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  • We always talk about preventative care in our society but never do it. Why? Because it isnt sexy. It is not high tech. It is not extremely difficult. It is not expensive. Preconception care is similar and is not adequately utilized.Get a pic of the tortise and the hare.
  • We often talk about the importance of prenatal care, but how important is it?
  • Inadequate prenatal care decreased but preterm birth increased
  • Late or no prenatal care has decreased for over a decade.
  • But low birthweight has increased
  • Early prenatal care is provided to a majority of americans
  • Early prenatal care has increased dramatically over the last decade
  • But birth defects have only gone down slightly and has seen no dip in almost a decade
  • Definition of insanity- doing the same thing and expecting a different result. Prenatal care has been maxed out in the U.S. There is nothing else to be gained.Below shows that there are studies of prenatal care with less visits is just as effective clinically.From Cochrane database on prenatal care:A reduction in the number of antenatal care visits with or without an increased emphasis on the content of the visits could be implemented without any increase in adverse biological maternal and perinatal outcomes.Women can be less satisfied with reduced visits. Lower costs for the mothers and providers could be achieved.
  • Epigenetics refers to how genes express themselves caused by mechanisms other than the specific alteration of the DNA itself. We all have thousands of genes within our cells. Did you ever wonder that when the egg and sperm come together as an embryo that many different types of cells are made? For example, some cells go on to be muscle, others develop into skin, and others change into nervous system tissue like in the brain. However, all of the original cells come from the first cells which developed from the egg and sperm. All of these cells have the same genetic material. How can they all form different types of cells as described above. The answer is epigenetics.
  • The starved fetus learns to live off less and its programming is changed. Hence when it gets unlimited supplies after birth the infant has a higher risk of medical problems.
  • Lower the birthweight the higher the risk of diabetes later in life
  • Metabolic syndrome is a type of pre-diabetes
  • Dutch Famine in WWII showed this programmingAfter D-day, Allies failed to control a key bridge and the western Netherlands was isolated
  • The Dutch Famine showed that exposure at different time periods in pregnancy changed outcomes late in life
  • Same slide
  • Also it doesn’t work due to bad habits, lifestyles, and medical conditions untreated
  • A large part of many women’s reproductive lives, from menarche to menopause, may be spent trying not to become pregnant.12 Effective contraception is important for women who wish to avoid pregnancy at certain times during their lives. However, recent research noted that 50% of all unintended pregnancies were among women who did not use contraception, and that the overall rate of unintended pregnancy could be cut in half if these women were to use highly effective contraception.
  • Not enough use of contraception leads to unwanted pregnancy.
  • We concentrate our message on who we think should be having babies and not who is capable and unknowledgeable and the least prepared. We should concentrate the message on who can get pregnant not who we think should be pregnant. That is why so many young women have unplanned pregnancies.
  • Medicaid pts have poorer access and possibly other factors leading to unintended pregnancy.
  • We spend so much money on prenatal care. But prenatal care only mildly decreases preterm birth- that is it! This does not count delivery costs or abnormal outcomes that can be prevented.
  • Title V consists of block grants to state health agencies on the basis of specified formulas, and discretionary grants referred to as Special Projects of Regional and National Significance.States must provide a three-dollar match for every four federal dollars allocated. To find the name and phone number of your state Title V contact, consult the MCHB web site.There is money out there for preconception care.
  • Our system is reactive not proactive. Although money is there, only 23 states have even a minimal focus on preconception care.
  • Main things to look at- although there are others
  • In red boxes there is a 70% reduction in preterm birth prior to 34 weeks in patients using vitaminsJanet M. Catov1,2, Lisa M. Bodnar1,2,3, Roberta B. Ness1,2,3, Nina Markovic1,2,4, and James M.Roberts1,2,3
  • Another study shows a 41% reduction in preterm birth less than 32 weeks but if used for preconception for 3 months the decrease is a whopping 86%. This is huge as the risk of death is equal to a term baby when born after 32 weeks. Also morbidity is only 1 % different.
  • Yellow box is important- but less than 40% of women are doing the right thing with folic acid•  In 2008, 39.0% of women age 18-45 reported taking a vitamin containing folic acid daily in the United States.  •  Up to 70% of neural tube defects--birth defects of the brain and spinal cord--may be prevented if women consume 400 micrograms of folic acid daily, prior to and during the early weeks of conception.
  • So little are doing the right thing as so few women actually know– only 10%.To better understand what women knew about folic acid, those who were aware of folic acid were asked what they recalled hearing or reading.  •  In 2008, 11.0% of women aware of folic acid mentioned that folic acid should be taken before pregnancy.  •  This figure has increased since 1995 when 2% of women mentioned that folic acid should be taken before pregnancy.
  • Preterm birth isnt the only thing decreased- so is anomalies or birth defects. Birth defects are decreased by 20-47% if a women takes multivitamins around or before conception.Most of the defects prevented are not NTDs
  • These are the amount of defects PER DAY eliminated by proper vitamin use if used by every woman around the world prior to conception.
  • Vit D is the new folic acid
  • Vitamin D is good for womens health overall not just during pregnancy although we will get to that in a bit.50% reduction in breast cancer with a level of 52 or above
  • 48% decrease in ovarian cancer with a level of 30 or above
  • The smile curve of vitamin D. As the latitude is higher there is less sunlight and diseases that go down at the equator are usually Vitamin D based.
  • This shows that months with minimal sunlight have a higher risk of multiple sclerosis in children. Also notice 6 months later the sun is opposite and so is the prevalence of MS in children
  • Autism has increased dramatically in the last 20 years.
  • Estrogen potentiates activated vitamin D, but testosterone does not. The differences in sex steroids during brain development may mean that estrogen protects developing female brains from vitamin D deficiencies, while testosterone exposes male brains to those same deficiencies
  • March is the time of lowest Vitamin D levels in the U.S.Clearly low autism risk in summer months
  • More sun exposure or sunlight the less autism
  • Autism is increased in africanamericans- so is autism.
  • This vitamin D deficiency passed onto children
  • Obesity increases Vit D deficiencyUnadjusted association between maternal prepregnancyBMI and the probability of maternal vitamin D deficiency (A) andneonatal vitamin D deficiency (B). Vitamin D deficiency is defined asserum 25(OH)D , 50 nmol/L. Probabilities were predicted based onresults from logistic regression models (BMI effect was significant atP , 0.05 in maternal model and P , 0.01 in neonatal model). The solidline represents the point estimate and the dashed lines represent the95% confidence bands.
  • A normal scene we don’t think much about but is worrisome
  • Many reasons for obesity
  • If you eat McDonalds you do not get a McDonalds baby instead you get……
  • This child
  • Go thru the following graphs in about 1-2 secs each
  • It has increased so much there is an obesity probe marketed in ultrasound now- we got one for every machine we have.
  • Activity has decreasedData are reported from 36 participating states from 1988–2007. The proportion of the U.S. population that reported no leisure-time physical activity decreased from about 31% in 1989 to about 28% in 2000, then decreased to about 24% in 2007.Recommended physical activity — reported moderate-intensity activities in a usual week (i.e., brisk walking, bicycling, vacuuming, gardening, or anything else that causes small increases in breathing or heart rate) for greater than or equal to 30 minutes per day, greater than or equal to 5 days per week; or vigorous-intensity activities in a usual week (i.e., running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate) for greater than or equal to 20 minutes per day, greater than or equal to 3 days per week or both. This can be accomplished through lifestyle activities (i.e., household, transportation, or leisure-time activities).
  • The BMI is body-mass index. The higher the number the worse the obesity. The worse the obesity the worse the problem
  • We hate to say bad things to our patients but this just harms them from making appropriate lifestyle changes.Are obese adults told by their health providers that they are overweight? Among obese adults, just over 65% were ever told by a health care provider that they were “overweight.” Obese women were more likely to be told they were “overweight” than were men.
  • Chemicals in a cigarette
  • Problem with smoking is it so accepted during pregnancy
  • Smoking is a horrible pregnancy habit and is the most easily modified habit with the largest impact.Childhood Obesity OR 2.73 after controlling for confounders
  • Smoking increases the risk of infertility and miscarriage. That is another reason for preconception cessation.
  • SAB =miscarriageSo this is a problem in women who binge drink before they know they could be pregnant.
  • Once people know they are pregnant, there intake of alcohol decreases or stops. People need to know they have to stop problem drinking prior to pregnancy.
  • Questions to ask your patient at preconception visit.
  • As your blood count improves so does birthweight- important to treat anemia.
  • 360% increase in small child if blood count is low
  • Ferritin is an acute phase reactant and marker of inflammation. Inflammation may be from infection and hence more preterm birth
  • Ferritin is an acute phase reactant and marker of inflammationNo signifigance but a trend
  • Teeth and gums are overlooked pus pockets and lead to complications.By the way low Vit D is associated with more periodontal disease.
  • Many problems with gum disease
  • 183% increase in preterm birth with gum disease.
  • Higher risk of toxemia with gum disease.
  • Treatment of gum disease during pregnancy may not help- possible reasons above
  • Dentists hate to treat pregnant patients- why- I don’t know.
  • Treating diabeticsprior to pregnancy also saves money as well as improving outcome.
  • Improperly treated thyroid disease leads to decreased IQ
  • Tell the thyroid disease patient to seek early care.
  • This ends it.
  • Transcript

    • 1. Preconception Care: The Only Care that Counts
      Brian K. Iriye, M.D.
      Center For Maternal-Fetal Medicine
      Las Vegas, NV
      www.cmfm.net
    • 2. The Hare
      Perinatology – exciting , taking care of the high-risk pregnancy
      Providing early prenatal care to high risk- situations or identifying risk
      Tortise versus the Hare
    • 3. The Tortise
      Preventative care
      Vaccinations
      Cholesterol levels
      Preconception care
      Tortise versus the Hare
    • 4. Prenatal Care
    • 5. Inadequate prenatal care
      US, 1992-2002
      Footnotes available in notes section.
      Source: National Center for Health Statistics, final natality data. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994; 84: 1414-1420. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 6. How Effective is Prenatal Care- Preterm birth
      US, 1995-2005
      Preterm is less than 37 completed weeks gestation.
      Source: National Center for Health Statistics, final natality data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 7. Late/no prenatal care
      US, 1992-2002
      Late/No prenatal care is pregnancy-related care beginning in the 3rd trimester (7-9 months) or when no pregnancy-related care was received at all.
      Source: National Center for Health Statistics, final natality data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 8. How Effective is Prenatal Care- Low Birthweight
      US, 1995-2005
      Low birthweight is less than 2500 grams (5 1/2 pounds).
      Source: National Center for Health Statistics, final natality data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 9. Most prenatal care in the U.S. starts in the 1st or 2nd trimester
      “Early” Prenatal Care
      83.7
    • 10. Early prenatal care – Does it Work?
      US, 1992-2002
      Early prenatal care is pregnancy-related care beginning in the first trimester (1-3 months).
      Source: National Center for Health Statistics, final natality data. Retrieved November 11, 2008, from www.marchofdimes.com/peristats.
    • 11. How Effective is Prenatal Care- Infant deaths due to birth defects
      US, 1996-2004
      Cause of death for 1996-1998 is based on the Ninth Revision, International Classification of Diseases (ICD-9); cause of death for after 1998 is based on the Tenth Revision, International Classification of Diseases (ICD-10).
      Source: National Center for Health Statistics, period linked birth/infant death data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 12. A large proportion of women receive prenatal care yet very little recent improvement in infant health
      12% Preterm birth
      8 % LBW
      3% major birth defects
      31% still suffer pregnancy complications
      Prenatal Care
      CDC Preconception Health and Care, 2006
    • 13. Prenatal Care Indicators
      Prenatal Care
      Adequate Prenatal Care
      Early Prenatal Care
      Birth Outcomes
      Preterm Birth
      Low Birthweight
      Birth Defects
      State of Prenatal Care in the U.S.
      Does this look like it is working?
    • 14. Critical Periods of Development
      Critical Periods of Development
      Weeks gestation
      from LMP
      4 5 6 7 8 9 10 11 12
      Most susceptible
      Central Nervous System
      Central Nervous System
      time for major
      malformation
      Heart
      Heart
      Arms
      Arms
      Eyes
      Eyes
      Legs
      Legs
      Teeth
      Teeth
      Palate
      Palate
      External genitalia
      External genitalia
      Ear
      Ear
      Mean Entry into Prenatal Care
      Missed Period
      From March of Dimes
    • 15. Reasons Prenatal Care Effects are Limited
      Average Prenatal Care starts after vital organs are formed
      Average Prenatal Care starts after vital genes are modified
    • 16. Old School- fetal health is determined by its genes
      New School- fetal genes are determined by the environment
      Epigenetics
      The New Buzzwords– Fetal Programming
    • 17. The thrifty phenotype hypothesis proposes that the epidemiological associations between poor fetal growth and the subsequent development of type 2 diabetes and the metabolic syndrome result from the effects of poor nutrition in early in utero life, which produces permanent changes in glucose-insulin metabolism
      Barker Hypothesis- Thrifty Phenotype
    • 18. Poor nutrition during fetal development leads to the development of a frugal or thrifty metabolism
      After birth if nutrition is readily available
      Metabolic syndrome
      Diabetes
      Obesity
      Barker Hypothesis- Thrifty Phenotype
    • 19. Fetal Programming- Thrifty Phenotype
    • 20. Fetal Programming- Thrifty Phenotype
      Odds ratio for risk of type II diabetes and or impaired glucose tolerance based upon birthweight
    • 21. Fetal Programming- Thrifty Phenotype
      Odds ratio for risk for the development of the metabolic syndrome based upon birthweight
    • 22. End of WWII food supplies became low in the Netherlands
      After D-day conditions worsened
      Nazi retaliatory embargo to western part of country
      Food supplies at 580 cal per day
      10,000 people died
      Dutch Famine- 1944-45
    • 23. Dutch Famine
    • 24. Dutch Famine- Programming Consequences
    • 25. During Pregnancy
      11% smoke
      10% drink
      Of women who could get pregnant
      69% do not take folate
      31% are obese
      3% take possible teratogenic Rx drugs
      4% have medical conditions that can seriously effect pregnancy if unmanaged
      Preconception Care
      CDC Preconception Health and Care, 2006
    • 26. 4 million pregnancies/yr in U.S
      2 million are unplanned
      Prenatal care benefits appear to have been maximized
      Preconception Care- the Problem
    • 27. Mistimed or Unwanted Pregnancy
    • 28. Contraceptive Use at Time of Conception
    • 29. Age: Unintended Pregnancy Among Women Having a Live Birth- 1999
    • 30. Medicaid Status: Unintended Pregnancy Among Women Having a Live Birth- 1999
    • 31. Race: Unintended Pregnancy Among Women Having a Live Birth- 1999
    • 32. On average, you'll visit your ob-gyn approximately 14 times for prenatal care.
      Average amount charged to patients for prenatal and postnatal care was $133 per visit.1
      Therefore, 14 appointments at a cost of $133 each adds up to $1,862.
      Tests such as laboratory blood work or ultrasound add to these costs.
      Prenatal Care Costs
      1 Agency for Healthcare Research and Quality 2003 (AHRQ), a part of the U.S. Department of Health and Human Services
    • 33. Title V of the Social Security Act has authorized the Maternal and Child Health Services Program since 1935, and it is a major source of state funds for women of childbearing age, infants and children with special health care needs.
      In 2008 (fiscal year) Maternal and Child Health Block Grant (Title V) funds to the United States included $544,537,666 from the federal government and $4.7 billion in state matching funds. States chipped in $3.5 billion. Overall 8 billion dollars
      Major Funding Programs
    • 34. Title V and Preconception Care
      23 states with focus on preconception care
    • 35. Vitamins
      Obesity
      Tobacco
      Alcohol
      Immunizations
      Anemia
      Medical Diseases
      What Can We Do or Act Against?
    • 36. For poor U.S women 70% do not get RDA required amounts of vitamins and minerals from their diets
      Multivitamin use for 3 months prior to pregnancy
      27% caucasian
      18% africanamericans
      Yet MVIs are associated with a dramatic decrease in several outcomes
      Multivitamin Usage
    • 37. Periconception Vitamin Use and Preterm Birth
      Catov JM et al . Am J Epidemiol. 2007 Aug 1;166(3):296-303.
    • 38. Preconception MVI use and PTB < 32 weeks
      Adjusted OR = 0.59 (0.29-1.21)
      Preconception users had increased h/o risk – SAB
      1st Trimester + Preconception Use (for 3 or more months)
      Adjusted OR= 0.14 (0.05-0.40)
      Periconception Vitamin Use and Preterm Birth < 32 weeks
      Scholl TO et al. Am J Epidemiol. 1997 Jul 15;146(2):134-41
    • 39. Daily use of folic acid among women 18-45 years
      Up to 70% of neural tube defects may be prevented if women consume 400 micrograms of folic acid daily, prior to and during the early weeks of conception
      US, 1995-2008
      Nationally representative telephone surveys conducted by the Gallup Organization, targeting approximately 2000 English-speaking women ages 18-45 each year. Margin of error is +/- 2%. Survey not conducted in 1996 and 1999.
      Source: March of Dimes Folic Acid Surveys, conducted by Gallup. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 40. Knowledge that folic acid should be taken before pregnancy
      US, 1995-2008
      Nationally representative telephone surveys conducted by the Gallup Organization, targeting approximately 2000 English-speaking women ages 18-45 each year. Margin of error is +/- 2%. Survey not conducted in 1996 and 1999.
      Source: March of Dimes Folic Acid Surveys, conducted by Gallup. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 41. Periconceptional MVI Use and Fetal Anomaly Risk
      Hungarian Trial: Czeizal AE Eur J ObstetGynecol Repro Biol 1998: 78:151-61
      Atlanta Trial: Mulinare J et al. Am J Epidimeol 1995: 141:S3
    • 42. Periconceptional Multivitamin Use and Birth Defect Prevention Worldwide
    • 43. Made by the skin thru direct conversion from sunlight
      Minimal contribution from foods
      Multivitamin rates of Vitamin D are too low to change deficiency (200-400 iu)
      Vitamin D Deficiency
    • 44. Vitamin D and Breast Cancer
    • 45. Vitamin D and Ovarian Cancer
    • 46. Multiple Sclerosis and Vitamin D
    • 47.
    • 48. Month of Birth and MS- Northern Countries (Canada and Europe)
    • 49. Autism and Vitamin D?
    • 50. Strong genetic basis but also epidemiologic evidence
      Large increase in autism over the last 20 years
      Corresponds with advice to avoid sun in last 20-30 years
      Animal data shows vitamin D deficiency leads to
      Dysregulation of proteins involved with brain development
      Enlarged ventricles and increased brain size
      Autism and Vitamin D
    • 51. Estrogen and testosterone have different effects on Vitamin D metabolism
      May explain male/female differences in autism (4:1)
      Calcitriol decreases inflammatory cytokine production
      Autism increased in climates of decreased sunlight
      Autism increased in darker skin individuals
      Autism and Vitamin D
    • 52. Autism and Vitamin D- United States
    • 53. Autism symptoms decrease in children:
      with MVI exposure
      Increased fish with Vitamin D
      Rural populations vs. Urban – indoor vs. outdoor activity
      Less air pollution areas
      Areas with less rain (move UV and more outside activity)
      Summer
      Circumstantial evidence linking Vitamin D and Autism
    • 54. Vitamin D deficiency and Race
      Prevalence of vitamin D deficiency [25(OH)D ,37.5 nmol/L], insufficiency
      [25(OH)D 37.5–80 nmol/L], and sufficiency [25(OH)D .80 nmol/L]
      among 200 white and 200 black women at 4–21 wk gestation
    • 55. Vitamin D deficiency and Race -Neonates
      Prevalence of vitamin D deficiency [25(OH)D ,37.5 nmol/L], insufficiency
      [25(OH)D 37.5–80 nmol/L], and sufficiency [25(OH)D .80 nmol/L] in neonates
    • 56. Vitamin D Deficiency and Obesity
    • 57. Want to get levels to approximately 50ng/mL
      If very low- less than 32ng/mL
      Give 50,000 units oral per week x 6-8 weeks
      Then repeat level, PTH, calcium
      Consider rebolus if still low
      If normal give 2000-2500 units per day (soon to be new recommended amount)
      Vitamin D Replacement
    • 58. Obesity
    • 59. Portion sizes
      High Fat diets
      Decreased Activity
      Current Cultural Habitat
    • 60.
    • 61. Obesity Trends in the U.S.
      1986-2007
    • 62. Obesity Trends* Among U.S. AdultsBRFSS, 1985
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14%
    • 63. Obesity Trends* Among U.S. AdultsBRFSS, 1986
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14%
    • 64. Obesity Trends* Among U.S. AdultsBRFSS, 1987
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14%
    • 65. Obesity Trends* Among U.S. AdultsBRFSS, 1988
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14%
    • 66. Obesity Trends* Among U.S. AdultsBRFSS, 1989
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14%
    • 67. Obesity Trends* Among U.S. AdultsBRFSS, 1990
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14%
    • 68. Obesity Trends* Among U.S. AdultsBRFSS, 1991
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19%
    • 69. Obesity Trends* Among U.S. AdultsBRFSS, 1992
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19%
    • 70. Obesity Trends* Among U.S. AdultsBRFSS, 1993
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19%
    • 71. Obesity Trends* Among U.S. AdultsBRFSS, 1994
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19%
    • 72. Obesity Trends* Among U.S. AdultsBRFSS, 1995
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19%
    • 73. Obesity Trends* Among U.S. AdultsBRFSS, 1996
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19%
    • 74. Obesity Trends* Among U.S. AdultsBRFSS, 1997
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% ≥20%
    • 75. Obesity Trends* Among U.S. AdultsBRFSS, 1998
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% ≥20%
    • 76. Obesity Trends* Among U.S. AdultsBRFSS, 1999
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% ≥20%
    • 77. Obesity Trends* Among U.S. AdultsBRFSS, 2000
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% ≥20%
    • 78. Obesity Trends* Among U.S. AdultsBRFSS, 2001
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    • 79. Obesity Trends* Among U.S. AdultsBRFSS, 2002
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    • 80. Obesity Trends* Among U.S. AdultsBRFSS, 2003
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    • 81. Obesity Trends* Among U.S. AdultsBRFSS, 2004
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    • 82. Obesity Trends* Among U.S. AdultsBRFSS, 2005
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    • 83. Obesity Trends* Among U.S. AdultsBRFSS, 2006
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    • 84. Obesity Trends* Among U.S. AdultsBRFSS, 2007
      (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
      No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    • 85. In 1990, 10 states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%.
      By 1998, no state had prevalence less than 10%, seven states had a prevalence of obesity between 20-24%, and no state had prevalence equal to or greater than 25%.
      In 2007, only one state had a prevalence of obesity less than 20%. Thirty states had a prevalence equal to or greater than 25%; three of these states (Alabama, Mississippi and Tennessee) had a prevalence of obesity equal to or greater than 30%.
      Obesity Trends Summary
    • 86.
    • 87. 1988–2007 No Leisure-Time Physical Activity Trend Chart
    • 88. One third of adult women in the United States are obese.
      During pregnancy, obese women are at increased risk for several adverse perinatal outcomes, including anesthetic, perioperative, and other maternal and fetal complications.
      Obstetricians should provide preconception counseling and education about the possible complications and should encourage obese patients to undertake a weight reduction program before attempting pregnancy.
      Obesity in Pregnancy- ACOG Committee Opinion 2005
    • 89. Increased risk of SAB
      “Women should be encouraged to undergo weight loss prior to infertility treatment” (ACOG CO)
      For type I Obesity (BMI 30-34.9) & type II (BMI 35-39.9)
      Obesity in Pregnancy
    • 90. Surgical Complications
      Increased blood loss
      Increased wound infection
      Increased endometritis
      Difficult anesthesia
      Obesity in Pregnancy
    • 91. Increased difficulty of ultrasound
      Increased risks of fetal anomalies
      Difficulty with fetal monitoring and UC monitoring
      Obesity in Pregnancy
    • 92. Bariatric surgery patients
      Decreased complications in comparison to obesity
      Delay surgery 12-18 months after surgery (rapid wt loss phase)
      Vitamin supplementation
      Wt loss recommended thru nutritional consult and exercise
      Obesity
    • 93. Obesity- Politically Correct and Medically Incorrect
    • 94. Smoking in Pregnancy
    • 95. Smoking in Pregnancy
    • 96. Smoking among women of childbearing age
      US, 1997-2007
      Footnotes available in notes section.
      Source: Smoking: Behavioral Risk Factor Surveillance System. Behavioral Surveillance Branch, Centers for Disease Control and Prevention. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 97. Approx 20% or reproductive age women smoke
      11% of all women smoke during pregnancy
      Nicotine substitute products in periconception period are associated with +/- risk of congenital malformation and possible neurotoxicity in the 2nd and 3rd trimester
      Negligible risk of congenital anomalies (but possible increased risk of clefts, double the risk of CHD septal defects)
      Preconception and Smoking
    • 98. IUGR
      Stillbirth
      Abruption
      Preterm Birth
      Possible increased risk of ADHD
      Lowered cognitive ability on childhood testing
      Increased risk of Childhood Obesity
      Smoking During Pregnancy
    • 99. Want to avoid nicotine substitute products during pregnancy
      Only 20 % of women completely stop smoking during pregnancy
      Many smokers fail on their first attempt
      Why Preconception Smoking Cessation?
    • 100. A meta-analysis of 12 studies found the overall OR for risk of infertility in the general population was 1.6 (95%CI 1.34–1.91) for smokers compared to non-smokers (Augood et al., 1998)
      An OR of 1.54 (95%CI 1.19–2.01) was found for delayed conception of 12 months in women who smoked compared with women who did not smoke and an OR of 1.14 (95%CI 0.92–1.42) for passive smoking
      The adjusted odds ratio (95% confidence interval) for spontaneous abortion among current smokers prior to conception was 1.20 (1.04-1.39) per every extra five cigarettes smoked per day
      Preconception and Smoking
    • 101. Increased risk of SABs
      Increased craniofacial defects
      Increased neurobehavioral deficits
      1st Trimester Moderate to Severe EtOH Usage
    • 102. 45% of women report alcohol use in the first 3 months of pregnancy prior to knowledge of pregnancy
      5% report 7 or more drinks per week
      Alcohol and Preconception
    • 103. Binge alcohol use among women of childbearing age
      US, 1997-2007
      Footnotes available in notes section.
      Source: Alcohol Use: Behavioral Risk Factor Surveillance System. Behavioral Surveillance Branch, Centers for Disease Control and Prevention. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
    • 104. Effect of Pregnancy on Drinking Behavior
    • 105. TACE Questionaire
    • 106.
    • 107. Preconception Hemoglobin
      The model was adjusted for maternal age, height, height-squared, BMI,
      education, work stress, maternal exposure to dust, noise, and passive
      smoking, infant gender, and gestational age.
      Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
    • 108. Preconception Hb level and SGA
      Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
    • 109. Ferritin and SGA
      Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
    • 110. Ferritin and PTB
      Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
    • 111. Periodontal Disease
    • 112. Periodontal disease has been associated with
      Preterm birth
      SGA
      Preeclampsia
      Gestational DM
      Fetal loss
      Maternal treatment of periodontal disease in pregnancy decreases risk of LBW in babies with PTB (pooled RR 0.53, 95% CI 0.30–0.95, P.05)
      Oral Health and Pregnancy
    • 113. Periodontal Disease and Preterm Birth
    • 114. Six studies, representing a total of 3420 women (493 pre-eclamptic and 2927 non-pre-eclamptic control women) were pooled for meta-analysis.
      Women with evidence of periodontal disease during pregnancy had a 1.76 fold higher risk of pre-eclampsia compared with women without periodontal disease (OR, 1.76, 95% CI: 1.43–2.18).
      Periodontal Disease and Preeclampisa
      Vergnes et al. Evidence-Based Dentistry (2008) 9, 46–47.
    • 115. Data with mixed outcomes with dental scaling in pregnancy
      Could this be due to treatment coming to late?
      Could periodontal disease be a marker for inflammation and suceptibility to infection?
      Treatment causes bacteremia
      Periodontal Disease – Treatment During Pregnancy
    • 116. Why treatment before pregnancy?
      Studies of treatment during pregnancy show some help but are not overly conclusive
      Treatment during pregnancy may be too late or associated with temporary rises in inflammatory mediators- may need treatment prior to pregnancy to get effect
      Hard to get treatment during pregnancy – especially for more difficult cases
    • 117. Generalists and Preconception Care
      Preconception care has special benefits for women with chronic medical problems many of whom are cared for by internists
      In one large study, 13.9% of women entering prenatal care had an identified medical problem
    • 118. Generalists and Preconception CareCommon conditions seen by generalists in practice include:
      Diabetes
      Asthma
      Hypertension
      Seizures
      Lupus erythematosus
      Inflammatory bowel disease
      Thyroid disorders
      Hemoglobinopathy
      Thromboembolic disease
      Congenital heart disease
      Rheumatic heart disease
    • 119. Decreases miscarriage
      Decreases anomalies
      Rule out renal disease as a contraindication to pregnancy
      Treatment of periodontal disease improves HbA1C by an average of 0.79%
      Emphasize need for diet, exercise, weight control
      Prevent unplanned pregnancy
      Preconception Diabetic Control
    • 120. Congenital Anomalies in DM and Gestational Age
      Caudal regression 5 weeks
      Situsinversus 6 weeks
      Spina bifida 6 weeks
      Anencephaly 6 weeks
      Heart anomalies 7-8 weeks
      Anal/rectal atresia 8 weeks
      Renal anomalies 7 weeks
    • 121. Hemoglobin A1c and Congenital Anomalies
    • 122. Prevention of Congenital Malformations in Diabetics
      Study by Fuhrmann, et al. 1983
      Preconception treatment, n=128
      1% malformations
      Late Pregnancy registrants, n=292
      7.5% malformations
    • 123. The costs ofpreconception plus prenatal care are $17,519/delivery, whereas the costs ofprenatal care only are $13,843/delivery.
      However, taking into account maternal andneonatal adverse outcomes
      net savings of preconception care are$1720/enrollee over prenatal care only
      Preconception Diabetes Care Cost
    • 124. Subclinical or clinical hypothyroidism is present in 2-3% of all pregnancies
      Fetus is fully dependent on maternal thyroid levels till 13 weeks of gestation
      Low thyroid levels associated with decreased IQ and severe hypothyroidism with poor neurodevelopment
      Hypothyroidism and Pregnancy
    • 125. Preconception thyroid medication should be adjusted to achieve a TSH level of less than 2.5 mU/mL before pregnancy
      Inform patient of need for increase in meds of approximately 50% in pregnancy by 20 weeks.
      Inform patient to take two extra pills per week to elevate thyroid levels at initial diagnosis of pregnancy (30% increase)
      Prevent unplanned pregnancy
      Preconception Treatment of Thyroid Disease
    • 126. Malformations in Fetuses of Women with Epilepsy
      Increased 2-3x over background risk
      Anticonvulsants have teratogenic risk.
      Seizures in pregnancy increase the risk of malformation
      An idiopathic seizure disorder is a risk independent of medications and seizure during gestation
      The best regimen is the one that best prevents seizure
      monotherapy whenever possible
    • 127. Who is an optimal candidate for withdrawal of anticonvulsants?
      No seizure in 2-4 years or longer on medications
      normal CT Scan of brain
      EEG normalized
      Absence of cerebral dysfunction
    • 128. Immunizations
      Women of childbearing age in the US should be immune to measles, mumps, rubella, varicella, tetanus, diptheria, and poliomyelitis through childhood immunizations
      If immunity is determined to be lacking, proper immunization should be provided
      Need for immunizations according to age group of women and occupational or lifestyle risks
    • 129. Cystic Fibrosis
      Jewish Screening panel
      Hemoglobinopathy screening
      Genetic Screening
    • 130. For your patients
      http://www.perinatalweb.org/images/stories/PDFs/Materials%20and%20Publication/becoming%20a%20parent_preconception_checklist.pdf
      For professionals – the answer key to the above
      http://www.perinatalweb.org/images/stories/PDFs/Materials%20and%20Publication/becoming_parent_provider_reference.pdf
      Other Helpful Sites

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