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
Concept has evolved over the last several decades
Form of primary care & prevention
12 NOT 9
Definition & Goals
Why Do We Need PCC?
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 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
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
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
Identify resources to help the patient develop problem solving and conflict-resolution skills, positive mental health, and strong relationships
6. Interconception care:
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
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.
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:
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
PPC for men
May be associated with physical & emotional abuse
May decrease fertility
Syphilis, herpes, HIV
Scientific Evidence Does PCC work?
There is evidence that individual components of PCC work:
Management and control of:
Folic Acid supplements (level 2)
Alcohol (level 2)
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)
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
“ 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
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.
Who Should Get PCC?
PCC should be provided to all reproductive age individuals
WHO TO PROVIDE?
Pediatricians, Family Medicine, Internists,
Why Should Ob/Gyns be Concerned with PCC?
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?
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