Preconception Counseling for the Primary Care Provider

1. Preconception Counseling for the Primary Care Provider Erin Dunn Snyder, MD January 6, 2008

2. Questions What is preconception care? What is the role of the internist in providing preconception care? What are risks of pregnancy in patients with chronic medical problems?

3. Typical Patient Visit Chief Complaint History of Present Illness Past Medical History Medications Family History Social History Physical Exam Assessment and Plan

4. Meet Jane Doe 32 years old Here to establish care with a new physician History of HTN, Diabetes

5. Chief Complaint/HPI Ask about reproductive life plan � pregnancies in the US are unintended Remember that any one who is menstruating and having sex can get pregnant. Help patients and partners develop a plan, and help them implement it

6. Jane Doe Has one 3 year old daughter Might want to have another child someday, but not now Married, hasn�t really talked about this with her husband, suspects he wants another child now

7. Typical Patient Visit Chief Complaint History of Present Illness Past Medical History Medications Family History Social History Physical Exam Assessment and Plan

8. Past Medical History Infections Immunizations Previous Pregnancies Chronic Diseases

9. Infection History TORCHES Toxoplasmosis: increased risk with handling raw meats, cat litter Other: Listeria, Coxsackie virus, Parvovirus Rubella CMV: seroconversion highest risk for day care workers caring for 12-36 month old children Hepatitis B, HIV, Herpes viruses Syphilis Torches viruses- perinatal exposure can lead to significant morbidity and mortalityTorches viruses- perinatal exposure can lead to significant morbidity and mortality

10. Immunizations TORCHES: Rubella, Hepatitis B, Varicella Tetanus Pertussis Flu: If woman expects to be at least 3 months pregnant during flu season

11. Reproductive History Pregnancies Outcome Perinatal difficulties Control of chronic diseases during pregnancy

12. Jane Doe Had chicken pox as a child Thinks she was immunized with all the routine childhood vaccines No known exposure to sexually transmitted diseases Last tetanus shot was when she finished high school at age 18 She doesn�t usually get a flu shot

13. Jane Doe One pregnancy 3 years ago, carried to term Complicated by gestational diabetes Hypertension Placed on Lisinopril one year ago, has been controlled since then Diabetes Currently on Avandia with �OK� control, doesn�t check blood sugar regularly Doesn�t know what a Hemoglobin a1C is

14. Cardiovascular Changes BP decreases 10-15mm HG during first 18-16 weeks, then rises gradually until about 36 weeks. May be exaggerated in women with chronic hypertensionBP decreases 10-15mm HG during first 18-16 weeks, then rises gradually until about 36 weeks. May be exaggerated in women with chronic hypertension

15. Chronic Hypertension-Maternal Morbidity Preeclampsia: 25% of women with chronic HTN 40% with severe HTN Renal failure, HELLP syndrome, Eclampsia Peripartum cardiomyopathy Exacerbated by increased blood volume, decreased oncotic pressure Preeclampsia- 2-4 fold higher risk than in general population HR for developing CAD, CVD, PAD at least 90 d after delivery was 2.0 in those with placental syndrome. If poor fetal growth- 3.1, if intrauterine fetal death- 4.4 Preeclampsia- 2-4 fold higher risk than in general population HR for developing CAD, CVD, PAD at least 90 d after delivery was 2.0 in those with placental syndrome. If poor fetal growth- 3.1, if intrauterine fetal death- 4.4

16. Chronic Hypertension-Neonatal Morbidity 2/3 Preterm delivery 1/3 Small for Gestational Age Mortality 2-4 times above baseline rate for population Other complications Placental Abruption Cesarean Delivery Intrauterine Growth Restriction

17. Glycemic Changes during Pregnancy ENHANCED insulin sensitivity- late first trimester More hypoglycemia, especially with coexistent vomiting Increased caloric requirements- 300kcal/day REDUCED insulin sensitivity- throughout pregnancy Allows for continuous glucose delivery to fetus, even at fasting state Increased cortisol, placental growth factor, progesterone, prolactin, human placental lactogen, others

18. Diabetes-Maternal Morbidity Ketoacidosis Develops more rapidly with less severe hyperglycemia than non pregnant patients Risk factors: new onset DM, infection, poor compliance, antenatal corticosteroids and tocolytics Preeclampsia Up to 50% of pts with Diabetes and Nephropathy Tocolytics are beta-mimetic, antenatal corticosteroids for fetal lung maturity in premature infants Preeclampsia in 5-10% of pts with DM and nl kidney, up to 50% with DM and renal diseaseTocolytics are beta-mimetic, antenatal corticosteroids for fetal lung maturity in premature infants Preeclampsia in 5-10% of pts with DM and nl kidney, up to 50% with DM and renal disease

19. Diabetes- Maternal Morbidity Retinopathy PROGRESSION of retinopathy due to tight glucose control Long term risk is not altered by pregnancy Nephropathy Risk Factors: baseline creatinine >1.5mg/dL, severe proteinuria Retinopathy progression- also seen in nonpregnant pts who initiate rapid tight control of glucose, effect worse if pts have worse baseline retinopathy (up to date article) Nephropathy complicates 5-10% of pregnancies Retinopathy progression- also seen in nonpregnant pts who initiate rapid tight control of glucose, effect worse if pts have worse baseline retinopathy (up to date article) Nephropathy complicates 5-10% of pregnancies

20. Diabetes-Congenital Malformations Hemoglobin a1c levels correlated directly with frequency of anomalies: 5-6%= anomaly rate near normalHemoglobin a1c levels correlated directly with frequency of anomalies: 5-6%= anomaly rate near normal

21. Diabetes-Congenital Malformations Cardiac: Transposition of great vessels, VSD, Coarctation, Patent Ductus Arteriosis, Situs Inversus Renal: Ureteral Duplication, Agenesis Neurologic: Anencephaly, Microcephaly, Neural tube defects Gastrointestinal: Duodenal atresia, imperforate anus, anorectal atresia Skeletal: Caudal Regression Syndrome 2/3 of defects are cardiac Neural tube defects: 2% diabetic pregnancies .1-.2% general pop: anencephaly, spina bifida Caudal Regression syndrome: abnl development of lower spine and limbs 2/3 of defects are cardiac Neural tube defects: 2% diabetic pregnancies .1-.2% general pop: anencephaly, spina bifida Caudal Regression syndrome: abnl development of lower spine and limbs

22. Diabetes- Neonatal Morbidity Neonatal hypoglycemia Transient fetal hyperglycemia leads to �-cell hyperplasia and hyperinsulinemia Macrosomia Increased risk shoulder dystocia at delivery Higher rates of primary cesarean delivery Insulin as a growth hormone leads to fetal macroscomia, double risk of shoulder dystocia Macrosomia: >4000gInsulin as a growth hormone leads to fetal macroscomia, double risk of shoulder dystocia Macrosomia: >4000g

23. Typical Patient Visit Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Physical Exam Assessment and Plan

24. Medications This may be an overly simplistic scheme- better to think about:1) is med necessary/can this be tx nonpharmacologically 2) what are consequences if med is NOT given 3) what are safety data availableThis may be an overly simplistic scheme- better to think about:1) is med necessary/can this be tx nonpharmacologically 2) what are consequences if med is NOT given 3) what are safety data available

25. Analgesic Drugs

26. Antidepressants/Anxiolytics Buproprion: Class B SSRIs, Mirtazepine, Trazodone, Venlafexine: Class C Tricyclics: Class D Buspirone, Zolpidem: Class B Benzodiazepines: Class D Temazepam (Restoril): Class X Lithium: Class D SSRI may be associated with persistent pulmonary hypertension of the newborn. Paroxetine was shown to increase asd/vsd by 1% 68% recurrence of depression during pregnancy if meds are stopped.SSRI may be associated with persistent pulmonary hypertension of the newborn. Paroxetine was shown to increase asd/vsd by 1% 68% recurrence of depression during pregnancy if meds are stopped.

27. Antimicrobials Penicillins, Cephalosporins, Clindamycin, Metronidazole, Macrolides: Class B Sulfonamides: Class B first and second trimester, Class D third trimester Quinolones, Trimethoprim, Vancomycin: Class C Tetracyclines: Class D Nystatin: Class B Fluconazole: Class D first trimester, Class C second and third trimesters

28. Allergy Treatments Diphenhydramine, Loratadine, Cetirizine : Class B Fexofenadine, Bromphenphiramine : Class C Pseudoephedrine: class C in second and third trimesters Guaifenesin: class C Nasal steroids are likely ok as systemic absorption is minimal, one study of leukotriene inhibitors showed no risk of malformation or obstetric morbidity.Nasal steroids are likely ok as systemic absorption is minimal, one study of leukotriene inhibitors showed no risk of malformation or obstetric morbidity.

29. GI Medications Ranitidine, Lansoprazole, Sulcrafate: Class B Omeprazole: Class C Metoclopromide, Dimenhydrinate (Dramamine): Class B Promethazine, Prochlorperazine: Class C Bismuth subsalicylate: Class D

30. Others Nicotine replacement: Patches, nasal spray, inhaler are Class D, gum is Class X Statins: class X Isotretinoin(Accutane): Class X Recent RCT compared nicotine gum to placebo in smoking pregnant women- nicotine gum reduced smoking rates, birth weight and gestational age were significantly greater.Recent RCT compared nicotine gum to placebo in smoking pregnant women- nicotine gum reduced smoking rates, birth weight and gestational age were significantly greater.

31. Jane Doe Rosiglitazone 4 mg po daily Lisinopril 20mg po daily Multivitamin for Women po daily

32. Chronic Hypertension- Treatment No data that treatment of Mild Hypertension will improve maternal/fetal outcomes Consider stopping/reducing RX in women who become pregnant. Restart for women with SBP>150-160 or DBP>100-110 Physiologic decrease in blood pressure in 2nd trimester may necessitate decreasing some existing blood pressure medicines Meta-analysis: 9 trials comparing treatment with no treatment. 6 had no difference in outcomes, 3 showed trend towards decreased perinatal mortality 4 trials assessed difference in development of preeclampsia with or without treatment. Only one showed risk reduction with treatment Physiologic decrease in blood pressure in 2nd trimester may necessitate decreasing some existing blood pressure medicines Meta-analysis: 9 trials comparing treatment with no treatment. 6 had no difference in outcomes, 3 showed trend towards decreased perinatal mortality 4 trials assessed difference in development of preeclampsia with or without treatment. Only one showed risk reduction with treatment

33. Chronic Hypertension-Treatment Safe Agents: Class C Methyldopa Labetalol Nifedipine Some Risk: Class D Diuretics Selective beta blockers, during second and third trimesters Avoid: Class D ACE-Inhibitors/ARBs Ca Channel Blockers/Nifedipine: second or third line; Diuretics: some role, as second agents. ACEI anomalies: renal dysgenesis, renal failure, oligohydramnios, pulmonary hypoplasia Ca Channel Blockers/Nifedipine: second or third line; Diuretics: some role, as second agents. ACEI anomalies: renal dysgenesis, renal failure, oligohydramnios, pulmonary hypoplasia

34. Diabetes-Treatment Good control BEFORE conception During Pregnancy Diet, Exercise, and Insulin therapy Close Monitoring Goals: fasting glucose <95mg/dL nighttime glucose >60mg/dL Hemoglobin A1c <6%

35. Diabetes-Treatment Insulin therapy Range from .7-1.2 U/kg/day Oral Agents: Glyburide: Class C, but does not cross placenta, comparable to insulin in improving control without evidence of complications Metformin: Class B TZDs: Not well studied, Class C All forms insulin are acceptable, insulin pumps used at times .7 units/kg/day at 1st trimester to higher levels later in pregnancy Oral agents: limited data, generally not usedAll forms insulin are acceptable, insulin pumps used at times .7 units/kg/day at 1st trimester to higher levels later in pregnancy Oral agents: limited data, generally not used

36. Typical Patient Visit Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Physical Exam Assessment and Plan

37. Carrier Screening by Ethnicity Caucasian: Cystic Fibrosis Black: Sickle cell, Beta-Thalassemia European Jewish: Tay-Sachs French Canadian: Tay-Sachs Mediterranean: Alpha-, Beta-Thalassemia Southeast Asian: Alpha-, Beta-Thalassemia Indian, Middle Eastern: Sickle Cell, Alpha-, Beta-Thalassemia

38. Jane Doe African American No history of sickle cell disease or sickle trait in the family

39. Typical Patient Visit Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Physical Exam Assessment and Plan

40. Social History Environmental Exposures Diet Social Stressors Substance abuse

41. Environmental Toxins Organic solvents (paint, cleaning fluids, pesticides) Anesthetic gases Radiation Heavy Metals Can cause difficulty with fertility, miscarriage/stillbirth, congenital malformations, low birth weightCan cause difficulty with fertility, miscarriage/stillbirth, congenital malformations, low birth weight

42. Diet Vegans, Lacto-ovo vegetarians may need supplements Fish: Limit to 12oz of safe fish per week. Unsafe fish: Shark, swordfish, king mackerel, tile fish, tuna Canned tuna (<2 cans per week) is OK Caffeine Associated with increased risk of miscarriage in one study: 12.5% nonusers, 15% users of <200mg/day, 25% users >200mg/day Folic Acid intake: Recommended 400mcg/day Study:1063 pregnant women in Kaiser Permanente system 1996-1998, self report, retrospective study 12 oz can Coke 35mg, Diet Coke 47mg, Mt. Dew 54mg Coffee:8oz cup 133mg; 16oz Starbucks house blend 320mg, Frappicchino 9.5oz 115mg Tea: 8oz 53mg, Starbucks Chai Latte 16oz 100mg; Nestea 12oz 26mgStudy:1063 pregnant women in Kaiser Permanente system 1996-1998, self report, retrospective study 12 oz can Coke 35mg, Diet Coke 47mg, Mt. Dew 54mg Coffee:8oz cup 133mg; 16oz Starbucks house blend 320mg, Frappicchino 9.5oz 115mg Tea: 8oz 53mg, Starbucks Chai Latte 16oz 100mg; Nestea 12oz 26mg

43. Social Stressors Emotional abuse Physical abuse

44. Substance Abuse Alcohol consumption: even small amounts can cause persistent neurobehavioral deficits. Tobacco: preeclampsia, placental abruption, low birthweight Illicit drug use: wide variety of effects

45. Jane Doe Works in a office, no chemical exposures Trying to cut back on red meat, otherwise typical American diet Drinks 3 cups regular coffee, 1-2 soft drinks per day Never smoked, never used illicits Drinks wine occasionally Denies any history of physical abuse

46. Typical Patient Visit Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Environmental exposures Diet Substances Social Stressors Physical Exam Assessment and Plan

47. Physical Exam Screening for/ evaluation of Chronic diseases Pulse, blood pressure Thyroid disease Hypoxemia Weight Oral Care

48. Jane Doe Vitals: AF, 75, 130/88, BMI 32 HEENT: benign, good dentition Neck: no thyromegaly CV: RRR, no murmur, PMI non displaced Lungs: no wheezing Abd: soft, non tender, no hepatomegaly Ext: no clubbing

49. Obesity Obesity is defined as BMI of 30-35 kg/m2 Morbid Obesity is BMI > 35 kg/m2 Institute of Medicine recommendations Normal weight 25-35lbs Overweight 15-25lbs Obese 15lbs

50. Obesity- Maternal Morbidity Gestational diabetes (GDM) NYC study: women 200-300+ lbs were 4 to 5 times more likely to develop GDM Preeclampsia Placental abruption Cesarean delivery Even when controlling for macrosomia Endometritis and wound infections

51. Obesity-Neonatal Morbidity Macrosomia Mount Sinai Study: mean birth weight 83 g (3 ounces) heavier Increased even when controlling for GDM Significant increase risk among morbidly obese women who gained >25 lbs during pregnancy Increased risk NICU stay

52. Periodontal Disease Perhaps related to preterm birth Multiple studies, varying designs/quality 3 studies: Treatment lead to significant reduction in preterm low birthweight infants, no significant difference in total preterm births 800 women randomized to tx during pregnancy vs tx postpartum: No difference in preterm birth, low birthweight Thought to be a marker for excessive local response to bacteria

53. Typical Patient Visit Chief Complaint History of Present Illness Past Medical History Immunizations Infections Previous Pregnancies Chronic Diseases Medications Family History Social History Environmental exposures Diet Substances Social Stressors Physical Exam BMI Oral Care Sign of chronic illness Assessment and Plan

54. Jane Doe 32 yo AA female No reproductive life plan No known risks for TORCHES exposures, suspect childhood immunizations One previous pregnancy with GDM Hypertension, on ACE-Inhibitor Diabetes, on TZD

55. Jane Doe No known Sickle cell disease or anemias in the family No environmental exposures Takes multivitamin, Folic acid intake unknown Some ETOH, no other substance use No social stressors Obese No other sign of undiagnosed chronic disease, periodontal disease

56. Reproductive Life Plan Encourage her to talk with partner, develop a plan for more children. Offer contraception Consider IUDs, contraceptive implants

57. Infections/Immunizations Screen for Rubella immunity Syphilis, HIV, Hepatitis B Vaccinate Routine: Pneumovax, Flu, Tetanus, Pertussis Consider Hepatitis B, HPV if risk factors

58. Chronic Diseases Screen for Anemia Hypothyroidism Cervical dysplasia Treat known diseases HTN DM Obesity

59. Hypertension Treatment Change Class D/X drugs before pregnancy, Consider Class C Change ACE-I to labetalol, methyldopa, thiazide, calcium channel blocker Remember that BP may drop early in pregnancy, pt may need to stop medications initially

60. Diabetes Treatment Delay pregnancy until good control achieved Educate regarding risks to fetus/patient Consider change to better studied agent Insulin Metformin, Glyburide

61. Obesity Treatment Diet and Exercise Goal to get to at least �overweight� BMI Surgical Treatment Less likely to develop GDM, hypertension, and macrosomia Avoid pregnancy during 12-18 months after surgery Fertility may be enhanced in some women after weight loss Nutritional supplements

62. Family History Specific questioning Consider genetic testing in certain groups

63. Environmental Exposures Collect material data safety sheets from employer Discuss safe practices: mask, clothing, etc Consider contraception/duty change if pt around potential hazards

64. Diet Folic Acid: 400mcg/day all women of reproductive age Prevents Neural Tube Defects May decrease preterm birth 38,000 women, self reported Folic Acid intake Those with one year of prenatal Folic Acid intake 70% decrease in very early preterm delivery (20-28 WGA) 50% decrease in early preterm delivery (28-32 WGA)

65. Diet Reduce/eliminate caffeine Reduce fish, especially cold water, denser fish Consider supplementation for specific populations Vegan, vegetarian Post Bariatric Surgery

66. Substances Smoking cessation Nicotine replacements may be dangerous in early pregnancy Limit alcohol Avoid illicit substances

67. Take Home Points Preconception counseling fits in to every phase of the patient visit Discuss a Reproductive Life Plan with every patient of childbearing potential Consider perinatal risk when managing chronic disease Folic Acid 400mcg/ day for ALL Reproductive age Women

68. References Kaaja RJ, Greer IA. Manifestations of Chronic Disease During Pregnancy. JAMA 2005; 294(21):2751-57. Lu, MC. Recommendations for Preconception Care. Am Family Physician. 2007; 76:397-400 Frey KA. Preconception Care by the Nonobstetrical Provider. Mayo Clin Proc 2002; 77:469-73 Brundage, SC. Preconception Health Care. Am Family Physician. 2002; 2507-14 American College of Obstetrics and Gynecology. Clinical Management Guidelines for Obstetrician-Gynecologists- Chronic Hypertension in Pregnancy. ACOG Practice Bulletin 2005; 29. Gregg AR. Hypertension in Pregnancy. Obstet Gynecol Clin. 2004;31(2):223-41. Obstetric Analgesia and Anesthesia: 1980 Bonica JJ. World Federation of Anaesthesiologists, Amsterdam, from http://homepages.ed.ac.uk/asb/SHOA2/chpt1.htm Rosenn B, Miodovnik M, Kranias G, et al. Progression of diabetic retinopathy in pregnancy: association with hypertension in pregnancy. AM J Obstet Gynecol 1992;13:34-40. Jovanovic, L. Pre-pregnancy counseling in women with diabetes mellitus. Up To Date 15.3 Ferrer RL, Sibai BM, Mulrow CD, et al. Management of mild chronic hypertension during pregnancy; a review. Obstet Gynecol. 2000; 96: 849-860 Driul L, Cacciaguerra G, Citossi A. Prepregnancy BMI and adverse pregnancy outcomes. Arch Gynecol Obstet. 2007 Bianco AT, Smilen SW, Davis Y, Lopez S, Lapinski R, Lockwood CJ. Pregnancy outcome and weight gain Recommendations for the morbidly obese. Obstet Gynecol. 1998;91:97-102 Rosenberg TJ, Garbers S, Chavkin W, Chiasson MA. Prepregnancy weight and adverse perinatal outcomes in an ethnically diverse population. Obstet Gyneco. 2003;102:1022-7. �Xiong, X, Buekens, P, Fraser, WD, et al. Periodontal disease and adverse pregnancy outcomes: a systematic review. BJOG 2006; 113:135. March of Dimes Foundation. Huge Drop in Preterm Birth Risk among Women. 2008 February 1 Weng, X; Odoluli, R; Li, DK. Maternal caffeine consumption during pregnancy and the risk of miscarriage: a prospective cohort study. Am J Obstet Gynecol. 2008; 198:279 Oncken C; Dornelas E; Green J; et al. Nicotine gum for pregnant smokers: a randomized controlled trial. Obstet Gynecol. 2008; 112:859-67

69. Physiologic Changes of Pregnancy Pulmonary system Elevated diaphragm, increased AP thoracic diameter, decreased residual volume Increased tidal volume- progesterone central ventilatory stimulant Increased ventilation results in respiratory alkalosis: helps with fetal CO2 elimination Hypercoagulability Prepare for possible blood loss at delivery Increase in procoagulant factors, decrease in anticoagulant factors, decreased fibrinolysis

70. Physiologic Changes of Pregnancy Increased Insulin resistance Allows for continuous glucose delivery to fetus, even at fasting state Secondary to increased cortisol, placental growth factor, progesterone, prolactin, human placental lactogen, etc Insulin resistance increases throughout pregnancy