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  • For example,since 2002, the American College of Obstetricians and Gynecologists has recommended that All health encounters during a woman’s reproductive years, particularly those that are a part of preconceptional care should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes.
  • In addition, the lack of existing CPT coding for preconception care.
  • In addition, the lack of existing CPT coding for preconception care.
  • In addition, the lack of existing CPT coding for preconception care.
  • In addition, the lack of existing CPT coding for preconception care.
  • Who should provide preconception care: Physicians, FP, Pediatricians, Internist, General Practitioners Nurse, Nurse Practitioners, Nurse-Midwife Health Education Specialist Genetic Counselor Family Panning Counselor
  • Preconception risk reduction activities have been practiced for many years, in one form or the other (e.g., .general counseling, testing for rubella and syphilis, family planning, genetic screening and counseling etc.) It’s only in the last 2 decades that the concept has emerged of an organized comprehensive program.
  • Given that 49% of pregnancies in the U.S. are unintended (Henshaw, 1998), preconception care must be introduced into health care settings that: - are convenient for the women - can reach as many women as possible Although preconception care should not be thought of as one more thing to do in the limited time we have for each patient visit, it is, in fact, a part of what most of us are already doing. Annual gynecological visit Pediatric visit Routine postpartum visit
  • Marion Our aim for Professional Education is to assist health care practitioners to improve preterm birth risk detection and address risk-associated factors (e.g., smoking)

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  • Preconception Care Aboubakr Elnashar Prof Obs Gyn, Benha University Hosp, Egypt [email_address]
    • Duration of pregnancy is no longer “9” months, it’s “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
  • Outline
    • Definition & Goals
    • Why Do We Need PCC?
    • Components
    • Scientific Evidence
    • Current Recommendations
    • Barriers
    • Implementation
  • Definition
    • A set of interventions that
    • aim to identify & modify (biomedical, behavioral & social) risks to a woman’s health or pregnancy outcome
    • through prevention & management (CDC, 2006)
  • Goal
    • Goal should be realistic
    • To identify pre-existing conditions that may affect an anticipated pregnancy
    • Identification process involves mother& fetus
    • This may allow for intervention (s) that could lead to more favorable outcome
  • Why?
    • Currently:
    • Poor pregnancy outcomes
    • Women enter pregnancy “ at risk ” for adverse outcomes
    • We intervene too late
    • There is consensus that:
    • Intervening before pregnancy will help improve outcomes
  • Early ANC is too late 1. To Prevent Some Birth Defects The heart begins to beat at 22 days after conception The neural tube closes by 28 days after conception The palate fuses at 56 days after conception Critical period of teratogenesis – D17 to D56 2. To Prevent Implantation Errors 3. To restore allostasis: Maintain stability through change An important objective of PCC is to restore allostasis to women’s health before pregnancy
  • Critical Periods of Development Critical Periods of Development 4 5 6 7 8 9 10 11 12 Weeks gestation from LMP Central Nervous System Central Nervous System Heart Heart Arms Arms Eyes Eyes Legs Legs Teeth Teeth Palate Palate External genitalia External genitalia Ear Ear Missed Period Mean Entry into ANC Most susceptible time for major malformation
  • From Anticipation & Management to Health Promotion& Prevention From Healthy Mothers Healthy Babies to Healthy Women Healthy Mothers Healthy Babies Paradigm Shift
    • Components
    • CDC, 2007
    • Risk Assessment
    • Health promotion
    • Interventions
    • A. Risk Assessment
    • 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
    • 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
    • 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
    • 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
    • II. Physical examination:
    • 1. Nutritional assessment:
    • Assess the ABCDs of nutrition:
    • a nthropometric factors (e.g., BMI)
    • b iochemical factors (e.g., anemia)
    • c linical factors
    • d ietary risks
    • 2. Focus on
    • Periodontal,
    • thyroid, heart,
    • breast,
    • pelvic examination
    • 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
    • 2. Genetic screening:
    • Based on:
    • family history
    • ethnic background
    • Age
    • Offer cystic fibrosis & other carrier screening as indicated
    • 3. Psychosocial concerns:
    • Screen for
    • depression,
    • anxiety,
    • domestic violence
    • major psychosocial stressors
    • 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
    • B. Health Promotion
    • Family planning:
    • Based on the patient’s reproductive life plan
    • Effective contraceptive use
    • Discuss emergency contraception
    • 2. Healthy weight and nutrition:
    • Ideal BMI : 20 to 26.0 kg/m 2 Exercise
    • Nutrition
    • Macro & micronutrients:
    • Getting “five a-day”: 2 servings of fruit +3 servings of vegetables
    • Daily multivitamin that contains folic acid
    • 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 A’s [Ask, Advise, Assess, Assist, Arrange] for smoking cessation
    • Alcohol
    • Substance abuse
    • 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
    • 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
    • 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.
    • 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.
    • 7. STD screening& TT
    • Reduce s 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.
  • 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.
    • 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 disease
    • PPC for men
    • Alcohol
      • May be associated with physical & emotional abuse
      • May decrease fertility
    • Genetic Counseling
    • Occupational Exposure
    • - lead
    • STD
      • Syphilis, herpes, HIV
  • Scientific Evidence Does PCC work?
  • There is evidence that individual components of PCC work:
    • Rubella vaccination
    • HIV/AIDS screening
    • Management and control of:
      • Diabetes
      • Hypothyroidism
      • PKU
      • Obesity
    • Folic Acid supplements (level 2)
    • Avoiding teratogens:
      • Smoking
      • Alcohol (level 2)
      • Oral anticoagulants
      • Accutane
  • Clinical Practice Guidelines
    • Clinical practice guidelines for PCC of specific maternal health conditions have been developed by professional organizations:
        • American Diabetes Association (Diabetes -2004)
        • American Association of Clinical Endocrinologists (Hypothyroidism – 1999)
        • American Academy of Neurology (Anti-epileptic drugs)
        • American Heart Association/American College of Cardiologists (Anti-epileptic drugs - 2003)
  • ACOG/AAP (2002)
      • All health encounters during a woman’s reproductive years, particularly those that are a part of PCC should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes.
      • ACOG/AAP Guidelines for perinatal care, 5 th edition, 2002
  •  
  • USPHS
    • “ Every woman (and, when possible, her partner) contemplating pregnancy within one year should consult a prenatal care provider. Because many pregnancies are not planned, providers should include preconception counseling, when appropriate, in contacts with women and men of
    • reproductive age….Such care should be integrated into primary care services.”
    • USPHS Expert Panel on the
    • Content of Prenatal Care, 1989
  • Barriers
    • I. Patient Aspects
    • High rate of unintended pregnancies
    • Ignorance about importance of good health habits prior to conception
    • Limited access to health services in general.
    • II. Provider Aspects
    • Feeling of having inadequate knowledge
    • Perception of PCC being time consuming
    • Lack of awareness of how to integrate PCC into practice
    • Concern about insurance reimbursement.
    • III. Other Barriers:
    • Availability of contraceptives
    • Health Insurance Coverage
    • Out of Pocket Expenses.
  • Implementation
    • Who Should Get PCC?
    • PCC should be provided to all reproductive age individuals
    • WHO TO PROVIDE?
      • OB-GYNs
      • Pediatricians, Family Medicine, Internists,
      • Nurses
      • Genetic Counselors
      • Health Educators
  • Why Should Ob/Gyns be Concerned with PCC?
    • OB/GYN’s
    • have the most frequent contact with women of childbearing age
    • are aware of prior poor pregnancy outcomes
    • Responsible for ANC
    • already have the knowledge & are applying it
    • advantage to improve pregnancy outcomes
    • How PCC can be Integrated into Practice?
      • OB-GYNs
    • 1. WHC:
    • Our best opportunity
    • Single or multiple visits
    • - Ask about reproductive life plan
    • - If she plans to have child in next 1-2 yrs: she & husband should return for full visit.
    • 2. Negative pregnancy test: an opportunity for PCC
    • 3. Family planning encounter
    • 4. Infertility evaluation
    • 5. Following a poor pregnancy outcome
  • CONCLUSION “PCC is the cornerstone of healthy infants, children, families & communities ” Thank you