Pre conception care-1st HO students.pptx

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1. Preconception care Prepared and organized by M elesech E. 10/31/2022 1

2. Introduction to P reconception C are [PCC] 10/31/2022 2 Chapter - one

3. It is a set of interventions that aim to identify & modify biomedical , behavioral , & social risks to a woman’s health or pregnancy outcome through prevention & management. (CDC) (2015 ) Means Preparing and planning for a healthy pregnancy It refers to evaluation of a woman who need to become pregnant with the objective of Optimizing the health of the mother before conception Begin at least three months before you get pregnant 10/31/2022 3 What is Preconception care?

4. Preconception care is the provision of; biomedical, behavioral and social health interventions to women and couples before conception occurs. It aims at; improving their health status, and reducing behavioral factors and individual and environmental factors that contribute to poor maternal and child health outcomes . Its ultimate aim is to improve maternal and child health, in both the short and the long term 10/31/2022 4 Conti…d

5. Even if preconception care aims primarily at improving maternal and child health ; it brings health benefits to the adolescents, women and men as individuals in their own right (not just as  potential parents). For example; many   nutritional, environmental, mental health interventions as well as interventions aiming to reduce psychoactive substance use and interpersonal violence improve health and well-being of girls and boys, women and couples irrespective of their plans to become parents. 10/31/2022 5 Conti…d

6. Concept of PCC over the last decades by; J.W. Ballantine [ concept of prenatal care Preconception and prenatal care are forms of primary care and prevention.  Opportunities exist in many settings Should target all women of reproductive age Education and preparation are key Worldwide maternal mortality approaches one million women annually Global risk of maternal death is 1 in 10,000 live births Unintended pregnancy rate approaches 40% annually 10/31/2022 6 Concept of preconception care

7. Improve knowledge, attitudes, & behaviors of men & women related to preconceptional health. Assure that all women of childbearing age receive preconception care services including evidence-based risk screening, health promotion, & interventions that will enable them to enter pregnancy in optimal health. 10/31/2022 7 Goals of Preconception care

8. Reduce risks indicated by a previous adverse pregnancy outcome through interconnectional interventions to prevent or minimize recurrent adverse outcomes. Reduce the disparities in adverse pregnancy outcomes. 10/31/2022 8 Con`t…

9. Preconception : A woman’s (or man’s) health status and risks before a first pregnancy and subsequent pregnancies. Interconception : The period between the end of one pregnancy and the conception of the next pregnancy. Periconception : The maternal health status and risks around the time of conception through the period of organogenesis 10/31/2022 9 Preconception terminologies

10. PREGNANCY FAMILY PLANNING/ PRECONCEPTIONAL FAMILY PLANNING INTERCONCEPTIONAL CHILDBIRTH MENOPAUSE MENARCHE PROMOTION OF HEALTHY FUTURE INFANTS PROMOTION OF HEALTHY AND DESIRED PREGNANCIES PROMOTION OF LIFELONG WELLNESS 10/31/2022 10 Life course – when to intervene?

11. 10/31/2022 11 Areas addressed by the PCC

12. T he most evidence based 'package of interventions' addressing 13 various areas are as follows: Nutritional conditions ; vaccine preventable diseases ; genetic conditions ; environmental health; infertility/subfertility ; female genital mutilation; too early, unwanted and rapid successive pregnancies ; sexually transmitted infections; HIV ; interpersonal violence; mental health; psychoactive substance abuse; and tobacco use 10/31/2022 12 Conti…d

13. The period of (when organs are formed) begins just 3 days after the first missed menstrual period. Most women are not aware they are pregnant by 3 days after the first missed menses. All organs formed by week 9 (organogenesis ) Days 17-56 post conception First day of “missed” period is day 14 post-conception Organogenesis is complete around the 56th day after conception: 8 weeks by conception date and 10 weeks by menstrual date. 10/31/2022 13 Conception and organogenesis

14. By the time most women realize they are pregnant—usually 1 to 2 weeks after the first missed period—the embryo has already begun to form. Many pregnant women do not start prenatal care until organogenesis is complete. Some poor pregnancy outcomes, including; spontaneous abortions and congenital anomalies (birth defects), have already occurred before the first prenatal visit. 10/31/2022 14 Con`t…

15. High prevalence of the risky conditions may be amenable to intervention during the preconceptional and interpregnancy periods However, to mitigate these potential pregnancy risks pre conception care must be provided before conception. Thus, many preventive steps—for example, folic acid to avoid neural-tube defects—will be ineffective if initiated at this time. PCC is more important than ANC for prevention of congenital anomalies 10/31/2022 15 Con`t…

16. 10/31/2022 16

17. Teratogen -is an agent that can disturb the development of the embryo or fetus to produce a permanent alteration of form or function. The study of birth defects and their etiology is termed teratology Teratogens halt the  pregnancy  or produce a congenital malformation (a birth defect). Pregnancy outcomes are dependent on the interaction of various maternal, fetal, and environmental factors. 10/31/2022 17 Potential problems in prenatal development

18. Classes of teratogens include; physical or environmental factor such as heat or radiation , maternal metabolite as in diabetes or phenylketonuria, or maternal infection such as cytomegalovirus and drugs. Even obesity is considered as teratogen All infectious diseases have a tendency to bring about death of the child and its subsequent expulsion from the uterus. 10/31/2022 18 Con`t…

19. Most serious when structure is forming (embryonic period) Susceptibility to harm is influenced by genetic makeup of mother and embryo Some defects can be caused by different teratogens One teratogen can cause different defects Longer exposure/higher dose, more harm Father exposure may affect embryo Long term effect depend on postnatal environment Some effects not apparent until later in life. 10/31/2022 19 Effects of teratogens

20. ACE (angiotensin converting enzyme) inhibitors such as: B enazepril , captopril , enalapril , fosinopril sodium , lisinopril , hydrochlorothiazide , quinapril  and ramipril   Acne  medication  isotretinoin  (Accutane). Alcohol, Cocaine. Androgens (male hormones). Antibiotics  tetracycline ,   doxycycline   and streptomycin. Anticoagulant (blood-thinner)  warfarin . Anticonvulsants ( seizure  medications) such as: phenytoin , valproic acid  ,trimethadione paramethadione and carbamazepine   20 Drugs that are capable of acting as teratogens include:

21. Anti-depressant drug  lithium . Antimetabolite/anticancer drugs  methotrexate  and aminopterin . Antirheumatic agent and metal-binder (chelator)  penicillamine   . Antithyroid drugs such as: thiouracil/ propylthiouracil  and carbimazole / methimazole . DES (diethylstilbestrol ) Thalidomide  (Thalomid) which was approved by the FDA for the treatment of a complication of  leprosy  ( erythema nodosum  leprosum). 10/31/2022 21 Con`t…

22. It should include: Informed choice, which helps women & men to understand health issues that may affect conception and pregnancy. Women & their partners being encouraged to prepare actively for pregnancy, & be as healthy as possible. Identifying couples who are at ↑ risk of having babies with a genetic malformation. Provide them with sufficient knowledge to make informed decisions. 10/31/2022 22 Preconceptual care is distinct from Antenatal care

23. Optimizing health of mother before conception by detecting potential risk factors Especially important in Medical disorders as DM and phenylketonuria Nutritional deficiencies (e.g. folate) Exposure to toxin or teratogen exposure (cigarette, alcohol, warfarin, isotretinoin…) More important than prenatal care to prevent congenital anomaly Rational:30% start ANC after 2 nd TM(after organogenesis i.e. 3-10 wks) Essential part of primary and preventive care 10/31/2022 23 Benefits of PCC

24. The importance of seeking care early for confirmation of pregnancy and gestational age dating can be discussed with the patient Reduce risk indicated by a previous adverse pregnancy outcome/prevent recurrence Reduce adverse pregnancy and labour outcome It increase the likelihood of healthy mother and baby by correcting unhealthy lifestyle choices Make sure mother is immunized prior pregnancy Reduces trying to conceive to conception time 10/31/2022 24 Con`t…

25. Reduce unintended pregnancy Prevent LBW and prematurity Promote healthy behaviors and reduce risk taking behaviors Prepare and reinforces parents for parenting Promote family planning utilization Institute preventable measure before pregnancy Educate couples regarding risks of pregnancy and strategies to minimize the risk Screen for conditions which may impact fertility, fetal development or mothers ability to adapt to pregnancy. 10/31/2022 25 Con`t…

26. Preconception care has a positive effect on a range of health outcomes. Among others, preconception care can: Reduce maternal and child mortality Prevent unintended pregnancies Prevent complications during pregnancy and delivery Prevent stillbirths, preterm birth and low birth weight Prevent birth defects Prevent neonatal infections Prevent underweight and stunting Prevent vertical transmission of HIV/STIs Lower the risk of some forms of childhood cancers Lower the risk of type 2 diabetes and cardiovascular disease later in life 10/31/2022 26 Summary of benefits of PCC

27. There are mainly four components of PCC. These are; Health promotion / Health education Counseling Risk assessment/screening Medical/psychosocial intervention& follow-up. 10/31/2022 27 COMPONENTS OF PRECONCEPTION care

28. Patient education regarding pregnancy risks, management options, and reproductive alternatives basicaly ; Effect of pregnancy on underlying disease Effect of underlying disease on pregnancy prevention of congenital anomalies Education focus on; Smoking, alcohol abuse and other drug use Folic acid supplementation [400 mcg or 0.4mg daily as a standard of care 10/31/2022 28 1. Education/ Health promotion

29. Initiation of interventions, when possible to provide optimum pregnancy outcome & t o control underlying medical condition Try to make the woman off from teratogenic drugs & substance abuse Folic acid supplementation- in those with history of neural tube defect 10/31/2022 29 Interventions to promote healthy pregnancy

30. Folate *** and iron supplementation Vitamin ‘D’ ,, Weight optimization Stop smoking and alcohol drinking Listeria/ brucella avoidance Mood assessment/domestic violence STI/ cervical cytology/ hep . b/c screenings Screening victims and discouraging FGM 10/31/2022 30 Positive interventions

31. Contraception Good preconception care begins with preconception care. Should be addressed at each visit including ; Primary care visit, emergency care visit and well women appointments ] Should be appropriate as regarding clients life style& health condition. 10/31/2022 31 Conti…

32. Pre-conception Care to promote healthy pregnancy include Supplementing iron and folic acid Iodization of salt Promoting exercise Vaccination against Vaccine-preventable diseases; (like tetanus , rubella, diphtheria, Hepatitis B,… etc.) 10/31/2022 32 Summary

33. Counselling; is a face-to-face, personal communication in which one person helps another to make decisions and then to act on them . Pre-conception counseling; is a meeting with a health care providers by a couple before attempting to become pregnant and Is a part of preventive medicine. Needs multidisciplinary team approach 10/31/2022 33 2. Pre-conception counselling

34. Counselors should be; knowledgeable regarding; relevant medical diseases, prior surgery, reproductive disorders, or genetic conditions and must be able to interpret data and recommendations provided by other specialists 10/31/2022 34 Conti…

35. Preconception evaluation & counseling provide an opportunity to; Inform pregnancy/fertility issues Identify some of the risks of pregnancy for the mother & fetus, educate them about these risks Interventions(when possible before pregnancy) 10/31/2022 35 Cont.…

36. Anytime a woman of childbearing age presents for a periodic health examination Postpartum check up Emergency visit Wait for infertility treatment Contraception counseling 10/31/2022 36 Potential opportunities for preconception counseling

37. Evaluation for sexually transmitted disease or vaginal infection Premarital counseling After a negative pregnancy test is also an excellent time for education Preconception Counseling includes; Sexually transmitted infections including HIV Family planning and pregnancy spacing Healthy body weight and diet 10/31/2022 37 Conti…

38. Importance of oral health Increased risk of hepatitis C in those with tattoos and/or body piercings Lead and other environmental and/or occupational exposures Genetic disorders (including cystic fibrosis and sickle cell genotypes 10/31/2022 38 Conti…

39. Environmental Toxins (Smoking cessation, Screen for alcoholism and use of illegal drugs, Occupational exposures, Material Safety, Household chemicals (avoid paint thinners/strippers, other solvents, pesticides), Radiation exposure, Recommend regular moderate exercise, avoid hyperthermia (hot tubs ), 10/31/2022 39 Conti…

40. Counsel to maintain a healthy weight Assess risk of nutritional deficiencies: Vegan/ fruitarian, Pica, Milk intolerance, Calcium or iron deficiency, To avoid over use of: Vitamin A, Vitamin D, Caffeine, and counsel on risk of nutritional deficiency. Counsel on the use of over-the-counter medications, Nutritional supplements, and naturopathic substances. 10/31/2022 40 Conti…

41. 1. Unplanned pregnancy: About 50% of all pregnancies are unplanned, & often these are at greatest risk. 2/3rds of unintended pregnancies and half of planned pregnancy had one or more indications for preconception counseling 10/31/2022 41 BARRIERS TO PRECONCEPTION COUNSELING & CARE

42. The 456 counseled women had a 50% greater likelihood of subsequent pregnancies that they considered “intended” compared with 309 uncounseled women. Moreover, compared with another group of women who had no health care before pregnancy, the counseled group had a 65-percent higher rate of intended pregnancy. 10/31/2022 42 Con`t…

43. 2. Risks for adverse outcome that cannot be modified (e.g., maternal age or genetic history) 3. Ignorance about importance of good health habits prior to conception 4. Financial issues (e.g., lack of health insurance) 5. Limited access to health service in general Inadequate knowledge/training of health care providers Long waiting time for appointment Perinatal deaths are 50% higher among children born to mothers under 20 years of age compared to mothers aged 20–29 years 10/31/2022 43 Con`t…

44. Up to 35% of pregnancies among women with untreated gonococcal infections result in low birth weight infants and premature deliveries, and up to 10% result in perinatal death In addition, the majority of women are unaware of the benefits to themselves and their future children of addressing specific risks before becoming pregnant. 10/31/2022 44 Conti…

45. A comprehensive survey on preconceptional risk done on 136 women, shows that almost 95 percent reported at least one problem that could affect a future pregnancy These included; Medical or reproductive problems—52% Family history of genetic disease—50% Increased risk of human immunodeficiency virus infection—30% Increased risk of hepatitis B and illegal substance abuse—25% Alcohol use—17% and Nutritional risks—54%. 10/31/2022 45 3. Risk assessment

46. Identification of risks related to pregnancy Age Reproductive history Medical conditions Family history Substance use Reproductive awareness Environmental toxins/teratogens Nutrition Genetics Medications Infections/vaccinations Psychosocial concerns 10/31/2022 46 Risk assessment con`t…

47. History is the key task in identifying risks to the woman & her pregnancy. a. Age : Women at both ends of the reproductive-age spectrum have unique outcomes to be considered.  Extremes of age are obstetrical risk factors The pregnant teenager has particular nutritional and emotional needs . Adolescents are at increased risk for anemia, preterm delivery, low birth weight, and preeclampsia compared with women aged 20 to 35 years The incidence of STDs—common in adolescents—is even higher during pregnancy 10/31/2022 47 Risk assessment: History

48. Unfortunately, because most of their pregnancies are unplanned, adolescents rarely seek preconceptional counseling . Perinatal deaths are 50% higher among babies born to adolescent mothers Advanced maternal age/age over 35  ↑ risk for almost all pregnancy related morbidities, risk of infertility, gestational diabetes, stillbirth, preeclampsia , maternal mortality, miscarriage , preterm birth, neonatal mortality and having chromosomally abnormal child 10/31/2022 48 Con`t…

49. The age of the father is also important, as there may be genetic risks to the fetus when the father is older than 55 years. However, it is important to emphasize that the increase in complication risk is modest and the majority of women over 35 have normal, healthy pregnancies. b. Reproductive: (gynecologic & obstetric) history; Recurrence risk of an adverse outcome (e.g. miscarriage, preterm birth, intrauterine growth restriction, preeclampsia, placenta previa , abruption placenta, congenital anomaly, perinatal death), history of ectopic pregnancy, c/s delivery, known uterine anomaly, 10/31/2022 49 Con`t…

50. Preventing prematurity Spacing of pregnancies Discontinue smoking preconceptionally Moderate exercise If a patient has a history of previous neonatal death, stillbirth, or preterm birth, records should be carefully reviewed so that the correct diagnosis is made and recurrence risk appropriately assessed. 10/31/2022 50 Cont …

51. The incidence of neural-tube defects (NTDs) is 0.9 % in 1000 live births , & they are second to cardiac anomalies as the most frequent structural fetal malformation. NTD is a multifactorial defect and is not influenced by maternal age, incidence in general population 1.4 to 2/1000. For a woman with a prior affected child, the recurrence risk of 3 to 5% is decreased by at least 70% and potentially by as much as 85 to 90% with periconceptional oral folic acid supplementation at a dosage of 4 mg/d 10/31/2022 51 3. History of NTDs

52. These disorders are also classic examples of multifactorial inheritance. Development of NTD may be influenced by hyperthermia, hyperglycemia, teratogen exposure, ethnicity, family history, and various genes . Selected risks are more strongly associated with the specific defect location. Hyperthermi a has been linked with anencephaly risk Pregestational diabetes with cranial and cervical-thoracic defects Valproic acid exposure with lumbosacral defects Serum screening for NTD is offered at 15 to 20 weeks 10/31/2022 52 Con`t…

53. Identifying & treating medical conditions, including; mental health issues prior to pregnancy, diabetes mellitus or phenylketonuria, or autoimmune , such as systemic lupus erythematosus DM in general population 2-3% risk of severe birth defects Normalizing blood glucose concentrations (HbA1C< 6.5%) before & early in pregnancy can; 10/31/2022 53 4. History of Maternal Medical Problems

54. ↓ the risk of miscarriage & ↓ congenital malformations due to DM (6-12%) b/c ↑4-7X than nondiabetic women. Oral anti-hyperglycemic agent may be switched to insulin during pregnancy . Referring all women with pregestational diabetes to a dialectologist For a patient with hypertension, the goal should be to control blood pressure prior to conception. 10/31/2022 54 Conti…

55. Certain agents, such as ACE inhibitors, should be avoided in pregnancy & switch to agents whose safety in pregnancy is established (e.g., methyldopa ) Asthma should be under good control prior to attempting conception. If necessary, the use of steroids (inhaled & systemic) in pregnancy is generally safe; particularly when compared with the risk of maternal acid base disturbance & hypoxemia to the fetus 10/31/2022 55 Con`t…

56. Patients with thyroid disease (hyper- & hypothyroidism) require close monitoring of thyroid function tests before & during pregnancy . A dietary supplementation of 150 mcg of iodine prior to a planned pregnancy or as soon as possible after diagnosed pregnancy; (ideally for at least 4 weeks before conception & 12 weeks after conception). For Cardiovascular disease a baseline cardiac assessment should be performed & potential pregnancy risks should be discussed 10/31/2022 56 Con`t…

57. Systemic lupus erythematosus : good prognosis pregnancy if SLE quiescent for at least 6 months prior to the pregnancy, & renal function is stable & normal or near normal. Women with inherited thrombophilia are at higher risk of thromboembolic complications during pregnancy. Heritable diseases  — For those with a positive history for a heritable disease, referral to a specialist in genetic counseling to discuss carrier testing 10/31/2022 57 Con`t…

58. Ideally , seizure control is optimized preconceptionally. The risk of seizures during pregnancy was ↓ by 50 to 70% if there were no seizures in the year preceding pregnancy. Seizure control with monotherapy & with medications considered less teratogenic . Epileptic women should be advised to take supplemental folic acid The risks of must be balanced against the risks of untreated depression 10/31/2022 58 Con`t…

59. With special attention to any abdominal or pelvic operations should be noted. A history of previous cesarean birth should include indication, type of uterine incision, and any complications. A copy of the surgical report may be informative . Allergies, particularly drug allergies, should be prominent on the problem list. 6. Infectious diseases such as urinary tract disease, syphilis, tuberculosis, or herpes genitalia should be identified. 10/31/2022 59 5. Surgical history

60. to  identify genetic risks to the fetus and maternal medical risks. Patients should be asked about family histories of Down syndrome, hematologic désordres , ( hemophilia and hemoglobinopathies), as well as mental retardation, diabetes, hypertension, tuberculosis, seizures, multiple prégnances, congenital abnormalities (NTDs, birth defects) and reproductive history should be elicited 10/31/2022 60 7. Family history:

61. Exposure to tobacco, alcohol, lead and illicit drugs can be harmful to both the mother & fetus, Cigarette: the potential teratogens in cigarette smoke are nicotine, carbon monoxide, cadmium, lead, hydrocarbon Tobacco And Women’s Health : Implicated the leading causes of death for women: Heart disease Stroke Lung cancer Lung disease 10/31/2022 61 8. Substance use

62. Tobacco and Reproductive Outcomes: Leading preventable cause of infant mortality, low birth weight and prematurity Associated with placental abnormalities Under-development of placenta Ectopic pregnancy Placenta previa Intra uterine growth retardation (IUGR) Subfertility and Cleft lip 10/31/2022 62 9. SMOKING

63. The mechanism for these adverse effects include increasing fetal carboxyl hemoglobin levels, reduce uteroplacental blood flow and leads to fetal hypoxia But tobacco use not related to increasing risk of congenital malformation However tobacco use has been associated with attention deficit, hyperactivity disorders and behavioral and learning problems 10/31/2022 63 Con`t…

64. Smoking is one of the most important modifiable causes of poor pregnancy outcomes. 15% and 29% of pregnant women smoke during pregnancy If smoking during pregnancy eliminated, estimated: 10% reduction in perinatal mortality 11% reduction in the incidence of low birth weight 10/31/2022 64 Con`t…

65. Ask every patient about tobacco use Advise them to quit Assess willingness to quit Assist them in quitting Pharmacotherapies and additional counseling each DOUBLE quit rate Arrange follow up 10/31/2022 65 SMOKING: Evidence based counseling. 5a`s

66. A . Cocaine : increase risk of congenital anomalies; ( skull defect, distraction of urinary tract development, limb defect and cardiac anomalies ), miscarriage , premature birth, lower IQ, poor language development skills B. Marijuana (cannabis): more depression/anxiety 10/31/2022 66 Con`t…