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APGO educational topic number nine
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preconception care meet our patient
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young reproductive aged she is a common
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patient in all medical and surgical
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scenarios it is always important to
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consider the likelihood of pregnancy in
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all of our reproductive aged patients
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the objectives of this video are to
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describe how certain medical conditions
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affect pregnancy to describe how
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pregnancy affects certain medical
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conditions to assess a patient’s genetic
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risk as well as a father’s genetic risk
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with regards to pregnancy to describe
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genetic screening options in pregnancy
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to recognize a patient’s risk of
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substance abuse and intimate partner
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violence and explain how this would be
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addressed for the patient to appraise a
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patient’s nutritional status and make
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recommendations to the patient on
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nutrition and exercise to assess a
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patient’s medications immunizations and
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environmental hazards in pregnancy to
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identify appropriate folic acid intake
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and to identify ethical issues
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associated with prenatal genetic
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screening and diagnostic tests many of
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our patients see their obstetrician
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gynecologist when they are already
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pregnant in a perfect world miss young
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would come in for a preconception
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counseling visit before she became
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pregnant especially if she has
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pre-existing medical conditions such as
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diabetes why is this important let’s
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look at fetal malformation rates and
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their relationship to maternal
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hemoglobin a1c levels at a hemoglobin
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a1c level of less than 7 the fetal
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malformation rate is the same as
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baseline at seven point two to nine
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point one there is a 14% rate at nine
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point two to eleven point one there’s a
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twenty three percent rate and if the
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hemoglobin a1c is greater than eleven
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point two there’s a 25% fetal
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malformation rate of the diabetic
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related fetal malformations cardio
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vascular malformations are the most
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common followed by central nervous
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system than gastrointestinal
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genitourinary and skeletal malformations
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in addition if a diabetic woman’s
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hemoglobin a1c level is 11 there is a
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44% miscarriage rate remember that organ
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formation occurs at approximately 3 to
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10 weeks estimated gestational age and
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fewer than 30% of diabetic women seek
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preconception counseling a savvy
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endocrinologist or primary care doctor
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should therefore always talk to their
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young reproductive age women about
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contraception and risk of pregnancy
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especially if glucose control as an
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issue if young came in for a
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preconception counts
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visit what should we address if she has
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medical issues we need to talk about
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optimizing control of the disease
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processes let’s start by discussing
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systemic lupus erythematosus SLE ideally
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pregnancy should occur during a period
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of disease quiescence for at least six
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months prior to conception if her SLE is
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active at the time of conception this is
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a strong predictor of adverse maternal
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and obstetric of complications all of
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her SLE medications need to be reviewed
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and adjusted prior to conception with
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the goal of maintaining disease control
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while maximizing safety profiles
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preconception counseling with SLE is
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thus especially important next let us
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discuss if young had hypertension there
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are several key issues pertaining to
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hypertension and pregnancy planning
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first blood pressure classifications we
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classify hypertensive pregnant women
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into three classes normal with blood
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pressures less than 140 over 90 mild to
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moderate hypertension with systolic’s of
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140 to 159 over a diastolic of 90 over
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109 and severe hypertension is greater
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than a systolic of 160 and a diastolic
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of 90 we know that treating severe
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hypertension leads to a reduction in
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stroke risk there is an unclear benefit
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of treating mild to moderate
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hypertension for there needs to be a
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balance for lowering maternal blood
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pressure too much reduces placental
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perfusion the medication classifications
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of ACE inhibitors angiotensin ii
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receptor blockers and direct renin
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inhibitors are contraindicated during
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all stages of pregnancy methyl dopa and
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labetalol are safe and commonly used
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during pregnancy pre pregnancy
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hypertension otherwise known as chronic
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hypertension is associated with greater
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risks during pregnancy of superimposed
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preeclampsia placental abruption and
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fetal growth restriction if young has
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diabetes in addition to the fetal issues
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we discussed earlier in this video
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pregnancy has been associated with
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exacerbation of many disease related
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complications poorly controlled pre
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gestational diabetes can lead to serious
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and organ damage that could become
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eventually life-threatening for example
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diabetic nephropathy diabetic
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retinopathy and chronic hypertension the
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good news is that perinatal mortality
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has decreased markedly in recent years
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because of the ability to achieve
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glucose control with medical therapy
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either with insulin or oral hypoglycemic
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agents
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going back to our preconception
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counseling checklist we have discussed
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some key medical issues that should be
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discussed what else should we talk about
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infectious disease issues vaccines live
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vaccines cannot be administered during
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pregnancy so the preconception
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counseling visit is an ideal time to
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offer vaccinations for a rare Acela and
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our rubella if a woman is not immune in
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addition consider the pertussis and
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hepatitis B vaccines additional
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screening issues to consider would be
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HIV all pregnant women and women
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planning a pregnancy should be counseled
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about being tested for HIV
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in addition screen for other sexually
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transmitted diseases also a woman who
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are trying to conceive should minimize
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exposure to outdoor cat feces secondary
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to the risk of exposure to toxic
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plasmosis
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during the preconception counseling
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visit we should also discuss genetic
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screening the genetic disorders are
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based on the ethnic and racial
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background of our patients sickle
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hemoglobin appa these are more common in
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African descent beta thalassemia is a
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more common and Mediterranean Southeast
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Asian and African descent and alpha
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thalassemias are more common in
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Southeast Asian Mediterranean and
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African descent tay-sachs disease is
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more common in Ashkenazi Jewish French
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Canadians and Cajun descent Canavan
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disease and familial dysautonomia are
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more common in Ashkenazi Jewish descent
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and cystic fibrosis is more common in
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Caucasians of European and Ashkenazi
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descent let’s discuss what would happen
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if young tested positive for one of
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these genetic disorders for example
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cystic fibrosis
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since cystic fibrosis is an autosomal
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recessive disorder and we find that she
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is a carrier denoted here with a capital
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C lowercase C then the next step is to
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test the father and the baby for cystic
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fibrosis
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if young is already pregnant it is
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important to have a private conversation
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with her to confirm the paternity of the
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pregnancy if the father of the baby also
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tests positive as a carrier for cystic
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fibrosis so both parents are carriers
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big C little C then 1/4 of their future
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pregnancies would have a chance of
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inheriting both genes little C little C
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and would thus be affected with cystic
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fibrosis
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if preconception testing reveals that
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young and her partner are both carriers
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then one of their options is
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pre-implantation genetic diagnosis this
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is a process by which in vitro
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fertilization is used to create an
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embryo and then this embryo can be
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tested for cystic fibrosis prior
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to being implanted alternatively young
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honor partner can conceive naturally and
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the fetus can be tested for cystic
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fibrosis with a chorionic villus
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sampling or amniocentesis procedure this
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can lead to very wrenching decisions for
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parents about whether to carry or
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terminate a pregnancy if the fetus is
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found to be affected continuing to move
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down our preconception counseling visit
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checklist folic acid supplementation all
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pregnant women and women trying to
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conceive should take at least 0.4
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milligrams of folic acid daily and women
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should take 4 grams daily if they have
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had a prior neural tube defect affected
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pregnancy let’s now discuss the
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importance of intimate partner violence
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screening intimate partner violence is
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estimated to affect as many as 324,000
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pregnant women per year there is a
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growing body of research on the
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connection between relationship violence
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and poor reproductive health care
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outcomes for women before and during a
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pregnancy are opportunities for the
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patient to begin developing trust with a
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health care provider lastly we will
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conclude the discussion about
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preconception counseling with the topics
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of nutrition and obesity counseling
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women about the importance of exercise
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and balanced nutrition and the
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preconception time can lead to healthier
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habits that can be more easily adapted
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during pregnancy and the postpartum time
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this concludes the aapko video on
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preconception care we have reviewed many
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aspects of preconception counseling and
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the importance are trying to optimize a
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woman’s health for pregnancy and beyond