PPK Rspad Obgin 2017, 1. Preconception Care, Jje 20170414

PRECONCEPTION
CARE
Joanna Quist-Nelson
Obstetric Evidence Based Guidelines, 3rd Ed, 2017

Power point disusun oleh:

Judi Januadi Endjun

RSPAD Gatot Soebroto Puskesad – FK UPN Veteran
Departemen Obstetri dan Ginekolog Subbagian Fetomaternal
2017
KATA PENGANTAR
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kepada kita semua dalam menjalani kehidupan ini.

Wassalamualaikum wr wb
1 Juli 2017, Judi Januadi Endjun

2
KEY POINTS
•  PreconcepLon care is a set of interven8on that
aim to iden8fy and modify biomedical,
behavioral, and social risks to a woman’s health
or pregnancy outcome thorough preven8on and
management.
•  he founda8on of preconcep8on care is
preven8on.
•  Preconcep8on care should occur any 8me if any
healthcare provider sees a reproduc8ve age
woman (e.g., 15-44 years old)
KEY POINTS
•  Personal and family history, physical exam,
laboratory screening, reproduc8ve plan,
nutri8on, supplements, weight, exercise,
vaccina8on, and injury preven8on should be
reviewed in all reproducLve-age women.
•  Folic acid 400 μg/day, as well as proper diet and
exercise, should be encouraged.
KEY POINTS
•  Regarding vaccina8on, women should receive
the influenza vaccine if planning pregnancy
during flu season; the rubella and varicella
vaccines if there is no evidence of immunity to
these viruses; and tetanus / diphtheria /
pertussis if lacking adult vaccinaLon.
•  Specific interven8ons to reduce morbidity and
mortality for both the woman and her baby
should be offered to those idenLfied with chronic
diseases or exposed to teratogens or iliicit
substances.
HISTORY
•  PreconcepLon care has ancient origins. Plutarch
(46–120 CE) wrote that the ancient Spartans “[...]
ordered the maidens to exercise [...], to the end
that the fruit they conceived might [...] take
firmer root and find be_er growth” [1].
DEFINITION
•  PreconcepLon care is a set of interven8ons that
aim to iden8fy and modify biomedical,
behavioral, and social risks to a woman's health
or pregnancy outcome through preven8on and
management [2,3]. This care has also been called
prepregnancy, interpregnancy care, or
periconcepLonal medicine [4].
AIM AND EFFECTIVENESS
•  The founda8on of preconcep8on care is
preven8on.
•  PrevenLon of disease is the most effecLve form of
medicine, and health care should shic from the
delivery of procedure- based acute care to the
provision of counseling-based prevenLve care [5,6].
•  For example, the two leading causes of death in the
first year of life—birth defects and disorders caused
by preterm birth (PTB)—can both be significantly
reduced by preconcepLon care.
AIM AND EFFECTIVENESS
•  Randomized controlled trials have corroborated
that women are likely to incorporate change in
modifiable health behaviors in response to
preconcep8on counseling [7].
•  General pracLLoner-iniLated preconcepLon
counseling not only decreases adverse pregnancy
outcomes but also reduces anxiety in
reproducLve-age women [8].
TIMING AND TARGET POPULATION
•  The Lme that people should start caring for a
pregnancy is not acer, but before, concepLon.
Preconcep8on care should occur any 8me any
health-care provider sees a reproduc8ve age
woman.
•  A reproducLve age woman is usually de ned as
between 15 and 44 years of age, but occasionally
even younger or older women contemplate, or at
least are at risk of, pregnancy.
•  The rst prenatal visit is “months too late!” [9].
•  It ocen happens acer first-trimester exposure to a
potenLal teratogen has already occurred.
•  There are about 1 billion reproducLve- age
women worldwide.
•  In the United States, as an example, only about
half of pregnancies are planned.
•  As women get pregnant later in life, disease
prevalence and medicaLon exposures increase.
Approximately 80% of reproducLve age U.S.
•  women have dental disease, 66% are obese or overweight,
55% drink alcohol, 11% conLnue to smoke during
pregnancy, 9% have diabetes, 6% asthma, 3%
hypertension, and 3% cardiac disease [2].
•  The incidences of many of these condiLons, even among
pregnant women, are on the rise.
•  While some beneficial intervenLons could be started as
soon as a pregnancy is diagnosed, this is unrealisLc.
•  Many of the prevenLve measures take Lme, ocen
months, such as quinng smoking, losing weight, folic acid
supplementaLon, and stabilizaLon of medical condiLons
with effecLve and safe medicaLons.
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  By age 25, about 50% of U.S. women have had at
least one birth.
•  The highest ferLlity rate occurs in 25- to 30-year-
old women.
•  By age 44, >85% have given birth at least once.
•  About 84% of reproducLve-age women, when
asked, answer that they had a health-care visit
within the prior year [6].
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  Therefore, universal preconcep8on care can be
achieved if health-care providers make it a
priority and plan for it at every opportunity
(Table 1.1).
•  The approach should be “every reproduc8ve-age
woman, every 8me” [6].
•  Every reproduc8ve-age woman should be asked
at every health-care encounter: “Are you
considering pregnancy?” and “Could you
possibly become pregnant?”
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  Increased awareness of preconcepLon care can
be accomplished through improving health
resources, public outreach, and adverLsing.
•  Despite its great effecLveness, not all health-care
plans cover preconcepLon care.
•  A preconcep8on visit (or ofen more than one)
should be standard primary care, as stated by
the Center for Disease Control [2].
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  It should be as rouLne, if not more so, as
prenatal care, as should the screening and
intervenLons associated with it.
•  A clear poliLcal will to drive the funding and
insurance coverage for preconcepLon care is
required.
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  Therefore, providers of all specialLes should be
aware of the evidence-based recommendaLons
(Tables 1.1–1.8).
•  OrganizaLons represenLng family and internal
medicine, obstetrics and gynecology, nurse
midwifery, nursing, public health, diabetes,
neurology, cardiology, and many other
associaLons have supported recommendaLons
for preconcepLon care.
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  Unfortunately, pracLLoners seldom implement
them [10], even though it is an opportunity to
opLmize the health of the woman independent
of whether she is planning pregnancy [6].
•  Only one out of six obstetrician-gynecologists
(ob-gyns) or family physicians provides
preconcepLon care to the majority of women for
whom they provide prenatal care [11].
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  PreconcepLon care may ocen need to be
mul8disciplinary care.
•  Prior to pregnancy, a woman can have numerous
different medical problems affecLng different
specialLes, and her care should occur in close
collaboraLon among the different fields involved.
•  Maternal physiology is different than
nonpregnant adult physiology.
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  An enLre field, maternal-fetal medicine, is
dedicated to the care of pregnancies with
maternal or fetal problems, and these specialists
are parLcularly adept at direcLng best pracLces
for preconcepLon counseling.
•  PreconcepLon care occurs best if all
pracLLoners, including primary and specialty
care, either directly implement or appropriately
refer for implementaLon of effecLve
preconcepLon screening and intervenLon.
OPPORTUNITIES FOR
PRECONCEPTION CARE
•  The worse scenario is the belief that a posiLve
pregnancy test is a good reason to “stop all
medicines” thereby stopping disease treatment.
•  Prevent panic: get women ready for a healthy
pregnancy before contracepLon is stopped.
CONTENT OF PRECONCEPTION CARE
•  Topics perLnent to opLmizing preconcepLon
health and therefore future maternal and
perinatal outcome should be discussed.
•  Topics to be discussed in preconcepLon care are
listed in Table 1.2 [2,12].
•  Further research is needed to determine the best
content of preconcepLon care and the most
effecLve way to implement it [13,14].
UNIVERSAL SCREENING AND
RELATED INTERVENTIONS
•  History, Exam, and Laboratory Screen
•  ReproducLve Health Plan
•  NutriLon, Weight, and Exercise
•  Supplements
•  Vaccines
•  Injury PrevenLon
•  Universal RecommendaLons
History, Exam, and Laboratory Screen
•  Suggested preconcepLon screening assessment is
shown in Table 1.3 [12,15].
•  A ques8onnaire should be completed ahead of
8me, either on paper or online, to review this
extensive list.
•  A standardized form improves the completeness
of preconcepLon screening, which necessitates
Lme and commitment [16].

•  This standardized preconcepLon form should be
integrated into the permanent record of all
reproducLve-age woman.
•  In a randomized trial, women assigned to be
screened with a preconcepLon risk survey were
found to have an average of nine risk factors,
supporLng the facts that even low-risk women
may benefit from preconcepLon screening [13].
•  History should be detailed, especially when
perLnent posiLves are detected. Prior inpa8ent and
outpa8ent medical records should be reviewed.
•  Women should be empowered with easy access to
their records (best if electronic), to facilitate
mulLspecialty care coordinaLon.
•  Personal prenatal medical record access has been
associated with increased maternal control,
saLsfacLon during pregnancy, and increased
availability of antenatal records during hospital
a_endance [17].
•  Prior obstetrical and gynecological history, including
prior pregnancy complicaLons, should be reviewed.
•  Other reproducLve issues should also be assessed:
ferLlity, including the possibility of assisted
reproducLve technology needs, sexuality (in
parLcular high-risk behaviors), contracepLon,
partner selecLon, and sexual funcLon.
•  Several social issues need to be reviewed as well
(Table 1.3).
•  All couples should have a basic screen for family
history of heritable gene8c disorders, with a
pedigree to at least the second prior generaLon.
•  Women belonging to an ethnic group at increased
risk for a recessive condiLon (Table 1.4) should be
offered appropriate screening.
•  All couples should be made aware of the opLon for
cys8c brosis (CF) screening, especially those who
have a family history of CF, are in a high-risk group,
or are reproducLve partners of individuals with CF
[18].
•  Women with a specific indicaLon for geneLc
tesLng should be referred for formal geneLc
counseling (see Chapters 5 and 6).
•  Physical exam details are shown in Table 1.3.
•  Pelvic exam may include cytologic and sexually
transmi_ed infecLon screening for women with
certain risk factors.
•  Laboratory tests are done rouLnely (Table 1.3)
and depend on risk factors (Table 1.4) [12].
Reproduc8ve Health Plan
•  Asking a reproduc8ve-age woman, and therefore
inducing her to think about, her reproduc8ve
health plan should be a priority of any medical visit
[19].
•  Such a plan should address the desire (or not) for

children; the opLmal number, spacing, and Lming of
pregnancies; contracepLon to achieve this plan;
opportuniLes to improve her health and therefore a
successful reproducLve life; and age-related
changes in ferLlity [19].
•  Having a reproducLve health plan reduces
unintended pregnancies, age-related inferLlity,
and fetal exposure to teratogens [2].
•  Very few women know that a short
interpregnancy interval (i.e., <6 months from
the end of last pregnancy to the next
concep8on) is associated with increased
incidence of both small-for-gestaLonal-age and
low-birth-weight neonates [20].
•  Folic acid depleLon may be the eLology for these
increased risks [21].
•  EducaLon and contracep8on advice are necessary
to aim for the wished reproducLve plan, avoiding
unplanned pregnancies, and opLmizing the 18- to
24-month interpregnancy interval goal.
•  In a nonrandomized study, preconcepLon care
decreased the number of unintended pregnancies
[22].
•  All women should be counseled that 2%–3% of
babies are born with minor (usually) or major
anomalies.
•  Screening and diagnosLc opLons to detect
aneuploidy and birth defects should be reviewed
so that women may consider their opLons in
relaLon to their personal values.
Nutri8on, Weight, and Exercise
•  Lifelong habits of healthy diet and regular
exercise should be established preconcepLonally
[23].
•  Proper diet and exercise can prevent several

complicaLons of pregnancy, including gestaLonal
diabetes and hypertensive complicaLons [24].
•  Some studies suggest a correlaLon between a
diet high in fruits, vegetables, nuts, and legumes,
less than two servings of meat weekly and at
least two servings of fish weekly (the
“Mediterranean Diet”) with decreased rates of
inferLlity and PTB [25–27].
•  In addiLon to following a healthy diet, issues of food
safety are important to review.
•  All meat, seafood, and shell- fish should be thoroughly
cooked.
•  EaLng at least 12 oz. of fish weekly is associated with
several benefits, including a lower rate of PTB (see Chapter
17), but women must avoid >2 serving/ week of shark,
sword fish, king mackerel, some tuna, or Lle fish, all of
which may contain high concentraLons of methyl mercury.
•  Albacore (white) tuna has more mercury than canned,
light tuna [28].
•  Other recommendaLons include ea8ng only
pasteurized eggs and dairy products and
washing raw fruits and vegetables before eaLng.
•  Women should try to obtain a minimum daily
iodine intake of 150 mg/day.
•  EducaLon about proper hand, food, and cooking
utensil hygiene is important, especially in
developing countries.
•  Body mass index (BMI) should be calculated at
least annually for reproducLve-age women [29].
•  For women with a BMI that falls outside the
normal range [28–34], preconcepLon counseling
regarding the woman’s increased risk of
complicaLons in pregnancy is extremely
important.
•  Formal nutri8onal counseling should be offered
and goals set to avoid pregnancy un8l op8mal
weight is achieved.
•  Women with low BMI should be screened for
eaLng disorders. In overweight and obese
women, calorie and por8on-size control may be
the most effecLve methods of sustained
preconcepLon weight loss.
•  Unfortunately, there are no current evidence-
based guidelines as to the most effecLve method
of weight loss in the preconcepLon period for
obese and overweight paLents [34].
•  Postpartum individual counseling on diet and
physical acLvity increased the proporLon of
women returning to prepregnancy weight from
30% to 50% in one randomized trial [30].
•  An exercise rouLne that can be started pre
concepLonally and safely conLnued in pregnancy
may include yoga; brisk walking (including hiking and
backpacking); jogging; swimming; biking; cross
country skiing; and using fitness equipment such as
an ellipLcal trainer, treadmill, or staLonary bike.
•  Women should be given standard advice for
engaging in regular physical acLvity for 30–60 min/
day for 5 or more days per week.
Supplements
•  The preconcepLon intervenLon with the most
evidence-based data to support its efficacy is
folic acid supplementa8on.
•  Folic acid supplementaLon is recommended,
with a minimum of 400 μg/day for all women
(93% decrease in neural tube defects [NTDs]),
and 4 mg/day for women with prior children
with NTDs (69% decrease in recurrent NTDs) [32].
Supplements
•  SupplementaLon should start at least 1 month
before concepLon and conLnue unLl at least 28
days acer concepLon (Lme of neural tube
closure).
•  Given the unpredictability of planned concepLon,
all reproducLve-age women should be on folic
acid supplementaLon from menarche to
menopause.
Supplements
•  Women taking anLseizure medicaLons, other drugs
that might interfere with folic acid metabolism,
those with homozygous methylenetet- rahydrofolate
reductase (MTHFR) enzyme mutaLons, or those who
are obese may need higher doses of folic acid
supplementaLon.
•  As increases in baseline serum folate level are
directly proporLonal with a decrease in the
incidence of NTD, some experts have advocated 5
mg of folic acid per day as opLmal universal
supplementaLon [33].
Supplements
•  Folic acid supplementaLon has also been
associated with a decrease in the risk of
congenital anomalies other than NTDs (e.g.,
cardiac, facial clecs) [34,35].
•  The overall benefits or risks of forLfying basic
foods such as grains with added folate have been
associated with a 140–200 μg/day increase in
supplementaLon and a 20%–50% decrease in
incidence of NTD [33,36].
Supplements
•  EducaLon with provision of printed material
[32,37], computerized counseling [38], and learner-
centered nutriLon educaLon [39] all increase the

awareness of the folate/NTDs associaLon and the
use of the folate supplements.
•  These intervenLons may be effecLve in
increasing the prophylacLc use of addiLonal
preconcepLon care acLviLes.
Supplements
•  There is insufficient evidence to jusLfy the
rouLne use of other supplements in
reproducLve-age women, especially in the
developed world, unless a nutriLonal deficiency
has been idenLfied. It is important to obtain a
minimum daily iodine intake of 150 mg/day and
10,000 IU daily of vitamin A (as beta-carotene) if
deficiencies in these nutrients are idenLfied.
Supplements
•  The use of certain supplements may be
detrimental, especially if excessive amounts of
lipid-soluble vitamins such as vitamin A (>10,000
IU/day) are taken, since they can be teratogenic.
•  All supplements, including alternaLve and
complementary medicines, should be reviewed
(see also Chapter 2) [40,41].
Vaccines
•  PreconcepLon vaccinaLon for the
prevenLon of fetal and maternal
disease is an important preconcepLon
intervenLon (Table 1.5) (see also
Chapter 38 in Maternal-Fetal Evidence
Based Guidelines).
Vaccines
•  Maternal immunity to infec8ons such as
rubella and varicella should be assessed for
potenLal vaccinaLon of nonimmune women,
thus eliminaLng their risk for congenital
syndromes associated with these viruses.
•  VaccinaLon with live a_enuated viruses
should occur at least 4 weeks prior to
concepLon due to theoreLcal risk of live virus
affecLng the fetus.
Vaccines
•  Annual influenza vaccina8on for women
and their partners contemplaLng pregnancy
will reduce the chance of maternal prenatal
infecLon, a Lme during which higher
morbidity has been documented.

Vaccines
•  Influenza vaccinaLon for new mothers and
other close contacts of the newborn will reduce
risk of infecLon for the child who is unable to
receive vaccinaLon unLl 6 months of age.
•  Through this process of “cocooning,” the
newborn is protected from the high morbidity
and mortality rates associated with influenza in
the first year of life [42].
Vaccines
•  Hepa88s B vaccina8on should be offered to all
suscepLble women of reproducLve age in regions
with intermediate and high rates of endemicity
(where ≥2% of the populaLon is hepaLLs B surface
anLgen [HBsAg] posiLve).
•  Perinatal transmission of hepaLLs B results in 90%
chance of chronic infecLon in the newborn, which
places the child at risk for future cirrhosis and
hepatocellular carcinoma.
•  In regions of low prevalence, vaccinaLon should be
targeted to high-risk groups (Table 1.5).
Vaccines
•  Tetanus vaccina8on should remain up-to-date in
reproducLve-age women, parLcularly in regions of the
world where maternal and neonatal tetanus is prevalent
[43].
•  This has been shown to markedly reduce the incidence of

tetanus related to parturiLon.
•  Due to increasing prevalence and the high morbidity and
mortality rates of neonatal pertussis, vaccinaLon (in
combinaLon with tetanus and diphtheria) is
recommended for all women and their partners of
reproducLve age who have not been immunized in their
adult lives (since age 11 years) [44].
Vaccines
•  It is well documented that 75% of cases of
neonatal pertussis have a family member as the
index case [45].
•  Again, through the concept of cocooning, the
incidence of neonatal pertussis can be reduced.
•  Other vaccinaLon recommendaLons based on
medical, occupaLonal, or social risks are
described in Table 1.5.
Injury Preven8on
•  The second leading cause of death in reproducLve-
age women is accidents.
•  Use of seat belts and helmets should be reviewed
and strongly encouraged where appropriate.
•  Inquiry should be made regarding occupaLonal
and recreaLonal hazards.
•  Possession and use of rearms should be evaluated.
Possession and use of rearms should be evaluated,
especially in individuals with a history of significant
mental health diagnoses.
Universal Recommenda8ons
•  PreconcepLon recommendaLons for all women
are listed in Table 1.6.
•  ReproducLve-age women should be aware of
these evidence-based recommendaLons, both
through their doctors and through public
awareness campaigns.
•  Several online resources are available [46–49].
•  Women and their partners should take more
responsibility for their care and the future health
of their offspring, and implement the health and
lifestyle changes recommended.
SPECIFIC INDIVIDUAL ISSUES
•  History of PTB
•  Advanced Maternal Age
•  Chronic Disease
•  MedicaLons/Teratogens
•  Substance Abuse/Environmental Hazards/Toxins
History of PTB
•  There are currently no preconcepLon
recommendaLons for a woman with a history of
PTB outside of the general recommendaLons for
women trying to conceive.
•  Randomized controlled trials examining
preconcepLon iniLaLon of low-dose aspirin did
not demonstrate an increased live birth rate or
decrease in PTB [50,51].
History of PTB
•  Interval anLbioLc treatment with azithromycin
and metronidazole between pregnancies in
women with a prior spontaneous PTB <34 weeks
has not been associated with decreased risk of
preterm delivery [52,53].
Advanced Maternal Age
•  In recent years, there has been a trend to delay
childbearing.
•  This trend is especially prevalent in developed
countries, for example, in the United States
where the birth rate in women age 40–44 has
increased from 5.2 births per 1000 in 1990 to
10.4 births per 1000 women in 2013 [54].
Advanced Maternal Age
•  It is well established that women of advanced
maternal age (AMA) are at increased risks of poor
obstetric outcomes, sLllbirth, and fetal death [55–57].
•  Women of extreme AMA (>45 years old) have been
found to increase the prevalence of preexisLng
chronic disease [58].
•  Although no Level I evidence exists for
preconcepLon tesLng in this populaLon, it is
reasonable to screen paLents of extreme AMA for
chronic hypertension, diabetes, hyperlipidemia, or
heart disease with a cardiac echocardiogram.
Chronic Diseases
•  The incidences of several medical disorders such as
obesity, diabetes mellitus, and hypertension are high
and on the rise in reproducLve-age women.
•  There is literature for evidence- based
recommendaLons on each disease or condiLon that can
involve the reproducLve-age woman and affect her
reproducLve health [3,4,15].
•  Full review of each is behind the scope of this chapter
(see individual chapters in Maternal-Fetal Evidence
Based Guidelines).
•  Some common condiLons are discussed for brief
preconcepLon management review (Table 1.7).
Chronic Diseases
Diabetes
•  Diabetes (see Chapters 4 and 5 in Maternal-Fetal
Evidence Based Guidelines) is associated with an
increased risk of congenital anomalies, in parLcular
cardiac defects and NTDs, if poorly controlled in the
first weeks of pregnancy.
•  The risk of congenital anomalies is related to long-
term diabeLc control, reflected in the level of
glycosylated hemoglobin (HgB A1c): <7% = no
increased risk (2%–3% baseline); 7%–9% = 15%; 9%–
11% = 23%; >11% = 25% [32].
Chronic Diseases
Diabetes
•  It has been es8mated that euglycemia (with normal
HgB A1c) during the first trimester, which can only
be achieved through alen8ve preconcep8on
counseling, could prevent >100,000 U.S. pregnancy
losses or birth defects per year [2].
•  Another cost analysis reported that universal pre-
concepLon care could lead to averted lifeLme costs
for the affected cohort of children as high as $4.3
billion [59,60].
Chronic Diseases
Diabetes
•  The benefits of preconcepLon diabetes care have
been previously demonstrated [61,62], even in
teenagers [63].
•  PreconcepLon care is also essenLal for
counseling of the woman with condiLons severe
enough to make a successful pregnancy
extremely unlikely.
Chronic Diseases
Diabetes
•  The diabeLc woman with either ischemic heart
disease, untreated proliferaLve reLnopathy,
creaLnine clearance <50 mL/min, proteinuria >2
g/24 hours, creaLnine >2 mg/dL, uncontrolled
hypertension, or gastropathy should be told not
to get pregnant before the above condiLons can
be improved, and counseled regarding adopLon
if the condiLons cannot be improved [64].
Chronic Diseases
Diabetes
•  The frequency of fetal/infant and maternal morbidity and
mortality is reduced in diabeLc women seeking
consultaLon in preparaLon for pregnancy, but
unfortunately only about one-third of these women
receive such consultaLon [65].
•  The preconcepLon consultaLon affords the opportunity to
screen for vascular consequences of the diabetes, with
ophthalmologic, electrocardiogram (EKG), and renal
evalua8on via a 24-hour urine collec8on for total protein
and crea8nine clearance, and determine ancillary
pregnancy risks.
Chronic Diseases
Diabetes
•  ProliferaLve reLnopathy should be treated with
laser before pregnancy.
•  A thyroid-sImulaIng hormone (TSH) level should
be checked, as 40% of young women with type 1
diabetes have hypothyroidism.
•  Of note, there is insufficient evidence to treat
subclinical hypothyroidism [66].
Chronic Diseases
Diabetes
•  Diabetes evaluaLon should emphasize the
importance of Lght glycemic control, with
normalizaLon of the HgB A1c to at least <7%.
•  To achieve euglycemia, diet, glucose monitoring,
and exercise are always stressed.
•  If euglycemia is not achieved with these means,
oral hypoglycemic agents or insulins are u8lized,
and their regimens should be opLmized preconcep-
Lonally.
Chronic Diseases
Diabetes
•  Of the oral hypoglycemic agents, glyburide and
glucophage can be used, and probably conLnued
during pregnancy.
•  The original safety data available for glyburide
showed that it did not cross the placenta in
appreciable amounts [67], but recent data have
shown a 70% level in umbilical blood compared
with maternal blood [68].
Chronic Diseases
Diabetes
•  The other oral hypoglycemic agents should not be
used for preconcepLon glycemic control, as there is
no sufficient evidence for their safety and efficacy in
pregnancy.
•  A common insulin regimen currently used by
diabetologists is long-ac8ng (e.g., glargine) and
short-ac8ng (e.g., lispro).
•  This is a safe and effecLve regimen in pregnancy,
too. Women compliant with insulin pumps should
conLnue this regimen.
Chronic Diseases
Diabetes
•  If a woman has a history of gestaLonal diabetes,
appropriate postpartum diabetes screening
should be performed.
•  InterconcepLon counseling and lifestyle
modificaLons may be beneficial for future
pregnancies [69].
Chronic Diseases
Hypertension
•  Hypertension (see Chapter 1 in Maternal-Fetal
Evidence Based Guidelines) is associated with several
maternal [worsening hypertension; superimposed
preeclampsia; severe preeclampsia; eclampsia;
hemolysis, elevated liver enzyme levels, and a low
platelet count (HELLP) syndrome; cesarean delivery]
and fetal (growth restricLon; oligohydramnios;
placental abrupLon; PTB; perinatal death) risks in
pregnancy.
Chronic Diseases
Hypertension
•  Serum crea8nine, 24-hour urine for total protein and
crea8nine clearance, EKG, and ophthalmologic exam are
suggested, especially in women with long-standing or
severe hypertension.
•  It is important to idenLfy cardiovascular risk factors and
any reversible cause of hypertension, as well as assess for
target organ damage or cardiovascular disease.
•  If hypertension is newly diagnosed and has not been
evaluated previously, a medical consult may be indicated
to assess for any of these factors.
Chronic Diseases
Hypertension
•  Secondary hypertension, target organ damage (lec
ventricular dysfuncLon, reLnopathy, dyslipidemia,
microvascular disease, and prior stroke), maternal age
>40, previous pregnancy loss, systolic blood pressure ≥180
mmHg, or diastolic blood pressure ≥110 mmHg are
associated with higher risks in pregnancy.
•  AbnormaliLes should be addressed and managed
appropriately. If, for example, serum creaLnine is >1.4 mg/
dL, the woman should be aware of increased risks in
pregnancy (pregnancy loss, reduced birth weight, PTB, and
accelerated deterioraLon of maternal renal disease).
Chronic Diseases
Hypertension
•  Even mild renal disease (creaLnine 1.1–1.4 mg/dL)
with uncontrolled hypertension is associated with
tenfold higher risk of fetal loss.
•  PreconcepLon prevenLon can be enormously
effecLve.
•  Thirty minutes of exercise five 8mes per week in all
women with hypertension and weight reduc8on if
overweight are recommended.
Chronic Diseases
Hypertension
•  RestricLon of sodium intake to the same <2.4 g
sodium daily intake recommended for essenLal
hypertension is beneficial in nonpregnant adults.
•  If anLhypertensive medical therapy is necessary,
angiotensin-conver8ng enzyme (ACE) inhibitors and
angiotensin II (AII) receptor antagonists should be
discon8nued as they are associated with birth
defects, fetal growth restricLon, oligohydramnios,
neonatal renal failure, and neonatal death in
pregnancy.
Chronic Diseases
Hypertension
•  All other anLhypertensive agents should be used
at the lowest effecLve dose and are probably
safe if started preconcepLonally and conLnued in
pregnancy.
Chronic Diseases
Seizure Disorders
•  ConcepLon should be deferred unLl seizures are
well controlled on the minimum effecLve dose of
medicaLon (see Chapter 19 in Maternal-Fetal
Evidence Based Guidelines).
•  Monotherapy is preferable.
•  Lamotrigine has been reported to be the first-line
therapy for nonpregnant adults for parLal seizures
[70–72] and is associated with a low incidence of
major malformaLons ([73], but not in all studies [74].
Chronic Diseases
Seizure Disorders
•  The best choice is the anLepilepLc drug (AED) that
best controls the seizures.
•  The AEDs are usually U.S. Food and Drug
AdministraLon (FDA) category C (human risk
unknown, but none proven yet) except for the
following AEDs that are known potenLal teratogens:
carbamazepine, primidone, phenytoin, and
valproate (Table 1.8).
Chronic Diseases
Seizure Disorders
•  These four AEDs should therefore be avoided if
possible, by using a different therapy beginning in
the preconcepLon period.
•  Women who have been seizure-free for ≥2 years
with a normal electroencephalogram (EEG) may
be eligible to stop an8convulsant therapy afer
consul8ng with a neurologist [75].
Medica8ons/Teratogens
•  Detailed discussion regarding prescribed and
over-the- counter medicaLons should occur at
the preconcepLon visit.
•  The indicaLon, safety, effecLveness, and
necessity of each drug need to be reviewed.
Ocen, women and their doctors stop
efficacious and necessary medicaLons as soon
as the woman finds out she is pregnant,
compromising the health of both the woman
and her baby.
•  The vast majority of prescribed medica8ons
are safe in pregnancy, even in the rst
trimester.
•  Only a few drugs, chemicals, infec- 8ons, or
radia8on are proven teratogens (Table 1.8)
[76,77].
•  These should be avoided, except in rare

circumstances (e.g., the woman with
mechanical cardiac valves who accepts the
teratogenic risk of warfarin).
•  This medicaLon counseling is ocen a crucial
part of preconcepLon care and can save
and ameliorate significantly the health of a
future offspring.
•  Great resources exist on the Web for up-to-
date teratologic informaLon [78–80].
Substance Abuse/Environmental Hazards/Toxins
•  Tobacco smoking during pregnancy is
associated with increased risks of several
complicaLons (see Chapter 22 in Maternal-Fetal
•  The benefits of smoking cessaLon are
tremendous: prevenLon of 10% of perinatal
deaths, 35% of low-birth weight births, and 15%
of preterm deliveries [81].
•  Smoking only one to ve cigare_es per day is
associated with a 55% higher incidence of low birth
weight compared with nonsmokers.
•  ReproducLve-age women should be informed of
other smoking-related diseases, such as ischemic
heart disease, cancer, lung diseases, pneumonia,
stroke, and congesLve heart failure.
•  Women at greatest risk for smoking are those <25
years old with less than a high school educaLon.
Smoking makes a major contribuLon to dispariLes
in mortality [82].
•  Smoking cessaLon programs are associated with a
6% increase in smoking cessaLon, and decreases in
incidences of low birth weight (by 19%) and PTB (by
16%) [83].
•  Support and reward techniques to help quit
smoking are one of the best form of evidence-based
medicine, supported by over 20 high-quality
randomized trials.
•  The “5 As” for screening and intervenLons to
prevent smoking in pregnancy are Ask, Advise,
Assess, Assist, and Arrange [67].
•  Counseling with behavioral and educa8onal
interven8ons is associated with highest cessa8on
rates.
•  If necessary, most pharmaco- therapies are
effec8ve preconcep8on, but contraindicated or with
uncertain safety and ef cacy during pregnancy.
•  NicoLne replacement therapy (e.g., patch, gum, and
bupropion) is safe and effecLve in reproducLve-age
women, but there is insufficient evidence for
recommending them in pregnant smokers.
•  NicoLne replacement therapy is associated with
known adverse fetal effects, and nicoLne is detected
in breast milk.
•  Possibly the best prevenLon of the adverse effects
of smoking on pregnancy is achieved by avoiding
sale of tobacco to young people, prohibiLon of
smoking in public places, increase in tobacco
taxaLon, workplace smoking cessaLon programs,
and banning of tobacco sponsorship of sporLng and
cultural events.
•  Numerous recreaLonal drug exposures have adverse
pregnancy effects (see Chapter 23 in Maternal-Fetal
•  This list is extensive and includes, but not limited to,
common recreaLonal drugs such as alcohol, cannabinoids,
cocaine, heroin, and methamphetamines.
•  Working to ensure that women with substance abuse
issues engage in safe sex pracLces and family planning is a
constant challenge, and these women are
disproporLonately overrepresented among women with
unplanned pregnancies.
THANK YOU

PPK Rspad Obgin 2017, 1. Preconception Care, Jje 20170414

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PRECONCEPTION

Power point disusun oleh:

Judi Januadi Endjun

1 Juli 2017, Judi Januadi Endjun

•  Such a plan should address the desire (or not) for

•  Proper diet and exercise can prevent several

centered nutriLon educaLon [39] all increase the

•  This has been shown to markedly reduce the incidence of

•  These should be avoided, except in rare

Вам также может понравиться

PPK Rspad Obgin 2017, 1. Preconception Care, Jje 20170414

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PPK Rspad Obgin 2017, 1. Preconception Care, Jje 20170414

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PRECONCEPTION

Power point disusun oleh:

Judi Januadi Endjun

1 Juli 2017, Judi Januadi Endjun

• Such a plan should address the desire (or not) for

• Proper diet and exercise can prevent several

centered nutriLon educaLon [39] all increase the

• This has been shown to markedly reduce the incidence of

• These should be avoided, except in rare

Вам также может понравиться

•  Such a plan should address the desire (or not) for

•  Proper diet and exercise can prevent several

•  This has been shown to markedly reduce the incidence of

•  These should be avoided, except in rare