Laura Tatpati, MD KUMC - Wichita Dept of Obstetrics and Gynecology

Preconception care
Laura Tatpati, MD
KUMC - Wichita
Dept of Obstetrics and Gynecology
No disclosures
Objectives
Understand the general importance of preconception care
Discuss the concept of a Reproductive Life Plan
Be able to define areas of concern for preconception care
Health promotion
Nutrition
Exposures
Substance abuse
Environmental
Medical/Psychiatric conditions & medication
Reproductive History
Family & Genetic History
Vaccination counseling
ID
Psychosocial risk
Special populations
1/2 of all pregnancies are
unintended
The challenge of preconception care lies not only in
addressing pregnancy planning for women who seek
medical care and consultation specifically in
anticipation of a planned pregnancy but also in
educating and screening all reproductively capable
women on an ongoing basis to identify potential
maternal and fetal risks and hazards to pregnancy
before and between pregnancies
ACOG Committee Opinion
Number 313, September 2005, reaffirmed 2012
Timing is everything
Vulnerability
Begins from 17-56d post-conception
Goals
Screen for risks
Recommend intervention
Promote health & provide education
(the non-judgemental)
Reproductive Life Plan
Do you plan to have any (more) children at any time in your future?
How many children would you like to have?
How long would you like to wait?
<6 mo btwn birth and conception assoc w/ LBW, PT & SGA; >
60mo incr PT & Very SGA
What family planning method do you plan to use until you are
ready?
Unintended: Method failure (5%); imperfect use (43%); no
contraception
Preconception care topics
Health promotion
Weight Status
Physical Activity
Nutrient Intake
Folate
Substance Use
STIs
Exposures
Weight status & Physical Activity
Weight Status
Near-normal BMI is ideal
Address disordered eating and variants
Malnutrition with obesity and anorexia
Counsel obesity risks: difficulty with conception, birth defects, GDM, C/S, Htn disorders,
thromboembolic event, preterm delivery
Physical Activity
Advise for uncomplicated 30min daily exercise most days of week
Review for healthy behaviors
Insulin resistance - increasing evidence for enhanced benefit peri-prandially
Health promotion
Nutrition
Eating disorders are more likely if:
Hx of eating disorder, body distortion endorsement, unusual
eating habits
Substance abuse hx
Hx pica in prior pregnancy
High parity
Mental illness
Bariatric surgery hx - vitamin absorption and B12 production
issues
Health promotion
Vitamins & Supplements
Folic acid
400mcg daily routine & 4mg daily for high risk groups
Initiate 1 mo prior to conception
NTD risk reduction; Cong heart disease and cleft lip/palate
Vitamin over-usage
What is the single day dose for their brand?
No “mega-dose” vitamins (particularly KADE)
Dietary Supplements - avoidance
Suggest consideration of intake of calcium, iron, Vit D, Vit A, Vit B12 and note
that Vit C enhances the absorption of iron
Health promotion
Substance Use/Abuse
Tobacco
5-A tool
Ask about use, Advise to quit, Assess willingness, Assist, Arrange f/u &
support
1-877-44U-QUIT
Pharmacotherapy/Refer back to PCP
Alcohol
Address use/misuse & unintended usage during pregnancy
Recreational and Prescription Drug Use/Abuse
Health promotion
Exposures
Environmental/Hobbies
Paucity of screening tools and interventions that
are rigorously evaluted
Discuss food safety & toxin exposure avoidance
Medications
Lowest effective dose of only necessary
medications
Address known teratogens and lack of safety data
Health promotion
Personal & Family Medical History
Reproductive
Prior Cesarean Delivery
Prior Miscarriage
Prior Preterm Birth
Known Genetic Conditions (self, child or
close family member)
Pre-pregnancy screening coverage???
Consideration of PGD for FH single
gene defects
Prior Stillbirth
FH MR/Autism/FXTAS
Uterine Anomalies
Ethnic based
Hemoglobinopathies
Ashkenazi Jewish panel
Cystic fibrosis
Personal & Family Medical History
Infectious Diseases
STI including HIV
Chlamydia - annually prior to
25 and p.r.n. in at-risk > 25
Hepatitis A
Hepatitis B (if high risk)
Rubella (confirm immunity or
document MMR)
Varicella (history of illness or
vaccination)
Hep C
Cytomegalovirus
Herpes Simplex Virus
Listeriosis
Malaria
Syphilis
Toxoplasmosis
Tuberculosis
Personal & Family Medical History
Immunizations
Avoid conception x 1 mo post-live virus vaccination
Ideal to complete others prior as well to avoid exposures, although no documented
issues
Flu: Inactivated flu vaccine (no mist)
Tdap: Offer vaccination (this will be repeated in pregnancy)
Rubella - screen for IgG (some do not convert)
Varicella - Historical screen
At risk populations - Hepatitis screen/vaccinate; Meningococcus, Pneumococcus
HPV - if not completed, recommend; hold completion until after pregnancy prn
Personal & Family Medical History
Medical conditions
Conditions and fetal and maternal risks
of pregnancy
Medications and risks of teratogenicity
or pregnancy associated complications
Action plan for pregnancy for
exacerbation or monitoring
Consideration of MFM &/or IM
specialist pre-pregnancy consultation
Hx of Bariatric Surgery
Cardiovascular Disease
Diabetes Mellitus
Eating Disorders
Hypertension
Lupus
Morbid Obesity
PKU - low phenylalanine diet
Psychiatric Conditions
Renal Disease
Rheumatoid Arthritis
Seizure Disorders
Thrombophilia
Thyroid Disease
Asthma
Personal & Family Medical History
Psychosocial Risks
Access to Care
Inadequate Financial Resources
(transportation/housing)
Safety (domestic violence assessment)
Special populations
Disability
Immigrant and Refugee Populations
Survivors of Cancer
Resources
http://www.acog.org/Resources-AndPublications/Guidelines-for-Perinatal-Care
cdc.gov - preconception care