professor of women’s health · ben-shlomo y, kuh d. (2002) a life course approach to chronic...
TRANSCRIPT
Jill Shawe
Professor of Women’s Health
Director of The Institute of Health and
Community
University of Plymouth
Summary
• Introduction and background to Preconception Care
• PREPARE - Programme of Research and Education in Preconception Care
Prof Jill ShaweDr Kath HartDr Ann RobinsonDr Martin WhyteDr Debbie CookeDr Marianne ColemanMarie McCormack
Professor Jane OgdenProfessor Christopher Pring
PrePreg Network
Doctoral Students: Chidi Nwolise, Marie McCormack, Fiona McGregor, Sarah Bolger, Amanda Bye, Bola Grace
Aim
To improve maternal & paternal health & pregnancy outcomes through collaborative
research with health professionals and service users.
Preconception Health
A set of interventions and/or programmes that aims to:
Identify and enable informed decision-making to modify biomedical, behavioural, and (psycho-) social risks to parental health and the health of their future child.
By counselling, prevention and management, emphasizing those factors that must be acted on before conception and in early pregnancy, to have maximal impact and/or choice.
Temel S, van Voorst SF, de Jong-Potjer LC, Waelput AJ, Cornel MC, de Weerd SR, et al. The Dutch national summit on
preconception care: a summary of definitions, evidence and recommendations. J Community Genet. 2015;6:107–15.
Preconception/Interconception careA Paradigm for Maternal, Child & Family Health
Preconception
Care
Child
Health
Neonatal
Care
Healthy
Sexual Life,
Education
Antenatal
Care
Perinatal
Care
Life Course Perspective
• Fetal Origins of Adult Disease (FOAD) & Epigenetic research shows lifestyle, environmental and societal factors can influence the health of future generations.
Gluckman PD et al. (2009) Epigenetic mechanisms that underpin metabolic and cardiovascular diseases. Nat Rev Endocrinol
Hanson M et al (2009). BMA Board of Science. Early life nutrition and lifelong health. British Medical Association.
Eriksson J G. (2005) The fetal origins hypothesis—10 years on. BMJ
Ben-Shlomo Y, Kuh D. (2002) A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and
interdisciplinary perspectives. Int J Epidemiol
Barker D J (1990) The fetal and infant origins of adult disease. BMJ
Physical and social
exposures in utero,
childhood and adult life
affect health and onset of
disease across the life
course and generations.
Barker DJP. Mothers, Babies and Health in Later Life. Edinburgh: Churchill Livingstone, 1998.
• Period before conception is seen as a critical period
WHO Global Action Plan for Prevention & Control of Non-communicable Diseases 2013-2020.
• Pregnancy acts as early ‘stress test’ for future disease risk
• Highlights potential for early intervention
Epigenetics
‘Reversible, heritable changes in gene regulation that occur without a change in
DNA sequences’
Överkalix Study
Cohort born in 1890,
1905, 1920 and their
1,818 children and
grandchildren.
Lalande, M. (1996)
Dutch Hungerwinter1944-45
.Northstone et al 2014 ‘Prepubertal start of father’s smoking and increased body
fat in his sons: further characterisation of paternal transgenerational responses’
European Journal of Human Genetics
First 56 Days - The Embryonic Period
Cell divisions, movement and
differentiation occur and most of the organ
systems are established
http://www.ehd.org/virtual-human-embryo/movie.php?stage=23&movie=18
This phase of pregnancy is
very vulnerable
Risk Identification
Age
Contraceptive use
Weight
Drugs
Smoking
Alcohol
Immunisations
Infections
Medical Conditions
Occupational hazard review.
Genetics
Folic acid / supplements
Photography - Anne Geddes
Obesity Complications in Pregnancy
Maternal
• Fertility issues
• Hypertensive Disorders of Pregnancy
• GDM
• Prolonged/Post term Pregnancy
Intrapartum
• Dysfunctional Labour
• Shoulder Dystocia
• Caesarean Delivery
• Wound Complications
• Haemorrhage
Neonatal
• Miscarriage
• Stillbirth
• Birth Defects
• Preterm Delivery
• Macrosomia
CMACE / RCOG (2010) Management of Women with Obesity in Pregnancy.
Https://www.rcog.org.uk/globalassets/documents/guidelines/cmacercogjointguidelinemanagementwomenobesitypregnancya.pdf
BMI >30
Hibbard ED, Smithells RW. Folic acid metabolism and human embryopathy. Lancet 1965
Smithells RW, Shephard S, Schorah CJ, et al. Possible prevention of neural-tube defects by
periconceptional vitamin supplementation. Lancet 1980
Medical Research Council. Prevention of neural tube defects: results of the Medical Research
Council Vitamin Study. MRC Vitamin Study Research Group. Lancet 1991
Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional
vitamin supplementation. N Engl J Med 1992.
>72% Protective effect
Prevention of Neural tube defects
Folic Acid
Vitamin B9Low Risk:
400 microgrammesper day
High risk:
5 milligrammesper day
(MRC 1991)
Smoking• Miscarriage• Still birth• Ectopic pregnancy• Obstetric complications• Preterm birth• Low birth weight• Otitis media as child• Asthma as child• Optic Nerve damage
NICE 2012 Pre-conception – advice & management https://cks.nice.org.uk/pre-conception-advice-and-management
Alcohol
• Avoid alcohol
• Not more than 1-2 units once or
twice a week
• No binge drinking
NICE 2012 Pre-conception – advice & management https://cks.nice.org.uk/pre-conception-advice-and-
management
Dental Health
Maternal periodontal disease is associated with
preterm birth, development of preclampsia and small
for dates babies
Govindaraju P et al J Indian Soc Periodontol. 2015 Sep-Oct; 19(5): 512–515.
Infections/ Vaccinations
• Zika Virus
• Toxoplasmosis
• Sexual Infections
• Varicella
• Rubella
• Hepatitis B
Women with Chronic Medical Conditions
• Obesity • Cystic Fibrosis• Diabetes• Epilepsy• Depression• Bipolar disorder• Eating disorders• Renal disease• Rheumatoid Arthritis
• Thyroid disease• PKU• Cardiac conditions • Hypertension• Asthma• Thalassemia• Sickle cell disorder• Tay Sachs Disease
Stillbirths 4.7 x risk
Death of baby in first four weeks 2.6 x risk
Major congenital anomaly 2 x risk
(Confidential Enquiry into Maternal and Child Health (CEMACH) 2005/2007. CMACE 2014)
Prescription for 5mg Folic acid daily
Increased risks for babies
of women with diabetes
Medications
• Isotretinolins – Roacutaine
• Anti hypertensives – Ace Inhibitors
• Anti depressants
• Medications for Epilepsy
• HIV medication
• Anti malarial medication
Dunlop et al 2008 The clinical content of preconception care :the use of medications and supplements
among women of reproductive age. ACOG
Pre-pregnancy genetic tests backed by Human Genetics Commission
Report:
Increasing options,Informing choice
HGC April 2011
All couples should be allowed to be
screened to see if they could pass on
diseases like cystic fibrosis, the Human
Genetics Commission has said.’
Pre-pregnancy Care for Men
• Healthy weight
• Exercise
• Stop smoking / No recreational drugs/Alcohol.
• Medical conditions & medications
• Occupational hazards
• STI screen
• Keep ‘cool’ • Sperm & Lubes
Pre-Pregnancy Health and Care in England: Exploring Implementation and Public Health Impact
• 2/3rds of women do plan their pregnancies.
• Knowledge of preconception care by women, partners and health professionals is lacking.
Preconception Research
• European Projects PrePreg network
• Mobile App - PADI
• Smarter Pregnancy UCL
• PARTNERS project
• Retinal Screening project
Pregnancy after Bariatric Surgery
• Young people Bariatric Surgery
& Reproductive Health
• NBSR data analysis
• GDM screening
• Contraception after Bariatric Surgery
Mobile Apps
• Mobile App - Preconception and Diabetes Information (PADI)
• Smarter Pregnancy App
PARTNERS project
PARents Together in Nutrition Exercise inteRconception Study
PREPARE GroupRecent papers
University of Surrey PREPARE Group
with
Western Sussex Hospitals NHS Foundation Trust
Homerton University Hospital
Observational Prospective Multicentre Cohort Study of micronutrient & ovulatory outcomes of women aged 18-45 undergoing Bariatric Surgery
What are the optimal physiological, nutritional, psychological and behavioural conditions necessary to ensure healthy pregnancy in women aged 18-45years
who have had bariatric surgery?