Making space for preconception counseling in primary care

When it comes to preconception care, many women might think they're covered by their obstetricians/gynecologists. However, internists have a vital role to play in helping both women and men with family planning and contraception.

In May 2018, ACP published a position paper in Annals of Internal Medicine on women's health policy in the United States, which stated that “internists are well-suited to provide high-quality women's health care and that clinicians in all specialties and fields, including internal medicine, who care for women should receive appropriate training in health issues of particular relevance to the population of women seen in their practice setting.” ACP also noted that primary care physicians traditionally play a role in preconception and postpartum care. Additionally, other experts have called for internists to integrate family planning into their practice as well as take a comprehensive approach to preconception care.

“The maternal morbidity and mortality rate in the U.S. during pregnancy is absolutely disgusting,” said Jean Marie McGowan, MD, FACP, co-director of the preconception clinic at Sanford Health in Fargo, N.D., citing CDC statistics that recorded an increase in pregnancy-related deaths since the agency first began monitoring them. The rate increased from 7.2 deaths per 100,000 live births in 1987 to 16.9 deaths per 100,000 live births in 2016.

“So many complications develop during pregnancy or afterward that both affect mom and baby,” she said. “As internal medicine physicians, we deal with a lot of these complications after the postpartum period. There's many reasons why the mortality rate is so bad, but if we could help at least one part, it would be that we can provide better care before they even get pregnant.”

In working with women who have the possibility to become pregnant, ACP Member Eleanor B. Schwarz, MD, MS, a professor in the department of general internal medicine at the University of California, Davis, said internists have a moral obligation to provide care that aligns with patients' reproductive goals.

“It's just about trying to recognize it's a priority,” she said. “Most women and families do endorse that family planning is of profound importance to them, and we need to make sure that people get the guidance they need in a timely fashion such that when it's relevant they know where to turn for help.”

Lifestyle changes, medical history, mental health

For ACP Member Rachael R. Dirksen, MD, a clinical assistant professor of internal medicine at the University of Iowa Hospitals and Clinics in Iowa City, the first step is establishing whether a patient is interested in pregnancy, and if so when. “That kind of gives me an idea of where we need to work toward,” said Dr. Dirksen, who coauthored a 2014 paper on contraceptive counseling by internists. “For example, if there's a patient who's smoking, we can work on smoking cessation before they begin trying for a pregnancy, or if there's a medication that would adversely affect a pregnancy, we can try to stop that one.”

Dr. McGowan also recommended taking a full history and focusing on complications with any prior pregnancies, which might provide clues for future problems. “Try not to use medical terms unnecessarily, or use several different ones,” she advised. “Ask: ‘Did you have high blood pressure? High sugars? Did you have toxemia?’ That's an old term, but some patients still use that.”

It's important to remember that certain underlying issues might only surface when a woman becomes pregnant, she said.

“Pregnancy is the ultimate stress test, especially when it comes to cardiovascular health,” Dr. McGowan said. “If a woman develops a cardiovascular disease, whether that's hypertension or cardiomyopathy, during pregnancy or during that postpartum period, then she has a higher risk for having this later in life. … So that is something that we would want to get a handle on beforehand, if possible.”

Beyond lifestyle, Dr. Schwarz said, “There's actually a very long list of things that might be worth considering, from immunizations to medication management, for families that are thinking about becoming pregnant.” She recommended using an app created by the U.S. Department of Veterans Affairs to help provide comprehensive preconception care.

While most of the focus is on women, men also deserve attention, Dr. Dirksen noted. “We shouldn't miss those moments to talk to men, since they have some issues as well or may have medications that affect that fertility,” she said. “It's important for us to talk to them too.”

Dr. Schwarz noted that the effect of pregnancy on mental health is relevant for both women and men, and Dr. McGowan said that although she primarily treats women, she enjoys when her patients bring along their male partners.

“It's always so much easier if both partners are involved,” she said. “I hear a lot of times from women, ‘Well, I want to cook healthy but my husband won't eat these things.’ If he's there, I can then say, ‘Well, it's important that you change your diet too.’ It can start the discussion.”

Chronic condition complications

For patients with preexisting chronic conditions, some extra care is needed to enable them to have healthy pregnancies.

“Diabetes is really a challenge because poorly controlled diabetes is one of the biggest teratogenic exposures that pregnancies can face,” Dr. Schwarz said, adding that women should have a hemoglobin A1c level less than 7% before becoming pregnant.

“The message, though, to any woman with a chronic condition who is thinking about pregnancy really has to be not that they shouldn't get pregnant but that the clinician wants to work with them to help them have the healthiest possible pregnancy,” she said.

She advised clinicians to speak about risk in absolute terms, as relative risks can be unnecessarily scary. “Although the relative risks are higher, pregnancy is always a risk to a woman's health,” she said. “In many situations it's a risk women want to take. It's about aligning the guidance we're providing with where that woman's personal reproductive goals are.”

Dr. Dirksen said that though each chronic condition is different, “We can target the therapy to best align with the goal for the pregnancy.” For diabetes, there are certain medications that are better than others. “I have patients that might be on a longer-acting insulin-like glargine but really NPH [neutral protamine Hagedorn] is a more preferred insulin in pregnancy. So if we know ahead of time, we can kind of work together to change those.” Patients with chronic conditions can be referred to maternal/fetal medicine for a preconception visit so that when they do become pregnant, they can be seen more quickly, Dr. Dirksen said.

For example, each month, Dr. McGowan staffs a half-day preconception clinic with a maternal/fetal medicine physician. Patients, sometimes with their partners, have about an hour to receive a comprehensive plan based on individualized factors. Any recommendations are also relayed to their primary care clinicians so they may follow up.

“We can outline the blood pressure meds, or how to titrate dosage. If the patient wants to switch to a different antidepressant, here's ones that we recommend. When she's ready to get pregnant she should start aspirin, et cetera,” Dr. McGowan said. “We also have access to a geneticist and a nutritionist if the patient might need that to optimize her care or to discuss potential karyotyping or other genetic testing. It's supposed to be very comprehensive and convenient for them.”

Barriers to uptake

One of the biggest barriers to proper preconception care in internal medicine is time. “We have 15 to 30 minutes with these patients,” Dr. McGowan said. “They have their own agenda. We have our own agenda. I feel sometimes that sexual health gets put on the back burner unless the patient brings it up.”

Access is another hurdle, especially in rural areas where patients need to travel to visit a clinic. Also, “Culturally, sexual health is an awkward topic to talk about,” Dr. McGowan said. “We know that providers do not feel comfortable doing it and it's not being done enough. Many, many surveys show that. For patients, if they don't bring it up, we might not be asking.”

To help address this, Dr. McGowan advised creating an environment where patients can feel comfortable. This might include bringing up the topic in general terms simply to start a conversation. Some questions she advised asking are: “Are you sexually active right now? Are you looking to get pregnant, or do we need to talk about contraception?” Dr. Schwarz added that it can also be helpful to ask “Do you have sex with men, women, or both?” and that it's important for patients to know that their physician supports them in all of their reproductive choices.

“Internal medicine is certainly very broad, and tackling things like preconception care or dealing with a medically complex pregnancy can feel very overwhelming, especially if we have less exposure to those kind of topics in our training,” Dr. Dirksen said, adding that it can be hard to find time to review these issues when speaking with medically complex patients. “Making systems to identify patients who are at risk for unintended pregnancy would be helpful, and it would sort of spark us to bring up the topic and open the door for patients to discuss with us.”

Remembering that expertise in this field is not a requirement can also enable internists to take the first step, she advised. “We can use our resources, like connect with obstetrics and gynecology or work with our specialty colleagues to alert them, ‘Hey, this patient is thinking about a pregnancy, what do you think about these medications that they're on? Do you think their disease state is controlled well enough that a pregnancy would go well?’” Working with others in a team can make this type of counseling less overwhelming, she said.

“Every clinic visit is really a personalized dance between the clinician and the patient, but in my experience, patients really appreciate when clinicians make space for asking about where pregnancy fits in their current life plans,” Dr. Schwarz said. “The best thing you can do for any pregnancy or child is to take good care of its mother, so really, we're always just talking about how to optimize a woman's health, and in so many ways, I think all of that applies to the father as well.”