Preconceptional care (PCC)(The Critical role of Primary Care Physician)(The Critical role of Primary Care Physician)

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

Introduction to Primary Care

a course of the Center of Post Graduate Studies in FM

Objectives of this session

1. Overview

2. Rational of PCC.

3. Objectives of PCC.

4. PCC implementation at PHC centers.

5. Physicians' role - delivering PCC

6. Obstacles of PCC.

7. Premarital check-up

8. Woman’s role2

Birth Rate United State 13.82 births/1000 population

Saudi Arabia 28.55 births/1000 population country comparison to the world 52

Egypt 21.70 births/1000 population

United Arab Emirates 16.02 births/1000 population Japan 7.64 births/1000 population

Prematurity & Infant Mortality

United State 7 deaths/1000 live births.

Saudia Arabia 11.7 deaths / 1000 live births

United Arab Eimares 12.70 daeths / 1000 live births Egypt 27.26 dathes / 1000 live births Japan 2.4 deaths / 1000 live births

Central Intelligence Agency, The WORLD FACTBOOK

Factors Leading to Infant Mortality

Maternal health problems Smoking Age <20 or > 40 Late entry into prenatal care Education Marital status Inter-pregnancy interval

Potentially all related to

maternal health prior to maternal health prior to pregnancypregnancy

(Preconception)(Preconception)

Maternal health is a key for healthy birth of new population

Key Factors

Health status overall1. Nutrition

2. Exercise habits

3. Infection risk (immuniztion)

Specific health risks 1. Chroinc medical conditions

2. Medication

3. Tobacoo use

Preconception Care : A window of opportunity

• All women of child-bearing yrs : pre- screened for health & risk potentials before attempting to be pregnant. • A woman should visit Dr. as soon as she contemplate having child. • Optimum: 3- 6 ms before conceiving attempt This time frame allows: 1- Successful conception & pregnancy 2- any within control health risks.

PCC has been advocated as a measure to improve pregnancy outcome.

Its components parallel those of prenatal care : risk assessment, health promotion and medical & physiological interventions

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Rational of PCC

Physician’ s role : providing PCC.Woman’s role : ….

Screening tool for physicians to assess women’s health

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Objectives of PCC

In one sense, PCC can be compared to: WBC visit: a baby is screened for N. health, N. Development to identify emerging unnoticed problems in an infant. For a woman: PCC assess N. health of a child-bearing woman, to identify:

1. Existing or emerging illness or disease which may have gone undetected before

2. Existing risks for the woman who may become pregnant

3. Existing risks which may affect a fetus if the woman does become pregnant.

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Objectives of PCC

PCC can be provided most effectively as part of ongoing primary care.

Physicians can deliver PCC during visits for routine health maintenance, during

examinations for school or work, at premarital or family planning visits, after a negative

pregnancy test or during well-child care for another family member.

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PCC at PHC centers

PCC for the woman who is planning to become pregnant involves:-

Comprehensive check-listsAssessments – History & examination Screening: Investigations.

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Components of PCC

If have pre-existing diseases / medication : may add to pre-natal risks & will need

ongoing evaluation.

Prescreening check-lists : 1. Reproductive & non- reproductive systems. Covers physical & psychological aspects.2.Woman's lifestyle3.Family history information. Begins with basic information then in-depth, especially if there is previous disease/operation…..Pre-screening assessments :a Qer filled by women generally before seeing Dr –with a nurse.

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What is involved in PCC?

1. Medical conditions2. Genetic counseling3. Immunization4. Lifestyle changes5. STDs6. Medications7. Occupational exposures8. Domestic violence.

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Assess & screen for:Too numerous conditions

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Medical conditions:1. DM:

• Screen for DM and pre-diabetes.• If already diabetic --- shift to insulin Rx.

Congenital anomalies: 2-6x > offspring of DM. PCC care & good DM control their rate Recent meta analysis: lower rate among

PCC recipients (2.1%) vs non-recipients (6.5%).

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Medical conditions …

2. HT3. UTI & Renal problems4. Obesity 5. Cardiac / pulmonary problems6. Epilepsy 7. Psychological disorders8. Others ….

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Genetic counseling

PCC is ideal time: Before a couple attempts to conceive

especially if the history reveals advanced maternal age, previously affected pregnancy,

consanguinity or FH of genetic disease.

Certain ethnic groups: relative high carrier incidence for certain genetic

disorders

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Genetic counseling

1. Blood conditions caries/ disease:• Sickle cell anemia, thalasemia, G6PD

2. Cystic fibrosis3. Mental retardation condition: Screen women with a known FH of fragile

X syndrome or FH of unexplained mental retardation or for women who have learning disabilities or mental retardation.

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Immunization

PCC is ideal time: Screen for rubella immunity.Why?

Immunization: RubellaHepatitis AHepatitis BTetanusChickenpox?

Check : EIP complete? women <18 yrs.

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Lifestyle changes

Caffeine: 1 cup coffee : ~ 120 mg caffeine. 1 cup tea : ~ 40 mg caffeine. 12- oz soft drinks (cola) : ~ 45 mg caffeine.Caffeine metabolism during pregnancy esp.

with cigarette smoking. Several studies: caffeine intake ± associated

with fertility, abortion & birth wt. 5-6 mg/kg/day spread on day + no smoke

+ no alcohol : no reproductive risk.

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Lifestyle changes

Tobacco : Smoking women during pregnancy :

subjects themselves & their infants to a no. of adverse health effects.

women contemplating pregnancy should quit smoking prior to conception.

Nicotine replacement could then be prescribed.

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Lifestyle changes

Tobacco …. :

Smoking cessation before / early pregnancy : associated with improvement in maternal airway function & at infant birth wt vs among nonsmoking pregnant women.

Alcohol & illicit drugs Both a major health problem in USA. Both harm fetus. 1981- USA : women abstain drinking alcohol

during pregnancy & when plan pregnancy.

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STD & medications

STD : PCC is a good opportunity to screen for genital infections such as chlamydia, gonorrhea, syphilis and HIV.

Medications : therapeutic regimens for chronic illnesses are best modified, if possible, in PC period to include the drugs that have been used the longest & have been determined to pose the lowest risk.

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Medications

Antihypertensives: Diuretics & angiotensin-converting enzyme : should be avoided

drug of choice: methyldopa- proven maternal & fetal safety.

Anticoagulants: Warfarin C.I. Switch to heparin

Oral hypoglycemic: Switch to insulin before pregnancy.

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Occupational exposures &

Worldwide: women entry to workforce. Most women are in reproductive age

Three most common occupational hazards reported to affect pregnancy are:

Video display terminals Organic solvents Lead

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Domestic violence

Is increasingly recognized as a major public health issue.

It crosses all SE, racial, religious & educational boundaries.

Physical abuse during pregnancy : significant RF low birth wt & maternal complications.

Physicians should assess the victims & refer to local community resources.

The most common obstacle to PCC : many pregnancies are still unplanned. If birth

control methods fail, there is no opportunity for pre-screening and assessment.

The second most common obstacle : most women do not know, realize, or

understand the benefits of visiting their physician before trying to become pregnant.

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Obstacles of PPC

Most women still take for granted the biological aspects of becoming pregnant, & do not consider the extreme value of pre-screening before becoming pregnant.Most women who want & anticipate having a baby are naturally prone to thinking in terms of having a well baby. In the majority of cases, women do not think about having a baby who has any kind of problem.

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Obstacles of PPC

The third most common obstacle: the lack of health insurance. However, most insurances will cover this as a screening visit. Also, many physicians will do the pre-conception screening during a regular office visit or gynecological visit if the woman just informs the doctor of her desire to become pregnant. Most gynecologists will inquire about child-bearing intentions anyway.

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Obstacles of PPC

Premarital check up : Mandatory. For limited inherited risks ……Not enough. PPC could be provided to the

married women at the center by:- health education of the patient at PNC,

WBC, chronic disease clinic ….etc Let the patient be aware of its importance

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PPC in Saudi Arabia

A woman may need to adjust certain aspects of her health and well-being which are in her control. These usually include aspects of lifestyle, drug and alcohol use, exercise, rest and stress reduction. In addition, she may need to discontinue certain herbs or over-the-counter medications as recommended by the physician. Many physicians will also recommend pre-natal vitamins before a woman actually conceives in order to boost her overall health.

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Woman’s role

تم بحمد تم بحمد Thankاللهاللهyou

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35Module 6 - ppt 1 Dr. Maysoon Al-Amoud

MCQMCQ

1 (Birth rate is

a) Annual number of births during one year/ 1000 persons

b) Crude birth rate.

c) Usually determine the rate of population groths.

d) All of the above.

2 (Infant mortality rate

a) Number of infant deaths in one year/1000 live birth in same year.

b) Incloude toal death rate.

c) It indicate the level of health in a community.

d) All of the above.

3 (Factors NOT leading to infant mortality

a) Maternal health problems

b) Smoking

c) Age >20 or < 40

d) Late entry into prenatal care

4 (Druges that need to be chnged for safe motherhood are all EXCEPT

a) Diuretics

b) Warfarin

c) Insulin

d) angiotensin-converting enzyme

41Module 6 - ppt 1 Dr. Maysoon Al-Amoud