Preconception care: Aboubakr Elnashar

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  • 1 Preconception Care Aboubakr Elnashar Prof Obs Gyn, Benha University Hospital, Egypt Aboubakr Elnashar
  • 2 Duration of pregnancy is no longer 9 months, its 12 months ACOG& AAP: prenatal care before conception PCC: Concept has evolved over the last several decades Form of primary care& prevention 12 NOT 9 Aboubakr Elnashar
  • 3 Outline Definition& Goals Why Do We Need PCC? Components Scientific Evidence Current Recommendations Barriers Implementation Aboubakr Elnashar
  • 4 Definition A set of interventions that aim to identify& modify (biomedical, behavioral& social) risks to a womans health or pregnancy outcome through prevention& management (CDC, 2006) Aboubakr Elnashar
  • 5 Goal Goal should be realistic Identify pre-existing conditions that may affect an anticipated pregnancy Intervention(s) that could lead to more favorable outcome Aboubakr Elnashar
  • 6 Why? Aboubakr Elnashar
  • 7 Currently: Poor pregnancy outcomes Women enter pregnancy at risk for adverse outcomes We intervene too late There is consensus that: Intervening before pregnancy: improve outcomes Aboubakr Elnashar
  • 8 Early ANC is too late 1. To Prevent Some Birth Defects Critical period of teratogenesis: D17 to D56 Heart: begins to beat at 22 ds after conception Neural tube: closes by 28 ds after conception Palate: fuses at 56 ds after conception 2. To Prevent Implantation Errors 3. To restore allostasis: Maintain stability through change An important objective of PCC is to restore allostasis to womens health before pregnancy Aboubakr Elnashar
  • 9 Critical Periods of DevelopmentCritical Periods of Development 4 5 6 7 8 9 10 11 12 Weeks gestation from LMP Central Nervous SystemCentral Nervous System HeartHeart ArmsArms EyesEyes LegsLegs TeethTeeth PalatePalate External genitaliaExternal genitalia EarEar Missed Period Mean Entry into ANC Most susceptible time for major malformation Aboubakr Elnashar
  • 10 From Anticipation& Management to Health Promotion& Prevention From Healthy Mothers Healthy Babies to Healthy Women Healthy Mothers Healthy Babies Paradigm Shift Aboubakr Elnashar
  • 11 Components CDC, 2007 I. Risk Assessment II. Health promotion III. Interventions Aboubakr Elnashar
  • 12 A. Risk assessment I. Reproductive life plan: If she plans to have children? How long she plans to wait until she becomes pregnant? Plan, based on: her values& resources, to achieve those goals Aboubakr Elnashar
  • 13 II. History 1. Reproductive history: Previous adverse outcomes: infant death, fetal loss, birth defects, low birth weight, PTL 2. Medical history: Rheumatic heart disease Thromboembolism Autoimmune diseases Hypertension Diabetes Aboubakr Elnashar
  • 14 3. Medication use: Current medication Avoid FDA Category X: Estrogen, androgens,Aminopterin, isotretinoin,Thalidomide Category D: Phenytoin, valporic acid, diazepam, Imipramine, captopril, thiazides, Spironolactone, coumarine, chlorpropamide, Progestins, tetracyclin, streptomycin, Quinine, methotrexate, vinblastin, Azathioprine. unless maternal benefits outweigh fetal risks; Over-the-counter medications, herbs& supplements Aboubakr Elnashar
  • 15 4. Substance abuse: Tobacco Alcohol Drug use 5.Toxins& teratogenic agents: At home, in the neighborhood, in the workplace: heavy metals, solvents, pesticides, endocrine disruptors, allergens Aboubakr Elnashar
  • 16 II. Physical examination: 1. Nutritional assessment: Assess the ABCDs of nutrition: anthropometric factors (e.g., BMI) biochemical factors (e.g., anemia) clinical factors dietary risks 2. Focus on Periodontal, thyroid, heart, breast, pelvic examination Aboubakr Elnashar
  • 17 III. Screening 1. Infections &immunizations: Screen for periodontal, urogenital & STD as indicated; Update immunization with hepatitis B, rubella, varicella, Tdap,HPV& influenza vaccines as needed Aboubakr Elnashar
  • 18 2. Genetic screening: Based on: family history ethnic background age Offer cystic fibrosis& other carrier screening as indicated Aboubakr Elnashar
  • 19 3. Psychosocial: Screen for depression, anxiety, domestic violence major psychosocial stressors Aboubakr Elnashar
  • 20 4. Laboratory testing: Testing should include CBC; urinalysis; blood type& screen When indicated screen for Rubella, syphilis, hepatitis B,HIV, gonorrhea, chlamydia Diabetes Thyroid Dysfunction Cervical cytology Aboubakr Elnashar
  • 21 B. Health promotion 1. Family planning: Based on the patients reproductive life plan Effective contraceptive use Discuss emergency contraception Aboubakr Elnashar
  • 22 2. Healthy weight & nutrition: Ideal BMI: 20 to 26.0 kg/m2 Exercise Nutrition Macro& micronutrients: Getting five a-day: 2 servings of fruit +3 servings of vegetables Daily multivitamin that contains folic acid Aboubakr Elnashar
  • 23 3. Healthy behaviors: Nutrition Exercise, Safe sex Effective contraceptive use Dental flossing Preventive health services Discourage risky behaviors: Douching Not wearing a seatbelt, Smoking: use the five As [Ask, Advise, Assess, Assist, Arrange] for smoking cessation Alcohol Substance abuse Aboubakr Elnashar
  • 24 4. Healthy environments: Discuss household, neighborhood& occupational exposures to heavy metals, organic solvents, pesticides, endocrine disruptors& allergens; Give practical tips such as how to avoid exposures Aboubakr Elnashar
  • 25 5. Stress resilience: Promote nutrition, exercise, sufficient sleep, and relaxation techniques; Address ongoing stressors (e.g., domestic violence) Identify resources to help the patient develop problem solving and conflict-resolution skills, positive mental health, and strong relationships 6. Interconception care: Promote breastfeeding, placing infants on their backs to sleep to reduce the risk of sudden infant death syndrome, positive parenting behaviors, and the reduction of ongoing biobehavioral risks Aboubakr Elnashar
  • 26 C. Interventions 1. Folic acid supplementation Reduces NTD by two thirds. 2. Rubella vaccination protection against congenital rubella syndrome. 3. Hepatitis B vaccination for at risk women: Prevents transmission of infection to infants Eliminates the risks to the women of hepatic failure, liver carcinoma, age cirrhosis& death due to HBV infection. Aboubakr Elnashar
  • 27 4. Diabetes management: reduces birth defects among infants of diabetic women. 5. Hypothyroidism: protects proper neurological development. 6. HIV/AIDS screening: Allows for timely treatment Provides women (or couples) with additional information that can influence the timing of pregnancy& treatment. Aboubakr Elnashar
  • 28 7. STD screening& TT Reduces the risk of ectopic pregnancy, infertility, chronic pelvic pain associated with Ct& NG Reduces risk to a fetus of fetal death or physical& developmental disabilities, including mental retardation& blindness. 8. Maternal PKU management: Prevents babies from being born with PKU-related mental retardation. Aboubakr Elnashar
  • 29 9. Switching women off Oral anticoagulant: avoids harmful exposure. 10. Antiepileptic drug: Changing to a less teratogenic tt reduces harmful exposure. 11. Accutane (isotretinoin) use management: Preventing pregnancy for women who use OR Stop before conception :eliminates harmful exposure. Aboubakr Elnashar
  • 30 12. Smoking cessation: Prevent: PTL low birth weight other adverse perinatal outcomes. 13. Eliminating alcohol use Prevents fetal alcohol syndrome other alcohol-related birth defects. 14. Obesity control: Reduces the risks of NTD, PTL, DM, CS, Hypertension Thromboembolic diseaseAboubakr Elnashar
  • 31 PPC for men Alcohol May be associated with physical& emotional abuse May decrease fertility Genetic Counseling Occupational Exposure - lead STD Syphilis, herpes, HIV Aboubakr Elnashar
  • 32 Scientific Evidence Does PCC work? Aboubakr Elnashar