Improving Preconception Health & Healthcare in Tulsa

1. Improving Preconception Health &Healthcare in Tulsa 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 Tulsa, Oklahoma October 11, 2011

2. Why Preconception Care?

3. Why Preconception Care? • Early prenatal care is too late.

4. When Does the Fetal Heart Begin to Beat?

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

6. Early Prenatal Care Is Too LateTo Prevent Implantation Errors Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400-8.

7. The Role of the Placenta in Fetal Programming Godfrey KM. The role of the placenta in fetal programming-a review. Placenta. 2002;23 Suppl A:S20-7.

8. Early Prenatal Care Is Too Late from A Life-Course Perspective • Early prenatal care is too late to restore allostasis and optimize women’s health before pregnancy

9. What Is Preconception Care?

10. 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. Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1-23.

11. Summary of the CDC/ATSDR Select Panel’s Recommendations to Improve Preconception Health and Health Care in the United States Recommendation 1. Individual responsibility across the life span. Each woman, man and couple should be encouraged to have a reproductive life plan. Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts. Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes. Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions (i.e. those with evidence of effectiveness and greatest potential impact). Recommendation 5. Interconception care. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birthweight, or preterm birth). Recommendation 6. Prepregnancy checkup. Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy. Recommendation 7. Health insurance coverage for women with low incomes. Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care. Recommendation 8. Public health programs and strategies. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes. Recommendation 9. Research. Increase the evidence base and promote the use of the evidence to improve preconception health. Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health. Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1-23.

12. Components of Preconception Care • Risk Assessment • Health Promotion • Medical & Psychosocial Interventions Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.

13. Preconception Health Promotion Ask about reproductive life plan Start prenatal care before you get pregnant Start eating for two Eat more brain foods Avoid toxic foods Take a multivitamin everyday Achieve a healthy weight Learn how not to get stressed out Give your immune system a tune-up Detoxify your environment

14. Get ready to get pregnant

15. Tip #1 Ask About Reproductive Life Plan

16. 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 http://www.cdc.gov/ncbddd/preconception/QandA.htm#5

17. Examples 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?

18. Tip #2 Start prenatal care before you get pregnant

19. Components of Preconception Care • 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 • Medical & Psychosocial Interventions • Preventive services and primary care • Individualized for identified risks Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.

20. Examples of Drugs to Avoid

21. Questions about Drug Use in Pregnancy OTIS (Organization of Teratogen Information Specialists) http://www.otispregnancy.org Toll-free (866) 626-OTIS

22. Tip #3 Start “eating for two” (in quality, not in quantity)

23. Make Healthy Food Choices http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid Whole grain foods: 5-7 servings Plant oils: 6 teaspoons Vegetable and fruits: 5 servings Nuts, beans and lentils: ½ to 1 cup Fish, poultry or egg: 1 serving a day Dairy: 3 servings Multivitamin: 1 a day

24. Make Healthy Food Choices • Eat more whole foods and less processed foods • Use a menu planner • www.MyPyramid.gov

25. Tip #4 Eat more brain foods

26. Top 10 Brain Foods Beans Eggs Nuts & seeds Olive oil Alaskan wild salmon Yogurt & kefir Whole grains Spinach, collards, kale & broccoli Prunes, raisin, blueberries Oranges, red bell pepper, tomato

27. Tip #5 Eat less toxic foods

28. Top 10 Toxic Foods Swordfish, shark, king mackerel and tile fish Soft cheese and unpasteurized milk Hot dogs, luncheon meats, deli meats, raw or smoked seafood Raw or undercooked meat Unwashed vegetables, raw vegetable sprouts, and unpasteurized juices Liver Saturated fats, trans fats, and partially hydrogenated oils Added sugars Refined flour Herbal preparations

29. Fish: Brain Food or Toxic Food?

30. What You Need to Know about Mercuryin Fish & Shellfish 2004 EPA/FDA Joint Advisory for Women who might become pregnant Women who are pregnant Nursing mothers Young children Do not eat Shark, Swordfish, King Mackerel, or Tilefish Eat up to 12 ounces (2 average meals) a week Shrimp, canned light tuna, salmon, pollock, catfish are low in mercury Albacore (“white”) tuna has more mercury than canned light tuna Check local advisories about locally caught fish www.epa.gov/ost/fish www.epa.gov/mercury

31. Tip #6 Take a multivitamin everyday

32. Micronutrients:Choosing Your Multivitamin Folic acid 400 mcg a day 4000 mcg a day with prior NTD Avoid excess(more isn’t always better) A>10,000 IU D>4,000 IU Nutrition first!

33. Tip #7 Achieve a healthy weight

34. Achieve A Healthy Pre-Pregnancy Weight Underweight: BMI<18.5 Normal: BMI = 18.5-24.9 Overweight: BMI = 25-29.9 Obese BMI>30 National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov

35. Achieve A Healthy Pre-Pregnancy Weight For weight loss, Decrease calories in Increase calories out (exercise) Keep track of weight & nutrition Maintain a healthy weight for 3-6 months before pregnancy National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov

36. Tip #8 Learn How Not to Get Stressed Out

37. Stress & Preterm Birth And his daughter in law, Phinehas' wife, was with child, near to be delivered; and when she heard the tidings that the ark of God was taken, and that her father in law and her husband were dead, she bowed herself and travailed; for her pains came upon her. Samuel 4:19

38. Fetal HPA Maturation (+) Hypothalamus + CRH (+) Pituitary CRH + ACTH Adrenal (+) Cortisol DHEA-S Placenta

39. Maternal HPA Activation Hypothalamus (+) CRH Hypothalamus Pituitary + CRH Pituitary (+) CRH + ACTH ACTH Adrenal (+) (+) Cortisol DHEA-S Placenta Adrenal Cortisol Norepinephrine

40. Exercise Eat right Get a good night’s sleep Learn how not to get stressed out

41. Relaxation techniques Breathing exercises Progressive relaxation Meditation Mindfulness Learn how not to get stressed out

42. Positive Mental Health A sense of meaning Self-acceptance Autonomy Positive relations with others Satisfaction with life Optimism Learn how not to get stressed out

43. Develop Positive Mental Health Find your purpose (“follow your bliss”) Use your strengths Count your blessings Live in gratitude Learn to forgive Savor life’s joy Spend time with friends and families Practice daily acts of kindness Learn to be optimistic Learn how not to get stressed out

44. Relationality is primary, All else is derivative. -Ronald David Learn how not to get stressed out

45. Tip #9 Tune-up your immune system

46. How to Give Your Immune System A Tune-Up? Get rid of ongoing infections & inflammation Make lifestyle changes to improve immune fitness

47. Immune Tune-Up Brush Floss Go see your dentist

48. How to Avoid Toxoplasmosis Wear gloves when you garden Cook all meat thoroughly Wash raw vegetables thoroughly Exercise precautionsaround cats Have someone else change the litter box Wear gloves when you change the litter box Change the litter box daily Cover outdoor sandboxes Never feed your cat raw meat Keep indoor cats indoors www.cdc.gov/ /toxoplasmosis

49. How to Avoid Cytomegalovirus Wash hands with soap and water after contact with diapers or saliva Do not share food, drinks, or utensils (spoons or forks) with young children Check your CMV titer if you work in day care www.cdc.gov/cmv

50. Immune Tune-Up Update your immunizations Tdap Hepatitis B Influenza MMR Chickenpox HPV