Womens Reproductive Health:

Preconception Care
Reproductive Life Planning

MODELS OF PREVENTION AND INNOVATION

What defines YOUR care?

Reproductive Life Plan

Definition
http://www.marchofdimes.com/professionals/profes

sionals.html
http://www.cdc.gov/preconception/freematerials.ht
ml
http://www.beforeandbeyond.org/?page=cme-modu
les
What are the components?

RECENT HISTORY: 1990s

ACOG published its first technical bulletin on

preconception care in 1995. In this bulletin, ACOG
recommended that routine visits by women who
may, at some time, become pregnant are important
opportunities to emphasize the importance of
prepregnancy health and habits and the advantages
of planned pregnancies.
ACOG, Technical Bulletin #205, 1995

Preconception Care
CDC National Summit on Preconception Care (2006)

4 GOALS
1. Improve the knowledge and attitudes and behaviors of men
and women;
2. Ensure all women of childbearing age in the U.S. receive
preconception care services;
3. Reduce risks indicated by a previous adverse pregnancy
outcome during INTERCONCEPTION period to prevent or
minimize future health problems for mom and children
4. Reduce the disparities in adverse pregnancy outcomes.

CDC National Summit on Preconception Care (2006): Clinical

Guidelines

CDC National Summit on Preconception Care (2006): Clinical

Guidelines

Every Woman California

http://everywomancalifornia.org/content_display.cf

m?ContentID=404&

Interconception Care CA

http://www.everywomancalifornia.org/

Preconception Visit
The counseling priorities to optimize pregnancy

outcomes are based on maternal assessments,

including.

What are the key components of this visit?

Components of Preconception Visit

(ACOG):
Family Planning and Spacing;
Family History;
Genetic History;
Med/Surg Psych and neurologic histories;
Current medications;
Substance use;
Domestic abuse and violence;
Nutrition;

Components of Preconception Visit

Environmental and occupational exposures;

Immunity and immunization status;
Risk factors for STIs;
OB and GYN histories;
PE;
Assessment of socioeconomic, education, and culture;

Sexual History.

Examples of Primary Prevention

Opportunities: Congenital Anomalies
The Opportunity:

The Potential Benefit:

Prevention of neural tube defects 50-70% can be prevented if a

woman has adequate levels of
folic acid during earliest weeks of
organogenesisbefore she
receives her prenatal vitamins
Birth Defects related to poor
glycemic control of mother
(including sacral agenesis,
cardiac defects and neural tube
defects)

Can be reduced from ~10% to 23% through glycemic control of

the woman before organogenesis

Examples of Primary Prevention

Opportunities: Congenital Anomalies
The Opportunity:

The Potential Benefit:

Minimize a prospective mothers

contact with teratogenic
exposures such as prescribed
medications, environmental
exposures and alcohol

Teratogenic substances interfere

with normal organ development
primarily during the period of
organogenesis

Advise avoiding pregnancy within one month of

receiving a live attenuated vaccine (Rubella).

MMR

(Measles, Mumps and

Rubella)
Attenuated, live viruses: do not give to
pregnant women and counsel to avoid
pregnancy for 4 weeks after vaccination

Tetanus, Diphtheria, and Pertussis (Tdap); & Tetanus

and Diphtheria (Td)
On October 24, 2012, the Advisory Committee on
Immunization Practices voted to recommend Tdap during
each pregnancy, preferably at 27 through 36 weeks
gestation.

Vaccinations:

Varicella
Influenza
Hepatitis

B
Assess for Travel Plans (immunization
review)

http://www.cdc.gov/vaccines/pubs/pregguide.htm

http://www.cdc.gov/vaccines/pubs/preg-guide.htm

HIV Screening and Treatment

Clinical Guidelines
CDC Website for Primary Care
http://www.cdc.gov/actagainstaids/provider/index.html

CDC recommends testing all patients ages 13-64

http://www.nccc.ucsf.edu/training_ta/

Review and teach safer sex to prevent HIV

infection.

CDC STI TX Guidelines 2010

http://www.cdc.gov/std/treatment/2010/

Screening and Treatment for STIs

prior to pregnancy
Review general screening protocols
http://www.cdc.gov/std/2010ebook.htm
Mantoux test with purified protein
derivative for TB

Medication Review

OCT, prescriptive and natural

remedies
Medication Review and Teratogens
Identified

www.otispregnancy.org
FDA Risk Factor Category NEW (no longer A,B,C,D, X)

Genetic Diseases
Why Screen? Prevalence and Impact
Phenylketonuria (PKU)

Genetic History /Ethnic Assessment

Sickle hemoglobinopathies (African Americans)
Beta-thalassemia (Southeast Asia, Mediterranean

dissent; African Americans)

Alpha-thalassemia (Southeast Asia, Mediterranean
dissent; African Americans)
Tay-Sachs disease (Ashkenazi Jews, French
Canadians, and Cajuns)
Canavan disease and familial dysautonomia
(Ashkenazi Jews)

Genetic History /Ethnic Assessment

Cystic Fibrosis

Frequency of 1:25 Caucasian, Ashkenazi Jewish, and Native

Americans; 1:46 Hispanic Americans; 1:65 African Americans;
1:94 Asian Americans
Information about CF screening should be available to all
clients

Screening for other genetic disorders on the basis of

family history.

Nutrition and Genetic Assessment

Neural-Tube Defects = Folic Acid supplementation

overcomes specific mutations in genes.

Folic Acid Supplementation

Need prior to pregnancy and first 12 weeks.

.4mg/day
If history, 4 mg/day

Recommendation: All women of childbearing age

should take a multivitamin supplement containing

0.4 mg of folic acid a day.

Controlling Chronic Medical Disorders

Research supports significantly better birth

outcomes with preconceptional counseling

(hypertension, renal disease, thyroid disease,
asthma, or heart disease 80% normal outcomes vs.
40% without counseling.

Chronic Medical Disorders

Diabetes Mellitus care = lowest hemoglobin A1c

level possible

Hemoglobin A1c Measurement can be used to compute risks for

major anomalies (4.6-7.6 low fourfold increase in risk with 1010.5)

Seizure Disorder
Monotherapy recommended and medications considered
less teratogenic (lamotrigine mono)
Folic Acid supplementation important in this population 4mg
per day at least one month prior to conception.

Chronic Medical Disorders

Hypothyroidism.

The dosages of Levothyroxine required for treatment of

hypothyroidism increases in early pregnancy.
Levothyroxine dosage needs to be adjusted for proper
neurologic development.

Preconception Care
TACE questions for Alcohol use assessment; non-

judgemental questioning key

Alcohol and Drug Use

Fetal toxicity is dose related; exposure time of greatest risk

in first trimester.
No established safe level of alcohol use during pregnancy.
Drug Use: Ask, Listen, Refer to Treatment Program

Smoking Cessation

Environmental Exposure
Evaluate exposure to infectious organisms and

chemicals. Assess work conditions, safety.

Encourage them to ask employers for Material Safety Data

Sheets
Consult databases for hazardous substances (Reprotox, March
of Dimes, OSHA) Refer if in doubt.
Identify ways to minimize exposure (safety precautions)

Mercury in Fish: FDA and EPA guidelines.

NEW

Mental Health
Depression Screen and Treat

Screen for symptoms of depression; Counsel for treatment and

high risk of exacerbation during pregnancy and postpartum

Domestic Abuse/Intimate Partner Violence

(upcoming lecture)

Pregnancy is a time of increased risk from an abusive partner

Preconception Nutrition
Obesity (BMI Measurements) control to reduce risks

of HTN, gestational diabetes, surgical births,

preeclampsia, postterm pregnancy, operative
delivery; also structural fetal anomalies.

Reduce weight before pregnancy

Increase weight if underweight

Nutrition Consult Key

Encourage Exercise

Preconception Nutrition
Take a nutritionally oriented history (24 hour recall)
Encourage healthy eating habits and balanced diet
Evaluate eating disorders
Evaluate anemia status
Vegetarians: assess those without animal proteins

and consider referral/supplementation

Discuss vitamins and minerals intake

Preconception to Prenatal Nutrition

How many extra calories for pregnant and

breastfeeding women?
New Guidelines for weight gain from IOM.
Cultural and International variablesASK.
Caffeine Intake Assessment.
My Pyramid Plan for Moms USDA (
http://www.mypyramid.gov/mypyramidmoms).

Nutrition
Exercise: Assess activities past and present.

Encourage regular exercise (enhance overall health

and wellbeing)
WIC Program

9.3 million women, infants, and children (under 5) each month

http://www.fns.usda.gov/wic/