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Preconception Counseling

Preconception Counseling. OB/Gyn Module. NEXT. “My husband and I want to have a baby. Do you have any advice before I get pregnant?”. What are the goals of this initial visit?. NEXT. Goals of Preconception Care.

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Preconception Counseling

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  1. Preconception Counseling OB/Gyn Module NEXT

  2. “My husband and I want to have a baby. Do you have any advice before I get pregnant?” What are the goals of this initial visit? NEXT

  3. Goals of Preconception Care • Identify modifiable and non-modifiable risk factors for poor obstetrical outcomes before conception begins. • Provide an opportunity to intervene when modifiable risk factors are identified and provide truly preventive care before conception. • Perform individualized patient education including information on the advantages of planned pregnancy. Click 3x for goals NEXT

  4. Amy’s medical history Amy T. is a 24 year old G0 white female requesting preconception counseling. She has no significant chronic medical problems. She has few visits to the clinic other than for physicals. Social history: Smokes ½ pack per day. Drinks alcohol socially and denies any illicit drug use. She lives at home with her husband and has no pets. Family history: Doesn’t recall any chronic diseases in her family. Thinks her mother has high blood pressure. What risk factors come to mind for Amy? NEXT

  5. Identifying Risk Factors Amy T is a healthy young female but she does present a few worrisome risk factors for a complicated pregnancy: • Smoking • Occasional use of alcohol • Family history of hypertension During typical preconceptional counseling, what types of risk should be focused on in the patient’s history? NEXT

  6. Social or Demographic Risk FactorsClick on the following bullets for more information regarding risk Click after reviewing information on each risk factor • Extremes of age • Race • Smoking • Alcohol • Drug use (prescriptive, over the counter, or illicit) • Cocaine • Caffeine • Marijuana • Herbal supplements • Occupational hazards • Abuse (Abuse assessment score) After reviewing Amy’s history again, are there any particular risks that weren’t addressed initially? NEXT

  7. Social or Demographic Risk FactorsClick on the following bullets for more information regarding risk Which are the more concerning age groups? • Teenagers • >35 years old • Father is >55 years old • All of the above NEXT

  8. That is certainly ONE of the concerning age groups, but there is more to the story. Try again. BACK

  9. Correct! • What ARE the issues and risks surrounding: • TEEN PREGNANCY • ADVANCED MATERNAL AGE • ADVANCED PATERNAL AGE Click after reviewing the risks for each of the above conditions

  10. Risks Associated with Teenage Pregnancy • Statistics • About 11% of all births in 2002 were to teens (15 – 19yo). The majority (67%) were 18-19yo • About 860,000 teens become pregnant resulting in about 425,000 births. • About 1:3 teens becomes pregnant before 20 years old. • Teen birth rate is declining. Between 1991 and 2002 the rate fell by 30%. • About 17% of teen mothers have a second baby within 3 years after the birth of their first. • Risks • Premature delivery. • Women <15 years old were more than 2x likely to deliver prematurely compared to women 30 – 34. • Nutrition. • Teens often have poor eating habits & neglect to take their vitamins. • More likely to smoke, drink alcohol, and take drugs. • Less likely to be of adequate pre-pregnancy weight or to gain adequate wt during pregnancy. • Prenatal Care • Least likely of all maternal age groups to get early and regular prenatal care. • Anemia • High blood pressure • Maternal death rates may be twice as high as those compared to 20 – 24 year old mothers. • More likely to have STD’s. • Microsomia • Social • Teen mothers are more likely to drop out of high school. • A child born to a teenage mother is 50% more likely to repeat a grade in school, perform poorly on standardized tests, and drop out of school. • 10x more likely to be living in poverty between the ages of 8 - 12 Back http://www.marchofdimes.com

  11. Risks Associated with Extremes of Age • Female >35 years old • Chromosomal abnormalities • Most common disorder is Trisomy 21 – Down Syndrome • Risk at age 25 = 1:1,250, age 35 = 1:400, age 40 = 1:100, age 45 = 1:30 • Optional Amniocentesis or Chorionic Villus Sampling should be made available. • Infertility • Hypertension and diabetes • 2-4x the risk in women >35 than women in their 20s of during pregnancy • Multiple pregnancy • Spontaneous abortion • Age 20-24 ~9%, Age 35-39 ~20%, Age 42 >50% • Placenta previa • Up to 8x the risk vs. women in their 20s • Microsomia • 20-40% more likely than women in their 20s • Premature • 20 % more likely than women in their 20s • Ectopic pregnancy • Cesarean section • 43% in first time mothers >40 years old • Father >55 years old • May be an increased risk of chromosomal abnormalities but evidence is lacking Back http://www.marchofdimes.com/professionals/681_1155.asp

  12. Genetic Diseases Associated with Race Including initial tests and frequency in American population Back • Genetic testing should be made available to any couple with concerns.

  13. Risks Associated with Smoking • Amy is a smoker, and has had trouble quitting in the past. She would like to know what risks she carried if she continues to smoke. Which of the following is true? • Increased risk of placenta previa and placental abruption • Increased risk of macrosomia • Increased risk of birth defects • None of the above

  14. Incorrect! GO BACK…

  15. Correct!Risks Associated with Smoking • Statistics • In the US more than 20% of women smoke. • At least 11% of women smoke during pregnancy • Smoking harms the fetus/newborn: • Nearly doubles the risk of microsomia: In 2002 12.2% of babies born to smokers in the US were of low birth weight compared to 7.5% of babies of nonsmokers. • May be a 3x risk for SIDS • Smoking effects pregnancy: • May double the risk of placenta previa and placental abruption. • May increase the risk of PROM and PPROM. • May increase risk of premature delivery. • Fertility • May be an increase risk for female infertility when compared to nonsmokers. http://www.marchofdimes.com/professionals/681_1171.asp Next

  16. Now Amy is worried. She has a friend who is pregnant and smoking. Amy wonders if she has already harmed the baby- is it even worth quitting at this point? What do you tell her? click here If a woman stops smoking by the end of her first trimester of pregnancy she is no more likely to have a low birth weight baby than a woman who never smoked. BACK to Social/Demographic Risk Factors

  17. Risks Associated with Alcohol • Statistics • Each year >40,000 babies are born with some degree of alcohol related damage. • In 1999, 12.8% of pregnant women reported having had at least one drink during pregnancy. 2.7% reported drinking more than 5 drinks on one occasion. 3.3% reported drinking more than 7 drinks per week. • No level of alcohol use during pregnancy has been proven safe. • Risks • Fetal Alcohol Syndrome • The CDC reports 1,300 to 8,000 cases a year • Occurs in about 6% of babies born to women who abuse alcohol. • One of the most common causes of mental retardation that is completely preventable. • Microsomia • Spontaneous abortion • Child is more likely to develop learning disabilities. • http://www.motherisk.org/updates/index.php?id=299 for more information about FAS. http://www.marchofdimes.com/professionals/681_1170.asp Back

  18. Risks Associated with Caffeine • Statistics • Strong evidence for a correlation between caffeine intake and complications during pregnancy is lacking. • Risks • Evidence may suggest that as little as one average cup of coffee a day (~150 mg of caffeine) may be associated with increased risk of spontaneous abortion, preterm delivery, and microsomia. • Infertility • >300mg of caffeine per day may delay conception by a year or more. • Click here for typical caffeine content in common beverages. http://www.motherisk.org/updates/apr00.php3 http://www.marchofdimes.com/professionals/681_1148.asp Back

  19. Caffeine in Beverages and Chocolate Back Source: U.S. FDA and National Soft Drink Association

  20. Risks Associated with Cocaine Use • Statistics • Since the mid-1980s, about 1 million babies have been born to mothers who used cocaine during pregnancy. • Risks • Spontaneous abortion • Stroke of mother or child • MI of mother or child • Premature delivery • Microsomia • Microcephaly • Mental retardation • Placental abruption • Birth defect • According to a CDC study, cocaine users are 5x as likely to have a baby with a malformation of the urinary tract. • Delayed motor skills • May adversely effect learning, behavior, and language abilities. • Most of these risks are complicated by abuse of other drugs including tobacco and alcohol. Back http://www.marchofdimes.com/professionals/681_1169.asp

  21. Risks Associated with Marijuana • Risks • Difficult to determine due to other confounders. • Women who use marijuana also use tobacco, alcohol, or other drugs. • Lower socioeconomic class may be another confounder. • Microsomia • Currently no teratogenic effect has been documented • Higher risk of meconium staining • 57% in users vs. 25% in non-users • Possible correlation with behavior problems of the child including inattention, hyperactivity and delinquency within the first 10 years of life. http://www.motherisk.org/updates/feb01.php3 Back

  22. Risks Associated with Herbal Supplements • Statistics • More than 60 million Americans report using herbal supplements • Accounts to $3-4 billion in out-of-pocket expense • There are over 400 herbs used widely and distributed as capsules, extracts, tablets, and teas. • Risks • Few studies have been conducted testing herbal preparations in pregnancy. • Herbs are considered dietary supplements and thus aren’t controlled by the FDA. • Manufacturers of herbs aren’t required to prove effectiveness or safety of their products. • There are no standard quality controls. As a result, the composition of herbal products may vary greatly from one batch to another. • Reports of herbal supplements being contaminated with lead or other substances have been reported. • Complications associated with herbal supplements include stimulation of uterine contractions which may result in miscarriage or preterm labor. • Patients assume herbal supplements are safe and often do not inform their physicians of their use. • The National Institute of Health’s National Center for Complementary and Alternative Medicine (NCCAM) is currently studying the safety and effectiveness of a number of herbal remedies. The results of these studies should help clarify who can benefit from these products. • Current recommendation of the March of Dimes organization is for physician discretion. All patients must be asked about herbal supplements and informed about the risk. • Click here for a list of herbs currently contraindicated during pregnancy. Back http://www.marchofdimes.com/professionals/681_1815.asp

  23. Herbal Supplements Contraindicated in Pregnancy Back

  24. Risks Associated with Occupational Hazards MORE Back http://www.cdc.gov/niosh/99-104.html

  25. Risks Associated with Occupational Hazards Back http://www.cdc.gov/niosh/99-104.html

  26. Risks Associated with Domestic Violence • Statistics • About 1.5 million women are abused each year • Includes physical or sexual abuse, threats, and psychological or emotional abuse. • Affects as many as 324,000 pregnant women each year • May actually be more common than conditions that are routinely screened such as gestational diabetes and hypertension. • Risks • Direct effects • Spontaneous abortion • Fetal injury or death from maternal trauma • Indirect effects • Maternal stress • Maternal drug abuse including smoking, and alcohol. • Screening • 96% of pregnant women receive some type of prenatal care and average 12-13 visits. Excellent opportunities to screen for abuse. • An Abuse Assessment Screen should be performed at the initial prenatal visit and at least once per trimester. The conversation should be well documented. • Make appropriate referrals immediately if there is a concern. (ie Law enforcement, shelters, local hotlines, and office or hospital staff with special training.) http://www.cdc.gov/reproductivehealth/violence/ipvdp.htm Back

  27. Abuse Assessment Screen 1. In the last year (since I saw you last), have you been hit, slapped, kicked, or otherwise physically hurt by someone? (If yes, by whom? Number of times? Nature of injury?) 2. Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? (If yes, by whom? Number of times? Nature of injury?) 3. Within the last year has anyone made you do something sexual that you didn’t want to do? (If yes, who?) 4. Are you afraid of your partner or anyone else? Back

  28. Social and Demographic Risk Factors Amy T. works as a department store manager that is not exposed to any chemicals, dusts, or other obvious occupational hazards. She does not report any type of abuse. Amy does mention taking herbs in the past for colds and “stress” but does not take them currently. You move on to her medical history. What in particular are you looking for as a risk to pregnancy? NEXT

  29. Medical IssuesClick here for more information on medical risk factors • Prescription Medications • Weight • Diabetes • Hypertension • Seizure disorder • Immunizations • Rubella • Infections • Toxoplasmosis • HIV • Genital Herpes • Cytomegalovirus • Thromboembolic disease • Neural tube defects What are some typical reproductive and obstetrical issues that should be addressed during preconceptional counseling? NEXT

  30. Medications:FDA Pregnancy Categories • Medications should be reviewed and the benefit vs. risk should be considered for both mother and fetus. Back

  31. Risks and Recommendations: Abnormal Pre-pregnancy Weight • Most studies report that a BMI >27 or <17 are associated with increased anovulatory infertility. • Obesity • Statistics • Approximately 15% of American women are overweight (BMI 25-30)and another 15% are obese (BMI >30). • Risks • Can be complicated by other comorbidities including hypertension and diabetes • Infertility including poor response to fertility treatment. • Includes disruption of menstruation and ovulation. • Spontaneous abortion • Macrosomia • Prolonged labor • Higher risk for developing pregnancy related diseases including preeclampsia and diabetes. • 13x more likely to have postdate pregnancies. • Increased risk for postpartum infections including endometritis. • Underweight • Risks • Microsomia • Preterm labor • Poor nutrition • Recommendations • Adjust diet and exercise according to weight goals. • May require referral to dietitian. • Click here for recommended weight gain during pregnancy. Back

  32. Recommended Average Weight Gain by BMI • Small women (BMI*< 19) - 28-40 lbs. • Average women (BMI* 19-24) - 25-35 lbs. • Heavy women (BMI* > 25) - 15-25 lbs. • Twin pregnancies- 35-45 lbs. Back

  33. Immunizations • Diphtheria-tetanus-pertussis (DTP) • Polio • Measles, mumps, and rubella • Hepatitis B • Haemophilus influenzae type B • Varicella Back

  34. Risks and Recommendations: Diabetes • Statistics • 17 million people have some form of diagnosed diabetes in the U.S. Another 6 million may be undiagnosed. • Approximately 4-6% of pregnancies are complicated by diabetes. • 90% of these are gestational diabetes and the rest is preexisting. • Risks • Poorly controlled diabetes (HbA1c >8.4) is associated with: • 32% rate of spontaneous abortion • 7x increase risk of severe fetal anomalies. • Most involve the CNS and cardiovascular system. • Macrosomia • Shoulder dystocia • Polyhydramnios • Other: hypertension, retinopathy, neuropathy, nephropathy. • Preconception recommendations • Use contraception until excellent glucose control is achieved. • Monitor with normal reference ranges for HgbA1c and accuchek diary • Train in self-monitoring and balancing food intake, exercise, and insulin. • Transition diabetes treatment to insulin • Insulin is the drug of choice in pregnancy because it does not cross the placenta. • Consider use of an insulin pump. • Research on glyburide is pending. • Identify, evaluate, and treat hypertension, nephropathy, retinopathy, thyroid disease, hyperlipidemia. • Discuss risks of pregnancy including the requirement for increased visits and close monitoring. Back http://www.marchofdimes.com/professionals/681_1197.asp

  35. Risks and Recommendations: Hypertension • Statistics • Complicates 2-3% of all pregnancies. • Most women should expect an uncomplicated pregnancy • Risks • DPB greater than 110 mm Hg has been associated with an increased risk of placental abruption and intrauterine growth restriction. • Maternal • Preeclampsia (>25% chance) • Placental abruption • Cerebral hemorrhage • DIC • Hepatic failure • Acute renal failure • Fetal • Microsomia • Spontaneous abortion • Increased neonatal morbidity and mortality • Recommendations • Review current medication list and weight benefits and risk to mother and fetus. • Methyldopa is the only antihypertensive drug whose long-term safety for the mother and the fetus has been adequately assessed. • Contraindicated: • ACE-I and thiazides. • Further drug recommendations can be found at the National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_preg.htm Back

  36. Risks and Recommendations:Seizure Disorder • Statistics • Approximately 1 million women of childbearing age in the U.S. have seizure disorders. • 20,000 of these give birth each year. • Risks • Fetal malformation • 2-5x increase. Complicated by the use of antiepileptic drugs (AED). • 4x increase in cleft palate • 3-4x increase in cardiac abnormalities • Increase in neural tube defects. • Spontaneous abortion • Increased seizure frequency • Observed in 17-33% of women. • Secondary to increased metabolism of (AED) and noncompliance with meds. • Recommendation • Trial of monotherapy for those patients receiving two or more AEDs. • Taper to lowest possible dose. • Seizure-free patients for 2-5 years may consider withdrawal from AEDs. • Adjust doses to avoid high peak plasma levels. • Valproic acid may be dosed TID-QID rather than BID. • Consider referral to OB or Neurology for further instructions. Back http://www.emedicine.com/med/topic3433.htm

  37. Risks and Recommendations: Rubella Infection • General Info • Viral infection spread by droplets • Incubation period 2-3 weeks. • Infectious from 1 week prior and 1 week following onset of rash. • 70-90% of the young adult population are immune • 77 cases in 1970. 2 cases in 1996. • Risks • Maternal • Rash, arthralgia, swelling, and occipital lymphadenopathy • Fetus • Infection during first 15 weeks is the most serious. • Risk of fetal abnormality highest (25%) during first trimester. • After 15 weeks is unlikely to produce fetal abnormalities. • Congenital Rubella Syndrome • Deafness, cataracts, microphthalmia, cardiac defects, and MR • Recommendation • Routinely test for rubella antibodies at first visit if no documentation of prior immunization. • Immunize all women before pregnancy. • According to ACOG guidelines women should use contraception 1-3 months after immunization. May be a risk with the live vaccine. Back

  38. Risks and Recommendations:Cytomegalovirus • Statistics • By age 30, ~50% of all adults have been infected • Most common congenital infection in the U.S. • Each year, 1% of all newborns infected. ~40,000 newborns. • 8,000 of these develop lasting disability • 90% of babies infected have no symptoms at birth • 15% of these develop one or more neurological symptoms within the first two years of life. • Risks • Congenital CMV syndrome • MR, hearing or vision loss. • No treatment • Spontaneous abortion • Recommendations • Spread by children. • As many as 70% of day care children can be excreting the virus • Practice careful hygiene. • Wash hands thoroughly after contact with other children. • Dispose of diapers and other contaminated objects immediately. • Health care workers should continue practicing universal precautions. Back

  39. Risks and Recommendations: HIV infected women • Statistics • An estimated 120,000 to 160,000 women in the U.S. are living with HIV. • Each year about 6,000-7,000 of these women give birth. • Approximately 15,000 children have contracted HIV. 90% of these contracted the disease from their mother. • Risks • Maternal • Opportunistic infections • Tumors • Spontaneous abortion • Fetus • Vertical transmission • Recommendation • Monitor and treat mother for opportunistic infections • Using AZT in first trimester is unclear. • The U.S. Public Health Service recommends that an HIV-infected pregnant woman should receive treatment just as if she were not pregnant. • Vertical transmission can be reduced by starting AZT at 14 weeks and continuing throughout pregnancy Back

  40. Risks and Recommendations: Genital Herpes • Statistics • Approximately 45 million Americans have Genital Herpes • According the CDC about 500,000 new cases a year. • About 1,000 of these in newborns • Risks • No viremia and no transplacental spread. Spread by contact with active skin lesions. • Women who acquire HSV2 for the first time near the time of delivery have a 30-50% chance of vertical transmission to their infant during vaginal delivery, regardless of symptoms. • Women with prior infection before pregnancy have less than a 3% chance of vertical transmission. • Risks to the newborn. • Skin or mouth sores. • Conjunctivitis • Encephalitis • Resulting in MR, cerebral palsy, seizures, blindness, or deafness. • Recommendations • Inform patient of symptoms and mode of transmission associated with HSV. • Currently no recommendation for treatment with acyclovir during pregnancy. No documented risk of transmission in utero. • May require treatment if active flare-up prior to delivery. • C-section necessary if active lesions present during delivery. Back http://www.marchofdimes.com/professionals/681_1201.asp

  41. Risks and Recommendations: Toxoplasmosis • Statistics • Between 1:1,000 and 1:10,000 babies are born infected. • Mother has an overall 40% chance of transmission to her fetus if infected. • 1st trimester: 15% chance of transmission • 2nd trimester: 30% chance • 3rd trimester: 60% chance • Risks • Gestational age dependent. Risks more severe in first trimester. • About 1:10 infected babies have severe disease. • Chorioretinitis, hepatosplenomegaly, juandice, MR, CNS damage. • Spontaneous abortion • Recommendation • Inform parents on ways of transmission. • Don’t eat raw meats • Wash hands thoroughly after handling raw meats. • Don’t empty or clean cat’s litter box. Have someone else do it daily. • Cat’s feces do not become infectious until 24 hours. • Keep the cat indoors or completely outdoors. Transmission can be from birds or rodents. • Avoid sandboxes or other sites cats may use as litter boxes • Wear gloves when gardening. Back

  42. Risks and Recommendations:Thromboembolic disease • Statistics • As many as 1:5 Americans have some type of clotting disorder • Risks • Spontaneous abortion: All trimesters • Placental abruption • Microsomia • Preeclampsia • Thromboembolism • Pulmonary embolism #1 cause of maternal death in the U.S. • Studies suggest that ~50% of these women have an underlying thrombophilia. • Recommendations • All women with previous thromboembolic events should be screened prior to pregnancy. • Consider screening women with family history of blood clots, PE, or strokes prior to 60 years of age. • History of 2 or more spontaneous abortions. • Determine if affected women have allergies to heparin or aspirin. Back

  43. Risks and Recommendations:Neural tube defects • Statistics • Decrease in incidence • 2.31 per 1000 births in 1930 • 1.3 per 1000 births in 1970 • 0.6 per 1000 births in 1989 • Most common NTD compatible with life is myelomeningocele • 1 per 1200-1400 births. • Affects 6,000 – 11,000 newborns each year in the U.S. • Recommendations • Folic Acid • Normal risk: 400 mcg • Diabetes mellitus or epilepsy: 1 mg • Previous history of neural tube defects: 4mg • Goal is to educate women of reproductive age about the benefits of taking folic acid. • Click here for recent survey results regarding folic acid. Back

  44. Goal is to make patients aware of the benefits of folic acid. Back

  45. Reproductive and Obstetrical History • Infertility • Uterine malformations • Autoimmune disease • Endocrine abnormalities • Genital infection • Chlamydia • Gonorrhea • Preterm birth: These women have the highest risk for recurrence. 17-37%. • Previous spontaneous abortion • Higher risk with previous spontaneous abortion. • May require further workup with 2 or more previous spontaneous abortions. • Abnormal pap smear: treatment of cervical cancer may affect cervical competence or ability to dilate. What are some typical risk factors that should Be discussed from the family history during preconceptional counseling? NEXT

  46. Infertility • Diagnosis • Unsuccessful conception after 1 year. • Statistics • Chances of pregnancy with normal fertility • 74% at 6 months • 93% at 1 year • 100% at 2 years • Rates of infertility • Of married couples who desire children 10-15% are childless. • About 33% of women who defer pregnancy until >35 years old are unable to conceive. • About 50% of women who defer pregnancy until >40 years old are unable to conceive. • Recommendations • Lifestyle changes • Stop smoking • Stop recreational drug abuse • Women should reduce vigorous exercise resulting in low body weight. • Obese women should try to reach a more ideal body weight. • Reduce risk of STD’s through safe sexual practices. • Screen high risk women • Aggressive evaluation of pelvic pain and dysmenorrhea • Reminding women >35 year of age their increased risk for infertility • Evaluation of male partner • Anatomy: hypospadias, varicoceles. • Familial syndromes: cystic fibrosis, genetic defects • History of cryptorchidism • Semen analysis Back

  47. Risks and Recommendations:Gonorrhea and Chlamydia • Statistics • Chlamydia is the most common reported notifiable disease in the U.S. • 2002 – 834,000 reported to CDC. • Estimated 2.8 million cases/year. • Gonorrhea infects 718,000 people/year. • Rates of both are highest in adolescent girls. • 2002 – 40% of reported infections in females 10-19yo • Risks • If untreated, 40% of cases will lead to pelvic inflammatory disease. • Common cause of infertility and ectopic pregnancy. • Recommendations • Inform patients on symptoms and transmission. • Treat infections promptly before conception. Back

  48. Family history • Thorough family history should be obtained to determine possible risk during pregnancy including: • Hypertension • Diabetes Mellitus • Tuberculosis • Seizures • Hematologic disorders • Multiple pregnancies • Congenital abnormalities • Mental retardation • Cystic Fibrosis What are some typical barriers health care providers face when offering preconceptional counseling NEXT

  49. Barriers to Preconceptional Counseling • Unplanned pregnancy • 33-50% of pregnancies are unplanned. • Goal is to provide preconceptional counseling early. • Non-modifiable risk factors • Examples: Age and genetic history • Financial issues • Examples: Lack of transportation or insurance • Unprepared health care providers In the face of these barriers, how can preconception care be improved? NEXT

  50. Overcoming barriers to preconceptional care • Educating women of reproductive age about pregnancy. • Schedule a preconception visit for women interested. • Incorporate into routine health maintenance visits. • Pamphlets • Referral to websites such as www.marchofdimes.com • Early recognition of high risk women through routine screening and examination. • The use of preprinted forms or computer templates that enable these visits to be time efficient while being complete. • Patient completed or physician completed forms. • These forms are available from various sources including www.marchofdimes.com NEXT

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