마더리스크라운드 발표자료. 이민영 제일병원 산부인과 전공의

1. Preconception care
: Longterm outcome

3. • 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)

4. • 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

5. Why preconception care?

6. “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)

7. • 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)

8. 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

9. 12.3% Increase 15.45% Increase
US, 1995-2005 US, 1995-2005

10. • 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

11. Weeks gestation 4 5 6 7 8 9 10 11 12
from LMP
Central Nervous System
Most susceptible
Heart
time for major
malformation Arms
Eyes
Legs
Palate
External genitalia
Ear
Missed Period Mean Entry into
Prenatal Care

12. • 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

13. Early prenantal care
is not enough,
In many cases it’s too late!!

15. • 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

16. Preconception care
;Women with chronic disease

17. • 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

18. • 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

19. • 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

20. • 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

21. • 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

22. • 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

23. • 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

24. • 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

25. • 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

26. • 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

27. • 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

30. • 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

31. Preconception care
; What should men do ?

32. • 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”

33. • 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

34. 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

35. 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

36. 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

37. 6)Risk Behaviors
① 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 DNA
② Alcohol
– Testosterone level, semen volume, sperm count, the
number of sperm with normal morphology were lower
than nonalcoholic men

38. 7)Risk Behaviors
③ Marijuana, cocaine, anabolic steroids
– Reduce testosterone production, sperm count, semen
quality, abnormal sperm morphology
④ 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

39. 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

40. 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

41. B. Health Promotion
1) 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

42. B. Health Promotion
2) 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 nutrition
3) Inflammation and immunization
• Chronic inflammation can cause oxidative damage to sperm
• Appropriate vaccines should be offered

43. 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

44. Longterm outcome of PC
; Fetal orgins of adult disease

45. • 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

47. Epigenetic
regulation
Fetal adaption
Maternal health
Placental health
Predisposition
to Adult life

48. A. Low birht weight
– About 7~8% of all liveborn infants
– Cause : Maternal factors, Placental pathology, Intrauterine
infection, smoking, alcohol, severe PGDM, etc

49. Coronary heart disease death rates
(Osmond et al United Kingdom, from 1911 to 1930, according to birth weight)

50. Incidence of death from CVD & incidence of diabetes
(Rinaudo PF, et al. Semin Reprod Med 2008; 26: 436-45, from Thieme Medical Publishers)

52. 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 syndrome
C. Newborns with SGA or LGA are at
increased risk to develop a metabolic
syndrome later in life

53. WHO definition

54. • 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

55. (C. Savona-Ventura et al : Int. J Risk Safety Med , 2007, 19:229-236)

57. • 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

58. • 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