age at every visit if she plans to have any children or any more children, and how long she plans to wait until she becomes pregnant.

26. 26 Example of a Reproductive Life Plan Do you hope to have any (more) children? How many children do you hope to have? How long do you plan to wait until you (next) become pregnant? How much space do you plan to have between your pregnancies: What do you plan to do until you are ready to become pregnant? What can I do today to help you achieve your plan?

27. 27 Content of Preconception CareRisk Assessment Past Pregnancy History Review old records Determine cause of prior adverse outcome Address ongoing biobehavioral risks to prevent recurrence It�s also important to review past pregnancy history because history has a way of repeating itself. If your patient had a preterm baby in a previous pregnancy, she has about a 20 to 30% chance of recurrence in her next pregnancy. As much as you can you need to determine the cause of prior adverse outcomes and address ongoing biobehavioral risks to prevent recurrrence.It�s also important to review past pregnancy history because history has a way of repeating itself. If your patient had a preterm baby in a previous pregnancy, she has about a 20 to 30% chance of recurrence in her next pregnancy. As much as you can you need to determine the cause of prior adverse outcomes and address ongoing biobehavioral risks to prevent recurrrence.

28. 28 Content of Preconception CareRisk Assessment Medical Assessment Ongoing medical conditions e.g. hypertension, diabetes, hypothyroidism, cardiac diseases, thrombophilia Medications e.g. Accutane, Warfarin, ACE inhibitors You need to ask her about her past medical history. If she has hypertension, diabetes, and hypercholesterolemia, these conditions need to be in good control before she gets pregnant. If she has pregestational diabetes there is about 10% chance that her baby will be affected with a major birth defect, mostly cardiac and neural tube defect. But that risk appears to depend on her glycemic control and there are studies that show that if her blood sugar is poorly control before and in early pregnancy, with a hemoglobin A1c of greater than 10 there is about 20% chance that her baby will be affected with a major birth defectYou need to ask her about her past medical history. If she has hypertension, diabetes, and hypercholesterolemia, these conditions need to be in good control before she gets pregnant. If she has pregestational diabetes there is about 10% chance that her baby will be affected with a major birth defect, mostly cardiac and neural tube defect. But that risk appears to depend on her glycemic control and there are studies that show that if her blood sugar is poorly control before and in early pregnancy, with a hemoglobin A1c of greater than 10 there is about 20% chance that her baby will be affected with a major birth defect

29. 29 Content of Preconception CareRisk Assessment And she may be on an ACE inhibitor for her hypertension which can interfere with fetal renal development in the second and third trimester and cause congenital anomalies and so you need to consider switching her to a safer antihypertensive like aldomet. And she may also be on a statin for her hypercholesterolemia which is a category X medication so you need to consider switching her to a safer antihyperlipidemic medication like a bile acid sequestrant (e.g. cholestyramine). Generally speaking category X and D medications should never be used just before or during pregnancy. Category A and B medications are probably safe. For category C medications, you need to weigh potential risks versus potential benefits.And she may be on an ACE inhibitor for her hypertension which can interfere with fetal renal development in the second and third trimester and cause congenital anomalies and so you need to consider switching her to a safer antihypertensive like aldomet. And she may also be on a statin for her hypercholesterolemia which is a category X medication so you need to consider switching her to a safer antihyperlipidemic medication like a bile acid sequestrant (e.g. cholestyramine). Generally speaking category X and D medications should never be used just before or during pregnancy. Category A and B medications are probably safe. For category C medications, you need to weigh potential risks versus potential benefits.

30. 30 Content of Preconception CareRisk Assessment Medical Assessment Infections RTI UTI STI Periodontal disease Immunizations Tdap Hepatitis B Influenza Measles, Mumps and Rubella Varicella HPV I�d pay special attention to ongoing infections such as RTI, UTI, STI and periodontal diseases, all of which have been linked to preterm birth. Take the opportunity also to update your patient�s immunizations. The six adult immunizations are Tdap Hepatitis B Influenza Measles, Mumps and Rubella Varicella HPV MMR, Varicella and HPV are contraindicated during pregnancy and your pt should wait at least 28 days after vaccination before attempting to conceiveI�d pay special attention to ongoing infections such as RTI, UTI, STI and periodontal diseases, all of which have been linked to preterm birth. Take the opportunity also to update your patient�s immunizations. The six adult immunizations are Tdap Hepatitis B Influenza Measles, Mumps and Rubella Varicella HPV MMR, Varicella and HPV are contraindicated during pregnancy and your pt should wait at least 28 days after vaccination before attempting to conceive

31. 31 Content of Preconception CareRisk Assessment Family history and genetic risks Family history Age Ethnic background �Ashkenazi Jewish Panel� Gaucher disease Type 1, Tay-Sachs, Cystic fibrosis, Familial dysautonomia (Riley-Day syndrome), Canavan disease, Niemann-Pick disease, Fanconi anemia group C, Bloom syndromeMucolipidosis IV Known genetic disorder (e.g. PKU) 

32. 32 Content of Preconception CareRisk Assessment Social Assessment Family violence, partner support Home, occupational, environmental exposures e.g. metals, pesticides, solvents, endocrine disruptors Social, financial, psychological stressors

33. 33 Content of Preconception CareRisk Assessment Behavior Smoking Alcohol Drugs Nutrition Anthropometry Biochemical Clinical Dietary

34. 34 Content of Preconception CareRisk Assessment Assessment of Mental Health Depression Anxiety Stress & Support

35. 35 Family planning Nutritional preparedness Stress resilience Immune allostasis Healthy environment Content of Preconception CareHealth Promotion

36. 36 Family planning & preconception care

37. 37 What Can Family Planning Do? Family planning services are necessary for the widespread adoption of preconception care for two reasons. First, preconception care is more likely if pregnancies are planned, and family planning services encourage pregnancy planning. Second, family planning services usually include counseling, and counseling provides an opportunity to discuss the advantages of preconception care.

38. 38 What Can Family Planning Do?You already do some preconception care already Risk Assessment Reproductive life plan Past pregnancy history Past medical & surgical history Medications & allergies Family & genetic history Social history Behavioral & nutritional assessment Mental health Laboratory testing Health Promotion Family planning Stress resilience Nutritional preparedness Immune allostasis Healthy environment Medical & Psychosocial Interventions Individualized for identified risks Preventive services and primary care

39. 39 Barriers to Preconception Care Services already provided by FP programs Reimbursement issues Budget constraints Services not provided by FP programs Categorical funding Provider training Lack of referral services Lack of systems integration

40. 40 Interconception Care Risk Assessment Family violence Infections/Immunizations Nutrition Depression Stress Health Promotion Breastfeeding Back-to-sleep Exercise Exposures Folate Family planning Medical & Psychosocial Interventions Individualized for identified risks Preventive services and primary care Enhanced contents

41. 41 The definition of insanity is doing the same thing over and over and expecting different results So you�ve heard a lot in the last day and a half. In the last 20 minutes you heard me talk about the life course perspective and the ecological model. You�ve heard me talk about the importance of allostasis and social determinants of health. So when you leave this conference, what are you going to do different? Because if you don�t, you are insane.So you�ve heard a lot in the last day and a half. In the last 20 minutes you heard me talk about the life course perspective and the ecological model. You�ve heard me talk about the importance of allostasis and social determinants of health. So when you leave this conference, what are you going to do different? Because if you don�t, you are insane.

42. 42 "We must become the change we want to see.� - MAHATMA GANDHI So, you see, I have a pretty wonderful life. And I want you to have a wonderful life. This doesn�t mean you have to become a doctor. Whatever you end up doing, and I know not all of you will want to become doctors � some of you may choose to become nurse practitioners, nurse midwives, physician assistants health educators, public health professionals, or do something that has nothing to do with medicine � whatever you end up doing, you will have a wonderful life if you dedicate your life to making a difference. So, you see, I have a pretty wonderful life. And I want you to have a wonderful life. This doesn�t mean you have to become a doctor. Whatever you end up doing, and I know not all of you will want to become doctors � some of you may choose to become nurse practitioners, nurse midwives, physician assistants health educators, public health professionals, or do something that has nothing to do with medicine � whatever you end up doing, you will have a wonderful life if you dedicate your life to making a difference.

43. 43 Preconception care provides an opportunity to promote family health Broaden family planning�s mission to promote family health Leverage additional resources to promote family health Enable service integration in women�s health care

44. 44 But also to try to get us to do some thinking outside the boxBut also to try to get us to do some thinking outside the box

45. 45 Michael C. Policar, MD, MPH Associate Clinical Professor Obstetrics, Gynecology, and Reproductive Sciences University of California, San Francisco School of Medicine June 30, 2008 PRECONCEPTION CARE: Family Planning Perspective Thank you very much. I�m delighted to be here, and very honored to be invited to speak at this Symposium. I am going to talk about preconception care this morning, in the contexts of both promoting maternal health and making smart and healthy babies who will grow up to be healthy women.Thank you very much. I�m delighted to be here, and very honored to be invited to speak at this Symposium. I am going to talk about preconception care this morning, in the contexts of both promoting maternal health and making smart and healthy babies who will grow up to be healthy women.

46. 46 Is A Pre-Pregnancy Visit Necessary? Pro argument A dedicated visit for physical assessment, risk screening, vaccinations, and counseling Con argument No studies of impact on pregnancy outcomes Can be duplicative of the first prenatal visit Should be done at all reproductive/ well woman health encounters

47. 47 Is A Pre-Pregnancy Visit Necessary? Can I bill for it? Family PACT Office visit: E/M or E&C code Use S50 as primary diagnosis code No lab tests, unless necessary for covered clinical indications Other payers Best ICD-9 diagnosis code : V26.49 �Other procreative management counseling and advice�

48. 48 Clinical Interventions Initiate folic acid Ensure that vaccinations are up to date Offer screening for conditions that will impact pregnancy decisions and management Switch to medications that are safe in pregnancy Control blood glucose in diabetics before pregnancy

49. 49 Clinical: Folic Acid Folic acid supplementation reduces occurrence of neural tube defects by two thirds Recommendations All women of childbearing age should be encouraged to take a folic acid-containing multivitamin supplement All women should ingest 0.4 mg (400 mcg) of folic acid daily, obtained from folate-rich food, fortified foods and/or supplements Start at least 3 months before conception

50. 50 Clinical: Vaccinations Rubella Prevention of congenital rubella syndrome Hepatitis B Prevention of vertical transmission of HBV Target men and women at risk of HBV infection Varicella-zoster Prevention of in-utero varicella exposure Influenza vaccine All pregnant women in flu season; all trimesters Also advised: TDaP, HPV vaccines

51. 51 Screening for Maternal Conditions HIV infection Once for all adults, then based on personal risks Type 2 diabetes Obesity, PCOS, stillbirth, baby >9 lbs Periodontal disease ? Increased risk of preterm labor Genetic conditions Personal+family history, age, ethnic background

52. 52 Clinical: Drugs to Avoid

53. 53 Clinical: Seizure Disorders All women with a history of seizures should be counseled about the risks of seizures during pregnancy and the risks of medications used to control them Consider a trial without medication for women who have not had a seizure in several years and who have a normal EEG

54. 54 Clinical: Seizure Disorders If anticonvulsants are needed, the least toxic anticonvulsant medication should be initiated before pregnancy and the medication adjusted frequently to keep serum levels in the lowest effective range For women taking antiepileptic drugs who are considering a pregnancy, folic acid supplementation 5 mg/day is recommended for 1 month prior to conception and until the end of the 1st trimester

55. 55 Blood Glucose Control in Diabetics All women with diabetes should be counseled about diabetes control before considering pregnancy Optimal weight control Maximize control with self-glucose monitoring Regular exercise program Before pregnancy, a near-normal glycosylated hemoglobin should be achieved Those with poor control of their diabetes should be encouraged to use effective birth control

56. 56 Clinical: Maternal Conditions Hypothyroidism Dosages of Levothyroxine� for treatment of hypothyroidism increase during early pregnancy Adjust dosage for proper fetal neurologic development Phenylketonuria Women with PKU as infants have an increased risk for delivering neonates/infants with mental retardation Prevented by adherence to a low phenylalanine diet before conception and throughout pregnancy

57. 57 Behavior Change: Stop Smoking Preterm birth, low birthweight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking before or during early pregnancy Because only 20% of women successfully control tobacco dependence during pregnancy, cessation of smoking is recommended before pregnancy

58. 58 Behavior Change: Stop Smoking Brief counseling (5-15 minutes) with self-help materials offered by a clinician can improve cessation rates by 30-70% Intervention works best for moderate (< 20 cigarettes per day) smokers A woman is more likely to quit smoking during pregnancy than at any other time in her life Obstetricians and other prenatal care clinicians are uniquely positioned to apply behavioral strategies that will help women quit smoking. Behavioral interventions lasting from 5 to 15 minutes, delivered by a clinician and supplemented with pregnancy-specific self-help materials, significantly increased smoking cessation rates among pregnant smokers. Pregnancy is a prime �teachable moment� in health care. Women are more likely to quit smoking during pregnancy than at any other time in their lives. Clinicians can tap into that motivation to help their patients achieve long-term healthy lifestyle changes for themselves and their families. Women and Smoking: A Report of the Surgeon General�2001. Available at: http://www.cdc.gov/tobacco/sgr_forwomen.htm. Accessed October 1, 2001. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tob Control 2000;9(suppl III):iii80�iii84. Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999;26(3):577�589.Obstetricians and other prenatal care clinicians are uniquely positioned to apply behavioral strategies that will help women quit smoking. Behavioral interventions lasting from 5 to 15 minutes, delivered by a clinician and supplemented with pregnancy-specific self-help materials, significantly increased smoking cessation rates among pregnant smokers. Pregnancy is a prime �teachable moment� in health care. Women are more likely to quit smoking during pregnancy than at any other time in their lives. Clinicians can tap into that motivation to help their patients achieve long-term healthy lifestyle changes for themselves and their families. Women and Smoking: A Report of the Surgeon General�2001. Available at: http://www.cdc.gov/tobacco/sgr_forwomen.htm. Accessed October 1, 2001. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tob Control 2000;9(suppl III):iii80�iii84. Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999;26(3):577�589.

59. 59 The 5 A�s Approach to Smoking Cessation A brief, five-step intervention program, the 5 A�s is recommended in clinical practice to help pregnant women quit smoking. The five steps are: 1. Ask the patient about tobacco use 2. Advise her to quit 3. Assess her willingness to make a quit attempt 4. Assist in her quit attempt 5. Arrange follow-up Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. June 2000. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tob Control 2000;9(suppl III):iii80�iii84. Smoking Cessation During Pregnancy. American College of Obstetricians and Gynecologists. ACOG Educational Bulletin Number 260. September 2000.A brief, five-step intervention program, the 5 A�s is recommended in clinical practice to help pregnant women quit smoking. The five steps are: 1. Ask the patient about tobacco use 2. Advise her to quit 3. Assess her willingness to make a quit attempt 4. Assist in her quit attempt 5. Arrange follow-up Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. June 2000. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tob Control 2000;9(suppl III):iii80�iii84. Smoking Cessation During Pregnancy. American College of Obstetricians and Gynecologists. ACOG Educational Bulletin Number 260. September 2000.

60. 60 Review Risks �What have you heard about smoking during pregnancy?� Reiterate benefits for her baby and her other children A previous trouble-free pregnancy is no guarantee that this pregnancy will be the same Review Rewards Your baby will get more oxygen after just 1 day Your clothes and hair will smell better You will have more money Food will taste better You will have more energy Counseling Women to Stop Smoking Risks. Make sure that the patient understands the risks of continued smoking by asking her what she considers to be potential negative consequences. One way to begin this part of the discussion is to ask, �Although you do not want to or are not ready to quit now, what have you heard about smoking during pregnancy?� If the patient seems unaware of the risks, this is a good time to give her pregnancy-specific information about risks.Risks. Make sure that the patient understands the risks of continued smoking by asking her what she considers to be potential negative consequences. One way to begin this part of the discussion is to ask, �Although you do not want to or are not ready to quit now, what have you heard about smoking during pregnancy?� If the patient seems unaware of the risks, this is a good time to give her pregnancy-specific information about risks.

61. 61 Smoking Cessation: Helpful Strategies Set quit date within 30 days and sign a contract Develop approaches to manage withdrawal symptoms Remove all tobacco products from her home What to do in situations in which she usually smokes Follow up to monitor progress and provide support Encourage the patient Express willingness to help Ask about concerns or difficulties Invite her to talk about her success During the Assist step, work with your patient to prepare to quit, anticipate problem areas, and develop strategies for dealing with them. Some women find it helpful to formalize their plans for a quit date by signing a contract with their clinician. Others want additional information about withdrawal symptoms and how to manage them. Others want to discuss ways to minimize the risk of smoking, such as removing all tobacco products from their home or creating smoke-free zones in their homes. Still others want to discuss how to manage situations in which the specific cues for smoking will offer serious temptations to smoke. It helps to address your patient�s most pressing concerns and then refer her to the materials that you are giving her, where she will find additional tips to make her quit attempt successful.During the Assist step, work with your patient to prepare to quit, anticipate problem areas, and develop strategies for dealing with them. Some women find it helpful to formalize their plans for a quit date by signing a contract with their clinician. Others want additional information about withdrawal symptoms and how to manage them. Others want to discuss ways to minimize the risk of smoking, such as removing all tobacco products from their home or creating smoke-free zones in their homes. Still others want to discuss how to manage situations in which the specific cues for smoking will offer serious temptations to smoke. It helps to address your patient�s most pressing concerns and then refer her to the materials that you are giving her, where she will find additional tips to make her quit attempt successful.

62. 62 Smoking Cessation: Success Rates From least to most successful Individual attempts at cessation: �Cold Turkey� Group therapy smoking cessation: �Buddy System� Nicotine replacement therapy (NRT) alone Nicotine gum, inhaler, nasal spray, and patch Group therapy + NRT Buproprion (Zyban) alone Group therapy + buproprion

63. 63 Alcohol and Reproductive Hazards Heavy drinking = 4-5 or greater drinks/day Poor/scant data on moderate-light drinking Day, 2002: growth affected by < 1 drink per day Sood, 2001: behavioral consequences of 1 drink per week EB Review 2007- �No convincing evidence of adverse effects of prenatal alcohol exposure at low-moderate levels�however weaknesses in the evidence preclude the conclusion that drinking at these levels during pregnancy is safe�

64. 64 Behavior Change: Achieve a Healthy Weight Calculate BMI at least annually All women with a BMI = 25 kg/m2 should be counseled about the risks to their own health, the and the risks to future pregnancies, including infertility All women with a BMI = 25 kg/m2 should Increase physical activity Be offered specific strategies to reduce caloric intake Be encouraged to consider enrolling in structured weight loss programs

65. 65 Pregnancy Intendedness Recommendation: Screen women for their intentions to become or not become pregnant in the short- and long-term and their risk of conceiving a pregnancy Educate patients about how the reproductive life plan impacts contraceptive and medical decision-making Every woman should receive information and counseling about all forms of contraception and emergency contraception

66. 66 Opportunities for Preconception Care Pregnancy desired Infertility services Intrauterine contraceptives (or implant) removed in order to become pregnant Clinician recommendations Folate supplementation HIV serology for women at risk Glucose control in diabetics Switch use FDA category C, D drugs to category B, in consultation with PCP

67. 67 Opportunities for Preconception Care Pregnancy test positive Immediate initiation of folate Cessation of alcohol use and cigarette smoking Offer HIV screening If continuing pregnancy, STI screening should be deferred until the initial OB visit

68. 68 Opportunities for Preconception Care Pregnancy test negative If attempting to become pregnant, provide advice regarding folate supplementation and positive behavior change in advance of pregnancy If at risk for HIV infection, a preconception HIV serology should be offered

69. 69 Opportunities for Preconception Care Type I or Type II Diabetics, irrespective of pregnancy plans Counsel regarding importance of blood sugar control before pregnancy is attempted, even if not currently attempting pregnancy Confirm that a relationship exists with a PCP who is involved in medical management their diabetes, and if not, refer for same

70. 70 Summary PCC is not just for the benefit of babies, but equally for the benefit of women; e.g., stop smoking Reduce prematurity and asthma in baby Reduce her risk of lung cancer and heart disease Many women make healthier decisions during pregnancy for the sake of their baby�s health�they can make changes prior to becoming pregnant and live longer and healthier themselves For preconception care to be successful there must be a shift from delivering procedure-based, acute care to counseling-based, preventive care

71. 71 Q & A

72. 72 Processing Forms Download Now: Evaluation Form Continuing Education Form Post Test No Web Access Now: Call 1-877-FAMPACT for forms All participants that return an evaluation form will receive a Certificate of Participation Those requesting CE credit must return evaluation, Post Test and CE Form Complete forms and fax to 213 368-4410 Thank you for your participation! Once you see the File Transfer Box, click on the file and then click download. Do this for each file.Once you see the File Transfer Box, click on the file and then click download. Do this for each file.