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Pre-pregnancy Evaluation and Planning: Optimizing Outcome in High-Risk Women

Pre-pregnancy Evaluation and Planning: Optimizing Outcome in High-Risk Women. Siri L. Kjos, MD Harbor-UCLA Medical Center. Preconception Care: Basics. Use complete history and physical form. Preconception Care The Goal. What factors can be positively changed to improve perinatal outcome?

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Pre-pregnancy Evaluation and Planning: Optimizing Outcome in High-Risk Women

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  1. Pre-pregnancy Evaluation and Planning: Optimizing Outcome in High-Risk Women Siri L. Kjos, MD Harbor-UCLA Medical Center

  2. Preconception Care: Basics Use complete history and physical form

  3. Preconception CareThe Goal What factors can be positively changed to improve perinatal outcome? Maternal Neonatal

  4. Preconception CareGenetic Screening • Identification of inheritable disorders in family • Determine if patient and/or partner should be screened for carrier status • Genetic referral? • Ever-expanding molecular genetic testing • Counseling for identified disorders

  5. Preconception CareGenetic Screening • Common inheritable/genetic disorders • Tay-Sachs • Thalassemia • Sickle cell anemia • Cystic fibrosis • Mental retardation (Fragile x) • Muscular dystrophy, Huntington’s Chorea • Fetal erythroblastosis (Rh disease) • Chromosomal anomalies

  6. Preconception Care: Medications • Prescription • Daily and irregularly used medication • Treatment for chronic conditions • Pain killers, tranquilizers • Weight loss medication • Over-the counter • Alternative or herbal medicines

  7. FDA Classification for Teratogenicity

  8. Known Teratogens

  9. Known Teratogens

  10. Known Teratogens

  11. Preconception Care: Drugs • Alcohol • Pattern of use? • Questionnaires: CAGE, TACE, TWEAK • TERATOGENIC: Fetal alcohol syndrome (abnormal facies, mental retardation, IUGR, microcephaly) • Cigarette Smoking • Amount smoked • IUGR (25%), LBW, PTD, Sudden infant Death • STOP SMOKING! • Smoking cessation programs, nicotine patches • Illicit Drug use

  12. Preconception Care: Hepatitis B • Transmission • parenteral and sexual contact • Vertical: mother to newborn • Infected newborns (HbSAg+) • Complete resolution: 85-90% • Chronically infected: 10-15% • Of these 15-30% develop chronic active dz (persisent hepatitis, cirrhosis, hepatocellular carcinoma)

  13. Preconception Care: Hepatitis B • Maternal HbSAg+: • 10-20% vertical transmission • HBeAg+ and HbSAg +: 80-90% • Timing of maternal infection • 1st trimester: 10% transmission • 3rd trimester: 80-90% transmission • Passive + active immunization at birth • 85-90% protection • ACOG: recommend preconception testing • Immunize high-risk (recombinant DNA) MMW 1991: 40(r13):1-25 ACOG Technical Bulletin: July 1998: No 248

  14. Preconception Care: Immunization ACOG Committee Opinion: Dec 2000: No 246

  15. Preconception Care: HIV testing • Maternal Rx during pregnancy reduces vertical transmission • AZT prophylaxis: ↓ from 26% to 8% • Combination Rx: transmission rare • US Public Health, ACOG*, IOM: • Recommend Universal testing in pregnancy • Recommend offering all women testing as part of preconception care and counseling *ACOG Statement of Policy May 1999

  16. http://www.mypyramid.gov/downloads/MyPyramid_Anatomy.pdf

  17. http://www.mypyramid.gov/downloads/MiniPoster.pdf

  18. http://www.mypyramid.gov/downloads/worksheets/Worksheet_1800_18.pdfhttp://www.mypyramid.gov/downloads/worksheets/Worksheet_1800_18.pdf

  19. Recommended Weight Gain during Pregnancy based on Pre-pregnancy BMI Nutrition During Pregnancy: National Academy of Sciences, 1990

  20. Nutrition: Prescription of a Balanced Diet Committee on Diet and Health of the National Research Council, 1989

  21. Preconception Care: Exercise • Cardiovascular Fitness • Ability to maintain prolonged period of physical activity • Low intensity program: 30-60 minutes • 3-4 times per week • Goal: ↑aerobic capacity (VO2 max) • Measure HR: (220-age) x 60-80% = target HR • All exercise should be encouraged: • Walking, cycling, swimming, dance… ACOG Technical Bulletin No 173: Oct 1992

  22. 1996 NIH Recommendations for Exercise 50% of people do not exercise at all or sporadically Goal: EVERY DAY: • 30 minutes of moderate-intensity exercise • Yard work, brisk walking, cycling, swimming • Minutes may be accumulated as long as individuals maintained moderate exertion for no less than 10-15 minutes at a time • Get sedentary people into daily exercise • Those already exercising moderately: exercise more rigorously and more frequently

  23. Risk of NTD from Heat Exposure Study Population: 23,491 women at time of amniocentesis or MSAFP Adjusted for folate supplement, family history of NTD, maternal age & other heat source Milunsky, JAMA 1992, 268:882-6

  24. Folic Acid: Prevention of NTD Milunsky, JAMA 1989, 262:2847 n=22,591

  25. Recommendation for Folic Acid Supplementation in Reproductive-age Women • All women of childbearing age capable of becoming pregnant: • Should consume 0.4 mg/d of folic acid • Total consumption should be < 1.0 mg/d • High-risk women (with prior infant with NTD) should consult MD • General population risk of NTD: 1/1,000 MMWR 1992, Sept 11, 41 (R-14):1-7

  26. Folic Acid: Prevention of NTDMRC Vitamin Study Research Group Multi-center Double-blind Randomized Trial in Women with a History of Infant with Prior Neural Tube Defect Lancet 1991, 338:131

  27. Prevention of Recurrent NTD • General risk of recurrent NTD: 2-3%* • Recommend folic acid 4.0 mg/d • Prior to conception • Continue until the 12th week of pregnancy • Other high-risk groups: • Epilepsy on AED; Diabetes *Lancet 1991: 338:131

  28. Preconception Care: Folic Acid

  29. Preconception Care: Past Obstetrical History • History of prior fetal loss after documented cardiac motion • Thrombophilic disease (History of hypercoagulopathy) Anti-phospholipid syndrome • Anti-cardiolipin Ab (aCL) • Lupus anti-coagulant (LAC: aPTT, KCT (Exner), RVVT) Anti-thrombin III deficiences Activated Protein C Resistence Protein S & Protein C deficiencies • Incompetent cervix (painless loss, PTD) • Uterine anomaly • Coexisting medical disease • Prior cesarean deliveries: ↑risk of previa/accreta

  30. Preconception CareWomen with Medical Disease • Establish pregnancy risk • Complete medical evaluation/therapy • Diagnostic evaluation/ consultation • Surgery or procedures • Determine optimal medical control of preexisting disease • Titrate medicine to lowest dose, safest Rx • Effective contraception until • Completed health evaluation • Optimal health status

  31. Preconception care & DiabetesEuglycemic Control

  32. Preconception Care & Diabetes

  33. Preconception Care & Epilepsy

  34. Preconception Care & Cardiac Disease

  35. Preconception Care & Cardiac Disease

  36. Preconception Care & Mitral Valve Prolapse

  37. Preconception Care & Chronic Anticoagulation

  38. Preconception Care & Chronic Anticoagulation

  39. Preconception Care & Chronic Hypertension

  40. Preconception Care & Chronic Hypertension

  41. Preconception Care & Systemic Lupus Erythematous

  42. Preconception Care & Systemic Lupus Erythematous

  43. Preconception Care & Chronic Renal Failure

  44. Preconception Care & Renal Disease on Dialysis

  45. Preconception Care & Sickle Cell Disease

  46. Preconception Care & Sickle Cell Disease

  47. Preconception Care • Minimize the risk • Optimize maternal health • Use contraception until evaluation complete and health optimized • Stress the positive steps your patient can do to improve her outcome • Share control/responsibility for her health

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