IN THE NAME OF GOD

1. IN THE NAME OF GOD

2. Preconception Counseling for women Dr,B.Khani

3. Questions • What is preconception care? • What is the role of the ob&gyn in providing preconception care? • What are risks of pregnancy in patients with chronic medical problems?

4. Opportunities for preconception counseling occur ; Premarital examination and testing Contraception counseling Evaluation for sexually transmitted disease or vaginal infection After a negative pregnancy test Presents for a periodic health examination

5. Barriers to preconception counseling Unplanned pregnancy Risk factors for adverse outcome that cannot be modified(maternal age or genetic history) Financial issues Inadequate training of health care providers and long waiting times for appointments

6. Chief Complaint History of Present Illness Past Medical History Medications Family History Social History Physical Exam Assessment and Plan Typical Patient Visit

7. Chief Complaint/HPI • Ask about reproductive life plan • ½ pregnancies in the US are unintended • Remember that any one who is menstruating and having sex can get pregnant. • Help patients and partners develop a plan, and help them implement it

8. Past Medical History • Infections • Immunizations • Previous Pregnancies • Chronic Diseases

9. Infection History • TORCHES • Toxoplasmosis: increased risk with handling raw meats, cat litter • Other: Listeria, Coxsackie virus, Parvovirus • Rubella • CMV: seroconversion highest risk for day care workers caring for 12-36 month old children • Hepatitis B,HIV, Herpes viruses • Syphilis

10. Immunizations • TORCHES: Rubella, Hepatitis B, Varicella • Tetanus • Pertussis • Flu: If woman expects to be at least 3 months pregnant during flu season

11. Reproductive History • Pregnancies • Outcome • Perinatal difficulties • Control of chronic diseases during pregnancy

12. Chronic Hypertension-Maternal Morbidity • Preeclampsia: • 25% of women with chronic HTN • 40% with severe HTN • Renal failure, HELLP syndrome, Eclampsia • Peripartum cardiomyopathy • Exacerbated by increased blood volume, decreased oncotic pressure

13. Chronic Hypertension-Neonatal Morbidity • 2/3 Preterm delivery • 1/3 Small for Gestational Age • Mortality • 2-4 times above baseline rate for population • Other complications • Placental Abruption • Cesarean Delivery • Intrauterine Growth Restriction

14. Glycemic Changes during Pregnancy • ENHANCED insulin sensitivity- late first trimester • More hypoglycemia, especially with coexistent vomiting • Increased caloric requirements- 300kcal/day • REDUCED insulin sensitivity- throughout pregnancy • Allows for continuous glucose delivery to fetus, even at fasting state • Increased cortisol, placental growth factor, progesterone, prolactin, human placental lactogen, others

15. Diabetes-Maternal Morbidity • Ketoacidosis • Develops more rapidly with less severe hyperglycemia than non pregnant patients • Risk factors: new onset DM, infection, poor compliance, antenatal corticosteroids and tocolytics • Preeclampsia • Up to 50% of pts with Diabetes and Nephropathy

16. Diabetes- Maternal Morbidity • Retinopathy • PROGRESSION of retinopathy due to tight glucose control • Long term risk is not altered by pregnancy • Nephropathy • Risk Factors: baseline creatinine >1.5mg/dL, severe proteinuria

17. Diabetes-Congenital Malformations • Risk of malformation proportional to HbA1c • Overall double the risk compared to infants born to non-diabetics • 5% risk if HbA1c is 7% • 23% risk if HbA1c is 8.6%

18. Diabetes-Congenital Malformations • Cardiac: Transposition of great vessels, VSD, Coarctation, Patent Ductus Arteriosis, Situs Inversus • Renal: Ureteral Duplication, Agenesis • Neurologic: Anencephaly, Microcephaly, Neural tube defects • Gastrointestinal: Duodenal atresia, imperforate anus, anorectal atresia • Skeletal: Caudal Regression Syndrome

19. Diabetes- Neonatal Morbidity • Neonatal hypoglycemia • Transient fetal hyperglycemia leads to β-cell hyperplasia and hyperinsulinemia • Macrosomia • Increased risk shoulder dystocia at delivery • Higher rates of primary cesarean delivery

20. Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Physical Exam Assessment and Plan Typical Patient Visit

21. Medications Up To Date 15.3, 2007

22. Analgesic Drugs • NSAIDS • Acetaminophen is class B, throughout pregnancy • Ibuprofen, Naproxen, Diclofenac are class B, in first and second trimesters • All NSAIDS are class D in third trimester • Narcotics: Class C

23. Antidepressants/Anxiolytics • SSRIs, Mirtazepine, Trazodone, Venlafexine: Class C • Tricyclics: Class D • Buspirone, Zolpidem: Class B • Benzodiazepines: Class D • Lithium: Class D

24. Antimicrobials • Penicillins, Cephalosporins, Clindamycin, Metronidazole, Macrolides: Class B • Sulfonamides: Class B first and second trimester, Class D third trimester • Quinolones, Trimethoprim, Vancomycin: Class C • Tetracyclines: Class D • Nystatin: Class B • Fluconazole: Class D first trimester, Class C second and third trimesters

25. Allergy Treatments • Diphenhydramine, Loratadine, Cetirizine : Class B • Fexofenadine, Bromphenphiramine : Class C • Pseudoephedrine: class C in second and third trimesters • Guaifenesin: class C

26. GI Medications • Ranitidine, Lansoprazole, Sulcrafate: Class B • Omeprazole: Class C • Metoclopromide, Dimenhydrinate (Dramamine): Class B • Promethazine, Prochlorperazine: Class C • Bismuth subsalicylate: Class D

27. Others • Nicotine replacement: Patches, nasal spray, inhaler are Class D, gum is Class X • Isotretinoin(Accutane): Class X

28. Chronic Hypertension- Treatment • No data that treatment of Mild Hypertension will improve maternal/fetal outcomes • Consider stopping/reducing RX in women who become pregnant. • Restart for women with SBP>150-160 or DBP>100-110 1 Ferrer et al. Obst Gynecol 2000

29. Chronic Hypertension-Treatment • Safe Agents: Class C • Methyldopa • Labetalol • Nifedipine • Some Risk: Class D • Diuretics • Selective beta blockers, during second and third trimesters • Avoid: Class D • ACE-Inhibitors/ARBs

30. Diabetes-Treatment • Good control BEFORE conception • During Pregnancy • Diet, Exercise, and Insulin therapy • Close Monitoring • Goals: • fasting glucose <95mg/dL • nighttime glucose >60mg/dL • Hemoglobin A1c <6%

31. Diabetes-Treatment • Insulin therapy • Range from .7-1.2 U/kg/day • Oral Agents: • Glyburide: Class C, but does not cross placenta, comparable to insulin in improving control without evidence of complications • Metformin: Class B • TZDs: Not well studied, Class C

32. Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Physical Exam Assessment and Plan Typical Patient Visit

33. Carrier Screening by Ethnicity • Caucasian: Cystic Fibrosis • Black: Sickle cell, Beta-Thalassemia • European Jewish: Tay-Sachs • French Canadian: Tay-Sachs • Mediterranean: Alpha-, Beta-Thalassemia • Southeast Asian: Alpha-, Beta-Thalassemia • Indian, Middle Eastern: Sickle Cell, Alpha-, Beta-Thalassemia

34. Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Physical Exam Assessment and Plan Typical Patient Visit

35. Social History • Environmental Exposures • Diet • Social Stressors • Substance abuse

36. Environmental Toxins • Organic solvents (paint, cleaning fluids, pesticides) • Anesthetic gases • Radiation • Heavy Metals

37. Diet • vegetarians may need supplements • Fish: Limit to 12oz of safe fish per week. Unsafe fish: Shark, swordfish, king mackerel, tile fish, tuna • Canned tuna (<2 cans per week) is OK • Caffeine • Associated with increased risk of miscarriage in one study: • 12.5% nonusers, 15% users of <200mg/day, 25% users >200mg/day • Folic Acid intake: Recommended 400mcg/day Weng, X; Odolui, R; Li, DK. Am J of Obstetrics and Gynecology, 2008

38. Social Stressors • Emotional abuse • Physical abuse

39. Substance Abuse • Alcohol consumption: even small amounts can cause persistent neurobehavioral deficits. • Tobacco: preeclampsia, placental abruption, low birthweight • Illicit drug use: wide variety of effects

40. Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Environmental exposures Diet Substances Social Stressors Physical Exam Assessment and Plan Typical Patient Visit

41. Physical Exam • Screening for/ evaluation of Chronic diseases • Pulse, blood pressure • Thyroid disease • Hypoxemia • Weight • Oral Care

42. Obesity • Obesity is defined as BMI of 30-35 kg/m2 • Morbid Obesity is BMI > 35 kg/m2

43. Obesity- Maternal Morbidity • Gestational diabetes (GDM) • NYC study: women 200-300+ lbs were 4 to 5 times more likely to develop GDM • Preeclampsia • Placental abruption • Cesarean delivery • Even when controlling for macrosomia • Endometritis and wound infections Rosenberg et al. Obstet Gynecol 2003

44. Obesity-Neonatal Morbidity • Macrosomia • Mount Sinai Study: mean birth weight 83 g (3 ounces) heavier • Increased even when controlling for GDM • Significant increase risk among morbidly obese women who gained >25 lbs during pregnancy • Increased risk NICU stay Bianco, Et al. Obstet Gynecol 1998

45. Periodontal Disease • Perhaps related to preterm birth • Multiple studies, varying designs/quality • 3 studies: Treatment lead to significant reduction in preterm low birthweight infants, no significant difference in total preterm births • 800 women randomized to tx during pregnancy vs tx postpartum: No difference in preterm birth, low birthweight • Thought to be a marker for excessive local response to bacteria Xiong, X et al.. BJOG 2006; 113:135.

46. Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Environmental exposures Diet Substances Social Stressors Physical Exam BMI Oral Care Sign of chronic illness Assessment and Plan Typical Patient Visit

47. Reproductive Life Plan • Encourage her to talk with partner, develop a plan for more children. • Offer contraception • Consider IUDs, contraceptive implants

48. Infections/Immunizations • Screen for • Rubella immunity • Syphilis, HIV, Hepatitis B • Vaccinate • Routine: Pneumovax, Flu, Tetanus, Pertussis • Consider Hepatitis B, HPV if risk factors

49. Chronic Diseases • Screen for • Anemia • Hypothyroidism • Cervical dysplasia • Treat known diseases • HTN • DM • Obesity

50. Hypertension Treatment • Change Class D/X drugs before pregnancy, Consider Class C • Change ACE-I to labetalol, methyldopa, thiazide, calcium channel blocker • Remember that BP may drop early in pregnancy, pt may need to stop medications initially