This is a recording of a webcast titled Guideline for Preconceptions and Interconceptionm Care given by Dr. Anna Kelly on October 18, 2010. Hello, thanks for joining us. We presented this Guideline in October of 2010 and now want to make it available to providers throughout the state at their own schedule. So, hopefully this is a topic that will be of interest to providers from a variety of backgrounds. This is not something that’s just for OBGYNs but, also, as you’ll see, is of importance to anyone who provides care.
For women of reproductive age. My name is Dr Anna Kelly. I’m an OBGYN by training, in private practice, currently. But I am the cochair of the Colorado Clinical Guidelines Collaborative now known as HealthTeamWorks, and their Preconception and Interconception Care work group. I also work with Healthy Women Healthy Babies running their Preconception Care working group. We need to thank the Colorado Department of Public Health and Environment for providing a grant that allowed us to write these guidelines in collaboration with HealthTeamWorks and in particular with the assistance of Thea Carruth, MPH with HealthTeamWorks.
So, without further ado, let’s move on to the reason for production of these guidelines. We want to outline why preconception health care is critical to improve birth outcomes in Colorado, and we’ll review this newest HealthTeamWorks guideline. In addition we’ll discuss, to some extent, what future steps will be taken to assist in the implementation of this guideline. Preconception care is not a new concept. We’ve known for centuries that the health of a mother directly impacts the health of her child. However, in the last 30 to 40 years, we’ve expanded on this.
Guidelines to Reduce Infant Mortality and Improve Infant Health Through Preconception Health Care
Knowledge with direct studies and data that confirms numerous individual interventions that can affect the outcome of that pregnancy. Between the years of about 1960 to 1980, infant mortality rates in the United States dropped significantly from about 26 per thousand to about half that, 12.6 per thousand. Again the infant mortality rate dropped between 1980 in 2000 from the 12.6 per thousand to about 6.9 per thousand. However, since the year 2000 we’ve kind of plateaued at about 6.9. And if we look at infant mortality rates throughout the developed world, the United States is essentially at the.
Bottom of the list. We do worse currently even than Cuba. Why did these improvements happen Primarily in the ’60s to ’80s, with improvements in delivery techniques and family planning. From 1980 to 2000 we did have further improvements in access to prenatal care for lowincome women as well as new technologies for premature and verylow birth weight babies. So what’s happened since 2000 that we’ve not kept up with improvements that have been seen in the rest of the developed world If we look at causes of infant mortality, we see on this.
Screen that birth defects are approximately half of the infant mortality rate. If we add prematurity risks, including the risk of RDS, that makes up almost the other half of infant mortality rates. There are few that are due to maternal pregnancy complications and SIDS. But to tackle infant mortality, the biggest categories would be to impact birth defects and prematurity. Infant mortality is just the tip of the iceberg, however. All of the same risk factors that affect infant mortality rates also are going to affect the health of that baby, long.
Term, if that baby does survive. So, the same factors that cause infant mortality also increase the risk of other poor birth outcomes. So in order to impact low birth weight, prematurity issues and birth defects, we need to change the paradigm. The first few weeks after conception are the most vulnerable for the fetus and for the placenta. We know that the organ systems are all essentially in place by ten weeks of development, and therefore in order to prevent congenital malformations, we need interventions that happened prior to that ten week timeline.
Also the placenta is laying down its primary vascular structure, so alterations in the placenta also affect its function for the remainder of the pregnancy. Here we see a table that lays out the critical periods of fetal development, and you can see on here that the central nervous system and heart are essentially present and in place by 8 to 9 weeks, arms, eyes, and legs, by 9 to 10 weeks teeth, pallet, external genitalia and ear by about 11 to 12 weeks. So, how do we change the paradigm.
Well the old paradigm was intense focus on the pregnant women from about 12 weeks until she delivered, and then very little concern until her next pregnancy. But you can see from the prior slide that by that time it’s too late to impact congenital malformations. So the new paradigm has to be to improve primary health care for women during their childbearing years, complementing prenatal care. And we need to emphasize good health for adult women and earlier interventions for those with chronic health conditions and risks, thereby having the woman enter into.
Pregnancy in a healthier state. So we have developed this Preconception Care Guideline with the assistance of HealthTeamWorks, with funding from the Colorado Department of Public Health and Environment. These are risk factors and screening methods that have been known for years to individually impact a woman’s health, and the improved pregnancy outcome. But this is the first time nationally that the risk factors have been grouped together in a simple, easytouse manner for all providers of care for women of reproductive age. The guidelines were developed based on the Center for.
Disease Control and Prevention, published in December of 2008 by their Select Panel on Preconception Care. This is an overview of the front page of the guideline, and of the back page. And you can see that it’s quite involved. There’s a lot of information on these two pages, front and back. But I’m going to go through them individually and you’ll see that the flow is relatively easy once administered in the clinical setting. So, why did we choose this as a topic for a new guideline Why should women, from menarche to menopause, have.
Preconception screening Well as we just learned, most of the fetal organs and placental vessels are in place and developing prior to the first prenatal visit. Therefore, many interventions to prevent birth defects and adverse outcomes have to happen before early pregnancy to be effective. Well, unfortunately, in the United States, half of all pregnancies in the United States are unplanned. And so we need to utilize other opportunities to intervene with these women of reproductive age. Therefore, we would like this tool to be used on women when they come in for other health care visits, whether it be for.
Routine annual visit with her OBGYN, or with an internist, or a family practitioner, potentially even with physicians in other subspecialty areas. Any interaction with the health care field could be seen as an opportunity discuss a woman’s health as it may relate to a possible pregnancy. Therefore, our screening question is Has the patient had a hysterectomy or other permanent sterilization If she has and can’t get pregnant, there are other prevention initiatives that can be administered and HealthTeamWorks has a prevention guideline to deal with these. However, if the woman has not had a hysterectomy or other.
Permanent sterilization, she is a possible candidate for these screening questions. She could potentially get pregnant. And so, contraceptive options should be discussed with her, but also she should go through the screening tool that we’re presenting. So, we’ve divided up the guideline into screening factors that should be administered to any woman who could potentially get pregnant on the front page, and on the back page are specific screening and interventions that can be done in women with specific chronic health conditions. So the first on our list of interventions for all women of.
Reproductive age who can potentially get pregnant is folic acid. All women should take a multivitamin containing 400 micrograms of folic acid daily. This one step, in and of itself, could reduce severe congenital anomalies by nearly half. And it’s critical that this intake of folic acid be prior to conception, because as we saw, the neural tube development is essentially complete by four weeks after conception, or six weeks after the last menstrual period. One exception to this rule is that women with a seizure disorder or a history of a previous baby with a neural.
Tube defect needs to take approximately 10 times the amount of folic acid daily, so 4 milligrams per day. The next on our list of interventions in all women of reproductive age is to address body weight. We use Body Mass Index as our scale to organize our interventions. First of all, underweight women who have a BMI of 18.4 and below should be assessed for eating, malabsorption and endocrine disorders. We also should counsel those patients that they’re at risk for an IUGR infant. Overweight patients, who have a BMI between 25 and 30,.
Should be offered specific strategies to decrease their caloric intake and increase their physical activity. Overweight patients who also have one additional risk factor for diabetes, need to be tested with a fasting blood sugar, or a two hour oral glucose tolerance test. The additional risk factors, listed here, include physical inactivity, a family history of diabetes, any history of hypertension or coronary vascular disease, a dyslipidemia, a history of gestational diabetes or previous ninepound baby, or any other signs or symptoms of insulin resistance, such as polysystic ovary syndrome. Also highrisk ethnicity groups, essentially any group.
Other than Caucasian, needs to be screened for diabetes if they are overweight. We know that overweight patients who have a BMI 30 and above are at much higher risk for Cesarean section, approximately three times the average population. A BMI of 40 and above puts them at quadrupole risk for Csection. Also, if they are obese, they are at risk for hypertension during the pregnancy, as well as just gestational diabetes, as well complications at the incision if they do need a Csection. Our next risk factor that we screen and need to intervene.
For prior to pregnancy is smoking. So the current recommendation is to ask if they currently smoke or use any form of tobacco, advise that they can improve the health of the pregnancy, and then refer to the QuitLine or other communitybased resources. With this single intervention, if we could have smoking eliminated we would reduce infant mortality by 10 percent. Smoking’s also associated with an increased risk of miscarriage, premature rupture of membranes, preterm delivery, abruption, intrauterine fetal demise, low birth weight, and SIDS. It actually accounts for the highest proportion of.
Preventable problems in pregnant women. Next on the list is alcohol and drugs. To screen for this we should ask When was the last time you had more than three drinks in one day And a positive is if they have done that in the past three months. You also should ask How many drinks do you drink per week A positive is more than seven. Also asking regarding any drugs other than those required for medical reasons. A brief intervention would be to address the hazardous or harmful use of alcohol and drugs and refer for more.
Intensive treatment. Contraceptive options should be discussed and pregnancy should be delayed until the individuals are alcohol and drug free. Alcohol is considered a teratogen, and no amount of alcohol is considered safe during pregnancy. Fifth on our list is chlamydia. The CDC currently recommends that sexually active women be screened annually if they are under 25 , and highrisk women should be screened ongoing annually. STDs and other infectious diseases should be screened for in women at risk. The definitions of atrisk women can be found in the USPSTF definitions.
As a side note, you will see on the screen here that many of these risk factors have asterisks next to them. This indicates that HealthTeamWorks has a separate guideline that can be accessed on the Web, on the Internet, on their website, simply by tapping on the intervention. Immunizations this should be available, generally, in a health intake form, and women should be up to date for all immunizations, in particular for rubella, varicella, Tdap, HPV and Hepatitis B. Psychosocial Risks. A simple screen for this would be to ask Over the past two.
Weeks have you felt down, depressed or hopeless And over the past two weeks, have you felt little interest or pleasure in doing things If the answers to these are yes, there is available a validated screening tool, such as the Edinburgh Postpartum Depression Scale, or the PHQ9, which can further delineate the risks. Also it’s important to ask, does a patient feel safe in her home environment If no, or ambivalent, she should be referred to the Colorado Coalition Against Domestic Violence, a safehouse andor law enforcement. Finally, all women should be screened as far as their.
Reproductive history. If they have a history of preterm delivery, stillbirth, or recurrent pregnancy loss, or uterine anomaly, they should be evaluated for modifiable risk factors. Women with a prior Csection should be counseled to wait at least 15 months before their next conception, i.e., two years before their next delivery. There has been some recent evidence that if deliveries are closer than two years, that there is possibly an increased risk autism. Also women with a history during their pregnancy of gestational diabetes should be screened postpartum, and also every one to three years with a twohour Oral Glucose.
Tolerance Test. Family and genetic history can be touched on assessing for genetic disorders, or congenital malformations that may run in the family. There is a complete list on the March of Dimes checklist if you’re interested in that. And then environmental and occupational exposures a brief question about the women’s occupation, and whether she’s possibly exposed to soil or water hazard concerns, can be referred to the local health department for soil and water testing, or to occupational medicine specialists for modification of exposures. If she has specific chronic health conditions or.
Psychiatric issues, the back page will deal with these for appropriate testing, counseling and treatment. So, our front page is basically organized according to risk factors from most common, including folic acid, to least common issues, with environmental and occupational exposures. We organized it that way hoping that providers could at least get through the first few on the list, and probably address the majority of issues that can impact a pregnancy. The back page, I’ll move on to, just briefly, deals with specific chronic health conditions that have more involved testing and interventions, and may need.
Referral to a specialist for treatment. The first on this list is women with a history of asthma. As you’ll see, there is also a separate HealthTeamWorks Asthma Guideline that can be accessed. Women with poor control of their asthma should use contraception until it is wellcontrolled. We divided the back page into four columns. The first column is what to say when counseling women with this particular condition. The second column is any specific testing that needs to be done for that condition. The third column is any medications that might be.
Contraindicated. And the fourth is what contraceptive methods are considered safe in women with these particular conditions And we addressed it looking at it from the positive aspect of what you can use, rather than from the negative aspect of what you cannot use, hoping to offer some positive options. I’ll just briefly go through these. We address cardiovascular disease, in particular women with potential lifethreatening risks, such as pulmonary hypertension. Contraception needs to be strongly recommended when pregnancy is contraindicated. Again, some contraindicated medications are ACE inhibitors and Coumadin beyond six weeks of gestation, and so this.
Woman may need to be switched to a medication that’s more compatible with the possibility of getting pregnant. We listed several safe contraceptive methods including Copper IUD, sterilization, Levonorgestrel, IUD, et cetera. Some women may need to be counseled to avoid estrogencontaining methods. Depression I’m going to let you look at this separately on the guideline. Diabetes Here the thing that should be mentioned is that uncontrolled diabetes has a threefold risk of increased birth defects, which can be reduced to normal risk with good glycemic control. So this is a positive message to women with diabetes.
Good control is considered a hemoglobin A1C of less than 6.5. Until that time, she should use effective contraception. HIV can be lifethreatening to the infant and so women who are at risk should be screened. There are medications that can reduce the risk of transmission to the infant, but none reduce the risk below about 2 percent. All contraceptive methods are considered safe in women who do not have AIDS, and concomitant use of condoms, obviously is strongly recommended. Hypertension conveys some specific risks in pregnancy and here we’ve listed again specifically ACE inhibitors.
Are contraindicated in women who can potentially conceive. Obesity we discussed a little bit earlier with screening for diabetes. A woman should use an effective contraceptive method until ideal body weight is achieved, and specific strategy should be offered to decrease caloric intake and increase physical activity. If a patient has had bariatric surgery, she needs to avoid pregnancy until weight stabilization, and then at least approximately one to two years after her surgery before conceiving. She obviously should also be screened for diabetes. Weightloss medication should not be used during pregnancy.
Renal disease Again, similar to cardiovascular disease, contraception should be strongly recommended for those who do not desire a pregnancy. Seizure disorder There are potential harmful effects of certain seizure medications on pregnancy, and patients should take four milligrams of folic acid per day for at least a month prior to conception. Contraindicated medications in particular include valproic acid, or Depakote. All methods of contraception are safe, although certain anticonvulsants may decrease the levels of steroid hormones, and so decrease their contraceptive efficacy. Lupus and rheumatoid arthritis Probably the one thing to mention here is that all progesteroneonly methods.
Are safe, including IUDs. Thyroid disease One note here is that TSH ideally should be less than 3 prior to pregnancy simply because the demand for thyroid hormone increases rapidly during the first trimester of pregnancy, so a patient who is on thyroid replacement needs to be well within the range of adequate replacement prior to conception. Thyroid hormone is particularly important for development of the neural tube and ongoing neural development of the infant. We’ve listed a few other common health conditions that really do not impact pregnancy, just more as a.
Reassurance uterine fibroids, tension headaches, fibrocystic breast disease, or family history of breast cancer, and age greater than 35 years. Really, the patient can be reassured that these conditions generally do not affect pregnancy. If the patient has a history of ectopic pregnancy, she should simply be advised to seek care immediately after conception to confirm the pregnancy is indeed in utero. These are a few other medical conditions. Obviously we couldn’t do a comprehensive list. We listed the more common chronic health conditions, but these conditions in particular may need special counseling or.
Intervention. We did list at the bottom of the guideline a contraception key, so that when you go through the fourth column there that lists safe contraceptive methods, you can see what the abbreviations are applying to. And then if there are any further questions on the guideline, you can contact Thea Carruth, who’s the guidelines project manager with HealthTeamWorks, and her phone number’s listed here, as well as reaching her on her website with HealthTeamWorks. This guideline will be updated periodically, probably annually for any further information that is found and.
Any new interventions that are recommended. So we hope that this guideline will be helpful in the clinical setting. There’s a fairly easy flow chart and comprehensive review of a woman’s health prior to her conceiving. And again, because only 50 percent of women plan their pregnancy in the United States, this screening tool should be administered to any woman who can potentially conceive, anywhere from menarche to menopause, and probably most conveniently, at an annual health exam. If you have any other questions, please let us know, and we hope that this presentation has been helpful.