Preconception Counseling

Dr. Julie Jenner

What is the purpose of preconception

counselling?

Goals of counselling

• Screen for conditions which may impact fertility, fetal development or mother’s ability

to adapt to pregnancy• Institute preventative measures before

pregnancyEducate couples regarding risks of pregnancy

and strategies to minimize the risks.

•Only 50-60% of pregnancies are planned

•Woman in Canada are delaying childbirth

•The average pregnant woman is older, heavier and less fit than 20 years ago

•Woman of childbearing years having increasing rates of HTN, NIDDM, and obesity

The Hard Reality

The advice

•Considering discussing pregnancy timing during a CPX

•Treat all woman as if they could have an unplanned pregnancy

•Lifestyle counseling is important to optimize pregnancy and so much more.

Kristin• 34 year old married lady here for CPX

• Hx of migraine headaches Rx Imitrex

• Non smoker, BP 135/82, 5’4” 150lbs (BMI 26)

• Executive for Canadian Tire 60 hour work week and travels to China

• Plays hockey 1X per week

• Family History Greek/English

• Both parents overweight 2 sisters 2 kids each

Advanced Maternal Age

•Given information about the risks to fertility with age, woman may choose to plan pregnancy sooner

•Many women feel IVF or in vitro solves the problem of AMA

When should women conceive?

•Women over 35 now account for 14% of deliveries

•With age comes wisdom…

•BUT…

• Infertility rises with age

•Chromosomal abnormalities increase

•Miscarriage rates increase

•Medical complication rate increases

•Surgical intervention increases

•Ectopic pregnancy, placental abnormalities

•Congenital malformations,neonatal complications, maternal death

Chance of childlessness

•Research based on age of marriage, before good access to contraception

•Age 20 6%

•Age 30-34 15%

•Age 35-39 30%

•Age 40-44 64%

Fecundity per cycle

•Age 19 50%

•Age 30 40%

•Age 37 30%

Maternal Mortality

•Rates are low in North America

•Rates do increase 5X after age 40

•25-29 9/100 000

•30-34 21/100 000

•above 40

•46/100 000 1/2175

Kristin #2

•Kristin wants to have children some day

•She is career focused right now

•Her sisters had their children at 20 and 25 “a big mistake”

•She agrees she is a little heavy due to demands of work and travel

•Drinks scotch only 2 per week

•Thinks diabetes runs in her dad’s family

NIDDM•Risk of gestational diabetes is 3%

overall

•Age >40 rate is 7 – 12%

•Moderate obesity increases ODDs ratio for NIDDM by 2.3

•Increases risk of macrosomia, perinatal death, infant hypoglycemia, maternal PIH

Obesity

•Obesity is associated with infertility

•Obesity is also a risk factor for PIH, gestational diabetes, congenital anomalies

•Childhood obesity positively associated with maternal obesity and maternal weight gain

Hypertension

•Essential HTN is a risk factor for abruption, PIH, IUGR

•Disproportionately higher risk to woman and child when combined with smoking or metabolic syndrome

•PIH overall rate is 3-4%

•PIH rate >40 increases to 5-10%

Intrapartum risks of advanced maternal age

•Older woman have increased risk of induction

•Increased risk of dystocia

•Increased risk of Cesarean Section

Kristin #3

•What does preconception counselling look like for Kristin?

Substance Abuse

•Cigarette smoking is common in women of child bearing age

•Pregnancy is a powerful incentive to try to quit

•Smoking increases preterm labour, low birth weight, miscarriage

•Marijuana risks are unclear-perhaps affects cognitive development

Marcy• 20 yo female

• Presents for meds renewal (Celexa 20mg Epival 1000mg)

• Dx of dysthymia, borderline personality disorder

• Not currently under psychiatric care

• Just enrolled in high school upgrading

• New “perfect” b/f of 4 weeks duration

• They are “being careful”

AHHHH!!!

•Please don’t get pregnant

Substance Abuse

•Advise all women of childbearing age to quit smoking

•Provide support ie:referral to group, advice re:patches Rx for Zyban

•Dispel myth that smokers have smaller babies therefore easier delivery

Alcohol

•Multiple effects are noted

•Spontaneous abortion

•Facial deformity

•Growth restriction

•Neurobehavioural

•Counsel not to drink during any month when not using contraception

Marcy #2•Marcy smokes 20 cigarettes per day

•She drinks on the weekends 5-7 drinks

•She uses marijuana occasionally

•She uses condoms or withdrawl

•G1P0 TA at age 17

•Marcy says she has never felt this good before

Marcy #3

•What would you do if you were pregnant?

•Marcy says she would never have another abortion

•Would quit drinking

•Would try to quit smoking

•Would quit her prescription meds

Prescription Drugs•Women and physicians fear use of

prescription drugs in pregnancy

•Most prescription drugs are safer to take than consequences of non treatment in pregnancy

•Women perceive untested herbal products (ie echinacea) as safer than well tested prescription drugs (ie Diclectin)

THE BLACK LIST

•Drugs known to be teratogenic

AVOID THESE

•Accutane

•Chemotherapy

•Valproic Acid, Carbamazepine, Septra (the folate inhibitors)

•Methotrexate

•Misoprostol

•Warfarin

•ACE inhibitors

Risk vs Benefit• SSRIs

• NSAIDs

• Antimalarials

• Live attenuated vaccines (ie yellow fever)

• Oral Steroids

• Colchicine

• Benzodiazepines

• Gadolinium

Medication Safety in pregnancy and breastfeeding

• Gideon Koren

Marcy #4

•How should we counsel Marcy?

Perfect Patient•25 year old Sally presents with her

supportive husband of 1 year

•They are ready to start a family and want the best advice available

•No meds

•No medical issues

•No drugs or alcohol

Bloodwork

•Rubella titre

•Varicella titre

•HIV, hep C, Hep BsAg, VDRL

•CBC

•Ferritin

•TSH

Consider

•Hemoglobin electrophoresis

•Toxoplasmosis titre

•CMV

•Fasting glucose

•TB testing