Transcript
Preconception Care: The Only Care that Counts
Brian K. Iriye, M.D.Center For Maternal-Fetal Medicine
Las Vegas, NVwww.cmfm.net
The Hare Perinatology –
exciting , taking care of the high-risk pregnancy
Providing early prenatal care to high risk- situations or identifying risk
Tortise versus the Hare
The Tortise Preventative care Vaccinations Cholesterol levels Preconception care
Tortise versus the Hare
Prenatal Care
Inadequate prenatal careUS, 1992-2002
Footnotes available in notes section.Source: National Center for Health Statistics, final natality data. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994; 84: 1414-1420. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
How Effective is Prenatal Care- Preterm birth
US, 1995-2005
Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
Late/no prenatal careUS, 1992-2002
Late/No prenatal care is pregnancy-related care beginning in the 3rd trimester (7-9 months) or when no pregnancy-related care was received at all. Source: National Center for Health Statistics, final natality data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
How Effective is Prenatal Care- Low Birthweight
US, 1995-2005
Low birthweight is less than 2500 grams (5 1/2 pounds). Source: National Center for Health Statistics, final natality data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
Most prenatal care in the U.S. starts in the 1st or 2nd trimester
“Early” Prenatal Care
83.7
Early prenatal care – Does it Work?US, 1992-2002
Early prenatal care is pregnancy-related care beginning in the first trimester (1-3 months). Source: National Center for Health Statistics, final natality data. Retrieved November 11, 2008, from www.marchofdimes.com/peristats.
How Effective is Prenatal Care- Infant deaths due to birth defects
US, 1996-2004
Cause of death for 1996-1998 is based on the Ninth Revision, International Classification of Diseases (ICD-9); cause of death for after 1998 is based on the Tenth Revision, International Classification of Diseases (ICD-10). Source: National Center for Health Statistics, period linked birth/infant death data. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
A large proportion of women receive prenatal care yet very little recent improvement in infant health 12% Preterm birth 8 % LBW 3% major birth defects 31% still suffer pregnancy complications
Prenatal Care
CDC Preconception Health and Care, 2006
Prenatal Care Indicators Prenatal Care Adequate Prenatal
Care Early Prenatal Care
Birth Outcomes Preterm Birth Low Birthweight Birth Defects
State of Prenatal Care in the U.S.
Does this look like it is working?
Critical Periods of DevelopmentCritical Periods of Development
4 5 6 7 8 9 10 11 12Weeks gestation from LMP
Central Nervous SystemCentral Nervous System
HeartHeart
ArmsArms
EyesEyes
LegsLegs
TeethTeeth
PalatePalate
External genitaliaExternal genitalia
EarEar
Missed Period Mean Entry into Prenatal Care
Most susceptible time for major malformation
From March of Dimes
Reasons Prenatal Care Effects are Limited
Average Prenatal Care starts after vital organs are formed
Average Prenatal Care starts after vital genes are modified
Old School- fetal health is determined by its genes
New School- fetal genes are determined by the environment
Epigenetics
The New Buzzwords– Fetal Programming
The thrifty phenotype hypothesis proposes that the epidemiological associations between poor fetal growth and the subsequent development of type 2 diabetes and the metabolic syndrome result from the effects of poor nutrition in early in utero life, which produces permanent changes in glucose-insulin metabolism
Barker Hypothesis- Thrifty Phenotype
Poor nutrition during fetal development leads to the development of a frugal or thrifty metabolism
After birth if nutrition is readily available Metabolic syndrome Diabetes Obesity
Barker Hypothesis- Thrifty Phenotype
Maternal Undernutrition
Fetal Undernutrition
Programming of glucose/insulin metabolism
Poor postnatal nutrition
Thin/Non-diabetic
Good postnatal nutrition
Obese/Type II DM
Fetal Programming- Thrifty Phenotype
Fetal Programming- Thrifty Phenotype
Odds ratio for risk of type II diabetes and or impaired glucose tolerance based upon birthweight
Fetal Programming- Thrifty Phenotype
Odds ratio for risk for the development of the metabolic syndrome based upon birthweight
End of WWII food supplies became low in the Netherlands
After D-day conditions worsened Nazi retaliatory embargo to western
part of country Food supplies at 580 cal per day 10,000 people died
Dutch Famine- 1944-45
Dutch Famine
Timing to exposure to famine
Late Gestation Mid Gestation Early Gestation
Glucose intolerance
Glucose intolerance Glucose intolerance
Microalbuminuria Atherogenic lipid profile
Obstructive Airways Dz
Altered blood coagulation
Obesity (women only)
Stress sensitivity
Coronary artery dz
Breast Cancer
Dutch Famine- Programming Consequences
During Pregnancy 11% smoke 10% drink
Of women who could get pregnant 69% do not take folate 31% are obese 3% take possible teratogenic Rx drugs 4% have medical conditions that can
seriously effect pregnancy if unmanaged
Preconception Care
CDC Preconception Health and Care, 2006
4 million pregnancies/yr in U.S 2 million are unplanned Prenatal care benefits appear to
have been maximized
Preconception Care- the Problem
Mistimed or Unwanted Pregnancy
Contraceptive Use at Time of Conception
Age Prevalence
< 20 66-84%
20-24 32-65%
25-34 24-37%
>35 18-36%
Age: Unintended Pregnancy Among Women Having a Live Birth- 1999
Medicaid Status Prevalence
Yes 50-70%
No 24-38%
Medicaid Status: Unintended Pregnancy Among Women Having a Live Birth- 1999
Race Prevalence
White 32-44%
Black 46-77%
Other 33-44%
Race: Unintended Pregnancy Among Women Having a Live Birth- 1999
On average, you'll visit your ob-gyn approximately 14 times for prenatal care.
Average amount charged to patients for prenatal and postnatal care was $133 per visit.1
Therefore, 14 appointments at a cost of $133 each adds up to $1,862.
Tests such as laboratory blood work or ultrasound add to these costs.
Prenatal Care Costs
1 Agency for Healthcare Research and Quality 2003 (AHRQ), a part of the U.S. Department of Health and Human Services
Title V of the Social Security Act has authorized the Maternal and Child Health Services Program since 1935, and it is a major source of state funds for women of childbearing age, infants and children with special health care needs.
In 2008 (fiscal year) Maternal and Child Health Block Grant (Title V) funds to the United States included $544,537,666 from the federal government and $4.7 billion in state matching funds. States chipped in $3.5 billion. Overall 8 billion dollars
Major Funding Programs
Title V and Preconception Care
23 states with focus on preconception care
Vitamins Obesity Tobacco Alcohol Immunizations Anemia Medical
Diseases
What Can We Do or Act Against?
For poor U.S women 70% do not get RDA required amounts of vitamins and minerals from their diets
Multivitamin use for 3 months prior to pregnancy 27% caucasian 18% african americans
Yet MVIs are associated with a dramatic decrease in several outcomes
Multivitamin Usage
Preterm Birth34-37 weeks
Preterm Birth < 34 weeks
prevalence
OR 95% CI prevalence
OR 95% CI
No Vitamins
5.8 1.0 3.5 1.0
+ Vitamins*(controlle
d)
6.1 1.13 (0.74-1.73)
1.2 0.29 (0.13-0.64)
Controlled for add’l
variables
1.07 (0.70-1.65)
0.31 (0.14-0.67)
Periconception Vitamin Use and Preterm Birth
Catov JM et al . Am J Epidemiol. 2007 Aug 1;166(3):296-303.
Preconception MVI use and PTB < 32 weeks Adjusted OR = 0.59 (0.29-1.21) Preconception users had increased h/o risk –
SAB
1st Trimester + Preconception Use (for 3 or more months) Adjusted OR= 0.14 (0.05-0.40)
Periconception Vitamin Use and Preterm Birth < 32 weeks
Scholl TO et al. Am J Epidemiol. 1997 Jul 15;146(2):134-41
Daily use of folic acid among women 18-45 years
US, 1995-2008
Nationally representative telephone surveys conducted by the Gallup Organization, targeting approximately 2000 English-speaking women ages 18-45 each year. Margin of error is +/- 2%. Survey not conducted in 1996 and 1999. Source: March of Dimes Folic Acid Surveys, conducted by Gallup. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
Up to 70% of neural tube defects may be prevented if women consume 400 micrograms of folic acid daily, prior to and during the early weeks of conception
Knowledge that folic acid should be taken before pregnancy
US, 1995-2008
Nationally representative telephone surveys conducted by the Gallup Organization, targeting approximately 2000 English-speaking women ages 18-45 each year. Margin of error is +/- 2%. Survey not conducted in 1996 and 1999. Source: March of Dimes Folic Acid Surveys, conducted by Gallup. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
Adjusted OR 95% CI
Hungarian Trial
All Anomalies 0.53 (0.35-0.70)
All Anomalies- NTDs
0.53 (0.38-0.75)
Atlanta Trial
All Anomalies 0.80 (0.69-0.93)
All Anomalies- NTDs
0.84 (0.72-0.97)
Periconceptional MVI Use and Fetal Anomaly Risk
Hungarian Trial: Czeizal AE Eur J Obstet Gynecol Repro Biol 1998: 78:151-61Atlanta Trial: Mulinare J et al. Am J Epidimeol 1995: 141:S3
Periconceptional Multivitamin Use and Birth Defect Prevention Worldwide
Made by the skin thru direct conversion from sunlight
Minimal contribution from foods Multivitamin rates of Vitamin D are
too low to change deficiency (200-400 iu)
Vitamin D Deficiency
Vitamin D and Breast Cancer
Vitamin D and Ovarian Cancer
Multiple Sclerosis and Vitamin D
Month of Birth and MS- Northern Countries (Canada and Europe)
1992
1994
1996
1998
2000
2002
0
20000
40000
60000
80000
100000
120000
140000
Prevalence of Autism 50 States and P.R.
Prevalence of Autism 50 States and P.R.
Autism and Vitamin D?
Strong genetic basis but also epidemiologic evidence
Large increase in autism over the last 20 years Corresponds with advice to avoid sun in last 20-
30 years Animal data shows vitamin D deficiency leads
to Dysregulation of proteins involved with brain
development Enlarged ventricles and increased brain size
Autism and Vitamin D
Estrogen and testosterone have different effects on Vitamin D metabolism May explain male/female differences in
autism (4:1) Calcitriol decreases inflammatory
cytokine production Autism increased in climates of
decreased sunlight Autism increased in darker skin
individuals
Autism and Vitamin D
Autism and Vitamin D- United States
Autism symptoms decrease in children: with MVI exposure Increased fish with Vitamin D Rural populations vs. Urban – indoor vs.
outdoor activity Less air pollution areas Areas with less rain (move UV and more
outside activity) Summer
Circumstantial evidence linking Vitamin D and Autism
Vitamin D deficiency and Race
Prevalence of vitamin D deficiency [25(OH)D ,37.5 nmol/L], insufficiency[25(OH)D 37.5–80 nmol/L], and sufficiency [25(OH)D .80 nmol/L]among 200 white and 200 black women at 4–21 wk gestation
Vitamin D deficiency and Race -Neonates
Prevalence of vitamin D deficiency [25(OH)D ,37.5 nmol/L], insufficiency[25(OH)D 37.5–80 nmol/L], and sufficiency [25(OH)D .80 nmol/L] in neonates
Vitamin D Deficiency and Obesity
Want to get levels to approximately 50ng/mL
If very low- less than 32ng/mL Give 50,000 units oral per week x 6-8
weeks Then repeat level, PTH, calcium Consider rebolus if still low
If normal give 2000-2500 units per day (soon to be new recommended amount)
Vitamin D Replacement
Obesity
Portion sizes High Fat diets Decreased Activity
Current Cultural Habitat
Obesity Trends in the U.S.
1986-2007
Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Obesity Trends* Among U.S. AdultsBRFSS, 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
In 1990, 10 states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%.
By 1998, no state had prevalence less than 10%, seven states had a prevalence of obesity between 20-24%, and no state had prevalence equal to or greater than 25%.
In 2007, only one state had a prevalence of obesity less than 20%. Thirty states had a prevalence equal to or greater than 25%; three of these states (Alabama, Mississippi and Tennessee) had a prevalence of obesity equal to or greater than 30%.
Obesity Trends Summary
1988–2007 No Leisure-Time Physical Activity Trend Chart
One third of adult women in the United States are obese.
During pregnancy, obese women are at increased risk for several adverse perinatal outcomes, including anesthetic, perioperative, and other maternal and fetal complications.
Obstetricians should provide preconception counseling and education about the possible complications and should encourage obese patients to undertake a weight reduction program before attempting pregnancy.
Obesity in Pregnancy- ACOG Committee Opinion 2005
Increased risk of SAB “Women should be encouraged to undergo
weight loss prior to infertility treatment” (ACOG CO)
For type I Obesity (BMI 30-34.9) & type II (BMI 35-39.9)
Obesity in Pregnancy
Type I Obesity (O.R.)
Type II Obesity (O.R.)
PIH 2.5 3.2Preeclampsia 1.6 3.3
GDM 2.6 4.0Macrosomia 1.7 1.9
C-section Rate
34% 47%
Surgical Complications Increased blood loss Increased wound infection Increased endometritis Difficult anesthesia
Obesity in Pregnancy
Increased difficulty of ultrasound
Increased risks of fetal anomalies
Difficulty with fetal monitoring and UC monitoring
Obesity in Pregnancy
Bariatric surgery patients Decreased complications in comparison
to obesity Delay surgery 12-18 months after
surgery (rapid wt loss phase) Vitamin supplementation
Wt loss recommended thru nutritional consult and exercise
Obesity
Obesity- Politically Correct and Medically Incorrect
Smoking in Pregnancy
Smoking in Pregnancy
Smoking among women of childbearing age
US, 1997-2007
Footnotes available in notes section.Source: Smoking: Behavioral Risk Factor Surveillance System. Behavioral Surveillance Branch, Centers for Disease Control and Prevention. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
Approx 20% or reproductive age women smoke
11% of all women smoke during pregnancy
Nicotine substitute products in periconception period are associated with +/- risk of congenital malformation and possible neurotoxicity in the 2nd and 3rd trimester
Negligible risk of congenital anomalies (but possible increased risk of clefts, double the risk of CHD septal defects)
Preconception and Smoking
IUGR Stillbirth Abruption Preterm Birth Possible increased risk of ADHD Lowered cognitive ability on
childhood testing Increased risk of Childhood Obesity
Smoking During Pregnancy
Want to avoid nicotine substitute products during pregnancy
Only 20 % of women completely stop smoking during pregnancy
Many smokers fail on their first attempt
Why Preconception Smoking Cessation?
A meta-analysis of 12 studies found the overall OR for risk of infertility in the general population was 1.6 (95%CI 1.34–1.91) for smokers compared to non-smokers (Augood et al., 1998)
An OR of 1.54 (95%CI 1.19–2.01) was found for delayed conception of 12 months in women who smoked compared with women who did not smoke and an OR of 1.14 (95%CI 0.92–1.42) for passive smoking
The adjusted odds ratio (95% confidence interval) for spontaneous abortion among current smokers prior to conception was 1.20 (1.04-1.39) per every extra five cigarettes smoked per day
Preconception and Smoking
Increased risk of SABs Increased craniofacial defects Increased neurobehavioral deficits
1st Trimester Moderate to Severe EtOH Usage
45% of women report alcohol use in the first 3 months of pregnancy prior to knowledge of pregnancy
5% report 7 or more drinks per week
Alcohol and Preconception
Binge alcohol use among women of childbearing age
US, 1997-2007
Footnotes available in notes section.Source: Alcohol Use: Behavioral Risk Factor Surveillance System. Behavioral Surveillance Branch, Centers for Disease Control and Prevention. Retrieved November 2, 2008, from www.marchofdimes.com/peristats.
Effect of Pregnancy on Drinking Behavior
TACE Questionaire
Preconception Hemoglobin
Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
The model was adjusted for maternal age, height, height-squared, BMI,education, work stress, maternal exposure to dust, noise, and passivesmoking, infant gender, and gestational age.
Hb level Percent with SGA
Adjusted
OR
95% CI
< 9.5 25 4.6 1.5-13.5
9.6-12.0 13 1.4 0.7-3.2
> 12.0 11 1.0
Preconception Hb level and SGA
Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
Ferritin level
Percent with SGA
Adjusted OR
95% CI
< 12 13 1.2 0.5-2.8
12-60 11 1.0
> 60 23 2.7 1.3-5.6
Ferritin and SGA
Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
Ferritin level
Percent with SGA
Adjusted OR
95% CI
< 12 11 2.3 0.8-6.5
12-60 5 1.0
> 60 9 1.9 0.7-5.5
Ferritin and PTB
Ronnenberg AG et al. J. Nutr. 134: 2586–2591, 2004
Periodontal Disease
Periodontal disease has been associated with Preterm birth SGA Preeclampsia Gestational DM Fetal loss
Maternal treatment of periodontal disease in pregnancy decreases risk of LBW in babies with PTB (pooled RR 0.53, 95% CI 0.30–0.95, P.05)
Oral Health and Pregnancy
Periodontal Disease and Preterm Birth
Six studies, representing a total of 3420 women (493 pre-eclamptic and 2927 non-pre-eclamptic control women) were pooled for meta-analysis.
Women with evidence of periodontal disease during pregnancy had a 1.76 fold higher risk of pre-eclampsia compared with women without periodontal disease (OR, 1.76, 95% CI: 1.43–2.18).
Periodontal Disease and Preeclampisa
Vergnes et al. Evidence-Based Dentistry (2008) 9, 46–47.
Data with mixed outcomes with dental scaling in pregnancy
Could this be due to treatment coming to late?
Could periodontal disease be a marker for inflammation and suceptibility to infection?
Treatment causes bacteremia
Periodontal Disease – Treatment During Pregnancy
Why treatment before pregnancy? Studies of treatment during
pregnancy show some help but are not overly conclusive
Treatment during pregnancy may be too late or associated with temporary rises in inflammatory mediators- may need treatment prior to pregnancy to get effect
Hard to get treatment during pregnancy – especially for more difficult cases
Generalists and Preconception Care
Preconception care has special benefits for women with chronic medical problems many of whom are cared for by internists
In one large study, 13.9% of women entering prenatal care had an identified medical problem
Generalists and Preconception CareCommon conditions seen by generalists in practice include:
Diabetes Asthma Hypertension Seizures Lupus
erythematosus Inflammatory
bowel disease Thyroid
disorders
Hemoglobinopathy
Thromboembolic disease
Congenital heart disease
Rheumatic heart disease
Decreases miscarriage Decreases anomalies Rule out renal disease as a
contraindication to pregnancy Treatment of periodontal disease
improves HbA1C by an average of 0.79% Emphasize need for diet, exercise,
weight control Prevent unplanned pregnancy
Preconception Diabetic Control
Congenital Anomalies in DM and Gestational Age
Caudal regression 5 weeks Situs inversus 6 weeks Spina bifida 6 weeksAnencephaly 6 weeksHeart anomalies 7-8 weeksAnal/rectal atresia 8 weeksRenal anomalies 7 weeks
Hemoglobin A1c and Congenital Anomalies
HbA1c % Anomalies
< 6.9 0
7.0-8.5 5
8.6-9.9 22.9
> 10.0 21.7
Prevention of Congenital Malformations in Diabetics
Study by Fuhrmann, et al. 1983 Preconception treatment, n=128
1% malformations Late Pregnancy registrants,
n=292 7.5% malformations
The costs of preconception plus prenatal care are $17,519/delivery, whereas the costs of prenatal care only are $13,843/delivery.
However, taking into account maternal and neonatal adverse outcomes net savings of preconception care are
$1720/enrollee over prenatal care only
Preconception Diabetes Care Cost
Subclinical or clinical hypothyroidism is present in 2-3% of all pregnancies
Fetus is fully dependent on maternal thyroid levels till 13 weeks of gestation
Low thyroid levels associated with decreased IQ and severe hypothyroidism with poor neurodevelopment
Hypothyroidism and Pregnancy
Preconception thyroid medication should be adjusted to achieve a TSH level of less than 2.5 mU/mL before pregnancy
Inform patient of need for increase in meds of approximately 50% in pregnancy by 20 weeks.
Inform patient to take two extra pills per week to elevate thyroid levels at initial diagnosis of pregnancy (30% increase)
Prevent unplanned pregnancy
Preconception Treatment of Thyroid Disease
Malformations in Fetuses of Women with Epilepsy
Increased 2-3x over background risk Anticonvulsants have teratogenic risk. Seizures in pregnancy increase the risk of
malformation An idiopathic seizure disorder is a risk
independent of medications and seizure during gestation
The best regimen is the one that best prevents seizure monotherapy whenever possible
Who is an optimal candidate for withdrawal of anticonvulsants?
No seizure in 2-4 years or longer on medications
normal CT Scan of brain EEG normalized Absence of cerebral dysfunction
Immunizations
Women of childbearing age in the US should be immune to measles, mumps, rubella, varicella, tetanus, diptheria, and poliomyelitis through childhood immunizations
If immunity is determined to be lacking, proper immunization should be provided
Need for immunizations according to age group of women and occupational or lifestyle risks
Cystic Fibrosis Jewish Screening panel Hemoglobinopathy screening
Genetic Screening
For your patients http://www.perinatalweb.org/images/stori
es/PDFs/Materials%20and%20Publication/becoming%20a%20parent_preconception_checklist.pdf
For professionals – the answer key to the above http://www.perinatalweb.org/images/
stories/PDFs/Materials%20and%20Publication/becoming_parent_provider_reference.pdf
Other Helpful Sites
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