|
|
Preconception Home > Questions and Answers
> Professionals |
|
Preconception Care Questions and
Answers
|
|
PROFESSIONALS
1. What are the
new recommendations for improving preconception health?
2. How should I, as a provider, address the issue
of reproductive planning with my patients?
3. What source for information and resources are
available to help me incorporate preconception care into my
practice?
4. What specific preconception interventions have
proven to be effective in improving pregnancy outcomes?
1. What are the new recommendations for
improving preconception health?
The CDC and its partners have released a set of 10 Recommendations
for Preconception Health. These recommendations reflect the best of
scientific evidence and programmatic experience in the field, and
are designed to guarantee optimal reproductive health outcomes for
all women and couples. There are four explicit goals for the
Recommendations:
-
Goal 1. Improve the
knowledge and attitudes and behaviors of men and women related
to preconception health.
-
Goal 2. Assure that all
women of childbearing age in the United States receive
preconception care services (i.e., evidence-based risk
screening, health promotion, and interventions) that will enable
them to enter pregnancy in optimal health.
-
Goal 3. Reduce risks
indicated by a previous adverse pregnancy outcome through
interventions during the interconception period, which can
prevent or minimize health problems for a mother and her future
children.
-
Goal 4. Reduce the
disparities in adverse pregnancy outcomes
Each of the Recommendations has an
associated detailed action plan. Below are the Recommendations:
-
Recommendation 1.
Individual responsibility across the life span. Each woman, man,
and couple should be encouraged to have a reproductive life
plan.
-
Recommendation 2.
Consumer awareness. Increase public awareness of the importance
of preconception health behaviors and preconception care
services by using information and tools appropriate across
various ages; literacy, including health literacy; and
cultural/linguistic contexts.
-
Recommendation 3.
Preventive visits. 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 risk and
improve pregnancy outcomes.
-
Recommendation 4.
Interventions for identified risks. Increase the proportion of
women who receive interventions as follow up to preconception
risk screening, focusing on high priority interventions (i.e.,
those with evidence of effectiveness and greatest potential
impact).
-
Recommendation 5.
Interconception care. Use the interconception period to provide
additional intensive interventions to women who have had a
previous pregnancy that ended in an adverse outcome (e.g.,
infant death, fetal loss, birth defects, low birthweight or
preterm birth).
-
Recommendation 6.
Pre-Pregnancy Check Ups. Offer, as a component of maternity
care, one pre-pregnancy visit for couples and persons planning
pregnancy.
-
Recommendation 7. Health
Insurance Coverage Women with Low Incomes. Increase public and
private health insurance coverage for women with low incomes to
improve access to preventive women’s health and preconception
and interconception care.
-
Recommendation 8. Public
Health Programs and Strategies. Integrate components of
preconception health into existing local public health and
related programs, including emphasis on interconception
interventions for women with previous adverse outcomes.
-
Recommendation 9.
Research. Increase the evidence base and promote the use of
evidence to improve preconception health.
-
Recommendation 10.
Monitoring improvements. Maximize public health surveillance and
related research mechanisms to monitor preconception health.
[Return to questions]
2. How should I, as a
provider, address the issue of reproductive planning with my
patients?
Reproductive health planning is about being intentional around
preparing for and starting pregnancies. It includes making decisions
about when to have children, how many to have, how to time
pregnancies, and how to ensure the healthiest pregnancies and
families. It sometimes involves contraception, sometimes fertility
promoting actions, sometimes other behavior changes. Providers can
start by asking women when they want their next (or first)
pregnancy, if ever. Providers can then ask about current sexual
activity, contraceptive use, and health status to determine whether
a woman is doing everything possible to realize her goals for
pregnancy. Reproductive planning should be addressed with everyone
of reproductive age. Because different people have different
cultural and personal concepts of sexuality, fertility, health, and
control over pregnancy, cultural competence is of critical
importance in communicating about reproductive planning. For
example, “planning to get pregnant”, “wanting to get pregnant”,
“trying to get pregnant”, and the opposites of each of these might
take on different meanings depending on the woman.
[Return to questions]
3. What source for
information and resources are available to help me incorporate
preconception care into my practice?
There have been numerous publications related to preconception care,
and there currently are many sets of recommendations. To simplify
matters, ACOG and AAP have grouped the main components of
preconception care under four categories of interventions: maternal
assessment (e.g., family history, behaviors, obstetric history,
general physical exam); vaccinations (e.g., rubella, varicella and
hepatitis B); screening (e.g., HIV, STD, genetic disorders); and
counseling (e.g., folic acid consumption, smoking and alcohol
cessation, weight management). Many of these interventions are
currently available to women and, when indicated, to couples;
however, they are not systematically delivered. Moreover, many
national professional organizations have developed and published
clinical practice guidelines (CPGs) for specific components of
preconception care. For example, the American Diabetes Association
developed CPGs to be started before pregnancy for women with
preconception diabetes. The American Association of Clinical
Endocrinologists has developed preconception CPGs for women with
hypothyroidism. CPGs have also been developed for women being
treated with teratogenic medications to guide the transition to
safer medications. CPGs for women using antiepileptic drugs or oral
anticoagulants have been developed by the American Academy of
Neurology and, the American Heart Association/American College of
Cardiologists, respectively. Guidelines, recommendations, and
strategies for reducing alcohol misuse and prevention of fetal
alcohol syndrome have been developed and published by the U.S.
Public Health Service, U.S. Preventive Service Taskforce, ACOG, and
the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol
Effect.
CDC, in collaboration with national partner organizations, will be
convening workgroups in June 2006, to review current knowledge and
practices and define and develop the content of preconception care
for clinical care providers, public health workers, and for
consumers. The deliberations of the workgroup are expected to result
in practice tools which will be disseminated to the public in early
2007.
[Return to questions]
4. What specific
preconception interventions have proven to be effective in improving
pregnancy outcomes?
A comprehensive review of the literature identified a long list of
risk factors suggested to be included in comprehensive preconception
care. The strength of evidence supporting the efficacy of the
various components of preconception care varies greatly. Clinical
practice guidelines (CPGs) have been developed for reducing the risk
related to some of these factors. The Select Panel on Preconception
care identified 14 conditions for which CPGs exist and for which
there is scientific evidence demonstrating effectiveness in
improving pregnancy outcomes:
-
Folic acid. Daily use of
vitamin supplements containing folic acid has been demonstrated
to reduce the occurrence of neural tube defects by at least 50%.
-
Rubella seronegativity. Rubella
vaccination provides protective seropositivity and prevents the
occurrence of congenital rubella syndrome.
-
Diabetes (preconception). The
three-fold increase in the prevalence of birth defects among
infants of women with type 1 and type 2 diabetes is
substantially reduced through proper management of diabetes.
-
Hypothyroidism. The dosages of
Levothyroxine® required for treatment of hypothyroidism
increases in early pregnancy. Levothyroxine® dosage needs to be
adjusted for proper neurologic development.
-
HIV/AIDS. If HIV infection is
identified before conception, timely treatment can be
administered and women (or couples) can be given additional
information that can influence the timing of the onset of
pregnancy.
-
Maternal phenylketonurea (PKU).
Women diagnosed with PKU as infants may have infants with mental
retardation. However, this adverse outcome can be prevented when
mothers adhere to a low phenylalanine diet before conception and
continue it throughout their pregnancy.
-
Oral anticoagulant. Warfarin,
which is used for the control of blood clotting, has been
demonstrated to be a teratogen. To avoid exposure to warfarin
during early pregnancy, medications can be changed to a
nonteratogenic anticoagulant before the onset of pregnancy.
-
Anti-epileptic drugs. Certain
anti-epileptic drugs are known as teratogens. Before conception,
women who are on a regimen of these drugs and who are
contemplating pregnancy should be prescribed a lower dosage of
these drugs.
-
Isotretinoins (Accutane®): Use
of isotretinoins in pregnancy to treat acne results in
miscarriage and birth defects. Effective pregnancy prevention
should be implemented to avoid unintended pregnancies among
women with childbearing potential who use this medication.
-
Smoking. Preterm birth, low
birthweight, and other adverse perinatal outcomes associated
with maternal smoking in pregnancy can be prevented if women
stop smoking during early pregnancy. Because only 20% of women
successfully control tobacco dependence during pregnancy,
cessation of smoking is recommended before pregnancy.
-
Alcohol or other recreational
drug misuse. No time during pregnancy is safe to drink alcohol
or other recreational drugs, and harm can occur early, before a
woman has realized that she is or might be pregnant. Fetal
alcohol syndrome and other drug-related birth defects can be
prevented if women cease intake of alcohol and use of other
drugs before conception.
-
Obesity. Adverse perinatal
outcomes associated with maternal obesity include neural tube
defects, preterm delivery, diabetes, cesarean section, and
hypertensive and thromboembolic disease. Weight loss before
pregnancy reduces these risks.
-
STDs. Chlamydia trachomatis and
Neisseria gonorrhea have been strongly associated with ectopic
pregnancy, infertility, and chronic pelvic pain. STDs during
pregnancy might result in fetal death or substantial physical
and developmental disabilities, including mental retardation and
blindness.
-
Hepatitis B. Vaccination is
recommended for men and women who are at risk for acquiring
hepatitis B virus (HBV) infection through sexual transmission or
through percutaneous or mucosal exposure to blood.. Preventing
HBV infection in women of childbearing age prevents transmission
of infection to infants and eliminates risk for to women of
sequelae of HBV infection, including hepatic failure, liver
carcinoma, cirrhosis, and death.
[Return to questions]
Date: April 12, 2006
Content source: National Center on Birth Defects and Developmental
Disabilities
|
|
|