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PubMed2006

A perspective of preconception health activities in the United States.

OBJECTIVES: Information regarding the type and scope of preconception care programs in the United States is scant. We evaluated State Title V measurement and indicator data and abstracts presented at the National Summit on Preconception Care (June 2005) in order to identify existing programs and innovative strategies for preconception health promotion. METHODS: We used the web-based Title V Information System to identify state Performance Measures and Priority Needs pertaining to preconception health as reported for the 2005-2010 Needs Assessment Cycle. We also present a detailed summary of the abstracts presented at the National Summit on Preconception Care. RESULTS: A total of 23 states reported a Priority Need that focused on preconception health and health care. Forty-two states and jurisdictions identified a Performance Measure associated with preconception health or a related indicator (e.g., folic acid, birth spacing, family planning, unintended pregnancy, and healthy weight). Nearly 60 abstracts pertaining to preconception care were presented at the National Summit and included topics such as research, programs, patient or provider toolkits, clinical practice strategies, and public policy. CONCLUSIONS: Strategies for improving preconception health have been incorporated into numerous programs throughout the United States. Widespread recognition of the benefits of preconception health promotion is evidenced by the number of states identifying related indicators.

Child↗
PubMed2002

Preconception and prenatal care.

Advances in preconception and prenatal care have been successful in reducing risk in a number of areas. Folic acid supplementation, abstinence from alcohol, tight glycemic control in pre-gestational diabetics, and the administration of rhogham all have been successful in reducing individual risks. Unfortunately, overall perinatal morbidity and mortality has not decreased in the past two decades. In light of this, clinicians must remain abreast of the latest research and technological advances, and adopt those practices that improve outcomes. Continued critical appraisal of persistent racial and ethnic disparities may be useful in understanding and reversing current trends. Additionally we must continue to creatively develop instruments of quantifying those aspects of high quality prenatal care, which are unmeasurable. Furthermore, we must advocate on a local, state, and national level for improved services for our prenatal patients not just in the office and the hospital, but in their homes and communities.

Alcohol Drinking↗
PubMed1996

Preconception health care for the primary care practitioner.

There will always be birth defects and pregnancy complications due to factors beyond our control. However, we are rapidly discovering many interventions women can use to optimize their chances of having a healthy pregnancy and baby. Most of these, such as immunization and normalization of a diabetic woman's glycosylated hemoglobin level, are most effective when begun before conception. Since the discovery of the congenital rubella syndrome in 1941, there has been a steady accumulation of information on the prevention of birth defects through preconception health. In just the last few years, we have learned that folic acid can decrease neural tube defects, angiotensin converting enzyme inhibitors are teratogenic, and zidovudine can decrease the vertical transmission rate of human immunodeficiency virus. The Varivax vaccine released last year is expected to decrease the perinatal morbidity from varicella. By using the time before conception, we may be able to fully maximize the benefits of good nutrition, exercise, medical screening, and avoidance of environmental toxins.

Female↗
PubMed2006

Outcome of fetuses in women with pregestational diabetes mellitus.

OBJECTIVE: To investigate the effects of pregestational diabetes on pregnancy outcome. METHODS: Data of 126 women with pregestational diabetes prospectively collected and controlled in a single tertiary center. HbA(1C) levels at early pregnancy were registered. Adverse pregnancy outcome was defined as spontaneous abortion, congenital defect, stillbirth, or neonatal death. RESULTS: There were 10 spontaneous abortions (7.9%) and 17 fetuses with congenital anomalies (13.4%), including 8 major malformations (6.3%). Compared with pregnancies with a favorable outcome, a higher HbA(1C) concentration in early pregnancy was observed in pregnancies with adverse perinatal outcome [mean (SD): 6.3 (1.6) vs. 7.2 (1.7), P=0.001]. A positive correlation between increased maternal HbA(1C) levels and the rate of fetal malformations was observed, and the group of women with poor metabolic control (early maternal HbA(1c) concentration >7%) showed a 3 to 5-fold increase in the major malformation rate. Cardiovascular and genitourinary defects accounted for 58.8% of the anomalies, and the ultrasound examinations detected seven of them (41.2%). For major malformations, the detection rate was 50% (4/8). Perinatal mortality rate was 26 per thousand (3/116). There was almost 5-fold increase in the total pregnancy loss rate in the poor control group compared with the group with fair control [22.2% vs. 5.3%, OR (95% CI): 5.1 (1.4-17.1)]. Only 11.9% of mothers used a preconception care program. CONCLUSIONS: Pregestational diabetes mellitus is a significant risk factor for the developing fetus. Spontaneous abortions and congenital defects are more common when a poor metabolic control is present in early pregnancy. It is most important to improve access to preconception care programs for achieving a good metabolic control in early pregnancy. Ultrasound examinations have a low performance for detecting congenital defects in diabetic pregnancies.

Abortion, Spontaneous↗
PubMed2001

Maternal diabetes: an independent risk factor for major cardiovascular malformations with increased mortality of affected infants.

BACKGROUND: Intensive medical care of women with diabetes has reduced their risks of bearing infants with congenital anomalies. To assess the preventive potential of preconceptional care, the data of a population-based study of cardiovascular malformations (CVM) were analyzed to determine the morphogenetic specificity of maternal diabetes risks, the morbidity and mortality of the infants, and maternal characteristics that might affect these risks. METHODS: The Baltimore-Washington Infant Study was a case-control study (1981-1989) that included all live born infants with confirmed CVM; control infants were a representative sample of the birth cohort. A questionnaire administered in home visits recorded parental information on social, medical, occupational, and environmental factors. For these analyses of preconceptional diabetes risks, the case group excluded chromosomal and mendelian disorders and was divided into 3 developmental categories and 12 diagnostic groups. RESULTS: Preconceptional maternal diabetes was strongly associated with CVM of early embryonic origin (odds ratio [OR] = 4.7, 95% confidence interval [CI] 2.8-7.9) and with cardiomyopathy (OR = 15.1, 95% CI 5.5-41.3), but not with obstructive and shunting defects (OR = 1.4, 95% CI 0.7-3.0). There was heterogeneity within these developmental categories: among laterality defects, diabetes was associated only with cardiovisceral and atrioventricular discordance (OR = 10.0, 95% CI 3.7-27.0); among outflow tract anomalies, the risk was strongly associated with normally related great arteries (OR = 6.6, 95% CI 3.2-13.3) but not with simple transpositions; and among atrioventricular septal defects, diabetes was associated with the complete but not with the partial forms (OR = 22.8, 95% CI 7.4-70.5). The association in early CVM was strongest among infants with multisystem, predominantly VACTERL, anomalies. All-cause mortality of infants with CVM was 39% among those with diabetic mothers and 17.8% in those with nondiabetic mothers. Deceased infants of diabetic mothers were also more likely to have extracardiac anomalies (P = 0.041), to be born prematurely (P = 0.007), and to have low birth weight (P = 0.011). Multivariate analyses of maternal factors revealed no significant confounders of the diabetes associations. CONCLUSIONS: The evidence of diabetes-induced major cardiac defects is of urgent clinical significance. The effectiveness of early preconceptional care in the prevention of congenital anomalies has been demonstrated repeatedly.

Adult↗
PubMed2003

French multicentric survey of outcome of pregnancy in women with pregestational diabetes.

OBJECTIVE: To evaluate perinatal outcome in pregnancies in women with type 1 and type 2 diabetes and the influence of preconception care 10 years after the St. Vincent's declaration. RESEARCH DESIGN AND METHODS: A cross-sectional study was conducted in 12 perinatal centers in France in 2000-2001. The main investigated outcomes were perinatal mortality, major congenital malformations, and preterm delivery. RESULTS: Among 435 single pregnancies, 289 (66.4%) were from women with type 1 and 146 (33.6%) from women with type 2 diabetes. Perinatal mortality rate was 4.4% (0.7% national rate), severe congenital malformations rate was 4.1% (2.2% national rate), and preterm delivery rate was 38.2% (4.7% national rate). Preconception care was provided in 48.5% women with type 1 diabetes and in 24.0% women with type 2 diabetes. Women whose first trimester HbA(1c) was >8% had higher rates of perinatal mortality (9.2 vs. 2.5%; odds ratio 3.9; 95% CI 1.5-9.7; P < 0.005), major congenital malformations (8.3 vs. 2.5%; 3.5; 1.3-8.9; P < 0.01), and preterm delivery (57.6 vs. 24.8%; 1.4; 1.1-1.7; P < 0.005) than those with first trimester HbA(1c) <8%. These results are similar to those reported in France in 1986-1988. CONCLUSIONS: Pregnancies in women with diabetes are still poorly planned and complicated by higher rates of perinatal mortality and major congenital malformations. Despite knowledge of the importance of intensified glycemic control before pregnancy, reaching the St. Vincent's target needs further implementation in France.

Cross-Sectional Studies↗
PubMedDate not supplied

Improving the care of women with gestational diabetes.

The article reviews gestational diabetes mellitus, including etiology, diagnostic and screening criteria, risk factors, and care of the affected woman. Gestational diabetes mellitus affects approximately 7% of all pregnant women, resulting in more than 200,000 cases each year, and is defined as glucose intolerance that begins or is first recognized during pregnancy. Women are considered at high risk for gestational diabetes if they are markedly obese, have a personal history of gestational diabetes, have a strong family history of diabetes, or have glycosuria. Risk assessment is essential in determining whether a woman should be screened or tested for gestational diabetes. Women who have had gestational diabetes should have comprehensive preconception care prior to a subsequent pregnancy to ascertain appropriate weight, nutrition, exercise, and signs of gestational diabetes.

Aftercare↗
PubMed1996

Content of prenatal care during the initial workup.

OBJECTIVE: In its landmark document Caring for Our Future: The Content of Prenatal Care, the Public Health Service Expert Panel on the Content of Prenatal Care presented a framework for refocusing prenatal care in the 1990s. The purpose of this study was to examine the extent to which the panel's recommendations for preconceptional care and for the content of the initial prenatal workup were followed 3 years after they were issued. STUDY DESIGN: A retrospective review of the prenatal records of 147 patients in Durham and Chatham counties, North Carolina, was conducted. Providers were selected at random, and their first 10 new prenatal patients were enrolled in the study. Data were analyzed descriptively to characterize patterns in content of care and, with multiple logistic regression analysis, to determine whether there were relationships between selected maternal characteristics and receipt of selected components of care. RESULTS: Only 11% of the patients had one or more preconceptional visits. During the initial prenatal workup risk assessment through history taking and physical examination was virtually complete, whereas documentation of laboratory tests varied. Only about half the population received routine counseling on pregnancy and health behaviors. Multiple logistic regression analysis revealed a consistent association between initiating prenatal care early in pregnancy and receipt of most laboratory tests. No other consistent relationships were found. CONCLUSIONS: This study suggests that adherence to such long-standing prenatal care practices as physical examination, history taking, and some laboratory tests was high. But the components of prenatal care recommended by the expert panel to ensure behavioral risk assessments and health promotion and education early in pregnancy were provided at lower and more variable rates. Use of preconceptional care was also low. Further research into the use and content of care before and during pregnancy is required to understand variations in practice patterns and levels of adherence to recommendations on the content of care.

Clinical Laboratory Techniques↗
PubMed1998

Addressing preconception risks identified at the time of a negative pregnancy test. A randomized trial.

BACKGROUND: A preconception care program has the potential to assist women who want to become pregnant by advising these women about risk factors, healthy lifestyles, and assessing readiness for pregnancy. We conducted a randomized controlled trial to determine whether comprehensive preconception risk assessment at the time of a negative pregnancy test followed by referral to primary care services is effective in initiating treatment for women with preconception risk factors. METHODS: One hundred seventy women were offered preconception risk assessment following a negative pregnancy test. Women were assigned randomly either to a usual care group or an intervention group. Women in the latter group were informed about the risks identified and received an appointment with a primary care clinician who was also informed. Women in the usual care group and their clinicians received no feedback. All charts were reviewed and the women were contacted by telephone to determine if interventions to reduce risk were offered by clinicians during the year following the assessment. RESULTS: An average of 8.96 risks were identified per woman. The proportion of women having risks in each of 12 risk categories studied ranged from 19% to 71%. One hundred women (59%) made at least one visit during the subsequent year, thus allowing the opportunity for preconception care. The proportion of these women who had a risk addressed ranged from 18% for psychosocial risks to 48% for those with fetal exposures (smoking, alcohol, and drug use). There was no difference between groups in the percentage of risks addressed. CONCLUSIONS: The notification of women and their clinicians of identified preconception risks did not improve intervention rates. A more organized intervention system including office-based protocols is needed.

Adolescent↗
PubMed2004

Reducing the risk for preterm birth: evidence and implications for neonatal nurses.

The incidence of preterm birth has been slowly rising despite advances in obstetric health care. Neonatal nurses have ongoing contact with women who have had a preterm birth and, thus, who are at high risk to have another preterm birth. This article discusses current evidence about reducing risk for preterm birth. Although preterm birth cannot always be prevented, preconception care can help identify and modify maternal risk and promote optimal health before conception. Quality prenatal care, as defined by the Institute of Medicine, consists of continuing risk assessment, health promotion, and interventions to modify medical and psychosocial risk. When these 3 components are consistently applied, they may confer some protection against preterm birth. Women at highest risk for preterm birth need to seek prenatal care from an expert in maternal-fetal medicine. Women also need to learn about the common, subtle signs of preterm labor so they can recognize symptoms and quickly seek treatment. Neonatal nurses can provide critical information and anticipatory guidance to women at risk for preterm birth so they can make sound decisions about future pregnancies.

Evidence-Based Medicine↗
PubMed2001

[Effect of preconceptional metabolic control in the course of pregnancy in diabetic patients].

BACKGROUND: We analysed the relationship between metabolic control parameters during the preconception stage and pregnancy outcome in diabetic patients. PATIENTS AND METHOD: We examined 69 diabetic patients who underwent a preconception control at the Diabetes and Pregnancy Unit between 1992-1998. At the end of the preconception care period, 50 women (72.6%) became pregnant. Eight out of them (16%) had an abortion. RESULTS: Women who had an abortion did not differ from those who had not an abortion with regard to HbA1c levels at the end of the preconception period, age, duration of diabetes, age at diagnosis,anti-thyroid antibodies or microvascular disease. Among 41 single age stations, fetal macrosomia was observed in 36.6% cases, neonatal hypoglycemia in 19.5% and major congenital malformations in one case. Average level of HbA1c was 7.6 +/- 1.3%and 6.5 +/- 0.7 at the beginning and at the end of the preconception period, respectively (p < 0.001). In the group with macrosomia,average HbA1c at the end of the preconception period was 6.8 +/- 0.66% as opposed to 6.3 +/- 0.7% for the non-macrosomic group (p < 0.05). A linear correlation was seen between HbA1c levels at the end of the preconception period and infant weight (r = 0,432; p = 0,014), birth weight ratio (r = 0,450; p = 0,009), and a morbidity score (r = 0,458;p = 0,007). CONCLUSIONS: A better metabolic control during the preconception period may contribute to lessen the risk of fetal macrosomia and neonatal morbidity.

Adult↗
PubMed2006

Counseling lesbian patients about getting pregnant.

OBJECTIVE: To describe an approach to counseling lesbian patients about getting pregnant. SOURCES OF INFORMATION: Information in this paper is based on evidence from randomized controlled trials (level I evidence), non-randomized trials (level II evidence), expert opinion (level III evidence), and government regulations. MAIN MESSAGE: We review 5 steps that comprise an approach to counseling lesbian patients about getting pregnant safely and efficiently. These steps are preconception care (including counseling, testing, and immunization); donor choice (including explaining the risks and benefits of choosing between a known or anonymous donor and the difference between fresh and frozen semen); donor testing (including Health Canada's requirements for semen processing and recommendations for testing before home insemination); ordering the semen (including information about sperm banks and the need for "Canadian compliant" semen); and the insemination process (including techniques for monitoring ovulation and various methods of insemination). CONCLUSION: Primary care physicians can help lesbians achieve pregnancy by providing education, testing, referrals, and insemination services.

Adult↗
PubMed2003

How should preconceptional cystic fibrosis carrier screening be provided? Opinions of potential providers and the target population.

BACKGROUND: Since the identification of the cystic fibrosis (CF) gene, large-scale CF carrier screening has become possible. One possible target group is couples planning a pregnancy (preconceptional screening), providing a maximum number of reproductive options and a minimum of time constraints. OBJECTIVES: To identify obstacles in the implementation of a preconceptional CF carrier screening programme, to find out how potential providers and the target population think the screening should be implemented, and to determine whether potential providers think they are able to provide the screening programme. METHODS: A survey was conducted among 200 general practitioners (GPs), 134 Municipal Health Service (MHS) workers and 303 recently married couples. RESULTS: 52% (102/197) of the eligible GPs participated, 84% (113/134) of the MHS workers and 70% (380/544) of the individuals planning a pregnancy. In general, potential providers and the target population had a positive attitude towards CF screening. Preferred methods of informing the target population were: in leaflets, during a GP consultation for those people seeking advice before pregnancy, and sending a personal invitation to all people of reproductive age. Potential providers believed that they would be able to provide the screening programme. Important perceived obstacles were the absence of a preconceptional care setting, high workload, and lack of financial resources. CONCLUSION: Different intervention strategies will be necessary to overcome the obstacles in the implementation. The positive attitude towards CF carrier screening in combination with the willingness of the potential providers to participate in the screening programme will make it easier to overcome the obstacles.

Adult↗