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
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……
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.
Preconception Care: The Only Care that Counts Brian K. Iriye, M.D. Center For Maternal-Fetal Medicine Las Vegas, NV www.cmfm.net
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
The Tortise Preventative care Vaccinations Cholesterol levels Preconception care Tortise versus the Hare
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.
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.
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.
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.
Most prenatal care in the U.S. starts in the 1st or 2nd trimester “Early” Prenatal Care 83.7
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.
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.
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
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?
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
Reasons Prenatal Care Effects are Limited Average Prenatal Care starts after vital organs are formed Average Prenatal Care starts after vital genes are modified
Old School- fetal health is determined by its genes New School- fetal genes are determined by the environment Epigenetics The New Buzzwords– Fetal Programming
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
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
Fetal Programming- Thrifty Phenotype Odds ratio for risk of type II diabetes and or impaired glucose tolerance based upon birthweight
Fetal Programming- Thrifty Phenotype Odds ratio for risk for the development of the metabolic syndrome based upon birthweight
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
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
4 million pregnancies/yr in U.S 2 million are unplanned Prenatal care benefits appear to have been maximized Preconception Care- the Problem
Age: Unintended Pregnancy Among Women Having a Live Birth- 1999
Medicaid Status: Unintended Pregnancy Among Women Having a Live Birth- 1999
Race: Unintended Pregnancy Among Women Having a Live Birth- 1999
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
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
Title V and Preconception Care 23 states with focus on preconception care
Vitamins Obesity Tobacco Alcohol Immunizations Anemia Medical Diseases What Can We Do or Act Against?
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
Periconception Vitamin Use and Preterm Birth Catov JM et al . Am J Epidemiol. 2007 Aug 1;166(3):296-303.
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
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.
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.
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
Periconceptional Multivitamin Use and Birth Defect Prevention Worldwide
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
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
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
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
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
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
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
Obesity Trends* Among U.S. AdultsBRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
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%
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%
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%
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%
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%
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%
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%
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%
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%
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%
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%
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
1988–2007 No Leisure-Time Physical Activity Trend Chart
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
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
Surgical Complications Increased blood loss Increased wound infection Increased endometritis Difficult anesthesia Obesity in Pregnancy
Increased difficulty of ultrasound Increased risks of fetal anomalies Difficulty with fetal monitoring and UC monitoring Obesity in Pregnancy
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
Obesity- Politically Correct and Medically Incorrect
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.
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
IUGR Stillbirth Abruption Preterm Birth Possible increased risk of ADHD Lowered cognitive ability on childhood testing Increased risk of Childhood Obesity Smoking During Pregnancy
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?
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
Increased risk of SABs Increased craniofacial defects Increased neurobehavioral deficits 1st Trimester Moderate to Severe EtOH Usage
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
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.
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
Preconception Hb level and SGA Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
Ferritin and SGA Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
Ferritin and PTB Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
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
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.
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
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
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
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
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
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
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
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
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
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
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
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
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