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Preconception Care
Aboubakr Elnashar
Prof Obs Gyn,
Benha University
Hospital, Egypt
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• Duration of pregnancy is no longer “9” months, it’s
“12” months
ACOG& AAP: prenatal care before conception
• PCC:
Concept has evolved over the last several
decades
Form of primary care& prevention
12 NOT 9
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Outline
• Definition& Goals
• Why Do We Need PCC?
• Components
• Scientific Evidence
• Current Recommendations
• Barriers
• Implementation
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Definition
A set of interventions that
aim to identify& modify (biomedical,
behavioral& social) risks to a woman’s
health or pregnancy outcome
through prevention& management (CDC,
2006)
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Goal
• Goal should be realistic
Identify pre-existing conditions
that may affect an anticipated
pregnancy
Intervention(s) that could lead to
more favorable outcome
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Why?
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 Currently:
 Poor pregnancy outcomes
 Women enter pregnancy “at risk” for
adverse outcomes
 We intervene too late
 There is consensus that:
 Intervening before pregnancy:
improve outcomes
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Early ANC is too late
1. To Prevent Some Birth Defects
Critical period of teratogenesis: D17 to D56
Heart: begins to beat at 22 ds after conception
Neural tube: closes by 28 ds after conception
Palate: fuses at 56 ds after conception
2. To Prevent Implantation Errors
3. To restore allostasis: Maintain stability through change
An important objective of PCC is to restore allostasis to women’s health
before pregnancy
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Critical Periods of DevelopmentCritical Periods of Development
4 5 6 7 8 9 10 11 12
Weeks gestation
from LMP
Central Nervous SystemCentral Nervous System
HeartHeart
ArmsArms
EyesEyes
LegsLegs
TeethTeeth
PalatePalate
External genitaliaExternal genitalia
EarEar
Missed Period Mean Entry into ANC
Most susceptible
time for major
malformation
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From
Anticipation& Management
to
Health Promotion& Prevention
From
Healthy Mothers Healthy Babies
to
Healthy Women Healthy Mothers Healthy Babies
Paradigm Shift
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Components
CDC, 2007
I. Risk Assessment
II. Health promotion
III. Interventions
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A. Risk assessment
I. Reproductive life plan:
If she plans to have children?
How long she plans to wait until she becomes pregnant?
Plan, based on:
her values& resources, to achieve those goals
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II. History
1. Reproductive history:
Previous adverse outcomes:
infant death, fetal loss,
birth defects, low birth weight, PTL
2. Medical history:
Rheumatic heart disease
Thromboembolism
Autoimmune diseases
Hypertension
Diabetes
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3. Medication use:
Current medication
 Avoid FDA
Category X:
Estrogen, androgens,Aminopterin, isotretinoin,Thalidomide
Category D:
Phenytoin, valporic acid, diazepam, Imipramine, captopril, thiazides,
Spironolactone, coumarine, chlorpropamide, Progestins, tetracyclin,
streptomycin, Quinine, methotrexate, vinblastin, Azathioprine.
unless maternal benefits outweigh fetal risks;
Over-the-counter medications, herbs& supplements
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4. Substance abuse:
Tobacco
Alcohol
Drug use
5.Toxins& teratogenic agents:
At home, in the neighborhood, in the workplace:
heavy metals,
solvents,
pesticides,
endocrine disruptors,
allergens
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II. Physical examination:
1. Nutritional assessment:
Assess the ABCDs of nutrition:
anthropometric factors (e.g., BMI)
biochemical factors (e.g., anemia)
clinical factors
dietary risks
2. Focus on
Periodontal,
thyroid, heart,
breast,
pelvic examination
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III. Screening
1. Infections &immunizations:
Screen for periodontal, urogenital & STD as indicated;
Update immunization with hepatitis B, rubella, varicella,
Tdap,HPV& influenza vaccines as needed
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2. Genetic screening:
Based on:
family history
ethnic background
age
Offer cystic fibrosis& other carrier
screening as indicated
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3. Psychosocial:
Screen for
depression,
anxiety,
domestic violence
major psychosocial stressors
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4. Laboratory testing:
Testing should include
CBC;
urinalysis;
blood type& screen
When indicated screen for
Rubella, syphilis, hepatitis B,HIV, gonorrhea, chlamydia
Diabetes
Thyroid Dysfunction
Cervical cytology
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B. Health promotion
1. Family planning:
 Based on the patient’s reproductive life plan
 Effective contraceptive use
 Discuss emergency contraception
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2. Healthy weight & nutrition:
Ideal BMI: 20 to 26.0 kg/m2
Exercise
Nutrition
Macro& micronutrients:
Getting “five a-day”: 2 servings of
fruit +3 servings of vegetables
 Daily multivitamin that contains
folic acid
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3. Healthy behaviors:
Nutrition
Exercise,
Safe sex
Effective contraceptive use
Dental flossing
Preventive health services
Discourage risky behaviors:
Douching
Not wearing a seatbelt,
Smoking:
use the five A’s [Ask, Advise, Assess, Assist, Arrange] for
smoking cessation
Alcohol
Substance abuse
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4. Healthy environments:
Discuss household, neighborhood& occupational
exposures to heavy metals, organic solvents, pesticides,
endocrine disruptors& allergens;
Give practical tips such as how to avoid exposures
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5. Stress resilience:
Promote nutrition, exercise, sufficient sleep, and
relaxation techniques;
Address ongoing stressors (e.g., domestic violence)
Identify resources to help the patient develop problem
solving and conflict-resolution skills, positive mental health,
and strong relationships
6. Interconception care:
Promote breastfeeding,
placing infants on their backs to sleep to reduce
the risk of sudden infant death syndrome,
positive parenting behaviors, and the reduction of
ongoing biobehavioral risks
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C. Interventions
1. Folic acid supplementation
Reduces NTD by two thirds.
2. Rubella vaccination
protection against congenital rubella syndrome.
3. Hepatitis B vaccination for at risk women:
 Prevents transmission of infection to infants
 Eliminates the risks to the women of hepatic failure, liver
carcinoma, age cirrhosis& death due to HBV infection.
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4. Diabetes management:
reduces birth defects among infants of diabetic women.
5. Hypothyroidism:
protects proper neurological development.
6. HIV/AIDS screening:
 Allows for timely treatment
 Provides women (or couples) with additional information
that can influence the timing of pregnancy& treatment.
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7. STD screening& TT
 Reduces the risk of ectopic pregnancy, infertility, chronic
pelvic pain associated with Ct& NG
 Reduces risk to a fetus of fetal death or physical&
developmental disabilities, including mental retardation&
blindness.
8. Maternal PKU management:
Prevents babies from being born with PKU-related
mental retardation.
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9. Switching women off Oral anticoagulant:
avoids harmful exposure.
10. Antiepileptic drug:
Changing to a less teratogenic tt reduces harmful
exposure.
11. Accutane (isotretinoin) use management:
Preventing pregnancy for women who use OR
Stop before conception
:eliminates harmful exposure.
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12. Smoking cessation:
Prevent:
PTL
low birth weight
other adverse perinatal outcomes.
13. Eliminating alcohol use
Prevents fetal alcohol syndrome
other alcohol-related birth defects.
14. Obesity control:
Reduces the risks of
NTD, PTL, DM, CS, Hypertension
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PPC for men
• Alcohol
May be associated with physical& emotional
abuse
May decrease fertility
• Genetic Counseling
• Occupational Exposure
- lead
• STD
– Syphilis, herpes, HIV
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Scientific Evidence
Does PCC work?
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There is evidence that individual components of PCC work:
• Rubella vaccination
• HIV/AIDS screening
• Management and
control of:
– Diabetes
– Hypothyroidism
– PKU
– Obesity
• Folic Acid supplements
(level 2)
• Avoiding teratogens:
– Smoking
– Alcohol (level 2)
– Oral anticoagulants
– Accutane
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Clinical Practice Guidelines
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Clinical practice guidelines for PCC of specific maternal
health conditions have been developed by professional
organizations:
• American Diabetes Association (Diabetes -2004)
• American Association of Clinical Endocrinologists
(Hypothyroidism – 1999)
• American Academy of Neurology (Anti-epileptic drugs)
• American Heart Association/American College of
Cardiologists (Anti-epileptic drugs - 2003)
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ACOG/AAP (2002)
All health encounters during a woman’s reproductive
years, particularly those that are a part of PCC
should include counseling on appropriate medical
care and behavior to optimize pregnancy outcomes.
ACOG/AAP Guidelines for perinatal care, 5th edition, 2002
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USPHS
“Every woman (and, when possible, her partner)
contemplating pregnancy within one year should consult
a prenatal care provider. Because many pregnancies
are not planned, providers should include preconception
counseling, when appropriate, in contacts with women
and men of
reproductive age….Such care should be integrated into
primary care services.”
USPHS Expert Panel on the
Content of Prenatal Care, 1989
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Barriers
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I. Patient Aspects
• High rate of unintended pregnancies
• Ignorance about importance of good health habits prior to
conception
• Limited access to health services in general.
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II. Provider Aspects
• Feeling of having inadequate
knowledge
• Perception of PCC being time
consuming
• Lack of awareness of how to
integrate PCC into practice
• Concern about insurance
reimbursement.
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III. Other barriers:
• Availability of contraceptives
• Health Insurance Coverage
• Out of Pocket Expenses.
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Implementation
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Who Should Get PCC?
• PCC should be provided to all reproductive age
individuals
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WHO TO PROVIDE?
– OB-GYNs
– Pediatricians, Family Medicine, Internists,
– Nurses
– Genetic Counselors
– Health Educators
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Why Should Ob/Gyns be Concerned with
PCC?
• OB/GYN’s
 have the most frequent contact with women
of childbearing age
 are aware of prior poor pregnancy outcomes
 Responsible for ANC
 already have the knowledge& are applying it
 advantage to improve pregnancy outcomes
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How PCC can be Integrated into Practice?
I. OB-GYNs
1. WHC:
- Our best opportunity
- Single or multiple visits
- Ask about reproductive life plan
- If she plans to have child in next 1-2 yrs: she& husband
should return for full visit.
2. Negative pregnancy test: an opportunity for PCC
3. Family planning encounter
4. Infertility evaluation
5. Following a poor pregnancy outcome
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Thank you
CONCLUSION
“PCC is the cornerstone
of healthy infants,
children,
families& communities
Yhank you
Aboubakr Elnashar