Gynecologists, internists, family practitioners, and pediatri- cians have the best opportunity to provide preventive coun- seling during periodic health maintenance examinations. The The Centers for Disease Control and Prevention defines pre-
conceptional care as “a set of interventions that aim to iden- tify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management” (Johnson, 2006). The following goals were established for advancing preconceptional care:
1. Improve knowledge, attitudes, and behaviors of men and women related to preconceptional health.
2. Assure that all women of childbearing age receive precon- ceptional care services—including evidence-based risk screening, health promotion, and interventions—that will enable them to enter pregnancy in optimal health.
3. Reduce risks indicated by a previous adverse pregnancy out- come through interconceptional interventions to prevent or minimize recurrent adverse outcomes.
4. Reduce the disparities in adverse pregnancy outcomes.
The American College of Obstetricians and Gynecologists (2012c) also has reaffirmed the importance of preconceptional and interpregnancy care.
To illustrate potentially modifiable conditions, data that describe the health status of women who gave birth to liveborn infants in the United States in 2004 are reviewed.Table 8-1
Preconceptional Counseling
CHAPTER 8
COUNSELING SESSION. . . . 156 MEDICAL HISTORY . . . . 157 GENETIC DISEASES . . . . 159 REPRODUCTIVE HISTORY. . . . 161 PARENTAL AGE. . . . 161 SOCIAL HISTORY. . . . 162 SCREENING TESTS. . . . 163
CHAPTER 8 MEDICAL HISTORY
With specific medical conditions, general points include how pregnancy will affect maternal health and how a high-risk con- dition might affect the fetus. Afterward, advice for improving outcome is provided. Detailed preconceptional information regarding a few conditions is found in the next sections as well as in the other topic-specific chapters of this text.
■ Diabetes Mellitus
Because maternal and fetal pathology associated with hypergly- cemia is well known, diabetes is the prototype of a condition for which preconceptional counseling is beneficial. Diabetes- associated risks to both mother and fetus are discussed in detail in Chapter 57 (p. 1125). Many of these complications can be avoided if glucose control is optimized before conception. The American College of Obstetricians and Gynecologists (2012b) has concluded that preconceptional counseling for women with pregestational diabetes is both beneficial and cost- effective and should be encouraged. The American Diabetes Association has promulgated consensus recommendations for preconceptional care for diabetic women (Kitzmiller, 2008).
These guidelines advise that a thorough inventory of disease duration and related complications be obtained and clinical and laboratory examination for end-organ damage be com- pleted. Perhaps most importantly, they encourage a precon- ceptional goal of the lowest hemoglobin A1c level possible without undue hypoglycemic risk to the mother. In addition to assessing diabetic control during the preceding 6 weeks, hemoglobin A1c measurement can also be used to compute risks for major anomalies (Fig. 8-1). Although these data are from women with severe overt diabetes, the incidence of fetal anomalies in women who have gestational diabetes with fast- ing hyperglycemia is increased fourfold compared with that in normal women (Sheffield, 2002).
Such counseling has been shown to be effective. In one review, Leguizamón and associates (2007) identified 12 stud- ies that included more than 3200 pregnancies in women with insulin-dependent diabetes. Of the 1618 women without preconceptional counseling, 8.3 percent had a fetus with a TABLE 8-1.Prevalence of Prepregnancy Maternal
Behaviors, Experiences, Health Conditions, and Previous Poor Birth Outcomes in the United States in 2004
Factor Prevalence (%)
Tobacco use 23
Alcohol use 50
Multivitamin use 35
Contraceptive nonusea 53
Dental visit 78
Health counseling 30
Physical abuse 4
Stress 19
Underweight 13
Overweight 13
Obesity 22
Diabetes 2
Asthma 7
Hypertension 2
Heart problem 1
Anemia 10
Prior low-birthweight infant 12
Prior preterm infant 12
aAmong women who were not trying to become pregnant.
Data from D’Angelo, 2007.
occasion of a negative pregnancy test is also an excellent time for education. Jack and colleagues (1995) administered a com- prehensive preconceptional risk survey to 136 such women, and almost 95 percent reported at least one problem that could affect a future pregnancy. These included medical or repro- ductive problems—52 percent, family history of genetic dis- ease—50 percent, increased risk of human immunodeficiency virus infection—30 percent, increased risk of hepatitis B and illegal substance abuse—25 percent, alcohol use—17 per- cent, and nutritional risks—54 percent. Counselors should be knowledgeable regarding relevant medical diseases, prior sur- gery, reproductive disorders, or genetic conditions and must be able to interpret data and recommendations provided by other specialists. If the practitioner is uncomfortable providing guid- ance, the woman or couple should be referred to an appropriate counselor.
Women presenting specifically for preconceptional evalua- tion should be advised that information collection may be time consuming depending on the number and complexity of fac- tors that require assessment. The intake evaluation includes a thorough review of the medical, obstetrical, social, and family histories. Useful information is more likely to be obtained by asking specific questions regarding each history and each family member than by asking general, open-ended questions. Some important information can be obtained by questionnaires that address these topics. Answers are reviewed with the couple to ensure appropriate follow-up, including obtaining relevant medical records.
5
4.6–7.6 7.7–8.6 8.7–9.9
Glycosylated hemoglobin (percent) 10 –10.5 > 10.6 10
25
Major malformations (percent)
FIGURE 8-1 Relationship between first-trimester glycosylated hemo- globin values and risk for major congenital malformations in 320 women with insulin-dependent diabetes. (Data from Kitzmiller, 1991.)
158 Preconceptional and Prenatal Care
SECTION 4
major congenital anomaly, and this compared with a rate of 2.7 percent in the 1599 women who did have counsel- ing. Tripathi and coworkers (2010) compared outcomes in 588 women with pregestational diabetes in whom about half had preconceptional counseling. Those women who received counseling had improved glycemic control before pregnancy and in the first trimester, had higher folate intake rates pre- conceptionally, and experienced lower rates of adverse out- comes—defined as a perinatal death or major congenital anomaly. These cited benefits are accompanied by reduced health-care costs in diabetic women. From their review, Reece and Homko (2007) found that each $1 expended for a pre- conceptional care program saved between $1.86 and $5.19 in averted medical costs. Despite such benefits, the proportion of diabetic women receiving preconceptional care is subopti- mal. In their study of approximately 300 diabetic women in a managed-care plan, Kim and colleagues (2005) found that only about half had preconceptional counseling. Counseling rates are undoubtedly much lower among uninsured and indi- gent women.
■ Epilepsy
Women who have epilepsy have an undisputed two- to three- fold risk of having infants with structural anomalies compared with unaffected women (Wide, 2004). Some early reports indi- cated that epilepsy conferred an increased a priori risk for con- genital malformations that was independent of any effects of anticonvulsant treatment. Although more recent publications have largely failed to confirm this increased risk in untreated women, it is difficult to refute entirely because women who are controlled without medication generally have less severe dis- ease (Cassina, 2013). Fried and associates (2004) conducted a metaanalysis of studies comparing epileptic women, both treated and untreated, with controls. In this study, increased malformation rates could only be demonstrated in the offspring of women who had been exposed to anticonvulsant therapy.
Veiby and coworkers (2009) used the Medical Birth Registry of Norway to compare pregnancy outcomes in 2861 deliver- ies by epileptic women with 369,267 control deliveries. They identified an increased malformation risk only in women who were exposed to valproic acid (5.6 percent) and polytherapy (6.1 percent). Untreated women had anomaly rates that were similar to those of nonepileptic controls.
Ideally, seizure control is optimized preconceptionally.
Vajda and colleagues (2008) reported data from the Australian Register of Antiepileptic Drugs in Pregnancy. The risk of sei- zures during pregnancy was decreased by 50 to 70 percent if there were no seizures in the year preceding pregnancy. There were no further advantages that accrued if the seizure-free period exceeded a year.
Efforts should attempt to achieve seizure control with mono- therapy and with medications considered less teratogenic (Aguglia, 2009; Tomson, 2009). As discussed in detail in Chapter 60 (p. 1190) and shown in Table 8-2, some one-drug regimens are more teratogenic than others. Valproic acid, in particular, should be avoided if possible, as this medication has consis- tently been associated with a greater risk for major congenital
malformations than other antiepileptic drugs (Jentink, 2010).
According to Jeha and Morris (2005), the American Academy of Neurology recommends consideration of antiseizure medica- tion discontinuation before pregnancy in suitable candidates.
These are women who satisfy the following criteria: have been seizure-free for 2 to 5 years, display a single seizure type, have a normal neurological examination and normal intelligence, and show electroencephalogram results that have normalized with treatment.
Epileptic women should be advised to take supplemental folic acid. However, it is not entirely clear that folate supple- mentation reduces the fetal malformation risk in pregnant women taking anticonvulsant therapy. In one case-control study, Kjær and associates (2008) reported that the congenital abnormality risk was reduced by maternal folate supplementa- tion in fetuses exposed to carbamazepine, phenobarbital, phe- nytoin, and primidone. Conversely, from the United Kingdom Epilepsy and Pregnancy Register, Morrow and coworkers (2009) compared fetal outcomes of women who received pre- conceptional folic acid with those who did not receive it until later in pregnancy or not at all. In this study, a paradoxical increase in the number of major e congenital malformations was observed in the group who received preconceptional folate.
These investigators concluded that folate metabolism may be only a part of the mechanism by which malformations are induced in women taking these medications.
■ Immunizations
Preconceptional counseling includes assessment of immu- nity against common pathogens. Also, depending on health TABLE 8-2.First-Trimester Antiepileptic Monotherapy and
the Associated Congenital Malformation Risk
Antiepileptic (n)
Major Congenital Malformations
n (%)
Relative Risk (95% CI)a Unexposed controls
(442)
5 (1.1) Reference Lamotrigine (1562) 31 (2.0) 1.8 (0.7–4.6) Carbamazepine
(1033)
31 (3.0) 2.7 (1.0–7.0) Phenytoin (416) 12 (2.9) 2.6 (0.9–7.4) Levetiracetam (450) 11 (2.4) 2.2 (0.8–6.4) Topiramate (359) 15 (4.2) 3.8 (1.4–10.6) Valproate (323) 30 (9.3) 9.0 (3.4–23.3) Phenobarbital (199) 11 (5.5) 5.1 (1.8–14.9) Oxcarbazepine (182) 4 (2.2) 2.0 (0.5–7.4) Gabapentin (145) 1 (0.7) 0.6 (0.07–5.2)
Zonisamide (90) 0 (0) NA
Clonazepam (64) 2 (3.1) 2.8 (0.5–14.8)
aRisk compared with that of the unexposed reference population of nonepileptic women.
NA= not applicable.
Data from Hernández-Díaz, 2012.
CHAPTER 8
status, travel plans, and time of year, other immunizations may be indicated as discussed in Chapter 9 (Table 9-9, p. 186).
Vaccines that contain toxoids—for example, tetanus, or that consist of killed bacteria or viruses—such as influenza, pneu- mococcus, hepatitis B, meningococcus, and rabies—have not been associated with adverse fetal outcomes and are not contraindicated preconceptionally or during pregnancy.
Conversely, live-virus vaccines—including varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow fever—are not recommended during pregnancy. Moreover, 1 month or longer should ideally pass between vaccination and conception attempts. That said, inadvertent administra- tion of measles, mumps, rubella (MMR) or varicella vaccines during pregnancy should not generally be considered indica- tions for pregnancy termination. Most reports indicate that the fetal risk is only theoretical. Immunization to smallpox, anthrax, and other bioterrorist diseases should be discussed if clinically appropriate (Chap. 64, p. 1258). Based on their study of approximately 300 women who received smallpox vaccination near the time of conception, Ryan and colleagues (2008) found that rates of pregnancy loss, preterm birth, and birth defects were not higher than expected.