Preconception Care

Question 1

When do most women have their first pregnancy visit?

Answer 1

• at 8 weeks

Question 2

What % of pregnancies are unintended?

Answer 2

over 50%

Question 3

What should be on a preconception checklist?

Answer 3

• When do you plan to get pregnant?
• Discuss pregnancy expectations (average time to pregnancy is 6 months).
• Discuss cycle lengths and ovulation.
• “Fertile Days” (2 weeks prior to menses).
• If already had a child, discuss pregnancy spacing.
• PRENATAL VITAMINS

Question 4

Are many doctors pushing long acting reversible contraception (LARC)?

Answer 4

YES because it is most effective.

Question 5

When should prenatal vitamins be taken?

Answer 5

• ideally before conception

Question 6

** What is the most important prenatal vitamin?

Answer 6

• FOLIC ACID (400 ug)= decreases incidence of neural tube defects.
• 1 mg if diabetes/epilepsy
• 4 mg if prior Hx of neural tube defect

Question 7

When does the neural tube normally close?

Answer 7

• by day 28 after conception (6 weeks gestation or menstrual age).

Question 8

What are the 2 categories of neural tube defects?

Answer 8

1. open (more common)

2. closed

Question 9

What are 3 important neural tube defects related to prenatal vitamin deficiency (folic acid)?

Answer 9

1. spina bifida= failure of the neural tube to close properly, causing defects in the spinal cord and in the bones of the vertebrae.
2. anencephaly= absence of a major portion of the brain, skull, and scalp.
3. encephalocele= neural tube defect characterized by sac-like protrusions of the brain and the membranes that cover it through openings in the skull

Question 10

*** What 3 questions should you ask yourself when a woman looking to get pregnant tells you a medical problem?

Answer 10

1. How does the disease affect the pregnancy?
2. How does the pregnancy affect the disease?
3. Does the disease have any affect on the fetus? (i.e. do any disease elements cross the placenta, or does the disease affect the mother’s nutritional provisions to the fetus?)

Question 11

How will DM affect the fetus?

Answer 11

• the higher the Hgb A1C, the greater the risk of poor outcomes (spontaneous abortion, fetal demise, or congenital abnormalities).

Question 12

What should you do for a diabetic pt looking to get pregnant?

Answer 12

• control their blood sugar and do a full work up.

Question 13

*** What should you do for a woman with hypertension who is looking to get pregnant?

Answer 13

• AVOID ACEs and ARBs
• Beta blockers are safe :)
• Surveillance of the patient should be increased
• Blood pressure should be evaluated frequently

Question 14

What may beta blockers do?

Answer 14

• decrease the amount of amniotic fluid

Question 15

What must you do for an obese pt looking to get pregnant?

Answer 15

• Evaluate and discuss the problem

- Optimize diet

Question 16

What issues can obesity cause in getting pregnant, or to the fetus itself?

Answer 16

• ovulatory disturbance
• fetal loss
• gestational diabetes
• increased likelihood that the child will need to be delivered via caesarian

Question 17

Are some SSRI’s safe during pregnancy?

Answer 17

YES, but some are not

Question 18

Are some patients sometimes on an SSRI unnecessarily?

Answer 18

YES

Question 19

What is another option for pts with depression other than an SSRI during pregnancy?

Answer 19

• psychotherapy
• some patients are never aware of this option
• some patients seek a way to reduce the medications that they are taking during pregnancy

Question 20

What carrier screening should be done for a woman looking to get pregnant?

Answer 20

• sickle hemoglobinopathies
• beta-thalassemia
• alpha-thalassemia

Question 21

If a woman is an Ashkenazi Jew, what other panels should be run prior to conception?

Answer 21

• CF (offered to every patient)
• Tay Sach’s
• Canavan
• Familial Dysautonomia

Question 22

What are some other familial diseases that could be screened?

Answer 22

• Fragile X

- 22q (DiGeorge)

Question 23

*** For what infectious diseases should you screen a women prior to conception?

Answer 23

• HIV (opt out not in). Treatment can decrease risk pf transmission from 25% to around 8%
• Syphilis
• Hepatitis B (must immunize)
• Rubella (German measles; must immunize)
• Varicella (herpes virus)
• Environmental Exposure
• CMV
• Parvovirus
• Toxoplasmosis

Question 24

*** How can congenital syphilis present?

Answer 24

• Hutchinson’s Triad= deafness, notched peg-shaped upper central incisors, and interstitial keratitis (inflammation of the cornea, which can lead to blindness).
• mulberry molars
• Du Bois sign= narrowing of the little finger
• frontal bossing= prominent, protruding forehead

Question 25

Can infants can varicella from their mother?

Answer 25

YES, called Congenital Varicella Syndrome (CVS)

Question 26

How does CVS present?

Answer 26

- hypertrophic skin - low birth weight - incomplete formation of the digits - cortical atrophy or dilated ventricles - mental retardation

Question 27

How does Congenital Rubella Syndrome (CRS) present if mother was not vaccinated, and become infected within the first 20 weeks of pregnancy?

Answer 27

- sensorineural deafness (58% of patients) - eye abnormalities (especially retinopathy, cataract, and microopthalmia; 43% of patients). - Congenital Heart Disease (especially pulmonary artery stenosis and patent ductus arteriosis; 50% of patients).

Question 28

What women are most at risk for environmental exposures?

Answer 28

teachers, healthcare workers, and veterinarians

Question 29

What are the 3 environmental exposure worries?

Answer 29

1. toxoplasmosis= rare; ingested from the feces of a cat, raw meat or milk. 2. parvovirus B19= transmitted via respiratory droplets. 3. CMV (herpes virus)= spread via body fluids.

Question 30

What can toxoplasmosis cause to a fetus?

Answer 30

- nasal malformations - encephalitis - necrotizing retinochoroiditis

Question 31

What can parvovirus B19 (5th's disease) cause to a fetus?

Answer 31

- called 5th’s disease due to a “slapped cheek” appearance. | - hydrops fetalis

Question 32

How does congenital CMV present?

Answer 32

- inflammation of retina, low birth weight, jaundice, rash, seizures, and microcephaly

Question 33

If the patient smokes less than 5 cigarettes/day, will this harm the fetus?

Answer 33

NO, but this is still a good time to talk about quitting, because this will affect the baby after birth.

Question 34

What other social screenings should you do for a woman looking to conceive?

Answer 34

- alcoholism/Drug Use - occupational exposures - household chemicals (home should be adequately ventilated) - domestic violence

Question 35

What should your physical entail?

Answer 35

- focus on lower genital tract - palpate the thyroid - check TSH if symptomatic. - external genitalia eval - speculum exam= visual eval of cervix, vaginal septum, discharge, and bimanual exam (uterine size, uterine mobility, adenexal masses, or pain on exam).

Question 36

Where should the uterus be at week 12?

Answer 36

- it has expanded past the pelvis, and the patient can have “round ligament pain”

Question 37

Where should the uterus be at week 20?

Answer 37

level of the umbilicus and is considered "locked in place."

Question 38

What could an adenexal mass indicate?

Answer 38

- ectopic pregnancy

Question 39

So what is the purpose of a preconception doctor's visit?

Answer 39

- to optimize a woman's health for pregnancy