Preconception Care and Counseling

PRE-CONCEPTION CARE AND COUNSELING

INTRODUCTION

• Concept of preconception care has evolved over the last several decades
• J.W. Ballantyne - originated 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
• Risk of maternal death in the is 1 in 10,000 live births
• Unintended pregnancy rate approaches 40% annually

COMPONENTS OF PRECONCEPTION CARE

• Risk assessment
• Education
• Intervention or modification
• Counseling

GOALS OF PRECONCEPTION CARE

• To identify pre-existing conditions that may affect an anticipated pregnancy
• This may allow for intervention(s) that could lead to more favorable outcome
• Goal should be realistic
• Identification process involves mother and fetus

CONTRACEPTION

• Good preconception care begins with appropriate contraception!!
• Should be addressed at each visit, including primary care visits, emergency room visits, and well woman appointments
• Should be appropriate as regards patient’s lifestyle and medical condition

MATERNAL RISK ASSESSMENT

• Family and genetic history (maternal and paternal)
• Medical history
• Medication use
• Environmental exposures (home and work)
• Obstetric and reproductive history
• Domestic abuse
• Emotional preparedness
• Infectious disease
• HIV
• Immunization history
• Sexually transmitted diseases

REPRODUCTIVE HISTORY

• Conditions with recurrence risk:
• Premature delivery
• Preeclampsia/eclampsia
• Placenta previa/abruption
• Gestational diabetes
• Preterm premature rupture of membranes
• Certain birth defects/genetic disorders
• Prior uterine surgery or anomalies
• Good time to discuss trial of labor
• Prior pregnancy losses
• Habitual abortion
• Must also deal with associated emotional issues

FAMILY HISTORY

• Coagulation disorders
• Mental retardation
• Other conditions (congenital adrenal hyperplasia, neurofibromatosis, inborn errors of metabolism) 

4                 Anueploidy Risk

•       Risk of any type of aneuploidy increases with maternal age
•       Offer genetics consultation
•       Important to obtain family pedigree
•       Risk increases with increasing maternal age
•        Risk of Trisomy 21 at age 35 is 1/378 and that of all aneuploidy is 1/192
•        Risk increases to 1/30 and 1/21 respectively, at age 45
•        Risk with increased paternal age probably small

RISK ASSESSMENT - MEDICAL HISTORY

• Possible effects of pregnancy on disease
• Possible effects of disease on pregnancy, mother and fetus
• Evaluate for any possible interventions
• Assess for possibility of teratogenic effects of medications
• Evaluate for presence of microvascular disease and level of glucose control
• Frequency of malformations 6-10 %
• Periconceptual control can significantly decrease malformation rate
• Hemoglobin A_1C crude marker of glucose control/ ? Association with anomaly rate
• Hypertension - assess for microvascular disease, severity, underlying etiology
• Hyperthyroidism
• Hypothyroidism
• Previous treatment for cancer
• History of organ transplantation

RISK ASSESSMENT - MEDICAL HISTORY

• Connective tissue disorders
• Hematological disease 
•  Inflammatory bowel disease
• Asthma
• Neurological and psychiatric disorders

SPECIAL RISKS

• Primary Pulmonary Hypertension
• Chronic Renal Disease
• Complicated coarctation of the aorta
• Sever mitral or aortic stenosis
• Vasculitis syndromes

RISK ASSESSMENT - IMMUNIZATIONS

• Rubella - should wait 3 months before conceiving
• Hepatitis B
• Tetanus
• Mantoux skin test
• Influenza, pneumovax as indicated
• Varicella

RISK ASSESSMENT - STD’S

• Assess for high risk behaviors and counsel appropriately
• HIV - treatment can decrease transmission to fetus from 30% to 8%
• Gonorrhea
• Chlamydia
• Trichomonas
• Bacterial Vaginosis - presence associated with increased risk of premature labor and delivery
• Group B beta streptococcus - ?
• HPV - human papillomavirus/PAP/possible colposcopy in select cases/neonatal infection possible
• HSV - as indicated
• congenital syphilis can occur at any stage of maternal disease
• Toxoplasmosis - cat owners or if handle raw meat
• Cytomegalovirus

SOCIAL HISTORY

• Illicit substance use and abuse major public health problem
• Alcohol
• Most common preventable cause of mental retardation
• No proven safe level of ingestion
• Tobacco use
• Associated with numerous pregnancy complications
• One of most common preventable cause of fetal growth restriction
• Increased risk of other health problems
• Illicit drug use
• Usually associated with other high risk behaviors
• Possible teratogen
• Increased pregnancy complications
• Associated with sudden death, infarction, hypertension
• Prescription drug dependency
• Evaluate for life stressors that may predispose to substance abuse
• Encourage counseling and rehabilitation prior to pregnancy
• May have co-existing psychological disorders
• Seen in all social classes

DOMESTIC VIOLENCE

• Incidence of abuse increases during pregnancy
• Physicians do a poor job of screening
• Look for: vague complaints; substance abuse; insomnia; injuries to central body areas; multiple ER visits
• Develop emergency plan/referral numbers

TERATOGENS

• Evaluate home environment
• Work exposure (plastics, vinyl monomers, heavy metals, viral agents)
• Medication or drug use
• Alcohol - fetal alcohol syndrome
• ACE - inhibitors - fetal renal dysfunction
• Coumarin derivatives - effects seen in up to 25% exposed
• Tegretol - craniofacial abnormalities; limb defects; growth and mental retardation
• Dilantin - fetal hydantoin syndrome
• Valproic acid - neural tube defects (1-2%)
• Lithium – congenital anomaly
• Tetracycline - deposition in fetal long bones
• Vitamin A derivatives - associated with numerous severe defects;
• X-Rays/radioactive isotopes
• DES - reproductive tract abnormalities
• Folic acid antagonists
• Thalidomide - limb defects
• Should consult specialist, poison control center or teratogen centers
• Some medications have different safety periods between cessation and conception

NUTRITIONAL ASSESSMENT

• Assess optimal nutritional needs
• Risk factors
• Low income
• Substance abuse
• Fad dieting/vegans
• Depression/mental illness
• Gastrointestinal disease
• Chronic disorders
• Must also assess for existence of eating disorders
• Folic acid supplementation beginning one month prior to conception can greatly reduce incidence of neural tube defects
• Utilize nutritionist for full evaluation
• Obesity
• Adolescence
• Pre-existing conditions - iron deficiency anemia, hyperlipidemia
• Evaluate exercise regimen

FINANCIAL AND EMOTIONAL CONCERNS

• Couples should be aware of maternity coverage provided by their insurance
• Leave benefits
• Stress importance of good family support
• May consult social services
• Emotional issues addressed

SUMMARY

• Thorough history taking
• Complete physical exam
• Necessary consultations
• Counseling
• Instruct on accurate menstrual history and on contraception
• Necessary laboratory evaluation
• Adequate preconception counseling can decrease risk of pregnancy complications
• Education can lead to healthy habits and realistic expectations
• Can lead to more efficient and less costly pregnancy care

REFERENCES

1. Adams EM, Bruce C, Shulman MS et al:  The PRAMS Working Group: pregnancy planning and preconception counseling.  Obstet Gynecol 82:955, 1993.
2. Moos MK, Cefalo RC:  Preconceptional health promotion : A focus for obstetric care.  Am J Perinatol 4:63, 1987.
3. MRC Vitamin Study research Group : Prevention of neural tube defects: results of the Medical Research Council Vitamin Study.  Lancet 338:131, 1991.
4. Resources: Reproductive Toxicology Center; Obstetrical textbooks