Slide 1 - cmfm.net

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