Preconceptional care (PCC) (The Critical role of Primary Care Physician)

Preconceptional care (PCC)(The Critical role of Primary Care Physician) Introduction to Primary Care a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

Objectives of this session Overview Rational of PCC. Objectives of PCC. PCC implementation at PHC centers. Physicians' role - delivering PCC Obstacles of PCC. Premarital check-up Woman’s role

Birth Rate • United State 13.82 births/1000 population • Saudi Arabia 28.55 births/1000 population country comparison to the world 52 • Egypt 21.70 births/1000 population • United Arab Emirates 16.02 births/1000 population • Japan 7.64 births/1000 population

Prematurity & Infant Mortality • United State 7 deaths/1000 live births. • Saudia Arabia 11.7 deaths / 1000 live births • United Arab Eimares 12.70 daeths / 1000 live births • Egypt 27.26 dathes / 1000 live births • Japan 2.4 deaths / 1000 live births Central Intelligence Agency, The WORLD FACTBOOK

Factors Leading to Infant Mortality • Maternal health problems • Smoking • Age <20 or > 40 • Late entry into prenatal care • Education • Marital status • Inter-pregnancy interval

Potentially all related to maternal health prior to pregnancy (Preconception)

Maternal health is a key for healthy birth of new population

Key Factors • Health status overall • Nutrition • Exercise habits • Infection risk (immuniztion) • Specific health risks • Chroinc medical conditions • Medication • Tobacoo use

Preconception Care : A window of opportunity • All women of child-bearing yrs : pre- screened for • health & risk potentials before attempting to be • pregnant. • A woman should visit Dr. as soon as she contemplate • having child. • Optimum: 3- 6 ms before conceiving attempt • This time frame allows: • 1- Successful conception & pregnancy • 2- any within control health risks.

Rational of PCC • PCC has been advocated as a measure to improve pregnancy outcome. • Its components parallel those of prenatal care : risk assessment, health promotion and medical & physiological interventions • Physician’ s role : providing PCC. • Woman’s role : ….

Objectives of PCC Screening tool for physicians to assess women’s health In one sense, PCC can be compared to: WBC visit: a baby is screened for N. health, N. Development to identify emerging unnoticed problems in an infant. For a woman: PCC assess N. health of a child-bearing woman, to identify: 

Objectives of PCC Existing or emerging illness or disease which may have gone undetected before Existing risks for the woman who may become pregnant Existing risks which may affect a fetus if the woman does become pregnant.

PCC at PHC centers PCC can be provided most effectively as part of ongoing primary care. • Physicians can deliver PCC during visits for routine health maintenance, during examinations for school or work, at premarital or family planning visits, after a negative pregnancy test or during well-child care for another family member.

Components of PCC PCC for the woman who is planning to become pregnant involves:- • Comprehensive check-lists • Assessments – History & examination • Screening: Investigations. If have pre-existing diseases / medication : may add to pre-natal risks & will need ongoing evaluation.

What is involved in PCC? • Prescreening check-lists : • Reproductive & non- reproductive systems. Covers physical & psychological aspects. • Woman's lifestyle • Family history information. • Begins with basic information then in-depth, especially if there is previous disease/operation….. • Pre-screening assessments :a Qer filled by women generally before seeing Dr –with a nurse.

Assess & screen for: Too numerous conditions Medical conditions Genetic counseling Immunization Lifestyle changes STDs Medications Occupational exposures Domestic violence.

Medical conditions: • DM: • Screen for DM and pre-diabetes. • If already diabetic --- shift to insulin Rx. • Congenital anomalies: 2-6x > offspring of DM. • PCC care & good DM control  their rate • Recent meta analysis: lower rate among PCC recipients (2.1%) vs non-recipients (6.5%).

Medical conditions … HT UTI & Renal problems Obesity Cardiac / pulmonary problems Epilepsy Psychological disorders Others ….

Genetic counseling • PCC is ideal time: • Before a couple attempts to conceive especially if the history reveals advanced maternal age, previously affected pregnancy, consanguinity or FH of genetic disease. • Certain ethnic groups: relative high carrier incidence for certain genetic disorders  

Genetic counseling • Blood conditions caries/ disease: • Sickle cell anemia, thalasemia, G6PD • Cystic fibrosis • Mental retardation condition: • Screen women with a known FH of fragile X syndrome or FH of unexplained mental retardation or for women who have learning disabilities or mental retardation.

Immunization • PCC is ideal time: • Screen • for rubella immunity. • Why? • Immunization: • Rubella • Hepatitis A • Hepatitis B • Tetanus • Chickenpox? Check : EIP complete? women <18 yrs.

Lifestyle changes • Caffeine: 1 cup coffee : ~ 120 mg caffeine. • 1 cup tea : ~ 40 mg caffeine. • 12- oz soft drinks (cola) : ~ 45 mg caffeine. • Caffeine metabolism  during pregnancy esp. with cigarette smoking. • Several studies: caffeine intake ± associated with  fertility,  abortion &  birth wt. •  5-6 mg/kg/day spread on day + no smoke + no alcohol : no  reproductive risk.

Lifestyle changes • Tobacco : • Smoking women during pregnancy : subjects themselves & their infants to a no. of adverse health effects. • women contemplating pregnancy should quit smoking prior to conception. • Nicotine replacement could then be prescribed.

Lifestyle changes • Tobacco …. : • Smoking cessation before / early pregnancy : associated with improvement in maternal airway function & at infant birth wt vs among nonsmoking pregnant women. • Alcohol & illicit drugs • Both a major health problem in USA. • Both harm fetus. • 1981- USA : women abstain drinking alcohol during pregnancy & when plan pregnancy.

STD & medications STD : PCC is a good opportunity to screen for genital infections such as chlamydia, gonorrhea, syphilis and HIV. Medications : therapeutic regimens for chronic illnesses are best modified, if possible, in PC period to include the drugs that have been used the longest & have been determined to pose the lowest risk.

Medications Antihypertensives: Diuretics & angiotensin-converting enzyme : should be avoided drug of choice: methyldopa- proven maternal & fetal safety. Anticoagulants: Warfarin C.I. Switch to heparin Oral hypoglycemic: Switch to insulin before pregnancy.

Occupational exposures & Worldwide: women entry to workforce. Most women are in reproductive age • Three most common occupational hazards reported to affect pregnancy are: • Video display terminals • Organic solvents • Lead

Domestic violence Is increasingly recognized as a major public health issue. It crosses all SE, racial, religious & educational boundaries. Physical abuse during pregnancy : significant RF low birth wt & maternal complications. Physicians should assess the victims & refer to local community resources.

Obstacles of PPC The most common obstacle to PCC : many pregnancies are still unplanned. If birth control methods fail, there is no opportunity for pre-screening and assessment. The second most common obstacle: most women do not know, realize, or understand the benefits of visiting their physician before trying to become pregnant.

Obstacles of PPC • Most women still take for granted the biological aspects of becoming pregnant, & do not consider the extreme value of pre-screening before becoming pregnant. • Most women who want & anticipate having a baby are naturally prone to thinking in terms of having a well baby. In the majority of cases, women do not think about having a baby who has any kind of problem.

Obstacles of PPC The third most common obstacle: the lack of health insurance. However, most insurances will cover this as a screening visit. Also, many physicians will do the pre-conception screening during a regular office visit or gynecological visit if the woman just informs the doctor of her desire to become pregnant. Most gynecologists will inquire about child-bearing intentions anyway.

PPC in Saudi Arabia • Premarital check up : • Mandatory. • For limited inherited risks …… • Not enough. PPC could be provided to the married women at the center by:- • health education of the patient at PNC, WBC, chronic disease clinic ….etc • Let the patient be aware of its importance

Woman’s role • A woman may need to adjust certain aspects of her health and well-being which are in her control. • These usually include aspects of lifestyle, drug and alcohol use, exercise, rest and stress reduction. • In addition, she may need to discontinue certain herbs or over-the-counter medications as recommended by the physician. • Many physicians will also recommend pre-natal vitamins before a woman actually conceives in order to boost her overall health.

تم بحمد الله Thank you

Module 6 - ppt 1 Dr. Maysoon Al-Amoud

MCQ

1) Birth rate is • Annual number of births during one year/ 1000 persons • Crude birth rate. • Usually determine the rate of population groths. • All of the above.

2) Infant mortality rate • Number of infant deaths in one year/1000 live birth in same year. • Incloude toal death rate. • It indicate the level of health in a community. • All of the above.

3) Factors NOT leading to infant mortality a) Maternal health problems b) Smoking c) Age >20 or < 40 d) Late entry into prenatal care

4) Druges that need to be chnged for safe motherhood are all EXCEPT • Diuretics • Warfarin • Insulin • angiotensin-converting enzyme

Module 6 - ppt 1 Dr. Maysoon Al-Amoud 41

Preconceptional care (PCC) (The Critical role of Primary Care Physician)