Preconception Care Flashcards
When do most women have their first pregnancy visit?
- at 8 weeks
What % of pregnancies are unintended?
over 50%
What should be on a preconception checklist?
- When do you plan to get pregnant?
- Discuss pregnancy expectations (average time to pregnancy is 6 months).
- Discuss cycle lengths and ovulation.
- “Fertile Days” (2 weeks prior to menses).
- If already had a child, discuss pregnancy spacing.
- PRENATAL VITAMINS
Are many doctors pushing long acting reversible contraception (LARC)?
YES because it is most effective.
When should prenatal vitamins be taken?
- ideally before conception
** What is the most important prenatal vitamin?
- FOLIC ACID (400 ug)= decreases incidence of neural tube defects.
- 1 mg if diabetes/epilepsy
- 4 mg if prior Hx of neural tube defect
When does the neural tube normally close?
- by day 28 after conception (6 weeks gestation or menstrual age).
What are the 2 categories of neural tube defects?
- open (more common)
2. closed
What are 3 important neural tube defects related to prenatal vitamin deficiency (folic acid)?
- spina bifida= failure of the neural tube to close properly, causing defects in the spinal cord and in the bones of the vertebrae.
- anencephaly= absence of a major portion of the brain, skull, and scalp.
- encephalocele= neural tube defect characterized by sac-like protrusions of the brain and the membranes that cover it through openings in the skull
*** What 3 questions should you ask yourself when a woman looking to get pregnant tells you a medical problem?
- How does the disease affect the pregnancy?
- How does the pregnancy affect the disease?
- Does the disease have any affect on the fetus? (i.e. do any disease elements cross the placenta, or does the disease affect the mother’s nutritional provisions to the fetus?)
How will DM affect the fetus?
- the higher the Hgb A1C, the greater the risk of poor outcomes (spontaneous abortion, fetal demise, or congenital abnormalities).
What should you do for a diabetic pt looking to get pregnant?
- control their blood sugar and do a full work up.
*** What should you do for a woman with hypertension who is looking to get pregnant?
- AVOID ACEs and ARBs
- Beta blockers are safe :)
- Surveillance of the patient should be increased
- Blood pressure should be evaluated frequently
What may beta blockers do?
- decrease the amount of amniotic fluid
What must you do for an obese pt looking to get pregnant?
- Evaluate and discuss the problem
- Optimize diet
What issues can obesity cause in getting pregnant, or to the fetus itself?
- ovulatory disturbance
- fetal loss
- gestational diabetes
- increased likelihood that the child will need to be delivered via caesarian
Are some SSRI’s safe during pregnancy?
YES, but some are not
Are some patients sometimes on an SSRI unnecessarily?
YES
What is another option for pts with depression other than an SSRI during pregnancy?
- psychotherapy
- some patients are never aware of this option
- some patients seek a way to reduce the medications that they are taking during pregnancy
What carrier screening should be done for a woman looking to get pregnant?
- sickle hemoglobinopathies
- beta-thalassemia
- alpha-thalassemia
If a woman is an Ashkenazi Jew, what other panels should be run prior to conception?
- CF (offered to every patient)
- Tay Sach’s
- Canavan
- Familial Dysautonomia
What are some other familial diseases that could be screened?
- Fragile X
- 22q (DiGeorge)
*** For what infectious diseases should you screen a women prior to conception?
- HIV (opt out not in). Treatment can decrease risk pf transmission from 25% to around 8%
- Syphilis
- Hepatitis B (must immunize)
- Rubella (German measles; must immunize)
- Varicella (herpes virus)
- Environmental Exposure
- CMV
- Parvovirus
- Toxoplasmosis
*** How can congenital syphilis present?
- Hutchinson’s Triad= deafness, notched peg-shaped upper central incisors, and interstitial keratitis (inflammation of the cornea, which can lead to blindness).
- mulberry molars
- Du Bois sign= narrowing of the little finger
- frontal bossing= prominent, protruding forehead
Can infants can varicella from their mother?
YES, called Congenital Varicella Syndrome (CVS)
How does CVS present?
- hypertrophic skin
- low birth weight
- incomplete formation of the digits
- cortical atrophy or dilated ventricles
- mental retardation
How does Congenital Rubella Syndrome (CRS) present if mother was not vaccinated, and become infected within the first 20 weeks of pregnancy?
- sensorineural deafness (58% of patients)
- eye abnormalities (especially retinopathy, cataract, and microopthalmia; 43% of patients).
- Congenital Heart Disease (especially pulmonary artery stenosis and patent ductus arteriosis; 50% of patients).
What women are most at risk for environmental exposures?
teachers, healthcare workers, and veterinarians
What are the 3 environmental exposure worries?
- toxoplasmosis= rare; ingested from the feces of a cat, raw meat or milk.
- parvovirus B19= transmitted via respiratory droplets.
- CMV (herpes virus)= spread via body fluids.
What can toxoplasmosis cause to a fetus?
- nasal malformations
- encephalitis
- necrotizing retinochoroiditis
What can parvovirus B19 (5th’s disease) cause to a fetus?
- called 5th’s disease due to a “slapped cheek” appearance.
- hydrops fetalis
How does congenital CMV present?
- inflammation of retina, low birth weight, jaundice, rash, seizures, and microcephaly
If the patient smokes less than 5 cigarettes/day, will this harm the fetus?
NO, but this is still a good time to talk about quitting, because this will affect the baby after birth.
What other social screenings should you do for a woman looking to conceive?
- alcoholism/Drug Use
- occupational exposures
- household chemicals (home should be adequately ventilated)
- domestic violence
What should your physical entail?
- focus on lower genital tract
- palpate the thyroid
- check TSH if symptomatic.
- external genitalia eval
- speculum exam= visual eval of cervix, vaginal septum, discharge, and bimanual exam (uterine size, uterine mobility, adenexal masses, or pain on exam).
Where should the uterus be at week 12?
- it has expanded past the pelvis, and the patient can have “round ligament pain”
Where should the uterus be at week 20?
level of the umbilicus and is considered “locked in place.”
What could an adenexal mass indicate?
- ectopic pregnancy
So what is the purpose of a preconception doctor’s visit?
- to optimize a woman’s health for pregnancy
