A Preconception Care Health Strategy Addressing STIs and Other Infections

1. A Preconception Care Health StrategyAddressing STIs and Other Infections Julia Lange Kessler, CM, MSM Maternal Fetal Medicine Outreach Coordinator Maria Fareri Children’s Hospital at Westchester Medical Center

2. What is preconception health care? Health care for women and men that takes place prior to pregnancy. Prevention infant mortalities and morbidities Prevention of maternal mortalities and morbidities AAP and ACOG classified the main components of PCC: Physical assessment, risk screening, vaccinations and counseling.

3. The origins of Preconception Care: • Late 1980s -the Public Health Service convened a multi-disciplinary group of experts in maternal and child health. • This lead to a report “Caring for our Future: The Content of Prenatal Care” • Public Health Service, US DOH. Caring for our Future: the content of prenatal care (a report of the Public Health Service Expert Panel on the Content of Prenatal Care). Washington (DC): US Government Printing Office, 1989.

4. What we learned : • Preconception Care should be in integral part of primary care services. How did that concept evolve?

5. Radiation Exposure→childhood–leukemiaDESThalidomide

6. Thalidomide → Phocomelia

7. 1962 legislation was passed so that the FDA could scrutinize drugs more carefully and from that a drug classification system evolved that for pregnancy and lactation.

8. Pregnancy Drug Classification System: A: Controlled studies in ♀- no risk to fetus or newborn B: Animal studies – no risk but studies in ♀ have not been done C: Animal studies indicate adverse effects but there are no studies in ♀ - give only when the risks outweigh the benefits D: There is + risk to the human fetus. Use only in life threatening situations X: Studies have shown abnormalities in fetus.

9. Preconception considerations when planning a pregnancy: • When to discontinue a family planning method • OC’s – wait one cycle before attempting pregnancy – optimized dating • Long term hormonal- make take several months to a year. • Irregular menses-Basel Body Temperature or ovulation predictor • 12 months of unprotected intercourse → infertility

10. Nutrition • BMI • Pica • Eating disorders • CDC: ≤ 1 gram Folic Acid • Good nutritional status: protein for brain and cell development “In one study, the reduced overall health status (including poorer physical and emotional health) of women with low income during the month before pregnancy was associated with and increase risk for preterm labor.” Haas JS, et al. Outcomes and health status of socially disadvantaged women during pregnancy. J Womens Health Gender Based Med 1999;8:547-53.

11. Genetic screening • Dental care • Cardiac risk • Consider Previous OB complications: • PTB • GDM • Hypertensive disorders • Previa • Low Birth Weight • Incompetent cervix • Fibroids • Pre eclampsia • Advanced maternal age

12. Preconception Issues for Men: • 50% of all infertility is male related • Medications or environmental factors can alter sperm shape, motility, count and sexual performance. • Some studies indicate male smoking may be linked to heart defects • Alcohol and marijuana impacts sperm quality • Deficiencies in zinc lowers sperm count • Heat (cycling, hot tubs, etc.) lowers sperm quantity. • STIs affect pregnancy

13. The issue that remains is the unplanned pregnancy • ~ 50% of all pregnancies are unintended. • Unintended pregnancies are associated with perinatal morbidity and very low birth weight

14. Early prenatal care is too late.

15. Organogensis occurs between days 17- 56 days before a ♀ may know that she is pregnant.

17. By the time a ♀ misses menses and the urine is + for HcG: • The fetal heart is formed and functioning • The spinal canal has closed • Eyes are formed • Limbs are moving

18. The time to prevent complications: • Before a woman conceives • This needs to become our “Standard of Care” : • Age appropriate preconception care and counseling by a majority of primary care providers • Created by the CDCs Select Panel on Preconception Care: • Prevention of pregnancy for adolescents • Changes in life sytle prior to conception • Assessment of Reproductive risks for all persons (male and female)

19. Preconception risk factors as a % of total risks at the time of negative pregnancy test. Brian, J. et al. The Journal of Family Practice.47(1), July 1998, p. 33-8.

20. Preconception Care Works • Risk Factors for Adverse Pregnancy Outcomes: • Folic acid • Rubella seronegativity • Diabetes (preconception) • Hypothyroidism • HIV/AIDS • Maternal phenylketonurea (PKU) • Oral anticoagulant • Antiepiletic drugs • Isotretinoins (Accutane) • Smoking • Alcohol misuse • Obesity • Hepatitis B • STIs Atrash HK, Johnson K, Adams MM, Cordero JF, Howse J. reconception Care for Improving Perinatal Outcomes: The Time to Act. Matern Child Health J. 2006 Jun 14.

21. Sexually Transmitted Infections

22. STIs can be devastating to a woman’s reproductive health • Intense physical discomfort • Pain • Mental anguish • Mortality from an ectopic pregnancy (PID) • Cervical cancer • HIV/AIDS

23. March 2008: A CDC study estimates that one in four (26 percent) young women between the ages of 14 and 19 in the United States – or 3.2 million teenage girls – is infected with at least one of the most common sexually transmitted diseases (human papillomavirus [HPV] 18%, chlamydia 4%, herpes simplex virus, and trichomoniasis). March 11, 2008 – Press Release – CDC.

24. Why are women more vulnerable? • More biologically susceptible • More apt to acquire an STI from a man than vice versa • More apt to be asymtomatic • STI complications are more severe • Powerlessness in abusive situations • Practice of douching

25. Trichomoniasis

26. Pregnancy and trich: • Vaginal trichomoniasis has been associated with adverse pregnancy outcomes : • premature rupture of the membranes • preterm delivery • low birth weight

27. Trichomoniasis • Trichomoniasis is caused by the protozoan parasite: T. vaginalis. • 7.4 million new cases occur each year (CDC) • 124,000 pregnant ♀ per year • Most men who are infected with T. vaginalis do not have symptoms.

28. Symptoms in ♀: • Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green discharge with vulvar irritation. 5-28 days after exposure. • However, some women have minimal or no symptoms.

30. Diagnosis of vaginal trichomoniasis • Is usually performed by microscopy of vaginal secretions, but this method has a sensitivity of only about 60%–70%. • Culture is the most sensitive commercially available method of diagnosis.

32. Recommended Regimen • Metronidazole 2 g orally in a single dose. Alternative Regimen: • Metronidazole 500 mg twice a day for 7 days.

33. Management of Sex Partners • Sex partners of patients with T. vaginalis should be treated. • Patients should be instructed to avoid sex until they and their sex partners are cured (i.e., when therapy has been completed and patient and partner(s) are asymptomatic [in the absence of a microbiologic test of cure]).

34. Gonorrhea

35. Untreated Gonorrhea in pregnancy: • Miscarriage • PTL • PROM • Stillbirth • low birth weight • Conjunctivitis • Pneumonia • neonatal sepsis • neurologic damage • blindness • deafness • acute hepatitis, meningitis, chronic liver disease, and cirrhosis.

36. Untreated • Women: gonorrhea is a major cause of PID, which can lead to chronic pelvic pain, ectopic pregnancy, infertility and HIV. • Men: untreated gonorrhea can cause epididymitis, a painful infection in the tissue surrounding the testicles that can result in infertility. • http://www.cdc.gov/STD/STATS/trends2006.htm

37. Gonorrhea • Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract, including the cervix , uterus , and fallopian tubes in women, and in the urethra in women and men. The bacterium can also grow in the mouth, throat, eyes, and anus. • http://www.cdc.gov/std/Gonorrhea/default.htm

38. Symptoms (within 10 days) • Pain or burning when passing urine • Vaginal discharge that is yellow or sometimes bloody • Bleeding between menstrual periods • Heavy bleeding with periods • Pain during sex • http://www.4woman.gov/faq/stdgonor.htm

39. Transmission: Oral, anal, or vaginal sex

40. In 2005, the national rate (115.6 cases per 100,000 population) increased for the first time since 1999 • 13,200 pregnant ♀ per year

42. Antibiotic Resistant Gonorrhea • Fluoroquinolone-resistant strains of N. gonorrhoeae have also been reported in the United States and Canada. The proportion of gonococcal isolates in Hawaii that are fluoroquinolone-resistant currently exceeds 10% and increasing numbers of resistant strains have been identified in the continental United States.  • http://www.cdc.gov/std/Gonorrhea/arg/default.htm

43. New Treatment-April 2007 • Ceftriaxone 125 mg IM in a single doseORCefixime*400 mg orally in a single dose or 400 mg by suspension (200 mg/5ml)PLUSTREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT * These regimens are recommended for all adult and adolescent patients, regardless of travel history or sexual behavior.† The tablet formulation of cefixime is currently not available in the United States • http://www.cdc.gov/STD/treatment/2006/updated-regimens.htm

44. Chlamydia

45. Untreated Chlamydia • PID: 40% which can cause permanent damage: • fallopian tubes • uterus • surrounding tissues. • The damage can lead to chronic pelvic pain, infertility, and potentially fatal ectopic pregnancy. • Women infected with chlamydia are up to five times more likely to become infected with HIV, if exposed.

46. Chlamydia • Caused by the bacterium, Chlamydia trachomatis, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. (75% ♀ and 50% ♂) • 100,000 pregnant ♀ per year • http://www.cdc.gov/STD/chlamydia/default.htm

47. Symptoms: • Any genital symptoms such as an unusual sore, discharge with odor, burning during urination, or bleeding between menstrual cycles • 50-75% are asymptomatic

48. Treatment for both partners: • A single dose of azithromycin -2 grams • Doxycycline 100 mg. BID • No sex until treatment for both (all) partners is complete.

49. Other STIs – Facts: • CDC’s baseline HIV drug-resistant surveillance data from 11 states in 2007 revealed that about 10.4 percent of HIV-infected persons have HIV drug-resistant mutations. • http://www.cdc.gov/nchhstp/docs/NCHHSTP2007AnnualReport_final-c.pdf

50. Candidiasis and Bacterial Vaginosis