Preconception Health Care

Question 1

Most 1st prenatal visits at 8 weeks or later

Answer 1

period of time before this visit carries the most risk to fetal development

Question 2

8wk or later fetus development

Answer 2

Fetal heart has been formed & functioning.
Spinal canal is closed.
Eyes are formed.
Limbs are actively moving.
Recognizable genitalia.

Question 3

by 8 weeks gestation

Answer 3

, any genetic risks or teratogenic effects of medications or environmental hazards have been expressed in the fetus.

Question 4

Preconception Counseling Visit”

Answer 4

offered for couples by many healthEvery contact with a woman of
childbearing age is an opportunity for preconception care.
care providers.

Question 5

Goals of Preconception Counseling:

Answer 5

Identify risk factors for maternal or fetal outcome.
Stabilize medical conditions before conception in order to optimize maternal & fetal outcomes.
Provide education & counseling targeted to patient’s needs.
Create a healthy environment for fetus.

Question 6

Benefits of Preconception Counseling

Answer 6

Helps prevent exposure to potentially harmful substances during early pregnancy.
Risk assessment helps prevent potential complications which would have adversely affect the mother & baby.
Prepares woman/couple physically & emotionally for pregnancy.
Opportunity to plan & arrange early prenatal care.

Question 7

Preconception Care Visit

Answer 7

Thorough history of woman & couple.
Physical exam.
Laboratory tests to identify medical & genetic conditions that increase risk for poor outcome.
Referral to appropriate health care provider for evaluation of medical/genetic problems

Question 8

Counseling/screening to include:

Answer 8

Psychological readiness to bear & raise children:
Room in relationship for a child? Expectations?
Emotional & financial stability or woman/couple.
Can be used as opportunity to screen for domestic violence.
Incidence of domestic violence shown to increase during pregnancy.

Question 9

Discontinuation of contraceptive method.

Answer 9

When & how to stop method.

Expected timeframe of return to fertility for method being used.

Question 10

Recording menstrual cycles

Answer 10

– crucial for dating a pregnancy.

Question 11

Nutrition:

Answer 11

Achieving ideal body weight, controlling eating disorders & pica, developing nutritionally balanced dietary habits → important preparation for growing a healthy baby & prevention of low birth weight.
Educate on minor dietary changes.

Question 12

Nutrition:

Answer 12

Refer to nutritionist → women with major nutrition deficits or obesity.

Refer for psychological evaluation → women with eating disorders.

Question 13

CDC Nutrition Guidelines:

Answer 13

Folic acid supplementation → reduce risk of spina bifida or other neural tube defects.

Women of childbearing age – 0.4 mg daily.
Most otc multivitamins have 0.4 mg folic acid.

Women with diabetes or epilepsy – 1 gm daily

Question 14

Women who have previously had infant with neural tube defect:

Answer 14

4.0 mgs daily for at least 1 month prior to conception & through 1st 12 weeks of pregnancy

Question 15

CDC cautions

Answer 15

against total folate consumption of more than 1mg daily for women who do not have a specific increased requirement

Question 16

CDC recommends

Answer 16

Ingesting a consistently adequate quantity of folate from food sources is difficult, supplementation is required.

Question 17

Exercise:

Answer 17

Regular moderate exercise – beneficial.
1st trimester – hyperthermia related to hot tub use has been associated with ↑ congenital anomalies.
Pregnant women should limit vigorous exercise to avoid an ↑ in body core temperature above 38ºC (100.4ºF).

Question 18

Dental care:

Answer 18

Advise to take care of any needed dental work prior to pregnancy.

Women with significant periodontal disease → ↑ risk of preterm labor & birth.

↑ blood volume during pregnancy & resulting hyperemia in the gums – cause excessive bleeding if gum surgery has to be done during pregnancy.

Question 19

Genetic Screening

Answer 19

Women over 35:
Higher risk for medical problems during pregnancy & chromosomal abnormalities in the fetus.
Counsel about genetic risks & availability of antenatal testing.
Amniocentesis.
Chorionic villus sampling.
Nuchal translucency ultrasound.
Testing is time sensitive – may not be an option if 1st prenatal visit is delayed.

Question 20

Ethnic background for prenatal screening

Answer 20

of either partner determines need for prenatal screening for:
Sickle cell trait.
Thalassemias.
Tay-Sachs disease carrier state.

Question 21

Family history of certain diseases

Answer 21

cystic fibrosis, congenital hearing loss) – indicates need for additional screening:
Carrier for CF – recommended with family history of disease in a cousin or closer relative.
Recent recommendation – CF screening offered to all patients.
50% congenital hearing loss are linked to a single genetic defect in the protein connexin-26.
Family with affected person – that person is usually tested.
If test +, preconception counseling should be offered.

Question 22

Refer to genetic counselor:

Answer 22

Specific risk factor identified.

Future parents with serious concerns.

Question 23

Medical Risk Factors

Answer 23

Medications
Rx & OTC medications taken by woman need to be evaluated for possible teratogenic effects.
Evaluate any herbal preparations being used.
Medications that may not be safe during pregnancy – risk/benefit ratio of medication use & pregnancy should be evaluated prior to pregnancy.

Question 24

Medical risk factors

Answer 24

Women with epilepsy, chronic hypertension, malaria, & other diseases – may be treated with drugs that are known teratogens.
MD consult – Risk to fetus? Can another nonteratogenic medication be used to treat disease effectively?
Important that woman does not just stop taking medication – may negatively effect their medical or mental health

Question 25

Drug Categories

Answer 25

Category A: Safe.
Category B: Probably safe.
Category C: Should be given only if potential benefit justifies potential risk to fetus.
Category D: Positive evidence of human fetal risk, but
benefits from use in
pregnant woman may
be acceptable despite
the risk.
Category X: Contraindicated in
women who are or may become pregnant.

Question 26

Specific medical conditions:

Diabetes

Answer 26

Consistently ↑ serum glucose levels at time of conception & early organogenesis → significantly ↑ risk of major congenital anomalies.
Diabetic women should have preconception counseling with perinatologist or endocrinologist who will manage diabetes during pregnancy.

Question 27

Specific medical conditions: Cardiac disease

Answer 27

Should plan to time pregnancy with a cardiologist & obstetrician.
May be minimal risk (mitral valve prolapse) or a life-threatening risk (pulmonary hypertension).
Cardiac status & risk should be thoroughly evaluated in preconception period.
In some cases, risk of maternal mortality is so high that a termination or the pregnancy is recommended for the mother’s sake.

Question 28

Seizure disorder:

Answer 28

Based on severity of disease – will need to at least collaborate with MD, may need referral to MD.
Most commonly used medications for control of seizures are teratogenic to fetus.

Question 29

Chronic hypertension

Answer 29

Most can anticipate the birth of normal, healthy infant.
Avoid use of ACE inhibitors & angiotensin II receptor antagonists in preconception period.
Educate about ↑ risk for preeclampsia & fetal growth restriction.

Question 30

Thyroid disorders:

Answer 30

Hyperthyroidism – associated with congenital malformation.
Hypothyroidism – associated with dwarfism & other anomalies.
Goal – woman euthyroid prior to pregnancy.
Medical consultation/referral – establish a plan for assessment of thyroid levels & potential medications during pregnancy.

Question 31

Infectious diseases:

Answer 31

Treatment with Retrovir ↓ risk of transmission to the fetus from 25.5% to 8.3%.

Question 32

Syphilis screening

Answer 32

Early treatment ↓ risk of transmission to the fetus

Question 33

Hepatitis B vaccine

Answer 33

Consider for women if they are at risk for sexually transmitted disease or blood exposure.
Can be given during pregnancy.

Question 34

Rubella & varicella screening

Answer 34

Live-virus vaccines – should be given at least one month before conception.

Question 35

Sexually transmitted infection screening

Answer 35

Can be treated prior to pregnancy

Question 36

Genital Herpes

Answer 36

Counsel about treatment options during pregnancy.

Counsel about management of birth.

Question 37

Toxoplasmosis, cytomegalovirus (CMV), parovirus B19 (fifth disease):

Answer 37

Serological testing not routinely done.
Positive titer indicates previous exposure – minimal risk.
Negative titer - can do counseling to ↓ risk of exposure.
Toxoplasmosis – parasite in raw meat, cat feces.
CMV – child care & health care workers are at risk.
5th disease – child care workers.

Question 38

Previous Obstetric History

Answer 38

Previous preterm birth
Best predictor for another preterm birth.
Hx of GDM, hypertensive disorders, placenta previa, dysfunctional labor, low birth weight – may repeat in subsequent pregnancies.
Incompetent cervix, uterine anomalies, previous pregnancy losses:
Need a plan for appropriate intervention to help ensure the best outcome.
Previous c/section:
Counsel @ risks/benefits of VBAC.

Question 39

Environmental Toxins

Answer 39

Embryo/fetus is more susceptible to environmental toxins than adults.
Drug or chemical exposure causes 3-6% of anomalies.

Question 40

Environmental Toxins

Answer 40

Woman, at home & in workplace → can be exposed to chemicals, temperature extremes, heavy metals, radiation, infectious agents, stress factors:
Can negatively affect a developing fetus

Question 41

Smoking:

Answer 41

↑ risk of miscarriage, low birth weight, perinatal mortality, & attention-deficit disorder in children.
Recommend behavioral techniques, support groups, family support.
Nicotine patches & gum may be helpful before conception, not recommended for use during pregnancy.

Question 42

Alcohol abuse:

Answer 42

Can cause mental retardation, malformation, growth retardation, miscarriage, & behavioral disorders in infants.
Refer for interventional counseling, admission to treatment programs.

Question 43

Illegal drug use:

Answer 43

Cocaine – associated with miscarriage, prematurity, growth retardation, & congenital defects.
Marijuana – prematurity, jitteriness in neonate.
Heroin – may lead to IUGR, hyperactivity, & severe neonatal withdrawal syndrome.
Woman will need help quitting prior to pregnancy – refer to substance abuse treatment program.

Question 44

Goal of Preconception Counseling

Answer 44

A Healthy Newborn