Williams Obstetrics, 24th Edition

CHAPTER 8. Preconceptional Counseling

COUNSELING SESSION

MEDICAL HISTORY

GENETIC DISEASES

REPRODUCTIVE HISTORY

PARENTAL AGE

SOCIAL HISTORY

SCREENING TESTS

The Centers for Disease Control and Prevention defines preconceptional care as “a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management” (Johnson, 2006). The following goals were established for advancing preconceptional care:

1. Improve knowledge, attitudes, and behaviors of men and women related to preconceptional health.

2. Assure that all women of childbearing age receive preconceptional care services—including evidence-based risk screening, health promotion, and interventions—that will enable them to enter pregnancy in optimal health.

3. Reduce risks indicated by a previous adverse pregnancy outcome through interconceptional interventions to prevent or minimize recurrent adverse outcomes.

4. Reduce the disparities in adverse pregnancy outcomes.

The American College of Obstetricians and Gynecologists (2012c) also has reaffirmed the importance of preconceptional and interpregnancy care.

To illustrate potentially modifiable conditions, data that describe the health status of women who gave birth to liveborn infants in the United States in 2004 are reviewed. Table 8-1 demonstrates the high prevalence of many conditions that may be amenable to intervention during the preconceptional and interpregnancy periods (D’Angelo, 2007). To be successful, however, preventative strategies that mitigate these potential pregnancy risks must be provided before conception. By the time most women realize they are pregnant—usually 1 to 2 weeks after the first missed period—the embryo has already begun to form. Thus, many prevention strategies—for example, folic acid to prevent neural-tube defects—will be ineffective if initiated at this time. Importantly, up to half of all pregnancies are unplanned, and often these are at greatest risk (Cheng, 2009).

TABLE 8-1. Prevalence of Prepregnancy Maternal Behaviors, Experiences, Health Conditions, and Previous Poor Birth Outcomes in the United States in 2004

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Few randomized trials evaluate preconceptional counseling efficacy, in part because withholding such counseling would be unethical. Also, because pregnancy outcomes are dependent on the interaction of various maternal, fetal, and environmental factors, it is often difficult to ascribe salutary outcomes to a specific intervention (Moos, 2004). There are, however, prospective observational and case-control studies that demonstrate the successes of preconceptional counseling. Moos and coworkers (1996) assessed the effectiveness of a preconceptional counseling program administered during routine health care provision to reduce unintended pregnancies. The 456 counseled women had a 50-percent greater likelihood of subsequent pregnancies that they considered “intended” compared with 309 uncounseled women. Moreover, the counseled group had a 65-percent higher rate of intended pregnancy compared with women who had no health care before pregnancy. There are interesting ethical aspects of paternal lifestyle modification reviewed by van der Zee and associates (2013).

COUNSELING SESSION

Gynecologists, internists, family practitioners, and pediatricians have the best opportunity to provide preventive counseling during periodic health maintenance examinations. The occasion of a negative pregnancy test is also an excellent time for education. 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 affect a future pregnancy. These included medical or reproductive problems—52 percent, family history of genetic disease—50 percent, increased risk of human immunodeficiency virus infection—30 percent, increased risk of hepatitis B and illegal substance abuse—25 percent, alcohol use—17 percent, and nutritional risks—54 percent. Counselors should be knowledgeable regarding relevant medical diseases, prior surgery, reproductive disorders, or genetic conditions and must be able to interpret data and recommendations provided by other specialists. If the practitioner is uncomfortable providing guidance, the woman or couple should be referred to an appropriate counselor.

Women presenting specifically for preconceptional evaluation should be advised that information collection may be time consuming depending on the number and complexity of factors that require assessment. The intake evaluation includes a thorough review of the medical, obstetrical, social, and family histories. Useful information is more likely to be obtained by asking specific questions regarding each history and each family member than by asking general, open-ended questions. Some important information can be obtained by questionnaires that address these topics. Answers are reviewed with the couple to ensure appropriate follow-up, including obtaining relevant medical records.

MEDICAL HISTORY

With specific medical conditions, general points include how pregnancy will affect maternal health and how a high-risk condition might affect the fetus. Afterward, advice for improving outcome is provided. Detailed preconceptional information regarding a few conditions is found in the next sections as well as in the other topic-specific chapters of this text.

image Diabetes Mellitus

Because maternal and fetal pathology associated with hyperglycemia is well known, diabetes is the prototype of a condition for which preconceptional counseling is beneficial. Diabetes-associated risks to both mother and fetus are discussed in detail in Chapter 57 (p. 1125). Many of these complications can be avoided if glucose control is optimized before conception. The American College of Obstetricians and Gynecologists (2012b) has concluded that preconceptional counseling for women with pregestational diabetes is both beneficial and cost-effective and should be encouraged. The American Diabetes Association has promulgated consensus recommendations for preconceptional care for diabetic women (Kitzmiller, 2008). These guidelines advise that a thorough inventory of disease duration and related complications be obtained and clinical and laboratory examination for end-organ damage be completed. Perhaps most importantly, they encourage a preconceptional goal of the lowest hemoglobin A1c level possible without undue hypoglycemic risk to the mother. In addition to assessing diabetic control during the preceding 6 weeks, hemoglobin A1c measurement can also be used to compute risks for major anomalies (Fig. 8-1). Although these data are from women with severe overt diabetes, the incidence of fetal anomalies in women who have gestational diabetes with fasting hyperglycemia is increased fourfold compared with that in normal women (Sheffield, 2002).

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FIGURE 8-1 Relationship between first-trimester glycosylated hemoglobin values and risk for major congenital malformations in 320 women with insulin-dependent diabetes. (Data from Kitzmiller, 1991.)

Such counseling has been shown to be effective. In one review, Leguizamón and associates (2007) identified 12 studies that included more than 3200 pregnancies in women with insulin-dependent diabetes. Of the 1618 women without preconceptional counseling, 8.3 percent had a fetus with a major congenital anomaly, and this compared with a rate of 2.7 percent in the 1599 women who did have counseling. Tripathi and coworkers (2010) compared outcomes in 588 women with pregestational diabetes in whom about half had preconceptional counseling. Those women who received counseling had improved glycemic control before pregnancy and in the first trimester, had higher folate intake rates preconceptionally, and experienced lower rates of adverse outcomes—defined as a perinatal death or major congenital anomaly. These cited benefits are accompanied by reduced health-care costs in diabetic women. From their review, Reece and Homko (2007) found that each $1 expended for a preconceptional care program saved between $1.86 and $5.19 in averted medical costs. Despite such benefits, the proportion of diabetic women receiving preconceptional care is suboptimal. In their study of approximately 300 diabetic women in a managed-care plan, Kim and colleagues (2005) found that only about half had preconceptional counseling. Counseling rates are undoubtedly much lower among uninsured and indigent women.

image Epilepsy

Women who have epilepsy have an undisputed two- to threefold risk of having infants with structural anomalies compared with unaffected women (Wide, 2004). Some early reports indicated that epilepsy conferred an increased a priori risk for congenital malformations that was independent of any effects of anticonvulsant treatment. Although more recent publications have largely failed to confirm this increased risk in untreated women, it is difficult to refute entirely because women who are controlled without medication generally have less severe disease (Cassina, 2013). Fried and associates (2004) conducted a metaanalysis of studies comparing epileptic women, both treated and untreated, with controls. In this study, increased malformation rates could only be demonstrated in the offspring of women who had been exposed to anticonvulsant therapy. Veiby and coworkers (2009) used the Medical Birth Registry of Norway to compare pregnancy outcomes in 2861 deliveries by epileptic women with 369,267 control deliveries. They identified an increased malformation risk only in women who were exposed to valproic acid (5.6 percent) and polytherapy (6.1 percent). Untreated women had anomaly rates that were similar to those of nonepileptic controls.

Ideally, seizure control is optimized preconceptionally. Vajda and colleagues (2008) reported data from the Australian Register of Antiepileptic Drugs in Pregnancy. The risk of seizures during pregnancy was decreased by 50 to 70 percent if there were no seizures in the year preceding pregnancy. There were no further advantages that accrued if the seizure-free period exceeded a year.

Efforts should attempt to achieve seizure control with monotherapy and with medications considered less teratogenic (Aguglia, 2009; Tomson, 2009). As discussed in detail in Chapter 60 (p. 1190) and shown in Table 8-2, some one-drug regimens are more teratogenic than others. Valproic acid, in particular, should be avoided if possible, as this medication has consistently been associated with a greater risk for major congenital malformations than other antiepileptic drugs (Jentink, 2010). According to Jeha and Morris (2005), the American Academy of Neurology recommends consideration of antiseizure medication discontinuation before pregnancy in suitable candidates. These are women who satisfy the following criteria: have been seizure-free for 2 to 5 years, display a single seizure type, have a normal neurological examination and normal intelligence, and show electroencephalogram results that have normalized with treatment.

TABLE 8-2. First-Trimester Antiepileptic Monotherapy and the Associated Congenital Malformation Risk

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Epileptic women should be advised to take supplemental folic acid. However, it is not entirely clear that folate supplementation reduces the fetal malformation risk in pregnant women taking anticonvulsant therapy. In one case-control study, Kjær and associates (2008) reported that the congenital abnormality risk was reduced by maternal folate supplementation in fetuses exposed to carbamazepine, phenobarbital, phenytoin, and primidone. Conversely, from the United Kingdom Epilepsy and Pregnancy Register, Morrow and coworkers (2009) compared fetal outcomes of women who received preconceptional folic 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 of major congenital malformations was observed in the group who received preconceptional folate. These investigators concluded that folate metabolism may be only a part of the mechanism by which malformations are induced in women taking these medications.

image Immunizations

Preconceptional counseling includes assessment of immunity against common pathogens. Also, depending on health status, travel plans, and time of year, other immunizations may be indicated as discussed in Chapter 9 (Table 9-9p. 186). Vaccines that contain toxoids—for example, tetanus, or that consist of killed bacteria or viruses—such as influenza, pneumococcus, hepatitis B, meningococcus, and rabies—have not been associated with adverse fetal outcomes and are not contraindicated preconceptionally or during pregnancy. Conversely, live-virus vaccines—including varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow fever—are not recommended during pregnancy. Moreover, 1 month or longer should ideally pass between vaccination and conception attempts. That said, inadvertent administration of measles, mumps, rubella (MMR) or varicella vaccines during pregnancy should not generally be considered indications for pregnancy termination. Most reports indicate that the fetal risk is only theoretical. Immunization to smallpox, anthrax, and other bioterrorist diseases should be discussed if clinically appropriate (Chap. 64p. 1258). Based on their study of approximately 300 women who received smallpox vaccination near the time of conception, Ryan and colleagues (2008) found that rates of pregnancy loss, preterm birth, and birth defects were not higher than expected.

GENETIC DISEASES

The Centers for Disease Control and Prevention (2013) estimate that 3 percent of neonates born each year in the United States will have at least one birth defect. Importantly, such defects are the leading cause of infant mortality and account for 20 percent of deaths. The benefits of preconceptional counseling usually are measured by comparing the incidence of new cases before and after initiation of a counseling program. Congenital conditions that clearly benefit from patient education include neural-tube defects, phenylketonuria, thalassemias, and other genetic diseases more common in individuals of Eastern European Jewish descent.

image Family History

Pedigree construction using the symbols shown in Figure 8-2 is the most thorough method for obtaining a family history as a part of genetic screening. The health and reproductive status of each “blood relative” should be individually reviewed for medical illnesses, mental retardation, birth defects, infertility, and pregnancy loss. Certain racial, ethnic, or religious backgrounds may indicate increased risk for specific recessive disorders.

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FIGURE 8-2 Symbols used for pedigree construction. (Redrawn from Thompson, 1991.)

Although most women can provide some information regarding their history, their understanding may be limited. For example, several studies have shown that pregnant women often fail to report a birth defect in the family or they report it incorrectly. Thus, any disclosed defect or genetic disease should be confirmed by reviewing pertinent medical records or by contacting affected relatives for additional information.

image Neural-Tube Defects

The incidence of neural-tube defects (NTDs) is 0.9 per 1000 live births, and they are second only to cardiac anomalies as the most frequent structural fetal malformation (Chap. 14p. 283). Some NTDs, as well as congenital heart defects, are associated with specific mutations. One example is the 677C → T substitution in the gene that encodes methylene tetrahydrofolate reductase. For this and similar gene defects, the trial conducted by the Medical Research Council Vitamin Study Research Group (1991) showed that preconceptional folic acid therapy significantly reduced the risk for a recurrent NTD by 72 percent. More importantly, because more than 90 percent of infants with NTDs are born to women at low risk, Czeizel and Dudas (1992) showed that supplementation reduced the a priori risk of a first NTD occurrence. It is currently recommended, therefore, that all women who may become pregnant take 400 to 800 μg of folic acid orally daily before conception and through the first trimester (U.S Preventive Services Task Force, 2009). Folate fortification of cereal grains has been mandatory in the United States since 1998, and this practice has also resulted in decreased neural-tube defect rates (Mills, 2004). Despite the demonstrated benefits of folate supplementation, only half of women have taken folic acid supplementation periconceptionally (de Jong-van den Berg, 2005; Goldberg, 2006). The strongest predictor of use appears to be consultation with a health-care provider before conception.

image Phenylketonuria

This inherited phenylalanine metabolism defect exemplifies diseases in which the fetus may not be at risk to inherit the disorder but may be damaged by maternal disease. Specifically, mothers with phenylketonuria (PKU) who eat an unrestricted diet have abnormally high blood phenylalanine levels. This amino acid readily crosses the placenta and can damage developing fetal organs, especially neural and cardiac tissues (Table 8-3). With appropriate preconceptional counseling and adherence to a phenylalanine-restricted diet before pregnancy, the incidence of fetal malformations is dramatically reduced (Guttler, 1990; Hoeks, 2009; Koch, 1990). It is recommended, therefore, that the phenylalanine concentration be normalized 3 months before conception and that these levels be maintained throughout pregnancy (American College of Obstetricians and Gynecologists, 2009b).

TABLE 8-3. Frequency of Complications in the Offspring of Women with Untreated Phenylketonuriaa (Blood Phenylalanine > 1200 μmol/L)

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image Thalassemias

These disorders of globin-chain synthesis are the most common single-gene disorders worldwide. As many as 200 million people carry a gene for one of these hemoglobinopathies, and hundreds of mutations are known to cause thalassemia syndromes (Chap. 56p. 1112). In endemic areas such as Mediterranean and Southeast Asian countries, counseling and other prevention strategies have reduced the incidence of new cases by up to 80 percent (Angastiniotis, 1998). For example, more than 25,000 students of Mediterranean origin were counseled and tested for β-thalassemia during a 20-year period (Mitchell, 1996). Within a few years of program initiation, all high-risk couples who requested prenatal diagnosis had completed the program, and remarkably, there were no affected children born during this period.

The American College of Obstetricians and Gynecologists (2013b) recommends that individuals of high-risk ancestry be offered carrier screening to allow them informed decision making regarding reproduction and prenatal diagnosis. One method—preimplantation genetic diagnosis, which is discussed in Chapter 14 (p. 301)—is available for patients at risk for certain thalassemia syndromes (Chen, 2008; Kuliev, 2011).

image Individuals of Eastern European Jewish Descent

Most individuals of Jewish ancestry in North America are descended from Ashkenazi Jewish communities and are at increased risk for having offspring with one of several autosomal recessive disorders. These include Tay-Sachs disease, Gaucher disease, cystic fibrosis, Canavan disease, familial dysautonomia, mucolipidosis IV, Niemann-Pick disease type A, Fanconi anemia group C, and Bloom syndrome. The American College of Obstetricians and Gynecologists (2009c) recommends preconceptional counseling and screening for these in this population. Carrier frequency and features of these conditions are discussed in Chapter 14 (Table 14-11p. 298).

REPRODUCTIVE HISTORY

During preconceptional screening, information should be sought regarding infertility; abnormal pregnancy outcomes that may include miscarriage, ectopic pregnancy, and recurrent pregnancy loss; and obstetrical complications such as preeclampsia, placental abruption, and preterm delivery (Stubblefield, 2008). As discussed in Chapter 35 (p. 664), details involving a prior stillbirth are especially important. For example, Korteweg and associates (2008) identified chromosomal abnormalities in 13 percent of stillborns who underwent karyotyping. More recently, Reddy and colleagues (2012) confirmed that chromosomal microarray analysis yielded better detection of genetic abnormalities than did standard karyotyping, primarily because nonviable tissue can be used for the analysis. Identification of a genetic abnormality in stillborns can help determine the recurrence risk and aid in the preconceptional or prenatal management in subsequent pregnancies.

PARENTAL AGE

image Maternal Age

Women at both ends of the reproductive-age spectrum have unique outcomes to be considered. First, according to the Centers for Disease Control and Prevention, in 2010, 3.4 percent of births in the United States were in women between the ages of 15 and 19 years (Martin, 2012). This rate represents a historical low in the United States for teenage births with a 45-percent decline since 1991. That said, adolescents are at increased risk for anemia, preterm delivery, and preeclampsia compared with women aged 20 to 35 years (Usta, 2008). The incidence of sexually transmitted diseases—common in adolescents—is even higher during pregnancy (Niccolai, 2003). Unfortunately, because most of their pregnancies are unplanned, adolescents rarely seek preconceptional counseling.

In contrast, conceptions after age 35 currently comprise approximately 15 percent of pregnancies in the United States (Martin, 2012). The older woman is more likely to request preconceptional counseling, either because she has postponed pregnancy and now wishes to optimize her outcome, or because she plans to undergo infertility treatment. Some studies—including data from Parkland Hospital presented in Figure 8-3—indicate that after age 35, there is an increased risk for obstetrical complications as well as perinatal morbidity and mortality (Cunningham, 1995; Huang, 2008). The older woman who has a chronic illness or who is in poor physical condition usually has readily apparent risks. For the physically fit woman without medical problems, however, the risks are much lower than previously reported.

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FIGURE 8-3 Incidence of selected pregnancy complications in relation to maternal age among 295,667 women delivered at Parkland Hospital, 1988–2012. (Courtesy of Dr. Donald McIntire.)

Overall, the maternal mortality rate is higher in women aged 35 and older (Chap. 1p. 5). Compared with women in their 20s, women aged 35 to 39 are 2.5 times more likely and women aged 40 or older are 5.3 times more likely to suffer pregnancy-related mortality (Geller, 2006). According to Buehler and coworkers (1986), improved medical care may ameliorate these risks. They reviewed maternal deaths in the United States from 1974 through 1982. Through 1978, older women had a fivefold increased relative risk of maternal death compared with that of younger women. By 1982, however, the mortality rates for older women had decreased by 50 percent.

For the fetus, maternal age-related risks primarily stem from: (1) indicated preterm delivery for maternal complications such as hypertension and diabetes, (2) spontaneous preterm birth, (3) fetal-growth disorders related to chronic maternal disease or multifetal gestation, (4) fetal aneuploidy, and (5) pregnancies resulting from assisted reproductive technology.

Assisted Reproductive Technologies

Recall that older women have subfertility problems. And although the incidence of dizygotic twinning increases with maternal age, the more important cause of multifetal gestation in older women follows the use of assisted reproductive technology (ART) and ovulation induction. Indeed, according to the Centers for Disease Control and Prevention, 40 percent of all multifetal gestations in the United States in 2005 were conceived with the use of ART (Martin, 2010). Multifetal pregnancies account for much of the morbidity and mortality from preterm delivery. Other obstetrical morbidities, such as placenta previa and abruption, are also risks associated with ART (Fong, 2014).

During the past decade, experience has accrued that links ART to increased major congenital malformation rates. Davies and colleagues (2012) reported that of 308,974 births in South Australia, 8.3 percent of infants conceived by ART had major birth defects. In this analysis, after adjustment for maternal age and other risk factors, intracytoplasmic injection continued to be associated with a significantly increased risk for malformations, but in vitro fertilization did not.

image Paternal Age

Although there is an increased incidence of genetic diseases in offspring caused by new autosomal-dominant mutations in older men, the incidence is still low (Chap. 13p. 270). Accordingly, targeted sonographic examination performed solely for advanced maternal or paternal age is controversial.

SOCIAL HISTORY

image Recreational Drugs and Smoking

Fetal risks associated with alcohol, marijuana, cocaine, amphetamines, and heroin are discussed in Chapter 12 (p. 253). The first step in preventing drug-related fetal risk is for the woman to honestly assess her use. Questioning should be nonjudgmental. Screening for at-risk drinking can be accomplished using a number of validated tools, like the well-studied TACE questions (American College of Obstetricians and Gynecologists, 2013a). This is a series of four questions concerning tolerance to alcohol, being annoyed by comments about their drinking, attempts to cut down, and a history of drinking early in the morning—the eye opener.

In a Canadian study of more than 1000 postpartum patients, Tough and coworkers (2006) found that a high percentage of women reported alcohol use concurrent with conceptional attempts. Specifically, nearly half of those planning for pregnancy reported a mean of 2.2 drinks daily during early gestation before they recognized their pregnancy. Of note, Bailey and associates (2008) found that rates of binge drinking and marijuana use by men were unaffected by their partner’s pregnancy. The frequency and pattern of such behaviors clearly underscore the opportunity for preconceptional counseling.

In 2005, approximately 14 percent of women giving birth in the United States smoked cigarettes (Tong, 2009). This practice has been consistently associated with numerous adverse perinatal outcomes. These risks are largely mitigated by cessation before pregnancy, highlighting the importance of screening for tobacco use in the preconceptional period and during prenatal care as outlined in Chapter 9 (p. 172).

image Environmental Exposures

Contact with environmental substances is inescapable. Thus, it is fortunate that only a few agents have been shown to cause adverse pregnancy outcomes (Windham, 2008). Exposures to infectious diseases have myriad deleterious effects, and these are detailed in Chapters 64 and 65 (p. 1239). Likewise, contact with some chemicals may impart significant maternal and fetal risks. As discussed in Chapters 8 and 12 (pp. 183 and 250), excess exposure to methyl mercury or lead is associated with neurodevelopmental disorders.

In the past, some concerns were raised over common everyday exposure to electromagnetic fields such as emanated by high-voltage power lines, electric blankets, microwave ovens, and cellular phones. Fortunately, there is no human or animal evidence that any of these cause adverse fetal effects (O’Connor, 1999; Robert, 1999). The effects of electrical shock are discussed in Chapter 47 (p. 956).

image Diet

Pica is the craving for and consuming of ice, laundry starch, clay, dirt, or other nonfood items. It should be discouraged due to its inherent replacement of healthful food with nutritionally empty products (Chap. 9p. 188). In some cases, it may represent an unusual physiological response to iron deficiency (Federman, 1997). Many vegetarian diets are protein deficient but can be corrected by increasing egg and cheese consumption. Anorexia and bulimiaincrease maternal risks of nutritional deficiencies, electrolyte disturbances, cardiac arrhythmias, and gastrointestinal pathology (Becker, 1999). With these, pregnancy-related complications include greater risks of low birthweight, smaller head circumference, microcephaly, and small for gestational age (Kouba, 2005).

In contrast, obesity is linked with several maternal complications. As discussed in Chapter 48 (p. 965), these include hypertension, preeclampsia, gestational diabetes, labor abnormalities, cesarean delivery, and operative complications (American College of Obstetricians and Gynecologists, 2013c). Obesity also appears to be associated with a range of structural fetal anomalies (Stothard, 2009). By comparing changes in prepregnancy body mass index (BMI), Villamor and Cnattingius (2006) found that modest increases in BMI before pregnancy could result in perinatal complications, even if a woman does not become overweight.

image Exercise

Conditioned pregnant women usually can continue to exercise throughout gestation (American College of Obstetricians and Gynecologists, 2009a). As discussed in Chapter 9 (p. 182), there are no data to suggest that exercise is harmful during pregnancy. One caveat is that as pregnancy progresses, balance problems and joint relaxation may predispose to orthopedic injury. A woman should be advised not to exercise to exhaustion, and she should augment heat dissipation and fluid replacement. Further avoidances include supine positions, activities requiring good balance, and extreme weather conditions.

image Intimate Partner Violence

Pregnancy can exacerbate interpersonal problems and is a time of increased risk from an abusive partner. According to the American College of Obstetricians and Gynecologists (2012a), approximately 324,000 pregnant women are abused each year. As discussed in Chapter 47 (p. 951), intimate partner violence has been associated with an increased risk for several pregnancy-related complications, including hypertension, vaginal bleeding, hyperemesis, preterm delivery, and low-birthweight infants (Silverman, 2006). Because domestic violence can escalate during pregnancy, even to the point of homicide, the preconceptional period provides an ideal time for screening, and if indicated, intervention (Cheng, 2010). As outlined in Chapter 9 (p. 174), the American College of Obstetricians and Gynecologists (2012a) has provided recommendations and resources for screening both pregnant and nonpregnant women for domestic violence.

SCREENING TESTS

Certain laboratory tests may be helpful in assessing the risk for and preventing some complications during pregnancy. These include basic tests that are usually performed during prenatal care and are discussed in Chapter 9. More specific tests may assist evaluation of women with certain chronic medical diseases. Examples of some, but certainly not all, chronic diseases that ideally would be assessed before conception are highlighted in Table 8-4. With several of these, optimizing maternal condition before conception will improve pregnancy outcomes. Cox and coworkers (1992) reviewed pregnancy outcomes in 1075 high-risk women who received such evaluation. They reported that the 240 women with hypertension, asthma, or renal, thyroid, or cardiac disease had better outcomes compared with the outcomes from their previous pregnancies.

TABLE 8-4. Selected Preconceptional Counseling Topics

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