Maximizing Prevention: Targeted Care for Those with High Risk Conditions The National Preconception Curriculum & Resources Guide for Clinicians MODULE

Maximizing Prevention: Targeted Care for Those with

High Risk ConditionsThe National Preconception Curriculum &

Resources Guide for CliniciansMODULE 3

Reviewed and revised on August 18, 2013Release Date: September 1, 2013

Termination Date: September 30, 2014

CME sponsored by Albert Einstein College of Medicine, New York Next

Faculty

Merry-K Moos, BSN, (FNP-inactive), MPH, FAAN Professor of Obstetrics & Gynecology (retired), and Consultant, Center for Maternal and Infant Health, UNC School of Medicine, Chapel Hill, NC

Peter Bernstein, MD, MPH, FACOG, Professor of Clinical Obstetrics & Gynecology, Albert Einstein College of Medicine, Bronx, NY

Disclosures

Dr. Bernstein and Ms. Moos present no conflict of interest. They will not present any off-label or investigational uses of drugs/devices in this activity.

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Accreditation StatementThis activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through joint sponsorship of Albert Einstein College of Medicine and the University of North Carolina Center for Maternal & Infant Health. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement

Albert Einstein College of Medicine designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians and others should only claim credit commensurate with the extent of their participation in the activity.

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Review of Key Information from Module 1

Preconconception Care: What It Is and What It Isn’t

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• In April, 2006 the CDC and the Select Panel released Recommendations to Improve Preconception Health and Health Care—United States The recommendations were based on:– Review of published research– CDC/ASTDR Work group representing 22 CDC

programs– Presentations at the National Summit on

Preconception Care, 2005– Proceedings of the Select Panel on Preconception

Care, 2005Click here to access full report.

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http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm

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Summary of CDC/Select PanelSummary of CDC/Select Panel’’s Ten Recommendations s Ten Recommendations to Improve Preconception Health to Improve Preconception Health

and Health Careand Health Care

Consumer• Individual responsibility across

the lifespan• Consumer awarenessClinical• Preventive visits• Interventions for identified risks• Interconception care• Prepregnancy checkup

Financing• Health insurance

coverage for women with low incomes

Public healthPrograms andStrategiesResearch• Surveillance of impact

Increase evidence base

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The Focus of this Module Will Be Recommendations 3 and 4:

“As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.”

“Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions.”

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Recommendation #3

Recommendation #4

ObjectivesObjectives

After participating in this activity you should be able to:After participating in this activity you should be able to:Explain the rationale targeting preconception health Explain the rationale targeting preconception health promotion to women with high risk conditionspromotion to women with high risk conditionsLink major threats to womenLink major threats to women’’s health with major threats to s health with major threats to pregnancy outcomespregnancy outcomesProvide examples of medical conditions and their potential Provide examples of medical conditions and their potential impacts on pregnancy outcomeimpacts on pregnancy outcomeBegin to develop strategies to view every encounter with a Begin to develop strategies to view every encounter with a woman of childbearing age as an opportunity for health woman of childbearing age as an opportunity for health promotion and disease prevention through the life cycle.promotion and disease prevention through the life cycle.

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THE RATIONALE FOR THE RATIONALE FOR TARGETING PRECONCEPTION TARGETING PRECONCEPTION

HEALTH ACTIVITIES TO WOMEN HEALTH ACTIVITIES TO WOMEN WITH HIGH RISK CONDITIONSWITH HIGH RISK CONDITIONS

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What Are What Are ““High RiskHigh Risk”” Conditions?Conditions?

• In this module, high risk conditions are defined as preexisting medical diseases which could result in compromised health for the woman, the fetus or the offspring should pregnancy occur.

• In subsequent modules, other definitions of high risk conditions, such as previous poor pregnancy outcome, will be explored

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The Rationale for Targeting Preconception Care To Women with

High Risk Conditions• Nearly 50% of pregnancies are conceived without intent• Even when pregnancy is intended, women may not have

discussed their desire or plans to conceive with their medical provider

• Women with high risk conditions frequently have contact with medical providers

• Medical providers often overlook the ramifications of pregnancy as they address a woman’s chronic disease needs

• Therefore overlooked opportunities may exist to reach women with important information on high risk conditions and their potential impact on maternal, fetal or newborn health

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The Role of the Clinician in Preconception Care

• Consider every visit as an opportunity to address preconception needs to:– Prevent unwanted/unintended pregnancies

– Provide preconception counseling, if pregnancy is desired

– Encourage women/couples to actively choose when and when not to become pregnant

– Provide general health promotion and disease prevention guidance

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Module Overview

• Epilepsy• Diabetes Mellitus• Chronic Hypertension

• HIV Infection• Obesity• Depression

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In this module we will examine preconception considerations for women with:

This is not meant to be an exhaustive list of conditions, but only examples to demonstrate some of the principles of preconception care.

Case Study: Seizure DisordersCase Study: Seizure Disorders

• A 22 yo woman has missed her period. A 22 yo woman has missed her period.

• Her pregnancy test in the office is Her pregnancy test in the office is ““negativenegative””

• She expresses a desire to have a baby She expresses a desire to have a baby

• She has been taking Dilantin since the age of 2She has been taking Dilantin since the age of 2

• She has not had any seizures during the past 5 She has not had any seizures during the past 5 yearsyears

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Preconception Care and Seizure Disorder Preconception Care and Seizure Disorder

• Epilepsy is the most common, serious Epilepsy is the most common, serious neurologic problem seen in pregnancyneurologic problem seen in pregnancy

• There is an increased incidence of congenital There is an increased incidence of congenital malformations in infants of mothers with malformations in infants of mothers with seizure disordersseizure disorders

• The prepregnancy period is the ideal time for The prepregnancy period is the ideal time for maternal evaluation maternal evaluation

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Preconception Care Goals: Preconception Care Goals: EpilepsyEpilepsy

• Implications for the woman if she Implications for the woman if she conceives (click conceives (click here))

• Implications for the pregnancy outcomeImplications for the pregnancy outcome if if she conceives (click she conceives (click here))

• Medication considerations (click Medication considerations (click here))

• Family planning needs (click Family planning needs (click here))

• Looking beyond the disease to the whole Looking beyond the disease to the whole woman (click woman (click here)) Next

Epilepsy: Implications for the Woman Epilepsy: Implications for the Woman If She ConceivesIf She Conceives

• Goal is to keep woman seizure-freeGoal is to keep woman seizure-free

• Approximately 90 % of women who have been without Approximately 90 % of women who have been without seizures for the 9 months prior to pregnancy will seizures for the 9 months prior to pregnancy will remain seizure free in pregnancyremain seizure free in pregnancy

• It is generally recommended that patients who enter It is generally recommended that patients who enter pregnancy on an anticonvulsant continue it throughout pregnancy on an anticonvulsant continue it throughout the gestationthe gestation

• Abrupt discontinuation of medications may precipitate Abrupt discontinuation of medications may precipitate seizures even among women who no longer require the seizures even among women who no longer require the medicationmedication

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Epilepsy: Implications for Epilepsy: Implications for pregnancy outcomespregnancy outcomes

Offspring of women with epilepsy have a risk of Offspring of women with epilepsy have a risk of congenital anomalies 2-3x greater than the congenital anomalies 2-3x greater than the general population and may have higher risk of general population and may have higher risk of developing epilepsy themselves developing epilepsy themselves

Goals are to:Goals are to:• decrease the incidence of congenital decrease the incidence of congenital

abnormalities in the infantabnormalities in the infant• reduce fetal exposure to maternal convulsionsreduce fetal exposure to maternal convulsions• reduce fetal exposure to anticonvulsant drugsreduce fetal exposure to anticonvulsant drugs

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Malformations in the Offspring of Women with Epilepsy

• Anticonvulsants may have teratogenic risk, Anticonvulsants may have teratogenic risk, particularly valproateparticularly valproate– Valproate therapy should be avoided during Valproate therapy should be avoided during

organogenesis whenever possibleorganogenesis whenever possible– Common anomalies are midline defects such as Common anomalies are midline defects such as

NTDs and cleft lip/palate and cardiac NTDs and cleft lip/palate and cardiac abnormalitiesabnormalities

• The best regimen is the one that best prevents The best regimen is the one that best prevents seizures at the lowest dose and, whenever seizures at the lowest dose and, whenever possible, relies on monotherapypossible, relies on monotherapy

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Epilepsy: MedicationsEpilepsy: Medications

• Increased risk (2-3x) of both major and minor malformations in Increased risk (2-3x) of both major and minor malformations in pregnancies exposed to one of the major anticonvulsants:pregnancies exposed to one of the major anticonvulsants:– Phenytoin, carbamazepine, valproatePhenytoin, carbamazepine, valproate– Valproate probably poses the greatest riskValproate probably poses the greatest risk– Harm has generally already occurred before prenatal care begunHarm has generally already occurred before prenatal care begun

• Exposure to medications may have long term impact on Exposure to medications may have long term impact on offspringoffspring’’s cognitive and neurologic functions cognitive and neurologic function– One study found children exposed to valproate in utero had One study found children exposed to valproate in utero had

significantly worse IQ scores at age 3 (6-9 points lower than those significantly worse IQ scores at age 3 (6-9 points lower than those exposed to other anticonvulsants)exposed to other anticonvulsants)

• Limited information exists on newer anticonvulsantsLimited information exists on newer anticonvulsants• Drug dosages may need to be changed to maintain serum levels Drug dosages may need to be changed to maintain serum levels

in the therapeutic range during pregnancyin the therapeutic range during pregnancyNext

Critical Periods of DevelopmentWeeks 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

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4 5 6 7 8 9 10 11 12

Epilepsy: Family Planning NeedsEpilepsy: Family Planning Needs

• A reproductive life plan should be encouragedA reproductive life plan should be encouraged• Appropriate contraceptive counseling in the Appropriate contraceptive counseling in the

woman not desiring pregnancy should include woman not desiring pregnancy should include consideration of drug interactions with consideration of drug interactions with contraceptives contraceptives

• The effectiveness of hormonal contraception is The effectiveness of hormonal contraception is decreased in women taking anticonvulsantsdecreased in women taking anticonvulsants– Many anticonvulsants induce the hepatic cytochrome Many anticonvulsants induce the hepatic cytochrome

P450 systemP450 system– Women using liver enzyme inducing anticonvulsants Women using liver enzyme inducing anticonvulsants

have at least a 4x greater risk of oral contraceptive have at least a 4x greater risk of oral contraceptive failure than women not taking these drugsfailure than women not taking these drugs

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Looking At and Beyond the Looking At and Beyond the Disease. . .Disease. . .

• Every woman with a chronic disease should be aware of Every woman with a chronic disease should be aware of the potential effects of her disease and its treatments on the potential effects of her disease and its treatments on herself, her pregnancy and her offspring, should she herself, her pregnancy and her offspring, should she conceive, as well as the opportunities for maximizing a conceive, as well as the opportunities for maximizing a healthy outcome healthy outcome

• All women of childbearing age should be taking a All women of childbearing age should be taking a multivitamin that includes folic acid every daymultivitamin that includes folic acid every day

• All women/couples should be encouraged to develop a All women/couples should be encouraged to develop a reproductive life planreproductive life plan

• All women should be routinely assessed and counseled All women should be routinely assessed and counseled about BMI, exercise, tobacco and alcohol use, other about BMI, exercise, tobacco and alcohol use, other exposures and immunization status (see module 2)exposures and immunization status (see module 2)

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Preconception Care for the Woman Preconception Care for the Woman with a Seizure Disorderwith a Seizure Disorder

• Underscore the importance of actively planning for any Underscore the importance of actively planning for any conceptionsconceptions

• Instruct woman to start folic acid at least 0.4 mg (many Instruct woman to start folic acid at least 0.4 mg (many recommend 1.0 or 4.0 mg) one month before desired conception recommend 1.0 or 4.0 mg) one month before desired conception and to continue this dose through the first trimesterand to continue this dose through the first trimester

• Evaluate the maternal condition and assess the plan for Evaluate the maternal condition and assess the plan for treatment--engage both obstetrical provider and neurologist or treatment--engage both obstetrical provider and neurologist or internist in preconception care of the woman internist in preconception care of the woman – Wean from anticonvulsants if possibleWean from anticonvulsants if possible– Utilize monotherapy if medication is needed Utilize monotherapy if medication is needed – The first prenatal visit is too late to adjust treatment regimen The first prenatal visit is too late to adjust treatment regimen

since organogenesis will be well underway (click since organogenesis will be well underway (click here))• Counsel the woman about the need to adhere to the treatment Counsel the woman about the need to adhere to the treatment

plan and not to suddenly stop medicationsplan and not to suddenly stop medications Next

Who Is An Optimal Candidate for Who Is An Optimal Candidate for Withdrawal of Anticonvulsants?Withdrawal of Anticonvulsants?

• No seizure in 2-4 years or longer on No seizure in 2-4 years or longer on medicationsmedications

• Normal CT Scan of brainNormal CT Scan of brain

• EEG normalizedEEG normalized

• Absence of cerebral dysfunctionAbsence of cerebral dysfunction

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Epilepsy: Primary Care v. Epilepsy: Primary Care v. Preconception CarePreconception Care

• Shared Elements: Shared Elements: – exploration of original diagnosis & workupexploration of original diagnosis & workup– drug regimen drug regimen – appropriateness of trial of withdrawal appropriateness of trial of withdrawal – educationeducation

• Unique aspects:Unique aspects:– waiting period before conception waiting period before conception – consideration of changing medication regimen to avoid consideration of changing medication regimen to avoid

valproatevalproate– early prenatal care planearly prenatal care plan– folic acid supplementationfolic acid supplementation Next

A Review of the Evidence Follows: (as published in: Evidence-based

Recommendations from the Clinical Workgroup of the CDC Select Panel on Preconception Care.

American Journal of Obstetrics & Gynecology, 2008;199:S266-279; S310-327.)

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Evidence-based Recommendations on Preconception Care for Women with

Seizure Disorders

Women of reproductive age with seizure disorders should be counseled about the risks of increased seizure frequency in pregnancy, the potential effects of seizures and anticonvulsant medications on pregnancy outcomes and the need to plan their pregnancies with a healthcare provider in advance of a planned conception.

Strength of evidence: A Quality of evidence: II-2Next


Seizure Disorders

Women who take liver enzyme-inducing anticonvulsants should be counseled about the increased risk of hormone contraceptive failure.

Strength of evidence: A Quality of evidence: II-2

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Seizure DisordersWhenever possible, women of reproductive age

should be placed on anticonvulsant monotherapy with the lowest effective dose to control seizures; women who are planning a pregnancy should be fully evaluated for consideration of alteration or withdrawal of the anticonvulsant regimen before conception



Seizure Disorders

Women who are planning a pregnancy should begin folic acid supplementation of at least 0.4 mg (some recommend 1 or 4 mg) per day starting 1 month before desired conception and continued through the end of the first trimester to prevent neural tube defects.


Case Study: DiabetesCase Study: Diabetes

• 38 yo college professor with Type 2 diabetes 38 yo college professor with Type 2 diabetes for 13 years. Deferred childbearing, nowfor 13 years. Deferred childbearing, now wants wants to conceiveto conceive

• Background retinopathy on exam 1 yr agoBackground retinopathy on exam 1 yr ago

• EKG: T inversions in 1, L, V6; no history of EKG: T inversions in 1, L, V6; no history of angina but notes mildly decreased exercise angina but notes mildly decreased exercise tolerancetolerance

• Microalbuminuria noted 3 yrs ago; creatinine Microalbuminuria noted 3 yrs ago; creatinine 1.11.1

• On ACE inhibitorOn ACE inhibitorNext

Preconception Care Goals: Preconception Care Goals: DiabetesDiabetes


• Implications for the pregnancy outcomeImplications for the pregnancy outcome if if she conceives (click she conceives (click here))




Diabetes: Implications for the Diabetes: Implications for the Woman If She ConceivesWoman If She Conceives

• Presence of vasculopathy, hypertension, or poor Presence of vasculopathy, hypertension, or poor glycemic control are risk factors for the glycemic control are risk factors for the development of preeclampsiadevelopment of preeclampsia

• Progression of pre-existing nephropathy is Progression of pre-existing nephropathy is possible during pregnancypossible during pregnancy

• Progression of retinopathy is often accelerated in Progression of retinopathy is often accelerated in pregnancy, threatening vision. Prior laser therapy pregnancy, threatening vision. Prior laser therapy is protective. is protective.

• Increased risk of urinary tract infection (which is a Increased risk of urinary tract infection (which is a risk factor for preterm birth and diabetic risk factor for preterm birth and diabetic ketoacidosis).ketoacidosis).

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Care for Diabetic Women in Care for Diabetic Women in Preparation for Planned ConceptionPreparation for Planned Conception

• Seek evidence of coronary artery disease Seek evidence of coronary artery disease (CAD) or cardiomyopathy through thorough (CAD) or cardiomyopathy through thorough history and physical exam (consider EKG in history and physical exam (consider EKG in patients with longstanding diabetes).patients with longstanding diabetes).

• Individualize further workup based on Individualize further workup based on findings of above plus age, duration of findings of above plus age, duration of disease, family history, lipid profile, etc.disease, family history, lipid profile, etc.

• CAD, if detected, poses a 5-15% risk of CAD, if detected, poses a 5-15% risk of maternal mortality maternal mortality

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Diabetes: Implications for Diabetes: Implications for Pregnancy OutcomesPregnancy Outcomes

• Increased incidence of congenital anomalies (click Increased incidence of congenital anomalies (click here) related to glycemic control) related to glycemic control

• Increased risk of fetal growth disturbancesIncreased risk of fetal growth disturbances– MacrosomiaMacrosomia– Intrauterine fetal growth restrictionIntrauterine fetal growth restriction

• Increased risk of intrauterine fetal demiseIncreased risk of intrauterine fetal demise– Can be mitigated by optimal glycemic controlCan be mitigated by optimal glycemic control

• Increased risk of preterm birthIncreased risk of preterm birth– Both spontaneous and indicatedBoth spontaneous and indicated

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Hemoglobin A1c & Congenital Hemoglobin A1c & Congenital AnomaliesAnomalies

• For each 1 standard deviation unit increase For each 1 standard deviation unit increase in Hgb A1c above normal (5.5 percent), the in Hgb A1c above normal (5.5 percent), the odds ratio of congenital anomalies increases odds ratio of congenital anomalies increases by 1.2 (95% CI 1.1-1.4)by 1.2 (95% CI 1.1-1.4)

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Guerin, Diabetes Care 2007

Critical Periods of DevelopmentWeeks gestation from LMPMost susceptible time for major malformation


HeartHeart

ArmsArms

EyesEyes

LegsLegs

TeethTeeth

PalatePalate


EarEar


4 5 6 7 8 9 10 11 12

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Congenital Anomalies in DM Congenital Anomalies in DM and Gestational Ageand Gestational Age

Caudal regressionCaudal regression 5 weeks 5 weeks

Situs inversusSitus inversus 6 weeks 6 weeks

Spina bifidaSpina bifida 6 weeks6 weeks

AnencephalyAnencephaly 6 weeks6 weeks

Heart anomaliesHeart anomalies 7-8 weeks7-8 weeks

Anal/rectal atresiaAnal/rectal atresia 8 weeks8 weeks

Renal anomaliesRenal anomalies 7 weeks7 weeks Next

9 weeks gestational age by LMP (7 weeks after conception)Back

Diabetes: MedicationsDiabetes: Medications

• Limited dataLimited data exists on oral hypoglycemics and pregnancy. exists on oral hypoglycemics and pregnancy. Metformin and glyburide are the most well studied (click Metformin and glyburide are the most well studied (click here for more information on oral hypoglycemic for more information on oral hypoglycemic medications)medications)

• Statins: Limited data on safety but theoretic concerns Statins: Limited data on safety but theoretic concerns because of the role of cholesterol in embryonic because of the role of cholesterol in embryonic developmentdevelopment

• ACE inhibitors: often prescribed to limit progression of ACE inhibitors: often prescribed to limit progression of nephropathy, should be discontinued prior to conception nephropathy, should be discontinued prior to conception because they are associated with fetal anomalies because they are associated with fetal anomalies (cardiovascular, CNS, and renal)(cardiovascular, CNS, and renal)

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• The American Diabetes Association recommends The American Diabetes Association recommends insulin for glycemic control in type 1 and type 2 insulin for glycemic control in type 1 and type 2 diabetes because the safety of oral anti-diabetes because the safety of oral anti-hyperglycemic agents has not been assured during hyperglycemic agents has not been assured during early pregnancy.early pregnancy.

• The American College of Obstetricians and The American College of Obstetricians and Gynecologists also recommends insulin and states Gynecologists also recommends insulin and states use of oral agents for control of type 2 diabetes use of oral agents for control of type 2 diabetes mellitus during pregnancy should be limited and mellitus during pregnancy should be limited and individualized until more data confirming safety individualized until more data confirming safety and efficacy become availableand efficacy become available

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Oral Hypoglycemics:Oral Hypoglycemics:– First generation sulfonylureas cross the placenta and First generation sulfonylureas cross the placenta and

can cause fetal hyperinsulinemiacan cause fetal hyperinsulinemia– No harmful effects noted in early or late pregnancy No harmful effects noted in early or late pregnancy

from glyburidefrom glyburide• Limited passage of glyburide across the placentaLimited passage of glyburide across the placenta

– No evidence of increased risk of major malformations No evidence of increased risk of major malformations with use of metformin in the first trimesterwith use of metformin in the first trimester

– Only sparse data about other oral hypoglycemicsOnly sparse data about other oral hypoglycemics– Some express concern that optimal pregestational Some express concern that optimal pregestational

control can only be achieved with insulincontrol can only be achieved with insulin

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Diabetes: Family Planning NeedsDiabetes: Family Planning Needs

• A reproductive life plan should be encouragedA reproductive life plan should be encouraged• No specific contraindications to any contraceptive method No specific contraindications to any contraceptive method

in women with diabetes who do not have end-organ in women with diabetes who do not have end-organ dysfunctiondysfunction

• Women with evidence of vascular disease or other end-Women with evidence of vascular disease or other end-organ dysfunction should avoid estrogen containing organ dysfunction should avoid estrogen containing contraceptivescontraceptives

• Other hormone containing contraceptives may also present Other hormone containing contraceptives may also present risksrisks

• Women with diabetes should take into consideration the Women with diabetes should take into consideration the likely progression of their disease when choosing when to likely progression of their disease when choosing when to conceiveconceive

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Looking at and beyond the disease. Looking at and beyond the disease. . .. .

• Every woman with a chronic disease should be aware of Every woman with a chronic disease should be aware of the potential effects of her disease and its treatments on the potential effects of her disease and its treatments on herself, her pregnancy and her offspring, should she herself, her pregnancy and her offspring, should she conceive, as well as opportunities for maximizing a conceive, as well as opportunities for maximizing a healthy outcome healthy outcome



• All women should be routinely assessed and counseled All women should be routinely assessed and counseled about BMI, exercise, tobacco and alcohol use, other about BMI, exercise, tobacco and alcohol use, other exposures and immunizations status (see module 2)exposures and immunizations status (see module 2)

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Preconception Care for Women Preconception Care for Women with Diabeteswith Diabetes

• Work with woman/couple to prevent unintended or Work with woman/couple to prevent unintended or unplanned pregnanciesunplanned pregnancies

• Discuss consequences of delayed childbearingDiscuss consequences of delayed childbearing• Educate about increased risks of congenital anomalies and Educate about increased risks of congenital anomalies and

the dramatic benefits of tight glucose control; educate about the dramatic benefits of tight glucose control; educate about other risks to both mother and fetusother risks to both mother and fetus

• Educate the woman/couple about the demanding prenatal Educate the woman/couple about the demanding prenatal regimen used to identify any risks to maternal or fetal regimen used to identify any risks to maternal or fetal health as early as possible.health as early as possible.

• Engage both obstetrical provider and endocrinologist or Engage both obstetrical provider and endocrinologist or other provider of diabetes care in coordinated other provider of diabetes care in coordinated preconception care of the womanpreconception care of the woman Next


Consider substituting insulin (either multi-dose regimen Consider substituting insulin (either multi-dose regimen or insulin pump) for oral hypoglycemicsor insulin pump) for oral hypoglycemics

Adjust medication regimen to achieve optimal glycemia Adjust medication regimen to achieve optimal glycemia for embryonic development (click for embryonic development (click here))

Goals: Normal Hgb A1c level; fasting blood sugar = Goals: Normal Hgb A1c level; fasting blood sugar = 60-90 mg/dl; 1 hr postprandial <140mg/dl; 2 hr <12060-90 mg/dl; 1 hr postprandial <140mg/dl; 2 hr <120

Goals achieved by home monitoring, multiple daily Goals achieved by home monitoring, multiple daily injections, close supervision, educationinjections, close supervision, education

Counsel to postpone conception until optimal control is Counsel to postpone conception until optimal control is achieved and stableachieved and stable Next

Hemoglobin A1c & Congenital Hemoglobin A1c & Congenital AnomaliesAnomalies

• For each 1 standard deviation unit increase For each 1 standard deviation unit increase in Hgb A1c above normal (5.5 percent), the in Hgb A1c above normal (5.5 percent), the odds ratio of congenital anomalies increases odds ratio of congenital anomalies increases by 1.2 (95% CI 1.1-1.4)by 1.2 (95% CI 1.1-1.4)

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Guerin, Diabetes Care 2007

Critical Periods of DevelopmentWeeks gestation from LMPMost susceptible time for major malformation


HeartHeart

ArmsArms

EyesEyes

LegsLegs

TeethTeeth

PalatePalate


EarEar


4 5 6 7 8 9 10 11 12

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Congenital Anomalies in DM Congenital Anomalies in DM and Gestational Ageand Gestational Age

•Caudal regressionCaudal regression 5 weeks 5 weeks

•Situs inversusSitus inversus 6 weeks 6 weeks

•Spina bifidaSpina bifida 6 weeks6 weeks

•AnencephalyAnencephaly 6 weeks6 weeks

•Heart anomaliesHeart anomalies 7-8 weeks7-8 weeks

•Anal/rectal atresiaAnal/rectal atresia 8 weeks8 weeks

•Renal anomaliesRenal anomalies 7 weeks7 weeks Next

9 weeks gestational age by LMP (7 weeks after conception)Back


• In women with long-standing diabetes screen In women with long-standing diabetes screen for:for:– proliferative retinopathyproliferative retinopathy

• retinopathy may progress during pregnancyretinopathy may progress during pregnancy

– nephropathy (creatinine & protein excretion)nephropathy (creatinine & protein excretion)• the presence of nephropathy increases maternal and fetal risksthe presence of nephropathy increases maternal and fetal risks

– coronary artery disease (CAD)coronary artery disease (CAD)• patients with CAD may better tolerate pregnancy after patients with CAD may better tolerate pregnancy after

revascularizationrevascularization

– urinary tract infectionsurinary tract infectionsNext

Diabetes: Primary care v. Diabetes: Primary care v. Preconception CarePreconception Care

• Shared Elements: Shared Elements: – Surveillance of glycemic control and end organ Surveillance of glycemic control and end organ

damage: retina, kidney, vasculature, nervous damage: retina, kidney, vasculature, nervous system, heartsystem, heart

– Manage medication regimen Manage medication regimen – Educate regarding diet, exercise, weight control, Educate regarding diet, exercise, weight control,

smokingsmoking– Attention to lipids, hypertension, Attention to lipids, hypertension,

microalbuminuria, infection and its preventionmicroalbuminuria, infection and its preventionNext

Diabetes: Primary Care v. Diabetes: Primary Care v. Preconception Care (cont.)Preconception Care (cont.)

• Unique aspects:Unique aspects:– Potential conversion to insulin prior to conceptionPotential conversion to insulin prior to conception

– Early prenatal care planEarly prenatal care plan

– Folic acid supplementationFolic acid supplementation

– Excellent preconception glycemic control (goal of Hgb Excellent preconception glycemic control (goal of Hgb A1c < 6 %) can reduce the risk of congenital anomalies A1c < 6 %) can reduce the risk of congenital anomalies (click (click here))

– Commonly used drugs for lipid disorders, nephropathy Commonly used drugs for lipid disorders, nephropathy are not safe during pregnancy and may need to be are not safe during pregnancy and may need to be stopped or changed.stopped or changed. Next

Prevention of Congenital Prevention of Congenital MalformationsMalformations

•Meta-analysis of 14 cohort studies:Meta-analysis of 14 cohort studies:– Incidence of major anomalies in women with Incidence of major anomalies in women with

preconception care was approximately 1/3 the preconception care was approximately 1/3 the incidence of those without preconception care incidence of those without preconception care (2.1% v. 6.5%, RR 0.36)(2.1% v. 6.5%, RR 0.36)

– Ray et al. 1994Ray et al. 1994

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A Review of the Evidence Follows:

(as published in: Evidence-based Recommendations from the Clinical Workgroup of the CDC Select

Panel on Preconception CareAmerican Journal of Obstetrics & Gynecology,

2008;199:S266-279; S280-289.)

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Evidence-based Recommendations on Preconception Care for Women with Diabetes

Mellitus

All women with diabetes mellitus should be counseled about the importance of diabetes mellitus control before considering pregnancy. Important counseling topics include achieving optimal weight, maximizing diabetes control, self glucose monitoring, a regular exercise program and tobacco, alcohol and illicit drug-use cessation along with social support to assist during pregnancy.

Strength of evidence: A Quality of evidence: INext


Diabetes Mellitus

• In the months before pregnancy, women with diabetes mellitus should demonstrate as near-normal glycosylated hemoglobin levels as possible (while avoiding hypoglycemia) for the purpose of decreasing the rate of congenital anomalies. Women with poor control should be encouraged to use effective birth control.

Strength of evidence: A Quality of evidence: INext


Diabetes Mellitus

• Testing to detect prediabetes and type 2 diabetes in asymptomatic women should be considered in adults who are overweight or obese and who have 1 or more additional risk factors for diabetes, including a history of gestational diabetes mellitus.

Strength of evidence: B Quality of evidence: II-2Next

Case Study: Chronic HypertensionCase Study: Chronic Hypertension

• 32 yo social worker who was diagnosed 32 yo social worker who was diagnosed with chronic hypertension 3 years agowith chronic hypertension 3 years ago

• Presents for an annual visit, not currently Presents for an annual visit, not currently taking any medicationstaking any medications

• BP at visit is 160/100BP at visit is 160/100

• Does not desire a pregnancy in the near Does not desire a pregnancy in the near future but is getting married in 2 monthsfuture but is getting married in 2 months

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Background: Chronic Background: Chronic Hypertension (CHTN)Hypertension (CHTN)

• Approximately 2-12.6% of women of childbearing Approximately 2-12.6% of women of childbearing age have CHTNage have CHTN

• 10-15% of pregnancies in the US are complicated 10-15% of pregnancies in the US are complicated by hypertensive disorders (i.e. CHTN, by hypertensive disorders (i.e. CHTN, preeclampsia, gestational hypertension)preeclampsia, gestational hypertension)

• Rates of pregestational hypertension complicating Rates of pregestational hypertension complicating pregnancy are increasing (from 12.3 per 1000 pregnancy are increasing (from 12.3 per 1000 deliveries in 1993 to 28.9 per 1000 deliveries in deliveries in 1993 to 28.9 per 1000 deliveries in 2002)2002)

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Preconception Care Goals: Preconception Care Goals: Chronic HypertensionChronic Hypertension


• Implications for pregnancy outcome if she Implications for pregnancy outcome if she conceives (click conceives (click here))




Hypertension: Implications for the Hypertension: Implications for the Woman if She ConceivesWoman if She Conceives

• Goal is to maintain good BP control on least Goal is to maintain good BP control on least medicationmedication

• High risk for the development of High risk for the development of preeclampsia/eclampsia particularly in preeclampsia/eclampsia particularly in women with severe HTN or vascular diseasewomen with severe HTN or vascular disease

• Risk exists for progression of renal disease if Risk exists for progression of renal disease if woman already has chronic renal woman already has chronic renal insufficiencyinsufficiency

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Hypertension: Implications for Hypertension: Implications for Pregnancy OutcomesPregnancy Outcomes

• Complications in pregnancy: Complications in pregnancy: – Spontaneous abortionSpontaneous abortion– Pre-eclampsiaPre-eclampsia– Fetal growth restrictionFetal growth restriction– Abruptio placentaeAbruptio placentae– Preterm birth (both spontaneous and indicated)Preterm birth (both spontaneous and indicated)

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Hypertension: MedicationsHypertension: Medications

• Methyldopa-most widely Methyldopa-most widely studied, but of limited studied, but of limited effectivenesseffectiveness

• Labetolol-most widely Labetolol-most widely used, may be associated used, may be associated with intrauterine growth with intrauterine growth restrictionrestriction

• Nifedipine-less well Nifedipine-less well studied but appears safestudied but appears safe

• Hydralazine-probably safe Hydralazine-probably safe but difficult to obtain oral but difficult to obtain oral formulationformulation

• Thiazide diuretics-Thiazide diuretics-controversial but can be controversial but can be continued if volume continued if volume depletion avoideddepletion avoided

• ACE Inhibitors and ACE Inhibitors and angiotensin receptor angiotensin receptor blockers-contraindicated blockers-contraindicated because teratogenicity riskbecause teratogenicity riskBack

Some examples:

Hypertension: Family Planning Hypertension: Family Planning NeedsNeeds

• A reproductive life plan should be encouragedA reproductive life plan should be encouraged

• Women/couples need to be aware of potential for Women/couples need to be aware of potential for progression of disease when choosing the optimal time to progression of disease when choosing the optimal time to conceiveconceive

• Estrogen containing contraceptives are not recommended Estrogen containing contraceptives are not recommended (may increase BP and increase risk of cardiovascular events)(may increase BP and increase risk of cardiovascular events)

• Progestin only methods are probably safeProgestin only methods are probably safe

• Women taking potentially teratogenic drugs (e.g. ACE Women taking potentially teratogenic drugs (e.g. ACE inhibitors) should be counseled about importance of using inhibitors) should be counseled about importance of using effective contraceptioneffective contraception

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• Every woman with a chronic disease should be aware of Every woman with a chronic disease should be aware of the potential effects of her disease and its treatments on the potential effects of her disease and its treatments on herself, her pregnancy and her offspring, should she herself, her pregnancy and her offspring, should she conceive, as well as opportunities for maximizing a conceive, as well as opportunities for maximizing a healthy outcome healthy outcome




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Management of Pregestational Management of Pregestational HTN in PregnancyHTN in Pregnancy

• No evidence that medical management of No evidence that medical management of mild HTN during pregnancy reduces mild HTN during pregnancy reduces pregnancy complications pregnancy complications

• Severe or complicated HTN is more often Severe or complicated HTN is more often associated with poor pregnancy outcomesassociated with poor pregnancy outcomes

• No conclusive data on optimal No conclusive data on optimal antihypertensive medication to chooseantihypertensive medication to choose

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Preconception Care for Women with Hypertension

• Work with woman/couple to prevent unintended Work with woman/couple to prevent unintended or unplanned pregnanciesor unplanned pregnancies

• Discuss consequences of delayed childbearingDiscuss consequences of delayed childbearing

• Engage both obstetrical provider and internist or Engage both obstetrical provider and internist or other provider of care for hypertension to other provider of care for hypertension to coordinate preconception care of the womancoordinate preconception care of the woman

• Stabilize the woman on the simplest medication Stabilize the woman on the simplest medication regimen, avoiding teratogenic medicationsregimen, avoiding teratogenic medications

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Hypertension: Primary Care v. Hypertension: Primary Care v. Preconception Care Preconception Care

• Shared elementsShared elements– Control of BP via lifestyle and diet modifications and Control of BP via lifestyle and diet modifications and

antihypertensive medicationsantihypertensive medications

– Goal to prevent cardiovascular complicationsGoal to prevent cardiovascular complications

– Assess for etiology of CHTN and for evidence of end Assess for etiology of CHTN and for evidence of end organ disease (esp. renal dysfunction)organ disease (esp. renal dysfunction)

– Want to choose the least aggressive treatment that will Want to choose the least aggressive treatment that will achieve the desired BP controlachieve the desired BP control

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Hypertension: Primary Care v. Hypertension: Primary Care v. Preconception Care (cont.)Preconception Care (cont.)

• Unique aspectsUnique aspects– Counsel on risk of poor pregnancy outcomesCounsel on risk of poor pregnancy outcomes– If medications required, avoid ACE inhibitors and If medications required, avoid ACE inhibitors and

angiotensin receptor blockersangiotensin receptor blockers– Counsel on optimal time to conceive (once BP under Counsel on optimal time to conceive (once BP under

control and before the development of end-organ disease)control and before the development of end-organ disease)– Counsel not to suddenly discontinue medication if Counsel not to suddenly discontinue medication if

conceivesconceives– Encourage early entry into prenatal careEncourage early entry into prenatal care– Not clear that medical management of mild CHTN Not clear that medical management of mild CHTN

impacts on the outcome of pregnancyimpacts on the outcome of pregnancyNext


(as published in: Evidence-based Recommendations from the Clinical Workgroup of the CDC Select Panel on Preconception Care.

American Journal of Obstetrics & Gynecology, 2008;199:S266-279; S310-327.)

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Evidence-based Recommendations on Preconception Care for Women

with Chronic HypertensionWomen of reproductive age with chronic

hypertension should be counseled about the risks associated with hypertension during pregnancy for both the woman and her offspring and the possible need to change the antihypertensive regimen when she is planning a pregnancy


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Chronic HypertensionAngiotensin-converting enzyme inhibitors and

angiotensin-receptor blockers are contraindicated during pregnancy; women who could become pregnant while taking these medications should be counseled about their adverse fetal effects and should be offered contraception if they are not planning a pregnancy. Women who are planning a pregnancy should discontinue these medications, under medical supervision, before pregnancy.



Chronic Hypertension

Women with hypertension of several years should be assessed for ventricular hypertrophy, retinopathy and renal disease before pregnancy.


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Case Study: HIV infectionCase Study: HIV infection

• 28 yo teacher presents for routine visit to 28 yo teacher presents for routine visit to monitor her HIV infectionmonitor her HIV infection

• Viral load is undetectable on current Viral load is undetectable on current regimenregimen

• Has had no opportunistic infectionsHas had no opportunistic infections

• Sexually active but using condomsSexually active but using condoms

• Partner is HIV-negativePartner is HIV-negativeNext

Background: HIV InfectionBackground: HIV Infection

• Perinatal HIV infection accounts for more than Perinatal HIV infection accounts for more than 90% of pediatric AIDS cases in the US90% of pediatric AIDS cases in the US– Many of these cases are born to women who didnMany of these cases are born to women who didn’’t t

know their HIV statusknow their HIV status

• Early identification and treatment is optimal Early identification and treatment is optimal method to reduce vertical transmissionmethod to reduce vertical transmission

• Treatment with antiretrovirals can reduce vertical Treatment with antiretrovirals can reduce vertical transmission to ≤ 2%transmission to ≤ 2%

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Preconception Care Goals: HIV Preconception Care Goals: HIV InfectionInfection


• Implications for the pregnancy outcome if Implications for the pregnancy outcome if she conceives (click she conceives (click here))




HIV Infection: Implications for HIV Infection: Implications for the Woman If She Conceivesthe Woman If She Conceives

• No evidence of increased risk for HIV infection progression as a result of pregnancy

• A woman not on antiretroviral medication will need to initiate an antiretroviral regimen in order to reduce risk of vertical transmission

• Women with end organ dysfunction (e.g. kidneys, heart) are at risk of worsening organ function and pregnancy complications

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HIV Infection: Implications for Pregnancy Outcomes

• Limited data on impact of medications on Limited data on impact of medications on pregnancy outcomespregnancy outcomes– To date, most appear to be safe for the pregnancyTo date, most appear to be safe for the pregnancy

• Risk of vertical transmission directly related Risk of vertical transmission directly related to viral loadto viral load– Women with viral loads >1000 copies/mL can Women with viral loads >1000 copies/mL can

further reduce risk of vertical transmission further reduce risk of vertical transmission through cesarean deliverythrough cesarean delivery

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HIV Infection: MedicationsHIV Infection: Medications• A combination antiretroviral drug regimen should be given antenatally to prevent A combination antiretroviral drug regimen should be given antenatally to prevent

vertical transmission. It is preferred that zidovudine is one of the active vertical transmission. It is preferred that zidovudine is one of the active medications in this regimen if there are no contraindications for its use. Other medications in this regimen if there are no contraindications for its use. Other antiretroviral medications are equally as effective in preventing transmission. antiretroviral medications are equally as effective in preventing transmission.

• Intrapartum zidovudine may not be necessary for patients with an undetectable Intrapartum zidovudine may not be necessary for patients with an undetectable viral load in laborviral load in labor

• Infants should receive oral zidovudine for the first six weeks after birthInfants should receive oral zidovudine for the first six weeks after birth• Specific medication issues:Specific medication issues:

– Efavirenz – should be avoided during the first 6 weeks of pregnancy (potentially teratogenic)Efavirenz – should be avoided during the first 6 weeks of pregnancy (potentially teratogenic)– Didanosine/Stavudine (ddI/d4T) - associated with the development of lactic acidosis during Didanosine/Stavudine (ddI/d4T) - associated with the development of lactic acidosis during

pregnancypregnancy– Nevirapine - associated with hepatotoxicity when initiated in individuals with CD4 counts > 250 Nevirapine - associated with hepatotoxicity when initiated in individuals with CD4 counts > 250

cells/mmcells/mm33

• Many protease inhibitors have decreased serum concentrations during the third Many protease inhibitors have decreased serum concentrations during the third trimester so dose adjustments may be necessarytrimester so dose adjustments may be necessary

• Most antiretroviral medications have not been adequately studied during pregnancyMost antiretroviral medications have not been adequately studied during pregnancy• It is important to work with a patientIt is important to work with a patient’’s HIV care provider before making s HIV care provider before making

changes to the patientchanges to the patient’’s medication regimens medication regimen

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HIV Infection: Family Planning HIV Infection: Family Planning NeedsNeeds

• Women/couples should be encouraged to develop a Women/couples should be encouraged to develop a reproductive life planreproductive life plan

• Need to be aware of potential drug interactions between Need to be aware of potential drug interactions between oral contraceptives and anti-retroviralsoral contraceptives and anti-retrovirals– Antiretroviral regimens containing protease inhibitors and Antiretroviral regimens containing protease inhibitors and

non-nucleoside reverse transcriptase inhibitors may non-nucleoside reverse transcriptase inhibitors may decrease levels of steroids released by hormonal decrease levels of steroids released by hormonal contraceptives. Drug interactions of antiretrovirals on contraceptives. Drug interactions of antiretrovirals on hormonal contraceptives are specific to the type of hormonal contraceptives are specific to the type of antiretroviral and hormonal contraceptive being utilized.antiretroviral and hormonal contraceptive being utilized.

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HIV Infection: Family Planning HIV Infection: Family Planning NeedsNeeds

• Condoms while most effective at reducing viral Condoms while most effective at reducing viral transmission during intercourse are not optimal for transmission during intercourse are not optimal for preventing pregnancypreventing pregnancy

• Unprotected intercourse for the purpose of conceiving Unprotected intercourse for the purpose of conceiving presents a risk to the womanpresents a risk to the woman’’s partners partner

– Should consider artificial inseminationShould consider artificial insemination

• Need to be aware of the potential for progression of co-Need to be aware of the potential for progression of co-morbid conditions when choosing the optimal time to morbid conditions when choosing the optimal time to conceive (sooner may be better than later)conceive (sooner may be better than later)

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• Every woman with a chronic disease should be aware of Every woman with a chronic disease should be aware of the potential effects of her disease and its treatments on the potential effects of her disease and its treatments on herself, her pregnancy and her offspring, should she herself, her pregnancy and her offspring, should she conceive, as well as the opportunities for maximizing a conceive, as well as the opportunities for maximizing a healthy outcomehealthy outcome

• All women of childbearing age should take a multivitamin All women of childbearing age should take a multivitamin that includes folic acid every daythat includes folic acid every day


• Providers should routinely assess and counsel all women Providers should routinely assess and counsel all women about optimal BMI, exercise, tobacco and alcohol use, about optimal BMI, exercise, tobacco and alcohol use, other exposures, and immunization status (see module 2)other exposures, and immunization status (see module 2)

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Preconception Care for Women with HIV Infections

• Work with woman/couple to explore safest Work with woman/couple to explore safest choices for conceptionchoices for conception

• Discuss potential consequences of delayed Discuss potential consequences of delayed childbearingchildbearing

• Assure that woman has access to appropriate Assure that woman has access to appropriate antiretroviral medications and is willing to take antiretroviral medications and is willing to take them consistentlythem consistently

• Engage both obstetrical provider and HIV Engage both obstetrical provider and HIV specialist to coordinate preconception care of the specialist to coordinate preconception care of the womanwoman Next

HIV Infection: Primary Care v. HIV Infection: Primary Care v. Preconception Care Preconception Care

• Shared elementsShared elements– Preserve cellular immune functionPreserve cellular immune function– Minimize viral loadMinimize viral load– Reduce the risk of opportunistic infectionsReduce the risk of opportunistic infections– Determine if other co-morbid conditions exist (e.g. Determine if other co-morbid conditions exist (e.g.

renal disease, cervical dysplasia) and treatrenal disease, cervical dysplasia) and treat– Limit development of viral mutations and drug Limit development of viral mutations and drug

resistanceresistance– Reduce the risk of viral transmissionReduce the risk of viral transmission

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HIV Infection: Primary Care v. HIV Infection: Primary Care v. Preconception Care (cont.)Preconception Care (cont.)

• Unique aspectsUnique aspects– Counsel about implications of a pregnancyCounsel about implications of a pregnancy

– Reassessment of optimal antiretroviral regimen (see Reassessment of optimal antiretroviral regimen (see Medications)Medications)

– Cesarean delivery can reduce vertical transmission in Cesarean delivery can reduce vertical transmission in women with a viral load > 1000 copies/mLwomen with a viral load > 1000 copies/mL

– Postpartum maternal morbidity is greater among HIV-Postpartum maternal morbidity is greater among HIV-infected women who undergo cesarean delivery infected women who undergo cesarean delivery

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HIV Infection: MedicationsHIV Infection: Medications• A combination antiretroviral drug regimen should be given antenatally to prevent A combination antiretroviral drug regimen should be given antenatally to prevent

vertical transmission. It is preferred that zidovudine is one of the active vertical transmission. It is preferred that zidovudine is one of the active medications in this regimen if there are no contraindications for its use. Other medications in this regimen if there are no contraindications for its use. Other antiretroviral medications are equally as effective in preventing transmission. antiretroviral medications are equally as effective in preventing transmission.

• Intrapartum zidovudine may not be necessary for patients with an undetectable Intrapartum zidovudine may not be necessary for patients with an undetectable viral load in laborviral load in labor

• Infants should receive oral zidovudine for the first six weeks after birthInfants should receive oral zidovudine for the first six weeks after birth• Specific medication issues:Specific medication issues:

– Efavirenz – should be avoided during the first 6 weeks of pregnancy (potentially teratogenic)Efavirenz – should be avoided during the first 6 weeks of pregnancy (potentially teratogenic)– Didanosine/Stavudine (ddI/d4T) - associated with the development of lactic acidosis during Didanosine/Stavudine (ddI/d4T) - associated with the development of lactic acidosis during

pregnancypregnancy– Nevirapine - associated with hepatotoxicity when initiated in individuals with CD4 counts > 250 Nevirapine - associated with hepatotoxicity when initiated in individuals with CD4 counts > 250

cells/mmcells/mm33

• Many protease inhibitors have decreased serum concentrations during the third Many protease inhibitors have decreased serum concentrations during the third trimester so dose adjustments may be necessarytrimester so dose adjustments may be necessary

• Most antiretroviral medications have not been adequately studied during pregnancyMost antiretroviral medications have not been adequately studied during pregnancy• It is important to work with a patientIt is important to work with a patient’’s HIV care provider before making s HIV care provider before making

changes to the patientchanges to the patient’’s medication regimens medication regimen

Back


(as published in: Evidence-based Recommendations from the Clinical Workgroup of the CDC Select Panel on Preconception Care.American Journal of Obstetrics & Gynecology,

2008;199:S266-279; S296-309.)

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with HIV

All men and women should be encouraged to know their human immunodeficiency virus status before pregnancy and should be counseled about safe sexual practices.

Strength of evidence: A Quality of evidence: I-b

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with HIVWomen who test positive for HIV must be informed

of the risks of vertical transmission to the infant and the associated morbidity and mortality probabilities. These women should be offered contraception. Women who choose pregnancy should be counseled about the availability of treatment to prevent vertical transmission and that treatment should begin before pregnancy.

Strength of evidence: A Quality of evidence: I-bNext

Case Study: ObesityCase Study: Obesity

• 33 yo homemaker with two children 33 yo homemaker with two children presents for management of a missed periodpresents for management of a missed period– Pregnancy test is negativePregnancy test is negative

• Did not lose gestational weight gain after Did not lose gestational weight gain after either of her pregnancieseither of her pregnancies

• Last pregnancy complicated by gestational Last pregnancy complicated by gestational diabetes (diet-controlled)diabetes (diet-controlled)

• Current BMI is 31 kg/mCurrent BMI is 31 kg/m22

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Background: ObesityBackground: Obesity

• Incidence of obesity rising dramatically in the USIncidence of obesity rising dramatically in the US– From 2001 to 2012, the incidence of obesity among From 2001 to 2012, the incidence of obesity among

women of reproductive age has risen from 17.6% to women of reproductive age has risen from 17.6% to 25% 25%

• Associated with subfertility and spontaneous Associated with subfertility and spontaneous abortionsabortions

• Associated with multiple other complications Associated with multiple other complications during pregnancy (see slide: Pregnancy during pregnancy (see slide: Pregnancy complications associated with maternal obesity)complications associated with maternal obesity)

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Preconception Care Goals: Preconception Care Goals: ObesityObesity

• Implications for the woman if she Implications for the woman if she conceives (click here)conceives (click here)

• Implications for the pregnancy outcome if Implications for the pregnancy outcome if she conceives (click here)she conceives (click here)

• Medication considerations (click here)Medication considerations (click here)

• Family planning needs (click here)Family planning needs (click here)

• Looking beyond the disease to the whole Looking beyond the disease to the whole woman (click here)woman (click here) Next

Obesity: Implications for the Obesity: Implications for the Woman If She ConceivesWoman If She Conceives

• Additional weight gainAdditional weight gain

• Gestational diabetes and Gestational diabetes and subsequent type 2 subsequent type 2 diabetes mellitusdiabetes mellitus

• Hypertensive DisordersHypertensive Disorders

• Thromboembolic Thromboembolic diseasedisease

• Obstructive sleep apneaObstructive sleep apnea

• Induction of laborInduction of labor

• Cesarean deliveryCesarean delivery

• Anesthesia complicationsAnesthesia complications

• Postpartum hemorrhagePostpartum hemorrhage

• Postpartum infectionPostpartum infection

• Wound complicationsWound complications

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Obesity: Implications for Pregnancy Obesity: Implications for Pregnancy OutcomesOutcomes

• Increased risk of spontaneous abortionIncreased risk of spontaneous abortion• Congenital malformationsCongenital malformations

– Neural tube, cardiovascular anomaliesNeural tube, cardiovascular anomalies– Standard doses of preconception folic acid may not be as Standard doses of preconception folic acid may not be as

effective at reducing risk of birth defectseffective at reducing risk of birth defects• MacrosomiaMacrosomia• Shoulder dystocia (ErbShoulder dystocia (Erb’’s Palsy)s Palsy)• Perinatal mortalityPerinatal mortality• Childhood obesityChildhood obesity

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Obesity: MedicationsObesity: Medications

• Sympathomimetic drugsSympathomimetic drugs– Not adequately studied in pregnancyNot adequately studied in pregnancy

– No clear evidence of teratogenicityNo clear evidence of teratogenicity

– Not recommended during pregnancyNot recommended during pregnancy

• Drugs that alter fat digestionDrugs that alter fat digestion– No evidence of harm during pregnancyNo evidence of harm during pregnancy

– May alter absorption of fat soluble vitaminsMay alter absorption of fat soluble vitamins

Selected Medications in Pregnancy:

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Obesity: Family Planning NeedsObesity: Family Planning Needs

• Women/couples should be encouraged to develop a Women/couples should be encouraged to develop a reproductive life planreproductive life plan

• Combined hormonal contraceptives may be less effective in Combined hormonal contraceptives may be less effective in obese womenobese women

• Obese women using depot medroxy- progesterone acetate Obese women using depot medroxy- progesterone acetate may take longer return to ovulatory functionmay take longer return to ovulatory function– Depot medroxy- progesterone acetate also may be associated with Depot medroxy- progesterone acetate also may be associated with

weight gainweight gain

• May be more procedural challengesMay be more procedural challenges

– Placing IUDPlacing IUD

– Performing sterilizationPerforming sterilization

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• Every woman with a chronic disease should be aware of the Every woman with a chronic disease should be aware of the potential effects of her disease and its treatments on herself, potential effects of her disease and its treatments on herself, her pregnancy and her offspring, should she conceive, as her pregnancy and her offspring, should she conceive, as well as the opportunities for maximizing a healthy outcomewell as the opportunities for maximizing a healthy outcome

• All women of childbearing age should be taking a All women of childbearing age should be taking a multivitamin that includes folic acid every daymultivitamin that includes folic acid every day– 400 mcg of folic acid may not be sufficient for obese women. Some 400 mcg of folic acid may not be sufficient for obese women. Some

authorities suggest 1 gm.authorities suggest 1 gm.• All women/couples should be encouraged to develop a All women/couples should be encouraged to develop a

reproductive life planreproductive life plan• All women should be routinely assessed and counseled All women should be routinely assessed and counseled

about BMI, exercise, tobacco and alcohol use, other about BMI, exercise, tobacco and alcohol use, other exposures and immunization status (see module 2)exposures and immunization status (see module 2)

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Obesity: Primary Care v. Obesity: Primary Care v. Preconception Care Preconception Care

• Appropriate weight loss utilizingAppropriate weight loss utilizing– Healthy diet with decreased caloric intakeHealthy diet with decreased caloric intake– Increased physical activityIncreased physical activity

• Weight lossWeight loss– Improves fertilityImproves fertility– May reduce long term risks of poor health outcomes May reduce long term risks of poor health outcomes

(e.g. diabetes, hypertension)(e.g. diabetes, hypertension)– Bariatric surgery may also improve pregnancy Bariatric surgery may also improve pregnancy

outcomes (click here for more information)outcomes (click here for more information)

Shared elements:

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Pregnancy after Bariatric Surgery

• Risks of maternal complications of pregnancy like Gestational Diabetes and Preeclampsia may be reduced

• Risks of neonatal complications of pregnancy like Preterm Birth and Low Birth Weight may be reduced

• Maternal nutritional deficiencies observed appear to be the result of supplement nonadherence

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Obesity: Primary Care v. Obesity: Primary Care v. Preconception Care (cont.) Preconception Care (cont.)

• Counsel about risks of poor pregnancy Counsel about risks of poor pregnancy outcomesoutcomes

• Planning for pregnancy may provide Planning for pregnancy may provide additional motivation to lose weightadditional motivation to lose weight

• Determine reproductive plansDetermine reproductive plans– Increased risks of hormonal contraceptive failure Increased risks of hormonal contraceptive failure

with certain methods (e.g. oral contraceptives, with certain methods (e.g. oral contraceptives, contraceptive patch, contraceptive implant)contraceptive patch, contraceptive implant)

Unique aspects:

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2008;199:S266-279; S280-289.)

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Evidence-based Recommendations for Preconception Care of Women

with ObesityAll women of reproductive age should have their body mass

index (BMI) calculated at least annually. All women with BMIs > 26 kg/m kg/m22 should be counseled about the risks to their own health, the risks to future pregnancies and the risks of infertility. These women should be offered specific behavioral strategies to decrease caloric intake and increase physical activity. They should be encouraged to consider participation in structured weight loss programs.

Strength of evidence: A Quality of evidence: III

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Case Study: DepressionCase Study: Depression

• 29 yo social worker presents to the 29 yo social worker presents to the emergency room with a complete emergency room with a complete spontaneous abortionspontaneous abortion– Pregnancy was unintended Pregnancy was unintended – History of depression controlled with History of depression controlled with

paroxetineparoxetine– Followed by psychiatrist for last 5 yearsFollowed by psychiatrist for last 5 years

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Background: DepressionBackground: Depression

• Prevalence of Major Depressive Disorder Prevalence of Major Depressive Disorder among adult women is 5-9%among adult women is 5-9%

• Increases risk of tobacco, alcohol and illicit Increases risk of tobacco, alcohol and illicit drug usedrug use

• Increases risk of self-injurious behaviorsIncreases risk of self-injurious behaviors

• US Preventative Services Task Force US Preventative Services Task Force recommends routine screeningrecommends routine screening

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Preconception Care Goals: Preconception Care Goals: DepressionDepression

• Implications for the woman if she Implications for the woman if she conceives (click here)conceives (click here)

• Implications for the pregnancy outcome if Implications for the pregnancy outcome if she conceives (click here)she conceives (click here)

• Medication considerations (click here)Medication considerations (click here)

• Family planning needs (click here)Family planning needs (click here)

• Looking beyond the disease to the whole Looking beyond the disease to the whole woman (click here)woman (click here) Next

Depression: Implications for the Depression: Implications for the woman if she conceiveswoman if she conceives

• Worsening of depressionWorsening of depression• Suicidal ideation and suicideSuicidal ideation and suicide• InsomniaInsomnia• AnxietyAnxiety• Increased risk postpartum depression and Increased risk postpartum depression and

psychosis (can also occur after any psychosis (can also occur after any pregnancy loss)pregnancy loss)

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Depression: Implications for Depression: Implications for Pregnancy OutcomesPregnancy Outcomes

• Impaired judgment leading to Impaired judgment leading to noncompliance with carenoncompliance with care

• Poor appetite/weight gainPoor appetite/weight gain

• Impaired maternal-infant bondingImpaired maternal-infant bonding

• Substance useSubstance use

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Depression: MedicationsDepression: Medications

• SSRIs and SNRIs: SSRIs and SNRIs: – Possible small risk for birth defectsPossible small risk for birth defects

• Weak association between paroxetine and CV defectsWeak association between paroxetine and CV defects

– Possible small risk of association with preterm birth Possible small risk of association with preterm birth (but depression is also associated with preterm birth)(but depression is also associated with preterm birth)

• Transient neonatal effects of SSRIs, and other Transient neonatal effects of SSRIs, and other antidepressantsantidepressants– ““poor neonatal adaptationpoor neonatal adaptation”” or or ““neonatal behavioral neonatal behavioral

syndromessyndromes””– SSRI exposure in the third trimester may be associated SSRI exposure in the third trimester may be associated

with persistent pulmonary hypertensionwith persistent pulmonary hypertension


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Depression: Family Planning NeedsDepression: Family Planning Needs

• No contraindication to any commonly used No contraindication to any commonly used contraceptive for women with depressioncontraceptive for women with depression

• Long acting progestins may increase the Long acting progestins may increase the risk for depressionrisk for depression

• Any drug that induces the cytochrome P450 Any drug that induces the cytochrome P450 enzymes in the liver may reduce the enzymes in the liver may reduce the effectiveness of combined hormonal effectiveness of combined hormonal contraceptives.contraceptives.– Examples: St. JohnExamples: St. John’’s wort, anticonvulsantss wort, anticonvulsants

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• Every woman with a chronic disease should be aware of Every woman with a chronic disease should be aware of the potential effects of her disease and its treatments on the potential effects of her disease and its treatments on herself, her pregnancy and her offspring, should she herself, her pregnancy and her offspring, should she conceive, as well as the opportunities for maximizing a conceive, as well as the opportunities for maximizing a healthy outcome All women of childbearing age should be healthy outcome All women of childbearing age should be taking a multivitamin that includes folic acid every daytaking a multivitamin that includes folic acid every day



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Depression: Primary Care v. Depression: Primary Care v. Preconception CarePreconception Care

•Achieving a euthymic mood with a Achieving a euthymic mood with a biopsychosocial approachbiopsychosocial approach

• If medical treatment is necessary, If medical treatment is necessary, choose lowest effective dose and choose lowest effective dose and simplest regimen that achieves desired simplest regimen that achieves desired resultsresults

Shared elements:

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Depression: Primary Care v. Depression: Primary Care v. Preconception Care (cont.)Preconception Care (cont.)

• Counseling about the implications of pregnancy in Counseling about the implications of pregnancy in the setting of depressionthe setting of depression

• Counseling about risks of medication use in Counseling about risks of medication use in pregnancy (see Depression: Medications)pregnancy (see Depression: Medications)

• Determine reproductive life planDetermine reproductive life plan• Risks of untreated maternal depression may Risks of untreated maternal depression may

outweigh risks of medication during pregnancyoutweigh risks of medication during pregnancy• Substance use is associated with unintended Substance use is associated with unintended

pregnancypregnancy

Unique aspects:

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Depression: MedicationsDepression: Medications

• SSRIs and SNRIs: possible low risk for birth SSRIs and SNRIs: possible low risk for birth defectsdefects– Possible association between paroxetine and CV Possible association between paroxetine and CV

defectsdefects

• Transient neonatal effects of SSRIs, and other Transient neonatal effects of SSRIs, and other antidepressantsantidepressants– ““poor neonatal adaptationpoor neonatal adaptation”” or or ““neonatal behavioral neonatal behavioral

syndromessyndromes””– SSRI exposure in the third trimester may be associated SSRI exposure in the third trimester may be associated

with persistent pulmonary hypertensionwith persistent pulmonary hypertension


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2008;199:S266-279; S280-289.)

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Evidence-based Recommendations for Preconception Care of Women

with Depression

Providers should screen and be vigilant for depression and anxiety disorders among women of reproductive age because treating or controlling these conditions before pregnancy may help prevent negative pregnancy and family outcomes.

Strength of evidence: B Quality of evidence: IIINext

Preconception Care Tips for Preconception Care Tips for ProvidersProviders

• Encourage women and their partners:Encourage women and their partners:– To develop reproductive life plansTo develop reproductive life plans– To actively choose when or when not to become pregnantTo actively choose when or when not to become pregnant

• Provide contraceptive method counseling for patients and their Provide contraceptive method counseling for patients and their partners based on medical condition and reproductive life planspartners based on medical condition and reproductive life plans

• Encourage women with medical conditions to discuss their desire Encourage women with medical conditions to discuss their desire to become pregnant with all of their providers before they become to become pregnant with all of their providers before they become pregnant (preferably at least 3 months before desired conception)pregnant (preferably at least 3 months before desired conception)– Consider effects of pregnancy on:Consider effects of pregnancy on:

• Patient and her conditionPatient and her condition• Fetus/newbornFetus/newborn

• Consult a maternal-fetal medicine specialist when appropriateConsult a maternal-fetal medicine specialist when appropriate– Click here for examples of conditions which might be appropriate Click here for examples of conditions which might be appropriate

for preconception consultationfor preconception consultation

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Some conditions that may benefit from preconception care with a

maternal-fetal medicine specialist

• Pregestational Diabetes

• Renal insufficiency

• Lupus

• History of Thrombo-embolism

• Antiphospholipid syndrome

• Significant cardiac disease

• History of malignancy

• Crohn’s disease

• Severe pulmonary disease

• History of organ transplantation

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ConclusionsConclusions

• Preconception Health Promotion is part Preconception Health Promotion is part of routine primary medical careof routine primary medical care

• Preconception Care is not an isolated Preconception Care is not an isolated activityactivity

• Pregnancy is part of a life-course Pregnancy is part of a life-course perspective on womenperspective on women’’s healths health

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You Are Now Done with Module 3You Are Now Done with Module 3

• Now that you have finished Module 3 of the curriculum you have these options:• Take the post test and register for the appropriate CMEs

• Move on to any of the other modules: we recommend they be taken in order but this is not essential

• Explore the rest of this website for the other offerings to help you incorporate evidence-based preconception care into your practice.

Documents

Maximizing Prevention: Targeted Care for Those with High Risk Conditions The National Preconception Curriculum & Resources Guide for Clinicians MODULE