Preconception and Ineterconception Care by Family Medicine Physicians

Preconception and Ineterconception Care by Family Medicine Physicians Goal of Preconception Care Preconception care aims to identify reversible risks to a woman’s health or pregnancy outcome, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact. Focus of Preconception Care Preconception care adds a different dimension to usual primary care by focusing on future pregnancy, anticipating change, and reframing issues in this light. Preconception Issues for Well Women • • • • • • • • Family planning Genetic risks: familial, ethnic, racial Nutrition and weight Tobacco, alcohol, OTC medications, illicit drugs Occupational and environmental hazards Domestic violence Infections and immunization Screening for inapparent medical disease Selected Physiologic Changes of Pregnancy • • • • • Cardiac output Plasma volume Heart rate Minute ventilation GFR Increase 40-50% 30-40% 15bpm 40% 40ml/min Common Inapparent Illnesses • • • • • Hypertension Diabetes Anemia Renal conditions Rheumatic heart disease • Substance abuse • Thyroid abnormalities • Chronic hepatitis • HIV infection • Depression Unplanned Pregnancy • Incidence of unplanned pregnancy is 49% • Usual entry into prenatal care in the 3rd month after LMP Family Medicine Practice: A Unique Setting for Preconception Care • Family medicine physicians care for women through various stages of life before, during, after and between pregnancies • Family medicine physicians treat family members of different generations Some Common Conditions Amenable to Preconception Care • • • • • Diabetes Hypertension Seizure disorder Thyroid disorders Thrombo-embolic disease • Hemoglobin disorders • STDs • Repetitive pregnancy losses • Eating disorders • Alcohol, tobacco and other drug use • Domestic violence • Poor nutrition Preconception Care When Pregnancy Is Contemplated • Consider the possibility of future pregnancy when choosing medications for female patients • Immunize teenage girls against rubella • Teaching males and females about safe sex practices and HIV prevention Case Study: New Patient • A 24 year old woman comes for a first visit to you because she is concerned about a persistent cough • History reveals she has smoked 1 pack per day since age 16 and has 1-2 alcoholic drinks on weekends • She is recently married and plans to have children soon • Her husband also smokes and drinks socially An Approach to Preconception Care • Review medical history and immunizations • Review family history for genetic disorders • Recommend 0.4mg/day of folic acid supplementation • Discuss life cycle issues -- screen for psychosocial concerns, domestic violence, readiness for parenthood • Review contraceptive options • Get to know her approach to life and how she makes decisions Alcohol Intake and Pregnancy • Fetal Alcohol Syndrome is a leading cause of preventable mental retardation • No level of alcohol consumption is considered “safe” • Advise her to abstain when attempting to conceive and during pregnancy • Assess for problem drinking with a standardized screening tool Preconception Issues and Tobacco Exposure • Smoking in pregnancy is associated with preterm delivery and low birthweight infants • Smoking in the household is associated with SIDS, childhood respiratory illness, asthma, and otitis media Case Study: An Adolescent • A 16 year old girl comes for a visit requesting completion of her working papers • She had last been seen by you two years ago • How would you approach this visit? Case Study: Diabetes • A 38 year old school principal has had Type 2 Diabetes Mellitus for 13 years • Married for 10 years, she has deferred childbearing but now wishes to conceive • She is on Glyburide for diabetes control and on an ACE inhibitor for microalbuminuria which was first noted 3 years ago Diabetes and Pregnancy • Diabetes mellitus is the most common serious disease to affect the maternal-fetal dyad • Maternal and perinatal mortality associated with diabetes has decreased over the past 50 years • The leading cause of perinatal death among women with diabetes is malformations Goals Of Preconception Care With Diabetes • To reduce the occurrence of: – diabetic complications – obstetric complications – congenital malformations Preconception Care for Women with Diabetes • Assist to achieve optimal glycemic control • Encourage the use of contraception until glycemic control is achieved • Discontinue ACE inhibitors • Educate about the need for insulin, special testing, frequent prenatal care visits Case Study: Seizure Disorder • A 22 year old woman misses her period. • Her pregnancy test in the office is “negative” • She expresses a desire to have a baby • She has been taking Dilantin since the age of 2 • She has not had any seizures during the past 5 years Preconception Care and Seizure Disorder • Epilepsy is the most common, serious neurologic problem seen in pregnancy • There is an increased incidence of congenital malformations in infants of mothers with seizure disorders • The prepregnancy period is the ideal time for maternal evaluation Goals of Preconception Care for the Woman with a Seizure Disorder • Keep the woman seizure-free • Decrease the incidence of congenital abnormalities in the infant Preconception Care for the Woman with a Seizure Disorder • Evaluate the maternal condition • Reassess the plan of treatment –Wean from anticonvulsants if possible –Utilize monotherapy if medication is needed • Supplement with folic acid • Counsel the woman about the need to adhere to the treatment plan Case Study: Medication Useage • A 22 year old woman is seen in your office for symptoms of a urinary tract infection • While taking an interval history, you learn that she is quite happy with the results of a new medication (Accutane) prescribed by her dermatologist for her acne • She is sexually active and inconsistently uses condoms for contraception Preconception Core Issue Choices Regarding Conception • Factors which may influence a woman’s decision to attempt or avoid conception: –Risk of maternal mortality and morbidity –Maternal prognosis, irrespective of pregnancy –A conflict between maternal treatment and the threat to fetal wellbeing –Extent of the risk to the infant –Optimal timing of pregnancy –Ability to conceive now and in the future Preconception Core Issue Optimizing the Maternal Condition • Diagnostic testing • Interventions to control disease processes Preconception Core Issue PATIENT EDUCATION • Need for planned pregnancy and preconception medical care • Medications and substance use • Expectations for care in pregnancy • Need for early prenatal care • Folic acid supplementation Preconception Care A National Goal “Every woman (and, when possible, her partner) contemplating pregnancy within one year should consult a prenatal care provider. Because many pregnancies are not planned, providers should include preconception counseling, when appropriate, in contacts with women and men of reproductive age….Such care should be integrated into primary care services.” USPHS Expert Panel on the Content of Prenatal Care, 1989 Preconception Care in Family Medicine Practice • Routinely discuss reproductive plans with patients • Review the basic elements of preconception care with all women • Consider the possibility of future pregnancy when making medical decisions • For each disease process, review the core issues and individualize care • Prescribe folic acid supplementation Think Preconception Care