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PRECONCEPTION CARE

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Improving infant health requires focus on the entire spectrum of ... Rubella & varicella immunization. Narcotic detoxification. Certain radiological procedures ... – PowerPoint PPT presentation

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Title: PRECONCEPTION CARE


1
PRECONCEPTION CARE
  • CityMatCH Conference
  • September 13, 2004
  • Janis Biermann, M.S.
  • jbiermann_at_marchofdimes.com

2
Preconception Care
  • Greater New York Chapter of the
  • March of Dimes
  • Preconception Care Curriculum Working Group
  • Albert Einstein College of Medicine/Montefiore
    Medical Center
  • www.marchofdimes.com/prematurity/5195_5785.asp

3
The Continuum of Reproductive Health
  • Improving infant health requires focus on the
    entire spectrum of reproductive health
  • Beginning before conception
  • Continuing through the first year of life
  • Extending throughout the womans childbearing
    years

4
Preconception Care
  • Identifies reducible or reversible risks
  • Maximizes maternal health
  • Intervenes to achieve outcomes

5
Preconception Care
  • Reframes issues
  • Adds an anticipatory element
  • Focuses on the impact of pregnancy

6
Elements of Preconception Care
  • Focus on elements which must be accomplished
    prior to conception or within weeks thereafter to
    be effective
  • Risk assessment
  • Education Health Promotion
  • Medical and psychosocial interventions

7
Components of Preconception Care
  • Medical history
  • Psychosocial issues
  • Physical exam
  • Laboratory tests
  • Family/genetic history
  • Nutrition assessment
  • Occupational/environmental risk assessment

8
Risk Assessment
  • STD Prevention
  • Genetic issues
  • Domestic violence
  • Substance abuse
  • Alcohol
  • Tobacco
  • Illicit drugs

9
Environmental Teratogens
  • Exposures
  • Home, workplace, environment
  • Physical/chemical hazards
  • ionizing radiation, lead, mercury, hyperthermia,
    herbicides, pesticides

10
Health Education Promotion
  • Smoking Cessation counseling 5As
  • Folic Acid
  • Genetic Counseling
  • Dietary and Nutritional Advice

11
Conditions that Need Time to Correct Prior to
Conception
  • Optimal weight
  • Optimizing choice and use of medications
  • Substance use/abuse
  • alcohol
  • tobacco

12
Some Medical ConditionsAmenable to Preconception
Care
  • Diabetes Mellitus
  • Hypertensive Disorders
  • Cardiac Disease
  • Thyroid Disorders
  • Epilepsy
  • Asthma
  • HIV Infection
  • Systemic Lupus
  • Thromboembolic Disease
  • Renal Disease
  • Hemoglobinopathies
  • Cancers

13
Intervention Usually Not Undertaken During
Pregnancy
  • Rubella varicella immunization
  • Narcotic detoxification
  • Certain radiological procedures
  • Thyroid ablation with radioactive iodine

14
Interventions considered because pregnancy is
planned
  • Correction of mitral stenosis
  • Switching from oral hypoglycemics to insulin and
    achieving tight glucose control in patients
    with diabetes mellitus
  • Evaluation of anticonvulsant therapy

15
Factors That Could Change Timing Of Or Choice To
Conceive A Pregnancy
  • Domestic violence
  • Birth spacing
  • Genetic disease
  • Diseases with poor prognosis (e.g. AIDS)
  • Diseases dangerous in pregnancy (e.g. CHF)
  • Conflicts between needed maternal care and fetal
    well-being
  • Recurrent Pregnancy loss

16
Does Preconception Care Work?
  • Outcomes Impacted
  • Fetal/Infant mortality and morbidity
  • Maternal mortality and morbidity

17
Historical Perspectives
  • 1979 PHS Primary Care Effectiveness. An
    approach to clinical quality assurance in BCHS
    Programs and Projects
  • 1985 IOM Preventing Low Birth Weight
  • 1989 Public Health Service Expert Panel on the
    content of Prenatal Care
  • 1991 USPHHS Healthy People 2000 - National
    Health Promotions and Disease Prevention
    Objectives
  • 1993 March of Dimes towards improving the
    outcome of pregnancy report
  • 1993 Alan Guttmacher Institutes Issues in
    Brief The nation will be well-served by making a
    commitment to advance preconception services to a
    similar extend as it has prenatal care.
  • 1996 Guide to Clinical Preventive Services
  • 1997 AAP ACOG Guidelines for Perinatal Care

18
Prevention of Birth Defects
  • Optimal glycemic control
  • No alcohol consumption
  • Preconception rubella immunization
  • Folic Acid supplementation

19
Goals of Preconception Carein Diabetes
  • To reduce the occurrence of obstetric and
    diabetic complications
  • To decrease the incidence of congenital
    abnormalities
  • Reduce risk of spontaneous abortions

20
How To Accomplish These Goals?
  • Education about need to change diabetes
    medication regimen ie substitute insulin for oral
    hypoglycemics
  • Optimal glycemic control achieved by home
    monitoring, multiple daily injections, adjustment
    of insulin, close supervision and education
  • Postpone conception until control is achieved
  • Reassess modifiable risks before conception by
    assessing end organ damage, retina, kidney,
    vasculature, heart, nervous system

21
Alcohol
  • Leading preventable cause of mental retardation
  • Most common teratogen to which fetuses are
    exposed
  • Effects related to dose
  • No threshold has been identified for safe use
    in pregnancy
  • Effects at all stages of pregnancy

22
Rubella Vaccination
  • Determine rubella immunity prior to conception
  • Vaccinate susceptible nonpregnant women
  • Congenital rubella syndrome may result from
    infection during pregnancy (microcephaly, fetal
    growth restriction, cardiac malformations, etc)

23
Prevention of Neural Tube Defects
  • Supplementation for all women of childbearing
    potential with folic acid
  • No history of NTD 0.4 mg. qd
  • Prior infant with NTD 4.0 mg. qd
  • Woman with NTD 4.0 mg. qd
  • Nutritional sources often inadequate

24
Barriers to Preconception Care
  • Patient Aspects
  • High rate of unintended pregnancies
  • Ignorance about importance of good health habits
    prior to conception
  • Limited access to health services in general.

25
Barriers To Preconception Care
  • Provider Aspects
  • Feeling of having inadequate knowledge
  • Perception of preconception care being
    time-consuming
  • Concern about insurance reimbursement.
  • Lack of awareness of how to integrate
    preconception care into ongoing primary care

26
Eligible Patients Seen for Preconceptional
Care Physicians (2002) vs. Other Providers (2003)
Mean Seen for Preconceptional
Visit Providers-2003 22 MDs-2002 20
Percentages are net of 108 physicians (2002) and
55 non-physician providers (2003) who do not
provide prenatal care.
27
Issues Addressed at Annual Well-Woman Exam
Physicians (2002) vs. Other Providers (2003)
Which issues do you always, usually,
occasionally, or never address at an annual
well-woman exam with a woman of reproductive
age, that is, under age 45? Statistically
significant difference between physicians and
non-physicians in always.
28
Reasons Providers Dont Always Recommend Folic
Acid or Multivitamins Physicians (2002) vs.
Other Providers (2003)
Responses were categorized from verbatim
comments. Statistically significant difference
between all physicians vs. all non-physician
respondents.



29
Other Barriers To Preconception Care
  • Availability of contraceptives
  • Health Insurance Coverage
  • Out of Pocket Expenses.

30
Who Should Get Preconception Care
  • 49 of pregnancies in the US are unintended
    (unwanted or mistimed) - Henshaw. 1988.
  • Preconception care should be provided to all
    reproductive age individuals

31
Preconception Care for Men
  • Alcohol
  • may be associated with physical and emotional
    abuse
  • may decrease fertility
  • Genetic Counseling
  • Occupational exposure
  • lead
  • Sexually transmitted diseases
  • syphilis, herpes, HIV

32
WHO TO PROVIDE
  • Health Care Providers
  • OB-GYNs, Pediatricians, Family Medicine,
    Internists,
  • Nurses, Nurse Practitioners, Nurse-midwives
  • Genetic Counselors
  • Health Educators

33
When Should Preconception Care Be Offered
  • As part of routine health maintenance care
  • At a defined preconception visit
  • For women with chronic illness

34
How Preconception Care can be Integrated into
Practice
  • As part of any routine medical visits
  • Episodic visit for any common complaints
  • Negative pregnancy test - an opportunity for
    preconception care
  • Family planning encounter
  • Infertility evaluation
  • Following a poor pregnancy outcome

35
Preconception Care
  • Primary Prevention
  • Essential to March of Dimes Mission to prevent
    birth defects and infant mortality

36
March of Dimes Products/Resources
  • Consumers
  • Pregnancy and Newborn Health Education Center
  • marchofdimes.com
  • nacersano.org
  • e-preconception newsletter (Spanish)
  • comenzando bien
  • Are You Ready?
  • Think Ahead for a Healthy Baby
  • Folic Acid brochures
  • Pre-Pregnancy Planning Fact Sheet

37
March of Dimes Products/Resources
  • Providers
  • marchofdimes.com
  • Preconception Health Promotion A Focus for
    Womens Wellness nursing module
  • Upper Hudson Prenatal Services
  • Preconception Screening and Counseling Tool
  • Chapter grants

38
Preconception health promotion is the
cornerstone of healthy infants, children,
families and communities
39
(No Transcript)
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