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PRECONCEPTION COUNSELING

PRECONCEPTION COUNSELING. A “BEST” BUT UNCOMMON PRACTICE. INTENDEDNESS. 2002 DATA: 30.8% ALL WOMEN AGE 15-44 HAVE EXPERIENCED AN UNINTENDED BIRTH ESTIMATE THAT 49.2% ALL PREGNANCIES UNININTENDE (nsfg). ORGANOGENSIS. DAYS 17-56 POST CONCEPTION

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PRECONCEPTION COUNSELING

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  1. PRECONCEPTION COUNSELING A “BEST” BUT UNCOMMON PRACTICE

  2. INTENDEDNESS • 2002 DATA: 30.8% ALL WOMEN AGE 15-44 HAVE EXPERIENCED AN UNINTENDED BIRTH • ESTIMATE THAT 49.2% ALL PREGNANCIES UNININTENDE (nsfg)

  3. ORGANOGENSIS • DAYS 17-56 POST CONCEPTION • FIRST DAY OF “MISSED” PERIOD IS DAY 14 POST-CONCEPTION • DAY 56 IS ABOUT 6 WEEKS • ALL ORGANS FORMED BY WEEK 9

  4. Prevention, in order to be truly preventive, must be antenatal J. W. Ballantyne in 1902

  5. 1960: Maternal complications of pregnancy not on top 10 list of leading causes of infant mortality 1980: Number 5 2001: Number 3 2002: 46% of infant mortality related to congenital anomalies, LBW, Preterm Delivery and Maternal complications

  6. 2004 Behavioral Risk Factor Surveillance System • Phone survey of Americans > 18 years of age • Median response rate >52% • Content varies by state • Defined as preconceptional if: • Wanted a baby in next 12 months, not using contraception, not sterile and not already pregnant

  7. BRFSS 2004

  8. Amongst reproductive aged women Maternal-Child Health J 2006 10:s3-s11

  9. Spartan Preconception Recommendations a la Plutarch • “ordered the maidens to exercise themselves with wrestling, running, throwing the quoit and casting the dart, to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth”

  10. Preventing Low BirthweightInstitute of Medicine 1985 • “…one of the best protections available against low birth weight and other poor pregnancy outcomes is to have a woman actively plan for pregnancy, enter pregnancy in good health with as few risk factors as possible, and be fully informed about her reproductive and general health”

  11. IOM-1985 • Family planning services essential to preconception initiatives • Reproductive health/family planning must introduce concept of pre-pregnancy wellness • Developed concept of preconception consultation

  12. Expert Panel on the Content of Prenatal Care: 1989 “Rosen Report” • Preconception visit may be the single most important health care visit with respect to impact on pregnancy outcome • Preconception counseling most likely to be effective when provided in context of general preventive care OR primary care visits • Concept of “Opportunistic Care”

  13. ROSEN REPORT • Risk Assessment • Health Promotion • Intervention • Follow up

  14. Healthy People 2000 • Increase to at least 60% the proportion of primary care providers who provide age-appropriate preconception care and counseling • Deleted in 2010 Healthy People as not measurable

  15. Toward Improving Outcome of Pregnancy: The 90’s and BeyondMOD 1993 • Concept of “reproductive awareness” • Called for a new strategy to reach each woman of child-bearing age with reproductive awareness messages at every health encounter

  16. ACOG 1995: First technical bulletin on Preconception Care • Thorough & Systematic ID of risks • Provision of education individualized to patient needs • Initiation of desired interventions

  17. 2002: Guidelines for Perinatal Care AAP/ACOG • Emphasized integration of pre-conceptional health into ALL health encounters in reproductive age women • Average woman of childbearing has 6.4 visits to MD’s per year

  18. Healthy People 2010 • No global comment • “Increase the proportion of pregnancies begun with an optimum folate level” (target 80%)

  19. HALLMARKS OF PRECONCEPTION CARE REYNOLDS • PROVIDES WOMEN & FAMILIES INFORMATION AND OPPORTUNITIES TO MODIFY UNHEALTHY BEHAVIORS AND THUS POTENTIALLY IMPROVE THE QUALITY OF THEIR LIVES • INCREASE REPRODUCTIVE CHOICES, POSSIBLY DECREASED UNINTENDED & UNWANTED PREGNANCIES

  20. HALLMARKS, cont’d • IMPROVE PREGNANCY OUTCOME BY DECREASING INFANT MORTALITY & MORBIDITY • REDUCES THE PROBABILITY OF DAMAGE DURING ORGANOGENESIS

  21. Which women most likely to get preconception care? • Older • Married or stable relationship • Non Hispanic White • Income >$20,000/year • Non-smokers • Private medical insurance • Positive bond with pre-pregnancy health care provider

  22. NEGATIVE PREGNANCY TEST • POPULATION OF ABOUT 100 WOMEN AT FAMILY PLANNING CLINIC WITH NEG. PREGNANCY TEST • ALL HAD ASSESSMENTS DONE USING PRECONCEPTION RISK SURVEY INSTRUMENT • ½ HAD RESULTS REPORTED TO DOC

  23. NEGATIVE PREGNANCY TEST • AVERAGE WOMAN HAD 9 IDENTIFIED ISSUES • 21% PSYCHIATRIC/BEHAVIORAL • 12% FETAL EXPOSURE • 7 – 10%: FAMILY PLANNING, NUTRITION, GENETIC, MEDICAL, BARRIERS TO CARE, DV, SEXUAL VIOLENCE • 2-6%:REPRODUCTIVE HISTORY, STD’S

  24. Best Evidence • Focus on a single intervention • Not in the context of improving pregnancy outcomes

  25. PROMOTION OF LIFELONG WELLNESS PROMOTION OF HEALTHY AND DESIRED PREGNANCIES PROMOTION OF HEALTHY FUTURE INFANTS

  26. PREGNANCY FAMILY PLANNING/ PRECONCEPTIONAL CHILDBIRTH MENARCHE FAMILY PLANNING INTERCONCEPTIONAL MENOPAUSE

  27. PREVENTING PREMATURITY • SPACING OF PREGNANCIES • LOWEST RATE VERY/MODERATELY PREMATURE INFANTS • 18 to 59 MONTHS BETWEEN PREGNANCIES • DISCONTINUE SMOKING PRECONCEPTIONALLY • MODERATE EXERCISE

  28. Tobacco And Women’s Health: Implicated the leading causes of death for women: Heart disease (1) Stroke (2) Lung cancer (3) Lung disease (4) Tobacco and Reproductive Outcomes: Leading preventable cause of infant mortality Preventable cause of low birth weight and prematurity Associated with placental abnormalities What We Know: Tobacco Use

  29. SMOKING • ECTOPIC PREGNANCY • PLACENTA PREVIA • UNDER-DEVELOPMENT OF PLACENTA • MAY INCREASE RISK OF PREMATURITY AND BABIES TOO SMALL

  30. 15% and 29% of pregnant women smoke during pregnancy • If smoking during pregnancy eliminated, estimated: • 10% reduction in perinatal mortality • 11% reduction in the incidence of low birth weight

  31. SMOKING:Evidence based counseling • Ask every patient about tobacco use • Advise them to quit • Assess willingness to quit • Assist them in quitting • Pharmocotherapies and additional counseling each DOUBLE quit rate • Arrange follow up • 305.10 ICD-10 Code for tobacco dependence

  32. Effectiveness of smoking cessation programs • 25-30% quit rates in general population • Many women spontaneously quit when pregnancy • 11-28% publically insured • 40-65% privately insured

  33. ACOG COMMITTEE OPINIONOctober 2006 # 316 • Smoking is one of the most important modifiable causes of poor pregnancy outcomes in the United States. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment has been proved to increase quit rates. For pregnant women who are light to moderate smokers, a short counseling session with pregnancy-specific educational materials often is an effective intervention for smoking cessation. The 5 A's is an office-based intervention developed for use by trained practitioners. Techniques for smoking reduction, pharmacotherapy, and health care support systems can help smokers quit.

  34. Alcohol and Women’s Health Risk for MV and other accidents Risk for unintended pregnancy Risk for addiction Risk for nutritional depletions and inadequacies Alcohol and Reproductive Outcomes Delayed fertility Increased SABs FAS and FAE What We Know: Alcohol Use

  35. ALCOHOL • 2002: 8% of American women 18-44 years of age were sexually active, fertile, not contracepting. • Women age 18-24: 20% binge drink • FAS 0.3-2 per 1000 live births

  36. Project CHOICES • CDC sponsored trial • Population at high risk of alcohol-exposed pregnancy (12% binge) • Focused on reducing risk drinking AND postponing pregnancy • 4 brief motivational visits and Family Planning provider visit • 68% at reduced risk at 6 months

  37. Obesity and Women’s Health: Diabetes Hypertension Cardiovascular disease Disabilities Obesity and Pregnancy: Glucose intolerance of pregnancy Pregnancy induced hypertension Thrombophlebitis Neural tube defects Prematurity Higher rates of difficult births Fetal injury from birth difficulty What We Know: Obesity

  38. OBESITY • Increased rates of: infertility, gestational diabetes, pre-existing diabetes, hypertension, preeclampsia, stillbirth, birth defects, LGA, cesarean sections, long dysfunctional labors, CPD, post partum anemia • Fat is not inert

  39. What can we do about it? • Weight loss programs • Tsai and Wadden:, 2005 • Weight Watcher least costly, maintenance of 3.2% of initial weight at 2 years • Very Low Calorie Commercial Diet: • Greatest initial weight loss; high costs; high attrition • Internet based and organized self-help: minimal weight loss • Low income obese women receiving 5 email messages in pregnancy around maintaining normal weight gain less likely to gain excessive weight • Interconception period important if woman retained a lot of pregnancy weight

  40. What we know: FOLATE • Peri conceptional supplementation with 400 micrograms of folate (folic acid) from 3 months preconceptionally to 8 weeks postconceptionally • Decreases rate of spina bifida by 50-70% • Decreases rate of cleft lip • Decreases rate of heart disease • Generally good health habit for adult cardiovascular health • Probably decreases placental problems

  41. EPILEPSY • MEDICATIONS • ASSOCIATION WITH SOME MEDICATIONS WITH SOME BIRTH DEFECTS • SOME WOMEN ON ANTI-SEIZURE MEDICATIONS FOR YEARS AFTER A SEIZURE AND MIGHT BE ABLE TO DISCONTINUE • LOWEST POSSIBLE EFFECTIVE DOSE • SINGLE DRUG VERSUS MULTIPLE DRUGS

  42. DIABETES • GENERAL POPULATION • 2-3% RISK OF SEVERE BIRTH DEFECTS • DIABETICS PRIOR TO PREGNANCY • POORLY CONTROLLED [Hgb A1c>7] • RISK INCREASES TO 6-9% • HEART DISEASE, SPINA BIFIDA, OTHER • WELL CONTROLLED PRECONCEPTIONALLY • BACK TO BASELINE RATE IN THE GENERAL POPULATION!

  43. INFECTIONS • HEPATITIS B • 90% CHRONIC CARRIERS ARE WITHOUT SYMPTOMS • PREGNANCY DOESN’T ALTER COURSE OF DISEASE • IDENTIFY NEONATES FOR FULL VACCINATION AND PROPHYLAXIS • HIGH RISK WOMEN WHO ARE HEP. NEG CAN BE VACCINATED

  44. HIV • HELPS INFECTED WOMEN MAKE INFORMED REPRODUCTIVE DECISIONS • BEGIN MATERNAL CARE PROGRAM • HIGH RISK WOMEN CAN BE COUNSELED RE: RISK REDUCTION

  45. TOXOPLASMOSIS • 85% US WOMEN NON-IMMUNE (NHANES) • 400-4000 CASES OF CONGENITAL TOXO/YR IN US • PRENATAL TESTING VERY DIFFICULT • TREATMENT IF KNOWN PRENATAL SEROCONVERSION • PRECONCEPTION TESTING CAN ALTER BEHAVIOR • AVOID FECES IN LITTERBOX/GARDEN • AVOID RAW OR UNDERCOOKED MEAT • DISPOSE OF CAT LITTER DAILY AND DISINFECT BOX;USE GLOVES • PEEL OR WASH FRUITS AND VEGETABLES

  46. CMV • 0.6-1.5% ALL BIRTHS IN US • ADULTS USUALLY ASYMPTOMATIC, MONO LIKE ILLNESS • LATENT STATE AFTER INFECTION • MOST COMMON SOURCE OF PRIMARY INFECTION: TODDLERS • MOST EFFECTIVE PREVENTION: HAND WASHING (URINE, SALIVA)

  47. OTHER INFECTIONS • STD’S • APPROPRIATE TREATMENT • DEAL WITH MONOGAMY ISSUES • VARICELLA AND RUBELLA: • IF NEGATIVE ANTIBODY, CAN IMMUNIZE • WAIT THREE MONTHS PRIOR TO CONCEPTION

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