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Preconceptional care (PCC) (The Critical role of Primary Care Physician). Introduction to Primary Care a course of the Center of Post Graduate Studies i n FM. PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847. Content of this session. Overview Rational of PCC. Objectives of PCC.

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Preconceptional care pcc the critical role of primary care physician

Preconceptional care (PCC)(The Critical role of Primary Care Physician)

Introduction to Primary Care

a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417

Tel: 4912326 – Fax: 4970847


Content of this session
Content of this session

Overview

Rational of PCC.

Objectives of PCC.

PCC implementation at PHC centers.

Physicians' role - delivering PCC.

Obstacles of PCC.

Premarital check-up.

Woman’s role.


Birth rate
Birth Rate

  • United State

    13.82 births/1000 population

  • Saudi Arabia

    28.55 births/1000 population

    country comparison to the world 52

  • Egypt

    21.70 births/1000 population

  • United Arab Emirates

    16.02 births/1000 population

  • Japan

    7.64 births/1000 population


Prematurity infant mortality
Prematurity & Infant Mortality

  • United State

    7 deaths/1000 live births.

  • Saudi Arabia

    11.7 deaths / 1000 live births

  • United Arab Emirates

    12.70 deaths / 1000 live births

  • Egypt

    27.26 deaths / 1000 live births

  • Japan

    2.4 deaths / 1000 live births

Central Intelligence Agency, The WORLD FACTBOOK


Factors leading to infant mortality
Factors Leading to Infant Mortality

  • Maternal health problems

  • Smoking

  • Age <20 or > 40

  • Late entry into prenatal care

  • Education

  • Marital status

  • Inter-pregnancy interval


Potentially all related to

Maternal Health Prior to Pregnancy

(Preconception)


Key factors
Key Factors

  • Health status overall

    • Nutrition

    • Exercise habits

    • Infection risk (immunization)

  • Specific health risks

    • Chronic medical conditions

    • Medication

    • Tobacco use


Preconception care a window of opportunity
Preconception Care: A window of opportunity

  • All women of child-bearing yrs : pre- screened for

  • health & risk potentials Before attempting to be pregnant.

  • Optimum: 3- 6 ms before conceiving attempt

  • This time frame allows:

  • 1- Successful conception & pregnancy

  • 2- any within control health risks.


Rational of PCC

  • PCC has been advocated as a measure to improve pregnancy outcome.

  • Its components parallel those of prenatal care : risk assessment, health promotion and medical & physiological interventions.

  • Physician’ s role : providing PCC.

  • Woman’s role : ….


Objectives of PCC

Screening tool for physicians to assess women’s health

In one sense, PCC can be compared to:

Will Baby Clinic visit

a baby is screened for Normal health, Normal Development to identify emerging unnoticed problems in an infant.


Objectives of PCC

For a Woman: PCC assess Normal health of a child-bearing woman, to identify: -

Existing or emerging illness or disease which may have gone undetected before.

Existing risks for the woman who may become pregnant.

Existing risks which may affect a fetus if the woman does become pregnant.


PCC at PHC centers

PCC can be provided most effectively as part of

ongoing primary care.

  • Physicians can deliver PCC during visits for

    • Routine health maintenance,

    • During examinations for school or work,

    • At premarital or family planning visits,

    • After a negative pregnancy test or

    • During well-child care for another family member.


Components of PCC

  • Comprehensive check-lists.

  • Assessments – History & examination.

  • Screening: Investigations.


What is involved in PCC?

  • Prescreening check-lists :

  • Reproductive & non- reproductive systems. Covers physical & psychological aspects.

  • Woman's lifestyle

  • Family history information.

    • Begins with basic information then in-depth, especially if there is previous disease/operation.

    • Pre-screening assessments: a Questionnaire filled by women generally before seeing the physician with a nurse.


Assess & screen for:

Medical conditions.

Genetic counseling.

Immunization.

Lifestyle changes.

STDs (STI)

Medications.

Occupational exposures.

Domestic violence.


Medical conditions:

  • DM:

    • Screen for DM and pre-diabetes.

    • If already diabetic --- shift to insulin Rx.

  • Congenital anomalies: 2- 6x > offspring of DM.

  • PCC care & good DM control  their rate

  • Recent meta analysis: lower rate among PCC recipients (2.1%) vs non-recipients (6.5%).


Medical conditions:

Hypertension.

UTI & Renal problems.

Obesity .

Cardiac / pulmonary problems.

Epilepsy .

Psychological disorders.


Premarital couselling

  • Genetic counseling in PCC is ideal time:

    • Before a couple attempts to conceive especially if the history reveals :-

      • Advanced maternal age,

      • Previously affected pregnancy,

      • Consanguinity or FH of genetic disease.


Examples Genetic counseling

  • Blood conditions caries/ disease:

    • Sickle cell anemia, thalasemia, G6PD

  • Cystic fibrosis.

  • Mental retardation condition:

  • Screen women with a known FH of fragile X syndrome or FH of unexplained mental retardation or for women who have learning disabilities or mental retardation.


  • Immunization

    • PCC is ideal time:

      • Screen

      • for rubella immunity.

    • Immunization:

    • Rubella

    • Hepatitis A

    • Hepatitis B

    • Tetanus

    • Chickenpox?

    Check : EIP complete? women <18 yrs.

    EIP = Expanded Immunization Program)


    Lifestyle changes

    • Caffeine: 1 cup coffee : ~ 120 mg caffeine.

    • 1 cup tea : ~ 40 mg caffeine.

    • 12- oz soft drinks (cola) : ~ 45 mg caffeine.

    • Caffeine metabolism  during pregnancy

    • especially with cigarette smoking.

    • Several studies: caffeine intake ± associated with

    •  fertility  abortion  birth wt.

    •  5-6 mg/kg/day spread on day + no smoke + no alcohol : NO  reproductive risk.


    Lifestyle changes

    • Tobacco :

    • Smoking women during pregnancy : subjects themselves & their infants to a no. of adverse health effects.

    • women contemplating pregnancy should quit smoking prior to conception.

    • Nicotine replacement could then be prescribed.


    Lifestyle changes

    • Tobacco :-

    • Smoking cessation before / early pregnancy : associated with improvement in maternal airway function & at infant birth wt vs among nonsmoking pregnant women.

    • Alcohol & illicit drugs

    • Both a major health problem in USA.

    • Both harm fetus.

    • 1981- USA : women abstain drinking alcohol during pregnancy & when plan pregnancy.


    Sexually Transmitted Infection (STI = STD)

    & medications

    STI : PCC is a good opportunity to screen for genital infections such as Chlamydia, gonorrhea, syphilis and HIV.

    Medications : therapeutic regimens for chronic illnesses are best modified, if possible, in PC period to include the drugs that have been used the longest & have been determined to pose the lowest risk.


    Medications

    Antihypertensives: Diuretics & angiotensin-converting enzyme should be avoided

    drug of choice: methyldopa- proven maternal & fetal safety.

    Anticoagulants:

    Warfarin ContraIndidated Switch to heparin

    Oral hypoglycemic:

    Switch to insulin before pregnancy.


    Occupational exposures

    Worldwide: women entry to workforce.

    Most women are in reproductive age

    • Three most common occupational hazards reported to affect

    • pregnancy are:

      • Radiation Exposure

      • Organic solvents

      • Lead


    Domestic violence

    Is increasingly recognized as a major public health issue.

    It crosses all racial, religious & educational boundaries.

    Physical abuse during pregnancy :

    significant Risk Factor low birth wt & maternal complications.

    Physicians should assess the victims

    & refer to local community resources.


    Obstacles of PPC

    • Pregnancies are still unplanned.

    • Women do not know, realize, or understand the benefits of visiting their physician before become pregnant.

    • The lack of health insurance.


    PCC in Saudi Arabia

    • Premarital check up :

    • Mandatory For limited inherited risks.

    • It could be provided to the married women at the center by:-

      • health education of the patient at Pre-Natal Care Well baby clinic , Chronic disease clinic ….etc

      • Let the patient be aware of its importance


    Woman’s role

    • A woman may need to adjust certain aspects of her health and well-being which are in her control.

    • These usually include aspects of lifestyle, drug and alcohol use, exercise, rest and stress reduction.

    • In addition, she may need to discontinue certain herbs or over-the-counter medications as recommended by the physician.

    • Many physicians will also recommend pre-natal vitamins before a woman actually conceives in order to boost her overall health.




    1 birth rate is
    1) Birth rate is

    • Annual number of births during one year/ 1000 population.

    • Crude birth rate.

    • Usually determine the rate of population growths.

    • All of the above.


    2 infant mortality rate
    2) Infant mortality rate

    • Number of infant deaths in one year/1000 live birth in same year.

    • Include total death rate.

    • It indicate the level of health in a community.

    • All of the above.


    3 factors leading to infant mortality include all except
    3) Factors leading to infant mortality include all EXCEPT

    a) Maternal health problems.

    b) Smoking.

    c) Age >20 or < 40

    d) Late entry into prenatal care.


    4 drugs that need to be changed for safe motherhood are all except
    4) Drugs that need to be changed for safe motherhood are all EXCEPT

    • Diuretics

    • Warfarin

    • Insulin

    • Angiotensin-Converting Enzyme Inhibitors


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