Post on 31-Mar-2015
Improving Preconception Health &Healthcare in Tulsa
Michael C. Lu, MD, MPHAssociate Professor
Department of Obstetrics & GynecologyDavid Geffen School of Medicine at UCLA
Department of Community Health SciencesUCLA School of Public Health
Tulsa, OklahomaOctober 11, 2011
Why Preconception Care?
Why Preconception Care?
Early prenatal care is too late.
When Does the FetalHeart Begin to Beat?
Early Prenatal Care Is Too LateTo Prevent Some Birth Defects
The heart begins to beat at 22 days after conception The neural tube closes by 28 days after conception The palate fuses at 56 days after conception Critical period of teratogenesis – Day 17 to Day 56
Early Prenatal Care Is Too LateTo Prevent Implantation Errors
Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400-8.
The Role of the Placenta in Fetal Programming
Godfrey KM. The role of the placenta in fetal programming-a review. Placenta. 2002;23 Suppl A:S20-7.
Early Prenatal Care Is Too Late from A Life-Course Perspective
Early prenatal care is too late to restore allostasis and optimize women’s health before pregnancy
What Is Preconception Care?
What is Preconception Care?
A set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management.
Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1-23.
Summary of the CDC/ATSDR Select Panel’s Recommendations to Improve Preconception Health and Health Care in the United States
Recommendation 1. Individual responsibility across the life span. Each woman, man and couple should be encouraged to have a reproductive life plan.
Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts.
Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.
Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions (i.e. those with evidence of effectiveness and greatest potential impact).
Recommendation 5. Interconception care. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birthweight, or preterm birth).
Recommendation 6. Prepregnancy checkup. Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy.
Recommendation 7. Health insurance coverage for women with low incomes. Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care.
Recommendation 8. Public health programs and strategies. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.
Recommendation 9. Research. Increase the evidence base and promote the use of the evidence to improve preconception health.
Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health.
Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1-23.
Components of Preconception Care
Risk Assessment Health Promotion Medical & Psychosocial Interventions
Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.
Preconception Health Promotion
1. Ask about reproductive life plan2. Start prenatal care before you get pregnant3. Start eating for two4. Eat more brain foods5. Avoid toxic foods6. Take a multivitamin everyday7. Achieve a healthy weight8. Learn how not to get stressed out9. Give your immune system a tune-up10.Detoxify your environment
Get ready to get pregnant
Tip #1 Ask About
Reproductive Life Plan
Reproductive Life Plan
A set of personal goals about having (or not having) children based on personal values and resources
A plan to achieve those goals
http://www.cdc.gov/ncbddd/preconception/QandA.htm#5
Examples of a Reproductive Life Plan
1. Do you hope to have any (more) children?2. How many children do you hope to have?3. How long do you plan to wait until you (next)
become pregnant?4. How much space do you plan to have between
your pregnancies?5. What do you plan to do until you are ready to
become pregnant?6. What can I do today to help you achieve your
plan?
Tip #2 Start prenatal care
before you get pregnant
Components of Preconception Care
Risk Assessment Reproductive life plan Past pregnancy history Past medical & surgical history Medications & allergies Family & genetic history Social history Behavioral & nutritional assessment Mental health Laboratory testing
Health Promotion
Medical & Psychosocial Interventions Preventive services and primary care Individualized for identified risks
Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.
Examples of Drugs to Avoid
Agent Comments
ACE inhibitors, ARBs Kidney abnl if exposed in 2nd or 3rd tri
Statins Abnormalities if exposure 4–9th week
Testosterone Masculinization of female fetus
Carbamazapine Fetal death, mental retardation, malformations of heart, genitals;cleft palate and arteries
Coumadin derivatives(warfarin)
Risk of bone+ cartilage deformities, mental retardation, vision problems
Lithium Increased risk of CV anomalies
Phenytoin Risk of fetal hydantoin syndrome
Valproic acid Use in 3-4 divided doses; not with carbamazapine + phenobarbitol
Isotretinoin Elevated risk of SAB and anomalies
Questions about Drug Use in Pregnancy
OTIS (Organization of Teratogen Information Specialists) http://www.otispregnancy.org Toll-free (866) 626-OTIS
Tip #3 Start “eating for two”(in quality, not in quantity)
Make Healthy Food Choices
Whole grain foods: 5-7 servings Plant oils: 6 teaspoons Vegetable and fruits: 5 servings Nuts, beans and lentils: ½ to 1 cup Fish, poultry or egg: 1 serving a day Dairy: 3 servings Multivitamin: 1 a day
http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid
Make Healthy Food Choices
Eat more whole foods and less processed foods
Use a menu planner www.MyPyramid.gov
Tip #4Eat more brain foods
Top 10 Brain Foods Beans Eggs Nuts & seeds Olive oil Alaskan wild salmon Yogurt & kefir Whole grains Spinach, collards, kale & broccoli Prunes, raisin, blueberries Oranges, red bell pepper, tomato
Tip #5Eat less toxic foods
Top 10 Toxic Foods Swordfish, shark, king mackerel and tile fish Soft cheese and unpasteurized milk Hot dogs, luncheon meats, deli meats, raw or smoked
seafood Raw or undercooked meat Unwashed vegetables, raw vegetable sprouts, and
unpasteurized juices Liver Saturated fats, trans fats, and partially hydrogenated
oils Added sugars Refined flour Herbal preparations
Fish:Brain Food or Toxic Food?
What You Need to Know about Mercuryin Fish & Shellfish
2004 EPA/FDA Joint Advisory for Women who might become pregnant Women who are pregnant Nursing mothers Young children
Do not eat Shark, Swordfish, King Mackerel, or Tilefish Eat up to 12 ounces (2 average meals) a week
Shrimp, canned light tuna, salmon, pollock, catfish are low in mercury
Albacore (“white”) tuna has more mercury than canned light tuna
Check local advisories about locally caught fish www.epa.gov/ost/fish
www.epa.gov/mercury
Tip #6Take a multivitamin
everyday
Micronutrients:Choosing Your Multivitamin
Folic acid 400 mcg a day 4000 mcg a day with prior NTD
Avoid excess (more isn’t always better) A>10,000 IU D>4,000 IU
Nutrition first!
Tip #7Achieve a healthy weight
Achieve A Healthy Pre-Pregnancy Weight
Underweight: BMI<18.5 Normal: BMI = 18.5-24.9 Overweight: BMI = 25-29.9 Obese BMI>30
National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov
Achieve A Healthy Pre-Pregnancy Weight
For weight loss, Decrease calories in Increase calories out (exercise) Keep track of weight & nutrition
Maintain a healthy weight for 3-6 months before pregnancy
National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov
Tip #8Learn How Not to Get
Stressed Out
Stress & Preterm Birth
And his daughter in law, Phinehas' wife, was with child, near to be delivered; and when she heard the tidings that the ark of God was taken, and that her father in law and her husband were dead, she bowed herself and travailed; for her pains came upon her.
Samuel 4:19
Fetal HPA Maturation
Hypothalamus
Pituitary
Adrenal
+ CRH
+ ACTH
CRH
Placenta
(+) Cortisol DHEA-S
(+)
(+)
Maternal HPA Activation
Hypothalamus
Pituitary
Adrenal
+ CRH
+ ACTH
CRH
Placenta
(+) Cortisol DHEA-S
(+)
(+)Hypothalamus
Pituitary
Adrenal
(+)
CRH
ACTH
Cortisol Norepinephrine
Exercise Eat right Get a good night’s sleep
Learn how not to get stressed out
Relaxation techniques Breathing exercises Progressive relaxation Meditation Mindfulness
Learn how not to get stressed out
Positive Mental Health A sense of meaning Self-acceptance Autonomy Positive relations with others Satisfaction with life Optimism
Learn how not to get stressed out
Develop Positive Mental Health Find your purpose (“follow your bliss”) Use your strengths Count your blessings Live in gratitude Learn to forgive Savor life’s joy Spend time with friends and families Practice daily acts of kindness Learn to be optimistic
Learn how not to get stressed out
Relationality is primary,All else is derivative.
- Ronald David
Learn how not to get stressed out
Tip #9Tune-up your
immune system
How to Give Your Immune System A Tune-Up?
Get rid of ongoing infections & inflammation Make lifestyle changes to improve immune fitness
Immune Tune-Up
Brush Floss Go see your dentist
How to Avoid Toxoplasmosis
Wear gloves when you garden Cook all meat thoroughly Wash raw vegetables thoroughly Exercise precautions around cats
Have someone else change the litter box Wear gloves when you change the litter box Change the litter box daily Cover outdoor sandboxes Never feed your cat raw meat Keep indoor cats indoors
www.cdc.gov/ /toxoplasmosis
How to Avoid Cytomegalovirus
Wash hands with soap and water after contact with diapers or saliva
Do not share food, drinks, or utensils (spoons or forks) with young children
Check your CMV titer if you work in day care
www.cdc.gov/cmv
Immune Tune-Up
Update your immunizations Tdap Hepatitis B Influenza MMR Chickenpox HPV
Tip #10Detoxify Your Environment
Detoxify Your Home
Bathroom Get rid of antibacterial soap
triclocarban and triclosan
Get rid of air fresheners phthalates, formaldehyde, glycol ethers, and petroleum
Get rid of personal care products containing Phthalates, formaldehyde, glycol ethers, petroleum
Get rid of bathroom cleaners containing ammonia, alkylphenol ethoxylate, chlorine bleach, glycol ether,
sodium hydroxide, sodium lauryl sulfate
Get rid of molds & mildew
Detoxify Your Home
Kitchen & dining room Get rid of non-stick pans
perfluorinated chemicals
Don’t microwave plastic Unless it says “microwave safe”
Get rid of glass & window cleaners containing Glycol ethers or ammonia
Get rid of stovetop, countertop & oven cleaners Lye, sodium hydroxide, chlorine bleach, silica
Get rid of drain cleaners containing Sodium hydroxide, sodium hypochlorite
Avoid using pesticides
Detoxify Your Home
Living Room and Bedrooms Get rid of vinyl wallpapers & blinds
Phthalates
Replace furniture containing urea-formaldehyde (ask for “exterior grade” products)
Replace mattress & sofas containing polybrominated diphenyl ethers (PBDEs)
Replace old carpets Volatile organic compounds, dusts & dustmites
Which # Plastic Bottles Should Be Avoided?
Tap vs. Bottled Water
Tap water Test your tap water for lead Use a water filter
www.nsf.org
Bottled water Check the recycle number on bottle
Plastics to Avoid#3 (polyvinyl chloride, which may contain phthalates) #6 (polystyrene) #7 (polycarbonate, which may contain BPA)
Keep bottled water away from heat Don’t reuse water bottles
Avoid Occupational Exposures
OSHA (Occupation Safety and Health Act) MSDS (Material Safety Data Sheet) OTIS (Organization Teratogen Information Specialists
http://www.otispregnancy.org Toll-free (866) 626-OTIS
Preconception Care for Men
Preconception Care for Men Protect Your Sperm DNA
Xenobiotics Pesticides, insecticides, fumigants Nonylphenol (super detergents) Polycyclic aromatic hydrocarbons (PAHs) (smoking) Polychlorinated biphenyls (fishing, old appliances) Dioxins (animal fat) Phthlates (plastics) Acrylamide (overcooking) Heavy metals (lead, cadmium, etc)
Infection/inflammation Hyperthermia Radiation
How Many SpermDoes a Man Make
in a Lifetime?
Preconception Care for Men? Reproductive life plan Past reproductive history Current medical conditions Medications Family history & genetic risks Work & hobbies Risk behaviors Mental health Weight Blood pressure Physical examinations Laboratory testing Immunizations Go see your dentist
Where is the FIn MCH?
Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Maidenberg M, Jones D, Garfield C, Rowley DL. Where is the F in MCH? Father involvement in African American Families. Ethn Dis. 2010;20:S2-49-61.
Father InvolvementBarriers
Individual Knowledge, attitude, behaviors Human capital
Interpersonal Gender relations (mother, grandmother, new partner)
Institutional & community Unemployment Incarceration Sterotypes Racism
Society & policy Temporary Assistance for Needy Families Earned Income Tax Credit Child Support
Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Jones D. et al. Where is the F in MCH? Father involvement in African American families. Ethnicity and Disease. 2010
Improving Father InvolvementAn Ecological Approach
Individual Educational programs Employment related services Legal & social services
Interpersonal Marriage counseling, family therapy Communication skills, conflict resolution skills, emotional intelligence
Institutional & community Full employment economy Criminal justice system Change norms, expectations, values, stereotypes Undo racism
Policy reforms Temporary Assistance for Needy Families Earned Income Tax Credit Child Support
Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Jones D. et al. Where is the F in MCH? Father involvement in African American families. Ethnicity and Disease. 2010
Father InvolvementA Life-Course Perspective
How do boys become men, and how do men become fathers?
The primary task of every civilization is to teach young men how to be fathers.
Margaret Mead
Interconception
Care
The definition of insanity is doing the same thing over and over and expecting different results
Benjamin Franklin
"We must become the change we want to see.”
- MOHANDAS GANDHI