Pre Pregnancy Assessment

1. Pre Pregnancy Assessment Nestor N. Demianczuk M.D. February 21, 2005

2. Overview • The period of greatest environmental sensitivity for the developing fetus is between days 17 and 56 after conception • cell organization • cell differentiation • organogenesis

3. Overview • Since many crucial stages in a baby’s development occur before a woman may realize she is pregnant, taking early interventions can minimize harm to the baby from certain infections, illnesses, nutritional deficiencies and environmental hazards. • Planned pregnancies are more likely to have good outcomes for both the mother and her baby Hellerstedt, W.L., Pirie, P.L., Lando, H.A., Curry, S.J., McBride, C.M., Grothaus, L.C. and Nelson, J.C., 1998. Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies. American Journal of Public Health 1998;88 4, pp. 663–666.

4. Overview Wenman WM, Joffres MR, Tataryn IV; Edmonton Perinatal Infections Group.A prospective cohort study of pregnancy risk factors and birth outcomes in Aboriginal women.CMAJ • September 14, 2004; 171 (6).

5. Overview • Reproductive risks are not well understood by the women • In a survey of 153 patients enrolled in a substance abuse program* • 66% believed their drug use would not change the likelihood of a baby born with mental difficulties • 9% believed drug use would decrease mental difficulties • *(Benita Walton-Moss.Perceived risk of adverse birth outcomes among substance dependent pregnant women. American Public Health Association 132nd Annual Meeting -- Washington, DC -- November 6-10, 200 Abstract #92394)

6. Overview • Alcohol use • 17-25% of women drank at some point during the pregnancy, • 7-9% drank throughout the pregnancy and • 5% drank only before knowing they were pregnant. • Of the women who reported drinking, • the majority (over 94%) consumed one to two drinks on the days they drank, • 3% had three to four drinks and • less than 3% had five or more drinks. Canadian Perinatal Surveillance SystemAlcohol and Pregnancy (November 1998)

7. Overview • 3% of all congenital anomalies may be attributable to drugs and chemicals (Brent RL. Pediatrics Vol. 113 No. 4 April 2004) • anorexia nervosa occurs between 1% and 4.2% and bulimia between 7.8% and 19.6% of general female population (Striegel-Moore R, Dohm F, et al. Am J Psychiatry 160:1326-1331, July 2003)

8. Overview • Drug use • in a survey of 2590 patients regarding drug use in the preceding week • 80% of adults population took at least 1 medication • 25% took at least 5 drugs • 40% of the population took 1 or more vitamin or mineral supplement • 14% of the population took one or more herbals/supplements Kaufman D.,Kelly J.,Rosenberg L., Anderson T.,Mitchell A. Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States. Jama, January 16,2002; Vol287, No 3 337-344

9. Overview Use of Medications During the Preceding Week, by Sex and Age Kaufman D, Kelly J, Rosenberg L, Anderson T, Mitchell A, Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States The Slone SurveyJAMA. 2002; 287:337-344.

10. Overview • In a review of data regarding 152,531 women who delivered between 1996 and 2000. • In 64% of women, a drug other than a vitamin or mineral supplement was dispensed in the 270 days before delivery. • Drugs for which human safety during pregnancy has not been established (category C) were dispensed to 37.8%, • drugs in which there is fetal risk, but benefits which may be acceptable (category D) were dispensed to 4.8%. • Moreover, drugs which are absolutely contraindicated in women who are pregnant (category X) were given to 4.6%. Andrade SE, Gurwitz JH, Davis RL, Chan KA, et al. Prescription drug use in pregnancy. Am J Obstet Gynecol 2004;191:398-407.

11. Overview • Smoking • Maternal smoking in the first 12 weeks of pregnancy is responsible for up to 25% of all low birth weight infants. • Smoking doubles the risk of ectopic pregnancy

12. Overview • A pre-pregnancy visit is especially important for women who have had problem pregnancies (miscarriages, preterm deliveries or a baby with a birth defect) • to diagnose and treat the cause of ANY identified problems • This visit is crucial for women with chronic health problems

13. Pre Pregnancy Interventions • All women should • Take folic acid daily; • Adopt a healthy lifestyle; • Get a pre-pregnancy health checkup.

14. Pre Pregnancy Folic Acid Can prevent neural tube defects and possibly other birth defects such as heart defects and cleft lip and cleft palate.

15. Pre Pregnancy Folic Acid • It is currently recommended that all women who could become pregnant take a multivitamin containing 400 micrograms of folic acid daily, in addition to eating a healthy diet that includes foods rich in folic acid. • The average woman receives about 100 mcg of folic acid per day from fortified breads and grains. Werler MM, Louik C, Mitchell AA. Achieving a public health recommendation for preventing neural tube defects with folic acid. Am J Public Health 1999;89:1637-40.

16. Pre Pregnancy Folic Acid • A woman who already has had a pregnancy affected with an NTD should take 4 milligrams of folic acid daily. • Studies have shown that these women can reduce their risk of having another affected baby by about 70 percent. • In addition, women with a diagnosis of diabetes or epilepsy, women who smoke, and those who frequently use aspirin or antacids may need higher doses of folic acid (1 milligram)

17. Pre Pregnancy Folic Acid • Foods that contain folates include: • orange juice, green leafy vegetables, beans, peanuts and whole-grain products. • Cooking and storage destroy some of the folates in foods. It is estimated that 50 percent of food folate is absorbed by the body • Fortified breakfast cereals, enriched grain products and vitamins contain a synthetic form of folic acid that is more easily absorbed by the body. • about 85 percent of folic acid in fortified foods and 100 percent in a vitamin supplement are absorbed.

18. Pre Pregnancy Folic Acid Folic acid should be started at least one month prior to pregnancy and continued through the first trimester.

19. Pre Pregnancy Screening Tests • Rubella(German measles). • A woman not immune can be vaccinated before pregnancy, although conception should then be postponed for three months. • Toxoplasmosis • If you have a cat, do not handle the cat litter. • Wear gloves while gardening in areas where cats may visit. • Don't eat uncooked or undercooked meats or fish.

20. Pre Pregnancy Screening Tests • Hepatitis B. • The Centers for Disease Control and Prevention recommends that all pregnant women be screened for hepatitis B. • Untreated infants of infected mothers have about a 50 percent risk of contracting the virus. Prompt immunization and treatment after birth usually can prevent infection in the baby. However, high-risk women (such as health care workers) should consider vaccination prior to pregnancy.

21. Pre Pregnancy Screening Tests • Chickenpox • Women not immune can be vaccinated before pregnancy. • Conception should be postponed for three months. • HIV/ Chlamydia • Pediatric AIDS Clinical Trials Study Group - treatment with zidovudine (Retrovir) reduces the risk of transmission to the fetus from 25.5 percent to 8.3 percent. • Other infections. • Screenings may find vaginal and urinary tract infections that may increase the risk of premature labor.

22. Pre Pregnancy Screening Tests • Pap smear if not performed in the last two years • Blood group and antibody screen • Thyroid studies

23. Pre Pregnancy Discussion - Carrier Screening by Ethnicity Adapted from Cowchock FS, Johnson A, Jackson LG. Screening for genetic abnormalities. Infertil Reprod Med Clin North Am 1994;5:177-95

24. Pre Pregnancy DiscussionsGenetic Diseases • A pre-pregnancy visit should include a discussion of genetic diseases. • Blood tests can identify carriers of: • Tay Sachs Disease • which causes fatal brain damage and primarily affects people of Eastern European Jewish ancestry. • Sickle Cell Disease • a blood disorder that mainly affects African-American individuals. • Thalassemia • a blood disorder primarily in those of Mediterranean, African and Southern Asian descent.

25. Pre Pregnancy DiscussionsGenetic Diseases • Age-related chromosomal defects such as Down Syndrome should be discussed if the woman is 35 or older. • Review of family history for aneuploidy and congenital diseases. • Discussion regarding early first and second trimester screening for aneuploidy

26. Pre Pregnancy Discussions • Overseas Travel • If planning to travel overseas it is advisable to determine what sort of diseases are common in the country you will be visiting. • If any inoculations are required, you will be advised as to their effect on your ability to conceive.

27. Pre Pregnancy Identification of Maternal Diseases Sablock, U.; Lindow, S. W.; Arnott, P. I. E.; Masson, E. A.. Prepregnancy counseling for women with medical disorders. Journal of Obstetrics & Gynaecology, Nov2002, Vol. 22 Issue 6, p637

28. Pre Pregnancy Identification of Maternal Diseases • Diabetes • Women with poorly controlled insulin-dependent diabetes are several times more likely than non diabetic women to have a baby with a serious birth defect. • They also are at increased risk of miscarriage and stillbirth. • Controlling blood sugar before and during pregnancy improves chances for a healthy baby.

29. Pre Pregnancy Identification of Maternal Diseases • Diabetes • Oral hypoglycemic agents are contraindicated during pregnancy. • Women with pre‑existing diabetes treated with oral agents should ideally be converted to insulin prior to conception. • Lipid lowering therapy must be ceased

30. Pre Pregnancy Identification of Maternal Diseases • Contraindications to Pregnancy • Poor glycemic control HbA1c > 8.0% until corrected • Active proliferative retinopathy until treated • Severe nephropathy creatinine ≥ 0.25 mmol/L • Macrovascular disease

31. Pre Pregnancy Identification of Maternal Diseases • In one study of 69 diabetic women • 69% of nulligravidae compared with 83% of multiparae were aware of the need for preconception planning. • Of the 18 multiparous women, only eight (44%) had attended for pre-pregnancy counseling prior to their last pregnancy. • Only 52% of nulligravidae, and 28% of multiparae reported the intention to seek advice before a future pregnancy. S. Rao, S. W. Lindow, E. A. Masson.Survey of pre-conception counseling .Diabetic Medicine, July2002 Volume 19 Issue 7 Page 615 -

32. Pre Pregnancy Identification of Maternal Diseases • High Blood Pressure • Chronic high blood pressure can increase risk of pregnancy complications, including placental problems and fetal growth retardation. • Good blood pressure control can minimize pregnancy complications. • Pre pregnancy change of medications if necessary - • avoid ACE inhibitors, angiotension II receptor antagonists, thiazide diuretics

33. Pre Pregnancy Identification of Maternal Diseases • Seizures. • Some seizure control medications increase the risk of birth defects. • During a pre-pregnancy visit, the physician may advise discontinuing drug treatment altogether, adjusting the dose or switching to a safer drug.

34. Pre Pregnancy Identification of Maternal Diseases • Phenylketonuria •  Women with this inherited error of body chemistry must be on a special diet beginning prior to pregnancy in order to prevent mental retardation and birth defects in their offspring. • Emphasize the importance of monitoring level of phenylalanine during pregnancy

35. Pre Pregnancy Identification of Maternal Diseases • Kidney disease. • Some women with severe kidney disease may suffer additional kidney damage during pregnancy, and their babies may be at increased risk of death and poor growth. • Patients with mild kidney disease usually have healthy pregnancies, although they must make sure that their blood pressure is well controlled, starting before pregnancy.

36. Pre Pregnancy Identification of Medications • Review the safety of all medications including over-the-counter cold medications and herbal preparations. • Avoid ACE inhibitors, angiotensin II receptor antagonists • switch from warfarin (coumadin) to heparin • avoid benzodiazepines

37. Pre Pregnancy Review of Prior Obstetrical Complications • If a woman has had two or more early miscarriages or one late (second trimester) miscarriage, try to determine the cause , do appropriate lab tests to rule out diseases and provide any necessary treatment. • Pre-pregnancy evaluation of women with preterm labor history also may reveal a treatable problem.

38. Pre Pregnancy Discussion of Lifestyle Changes • Stop drinking alcohol, • Estimates from the United States of America Centres for Disease Control give a rate for Fetal Alcohol Syndrome of 6.7 births per 10,000 live birth • Stop smoking • Maternal smoking in the first 12 weeks of pregnancy is responsible for up to 25% of all low birth weight infants. • Smoking doubles the risk of ectopic pregnancy • Increases the risk of having a low-birthweight baby. • Stop using illicit drugs • Cocaine use in early pregnancy appears to increase the risk of certain birth defects and miscarriage. Women who continue drug use have up to six times the normal risk of having a low-birthweight baby.

39. Pre Pregnancy Discussion of Lifestyle Changes • Avoid hot tubs, saunas and Jacuzzis, • Elevated body temperatures in the first trimester may increase the risk of NTDs.

40. Pre Pregnancy Discussion of Hazard Exposure Adapted from Cefalo RC, Moos MK. Preconceptional health promotion. In Cefalo RC, Moos MK, eds. Preconceptional health care: a practical guide. 2d ed. St. Louis; Mosby, 1995:41-42

41. Pre Pregnancy Discussion of Hazard Exposure • Pregnant women should avoid high levels of mercury in • shark • swordfish • king mackerel • tilefish • Pregnant women should limit intake of • albacore tuna to no more than six ounces a week. • Avoid infections with listeria by limiting or eliminating • soft unpasteurized cheeses • deli meats • uncooked hot dogs

42. Pre Pregnancy Discussion of Hazard Exposure Adapted from Cefalo RC, Moos MK. Preconceptional health promotion. In Cefalo RC, Moos MK, eds. Preconceptional health care: a practical guide. 2d ed. St. Louis; Mosby, 1995:41-42

43. Pre Pregnancy Discussion of Hazard Exposure Adapted from Cefalo RC, Moos MK. Preconceptional health promotion. In Cefalo RC, Moos MK, eds. Preconceptional health care: a practical guide. 2d ed. St. Louis; Mosby, 1995:41-42

44. Pre Pregnancy Discussion of Hazard Exposure • External environmental toxins known to adversely affect the developing child include solvents (e.g., paint thinners and strippers, fertilizers, and pesticides) and heavy metals (e.g., lead, mercury, and cadmium) • Identify and avoid hazardous chemicals at work and at home. • Women who work with solvents can minimize their exposure by making sure their workplace is well ventilated and by wearing appropriate protective equipment. • Post-conception days 17 to 56 are the time of greatest vulnerability to environmental insult for the developing embryo and fetus Briggs, G.G., Freeman, R.K. and Yaffee, S.J., 2002. In: A reference guide to fetal and neonatal risk: Drugs in pregnancy and lactation (6th ed.), Lippincott Williams & Wilkins, Philadelphia.

45. Pre Pregnancy Discussion of Lifestyle Changes • Seriously overweight women should get help in losing weight before pregnancy, • There is a significant association between pre-pregnancy weight and pregnancy-related death, cesarean section, chronic hypertension, pregnancy-induced hypertension, diabetes, and maternal age.

46. Pre Pregnancy Discussion of Lifestyle Changes • Start an exercise program. • Exercise helps a woman to maintain or lose weight and reduce stress, as well as helps prevent health problems such as heart disease and high blood pressure. • Exercise eases many of the common discomforts of pregnancy such as constipation, backaches, fatigue and varicose veins.

47. Pre Pregnancy Discussion of Violence • Violence • Screen for feeling safe at home, abuse as child, child abuse, • Support reporting and know shelters

48. Pre Pregnancy Discussion of Psychosocial Issues • Psychosocial • screen for depression, access to basic necessities, money worries, knowledge of safety net programs, difficult life events, social support

49. Pneumonic to remember topics (REFRAMED) Reproductive awareness Environmental toxins and teratogens Folic acid and nutrition Review genetic history Alcohol, tobacco, and other use Medical conditions and medications Evaluate immunizations and infectious diseases Domestic violence and psychosocial issues

50. Women’s interest in Pre Pregnancy Counseling • A cohort of women (n = 1206) received a personal letterfrom their own GP with an offer of pre-conception counseling • Almost 70% of the women returned the reply form. • Upto the age of 29 years, at least 80% of the respondents wereinterested or might be interested should they decide to havechildren. • Regardless of age or parity,>70% of the respondents were interested. • Only 11% of therespondents indicated specifically that they were not interestedin advice. Fam Pract. 2003 Apr;20(2):142-6.