Preconception counseling: Make it part of the annual exam

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Applied Evidence

Preconception counseling: Make it part of the annual exam

J Fam Pract. 2009 June;58(6):307-314

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References

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2. Proceedings of the Preconception Health and Health Care Clinical, Public Health, and Consumer Workgroup Meetings. Atlanta, GA: Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities; 2006. Available at: http://www.cdc.gov/ncbddd/preconception/documents/Workgroup%20Proceedings%20June06.pdf. Accessed May 14, 2009.

3. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care—United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006;55(RR-06):1-23.Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm. Accessed May 14, 2009.

4. Lumley J, Watson L, Watson M, et al. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database Syst Rev. 2001;(3):CD001056.-

5. Iqbal MM. Prevention of neural tube defects by periconceptional use of folic acid. Pediatr Rev. 2000;21:58-66.

6. de Weerd S, Thomas CM, Cikot RJ, et al. Preconception counseling improves folate status of women planning pregnancy. Obstet Gynecol. 2002;99:45-50.

7. Mofenson LM. Centers for Disease Control and Prevention, US Public Health Service Task Force. US Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. MMWR Recomm Rep. 2002;51(RR-18):1-38.

8. Robinson HE, O’Connell CM, Joseph KS, et al. Maternal outcomes in pregnancies complicated by obesity. Obstet Gynecol. 2005;106:1357-1364.

9. Kiel DW, Dodson EA, Artal R, et al. Gestational weight gain and pregnancy outcomes in obese women: How much is enough? Obstet Gynecol. 2007;110:752-758.

10. US Food and Drug Administration. Food safety for moms-to-be. August 24, 2005. Available at: http://www.cfsan.fda.gov/~pregnant/pregnant.html. Accessed September 18, 2008.

11. Cheschier N. ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin. Neural tube defects. Number 44, July 2003. (Replaces committee opinion number 252, March 2001). Int J Gynaecol Obstet. 2003;83:123-133.

12. Castles A, Adams EK, Melvin CL, et al. Effects of smoking during pregnancy. Five meta-analyses. Am J Prev Med. 1999;16:208-215.

13. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. May 27, 2004. Available at: http://www.surgeongeneral.gov/library/smokingconsequences. Accessed July 6, 2008.

14. National Center for Health Statistics. Health, United States, 2004: With Chartbook on Trends in the Health of Americans. Hyattsville, MD: NCHS; 2004. Available at: http://www.cdc.gov/nchs/data/hus/hus04.pdf. Accessed September 18, 2008.

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16. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; May 2008. Available at: http://www.ahrq.gov/path/tobacco.htm. Accessed May 14, 2009.

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21. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstet Gynecol. 2005;105:675-685.

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23. American Academy of Neurology. Guideline summary for clinicians—management issues for women with epilepsy. Available at: www.aan.com/professionals/practice/pdfs/women_epilepsy.pdf. Accessed May 14, 2009.

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FAST TRACK

Recent studies have linked excessive caffeine intake with miscarriages in the first trimester.

The use of oral hypoglycemic medications during pregnancy is somewhat controversial. For that reason, you may want to refer these patients to an endocrinologist or other expert in diabetes management during pregnancy for consideration of scheduled insulin injections or an insulin pump.²⁰

Patients with diabetes should be screened for retinal disease, renal disease, hypertension, and hyperlipidemia prior to conception, including a 24-hour urine collection for protein and creatinine clearance. Because women with type 1 diabetes have up to a 40% incidence of thyroid dysfunction, consider screening for thyroid disorders as well.²¹

While counseling patients with diabetes, keep in mind that a blood urea nitrogen concentration of more than 30 mg/dL, current coronary artery disease, and creatinine clearance of less than 30 mL/min are considered contraindications for pregnancy.²⁰ All women who have had diabetes for more than 10 years should have an electrocardiogram (EKG).

Hypothyroidism. Poorly controlled hypothyroidism may cause developmental, growth, and neurologic abnormalities. Patients with thyroid abnormalities should have their medication dosage optimized before they conceive.

Epilepsy. Seizure disorders generally do not worsen during pregnancy, but several antiseizure medications have a potential for harming the fetus ( TABLE 2 ). Counsel patients about the increased risk of congenital anomalies (4%-8%) in neonates born to women with seizure disorders, either because of the disorder itself or as a consequence of antiseizure medication.²²

Patients taking anti-epileptic drugs should take 4 mg/d of folate supplementation. According to the American Academy of Neurology, best practice is to use a single agent best suited to the type of seizures the patient experiences, at the lowest effective dose. Avoid multiple anti-epileptic drugs, if possible. Do not change an effective medication regimen if the patient becomes pregnant, but do check drug levels.²³ Also counsel patients about the possibility of decreased effectiveness of hormonal contraception while taking enzymeinducing (cytochrome P450) antiepileptic drugs.²⁴

Psychiatric disorders. Approximately 1 of every 7 pregnant women meets the diagnostic criteria for depression.²⁵ Depression, anxiety, and other psychiatric conditions can adversely impact the patient and her developing fetus if the condition is undertreated. Unfortunately, some women stop psychiatric medications when they discover they are pregnant. In 1 study of 201 pregnant women with depression, 43% had a relapse during the course of pregnancy. Patients with relapse included 68% of those who stopped medication during the pregnancy, vs 26% of those who continued taking medication.²⁶

Most antidepressants are relatively safe during pregnancy, with the exception of paroxetine (Paxil), which is associated with fetal cardiac defects.²⁷ When a patient taking psychiatric medications comes in for a preconception visit, consider higher doses of 1 psychotropic medication rather than lower doses of multiple medications. This will decrease fetal medication exposure. If a patient on a stable regimen becomes pregnant, do not switch medications. Always collaborate with the patient’s mental health care team.

Venous thromboembolic disease. Some inherited thrombophilias can lead to a VTE during pregnancy or the postpartum period. Consider testing patients who have had a VTE or have a family history of VTE for anticardiolipin antibodies, protein S deficiency, and other thrombophilias before conception, because some of the lab values that indicate these conditions can change during pregnancy.

FAST TRACK

Administering influenza vaccine is not contraindicated during pregnancy, although most experts advise waiting until the second trimester.

Patients with a history of a VTE related to hormone use or pregnancy will require prophylactic anticoagulation. When in doubt, refer to a hematologist or perinatologist. Both heparin and low-molecular-weight heparin are safe during pregnancy. Because warfarin is a suspected teratogen, patients taking warfarin should be converted to either heparin or low-molecular-weight heparin.

Hypertension. Hypertensive disorders may lead to pregnancy-induced hypertension, growth restriction, and renal disease. If patients are taking thiazide diuretics, angiotensin receptor blockers, or angiotensin-converting enzyme inhibitors ( TABLE 2 ), switch to medications such as methyldopa (Aldomet), nifedipine, or labetalol, which are safer during pregnancy.²⁸ Screen patients with long-standing hypertension for cardiac disease (via EKG) and nephropathy before conception.

TABLE 2
Medications that can harm the unborn child^32,33

MEDICATION	POTENTIAL HARM TO FETUS	FDA CATEGORY*
Cardiovascular
ACE inhibitors: captopril, enalapril, lisinopril	Cardiovascular malformations, hypotension, anuria, oligohydramnios	C (1st trimester), D (2nd, 3rd trimesters)
Statins: atorvastatin, simvastatin	Polydactyly, cleft lip, club foot	X
Antidepressants
SSRIs: citalopram, fluoxetine, paroxetine, sertraline	Pulmonary hypertension, withdrawal syndrome; paroxetine: cardiac malformations, NTDs	C (D, paroxetine)
Anxiolytics
Benzodiazepines: alprazolam, clonazepam, diazepam, lorazepam	Withdrawal syndrome, congenital anomalies (various), floppy infant syndrome	D
Anti-epileptic drugs
Valproic acid and derivatives	NTDs, facial/cardiac defects	D
Carbamazepine	See valproic acid	D
Phenobarbital	Cardiac defects, hemorrhagic disease of the newborn	D
Phenytoin	Fetal hydantoin syndrome	D
Other
Isotretinoin	Hydrocephalus, microcephaly, limb anomalies, preterm labor, increased spontaneous abortions	X
Warfarin	Skeletal defects, intrauterine growth restriction, neurologic defects	X
Methotrexate	Fetal malformations, spontaneous abortion	X
ACE, angiotensin-converting enzyme; NTDs, neural tube defects; SSRIs, selective serotonin reuptake inhibitors.
*FDA categories describe the relative risk of medication use during pregnancy. The FDA is currently proposing major revisions to the system to upgrade the usefulness of this information. Please reconfirm categories prior to prescribing.
A: Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities in any trimester of pregnancy.
B: Animal studies have revealed no evidence of harm to the fetus, but no adequate and well-controlled studies in pregnant women are available OR animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.
C: Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women OR no animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women.
D: Adequate well-controlled or observational studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective.
X: Adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks. The use of the product is contraindicated in women who are or may become pregnant.
FDA categories source: Meadows M. Pregnancy and the drug dilemma. FDA Consumer Magazine. May-June 2001. Available at www.fda.gov/fdac/features/2001/301_preg.html. Accessed May 6, 2009.