Preconception

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Preconception
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What is preconception health care?

• Preconception health care is care given to a
  woman before pregnancy to manage conditions and
  behaviors which could be a risk to her or her
  baby. There are many topics covered under
  preconception care.

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• Folic acid supplements to prevent neural tube
  defects.
• Rubella vaccinations to prevent Congenital
  Rubella Syndrome.
• Detecting and treating existing health conditions
  to prevent complications in the mother, and
  reduce the risk of birth defects
• Diabetes
• Hypothyroidism
• HIV/AIDS
• Hepatitis B
• PKU
• Hypertension
• Blood diseases
• Eating disorders

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• Reviewing medications that can affect the fetus
  or the mother, such as epilepsy medicine, blood
  thinners, and some medicines used to treat acne,
  such as Accutane.
• Reviewing a womans pregnancy history has she
  lost a baby before?
• Stopping smoking to reduce the risk of low birth
  weight
• Eliminating alcohol consumption to prevent Fetal
  Alcohol Syndrome, and other complications.

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• Family planning counseling to avoid unplanned
  pregnancies.
• Counseling to promote healthy behaviors such as
• appropriate weight,
• nutrition,
• exercise,
• oral health.
• Counseling can help a woman avoid substance abuse
  and toxic substances.
• It can help women and couples understand genetic
  risks, mental health issues (such as depression),
  and intimate partner domestic violence.

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Good preconception health care

• Managing current health conditions.
• By taking action on health issues BEFORE
  pregnancy,
• Future problems for the mother and baby can be
  prevented.
• Preconception health care must be tailored to
  each individual woman.
• It means helping women and their partners reduce
  risks and get ongoing care.
• Men and other family members are also very
  important in supporting the goals of
  preconception health.

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• The new recommendations say that everyone
  should have a reproductive life plan.
• What does this really mean?

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A reproductive life plan

• A set of personal goals about having (or not
  having) children.
• It also states how to achieve those goals.
• Everyone needs to make a reproductive plan based
  on personal values and resources.
• Give me some examples

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• Im not ready to have children now. Ill make
  sure I dont get pregnant. Ill correctly use
  effective contraception.

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• Ill want to have children when my relationship
  feels secure and Ive saved enough money. I wont
  become pregnant until then. After that, Ill
  visit my doctor to discuss preconception health.
  Ill try to get pregnant when Im in good
  health.

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• Id like to be a father after I finish school
  and have a job to support a family. While I work
  toward those goals, Ill talk to my wife about
  her goals for starting a family. Ill make sure
  we correctly use an effective method of
  contraception until were ready to have a baby.

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• Id like to have two children, and space my
  pregnancies by at least two years. Ill visit my
  certified nurse midwife to discuss preconception
  health now. Ill start trying to get pregnant as
  soon as Im healthy. Once I have a baby, Ill get
  advice from a health professional on birth
  control. I dont want to have a second baby
  before Im ready.

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• I will let pregnancy happen whenever it
  happens. Because I dont know when that will be,
  Ill make sure Im in optimal health for
  pregnancy at all times.

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• There are many kinds of reproductive life
  plans. Whats important is that the couple think
  about when and under what conditions they want to
  have a baby. Health care providers and counselors
  can help them understand the clinical and
  lifestyle options that are best for them.

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The goal of preconception care

• as described in reports, recommendations of The
  American Academy of Pediatrics, American
  Academy of Family Physicians, The American
  College of Obstetricians and Gynecologists, is to
  provide
• screening for risks,
• health promotion and education, and
• interventions to address identified risks.

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Preconception care can be provided most
effectively as

• Part of ongoing primary care
• Or initiated during visits for routine health
  maintenance
• During examinations for school or work
• At premarital or family planning visits
• After a negative pregnancy test
• During well-child care for another family member

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• The Select Panel on Preconception care
  identified 14 conditions for which there is
  scientific evidence demonstrating effectiveness
  in improving pregnancy outcomes

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• 1- Folic acid

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• 2- Obesity

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• 3- Rubella seronegativity

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• 4- Hepatitis B

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• 5- HIV/AIDS

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• 6- STDs

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• 7- Diabetes (preconception)

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• 8- Hypothyroidism

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• 9- Maternal phenylketonurea (PKU)

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• 10- Oral anticoagulant

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• 11- Anti-epileptic drugs

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• 12- Isotretinoins (Accutane)

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• 13- Smoking

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• 14- Alcohol or other recreational drug misuse

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Health care provider should

• 1- Review family, medical, and previous obstetric
  history and use of birth control methods.

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• 2- Ask about lifestyle, behaviors, and social
  support concerns that affect the woman's health.
• As smoke,
• drink alcohol,
• use drugs, or
• have psychological problems, including depression?

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• 3- Do she have nutrition and diet issues?
• 4- Concerns about health conditions in her or her
  partners family?
• 5- Are there issues around intimate partner
  domestic violence?

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• 6- What are the medications she is taking?
• Are there chemicals,
• solvents,
• radiation, or
• other potential risks at her workplace or home
  that could harm her or her baby?

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7- Schedule health screening tests

• Pap smear,
• urinalysis,
• blood tests.
• blood type,
• Rh factor,
• whether she has diabetes,
• sexually transmitted infections, or other
  conditions.
• review her immunization status and update them
  if
• needed.
• perform a physical exam, including a pelvic exam
  and a blood pressure check.

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• 1- Nutrition

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a) Folic acid supplementation

• Neural tube defects (NTDs) including
• spina bifida,
• anencephaly and
• encephalocele affect large number every year.
• Several studies have shown a reduced risk of
  Neural tube defects in infants whose mothers used
  folic acid supplements.

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• - All women who are capable of being pregnant
  take 0.4mg of folic acid daily to reduce the risk
  of NTDs in pregnancy.
• A daily dose of 4 mg of folic acid started 4
  weeks prior to conception and continued through
  the first trimester of pregnancy played a big
  role in prevention of that defect.
• - It is recommended that patients who had a
  pregnancy with NTDs defect should take 4 mg of
  folic acid 1- 3 months before conception and
  continuing through first 3 months of pregnancy.

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• Despite the recommendation compliance has been
  poor. So the FDA (US food and drug
  administration) mandated the fortification of
  cereals and grains with folic acid of 0.14 mg per
  100g of grain. This amount increase the average
  consumption of folic acid by 0.1mg/day.

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b) Obesity

• Obesity is the most common nutritional disorder
  in More Economically developed countries. Obese
  women are at increased risk for prenatal
  complications such as
• hypertensive disorders of pregnancy,
• gestational diabetes and
• urinary tract infections.
• They are more likely to deliver large-for
  gestational age infants and
• as a result, have a higher incidence of
  intrapartum complications.

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• Because dieting is not recommended during
  pregnancy, obese women should be encouraged to
  lose weight prior to conception.
• On the other hand, underweight women are more
  likely to have under weight baby.
• At the preconception visit, the patients weight
  and height should be assessed

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c) Vitamin A

• It is a known teratogen at high doses.
  Supplemental doses exceeding 5000IU/day should be
  avoided by women who are or who may become
  pregnant. The form of vitamin A that is
  teratogenic is retinol not ß carotene, so large
  consumption of fruits and vegetables rich in ß
  carotene is not a concern.

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• 2- Immunization

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Rubella seronegativity

• The preconception visit is an ideal time to
  screen for rubella immunity, because rubella
  infection in pregnancy can result in
• miscarriage,
• stillbirth, or
• an infant with congenital rubella syndrome (CRS).
  The risk for developing CRS (hearing impairment,
  eye defect, congenital heart defects, and
  developmental delay) is greatest if the mother is
  infected in the first trimester of pregnancy.

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• Immunization should be given to any woman with
  a negative rubella titer and advice given to
  avoid conception for one month.

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Varicella immunity

• If a pregnant woman acquires varicella before
  20 weeks gestation, the fetus has a 1-2 risk of
  developing fetal varicella syndrome, which is
  characterized by
• skin scarring,
• eye defects and
• neurologal complications.
• Infants born to mothers who manifest varicella 5
  days before to 2 days after delivery may
  experience a severe infection and have a
  mortality rate of as high as 30.

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• At the preconception visit, patients who do
  not have a prior history of chickenpox and who
  are seronegative should be offered vaccination.
• Women should avoid becoming pregnant for at
  least 4 weeks after the second dose.

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Hepatitis B Vaccine

• Since 1988, the CDC has recommended universal
  screening of pregnant women for hepatitis B.
  Although hepatitis B vaccine can be given
  during pregnancy, women with social or
  occupational risks for exposure to hepatic B
  should be ideally identified and offered
  immunization prior to conception.

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• Vaccination is recommended for men and women who
  are at risk.
• Preventing HBV infection in women of
  childbearing age
• prevents transmission of infection to infants
• eliminates risk for to women of sequelae of HBV
  infection, including
• - hepatic failure,
• - liver carcinoma,
• - cirrhosis, and
• - death.

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• 3- Infections

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Sexually Transmitted diseases (STD)

• The latest estimates suggest that there are a
  huge number of new cases of STD each year.The
  preconception visit is a good opportunity to
  screen for genital infections as
• Chlamydia,
• gonorrhea,
• syphilis and
• HIV.

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• Chlamydia trachomatis and Neisseria gonorrhea
  have been strongly associated with
• - ectopic pregnancy,
• - infertility, and
• - chronic pelvic pain.
• - fetal death, mental retardation and
• blindness.

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• 4- Medical conditions

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Diabetes

• Congenital anomalies occur two to six times more
  often in the offspring of women with diabetes
  mellitus and have been associated with poor
  glycemic control during early pregnancy.
• Preconceptional care with good diabetic control
  during early embryogenesis has been shown to
  reduce the rate of congenital anomalies to
  essentially that of a control population.

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According to the American Diabetes Association
recommendations

• The goal for blood glucose management in the
  preconception period and in the first trimester
  is to reach the lowest HbA1C level possible
  without undue risk of hypoglycemia to the mother.
  

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• Diuretics should be avoided.
• Oral hypoglycemic agents should be discontinued
  because they may cause fetal anomalies and
  neonatal hypoglycemia and
• Insulin should be prescribed for patients with
  either type 1 or type 2 diabetes.

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Epilepsy

• Epilepsy occurs in 15of the population and is
  the most common serious neurologic problem seen
  in pregnancy.
• Much can be done to achieve a favorable
  outcome of pregnancy in women with epilepsy.
  Ideally this should start before conception.

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• Certain anti-epileptic drugs are known as
  teratogens. Before conception, women who are on
  these drugs and who are planning to be pregnanat
  should be prescribed a lower dosage of these
  drugs.

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Phenylketanuria

• It is one of the most common inborn errors of
  metabolism.
• It is associated with deficient activity of
  liver enzyme phenylalanine hydroxylase, leading
  to accumulation of phenylalanine in the blood and
  other tissues.
• If untreated it result in mental retardation
  microcephaly and many other problems. When
  discovered early and the infant had special
  formula he will have a normal life span.
• If this one later plan for pregnancy she
  should be on phenylalanine restricted diet before
  pregnancy .

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• 5- Medications

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Antihypertensive

• Women with chronic hypertension who are
  receiving angiotensin-converting enzyme
  inhibitors as Capoten or Vasotec should be
  advised to discontinue them before becoming
  pregnant. Or as soon as they know they are
  pregnant because of the possible hazards to the
  fetus.

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• In the absence of congestive heart failure or
  pulmonary edema diuretics are best avoided
  during pregnancy because they reduce maternal
  plasma volume which may diminish utroplacental
  perfusion.

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• Methyldopa (Aldomet) is the drug of choice in
  pregnancy Methyldopa affects the nerves that
  relax the walls of blood vessels, causing the
  blood vessels to widen (dilate) and thus reducing
  blood pressure.

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Anticoagulants

• Warfarin (Marevan) readily crosses the
  placenta and is a known human teratogen. In
  patients who require prolonged anticoagulation
  therapy, discontinuing warfarin in early
  pregnancy and subsituting heparin will reduce the
  incidence of congenital anomalies because heparin
  does not cross the placenta.

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Hypothyrodism

• The dosages of Levothyroxine required for
  treatment of hypothyroidism increases in early
  pregnancy. Levothyroxine dosage needs to be
  adjusted for proper neurologic development.

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Antithyroid drug

• Both propylthiouracil and methimazole are
  effective in the management of hyperthyrodism in
  pregnancy. Propylthiouracil is the preferred
  agent because in addition to inhibition of T4 it
  also inhibit T3. Methimazole crosses the placenta
  in larger amounts and cause fetal problems so
  Propylthiouracil is the drug of choise.

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Oral hypoglycemics

• patients with diabetes should be shift to
  insulin

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Isotretinoins (Accutane)

• Use of isotretinoins in pregnancy to treat acne
  results in miscarriage and birth defects.
  Effective pregnancy prevention should be
  implemented to avoid unintended pregnancies among
  women with childbearing potential who use this
  medication.

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• 6- Life-style changes

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Caffeine

• Caffeine is present in many beverages
• in chocolate, and
• in over-the counter medications such as cold and
  headache medicines.
• Several studies have suggested that caffeine
  intake may be associated with decreased
• fertility,
• increased spontaneous abortion and
• decreased birth weight.
• But recently most of the studies revealed that a
  pregnant who consume 5 to 6 mg/kg/day , spread
  all over the day and do not smoke or drink
  alcohol have no increased reproductive risk.

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Tobacco

• Smoking during pregnancy has been associated
  with
• spontaneous abortion,
• prematurity,
• placenta previa ,
• intrauterine growth restriction,
• as well as an increased risk of sudden infant
  death.
• Women should advised to stop smoking prior to
  conception.

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Alcohol

• The most severe consequences of exposure to
  alcohol during pregnancy is fetal alcohol
  syndrome (FAS). It is characterized by a triad of
  
• Prenatal or postnatal growth retardation
• Central nervous system neurodevelopmental
  abnormalities
• Facial anomalies as thin upper lip

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illcit drugs

• all illicit drugs are a major health hazard as
  Marijuana, cocaine and heroin.
• At the preconception visit all patients should
  be questioned about drug use and offered
  counseling, referral, and access to recovery
  programs.

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Domestic violence

• Domestic violence is recognized as a major
  public health problem. Victims of domestic
  violence should be identified preconceptionally
  because the type of violence can affect
  pregnancy.
• Where as violence usually directed in non
  pregnant towards head ,chest , neck and breasts
  but in pregnancy the target is the abdomen.
• Physical abuse during pregnancy is a
  significant risk factor of low birth weight and
  many other complications.

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• What can men do to support the preconception
  health of their female partners and their future
  babies?

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• Men who work with chemicals or other toxins
  need to be careful that they dont expose women
  to them. For example, men who use fertilizers or
  pesticides in agricultural jobs should change out
  of dirty work clothes before coming near their
  female partners. They should handle and wash
  soiled clothes separately.

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• The family health histories of men are also
  important when planning a pregnancy.
  Understanding genetic risks from both sides
  enables providers to give more accurate advice.

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• Screening for and treating STDs (sexually
  transmitted infections) in men can help make sure
  that the infections are not passed to female
  partners.

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• Men can improve their own reproductive health
  by
• reducing stress,
• eating right,
• avoiding excessive alcohol use,
• not smoking, and
• talking to their health care providers about
  their own medications.
• It is also important for men who smoke to stop
  smoking around their partners, to avoid the
  harmful effects of second-hand smoke.

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• Thank you