Keywords
preconception counseling - MFM - maternal-fetal medicine - conception - prenatal
Preconception care is aimed at optimizing women's health prior to pregnancy to achieve
the ideal safety and well-being of the woman, fetus, and neonate.[1] The objective of preconception counseling is to educate women on how best to achieve
a healthy pregnancy by addressing current health issues and modifiable risk factors
so that the patient may experience the safest possible pregnancy while reducing the
risk of adverse events for the fetus and neonate.[2] Education is a crucial component to achieving health before and through pregnancy
and is a cornerstone of preconception counseling.[3]
Research has suggested that access to preconception care increases favorable birth
outcomes through health maintenance and education.[4] The American College of Obstetrics and Gynecology provides guidelines for preconception
which are aimed at improving pregnancy outcomes for all women, but especially those
considered to be at high risk for pregnancy, delivery, and child complications.[2] While some aspects of preconception care are based on research findings, many women
do not access this care[5] and little work has been done to specifically examine how preconception care is
implemented, how well advice is followed, and ultimately whether care or specific
aspects of care improve specific outcomes.[6]
[7]
[8]
[9]
Most of the published literature about preconception care has focused either on preconception
care as part of primary care[9]
[10] or various aspects of preconception recommendations in respect to specific disease
states,[11]
[12] with little focused on specifically addressing the characteristics and outcomes
of the spectrum of care provided by Maternal-Fetal Medicine (MFM) specialists. MFM
practice provides care for high-risk pregnancies and conditions ranging from systemic
lupus erythematosus to patients with a history of gestational diabetes or hypertension,
as well as providing guidance to women with prior poor pregnancy outcomes.[13] Preconception care in the primary care setting is crucial for many women to achieve
healthy pregnancies, but there is little information on how to optimize the expertise
of MFM physicians in the management of more typical high-risk patients or for women
seeking preconception counseling for other reasons.
The aim of this retrospective study was to evaluate the conditions for which preconception
services are provided and what specific services and recommendations are offered through
the MFM group at the University of Colorado (CU). The study sought to determine how
services and recommendations differ by maternal condition, demographics, and reproductive
health history.
Methods
Electronic medical records (EMRs) were used to identify women who received preconception
care at the University of Colorado Maternal-Fetal Medicine Preconception Clinic between
January 2018 and December 2018. Fifty-nine women were determined to have preconception
counseling listed as a chief compliant or reason for the clinic visit during this
date range, making them eligible for this retrospective study.
A chart review was conducted on each study participant by a single individual (K.B.)
using an EMR system. The primary location of patient information within the EMR was
the preconception visit notes. The visit notes recorded the recommendations made by
the provider, any laboratory tests or imaging advised, as well as information on results
and referrals made. Information about the patient's obstetrical history, including
the outcomes of all previous pregnancies and the well-being of the patient during
the pregnancy was also collected, if available. This included any pregnancies that
occurred during the 12 months following the original preconception counseling visit.
When available, demographics, gynecologic/obstetric (OB) history, general health history,
medications, immunizations, substance use, and mental/social/family history were collected
on each patient and recorded in a secure REDCap database. Data on general health/medical
history were collected and included a positive history of any of the following: polycystic
ovary syndrome, asthma, diabetes mellitus (types I or II), chronic hypertension, systemic
lupus erythematosus, irritable bowel disease, cancer, thyroid disorders, depression,
anxiety, bipolar, deep vein thrombosis/pulmonary embolism, eating disorders, and previous
surgical history.
Reasons patients were referred to preconception counseling fell into five main categories
based on the presence of diagnoses in the patients' EMR: (1) maternal disease, (2)
infertility, (3) previously poor OB outcomes, (4) advanced maternal age (AMA), and
(5) gynecologic anatomical abnormality. Patients were often referred to counseling
for more than one reason, and therefore, one patient might be grouped into multiple
categories of referral. Of the 59 patients referred, there were a total of 101 reasons
for preconception referral. Examples of referral for maternal disease included high
body mass index (BMI), history of thrombophilia, mental health, cancer, and cardiac
disease. Previously, poor OB outcome included recurrent pregnancy loss, intrapartum
maternal health complications, preterm premature rupture of membranes (PPROM), and
postpartum complications. AMA is defined by the patient being at least 35 years of
age at the time of prospective due date. Patients referred for uterine, cervical,
tubal, or ovarian abnormality were grouped into a gynecologic anatomic abnormality
category. Examples included uterine fibroids, bicornuate, unicornuate, or septum uterus.
Recommendations given to patients after their preconception appointments were grouped
into three categories: (1) no concern with immediate conception, (2) delay conception
until recommendation are met, and (3) advised not to conceive. Data for these groups
were found in the provider notes for the preconception counseling appointment.
This study was approved as exempt by the Colorado Multiple Institutional Review Board.
Results
EMR data from 59 women who attended a preconception counseling appointment at the
University of Colorado Maternal-Fetal Medicine Preconception Clinic in 2018 were included
in this retrospective chart review. The majority (73%, n = 43) of the patients were Caucasian and married (76%, n = 45). Twenty-five percent (n = 15) of all patients identified as nonwhite, with the largest nonwhite percentage,
(10%, n = 6) identifying as other.
The median maternal age of patients was 37.5 years. Thirty-seven percent (n = 22) had a normal BMI, while 56% (n = 33) were overweight, obese, or morbidly obese. Twenty-two percent (n = 13) of all patients had a mental health diagnosis abstracted from their medical
record, though only one patient was referred to preconception counseling for having
the mental health diagnosis of bipolar type 1. Of the 59 patients, 3% (n = 2) were current tobacco smokers, 8% (n = 5) were current marijuana smokers, 22% (n = 13) reported current alcohol use, and 45% (n = 27) had an unknown substance use history ([Table 1]). Most (73%; n = 43) of the women were planning pregnancy within the next calendar year.
Table 1
Demographics for patients receiving preconception counseling through the University
of Colorado Department of Maternal-Fetal Medicine during 2018
|
Number of patients (%)
|
|
Total number of patients in the study
|
|
59
|
|
Maternal age group (y)
|
15–20
|
0 (0%)
|
|
21–25
|
4 (6.78%)
|
|
26–30
|
8 (13.56%)
|
|
31–35
|
18 (30.51%)
|
|
36–40
|
14 (23.73%)
|
|
41–45
|
7 (11.86%)
|
|
46–50
|
7 (11.86%)
|
|
51–55
|
1 (1.69%)
|
|
56–60
|
0 (0%)
|
|
Maternal BMI (kg/m2)
|
Underweight (< 18.5)
|
4 (6.78%)
|
|
Normal (18.5–24.9)
|
22 (37.29%)
|
|
Overweight (25–29.9)
|
17 (28.81%)
|
|
Obesity (30–34.9)
|
7 (11.86%)
|
|
Morbid obesity (> 35)
|
9 (15.25%)
|
|
Average maternal weight, height, BMI
|
Average weight
|
168.5 lbs
|
|
Average height
|
65.4 in
|
|
Average BMI
|
27.4
|
|
Median maternal weight, height, BMI
|
Median weight
|
153 (100–306 lbs)
|
|
Median height
|
66 in (54–71in)
|
|
Median BMI
|
25.6 (15.7–49.4)
|
|
Marital status
|
Married
|
45 (76.27%)
|
|
Unmarried
|
5 (8.47%)
|
|
Single
|
3 (5.08%)
|
|
Maternal race/ethnicity
|
Caucasian
|
43 (72.88%)
|
|
African American
|
3 (5.08%)
|
|
Asian/Pacific
|
1 (1.69%)
|
|
Native American
|
2 (3.39%)
|
|
Hispanic
|
3 (5.08%)
|
|
Other
|
6 (10.16%)
|
|
Unknown
|
1 (1.69%)
|
|
Insurance
|
Private
|
53 (89.83%)
|
|
Income dependent
|
2 (3.39%)
|
|
Uninsured
|
0 (0%)
|
|
Unknown
|
4 (6.78%)
|
Abbreviation: BMI, body mass index.
Depending on indication for referral, patients were typically evaluated according
to an algorithm demonstrated by the embedded flowcharts. Fifty-three percent (n = 31) of the 59 women were referred to preconception counseling because of maternal
disease. The most common reasons for inclusion into this group were high BMI (23%,
n = 7) and history of thrombophilia (23%, n = 7). Of these 31 patients, 52% (n = 16) were found to have no concern for immediate conception, 19% (n = 6) were advised to defer conception pending completion of recommendations, and
10% (n = 3) were counseled to not proceed with immediate conception ([Fig. 1]). Twenty-four patients were referred for infertility, of which 50% (n = 12) were planning in vitro fertilization and 29% (n = 7) had a diagnosis of primary infertility. Fifty-four percent (n = 13) were determined to have no concerns for immediate conception, 25% (n = 6) were advised to defer, and 4% (n = 1) were advised to not proceed with immediate conception ([Fig. 2]). Thirty-two percent (n = 19) of women were referred to preconception counseling because of previous poor
OB outcomes. Among this group, the primary reasons for referral included recurrent
pregnancy loss (36%, n = 7), pre-eclampsia (15%, n = 3), PPROM (10%, n = 2), and postpartum hemorrhage (10%, n = 2). Fifty-seven percent (n = 11) of women who were referred to counseling because of previous poor OB outcomes
were determined to have no concerns with conception, 36% (n = 7) were advised to defer pending completion of recommendations, and 5% (n = 1) were advised not to conceive. Fifteen percent (n = 9) of patients had a uterine, cervical, tubal, or ovarian anatomic abnormality
for which they were referred. Of these, 33% (n = 3) were found to have no concern for immediate conception, 44% (n = 4) were counseled to defer pending completion of recommendation, and 0% was advised
to not proceed with conception ([Fig. 3]). Thirty-one percent (n = 18) of women were referred for AMA. Among women in referral group 4 AMA, 72% (n = 13) were determined not to be at immediate conception risk, while 22% (n = 4) were advised to defer conception pending completion of recommendations and 0%
was advised not to conceive ([Fig. 4]).
Fig. 1 Maternal disease and mental health recommendations. Flowchart guide for counseling
patients referred to MFM counseling for maternal disease and/or mental health conditions.
EKG, electrocardiogram; HbA1c, hemoglobin A1c; MFM, Maternal-Fetal Medicine; PCP,
primary care provider; TSH, thyroid-stimulating hormone.
Fig. 2 Infertility recommendations. Flowchart guide for counseling patients referred to
MFM counseling for infertility. ASA, Aspirin; APLA, antiphospholipid antibody; HbA1c,
hemoglobin A1c; MFM, Maternal-Fetal Medicine; REI, reproductive endocrinology and
infertility; TSH, thyroid-stimulating hormone.
Fig. 3 Previous poor obstetric outcome and abnormal gynecologic anatomy recommendations.
Flowchart guide for counseling patients referred to MFM counseling for previous poor
obstetric outcome and/or abnormal gynecologic anatomy. ASA, Aspirin; APLA, antiphospholipid
antibody; HbA1c, hemoglobin A1c; MFM, Maternal-Fetal Medicine; TSH, thyroid-stimulating
hormone.
Fig. 4 Advanced maternal age recommendations. Flowchart guide for counseling patients referred
to MFM counseling for advanced maternal age.
Of the 59 total patients, 58% (n = 34) were found to have no concern with immediate conception, regardless of reason
for referral to preconception counseling, 5% (n = 3) were advised not to proceed with immediate conception, and 11% (n = 7) did not have a documented initial preconception recommendation ([Fig. 5]).
Fig. 5 Referral specific patient recommendations for proceeding with conception. Figure
demonstrates the breakdown for patient referral reason and the preconception counseling
recommendation given (colorized).
Twenty-five percent (n = 15) of patients were advised to defer immediate conception until the completion
of recommendation(s). These patients were further advised to undergo further evaluation
and/or testing. The first category was laboratory testing, which often included thyroid-stimulating
hormone (TSH) and hemoglobin A1c (HbA1c). The second was evaluation by a specialist
or management by a primary care provider (PCP). For maternal disease, these recommendations
were often referrals to cardiology for cardiac function testing (46%, n = 7), dietician for weight and nutrition optimization or to the patient's PCP for
medication management and optimization (13%, n = 2). The final category was lifestyle changes which typically included weight loss
(46%, n = 7), smoking cessation, and exercise. After completing the recommendation(s), patients
were re-evaluated for a final conception recommendation. The final recommendations
included: (1) ultimately no concern with conception, (2) recommendation of delaying
conception, and (3) ultimately advised not to conceive.
Forty percent (n = 6) of patients initially advised to defer conception were referred for maternal
disease, of these patients, 57% (n = 4) were ultimately cleared for conception with no concern, 14% (n = 1) were advised to delay conception, and 14% (n = 1) were advised against conception. Another 40% (n = 6) of patients initially advised to defer conception were referred for infertility.
Of these patients, 66% (n = 4) ultimately had no concern for proceeding with conception on final recommendation
and 22% (n = 2) were still pending recommendation completion at the time this study was submitted.
Forty-seven percent (n = 7) of patients initially advised to defer conception were referred for previous
poor OB outcome. For these patient's final recommendation upon completion of initial
studies/lifestyle modifications, 28% (n = 2) were cleared for conception, 28% (n = 2) were advised to delay conception, and 42% (n = 3) were still pending results. Twenty-seven percent (n = 4) of the patients initially recommended to delay conception were referred for
AMA, of these patients, 75% (n = 3) ultimately had no concern for conception and 25% (n = 1) were still pending result at the time of this study. Finally, 27% (n = 4) of patients initially advised to defer conception were referred for a gynecologic
anatomic abnormality. One hundred percent of these patients after completing recommended
evaluations or procedures were then ultimately found to have no concern for moving
forward with conception.
Discussion
Women were referred to preconception counseling at a University of Colorado Maternal-Fetal
Medicine Preconception Clinic for a variety of reasons with maternal health being
the most cited reason for referral. Referred women also had a diverse range of reproductive
history and previous OB outcomes. In our study, 7% (n = 4) of patients were ultimately counseled to either further delay conception or
to not conceive. This is the first study we are aware of to publish the percentage
of patients advised by MFM providers to not conceive.
Almost three quarters of our sample was Caucasian. According to the most recent census
data, the Denver area demonstrates a diverse racial distribution with 55% of the population
identifying solely as Caucasian, not Hispanic or Latino, 30% identifying as Hispanic,
10% identifying as African American, and 4% identifying as Asian.[14] Thus, our sample does not reflect our geographic area or even the demographics of
the OB/gynecology clinics at the same institution. This is concerning because women
of minority groups have increased maternal morality and adverse fetal outcomes[15]
[16] and are also less likely to access preconception care.[17]
Different reasons for the incongruity between the population and the patients referred
have been suggested. One study found that patients with Hispanic ethnicity, higher
parity, unintended pregnancy, or without insurance were less likely than their Caucasian
counterparts to receive preconception counseling.[18] Another study of Hispanic and African American women demonstrated one-third of participants
with chronic medical conditions was unaware of preconception health risks and, therefore,
did not seek preconception care.[19] Health disparities affecting minority women has also been found to decrease these
women's access to preconception counseling and management of preexisting conditions,
directly affecting pregnancy outcomes.[20] Another study examining the intricacies of delivering preconception care to adolescent,
diabetic women identifying as Hispanic, demonstrated the extent to which cultural
and religious barriers need to be carefully addressed to optimize preconception counseling.[21] Since providing adequate preconception care allows for health intervention and management
offering improved pregnancy outcomes, it is a vital aspect of health care that should
be available to all women of childbearing age.[22]
[23] It is crucial for preconception counseling to be widely available to all women,
not just those actively contemplating conception, to optimize maternal and fetal health.[15] The discrepancy of women from minority groups receiving prenatal care represents
a serious health care system flaw that needs to be remedied with improved patient
outreach and provider referrals.
Of the women referred for preconception care, 56% (n = 33) were either overweight, obese, or morbidly obese, though only 11% (n = 7) were referred to counseling for high BMI. The average BMI for patients referred
for this reason was 41, while the average BMI for all patients was 27. Although a
conversation regarding weight optimization was frequently documented by health care
providers for patients with BMIs categorized as overweight or greater, there was not
an agreed-upon target for BMI, weight, or target pound loss. Reduction in maternal
BMI by 10% prior to conception has been associated with a decrease in peripartum maternal
complications such as preeclampsia, preterm delivery, and stillbirth.[24] According to the World Health Organization, the recommended BMI for pregnant women
is within the normal BMI range of 18.5 to 24.9 to decrease complications associated
with underweight patients, including small for gestational age and low birth weight
as well as prepregnancy overweight/obesity complications such as macrosomia, and subsequent
childhood overweight/obesity.[25]
[26] Chart documentation for all patients who are counseled on preconception weight loss
should detail the conversation to provide direction for future appointments and pregnancies.
Patients were most likely to be referred for maternal disease. Preconception recommendations
included, laboratory testing, evaluation by a specialist or management by a PCP. Lifestyle
changes were also widely recommended and included weight loss, smoking cessation,
and exercise. Previous authors have suggested that these interventions can improve
pregnancy outcomes.[1] For patients who were found to have no concern for immediate conception, they were
offered general preconception counseling which included discussions of prenatal vitamin
use, genetic carrier screening, dietary optimization, and substance use avoidance.
We found that there was significant variability in the provider documentation of recommendations
and which recommendations were standard. For the patients advised to not immediately
conceive, they were offered individualized counseling based on their specific referral
reason and health conditions.
The second most common reason for referral was infertility. Patients with infertility
are referred to preconception clinics with MFM providers to be evaluated for any maternal
medical concerns prior to proceeding with pregnancy. After receiving medical clearance,
patients are then evaluated for infertility in separate reproductive endocrinology
and infertility clinics. For patients advised to defer immediate conception, the laboratory
tests recommended were most often TSH, HbA1c, and antiphospholipid laboratories. The
specialty referrals were to reproductive endocrinology and cardiology. Specialty imagining
most often advised was for uterine ultrasound or hysterosalpingogram (HSG). Patients
were also advised on lifestyle changes, including starting aspirin with pregnancy.
Patients referred for infertility who were recommended to proceed with conception
received general preconception counseling. Though there were consistent recommendations
from different providers regarding infertility counseling, there was not a standard
collection of recommendations. There is no standard patient, making it difficult to
widely structure and define how individual counseling appointment should be arranged.
Patients referred for previous poor OB outcomes and abnormal anatomy were similarly
counseled. For patients with previous poor OB outcomes, laboratory testing was similar
to that recommended for infertility and included TSH and antiphospholipid laboratories.
For patients with both poor OB outcome and abnormal anatomy, recommendations for specialty
testing included uterine ultrasound, cerclage placement, use of progesterone prophylaxis
in a subsequent pregnancy, cervical length surveillance, and HSG. Lifestyle recommendations
for both groups of patients included weight management, smoking cessation, and blood
pressure control.
Patients referred for AMA received general preconception counseling, though there
was often an emphasis in the documentation about routine prenatal screening. Patients
referred for AMA who were recommended not to conceive had coexisting referral reasons,
such as maternal health concerns.
The patients who were cleared for immediate conception received general preconception
counseling in addition to patient-specific counseling to optimize their health before
and throughout pregnancy. The majority of these patients had documentation outlining
the general preconception counseling in their EMR. For these patients, the documentation
regarding counseling was provider specific, though usually included recommendation
for the patient to continue or begin taking a prenatal vitamin and aspirin, a schedule
for routine screenings and other recommendations related to maintaining a healthy
diet and lifestyle recommendations. There was not clinic-wide documentation used by
providers to encompass general preconception recommendations and some of the patients
did not have documentation of standard preconception advice. The patients without
general preconception recommendations documented tended to be the relatively more
complex patients. Documentation for these patients reflected more extensive conversations
about specific aspects of the patient's health or previous reproductive complications.
More often for these patients, provider documentation focused on counseling for the
specific referral reason with less emphasis on general preconception topics.
The primary limitation to this study is the lack of consistent follow-up for patients.
There are several reasons patients were often lost to follow-up after their initial
preconception counseling visit. The most common being that the patient was referred
to MFM by a PCP who is outside the University of Colorado Hospital system, so any
subsequent pregnancy outcomes were unknown and not documented in their CU EMR. Additionally,
without documentation in their CU EMR, it could not be determined whether a patient
followed the MFM specialist's recommendations. Patients may have also been lost to
follow-up due to changes in the desire for pregnancy and/or exploration of other options
for parenthood. At the time of this study, there was not a system in place to follow-up
with patients to evaluate the efficacy of the recommendations and referrals in regard
to optimized preconception health. There was also not any method of following patients
to assess for how often patients seen at a MFM clinic were successful in conceiving
and the outcomes of any pregnancies. Obtaining follow-up information on patients is
crucial to properly guide future MFM practice recommendations as well as to understand
how patients follow counseling and what effect this counseling may have on their pregnancy
health and outcomes. Ideally, patients seen at CU MFM clinics will be followed up
for 2 years to observe how well recommendations were followed and to track the extent
to which following recommendations resulted in pregnancy success.
Another limitation is that not all the relevant information for patients was available
in their EMR. Upon data collection, it was apparent that there was a lack of standardization
in the type and amount of information collected from each patient. Although each patient
filled out a clinic intake form with demographic information, missing from the form
was pertinent data which would better allow providers to counsel patients and make
recommendations. Utilizing a detailed intake form which is standard to all CU MFM
clinics will bridge this gap in patient data and allow for a more complete MFM counseling
appointment.
The finding of documentation and recommendation discrepancies among MFM providers
suggests the use of a standardized template would be beneficial for MFM clinics. A
standardized template would provide a user-friendly method for documenting general
preconception recommendations on which all women should be counseled. We recommend
that MFM preconception clinics can implement a standardized intake form and standard
recommendations for all preconception patients. These recommendations include prenatal
vitamin (PNV), hand washing, vaccine status, and carrier screening. An ideal template
would also address standard lifestyle counseling such as dietary and substance avoidance
and optimal preconception BMI. The standardized template should also consistently
include a section to document discussions regarding contraception. While documenting
contraception should be standard for all women, it should be particularly emphasized
for women who are recommended to delay conception. In addition to a template detailing
common recommendations for all women, this study suggests modifiable templates, notably
in regard to the reason for referral, will streamline both follow-up care. These modifiable
templates will also increase the ease with which other providers, such as those the
patient is referred to or their PCP, are able to review a patient's notes from their
MFM consultation.
The goal of this article was to identify opportunities for preconception care improvement
and to develop a rubric to guide providers of preconception care to facilitate delivery
of optimal care. The findings of our study allowed us to develop flowcharts based
on the recommendations and overall course of action taken by CU MFM providers. These
flowcharts, illustrated in the results section, are intended to serve as a foundation
of standard preconception recommendations. The findings from this study also support
the implementation and use of a standard intake in MFM clinics. A standardized form
that all patients fill out upon clinic intake should include several sections to optimize
the patient's preconception recommendations by providing all relevant details of the
patient's health and well-being. The important sections on a standard intake form
include demographics, reproductive history, medical and mental health history, vaccination
history, substance use, family and travel history, intimate partner violence, dietary
and exercise habits, and desire for carrier screening. Reproductive history should
detail outcomes of all previous pregnancies, any pregnancy complications, pregnancy
plans, and contraception use. By utilizing a standardized intake form, MFM specialists
will be provided with all relevant patient information to counsel patients. These
forms will also contribute valuable data for future retrospective studies looking
at different populations of patients or certain risk factors and the effect on conception
and pregnancy outcomes.
Conclusion
Reviewing the available EMR data provided a range of recommendations with information
on how frequently the recommendations are followed by patients referred to preconception
care. By identifying aspects and outcomes of the current preconception care at CU,
this study developed clinical care recommendations for improved preconception care
and provides preliminary data for a prospective study of the success and limitations
of preconception services. Findings also contribute relevant details about the specifics
of preconception care, the utility for patients, and the impact on pregnancy outcomes.
