Module 2 Preconception Period Unit A-C

Question 1

Which elements of someone’s medical history (including mental health, infection history, social history, vaccination history, family and genetic history) are relevant for a future pregnancy?

Answer 1

Reproductive/Gynecologic Hx: G/P, menstural hx, STI hx
Medical Hx: To identify meds and conditions that may affect a pregnancy
Infection Screening: Some infections can affect ability to get pregnant (ex. chlamydia), if vaccines are not up to date; some cannot be given in pregnancy
Social Hx: important to review alcohol intake, drug/tobacco use, diet and nutrition, exercise, occupational hazards, trauma exposure, and social determinants of health.
Family/Genetic Hx: To open discussion for potential need/want for carrier screening.

Question 2

Which physical exam components are necessary during a preconception visit?

Answer 2

Not always done if a full exam was done recently. The purpose is to identify conditions that may impact pregnancy.

Examples: HTN, high body weight, heart murmurs/extra sounds, fibroids, spinal deformity, pelvic injury/deformity

Question 3

Which infections are high-priority to screen for during a preconception visit and in which patients (given their risk factors)? What significance do those infections potentially have in an upcoming pregnancy?

Answer 3

-G/C can cause PID and cause infertility and increased risk of ectopic
-HIV, Hep B/C require interdisciplinary management to reduce transmission to future pregnancies

Standard Pregnancy screening: Rubella, HIV, Hep B, Syphilis, GBS, G/C

Question 4

Which history or physical exam findings will you need to consider to determine which lab tests you will order?

Question 5

How will you assess which vaccinations should be given preconceptually to each patient? Which vaccinations are the highest priority to assess prior to pregnancy?

Answer 5

Highest Priority during pregnancy: Tdap, flu

Before Conception: MMR-1 month before (Rubella can cause loss or birth defects, Varicella (2 doses; 4-8 w apart), Hep B (ok to give in preg but only if high risk, ie iv drug use/multiple sex partners

After Pregnancy: HPV

Question 6

In general, how does screening for gene conditions differ from screening for chromosome or fetal anatomical development conditions?

Answer 6

Screening for gene conditions tests only for conditions in which the parent can carry the gene for that condition. This is a test done on the parent(s) to see if they have a gene that may be passed down. If both parents are carriers for an autosomal recessive disorder, then future pregnancies have a higher chance of having the condition.

Chromosome condition testing (ex T. 21) and fetal anatomical development condition testing (ex spina bifida) are done on the fetus during the pregnancy.

Question 7

Why do we offer carrier screening?

Answer 7

The major goal of carrier screening: to provide individuals/couples with information that they can use to make reproductive decisions, based on their preferences and values.

Question 8

Why is it preferable to offer carrier screening before pregnancy, rather than during pregnancy?

Answer 8

This will help them decide what to do with the information. If the carrier screening is done during pregnancy, they will have to consider if they want to continue with the pregnancy.

Question 9

How do ethnic-specific, pan-ethnic, and expanded screening approaches differ?

Answer 9

Ethnic-specific: screens for conditions common to the patient’s identified ethnic groups and conditions identified through family hx.

Pan-Ethnic: Screens all patients for conditions regardless of ethnicity/ancestry.

Expanded: Screens for a large number of conditions simultaneously without regard to ethnicity/ancestry

Question 10

How can we advance health equity in carrier screening?

Answer 10

Avoid making assumptions about patients being/not being interested in screening. Advocate for equity in insurance coverage. Do not assume about insurance coverage or ability/willingness to pay for screenings.

Question 11

What are the major pretest and posttest priorities for carrier screening?

Answer 11

Pretest: “Is it useful to you and your family to have information about the chance to have a child with a genetic condition?”

Posttest: Reviewing results with the patient is the priority posttest. A negative test gives a substantially low likelihood that a person is a carrier for a condition but does not eliminate risk. See canvas for positive results if refresher needed.

Question 12

When should a midwife or WHNP involve a genetic counselor in carrier screening?

Answer 12

If the patient has a family history of a genetic condition or an individual issue that is suggestive of a genetic condition, we should consult or arrange for a patient to see a genetic counselor before carrier screening. We should consult or arrange for a patient to see a genetic counselor after carrier screening if one or both partners are carriers.

Question 13

How can we incorporate shared decision-making in carrier screening counseling?

Answer 13

Shared decision-making is the appropriate framework to discuss carrier screening options because the needs and values of the patient and partner should drive the decision-making process.

-Explaining the evidence
oWhat are the risks and benefits of different care options for maternal and neonatal health outcomes?
oHow much evidence is there?
oWhat is the quality of the evidence?
oIs there bias?
oIs there conflicting evidence?
oAre there enough high-quality studies to recommend one care option over another?
oUse absolute risk not percentages, ratios, relative risk
-Role of provider opinion [consider carefully whether this is an appropriate situation for recommendations]
-Professional guidelines
-Explore the patient’s values/needs
-Awareness of own values/preferences to prevent biased counseling [consider wording carefully so as not to convey values/preferences when talking with clients]

Question 14

What have you learned in previous education and practice about race as a risk factor for certain health outcomes?

Answer 14

Race is often identified as a risk factor for different medical diagnoses. Race is a social construct and this falsely identified trends. Patients should not be considered high-risk just because of their race.

Question 15

Given that race is a social/political construct and not a biological one, why is color-blindness (ignoring race) not a solution to dismantling racism in health care?

Answer 15

Ignoring something does not make it go away, so pretending race doesn’t exist doesn’t make racism go away within healthcare. Saying that you don’t see color is also just a lie.

Even though the risks to patients may come from systemic racism, they still may be at higher risk of a condition

Question 16

Imagine that a nursing student asked you to explain the difference between the evidence supporting a preconception health behavior, like attaining/maintaining a healthy weight, and the evidence supporting a clinician’s health promotion activity of helping someone attain/maintain a healthy weight. How would you explain it in your own words?

Answer 16

Health behavior is something the patient does or does not do (ex., exercise, balanced diet) to attain and maintain a “healthy” weight, whereas health promotion is what the clinician can do to help the patient make changes to attain/maintain a “healthy” weight.

Question 17

What are some of the barriers to a preconception patient adhering to preconception health promotion elements that the USPSTF discusses, e.g. avoiding tobacco and alcohol, being vaccinated, and being screened for depression?

Answer 17

Examples
-Depression: research needs to be done to assess barriers
-Folic Acid: Potential barrier to access to vitamins and foods high is folic acid. Potential barrier due to education level.
-Smoking/Alcohol/Substances: Patient may be uneducated about risks to self or fetus, may be resistant to change or uninterested in change.

Question 18

What are the doses of folic acid recommended for individuals at low, moderate and high risk of having an infant with neural tube defects? Which people are in which risk group? (Note: this is the risk category system in the Prenatal & Postnatal Care textbook which may be different than other learning resources.)

Answer 18

Preconceptually:
0.4 mg (=400 mcg) of folic acid daily if low risk
1 mg of folic acid daily if moderate risk (diabetes and excessive alcohol intake)
4 mg of folic acid daily if high risk (having a personal history or previous child with a neural tube defect)

Question 19

Why is folic acid supplementation recommended prior to conception?

Answer 19

Neural tube defects (like anencephaly and spina bifida) happen in the first few weeks of pregnancy, often before a person finds out they are pregnant. Also, almost half of all pregnancies in the United States are unintended. This is why it is important for all people who can become pregnant to get 400 mcg of folic acid every day, even if they are not planning a pregnancy. By the time a person realizes they are pregnant, it might be too late to prevent these birth defects.

Question 20

Why is reducing or quitting smoking beneficial in the preconception period?

Answer 20

Quitting smoking can help reduce your risk for cancer and other diseases. Smoking during pregnancy can cause problems for your baby, like premature birth and birth defects. It also increases your baby’s risk for SIDS.

Question 21

Why is avoiding alcohol beneficial in the preconception period?

Answer 21

It is best to stop drinking alcohol when you start trying to get pregnant because many women become pregnant and do not know it right away. It may be up to 4 to 6 weeks before you know for sure that you are pregnant. This means you might be drinking and exposing your developing baby to alcohol without meaning to.

There is no known safe amount of alcohol during pregnancy

Question 22

What are the benefits of optimal weight and physical activity in the preconception period? What is the relationship between weight and ovulatory cycles?

Answer 22

If possible, attaining a healthy weight prior to pregnancy is ideal because once a person is pregnant, we don’t recommend weight loss. Review the physiologic benefits of being at a healthy weight periconceptually in the ACOG Committee Opinion (p. e85) and on p. 73 of Prenatal & Postnatal Care. One particularly important preconception benefit of being at a healthy weight is that normal-weight individuals tend to have more ovulatory cycles compared with individuals who are overweight or obese.

Question 23

In what ways can you incorporate Motivational Interviewing principles in discussing topics such as weight, physical activity, and tobacco use with a preconception patient?

Answer 23

Let the patient lead the discussion. Don’t use judgmental words and avoid bias. Ask the patient if they are open to talking about it. Don’t just tell them what to do.

Question 24

Which physiologic indicators might tell someone that they will soon ovulate? Which physiologic indicators might indicate that they have already ovulated?

Answer 24

Soon to ovulate: Sticky clear egg-white like discharge, LH surge,
Already Ovulated: Thick white discharge, BBT elevation

Question 25

Which hormones are responsible for each of the events in the normal menstrual cycle? (You should be able to draw the cycle from memory and explain it as you draw!)

Answer 25

Estrogen: Day 1 estrogen begins to slowly rise causing growth of the uterine lining in preparation, has a distinct peak around day 11-15 which signals for the FSH and LH to spike.

LH: Slowly rises from Day 1 of the cycle and has a distinct spike from days 13-15 which signals for ovulation. Also stimulated estrogen and progesterone production.

FSH: Stimulates egg development and the release of estrogen. Also has a small spike at the same time as LH.

Progesterone: Elevates after ovulation to maintain the uterine lining and pregnancy after implantation. Inhibits LH after ovulation.

Question 26

What does a regular cycle indicate about ovulatory status? What does an irregular cycle indicate about ovulatory status? WHY?

Answer 26

Indicated likelihood of ovulation. An irregular cycle indicates that the patient likely ovulates occasionally. No menstruation likely indicated no ovulation.

Question 27

**How often and when during the menstrual cycle should clinicians advise intercourse when a couple desires pregnancy?

Answer 27

Sex every 1-2 days during fertile window (3 days before to 3 days after ovulation)

Rewatch bbb**

Question 28

How long does an oocyte survive if not fertilized? How long do sperm remain capable of fertilizing an egg? (We’ll discuss this in the Week 3 BBB!)

Answer 28

Sperm is capable of fertilizing for up to five days. Oocyte is able to be fertilized for 24-36 hours?

Question 29

In addition to intercourse timing, what other counseling should the clinician provide to a couple who desires pregnancy? What are the pros and cons (logistically, emotionally, financially) of those methods of determining the fertile window?

Answer 29

There are options for LH testing, BBT testing, and fertility testing for both partners if indicated/wanted. All can be financially and emotionally draining.

Question 30

What are the general timeframes for fertilization, traveling toward implantation, and implantation? (Figure 2.1 on p. 21 in Prenatal & Postnatal Care will be helpful.)

Answer 30

Fertilization: 12-24 hours post ovulation
Traveling toward implantation
-Cleavage: 30 hours after fertilization
-Morula: 3-4 days after fertilization
-Blastocyst: 4.5-5 days after fertilization
Implantation: about 6 days after fertilization

Question 31

What are the general timeframes for the embryonic vs. fetal periods? For organogenesis?

Answer 31

The embryonic period begins 2 weeks after fertilization and ends 6 weeks later. Thus the embryonic period is weeks 3-8 in post-conceptual weeks and weeks 5-10 in post-menstrual weeks. Importantly, this is the period of organogenesis when all major organ systems begin to develop and when the embryo is most vulnerable to teratogens.

Question 32

What is the definition of teratogen?

Answer 32

Any substance that can compromise normal embryonic/fetal development and result in a change in embryonic/fetal growth, structure or function. Some substances that can be teratogenic are medications, drugs, alcohol, tobacco, some viruses and bacteria, certain health conditions such as uncontrolled diabetes, and environmental agents such as mercury, lead, and endocrine-disrupting compounds.

Question 33

How are teratogens usually identified?

Answer 33

Most teratogens are identified by observations of affected individuals post-exposure.

Question 34

What are some common teratogens and how can clinicians assess for potential exposure in the preconception period? What resources are available to assist in determining workplace environmental exposures?

Answer 34

Thalidomide. This drug was widely used in Europe, Australia, and Japan in the late 1950s and early 1960s as a treatment for nausea in pregnant women. Animal experiments had not demonstrated any malformations in offspring but within a few years of use in humans, clinicians identified a tragic cluster of babies with severe birth defects. Approximately 10,000 children whose mothers had taken thalidomide were born with missing or severely underdeveloped limbs. The thalidomide tragedy sharpened the focus around the world on rigorous testing of medications prescribed to pregnant women.

Diethylstilbestrol (DES). Unlike thalidomide whose effects were seen immediately after birth, DES is a teratogen with a long interval before effects could be identified. DES is a synthetic estrogen that was prescribed to prevent miscarriage and premature labor during the 1940s and 1950s, with some use continuing until 1971. In 1971, researchers noted a link between prenatal DES exposure and adenocarcinoma of the cervix and vagina in women whose mothers had taken DES while pregnant. The affected individuals are often called DES daughters. DES is now known to be an endocrine-disrupting chemical.

Question 35

What is considered the most critical time for teratogenesis, particularly for harm to the embryonic/fetal central nervous system?

Answer 35

The embryonic period, during which organogenesis takes place, occurs between implantation at around 14 days to around 60 days postconception.

Question 36

What is the “all-or-nothing” period in early pregnancy?

Answer 36

This pre-embryonic period, beginning with fertilization and ending with full implantation about 2 weeks later, is sometimes called the “all-or-nothing period.” This means that exposures during this period will usually result in EITHER damage to all cells and early pregnancy loss OR no significant effects on the pregnancy.

Question 37

In a preconception setting, how can you communicate with patients about vulnerable periods in embryologic development? How can you provide accurate information that they can use to make decisions but without being unnecessarily alarmist?

Answer 37

Provide patients with the information in an easy to understand way. For example, dont use 5% of infants have …, instead say 1 in 100 babies have ….

Being factual is important but the way the info is presenting can make it more alarming.