How to prevent, I m pregnant, so now what?

Transcription

1 How to prevent, I m pregnant, so now what? Use of reproductive life plans in practice Shanna M. Combs, MD

2 Objectives Apply the use of reproductive life plan to discuss future and long term fertility plans with a patient Understand the need to optimize patient s medical health prior to conceiving Identify types of testing indicated prior to a patient conceiving

3 Background

4 Unintended Pregnancy Over the past 20 years, the unintended pregnancy rate in the U.S. has not changed and remains at approximately 50% of all pregnancies Half of these are from non-use of any contraception, but half are from either failure to effectively use contraception or failure to use effective contraception The U.S. unintended pregnancy rate is significantly higher than the rate in many other countries In 2010, 54% of all pregnancies (298,000) in Texas were unintended, compared with 51% nationally

5 Reproductive Life Women are capable of getting pregnant for approximately years of their life span Any medical visit during this time frame should consider the possibility of the female patient being pregnant or the possibility of becoming pregnant

6 Maternal and Infant Mortality The United States has one of the highest rates of maternal mortality in the developed world A growing proportion of maternal deaths are attributable to chronic medical conditions The United States ranks behind most other industrialized nations in infant mortality Primarily because of congenital anomalies and preterm birth As prenatal care is often initiated too late for meaningful intervention, we need to address the preconception period as a way to address maternal and infant mortality

7 Preconception Care Preconception care Per CDC: A set of interventions aimed at identifying and modifying biomedical, behavioral, and social risks to a woman s health or pregnancy outcome through prevention and management The goal is to ensure that a woman is as healthy as possible before conception to promote her health and the health of her future children The goals of comprehensive primary care align with that of preconception care with some additions (ie: contraception)

8 Reproductive Life Plan

9 Reproductive Life Plan Assess a reproductive-aged woman s pregnancy desires and plans CDC and ACOG recommend that providers routinely ask women about their reproductive goals and encourage women to create a reproductive life plan Long term planning may be difficult for many women, so providers can address a shorter time frame Are you hoping to become pregnant in the next year?

10 Someday Starts Now

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17 Questions to ask if desires pregnancy How many children would you like to have? How long would you like to wait until you become pregnant? What family planning method do you plan to use until you are ready to become pregnant? How sure are you that you will be able to use this method without any problems? If desires pregnancy in the near future, assess preconception risk and provide counseling

18 Questions to ask if does not desire pregnancy What family planning method will you use to avoid pregnancy How sure are you that you will be able to use this method without any problems? Is it possible you could ever decide to become pregnant?

19 Preconception Care

20 Preconception Care Assess woman s desire to become pregnant If does not desire pregnancy, provide reliable contraception Advise folic acid supplementation (400 mcg daily) to reduce neural tube defects Assess BMI and counsel women who are overweight or obese about achieving a healthy body weight prior to conceiving Review medical history and medications 1 in 6 women of reproductive age receive a prescription for a potentially teratogenic medication each year in the United States Ask about dietary and herbal supplements as well Use the fewest medications at the lowest dosages needed to control disease

21 Preconception Care Assess for environmental exposures Workplace, household, and dietary Lead: Avoid potential sources (paint, construction, ceramics) Mercury: Eat low mercury fish (2 servings/week); avoid swordfish, shark, king mackerel, and tile fish Assess for STDs and other communicable diseases (i.e. TB, Hepatitis, etc) Screen for IPV, tobacco abuse, and substance abuse Review immunization history as well as infectious disease history

22 Preconception Care Infection exposures No vaccine available Toxoplasmosis: avoid cat litter, undercooked and raw meats CMV: Practice frequent hand washing, especially when in contact with children Listeria: Avoid cold cuts, unpasteurized milk and soft cheeses, and unwashed raw produce Vaccine available Varicella: assess for history of infection or assess immunization status Rubella: assess immunization status Avoid pregnancy for 1 month after vaccination

23 Preconception Care Assess for prior poor pregnancy outcomes Recurrent miscarriage, low birth weight, preterm delivery, GDM, baby with NTD, baby with other birth defects, and still birth Screen for personal or family history of genetic disorders Beta or alpha-thalassemia, cystic fibrosis, sickle cell disease, Tay-Sachs disease, mental retardation or Fragile X syndrome Refer couples to a genetic counselor when risk factors are identified Perform carrier testing when appropriate to determine risk to future pregnancy

24 Optimization of Chronic Conditions

25 Diabetes Affects ~10% of women of reproductive age and about 1% of pregnancies are complicated by pre-gestational diabetes Elevated blood glucose is teratogenic Uncontrolled diabetes increases risk for spontaneous abortion and congenital anomalies, and later in the pregnancy is associated with macrosomia, preterm birth, stillbirth, and neonatal death Women who can lower the HgbA1c levels to normal reduce their risks to close to that of a nondiabetic woman

26 Diabetes Optimize glucose control prior to conceiving Target HgbA1c of 7% Consider transitioning from oral glycemic medication to insulin Metformin and Glyburide may be continued Avoid ACE inhibitors, ARBs, and statins Assess renal function, cardiac function, and perform a comprehensive eye examination

27 Hypertension ~8% of reproductive age women have hypertension Women with HTN are more likely to experience IUGR, stillbirth, iatrogenic preterm birth, placental abruption, super-imposed pre-eclampsia, and fetal death 25% of women with HTN develop super-imposed pre-eclampsia Women with HTN are at risk of worsening end-organ damage Many commonly used anti-hypertensive medications are teratogenic

28 Hypertension Consider weaning women with mild HTN (BP <160/105) off of medication prior to conceiving under close observation Recommended anti-hypertensives for BP >160/105 Labetalol Nifedipine Methyldopa Women with long-standing HTN should be assessed for end organ damage (i.e. retinopathy, renal disease, and ventricular hypertrophy)

29 Obesity 1/3 of reproductive-age women in the United States are obese Obesity is associated with many adverse outcomes in pregnancy Gestational diabetes, pre-eclampsia, iatrogenic preterm delivery, dysfunctional labor, post-term pregnancy, large for gestational age, IUGR, should dystocia, fetal and infant death, congenital anomalies, cesarean delivery, postpartum complications Infants born to obese mothers are more likely to develop childhood obesity, Type II DM, and cardiovascular disease later in life Obese women are at increased risk for subfertility and miscarriage

30 Obesity Women should be educated on the risks in pregnancy associated with obesity Modest weight reductions of 5-15% can improve fertility as well as pregnancy outcomes Women who undergo bariatric surgery should avoid pregnancy for months and ideally be placed on a reliable from of contraception prior to surgery as their infertility tends to improve with weight loss

31 Depression and Anxiety Disorders Depression is highly prevalent in women in the United States Perinatal depression (conception to 3 months postpartum) prevalence ranges from 11-32% Depressive symptoms during pregnancy have been associated with low birth weight, preterm delivery, and postpartum depression Anxiety symptoms have also been linked to low birth weight and preterm delivery

32 Depression and Anxiety Disorder Many anti-depressant and anxiety medications are teratogenic or not well studied in pregnancy Depression and anxiety disorders should be addressed in the preconception period and work towards treatment with a goal of euthmia of 6-12 months If symptoms are mild or no longer present for 6 or more months, consider tapering or stopping medication prior to conceiving Sertraline may be a reasonable first-line medication during pregnancy and breast-feeding Patients with serious mental illness should remain on their medications

33 Seizure Disorders Seizure disorders are the most common neurologic disorders that affect pregnant women Both the disease and the medications can adversely affect pregnancy ~1/3 of women with a seizure disorder will have more frequent seizures in pregnancy Seizure disorders are associated with miscarriage, low birth weight, developmental disabilities, microcephaly, hemorrhagic disease of the newborn, and congenital anomalies

34 Seizure Disorders Monotherapy should be used when possible and at the lowest effective dose Folic acid supplementations should be initiated 1 month before conception and continued in the first trimester Folic acid supplementation is higher at 4 mg/day (compared to 0.4 mg/day)

35 Thrombophilia Women with thrombophilia are more likely to develop venous and arterial clots in pregnancy and are at risk in pregnancy Effects on the fetus include placental infarction, IUGR, placental abruption, recurrent miscarriage, fetal stroke, and fetal death Warfarin (Coumadin) is teratogenic There are many new anti-coagulant medications that have yet to be studied in pregnancy

36 Thrombophilia Women on anti-coagulant medication should transition to heparin or lowmolecular weight heparin prior to conceiving Consider genetic testing for any inherited thrombophilia

37 It s not a question of whether you provide preconception care, rather it s a question of what kind of preconception care you are providing. Joseph Stanford and Debra Hobbins

38 Questions?

39 References Farahi N & Zolotor A. Recommendations for preconception counseling and care. American Family Physician. 2013; 88: Callegari L, et al. Preconception care and reproductive planning in primary care. Medical Clinics of North America. 2015; Dean S, et al. Preconception care: promoting reproductive planning. Reproductive Health. 2014; 11 (Suppl 3)