Preconception care: clinical approach
文摘
科学
2024-07-09 14:39
澳大利亚
If you would like to view past exciting content, please click on the following link.Preconception care is focused on optimizing health, addressing modifiable risk factors, and providing education before conception occurs. The aim is to ensure the patient's health is in the best possible state for a safe pregnancy. Initiating a conversation with a simple question such as, “Do you have a desire to become pregnant in the next year?” can lead to preconception counseling if the answer is affirmative, or guide the discussion towards contraceptive options if the answer is negative. This type of counseling can occur during a specific appointment or any visit where a patient expresses a desire to conceive.When a patient seeks preconception care, begin by screening for essential elements of preconception health. Start with evaluating any significant medical conditions that could impact pregnancy, such as diabetes mellitus (DM), thyroid dysfunction, hypertension, thrombophilias, a history of bariatric surgery, HIV, mood disorders, and prior pregnancy complications.Moving into specifics, advise patients with DM that achieving a pre-pregnancy hemoglobin A1c below 6.5% can minimize the risk of congenital anomalies and other pregnancy complications. Recommend screenings that include vision tests for vasculopathy, urine protein tests for renal disease, and an electrocardiogram for cardiac conditions. Additionally, thyroid function tests are recommended for patients with pregestational type 1 diabetes, those with a personal or family history of thyroid issues, individuals over 30, those who are obese, and anyone with a history of pregnancy loss, preterm delivery, or infertility.For patients with persistent or poorly controlled hypertension, recommend similar tests as for diabetic patients. Also, review their current antihypertensive medications, as some, like ACE inhibitors and angiotensin receptor blockers, are teratogenic. Advise these patients about the heightened risk of preeclampsia and intrauterine growth restriction, and consider starting a low-dose aspirin regimen after the first 12 weeks of pregnancy to lower the risk of preeclampsia.Patients with thrombophilias, who are at an increased risk of deep venous thrombosis or pulmonary emboli during and after pregnancy, should be counseled on the pros and cons of thromboprophylaxis, and possibly referred to a hematologist.If a patient has undergone bariatric surgery, advise against conceiving in the first 12 to 24 months post-surgery due to potential impacts on fetal growth from rapid weight loss. Note that oral contraceptives might be less effective post-surgery due to reduced gastrointestinal absorption. Monitor these patients for nutritional deficiencies and dumping syndrome, a condition caused by rapid gastric emptying, and be aware that typical pregnancy symptoms could obscure complications from the surgery.For patients with HIV, emphasize the importance of antiretroviral therapy to reduce the risk of vertical transmission. Encourage starting therapy before pregnancy and maintaining it to achieve and keep an undetectable viral load before and during pregnancy.Discuss with patients with mood disorders, such as anxiety and depression, the risks and benefits of continuing or discontinuing medication during pregnancy. Untreated or inadequately treated conditions can lead to issues such as impaired maternal-infant bonding, maternal self-harm, and neglect. Discuss safe medication options and encourage engagement with mental health professionals if not already established.For those with prior pregnancies, review their obstetric history and discuss any complications to assess the risk of recurrence and consider preventive measures for future pregnancies. In patients with a history of pregnancy loss or preterm delivery, also consider screening for thyroid dysfunction.Preconception care encompasses general screenings such as routine checks for tobacco, alcohol, cannabinoid, and other substance use disorders; STI screenings; and screenings for environmental and occupational teratogens like pesticides, lead paint, asbestos, and radiation. Patients are also assessed for risks associated with infectious diseases, notably Zika and toxoplasmosis. To prevent toxoplasmosis, avoid travel to Zika-prevalent regions, contact with cat feces, and consumption of raw or undercooked meats. Additionally, screenings for intimate partner violence are crucial, continuing through to the postpartum checkup. These screenings can be conducted through direct patient questioning or standardized questionnaires.Diet and exercise also play critical roles in preconception care. A nutritious diet, inclusive of sufficient daily vitamins, calcium, and iron is essential. For instance, vegan patients should supplement with vitamin B12. During pregnancy, women should increase their caloric intake by approximately 350 calories daily in the first trimester and 450 calories daily thereafter. The initiation of folic acid supplementation before pregnancy is advised to prevent neural tube defects; this is especially pertinent for all women of reproductive age, particularly those contemplating pregnancy or who are sexually active without contraception. Encourage at least 150 minutes of moderate exercise weekly.Reviewing the patient’s current medications is another vital aspect, including prescription and over-the-counter drugs, as well as supplements and herbal products. Discuss the safety of these medications during pregnancy, and adjust any teratogenic medications in collaboration with the healthcare provider. Aim to use the minimal effective dosage of safe medications. Additionally, evaluate the use of supplements and herbal remedies, such as low-dose ginger for nausea; however, bear in mind that most supplements are not FDA-approved and guidelines are limited.Maternal carrier screening is important, beginning with a comprehensive family and genetic history of both the patient and their partner to identify potential carriers of autosomal recessive disorders. Basic genetic screening should include tests for cystic fibrosis and spinal muscular atrophy, universally offered to all patients. Moreover, specific populations, such as those of Ashkenazi Jewish descent, might be at heightened risk for disorders like Canavan disease, Familial dysautonomia, and Tay-Sachs disease, and should be offered targeted carrier screening.Discussing optimal birth spacing is crucial, noting that short intervals, particularly those less than six months, pose risks such as reduced chances of successful vaginal birth after cesarean. The recommended interval between pregnancies is at least 18 months.Finally, ensure all preventative care measures are up to date to optimize pre-pregnancy health. This includes confirming that cervical cancer screenings are current, and checking if a mammogram or colonoscopy is needed. Also, verify and update immunization status for vaccines like Tdap, MMR, Hepatitis B, varicella, annual influenza, COVID-19, and HPV. Note that live vaccines, such as those for MMR and varicella, require postponing pregnancy for at least one month post-vaccination, and HPV vaccines are not recommended during pregnancy.Regular dental and vision care are integral parts of preconception health. Encourage all patients to maintain consistent dental check-ups to prevent and manage oral health issues that can affect overall health and pregnancy. For those at a higher risk of eye diseases, such as patients with diabetes or chronic hypertension, regular vision care is crucial to manage and monitor potential complications.Additionally, managing body weight is important in preconception care. Review and discuss the ideal body mass index (BMI) with your patients, and encourage steps towards achieving an optimal BMI before attempting to conceive. Both high and low BMIs are linked to increased risks of infertility, and maternal and fetal complications during pregnancy.When counseling a patient who is trying to conceive, emphasize the importance of optimizing health and reducing modifiable risk factors before attempting pregnancy. Part of the preconception counseling should also include an overview of the menstrual cycle, understanding the optimal timing for intercourse, and knowing when to consider a fertility evaluation if conception does not occur. Advise patients to engage in regular, unprotected intercourse during their estimated fertile window to increase chances of conception. If conception is successful, prompt them to establish obstetrical care promptly.If pregnancy does not occur, a fertility evaluation may be necessary. The guidelines for fertility assessment suggest that if a patient under 35 years old has not conceived after 12 months of well-timed, unprotected intercourse, or if a patient is 35 years or older and has not conceived after 6 months, an evaluation should be initiated. Additionally, if the patient is anovulatory or presents with other clear indicators of infertility, it's advisable to seek a fertility evaluation earlier.To summarize, preconception care is comprehensive and aims to optimize the health of an individual before pregnancy. It includes:- **Health Optimization**: Addressing modifiable risk factors and providing education tailored to pre-pregnancy health.- **Medical Review**: Evaluating the patient’s medical history for any conditions that might affect pregnancy, such as diabetes or hypertension.- **Screenings**: Conducting routine checks for substance use, sexually transmitted infections (STIs), environmental and occupational exposures to teratogens, and assessing risks for specific infectious diseases like Zika and toxoplasmosis. Screening for intimate partner violence is also crucial.- **Carrier Screening**: Offering genetic carrier screenings to identify potential autosomal recessive disorders.- **Medication Review**: Checking both prescription and non-prescription medications for safety during pregnancy and making necessary adjustments.- **Family Planning and Birth Spacing**: Counseling on menstrual cycle, timing intercourse, and the optimal intervals between pregnancies.- **Diet and Exercise**: Encouraging a balanced diet rich in essential nutrients and regular physical activity.- **Supplementation**: Recommending the initiation of folic acid to prevent neural tube defects.- **Preventative Care**: Ensuring that all necessary vaccinations are up to date and that routine health screenings like cervical cancer screening are current. - - - - - - - END - - - - - - -
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