Alabama COIIN Interconception Care (ICC) Diagnosis Guidelines

Counsel
Women with poor control of their asthma should use contraception until it is well controlled.
Tests
See NHLBI Guidelines for Diagnosis and Management of Asthma
Contraindicated Medications
None
Contraception
All methods considered safe

Counsel
Pregnancy is a stressor on the CV system. Discuss potential life-threatening risks especially with pulmonary hypertension. Contraception should be strongly recommended when pregnancy is contraindicated.
Tests
Consult with a cardiac specialist. See CDC Heart Disease and Stroke Prevention
Contraindicated Medications
ACE inhibitors. Coumadin beyond 6 weeks
Contraception
Avoid: estrogen containing methods See ACOG ref* for details.

Counsel
Screening prior to pregnancy allows for treatment and control of symptoms that may help prevent negative pregnancy and family outcomes.
Tests
See NIMH Women and Depression: Discovering Hope
Contraindicated Medications
Paroxetine
Contraception
All methods considered safe

Counsel
Hyperglycemia during the first trimester is a risk factor for abnormal fetal organogenesis. Stress the importance of euglycemic control before pregnancy. Convert women on oral agents to insulin before conception. High risk for neural tube defect: instruct them to take multivitamin with 400 μg of folic acid before conception.
Tests
Evidence of good glycemic control: HgbA1c < 6.5. On select women: examine for underlying vasculopathy: retinal exam by an ophthalmologist, 24-hour urine for protein and creatinine clearance, thyroid function tests, and an ECG. See ADA Standards of Medical Care in Diabetes 2012
Contraindicated Medications
ACE Inhibitors, Statins
Contraception
Avoid: estrogen containing methods in some women. See ACOG ref* for details.

Counsel
HIV may be life-threatening to the infant if transmitted. Antiretroviral therapy can reduce the risk of transmission but the risk is still ~2%.
Tests
Refer to subspecialist. See HIV/AIDS medical practice guidelines for treatment.
Contraindicated Medications
Efavienz (Sustiva®)
Contraception
See ACOG ref* for details.

Counsel
Increased maternal and fetal risk during pregnancy, especially for pre-eclampsia. Discuss importance of finding alternative to ACE inhibitor prior to pregnancy.
Tests
Women with HTN for several years should be assessed for ventricular hypertrophy, retinopathy and renal disease. Consult with a cardiac specialist. See NHLBI Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 Express)
Contraindicated Medications
ACE inhibitors
Contraception
Avoid estrogen methods in other women. See ACOG ref* for details.

Counsel
Increased risk for birth defects, spontaneous abortion, pre-eclampsia, gestational diabetes, prematurity, perinatal death, maternal death, and childhood obesity. Offer specific strategies to decrease caloric intake and increase physical activity.
Tests
Screen for diabetes with 2 hr OGTT with a 75 gram glucose load. Check blood pressure and manage appropriately. Provide nutrition and exercise counseling. Refer to NIH Health Information
Contraindicated Medications
Weight loss medications should not be used during pregnancy.
Contraception
All methods considered safe

Counsel
Counsel to achieve optimal control (serum Cr <1.4 mg/dl) of condition prior to conception. Discuss potential life-threatening risks during pregnancy. After transplant, wait 12-18 mo. And until comorbid risk factors under control (no or minimal proteinuria, absence or well-controlled HTN, stable serum Cr <1.4, no graft rejection).
Tests
Consult with renal specialist.
Contraindicated Medications
ACE inhibitors
Contraception
ee ACOG ref* for details.

Counsel
Counsel on potential effects of seizures and seizure medications on pregnancy outcomes. Counsel to take 4 mg folic acid per day at least 1 month prior to conception.
Tests
Whenever possible, monotherapy in the lowest therapeutic dose should be prescribed.
Contraindicated Medications
Valproic Acid (Depakote®)
Contraception
ee ACOG ref* for details.

Counsel
Disease should be in good control prior to pregnancy.
Tests
Evaluate renal function and for end-organ disease.
Contraindicated Medications
Cyclophosphamide
Contraception
See ACOG ref* for details.

Counsel
Proper dosage of thyroid medication prior to conception for normal fetal development. Iodine intake 150 mcg per day.
Tests
TSH < 3.0 and normal free T4 prior to pregnancy.
Contraindicated Medications
Radioactive iodine
Contraception
All methods considered safe.

Counsel
Counsel regarding risk for venous thromboembolism during pregnancy and postpartum.
Tests
Patient with history of venous thromboembolism: test for inherited thrombophillias and antiphoshpholipid syndrome
Contraindicated Medications
Coumadin beyond 6 weeks GA
Contraception
See ACOG ref* for details.

*ACOG Committee Opinion #505 Understanding and Using the U.S. Medical Eligibility Criteria for Contraceptive Use

This document should not be construed as dictating an exclusive course of treatment or procedure to be followed. Version 2 1/17/2013

Counseling and Interventions
50% of all pregnancies are unintended. Promote awareness that control over number of pregnancies and children lies with the couple. Encourage pregnancy planning with use of contraceptive method to decrease maternal and infant mortality, decrease unintended pregnancy, and prevent STI/HIV transmission. Ideal spacing of pregnancies: 18 to 24 months, gives time to replenish nutritional reserve and treat infection or other systemic illness. See ACOG #505 on Contraception Use

Counseling and Interventions
Assess BMI and use as a baseline to develop a regimen for healthy eating and physical activity to optimize weight. Encourage moderate physical activity (walking 30 min 5 days/week) into their daily routine to improve cardiovascular and weight related complications. BMI < 18.5 kg/m2: slightly greater risk for having premature, low-birthweight newborns. Screen for malnutrition/undernourishment and take measures to improve access to healthy foods. BMI > 25 kg/m2 (overweight & obese): higher risk for preterm birth. Promote dietary modification and healthy eating habits along with physical activity. See Super Tracker

Counseling and Interventions
Assess and document status of MMR, varicella, TdaP, HPV and Hepatitis B. Provide immunization as needed. Influenza vaccine is recommended annually. See CDC recommendations

Counseling and Interventions
Screen and treat chlamydia and gonorrhea in sexually active women age 25 or younger annually. Screen and treat all high risk women for chlamydia, gonorrhea, HIV, TB, syphilis, and Hepatitis B. Sexually Transmitted Diseases (STDs)

Counseling and Interventions
Cigarette smoking doubles the risk of PTB and fetal growth restriction. Initial counseling with the 5-A intervention http://www.ahrq.gov/clinic/tobacco/5steps.htm and Quitline (1-877-44U-QUIT) tools. Involving partners in smoking cessation programs can increase the number of women who quit smoking during pregnancy. Screen for exposure to environmental tobacco smoke and indoor air pollution. Screen for substance use and abuse utilizing the SBIRT tool

Counseling and Interventions
Maternal stressors such as depression, socioeconomic hardship and intimate partner violence have been linked to preterm birth. Women with psychosocial stressors have a greater likelihood of engaging in risky behavior such as smoking and alcohol use. Refer for counseling.

Counseling and Interventions
Assess parity, number of cesarean sections, prior preterm births, stillbirths, recurrent pregnancy loss, GDM, HTN, thyroid disease. Encourage spacing of pregnancies: 18 to 24 months; women with history of GDM should be screened with a 75 gm OGTT and HgbA1c every 1-3 years. Refer women with history of fetal death, infant death, preterm birth, low birth weight and very low birth weight for preconception counseling.

Counseling and Interventions
Review all medications: prescription, over the counter, and herbal therapies. Using the lowest effective dose of only necessary medications is recommended. Known or potential teratogenic medications and exposure should be addressed: warfarin, valproic acid, carbamazepine, isotretinoin, and ACE inhibitors. MotherToBaby

Counseling and Interventions
Balanced diet with appropriate distribution of the basic food groups should be promoted. All women should take a multi-vitamin with 0.4 mg (400 mcg) of folic acid daily. Women with a seizure disorder or history of neural tube defect should take 4.0 mg daily. Promote breastfeeding for 24 months. Encourage 30 minutes of moderate physical activity per day for at least 5 days per week. Weight-control Information Network

Counseling and Interventions
Screen for personal or family history of genetic disorders, congenital malformations, intellectual History disabilities and ethnicity of mother & father of the baby. Refer to geneticist if indicated.

Counseling and Interventions
Screen for household, environmental and occupational exposures. Refer women with soil and/or water Occupational Exposures hazard concerns to the local health department for soil and water testing. Refer women with household or workplace exposure concerns to an occupational medicine specialist for modification of exposures.