1: Patient Care
5 Topics
2: Normal Obstetrics
7 Topics
3: Abnormal Obstetrics
13 Topics
4: General Gynecology
8 Topics
7: Neoplasia
6 Topics
Preconception Care
Duration = 8:16
00:00
APGO educational topic number nine
00:02
preconception care meet our patient
00:04
young reproductive aged she is a common
00:07
patient in all medical and surgical
00:09
scenarios it is always important to
00:11
consider the likelihood of pregnancy in
00:13
all of our reproductive aged patients
00:15
the objectives of this video are to
00:17
describe how certain medical conditions
00:19
affect pregnancy to describe how
00:21
pregnancy affects certain medical
00:22
conditions to assess a patient’s genetic
00:24
risk as well as a father’s genetic risk
00:26
with regards to pregnancy to describe
00:28
genetic screening options in pregnancy
00:30
to recognize a patient’s risk of
00:32
substance abuse and intimate partner
00:34
violence and explain how this would be
00:35
addressed for the patient to appraise a
00:37
patient’s nutritional status and make
00:39
recommendations to the patient on
00:40
nutrition and exercise to assess a
00:42
patient’s medications immunizations and
00:45
environmental hazards in pregnancy to
00:47
identify appropriate folic acid intake
00:49
and to identify ethical issues
00:51
associated with prenatal genetic
00:52
screening and diagnostic tests many of
00:55
our patients see their obstetrician
00:56
gynecologist when they are already
00:57
pregnant in a perfect world miss young
01:00
would come in for a preconception
01:01
counseling visit before she became
01:03
pregnant especially if she has
01:04
pre-existing medical conditions such as
01:06
diabetes why is this important let’s
01:09
look at fetal malformation rates and
01:11
their relationship to maternal
01:12
hemoglobin a1c levels at a hemoglobin
01:15
a1c level of less than 7 the fetal
01:17
malformation rate is the same as
01:18
baseline at seven point two to nine
01:21
point one there is a 14% rate at nine
01:23
point two to eleven point one there’s a
01:25
twenty three percent rate and if the
01:27
hemoglobin a1c is greater than eleven
01:29
point two there’s a 25% fetal
01:31
malformation rate of the diabetic
01:33
related fetal malformations cardio
01:35
vascular malformations are the most
01:37
common followed by central nervous
01:38
system than gastrointestinal
01:40
genitourinary and skeletal malformations
01:43
in addition if a diabetic woman’s
01:46
hemoglobin a1c level is 11 there is a
01:48
44% miscarriage rate remember that organ
01:52
formation occurs at approximately 3 to
01:54
10 weeks estimated gestational age and
01:56
fewer than 30% of diabetic women seek
01:59
preconception counseling a savvy
02:01
endocrinologist or primary care doctor
02:04
should therefore always talk to their
02:05
young reproductive age women about
02:07
contraception and risk of pregnancy
02:08
especially if glucose control as an
02:10
issue if young came in for a
02:12
preconception counts
02:13
visit what should we address if she has
02:15
medical issues we need to talk about
02:17
optimizing control of the disease
02:19
processes let’s start by discussing
02:21
systemic lupus erythematosus SLE ideally
02:25
pregnancy should occur during a period
02:26
of disease quiescence for at least six
02:29
months prior to conception if her SLE is
02:32
active at the time of conception this is
02:34
a strong predictor of adverse maternal
02:36
and obstetric of complications all of
02:38
her SLE medications need to be reviewed
02:40
and adjusted prior to conception with
02:43
the goal of maintaining disease control
02:44
while maximizing safety profiles
02:46
preconception counseling with SLE is
02:48
thus especially important next let us
02:51
discuss if young had hypertension there
02:54
are several key issues pertaining to
02:55
hypertension and pregnancy planning
02:57
first blood pressure classifications we
02:59
classify hypertensive pregnant women
03:01
into three classes normal with blood
03:03
pressures less than 140 over 90 mild to
03:06
moderate hypertension with systolic’s of
03:08
140 to 159 over a diastolic of 90 over
03:11
109 and severe hypertension is greater
03:14
than a systolic of 160 and a diastolic
03:16
of 90 we know that treating severe
03:19
hypertension leads to a reduction in
03:20
stroke risk there is an unclear benefit
03:23
of treating mild to moderate
03:24
hypertension for there needs to be a
03:26
balance for lowering maternal blood
03:27
pressure too much reduces placental
03:29
perfusion the medication classifications
03:32
of ACE inhibitors angiotensin ii
03:34
receptor blockers and direct renin
03:36
inhibitors are contraindicated during
03:38
all stages of pregnancy methyl dopa and
03:41
labetalol are safe and commonly used
03:43
during pregnancy pre pregnancy
03:45
hypertension otherwise known as chronic
03:47
hypertension is associated with greater
03:48
risks during pregnancy of superimposed
03:51
preeclampsia placental abruption and
03:53
fetal growth restriction if young has
03:56
diabetes in addition to the fetal issues
03:58
we discussed earlier in this video
04:00
pregnancy has been associated with
04:01
exacerbation of many disease related
04:03
complications poorly controlled pre
04:06
gestational diabetes can lead to serious
04:08
and organ damage that could become
04:09
eventually life-threatening for example
04:11
diabetic nephropathy diabetic
04:13
retinopathy and chronic hypertension the
04:16
good news is that perinatal mortality
04:18
has decreased markedly in recent years
04:20
because of the ability to achieve
04:22
glucose control with medical therapy
04:24
either with insulin or oral hypoglycemic
04:27
agents
04:27
going back to our preconception
04:29
counseling checklist we have discussed
04:31
some key medical issues that should be
04:32
discussed what else should we talk about
04:34
infectious disease issues vaccines live
04:38
vaccines cannot be administered during
04:39
pregnancy so the preconception
04:41
counseling visit is an ideal time to
04:43
offer vaccinations for a rare Acela and
04:45
our rubella if a woman is not immune in
04:47
addition consider the pertussis and
04:49
hepatitis B vaccines additional
04:52
screening issues to consider would be
04:54
HIV all pregnant women and women
04:56
planning a pregnancy should be counseled
04:58
about being tested for HIV
04:59
in addition screen for other sexually
05:01
transmitted diseases also a woman who
05:04
are trying to conceive should minimize
05:05
exposure to outdoor cat feces secondary
05:07
to the risk of exposure to toxic
05:09
plasmosis
05:09
during the preconception counseling
05:11
visit we should also discuss genetic
05:13
screening the genetic disorders are
05:15
based on the ethnic and racial
05:17
background of our patients sickle
05:19
hemoglobin appa these are more common in
05:20
African descent beta thalassemia is a
05:22
more common and Mediterranean Southeast
05:24
Asian and African descent and alpha
05:26
thalassemias are more common in
05:28
Southeast Asian Mediterranean and
05:30
African descent tay-sachs disease is
05:32
more common in Ashkenazi Jewish French
05:34
Canadians and Cajun descent Canavan
05:37
disease and familial dysautonomia are
05:39
more common in Ashkenazi Jewish descent
05:41
and cystic fibrosis is more common in
05:43
Caucasians of European and Ashkenazi
05:46
descent let’s discuss what would happen
05:48
if young tested positive for one of
05:50
these genetic disorders for example
05:51
cystic fibrosis
05:53
since cystic fibrosis is an autosomal
05:56
recessive disorder and we find that she
05:58
is a carrier denoted here with a capital
06:00
C lowercase C then the next step is to
06:02
test the father and the baby for cystic
06:04
fibrosis
06:04
if young is already pregnant it is
06:06
important to have a private conversation
06:08
with her to confirm the paternity of the
06:10
pregnancy if the father of the baby also
06:12
tests positive as a carrier for cystic
06:14
fibrosis so both parents are carriers
06:16
big C little C then 1/4 of their future
06:19
pregnancies would have a chance of
06:21
inheriting both genes little C little C
06:23
and would thus be affected with cystic
06:25
fibrosis
06:26
if preconception testing reveals that
06:28
young and her partner are both carriers
06:29
then one of their options is
06:31
pre-implantation genetic diagnosis this
06:34
is a process by which in vitro
06:35
fertilization is used to create an
06:37
embryo and then this embryo can be
06:39
tested for cystic fibrosis prior
06:41
to being implanted alternatively young
06:43
honor partner can conceive naturally and
06:45
the fetus can be tested for cystic
06:47
fibrosis with a chorionic villus
06:49
sampling or amniocentesis procedure this
06:52
can lead to very wrenching decisions for
06:54
parents about whether to carry or
06:55
terminate a pregnancy if the fetus is
06:57
found to be affected continuing to move
07:00
down our preconception counseling visit
07:02
checklist folic acid supplementation all
07:04
pregnant women and women trying to
07:06
conceive should take at least 0.4
07:08
milligrams of folic acid daily and women
07:11
should take 4 grams daily if they have
07:13
had a prior neural tube defect affected
07:15
pregnancy let’s now discuss the
07:17
importance of intimate partner violence
07:18
screening intimate partner violence is
07:21
estimated to affect as many as 324,000
07:24
pregnant women per year there is a
07:26
growing body of research on the
07:28
connection between relationship violence
07:29
and poor reproductive health care
07:31
outcomes for women before and during a
07:34
pregnancy are opportunities for the
07:35
patient to begin developing trust with a
07:37
health care provider lastly we will
07:40
conclude the discussion about
07:41
preconception counseling with the topics
07:43
of nutrition and obesity counseling
07:45
women about the importance of exercise
07:47
and balanced nutrition and the
07:49
preconception time can lead to healthier
07:51
habits that can be more easily adapted
07:52
during pregnancy and the postpartum time
07:54
this concludes the aapko video on
07:57
preconception care we have reviewed many
07:59
aspects of preconception counseling and
08:01
the importance are trying to optimize a
08:02
woman’s health for pregnancy and beyond