Preconception Care.docx

**Preconception Care:** - The goal of preconception care is to begin pregnancy as healthy and prepared as possible - Family history: genetic disorders, congenital heart disease, metal health issues (depression) - Social history: substance use like alcohol, tobacco, opioids; empl...

**Preconception Care:** - The goal of preconception care is to begin pregnancy as healthy and prepared as possible - Family history: genetic disorders, congenital heart disease, metal health issues (depression) - Social history: substance use like alcohol, tobacco, opioids; employment; living situation - Health maintenance: diet/caffeine, exercise, screenings (dental and eye care), immunizations - Physical exam: head to toe, BMI, Gyn exam - Diagnostic tests: CBC, CMP, TSH/T4, Cervical cancer screening, STD, A1C (if obesity, DM or GDM, metabolic syndrome, or family history) - Remember can refer to genetic counseling if needed - Assess knowledge: plan for conceiving -- intercourse, sperm/egg donor, surrogate - Provide education and health promotion and dispel misconceptions - Current and past medical history: Diabetes, Seizure disorders, CV disorders, HTN, thyroid disorders, VTE, psychiatric, genetic disorders - Surgical history: GYN including cervical procedures i.e. LEEP procedures; abdominal/pelvic - Reproductive history: menstrual history (want to know age at menarche, cycle length and duration, flow, cramping, clots), pregnancies (outcomes, complications like gestational diabetes, preeclampsia, VTE, preterm, neural tube defect) and delivery method, STD's including HIV, contraception, PCOS - Important history for men/assigned men at birth: prior pregnancies/children, and STI's - **[HTN]**: avoid ACE and ARB due to fetal malformations and growth restriction use **Labetalol and nifedipine**. - **[Diabetes]:** meds probably need to be adjusted with pregnancy; blood sugars can fluctuate more and could lead to significant **kidney damage** when mom is pregnant; could use metformin - [**Thyroid disorders**:] **levothyroxine** is safe but may need adjustment with pregnancy; no Methimazole. Propylthiouracil is safer but associated with head and neck cysts and male urinary track abnormalities. Iodine ablation need to wait 6 months before getting pregnant - [**Seizure Disorders**:] **Lamotrigine** has the lowest rate of malformations; need to refer to neurologist and start folate prior to conception. Valproic acid leads to congenital malformations. Phenobarbital and carbamazepine leads to congenital malformations (cardiac and oral clefts) and long-term cognitive delays. Need to refer to Neurologist and start folate prior to conception. - [**VTE:**] no warfarin but do **low-weight- molecular heparin** prior to pregnancy. Must see **hematologist** or maternal fetal medicine specialist. - [**Psychiatric:**] **SSRIs and SNRIs** (except paroxetine) generally safe but at risk for pulmonary HTN. Bupropion is generally safe with small risk of cardiac defects. Concern for neonatal withdrawal at birth. - [**Supplements and Herbs:**] not regulated and may not contain ingredients listed - [**Supplements that are safe**:] **folate, PNV-perinatal vitamin, iron, fish oil, vitamin D, magnesium, ginger, probiotics** **[Risk Assessment:]** **[Family history:]** patient and partner/source of sperm/egg checking for genetic conditions/abnormalities. Thrombophilia, psychiatric disorders like depression, anxiety, bipolar disorder, post partum depression Social history: substance use (alcohol, tobacco, vaping, opioids, cocaine, marijuana, meth); employment (heavy lifting, standing, sitting, exposure to heavy metals, chemicals or toxins); living situation (housing, food security, access to care, financial resources) Health maintenance: diet/caffeine, exercise, screenings like dental and eye care, immunizations Physical Exam: - Head to toe - BMI - Gynecological exam - Diagnostic tests: CBC, CMP, TSH/T4, Cervical cancer screening, STI testing, Thrombophilia workup if there is a history of VTE or family hx, A1C if obese has DM or GDM, metabolic syndrome or history of DM in family Evaluation of Risk and Recommendations: - Address medical concerns - Healthy diet - Encourage exercise - Avoid substances - Immunizations - Folic acid 400 mcg daily - Fertility awareness - Address misconceptions in sexual knowledge Preconception video- the higher the A1C (\>7%) the higher the fetal malformation rate is so it is important especially for women who are diabetic to get preconception counseling. Diabetic related fetal malformations include cardiac, neurologic, GI and GU, and skeletal. HbA1C \>11 is a 44% miscarriage rate. - Need to talk about medical issues: 1. Systemic Lupus Erythematous (SLE): pregnancy should occur when there are at least 6 months of quiescence; all SLE meds should be reviewed and adjusted prior to conception 2. Hypertension: different classes; lowering maternal blood pressure too much reduces fetal placenta flow. Usually use labetalol and nifedipine as blood pressure meds in pregnancy. Chronic HTN in pregnancy can lead to superimposed preeclampsia, placental abruption, fetal growth restriction 3. Diabetes: poorly controlled pre-gestational diabetes can lead to end organ damage - Infections disease issues: no live vaccines (varicella and rubella), HIV screening, STD screening, minimize exposure to outdoor cat feces - Genetic screening: sickle cell more common in African descent; beta thalassemia more common in mediterranean, southeast Asian and African descent; alpha thalassemia more common in southeast Asian; tay-sachs in jewish and French Canadians, cystic fibrosis more common in Caucasian Cystic fibrosis: if both parents are carriers then 25% of future pregnancies can get cystic fibrosis could do preimplantation genetic diagnosis - Folic acid: 0.4 mg folic acid daily - Intimate partner violence - Nutrition and obesity