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 among 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.