Chapter 9. Preconceptional Counseling
BS. Nguyễn Hồng Anh
Te Centers or Disease Control and Prevention (CDC) denes preconceptional health to encompass the overall health o nonpregnant women during their reproductive years (Robbins, 2018). Te American College o Obstetricians and Gynecologists (2019b) and the Society or Maternal–Fetal Medicine (2014, 2021) attest to the importance o preconceptional care and promote the ollowing objectives to advance it:
1. Improve knowledge, attitudes, and behaviors o men and women related to preconceptional health
2. Assure that all childbearing-aged women receive preconceptional care services—including evidence-based risk screening, health promotion, and interventions—that will enable them to enter pregnancy in optimal health
3. Implement interconceptional interventions to prevent or minimize recurrent adverse outcomes
4. Reduce the racial and socioeconomical disparities in adverse pregnancy outcomes
Table 9-1 lists the prevalence o many conditions oten amenable to preconceptional intervention (Robbins, 2018).
Tese are requently encountered by generalist obstetrician– gynecologists, who can help optimize health entering pregnancy (Arluck, 2018). For example, by the time most women realize they are pregnant—usually 1 to 2 weeks ater the rst missed period—the embryo has already begun to orm. Tus, many preventive steps—such as olic acid to avoid neural-tube deects—will be ineective i initiated at this time. Moreover, 45 percent o all pregnancies in the United States are unplanned, and oten these are at greatest risk (Finer, 2016).
Last, a disproportionate number o indigent women receive less preconceptional care compared with their more auent counterparts (Easter, 2017). Few randomized trials evaluate preconceptional care ecacy, in part because withholding such counseling would be unethical.
Te Centers or Disease Control and Prevention (CDC) denes preconceptional health to encompass the overall health o nonpregnant women during their reproductive years (Robbins, 2018). Te American College o Obstetricians and Gynecologists (2019b) and the Society or Maternal–Fetal Medicine (2014, 2021) attest to the importance o preconceptional care and promote the ollowing objectives to advance it:
1. Improve knowledge, attitudes, and behaviors o men and women related to preconceptional health
2. Assure that all childbearing-aged women receive preconceptional care services—including evidence-based risk screening, health promotion, and interventions—that will enable them to enter pregnancy in optimal health
3. Implement interconceptional interventions to prevent or minimize recurrent adverse outcomes
4. Reduce the racial and socioeconomical disparities in adverse pregnancy outcomes
TABLE 9-1. Preconceptional Health Indicators—United States, 2013–2015
Also, pregnancy outcomes are dependent on the interaction o various maternal, etal, and environmental actors. Tus, ascribing a salutary outcome to a specic intervention is dicult (emel, 2014; ieu, 2017). However, prospective observational and case-control studies have demonstrated the successes o preconceptional counseling (Yamamoto, 2018). Tereore, routine pregnancy intention screening should be done (Manze, 2020).
COUNSELING SESSION
Obstetricians–gynecologists, internists, amily practitioners, and pediatricians have the best opportunity to provide preventive counseling during periodic health maintenance examinations. Te occasion o a negative pregnancy test is also an excellent time or education (Skogsdal, 2018). Jack and colleagues (1995) administered a comprehensive preconceptional risk survey to 136 such women, and almost 95 percent reported at least one problem that could aect a uture pregnancy (see able 9-1). Providers should be knowledgeable regarding relevant medical diseases, prior surgery, reproductive disorders, or genetic conditions and be able to interpret data and recommendations provided by other specialists ( Simpson, 2014).
Women presenting specically or preconceptional evaluation are advised that inormation collection may be time consuming, depending on the number and complexity o actors. Te intake evaluation includes a thorough review o the medical, obstetrical, social, and amily histories. Useul inormation is more likely to be obtained by asking specic questions regarding each o these histories and the health o each amily member than by asking general, open-ended questions. Some important inormation can be obtained by questionnaires that address these topics. Answers are reviewed with the couple to ensure appropriate ollow-up, including obtaining relevant medical records.
■ The Fourth Trimester
Another optimal time to begin preconceptional counseling is during the “ourth trimester.” Tis was emphasized by the Presidential ask Force on Redening the Postpartum Visit (American College o Obstetricians and Gynecologists, 2018e). Designed to optimize postpartum care and provide contraceptive counseling, it also sets the stage or any subsequent pregnancy and or the woman’s long-term health. o assist the
provider, the American College o Obstetricians and Gynecologists (2019b) has joined the Society o Maternal–Fetal Medicine to provide an Obstetric Care Consensus guide that emphasizes the interpregnancy period.
MEDICAL HISTORY
With specic medical conditions, general points include the pregnancy’s eect on the condition and the disorder’s infuence on the etus and pregnancy course. Some chronic conditions that may worsen pregnancy outcomes include treated or active cancer, prior peripartum cardiomyopathy, antiphospholipid antibodies, systemic lupus erythematosus, and congenital heart disease (Amant, 2015; Cunningham, 2019; Davis, 2021; Foeller, 2018; Gibbins, 2018; Hopkins, 2018). Importantly, psychological health also is considered (Barker, 2020; Lassi, 2014). Detailed preconceptional inormation regarding a ew exemplary conditions is ound in the next sections and in the other topic-specic chapters o this text.
■ Diabetes Mellitus
Because maternal and etal pathology associated with hyperglycemia is well known, diabetes is the prototype o a condition or which preconceptional counseling is benecial. Diabetesassociated risks to both mother and etus are discussed in detail in Chapter 60 (p. 1068). I a patient maintains glucose levels close to normal, many o these complications can be avoided beore conception. Another important aspect o counseling pertains to the requent use o teratogenic angiotensin-converting enzyme inhibitors in this population (Podymow, 2015).
Te American College o Obstetricians and Gynecologists (2018) has concluded that preconceptional counseling or women with pregestational diabetes is benecial and costeective and should be encouraged. Te American Diabetes Association (2004) has promulgated consensus recommendations or preconceptional care or women with diabetes. Tese guidelines advise an inventory o disease duration and related complications and clinical and laboratory examination or end-organ damage. Perhaps most essential, they encourage a preconceptional hemoglobin A1c level goal below 7 percent. In addition to assessing diabetic control, hemoglobin A1c measurement can also orecast the risks or gestational diabetes and or major anomalies (Fig. 9-1) (Hinkle, 2018; Martin, 2020).
Although no randomized trials attest to the success o preconceptional counseling in women with diabetes, cohort studies do demonstrate its eectiveness (ieu, 2017). In a prospective study o 5075 aected women, preconceptional counseling improved hemoglobin A1c levels, olic acid compliance, and “optimal” pregnancy preparation (Yamamoto, 2018). Diabetic women who undergo preconceptional counseling also have improved glycemic control beore pregnancy and in the rst trimester and experience lower rates o adverse outcomes—dened as a perinatal death or major congenital anomaly (ripathi, 2010). Despite
FIGURE 9-1 Relationship between first-trimester glycosylated hemoglobin values and risk for major congenital malformations in 320 women with insulin-dependent diabetes.
such benets, in one study o approximately 300 diabetic women in a managed-care plan, only approximately hal received preconceptional counseling (Kim, 2005).
■ Epilepsy
Compared with unaected women, those with a seizure disorder carry an augmented risk o neonates with structural anomalies. Some early reports indicated that epilepsy conerred an elevated a priori risk or congenital malormations that was independent o anticonvulsant treatment eects. More recent studies have largely ailed to conrm this, but it is dicult to reute entirely because women who are controlled without medication generally have less severe disease (Cassina, 2013; Vajda, 2015). Polytherapy is associated with a higher malormation risk compared with monotherapy (Bromley, 2017). Last, in women using antiseizure medications, the risks or miscarriage and stillbirth in do not appear elevated (Aghajanian, 2015; Bech, 2014).
Ideally, medications are adjusted preconceptionally to minimize seizure requency. From one national registry, the seizure risk during pregnancy was 50 to 70 percent lower in women without a seizure in the year preceding pregnancy compared with a group experiencing seizures in this preceding year (Vajda, 2008). No urther advantages accrued i the seizure- ree period exceeded a year. reatment goals attempt to control seizure requency with monotherapy and with medications considered less teratogenic (Aguglia, 2009; omson, 2009). Discussed in Chapter 63 (p. 1129) and shown in Table 9-2, some one-drug regimens are more teratogenic than others. In particular, valproic acid is avoided i possible, as it has consistently been associated with a greater risk or major congenital malormations than other antiepileptic drugs (Jentink, 2010; Vajda, 2015). Inormation concerning the teratogenicity o newer antiepileptics is limited (Knight, 2021). Te American Academy o Neurology recommends consideration o antiseizure medication discontinuation beore pregnancy in suitable candidates (Jeha, 2005). Tese include women who satisy the ollowing criteria: (1) have been seizure- ree or 2 to 5 years, (2) display a single seizure type, (3) have a normal neurological examination and normal intelligence, and (4) show electroencephalogram results that have normalized with treatment.
Women with seizures should be advised to take a daily 4-mg oral olic acid supplement. Even so, the value o olate to reduce etal malormation rates in pregnant women taking anticonvulsant therapy is not entirely clear. In one casecontrol study, the congenital abnormality risk was reduced by maternal olate supplementation in etuses exposed to carbamazepine, phenobarbital, phenytoin, and primidone (Kjær, 2008). Conversely, Morrow and coworkers (2009) compared etal outcomes o women who received preconceptional olic 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 o major congenital malormations was observed in the group who received preconceptional olate. Tese investigators concluded that olate metabolism may be only a part o the mechanism by which malormations are induced in women taking these medications.
■ Immunizations
Preconceptional counseling includes assessment o immunity against common pathogens. Also, depending on health status, travel plans, and time o year, other immunizations may be indicated as discussed in Chapter 10 (p. 189). Several immunization resources are listed in Table 9-3. Vaccines that contain toxoids such as tetanus are suitable beore or during gestation. Also, those containing killed bacteria or viruses—such as infuenza, pneumococcus, hepatitis B, meningococcus, and rabies vaccines—are not associated with adverse etal outcomes and are not contraindicated preconceptionally or during pregnancy. Conversely, live-virus vaccines are not recommended during pregnancy. Examples are vaccines against varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow ever. Moreover,
TABLE 9-2. First-Trimester Antiepileptic Monotherapy and the Associated Major Malformation Risk Antiepileptic (n)
TABLE 9-3. Immunization Resources American College of Obstetricians and Gynecologists website: www.acog.org/programs/immunization-for-women Centers for Disease Control and Prevention website: www.cdc.gov/vaccines/hcp/ Immunization Action Coalition: www.immunize.org
1 month or longer should ideally pass between vaccination and conception attempts. Tat said, inadvertent administration o measles, mumps, rubella (MMR) or varicella vaccines during pregnancy should not generally be considered indications or pregnancy termination. Most reports indicate that the etal risk is only theoretical. Immunization to smallpox, anthrax, and other bioterrorism diseases is discussed i clinically appropriate (Chap. 67, p. 1200). With some inections, vaccines are unavailable. One recent example is the Zika virus (Brasil, 2016). For this virus, during the 2016 epidemic, the CDC issued travel advisories or pregnant women (Petersen, 2016; Schuler-Faccini, 2016).
GENETIC DISEASES
Te CDC (2016) estimates that 3 percent o neonates born each year in the United States will have at least one birth deect. Importantly, such deects are the leading cause o inant mortality and account or 20 percent o deaths. Ethics preclude randomized trials o preconceptional counseling or genetic risk (Hussein, 2018). Instead, the benets o preconceptional counseling usually are measured by comparing the incidence o new cases beore and ater initiation o such a program. Specic congenital conditions that clearly benet rom patient education include neural-tube deects, phenylketonuria, thalassemias, and other genetic diseases more common in individuals o Eastern European Jewish descent (King, 2018). Other missed opportunities or genetic consultation were ound or women with a personal or amily history o birth deects, intellectual disability or autism, and a prior positive genetic carrier screening test (McClatchey, 2018).
■ Family History
Pedigree construction using the symbols shown in Figure 9-2 is the most thorough method or obtaining a amily history as a part o genetic screening. Te health and reproductive status o each “blood relative” are individually reviewed or medical illnesses, mental retardation, birth deects, inertility,
FIGURE 9-2 Symbols used for pedigree construction.
and pregnancy loss. Certain racial, ethnic, or religious backgrounds may indicate elevated risk or specic recessive disorders. Although most women can provide inormation regarding their history, their understanding may be limited. Pregnant women may ail to communicate a birth deect in the amily or may report it incorrectly. Tus, any disclosed deect or genetic disease is ideally conrmed by reviewing pertinent medical records or by contacting aected relatives or additional inormation.
■ NeuralTube Defects
Te incidence o neural-tube deects (NDs) is 0.9 per 1000 live births, and they are second only to cardiac anomalies as the most requent structural etal malormation. Some o these malormations are associated with specic mutations. One example is the 677C → substitution in the gene that encodes methylene tetrahydroolate reductase. For this and similar gene deects, one seminal trial showed that preconceptional olic acid therapy signicantly reduced the risk or a recurrent ND by 72 percent (Medical Research Council Vitamin Study Research Group, 1991). More importantly, because more than 90 percent o neonates with NDs are born to women at low risk, Czeizel and Dudas (1992) showed that universal supplementation reduced the a priori risk o a rst ND.
Because o these ndings, all women who may become pregnant are recommended to take daily 400 to 800 μg o olic acid orally beore conception and through the rst trimester (U.S. Preventive Services ask Force, 2019). Folate ortication o cereal grains has been mandatory in the United States since 1998, and this practice has lowered neural-tube deect rates (Williams, 2015). Despite the demonstrated benets o olate supplementation, only hal o women take olic acid supplementation periconceptionally (de Jong-van den Berg, 2005; Goldberg, 2006).
■ Phenylketonuria
More than 600 mutations have been identied in the phenylalanine hydroxylase gene. Te inherited deect in phenylalanine metabolism exemplies diseases in which the etus may not be at risk to inherit the disorder but may be damaged by maternal disease. Specically, mothers with phenylketonuria (PKU) who eat an unrestricted diet have abnormally high blood phenylalanine levels. Tis amino acid readily crosses the placenta and can damage developing etal organs, especially neural and cardiac tissues.
With appropriate preconceptional counseling and adherence to a phenylalanine-restricted diet beore pregnancy, the incidence o etal malormations is dramatically reduced (Camp, 2014; Vockley, 2014). Tereore, the phenylalanine concentration is ideally brought into normal range 3 months beore conception and then maintained there throughout pregnancy (American College o Obstetricians and Gynecologists, 2020a). Te target phenylalanine blood concentration is 120 to 360 µmol/L (Camp, 2014).
■ Thalassemias
Tese disorders o globin-chain synthesis are the most common single-gene disorders worldwide (Forget, 2013; Vichinsky, 2013). As many as 200 million people carry a gene or one o these hemoglobinopathies, and hundreds o mutations are known to cause thalassemia syndromes (Chap. 59, p. 1053). In endemic areas such as Mediterranean and Southeast Asian countries, counseling and other prevention strategies have reduced the incidence o new cases by up to 80 percent (Cao, 2013).
Te American College o Obstetricians and Gynecologists (2018a) recommends that individuals o high-risk ancestry be oered carrier screening to allow them inormed decision-making regarding reproduction and prenatal diagnosis. One method o early prenatal diagnosis or some thalassemia syndromes is preimplantation genetic testing (PGT), which is coupled with assisted reproductive technology (Chap. 17, p. 348).
■ Individuals of Eastern European
Jewish Descent
Most individuals o Jewish ancestry in North America are descended rom Ashkenazi Jewish communities and are at greater risk or having ospring with one o several autosomal recessive disorders. Tese include ay-Sachs disease, Gaucher disease, cystic brosis, Canavan disease, amilial dysautonomia, mucolipidosis IV, Niemann-Pick disease type A, Fanconi anemia group C, and Bloom syndrome. Te American College o Obstetricians and Gynecologists (2017a; 2019a) recommends preconceptional counseling and screening or these disorders in this population. Carrier requency and eatures o these conditions are discussed in greater detail in Chapter 17 (p. 343).
REPRODUCTIVE HISTORY
During preconceptional screening, inormation is sought regarding inertility; abnormal pregnancy outcomes that may include miscarriage, ectopic pregnancy, molar pregnancy, and recurrent pregnancy loss; and obstetrical complications such as cesarean delivery, preeclampsia, placental abruption, and preterm delivery (Stubbleield, 2008).
As discussed in Chapter 35 (p. 626), details involving a prior stillbirth are especially important. For example, Korteweg and associates (2008) identied chromosomal abnormalities in 13 percent o stillborns who underwent karyotyping. And, Reddy and colleagues (2012) conrmed that chromosomal microarray analysis (CMA) yields better detection o genetic abnormalities than does standard karyotyping. Tis primarily stems rom CMA’s ability to assess nonviable tissue (Chap. 16, p. 325). Identication o a genetic abnormality in a stillborn can help to determine recurrence risk.
■ Maternal Age
Women at both ends o the reproductive-age spectrum have unique outcomes to consider. First, according to the CDC, 3.4 percent o births in the United States in 2010 were in women aged 15 to 19 years (Martin, 2012). An international study reported a rate o 11.9 percent or this age group globally (Althabe, 2015). Tese adolescents are at higher risk or anemia, preterm delivery, and preeclampsia compared with women aged 20 to 35 years (Usta, 2008). Te incidence o sexually transmitted diseases—common in adolescents—is even higher during pregnancy (Niccolai, 2003). Unortunately, because most o their pregnancies are unplanned, adolescents rarely seek preconceptional counseling. Conceptions ater age 35 currently constitute approximately 15 percent o pregnancies in the United States (Martin, 2012). By contrast, these women are more likely to request preconceptional counseling. Motivations may stem rom a desire to optimize outcomes at their age or with inertility treatment or both. Some studies—including data rom Parkland Hospital presented in Figure 9-3–indicate that risks or obstetrical complications and or perinatal morbidity and mortality rise ater age 35 (Waldenström, 2015). Te older woman who has a chronic illness or who is in poor physical condition usually has readily apparent risks. For the physically t woman without medical problems, however, the risks are lower.
Overall, the maternal mortality rate is higher in women aged 35 and older (Chap. 1, p. 5). Creanga and coworkers (2017) analyzed pregnancy-related deaths in the United States or 2011 through 2013. Although women older than 35 years contributed less than 15 percent o all live births, they constituted 31 percent o maternal deaths. For the etus, maternal age-related risks primarily originate rom (1) indicated preterm delivery or maternal complications such as hypertension and diabetes, (2) spontaneous preterm birth, (3) etal-growth disorders related to chronic maternal disease or multietal gestation, (4) etal aneuploidy, and (5) pregnancies resulting rom assisted reproductive technology.
Assisted Reproductive Technologies
Recall that older women have subertility problems. And, although the incidence o dizygotic twinning rises with maternal age, the more important cause o multietal gestation in older women ollows the use o assisted reproductive technology (AR) and ovulation induction. Indeed, according to the CDC, 30 to 40 percent o all multietal gestations in the United States in 2012 were conceived with the use o AR (Sunderan, 2015). Morbidity and mortality with multietal pregnancies stem rom preterm delivery and placentation complications, such as placenta previa and abruption (Qin, 2016). With AR, transmission o inectious agents is a risk. For women without human immunodeciency virus (HIV) inection who plan conception with their HIV-aected partners, the CDC has published prevention strategies (Kawwass, 2017).
Also, Zika virus inection acquisition through in vitro ertilization (IVF) has been described (Washington Cross, 2017). Last, some data links AR to higher major congenital malormation rates. In a registry o 308,974 births, 8.3 percent o neonates conceived by AR had major birth deects, and intracytoplasmic injection was also associated with an elevated risk or mal- ormations (Davies, 2012).
■ Paternal Age
Advanced paternal age has doubled in the United States over the past generation. It is associated with a higher risk o preterm birth and new autosomal-dominant mutations (Chap. 16, p. 320) (Khandwala, 2018). One example is the possible link between increasing paternal age and complex neuropsychiatric conditions (Malaspina, 2015). Parental history and experiences can also exert eects on progeny through epigenomic inormation not contained in the DNA sequence. Variations in sperm and oocyte cytosine methylation and noncoding RNAs are examples (Cedars, 2015; Lane, 2014).
SOCIAL HISTORY
■ Recreational Drugs and Smoking
Fetal risks associated with alcohol, marijuana, cocaine, amphetamines, and heroin are discussed in Chapters 8 (p. 148) and 64 (p. 1150). Te rst step in preventing drug-related etal risk is an honest assessment o use by the patient (American College o Obstetricians and Gynecologists, 2017c). oward this end, questioning should be nonjudgmental.
Several validated tools screen or at-risk drinking. One is the well-studied ACE questions (American College o Obstetricians and Gynecologists, 2019d). Tese our questions investigate having a tolerance to alcohol, being annoyed by comments about their drinking, attempting to cut down, and drinking early in the morning—the eye opener.
FIGURE 9-3 Incidence of selected pregnancy complications in relation to maternal age among 295,667 women delivered at Parkland Hospital.
O more than 1000 postpartum patients in one Canadian study, a high percentage reported alcohol use concurrent with conception attempts (ough, 2006). Specically, nearly hal o those planning or pregnancy consumed a mean o 2.2 drinks daily during early gestation and beore they recognized their pregnancy. Tis requency and pattern clearly underscore the opportunity or preconceptional counseling.
In 2014 to 2015, 17 percent o reproductive-age women in the United States smoked cigarettes according to the CDC (Robbins, 2018). Smoking in pregnancy is consistently associated with numerous adverse perinatal outcomes (Chap. 8, p. 156). Tese risks are largely mitigated by cessation beore pregnancy, highlighting the importance o screening or tobacco use prior to and during pregnancy (Chap. 10, p. 179).
■ Environmental Exposures
Only a ew environmental agents have been shown to cause adverse pregnancy outcomes (McCue, 2019; Windham, 2008). For example, contact with some chemicals may impart signicant maternal and etal risks. Discussed in Chapter 8 (p. 153), excess exposure to methyl mercury or lead is associated with neurodevelopmental disorders. For lead, the American College o Obstetricians and Gynecologists (2018b) endorses guidelines that recommend blood lead testing only i a leadexposure risk actor is identied. I the levels are >5 µg/dL, counseling is completed, and the lead source is sought and removed. Blood lead levels >45 µg/dL are consistent with lead poisoning, and women in this group may be candidates or chelation therapy (Centers or Disease Control and Prevention, 2019).
In contrast, everyday exposures to electromagnetic felds are not linked to adverse etal outcomes (Robert, 1999). Examples include energy emanated by high-voltage power lines, electric blankets, microwave ovens, and cellular phones.
■ Diet
Pica is the craving or and consuming o ice, laundry starch, clay, dirt, or other nonood items. It should be discouraged due to its inherent replacement o healthul ood with nutritionally empty products (Chap. 10, p. 191). In some cases, it may represent an unusual physiological response to iron deciency (Epler, 2017). Many vegetarian diets are protein decient but can be corrected by increasing egg and cheese consumption. Anorexia and bulimia raise maternal risks o nutritional deciencies, electrolyte disturbances, cardiac arrhythmias, and gastrointestinal pathology (American Psychiatric Association, 2013). Discussed in Chapter 64 (p. 1149), pregnancy-related complications with these eating disorders include greater risks o low birthweight, smaller head circumerence, microcephaly, and small-orgestational-age newborns. Obesity is linked with several maternal complications. Discussed in Chapter 51 (p. 905), these include hypertension, preeclampsia, gestational diabetes, labor abnormalities, cesarean delivery, and operative complications (American College o Obstetricians and Gynecologists, 2018d). Obesity also appears to be associated with a range o structural etal anomalies (Stothard, 2009).
■ Exercise
Conditioned pregnant women usually can continue to exercise throughout gestation (American College o Obstetricians and Gynecologists, 2020b). Discussed in Chapter 10, covering prenatal care (p. 187), no data suggest that exercise is harmul during pregnancy. However, as pregnancy progresses, balance problems and joint relaxation may predispose to orthopedic injury. During exercise, gravidas should avoid exhaustion, overheating, dehydration, and prolonged supine position.
■ IntimatePartner Violence
Pregnancy can exacerbate interpersonal problems and is a time o elevated risk rom an abusive partner. According to the American College o Obstetricians and Gynecologists (2012), approximately 324,000 pregnant women are abused each year. Intimate-partner violence (IPV) is associated with greater risk or several pregnancy-related complications that include hypertension, vaginal bleeding, hyperemesis, preterm delivery, and low-birthweight neonates (Chap. 50, p. 891) (Silverman, 2006). Because IPV can escalate during pregnancy, even to the point o homicide, the preconceptional period provides an ideal time or screening and intervention (Cheng, 2010). In support, the American College o Obstetricians and Gynecologists (2019c) provides recommendations and resources or screening both pregnant and nonpregnant women or IPV.
■ Lesbian, Gay, Bisexual, Transgender, and Queer Individuals
Preconceptional care has traditionally been based on the assumption o heterosexuality and has oten excluded lesbian women (Bushe, 2017). Te American College o Obstetricians and Gynecologists (2018c) endorses quality health care or all women regardless o sexual orientation. Indeed, in a study by Carpinello and colleagues (2016), three ourths o lesbian couples planned or one partner to conceive. Paradoxically, adolescent bisexual and lesbian women are at greater risk or undesired pregnancies (Charlton, 2018; Hodson, 2017). O special risks in this group, lesbian and bisexual women have higher incidences o obesity, tobacco and alcohol use, depression, diabetes, and low parity compared with heterosexual women (Mravcak, 2006; O’Hanlan, 2007). In some o these groups, knowledge o surrogacy laws is imperative (sai, 2020).
SCREENING TESTS
Highlighted in Table 9-4, women with certain chronic medical diseases ideally would be evaluated beore conception. With several o these, optimizing maternal condition will improve pregnancy outcomes.
TABLE 9-4. Selected Preconceptional Counseling Topics Condition Reference Chapter Recommendations for Preconceptional Counseling
Counsel on cardiac risks during pregnancy; discuss situations in which pregnancy is contraindicated. Optimize cardiac function. Discuss medication teratogenicity (warfarin, ACE inhibitor, ARB) and, if possible, switch to less dangerous agent when conception planned. Offer genetic counseling to those with congenital cardiac anomalies (Table 52-4, p. 920). Chronic HTN Chap. 53, p. 944 Chap. 8, p. 150
Counsel on specific risks during pregnancy. Assess those with long-standing HTN for ventricular hypertrophy, retinopathy, and renal disease. Optimize blood pressure control. Assess for teratogenic drug use.
Asthma Chap. 54, p. 960 Counsel on asthma risks during pregnancy. Optimize pulmonary function preconceptionally. Treat women with pharmacological step therapy for chronic asthma.
Thrombophilia Chap. 55, p. 976 Question for personal or family history of thrombotic events or recurrent poor pregnancy outcomes. If a thrombophilia is found or known, counsel and offer appropriate anticoagulation regimen.
Renal disease Chap. 56, p. 1003 Chap. 8, p. 150
Chronic renal disease: Counsel on specific risks during pregnancy. Optimize blood pressure control before conception. Counsel women taking ACE inhibitors and ARBs about teratogenicity.
Gastrointestinal disease Chap. 57, p. 1021 Chap. 8, p. 152
Inflammatory bowel disease: Counsel affected women on subfertility risks and risks of adverse pregnancy outcomes. Discuss teratogenicity of methotrexate and the other immunomodulators. Offer effective contraception during their use.
Hepatobiliary disease
Chap. 58, p. 1037 Hepatitis B: Vaccinate all high-risk women before conception (Table 10-7, p. 189). Counsel chronic carriers on transmission prevention to partners and fetus. Treat if indicated.
Hepatitis C: Screen high-risk women. Counsel affected women on risks of disease and transmission. If nonpregnant treatment indicated, discuss ramifications and appropriateness of pregnancy.
Hematological disease Chap. 59, p. 1048 Iron-deficiency anemia: Iron supplementation.
Sickle-cell disease: Screen all black women. Counsel those with trait or disease. Test partner if desired.
Thalassemias: Screen women of Southeast Asian or Mediterranean ancestry.
Diabetes Chap. 60, p. 1070 Optimize glycemic control to minimize teratogenicity of hyperglycemia. Evaluate for end-organ damage such as retinopathy, nephropathy, hypertension, and others. Discontinue ACE inhibitors.
Thyroid disease Chap. 61, p. 1089 Screen those with thyroid disease symptoms. Ensure iodine-sufficient diet. Treat overt hyper- or hypothyroidism. Counsel on risks to pregnancy outcome.
Connective tissue disease Chap. 62, p. 1109 Chap. 8, p. 144
Rheumatoid arthritis: Counsel on flare risk after pregnancy. Discuss methotrexate and leflunomide teratogenicity, as well as possible effects of other immunomodulators. Switch these agents before conception. Stop NSAIDs by 27 weeks’ gestation.
Lupus: Counsel on risks during pregnancy. Assess renal involvement. Optimize disease before conception. Discuss mycophenolate mofetil and cyclophosphamide teratogenicity as well as possible effects of newer immunomodulators. Switch these agents before conception. (continued)
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