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Preconception care : long term outcome


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마더리스크라운드 발표자료. 이민영 제일병원 산부인과 전공의

마더리스크라운드 발표자료. 이민영 제일병원 산부인과 전공의

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  • 1. Preconception care : Longterm outcome
  • 2. • A set of prevention and management interventions that aim to identify and modify biomedical , behavioral, and social risks to a woman’s health or pregnancy outcome (CDC’s Select Panel on Preconception Care, June 2005)
  • 3. • Optimize the woman’s health• Minimize risks to her and the fetus and improve pregnancy outcomne• Provide information necessary to maked informed decisions about future reproduction
  • 4. Why preconception care?
  • 5. “The physical treatment of children should begin as far as may be practicable, with the earliest formation of the embryo ; it will, therefore, necessarily involve the conduct of the mother, even before her marriage, as well as during her pregnancy.”(1825 , William Potts Dewees first American textbook on Pediatrics)
  • 6. • Adverse pregnancy outcomes remain a prevalent health problem – 12% of babies are born premature, 8% with low birth weight – 3% have major birth defects – 31% of women giving birth suffer pregnancy complications• Risk factors for adverse pregnancy outcomes remain prevalent among woment of reproductive age – Smoking, obesity, teratogenic drugs, preexisiting medical conditions (diabets)
  • 7. Infant Deaths per 1,000 Live Births 25 20.01 20 US 15 10 6.8 5 0 1970 1975 1980 1985 1990 1995 2000 2004 Year
  • 8. 12.3% Increase 15.45% Increase US, 1995-2005 US, 1995-2005
  • 9. • To prevent some birth defects – The heart begins to beat at 22 days after conception – The neural tube closes by 28days after conception – The palate fuses at 56days after conception – Critical period of teratogenesis ; Day 17~56• To prevent implantation errors
  • 10. Weeks gestation 4 5 6 7 8 9 10 11 12from LMP Central Nervous SystemMost susceptible Hearttime for majormalformation Arms Eyes Legs Palate External genitalia Ear Missed Period Mean Entry into Prenatal Care
  • 11. • Currently – Poor pregnancy outcomes – Women enter pregnancy “at risk” for adverse outcomes – We intervene too late• There is consensus that we must act before pregnancy – Intervening before pregnancy will help improve outcomes
  • 12. Early prenantal care is not enough,In many cases it’s too late!!
  • 13. • Reducing unintended pregnancy• Prevent birth defects• Prevent LBW and prematurity• Prevent poor pregnancy outcomes and recurrence• Promote healthy behaviors and reduce risk-taking behaviors• Prepares and reinforces parents for parenting• Promote family planning
  • 14. Preconception care ;Women with chronic disease
  • 15. • Associated with adverse pregnancy outcomes – HTN – Kidney disease – DM – Autoimmune disease – Blood disease – Thyroid dz. – Epilepsy – Tuberculosis – Asthma – Mental health – Infectious disease – Other – Cardio-vascular disease – Cancer
  • 16. • Thyroid disease – The second most common endocrine disease that affects women of reproductive age – Overt thyroid disease is present in 1% of women of childbearing age
  • 17. • In thyroid function associated with pregnancy – Hormone change • hCG(Human chorionic gonadotropin) – High circulating hCG levels in the first trimester may result in a slightly low TSH, TSH return to normal throughout the duration of pregnancy • Estrogen (placenta origin) – Increases the amount of thyroid hormone binding proteins in the serum which increases the total thyroid hormone levels – Size change • Increase in size during pregnancy • Usually only a 10-15% increase in size
  • 18. • First 10~12weeks of pregnancy – Baby is completely dependent on mother for the production of thyroid hormone• By the end of the first trimester – Baby’s thyroid begins to produce thyroid hormone on its own
  • 19. • Occur in approximately 0.2% of all pregnancies• Most common cause – 80~85% : Grave’s disease , 1/1500 pregnant patients – Transient hyperthyroidism; hyperemesis gravidarum• Maternal and fetal outcome is directly related to the control of hyperthyroidism
  • 20. • Uncontrolled maternal hyperthyroidism – Fetal tachycardia – SGA ,Prematurity, stillbirth, Preecalmpsia – Possibly congenital malformations• Extremely high level of TSI – TSI cross the placenta, interact with baby’s thyroid – Cause fetal or neonatal hyperthyroidism• Anti-thyroid drug therapy – Methimazole cross the placenta, potentially impair the baby’s thyroid function and cause fetal goiter
  • 21. • Treatment of thyroid conditions improves pregnancy outcomes• Overt maternal hyperthyroidism should be treated with antithyroid medication – PTU is the drug of choice – Methimazole has been associated with fetal develpomental abnormalities – If a women is currently on methimazole, she should be converted to PTU prior to pregnancy
  • 22. • Radioactive iodine treatment – Customary to avoid pregnancy for the first 6 months after radioactive iodine treatment – Contraindicated to treat hyperthyroidism during pregnancy ; If given after 12 weeks of GA, Crosses the placneta Increased risk of fetal thyroid destruction  Permanent hypothyroidism
  • 23. • Occurs approximately 2.5% of all pregnancies in the US – Subclinical hypothyroidism; 2~5% of pregnant women – Most common cause ; Autoimmune disorder known as Hashimoto’s thyroiditis• Negative impact on pregnancy outcomes
  • 24. • Mother (Severe hypothyroidism) – Maternal anemia, Myopathy(muscle pain, weakness) – Congenital heart disease – Preeclampsia, placenta abnormality, etc• Baby – Untreated maternal severe hypothyroidism can lead to impaired baby’s brain development – Children born with congenital hypothyroidism can have severe cognitive, neurological, developmental abnormalities
  • 25. • Adquate replacement of thyroid hormone in the form of Synthetic levothyroxine• Anticipate that thyroid medications will need to be increased by 30~50% through the course of the pregnancy, likely as early as 6~8wks• Subclinical hypothyroidism poses an unclear risk for fetal intellectual development, however replacement therapy is recommended
  • 26. • Universal thyroid laboratory tests are not recommended for all women seeking fertility• Women may benefit from screening – History of thyroid dysfuction in the past, including thyroid surgery – Family history of thyroid disease – Goiter – Clinical signs of hyper/hypothyroidism – Other autoimmune disorders
  • 27. Preconception care ; What should men do ?
  • 28. • Little attention has been given to men’s preconception health and health care• In the US, there has been a steady increase in research and programs on men’s health “ Men as Partners in reproductive health”
  • 29. • Why Preconception care for men is important? – Improving family planning and pregnancy outcomes, enhancing the reproductive health and health behavior of their female partners, and preparing men for fatherhood – Offer an opportunity for disease prevention and health promotion in men
  • 30. A. Risk Assessment 1) Reproductive life plan • A set of personal goals about having children 2) Past medical and surgical history • Review about the patient’s past medical and surgical history, including ant ongoing medical conditions that may impair his reproductive health • Several medical conditions; DM, varicocele, STD, etc 3) Medications • Review about past and current medication use, including prescription, nonprescription and herbal products
  • 31. 4) Family history and genetic risks • Genetic risk assessment should be based on family history, paternal age, and ethnicity • Several genetic disorders may impair fertility and sperm quality; Cystic fibrosis, Klinefelter sydrome, Kartagener syndrome, polycystic kidney disease, etc • If the patient belongs to an ethnic group at increase risk for certain genetic disorders, the provider should screen the patient ; Ashkenazi Jews, African Americans, Southeast Asians, Mediterranean
  • 32. 5) Social History• Review about social history, potential occupational exposures, potential reproductive toxicity• Exposures to metals, solvents, endocrine disruptors, any chemical exposure, pesticides at work• Impair sperm quality, lead to infertility, miscarriage, birth defects
  • 33. 6)Risk Behaviors① Tobacco – Associated with decreased sperm count , abnormal sperm morphology, motility, fertilizing capacity – Nocotine , other chemical s in cigarettes can also induce oxidative damage to sperm DNA② Alcohol – Testosterone level, semen volume, sperm count, the number of sperm with normal morphology were lower than nonalcoholic men
  • 34. 7)Risk Behaviors③ Marijuana, cocaine, anabolic steroids – Reduce testosterone production, sperm count, semen quality, abnormal sperm morphology④ Several Hobbies – Hazard exposure to organic solvents, lead or other heavy metals; Refinishing furniture, repairing cars, painting, building models, or pottery, making stained glass windows, or cleaning guns
  • 35. 8) Nutrition• Zinc and folate have antioxidant properties and protect sperm against oxidative stress and DNA damage• Other antioxicants have also been used to treat male infertility – Vitamin C, vitamin E, Selenium, Glutathione, ubiquinol, carnitine, and carotenoids
  • 36. 9) Physical Examination and Laboratory testing• Guided by clinical history – Men at increase risk for STD should be offered screening for HIV, syphilis, etc – The United States Preventive Services Task Force (USPSTF) recommends • For high blood pressure and obesity; men aged 35 and older for lipid disorders; men with hypertension or htperlipidemia for type 2 diabetes mellius; men aged 50 and oler for colorectal cancer • Testicular cancer in young men or prostate cancer in men aged 50 and older
  • 37. B. Health Promotion1) Healthy weight and nutrition • Overweight or obese men ;associated with lower testosterone level, poorer sperm quality, and reduced fertility • Infertility increases by 10% for every 20Ibs overweight • Men should be encouraged to set weight loss goals, ant to exercise at least 30 minutes a day on most days of the week
  • 38. B. Health Promotion2) Stress reduction and enhancing resilience • Impact of chronic stress • Reproductive health ; decrease steroidogenesis and spermatogenesis, oxidative damage to sperm • Recommends • Promote stress reduction • Regular exercise, adequate sleep, balanced nutrition3) Inflammation and immunization • Chronic inflammation can cause oxidative damage to sperm • Appropriate vaccines should be offered
  • 39. C. Clinical and Psychosocial Interventions – Three types of psychosocial services • Social services; financial literacy training or assistance with job placement • Clinical support • Partner and Parenting support
  • 40. Longterm outcome of PC ; Fetal orgins of adult disease
  • 41. • Fetal nutrition and endocrine status result in developmental adaptations that permanently change structure, physiology, and metabolism, thereby predisposing individuals to cardiovascular, metabolic, and endocrine disease in adult life – Barker(thrifty) hypothesis – Catch up growth hypothesis
  • 42. Epigenetic regulation Fetal adaption Maternal health Placental healthPredispositionto Adult life
  • 43. A. Low birht weight – About 7~8% of all liveborn infants – Cause : Maternal factors, Placental pathology, Intrauterine infection, smoking, alcohol, severe PGDM, etc
  • 44. Coronary heart disease death rates (Osmond et al United Kingdom, from 1911 to 1930, according to birth weight)
  • 45. Incidence of death from CVD & incidence of diabetes(Rinaudo PF, et al. Semin Reprod Med 2008; 26: 436-45, from Thieme Medical Publishers)
  • 46. B. Macrosomia (LGA) – Referred to a birth weight above the 90ieth percentile – Cause; Maternal diabetes, Maternal overweight prior to pregnancy and excessive weight gain during pregnancy, prolonged pregnancy, polyhydramnios, etc – LGA infants who were not exposed to maternal diabetes or obesity were not at increased fisk for metabolic syndromeC. Newborns with SGA or LGA are at increased risk to develop a metabolic syndrome later in life
  • 47. WHO definition
  • 48. • Offspring of diabetic mothers – Depend on the severity of diabetes • Good control : nomalize fetal growth • Poorly control (absence complication):Macrosomia • Severe diabetics (if, nephropahty) : SGA – The rate of overweight at childhood and adolescence is generally higher in the offspring of diabetic mothers compared to children of mothers without GDM
  • 49. (C. Savona-Ventura et al : Int. J Risk Safety Med , 2007, 19:229-236)
  • 50. • Ensure that metabolic control is at an optimum level to prevent congenital anomalies• Check for and treat any proliferative retinopathy• Assess kidney function• Assess thyroid fuction• Blood pressure control• Cardiac evaluation• Neurological evaluation• Stop smoking
  • 51. • Nutritional prescriptions should be personalised taking into account personal habits, body weight, physical actibity, etc• Recommended daily caloric intake – BMI<19.8 kg/m2  35~40kcal/kg body weight – BMI 19.9~29 kg/m2  30~32kcal/ kg body weight – BMI >29 kg/m2  24~25kcal/kg body weight• Remember folic acid supplements and foods rich in antioxidants• Exercise should be promoted  Walking for at leat 30 min per day