Pregnancy and Prenatal Periods Critical Issues By: Dr. Pat Mousmanis

2. The Early Years Intervention

3. Risk Factors: Clinical Implications �Research supports evidence that neuromaturation is directed by genetic mechanisms whose timing is regulated by and whose unfolding is sensitive to environmental influences� Early brain development is very vulnerable to environmental influences Neurodevelopmental delays become risk factors themselves Nature and nurture are continuously interacting Children and families are �at risk� as circumstances change

4. Risk Factors: Clinical Implications Factors that may be risks to a vulnerable fetus or child can occur in any of the following times: Preconception Prenatal Perinatal Postnatal

5. Risk Factors: Preconception & Prenatal As many as � of all pregnancies are unplanned (Health Canada 1999, 2000) 60 % of congenital anomalies are preventable. Preconception care showed benefit in preventing congenital anomalies (Czeizel, 1995) Day 17 to 56 is the most critical period of development for the Central Nervous System, limbs, internal organs, etc. (Moos 1989, Perry 1996)

6. Risk Factors: Preconception Genetic Factors Pre-existing Maternal Conditions Epilepsy Hypertension (high blood pressure) Diabetes Women with diabetes run a higher rate of spontaneous abortion, perinatal mortality and greater incidence of congenital anomalies in their babies than the non-diabetic population

7. Preconception Planning The preconception period is not a neatly defined period of time. Throughout their reproductive lives, most women never really "know" when, or if, they will become pregnant. Women have choices, however, about becoming pregnant. (Raphael-Lerr, 1991). Any fertile woman having heterosexual sex or planning to be fertilized is in the preconception period.

8. COMPLEX INFLUENCES ON SUCCESS OF PRECONCEPTION COUNSELING Preparing for a healthy pregnancy is not the sole responsibility of either the mother or the family. Social support networks, and social living conditions are important factors in conceiving, giving birth to, and raising healthy children. It is critical that children and families are supported in safe and caring communities and in society in general.

9. ATTITUDES � Preconception Period Diversity is the norm in our society: Same-sex couples Single women Age (teenagers and older women) Cultural norms (e.g., female genital cutting) Health care providers must be sensitive to this and must plan preconception programs accordingly

10. Prenatal Risk Factors: Chronic Illness Cancer CVS Disease Diabetes Epilepsy Lupus Maternal PKU Psychiatric Illness Thyroid Problems

11. Prenatal Risk Factors: Nutrition Body Weight Calcium and Vitamin D Folic Acid Iron Zinc Vitamin A Caffeine Vegetarian considerations Herbal Products

12. Prenatal Risk Factors: Substance Use/Abuse Alcohol Drugs � including medications There are no safe levels (see information at Motherisk.org)

13. Prenatal Risk Factors: Substance Use (con�t) Paternal and/or Maternal Tobacco Use shown to be associated with: Infertility - low sperm counts, abnormal sperm Menstrual disorders, spontaneous abortions, ectopic pregnancies Low birth weight, prematurity, placental irregularities Infant mortality, sudden infant death syndrome (SIDS), and infant and childhood morbidity (Baird and Wilcox, 1985; Cefalo and Moos, 1988; Scher and Dix, 1990) Second hand smoking related to child health issues

14. Prenatal Risk Factors: Infections (Including Sexually Transmitted Diseases) CMV, Human Parvovirus, Rubella, Toxoplasmosis, Varicella Chlamydia, GC, HPV, Syphilis Hepatitis B, Herpes, HIV/AIDS

15. Prenatal Risk Factors: Immunizations Live vaccines should be administered at least 3 months prior to conception Rubella vaccine in pregnancy = teratogenic risk of < 5% ( German Measles) Varicella syndrome affects <2% on infants whose mothers were infected in the first 20 weeks of pregnancy ( chickenpox infection)

16. Prenatal Risk Factors: Environmental Concerns Electromagnetic Fields Cleaning Products Paints & Solvents Plastics Pesticides Lead Mercury ( fish consumption) Asbestos

17. Prenatal Risk Factors: Other Issues Family Relationships Abuse Genetics Home and Leisure Activities Hot Tubs and Saunas Infertility Previous Pregnancy Outcomes Social Supports Workplace Concerns

19. Tools For Practitioners: Preconception Opportunities Well Woman Periodic Health Exam Birth Control Renewal Pap tests Sexually Transmitted Disease check Use of Preconception checklist (Call Motherisk)

20. Tools For Practitioners: Prenatal Opportunities Provincial Antenatal Record Guides for Obstetrical care Other Evaluation may include: Blood Testing: Hemoglobin & blood typing; Rubella titre; Hepatitis B; HIV Education about folic acid levels and nutrition Education about eliminating tobacco and alcohol usage Education about avoiding environmental toxins Genetic background discussion Health problems discussion Domestic violence screening

21. Tools for Obstetrical Health Professionals � Prenatal Period Antenatal Psychosocial Health Assessment (ALPHA) Provider Version /Patient Self-Report Critical Review of the Literature found 15 antenatal factors associated with adverse postpartum outcomes: woman abuse (WA) child abuse (CA) couple dysfunction (CD) postpartum depression (PD) increased childhood physical illness (PI)

22. THE ALPHA Forms/Antenatal Factors Family Factors Social Support (CA, WA,) Recent Stressful Life Events (CA, WA, PD,PI) Couple�s Relationship (CD, PD, WA,CA) 2. Maternal Factors Prenatal care (late onset) (WA) Prenatal education (refusal or quit) (CA) Feelings toward pregnancy/20 week (CA,WA) Relationship with parents in childhood (CA) Self-esteem (CA, WA) History of psychiatric/emotional problems (CA, WA, PD) Depression in this pregnancy (PD)

24. THE ALPHA FORM Suggestions for use: Complete after 20 weeks gestation Can be completed in 1 visit or over several regular prenatal visits Give self-report form to be completed in office (if concern over woman abuse) and book longer next visit to review the form Can bill for counselling/psychotherapy where appropriate Be sensitive to cultural issues; use non-family interpreters Maintain confidentiality; discuss with woman before sharing info Remember associations do not imply causality!

32. Tools for Obstetrical Health Professionals � Prenatal Period Larson Tool used by Healthy Babies Healthy Children in Ontario Asks 3 questions about: Level of education Participation in prenatal classes Smoking Predicts outcomes at six months

33. Perinatal Developmental Vulnerability Neonatal Risk Factors, i.e., birth trauma, prematurity, infection, metabolic/endocrine, Rh ABO incompatibility Maternal Risk Factors, i.e., Postpartum Depression, limited social support, substance abuse Paternal Issues, i.e., process, family support issues Parkyn Postpartum Screening Tool identifies children with congenital or acquired health challenges, developmental factors, family interaction factors that can negatively affect development

36. Summary Points Preventive strategies work to decrease poor pregnancy outcomes Other service providers can help provide information to women who are of childbearing age to optimize childhood developmental outcomes Best approach is to offer assistance to all families universally with additional support for those who require professional services (Early Years Report)