The document provides a comprehensive overview of preconceptual counseling aimed at improving maternal and fetal health through the identification and management of health risks before pregnancy. It highlights the importance of medical history, dietary considerations, exercise, substance use, and weight management in optimizing pregnancy outcomes. Additionally, it addresses various maternal medical conditions and emphasizes the need for prenatal education to ensure better self-care and pregnancy results.

1. Pre-pregnancy 101 Melissa Stoffel D.O. Marshfield Clinic OB/GYN May 26, 2009

2. Preconceptual Counseling Definition: Identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management. Goal: Help the mother maintain her well-being and achieve a healthy outcome not only for herself, but for her unborn child.

3. Preconceptual Counseling Optimal time to assess, manage and treat many conditions/complications before conception. Improves pregnancy outcomes. Reduced maternal/neonatal morbidity and mortality.

4. Components Identification of pregnancy related risks Pt education regarding pregnancy risks, management options, and reproductive alternatives Initiation of interventions, when possible, to provide optimum pregnancy outcome

5. What to Expect Complete medical/family history Physical exam laboratory

6. Comprehensive History Age Teens – nutritional/emotional needs, STD’s >35 yrs – increase pregnancy risks Father >age of 55

7. Comprehensive History Reproductive history (obstetrical/gynecologic) May identify factors that may contribute to infertility or pregnancy complications Menstrual calendar (accurate dating is critical for obstetric decision making)

9. Personal Medical History Medications STI hx Chronic medical conditions Immunization hx – up to date Surgeries Mental Health

11. Family History Helps identify genetic risks to fetus and maternal medical risks Ethnicity

12. Psychosocial Issues Stress, financial issues, mental health Maternal suffering can lead to poor compliance, nutrition, substance abuse, or disturbed relationship between mom and baby

13. Weight and pregnancy Obesity is associated with decreased fertility Normal Pre-pregnancy BMI 19.8 – 26.0 Increased pregnancy complications with extremes of BMI Weight reduction attempted prior to pregnancy

14. Exercise Mild – moderate exercise while pregnant is not harmful if done on a regular basis prior to pregnancy Do not initiate a strenuous exercise regime during pregnancy Low impact routine

15. Substance Use Tobacco Increase miscarriage, prematurity, and low-birth weight infants, IUGR, placenta abruption, Smoking cessation/decreased amount during pregnancy improves pregnancy outcomes Chantix not used in pregnancy

16. Substance Use Alcohol and Illicit Drugs Increase preterm delivery, IUGR, FAS, neonatal withdrawal Avoidance of all = better pregnancy outcomes Methadone Clinic

17. Substance Use Caffeine Limit 300mg/d Consumption of >250mg/d can decrease fertility >500mg/d increase miscarriage, stillbirth, low-birth weight infants

19. Environmental Exposures Avoid organic solvents Toxoplasmosis Mercury Lead (paint, arts/crafts) No harm from computer monitors, electric blankets, heated water beds, microwave Work place (OSHA)

20. Nutrition The fetal environment affects infant and childhood development. Dietary changes that optimize growth and development have life long health benefits. Vegetarian diets lack adequate amts of amino acids and iron, vitamin B12 and complex lipids.

21. Nutrition Discontinue megavitamins, non-essential dietary supplements, and herbal preparations. (not studied to evaluate fetal risk) No evidence that Nutrasweet, Splenda, Sweet N’ Low increase risk of birth defects above the general population. Multivitamin/prenatal vitamin with 400mcg (0.4mg) of folic acid needed

22. Physical Exam General head/toe exam Thyroid/dental carries Pelvic exam Pap Gonorrhea/chlamydia cultures

23. Laboratory Rubella titer Varicella titer Hepatitis B CBC (anemia) Blood type and RH factor HIV Glucose screen Toxoplasmosis CMV

24. Maternal Medical Conditions -Optimal management -Change in medications that are safer in pregnancy prior to conception

25. Maternal Medical Conditions Diabetes Referral to endocrinology Achieve tight glycemic control prior to conception Dietary consultation Hypertension BP control prior to pregnancy Safer meds (no ACE inhibitors)

26. Maternal Medical Conditions Asthma Good control prior to pregnancy Most meds safe in pregnancy Thyroid disease Close monitoring of thyroid function Adjusting medication dose common Neuropsychological impairment

27. Maternal Medical Conditions Epilepsy Neurology referral for drug adjustments Frequent blood levels Extra folic acid 1gram Vitamin K (36wks – delivery) Lupus Better prognosis for both mom and baby is quiescent for 6 mos before conception Better prognosis if normal renal function

28. Maternal Medical Conditions Anemia HGB 6g/dl (decreased AFI, abnormal FHT, increase fetal death) Depression If controlled and doing well on medication = continue taking drug

29. Prenatal Education Pt education leads to better self-care and pregnancy outcomes. Radiologic studies (dental/radiologic) Can be performed when indicated Delay if elective Medications Take only medications approved or prescribed by your doctor. When in doubt…ask!

30. Prenatal Education Nutrition Iron 30mg/d (take between meals, empty stomach) Necessary for fetal/placenta development and to expand the maternal RBC mass Calories: increase by 340 – 450 kcal/d Calcium 1000mg/d Three servings of dairy daily

33. Weight Gain 3-6# wt gain in first trimester 0.5 – 1#/wk in last 2 trimesters Inadequate wt gain during pregnancy is associated with increase low-birth-weight infants, and preterm delivery.

34. Weight Gain Underweight women BMI <19.8 kg/m2 26-40# Normal weight women BMI 19.9-26.0 kg/m2 26-35# Overweight women BMI 26-29 kg/m2 15-26# Obese women BMI >29 15#

35. Weight Gain 2-3# = increased fluid volume 3-4# = increased blood volume 1-2# = breast enlargement 2# = enlarged uterus 2# = amniotic fluid 6-8# = baby 1-2# = placenta 4-6# = maternal stores of fat and protein (lactation)

36. Prenatal Education Activity and Employment Avoid heavy lifting (25-30#) Most are able to maintain normal activity level Travel Avoid prolonged sitting in car/plane (clotting risk) Support hose Seat belt Driving 6 hours/d (stop every 2 hours for 10 min)

37. Prenatal Education Nausea and vomiting Avoid greasy/spicy foods Frequent small meals Crackers at bedside Protein snack at night GERD Relaxation of esophogeal sphincter Don’t eat before lying down Worse with overeating and spicy foods Hemorrhoids Varicose veins of rectum Avoid constipation/straining/prolonged sitting Regress after delivery (not go away completely)

38. Prenatal Education Constipation Decrease bowel transit time Fresh fruit/veggies/water Metamucil/colace Urinary frequency Growing uterus and fetal head increase pressure on the bladder. Round ligament pain Sharp groin pains = spasm of round ligament associated with movement Right > left Local heat, gradual rising/sitting, avoid sudden movement

39. Prenatal Education Syncope Compression of veins in legs from the growing uterus causes venous pooling with prolonged standing = faint Compression stockings Back ache Prevented by excessive weight gain Exercises to strengthen back muscles Posture, sensible shoes Intercourse Usually no restrictions May cause increase uterine activity and spotting

40. Prenatal Education Breast feeding Avoid soap/lotions on breasts Preparation for childbirth Studies have shown that prepared childbirth can have a beneficial effect on performance in labor and delivery

41. Questions How long after a miscarriage should I wait before trying to get pregnant again?

42. Questions Are there any cosmetics or body lotions that should be avoided if I’m trying to get pregnant?

43. Questions When in the menstrual cycle would I most likely get pregnant?

44. Questions How long after a person stops taking oral contraception do recommend waiting before trying to get pregnant?

45. Questions Do women who have had abnormal pap smears and a colposcopy have problems getting pregnant or delivering a baby?

46. Questions How often during the menstrual cycle should I have intercourse?

47. Questions Can I use natural planning to help get pregnant?

48. Questions If you are considering getting pregnant or are already pregnant and you need to choose a doctor what are the reasons to choose an OB versus choosing a family practitioner, what things should a person think about when making that decision?

49. Questions If you had a pre-term delivery in the past would there be something you would recommend to do differently during the pre-pregnancy planning stage or during the first trimester?

50. Questions Hot tubs in pregnancy?

51. Questions How much fish can I eat during pregnancy?

52. Questions What about using sunscreen when you’re pregnant?

53. Questions Is there anything out there to help prevent stretch marks?

54. Questions I’ve seen some women where a belt during pregnancy, what is that for?

55. Questions What about chiropractic care or messages during pregnancy?

56. Questions When can I begin to slim down post pregnancy?