Preconception Care: Common Medical Problems

00:00 Hi there. I’m Dr. Veronica Gillespie and today I’ll be talking to you about preconception care.

00:07 So, let’s go through the case. "Grace is a 25-year-old gravida 0 female who presents to your office for preconception care. She and her husband are interested in conceiving in 6 to 8 months.

00:19 She has a history of asthma but has never been intubated." What advice would you give this patient to prepare for pregnancy? Well, let’s go through the lecture to see. So, after this lecture, you will be able to describe the key concepts that are related to preconception care.

00:35 So, let us first go through some terminology. You’ll need to know this to understand the other parts of the lecture. So, first, gravidity, well this is the number of times that a woman has been pregnant. Next is parity, this is the number of times that a woman has given birth. Now, this can be a little bit tricky. So, 2 things to note about this. If we have a patient that has multiples because that is only 1 pregnancy, her gravidity does not change. So, for example, a patient that gives birth to twins, her gravidity will be 1, her parity would be 2. You get it? Two children for that 1 pregnancy. Some other things to remember about parity is sometimes it can be better defined by a little acronym called TPAL. So, that’s term birth, so birth after 37 weeks; preterm birth, birth before 37 weeks; abortions, births that are before 20 weeks; and then the number of live births. So, another term is LMP or last menstrual period. You’ll see this abbreviated a lot, and last menstrual period is very important in pregnancy because it helps us to determine the gestational age. So, EDD and EDC, that’s the estimated date of delivery and the estimated date of confinement. These terms are used interchangeably and this tells us when we expect the patient to deliver, so this would be 40 weeks of pregnancy. And then GA is the gestational age. So that’s how many weeks and days a patient is pregnant throughout their pregnancy.

02:00 Again, these terms are really important as we go through the rest of the lecture. So, when we start thinking about preconception care, one of the big points that we want to make sure that our patients are aware of is folic acid. We often recommend prenatal vitamins but the big part of the prenatal vitamin that our patients need is the folic acid. It’s really important that this begins about 3 months prior to conception and folic acid is really important to prevent neural tube defects. The amount that we recommend is 400 mcg for a normal pregnancy. However, for women that have had a pregnancy that was affected by a neural tube defect or if they are taking medications that can make their folic acid lower, we expect them to take 4 mg. So, there are medical problems that we often have to address in pregnancy and the goal of preconception care is to make sure we are optimizing medical problems to decrease maternal and fetal morbidity and mortality. So, we’ll go through a couple of medical problems here. So, one of those issues that we need to address is chronic hypertension. So, it’s really important to note that in pregnancy, in the first and second trimester, blood pressure often decreases. So, for patients that are on chronic hypertension medications, they may not need them in the beginning of pregnancy, and they may need them later on in the pregnancy. Third trimester blood pressures usually go back to pre-pregnancy levels. So speaking of medications, we need to review a patient’s medications prior to pregnancy to make sure their medication is safe for pregnancy. So, for example, lisinopril.

03:35 That’s an ACE inhibitor. That can often cause renal agenesis, and so when patients come in to see us before pregnancy, we need to change them over to a medication that is safe such as labetalol, alpha methyldopa, or nifedipine. The other thing we need to make sure patients are aware of is that chronic hypertension in pregnancy increases their problems throughout the pregnancy. One notably is preeclampsia, the other is preterm labor, and especially if blood pressures are not controlled, they have an increased risk of placental abruption. So moving on from chronic hypertension to diabetes. Diabetes is a medical problem that we often have to address prior to pregnancy as well. In general, if patients have diabetes, they have a risk to the pregnancy such as congenital malformations, sacral agenesis being the most common, increased risk of pregnancy loss, increased risk of fetal macrosomia, meaning a big baby, or they can have growth restriction because diabetes can affect those vessels going to the placenta. They also have an increased risk of diabetic ketoacidosis especially if their blood sugars are not controlled and overall this increases maternal as well as perinatal morbidity and mortality. So, if we think back to the case that we had, our patient was 25 years old and she had a history of asthma, but she had never been intubated, so that is good to know that her asthma has been pretty much controlled throughout her lifetime. However, asthma is a tricky, tricky disease in pregnancy. For a third of women, their asthma gets worse in pregnancy; for a third of women, their asthma stays the same; and for a third, their asthma gets better. We don’t really know why this happens. It may have to do with the increased secretions that happen throughout pregnancy, but again this is a clinical pearl that’s important to note for women that have asthma in pregnancy.

05:27 So, going back to our patient, Grace. Remember, she’s a 25-year-old patient that’s coming in for preconception care. We need to make sure that she is taking folic acid as she is looking to conceive in 6 to 8 months and we need to address her history of asthma, making sure that she’s aware that her asthma may get worse in pregnancy, it may stay the same, and it may get better.