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Table of contents
- Table of contents
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- Chapter 2: Preconception care
Fluoxetine and other selective serotonin reuptake inhibitors SSRIs remain first-line antidepressant choices during pregnancy. The majority of preconception care involves taking a careful history and providing specific counselling. There is little evidence to support routine physical examination in healthy women of reproductive age. However, HCPs will want to measure blood pressure, perform cervical cancer screening based on provincial recommendations, and screen for STIs.
A conversation about a history of breast surgery or inverted nipples would provide an opportunity to identify any potential breastfeeding concerns and educate on breastfeeding. A growing number of women in Canada are choosing to delay pregnancy until they are well into their 30s. The reasons are multifactorial, including later marriage, access to contraception, desire for career and financial stability, changes in values and the absence of supportive family policies. Biologically, the optimal time for pregnancy is between the ages of 20 and 35 years.
This decreases the probability of conception and increases spontaneous abortion rates. In addition to her declining fertility and increased risk of miscarriage, obstetrical and perinatal complications such as preterm birth, low birth-weight, stillbirth, placenta previa, gestational diabetes, preeclampsia, and Caesarean birth increase after age Chromosomal anomalies, accounting for the majority of spontaneous abortions and congenital malformations, increase with age: the risk of total chromosomal abnormalities is 1 in at age 30 and 1 in 63 at age Due to their reduced fertility, women aged over 35 are more likely to use assisted reproductive technology.
Counselling patients about the consequences of delaying childbearing can help those who are considering starting a family at some point in their future to reach an informed reproductive-life plan decision. Up to 1 in 7 Canadian couples experience infertility. In contrast, assisted reproductive technology ART is commonly defined as any procedure that involves handling eggs, sperm or both outside of the human body in vitro.
Individuals and couples who need help in conceiving may experience significant emotional and financial stress. Such stress can impact the mental health of the parent s , affecting the relationship between them and with any other children. Families may require added support from their HCP as well as counselling to help them make informed choices around the use of ART. In addition to the psychological impacts, some medical interventions may involve risks to the potential parent s. Some fertility drugs for egg stimulation and ovulation are associated with a risk of ovarian hyperstimulation syndrome OHSS , which can be serious or even fatal in rare cases.
Although the majority of children conceived with ART are healthy, couples and individuals considering the use of ART need to be aware of the risks associated with these interventions. Women who have singleton pregnancies conceived through ART have increased rates of preterm birth and low birth-weight babies, although this is also influenced by factors such as ART techniques, maternal age and the underlying medical issues including infertility itself. Again, this increase may be attributable to ART or to a number of other factors.
Pregnancies conceived after transfer of frozen-thawed embryos may have decreased risks of preterm birth, small-for-gestational age and congenital abnormalities as compared to conceptions after fresh embryo transfer, but risks remain higher than the background rate. Women who undergo ART experience more breastfeeding challenges, due to delayed lactogenesis or insufficient milk supply.
Providers can refer to the clinical practice guidelines from the Canadian Fertility and Andrology Society for standard of care with respect to AHR. Pregnancy during adolescence has been associated with an increased risk of adverse perinatal outcomes such as prematurity and intrauterine growth restriction.
Psychosocial outcomes for both the adolescent mothers and their infants are poorer than those of adult mothers and their infants, although the relative contributions of biological immaturity and socioeconomic factors are under discussion. Pregnancy and parenting among adolescent women is common in Indigenous communities. Proactive health care of adolescent patients includes having conversations about current sexual activity and plans to become sexually active. Initiation of contraception should precede, not follow, the onset of sexual activity.
Adolescents often fall under the radar for preconception counselling, since pregnancy in this population is widely viewed as accidental. However, studies show that a substantial number of pregnancies among adolescents are wanted or at least not actively avoided. Ambivalence about childbearing or possibly concealed intent to become pregnant may explain why an adolescent declines contraception, uses contraception inconsistently, or presents for repeated pregnancy tests.
Openly discussing this possible ambivalence provides an opportunity for the adolescent to reflect on their feelings and beliefs in a safe, neutral environment that acknowledges their agency, respects their competence and equips them with useful information for self-care. Ineffective contraception use should prompt a conversation about preconception preparation. In particular, folate supplementation has no adverse effects and may prevent the birth of an infant with an NTD. A young woman presenting for pregnancy testing offers a rich, teachable opportunity to hold an open, non-judgmental conversation, including hopes for the outcome, prior to doing the test.
For those who clearly prefer not to be pregnant, the HCP can bring up current contraception use and work with the patient to enhance contraceptive effectiveness including the option of emergency contraception. For adolescents who are clearly hoping to be pregnant, the provider can then follow up on ways to optimize pregnancy outcomes.
Female genital cutting FGC , also referred to as female genital mutilation or circumcision, refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. Health consequences of the practice include difficulties with menstrual flow, intercourse and sexual responsivity, and with using contraception. Sexual dysfunction—including increased pain during intercourse and reduced sexual desire—often occurs, particularly with the most severe form of infibulation.
Any contraceptives that involve vaginal insertions may not be acceptable or feasible. Procedures involving penetration of the vaginal canal may be difficult, if not impossible, and may cause excessive pain. HCPs tend to lack education about this procedure, its health consequences and its cultural implications.
As such, it is difficult for them to provide appropriate care before and during pregnancy and birth.
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Women with FGC fear censure from caregivers and may avoid maternity care. During perineal examinations of women with FGC, extra care is required in two equally important areas:. A variety of small narrow specula should be available, and the need for any testing explained and performed in a careful and respectful manner. During vaginal birth, the infibulation must be opened defibulation to allow for passage of the baby. It is far better to undertake this procedure, with appropriate anesthesia, before conception or during pregnancy at the latest.
If performed only at birth, the risk of haemorrhage increases significantly, since the clitoral area is vascular. By discussing the need for defibulation and the illegality in Canada of FGC and infibulating again with the woman before conception—preferably with her partner present—the HCP may help deter the couple from seeking traditional providers to infibulate again after a birth. FCMNC is based on a mutually respectful and trusting relationship, and individual need. While important progress has been made in providing equitable health care to the LGBTQ Footnote b community, these populations often still face barriers to accessing health care that is culturally safe and that meets their needs.
For example, lesbians and bisexual women may:. The World Professional Association for Transgender Health recommends that health care for transgendered people be situated within the primary health care system, including hormone therapy and assessment for surgery, if the primary HCP has received proper training.
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The need for effective communication and coordination between HCPs is intensified when providing family-centred care for transgendered people. It is important to note that transgendered people have all the same care needs as others, such as preventative healthcare, and treatment for acute and chronic illnesses. Optimal care requires not only cultural competency, but also clinical competency in caring for the sex-specific needs of this population. Transgendered people may also seek trans-specific care, such as access to hormone replacement therapy and gender confirmation surgery.
All LGTBQ individuals should be encouraged to develop an appropriate and inclusive reproductive-life plan. Those who want children will likely rely on their HCP for information and options on becoming a parent safely and efficiently. Discussions regarding options for conception and pregnancy are valid for everyone.
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LGTBQ people may have difficulty accessing fertility services. Education is the first step towards improving care for the LGBTQ community, and training is available to help increase the knowledge and sensitivity of HPCs in this area. The most common conditions are asthma, hypertension, diabetes, epilepsy and mental health disorders. The preconception period is also a good time to rule out underlying secondary causes of hypertension and to assess for end-organ effects of hypertension with an ECG, electrolytes, creatinine and urinalysis.
If the ECG is abnormal, proceed with an echocardiogram. If the results are abnormal, proceed with hour urine collection for confirmation, plus consider referring the woman to a specialist to rule out co-existing renal disease. Antihypertensive medications should be evaluated with respect to risks and benefits for the mother and fetus. Rates of type 1, type 2, and gestational diabetes are all increasing in Canada.
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Screening is also recommended for women and men who are immigrants and refugees from South Asia, Latin America, and Africa who are older than 35 years. Women with pregestational diabetes require evaluation for complications. Specifically, proliferative retinopathy may worsen as a result of pregnancy, particularly if diabetes and hypertension are not controlled note that pregnancy does not affect mild—moderate stable retinopathy.
Traditionally, diabetes in pregnancy was managed with insulin to achieve as normal an HbA1c as possible without inducing hypoglycemia. Recent research has demonstrated that some oral hypoglycemic agents may be safe during pregnancy, potentially negating the need to switch to insulin if a pregnancy is planned. In addition, because of their higher risk of NTDs, these women are advised to take a higher dose of folic acid for 3 months prior to conception. Thyroid requirements increase significantly in pregnancy, with most of the change occurring in the first trimester and as early as 4 to 6 weeks gestation.
However, many anticonvulsant medications are associated with possible congenital malformations. This risk increases with multiple medications. The preconception period is important for evaluating whether medications can or should be modified. Medications with a higher risk of organogenesis and cognitive development include valproic acid and phenytoin. If possible, a switch to carbamazepine, lamotrigine or levetiracetam is recommended prior to pregnancy, taking into consideration the time required for the taper and overlap of medications.
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Women with asthma that is sub-optimally treated have higher rates of pregnancy complications, including preeclampsia, and low birth-weight infants. In , there were new cases of HIV in Canadian women and cases of perinatally exposed infants by maternal exposure. All HIV-positive individuals, or those with an HIV-positive partner, should be offered counselling including contraception and reproductive planning that focuses on their specific health needs. Depending on their reproductive plan, this would include counselling on pregnancy prevention or attaining a healthy pregnancy.
Women with a positive hepatitis B surface antigen HBsAg that persists for at least 6 months after the initial test have chronic HBV infection. Further testing is required at that point to help guide management decisions, including the need for treatment. Preconception is the ideal time to establish a diagnosis of chronic hepatitis, as family planning may have implications for the choice of therapy. In contrast, oral antivirals such as tenofovir, telbivudine or lamivudine offer a good safety profile for fetal development, lower risk of developing viral resistance, and efficacy in reducing viral load.
Chapter 2: Preconception care
Additional counselling is required for these patients. This chapter supports the many ways in which the initial health of parents, prior to pregnancy, is vital to the subsequent health of the baby. As such, promoting the overall health and wellness of women, men, and families before pregnancy forms an important component of FCMNC.
Individual life patterns, social support networks, and social determinants of health are all important factors in conceiving, giving birth to, and raising healthy children. Because Canadian women and families are so diverse in nature, it will be programs, clinical care, and supports based on individual characteristics, experiences, and needs that prove to be truly successful. Effective preconception care is delivered through a wide range of clinical and community settings and cuts across many sectors, including health, education and social.
HCPs are ideally positioned to offer preconception care and to serve as advocates for the creation of healthy, supportive communities for women and men throughout the childbearing phase of their lives.