Preconception Evaluation Research Articles

The Intake of Omega-3 Fatty Acids, the Omega-3 Index in Pregnant Women, and Their Correlations with Gestational Length and Newborn Birth Weight.

During pregnancy, the demand for omega-3 fatty acids, notably docosahexaenoic acid (DHA), escalates for both maternal and foetal health. Insufficient levels can lead to complications and can affect foetal development. This study investigated omega-3 status and its relation to dietary intake in pregnant Latvian women, along with its impact on gestational duration and newborn birth weight. The study comprised 250 pregnant and postpartum women with a mean age of 31.6 ± 4.8 years. Nutrition and omega-3 supplementation data were collected through a questionnaire covering 199 food items and 12 supplements. Fatty acids in erythrocyte membrane phospholipids were analysed via gas chromatography with flame ionization detection. The median omega-3 fatty acid intake, including eicosapentaenoic acid (EPA) and DHA from diet and supplements, was 0.370 g/day, which is deemed sufficient. However, the median weekly fish intake (126.0 g) and daily nut/seed intake (7.4 g) were insufficient. The median omega-3 supplement intake was 1.0 g/day. No correlation between omega-3 supplement intake and the omega-3 index was observed. There was a weak correlation between the DHA intake from fish and the omega-3 index (r = 0.126, p = 0.047), while a significant correlation between the total EPA and DHA intake from various sources and the omega-3 index was noted (r = 0.163, p = 0.01). Most women (61.6%) had an omega-3 index < 4%, while 34.8% had an index between 4 and 8%, and only 3.6% had an index > 8%. Notably, significant differences in EPA levels and the omega-3 index were found among respondents with differing infant birth weights (p < 0.05). The omega-3 intake during pregnancy adheres to the established guidelines, although fish consumption remains insufficient. A preconception evaluation of the omega-3 index is advocated to optimize prenatal intake. The indications suggest potential correlations between EPA levels, the omega-3 index, and infant birth weight.

Adverse cardiovascular, obstetric and perinatal events during pregnancy and puerperium in patients with heart disease

Background and objectivescardiovascular changes during pregnancy carry greater risk in heart disease. We analyze cardiovascular, obstetric and perinatal adverse effects associated with congenital and acquired heart disease during pregnancy and postpartum. Materials and methodsCross-sectional and retrospective study, which included the 2017–2023 registry of pregnant or postpartum patients hospitalised with diagnosis of congenital or acquired heart disease. Adverse events (heart failure, stroke, acute pulmonary edema, maternal death, obstetric haemorrhage, prematurity and perinatal death) were compared with the clinical variables and the implemented treatment. Results112 patients with a median age of 28 years (range 15−44) were included. Short circuits predominated 28 (25%). Thirty-six patients (32%) were classified in class IV of the modified WHO scale for maternal cardiovascular risk.Heart failure occurred in 39 (34.8%), acute lung edema 12 (10.7%), stroke 2 (1.8%), maternal death 5 (4.5%), obstetric haemorrhage 4 (3.6%), prematurity 50 (44.5%) and perinatal death 6 (5.4%). Shunts were associated with prematurity (adjusted odds ratio 4; 95% CI: 1.5−10, p = 0.006). Peripartum cardiomyopathy represented higher risk of pulmonary edema (adjusted OR 34; 95% CI: 6−194, p = 0.001) and heart failure (adjusted OR 16; 95% CI: 3−84, p = 0.001). An increased risk of obstetric haemorrhage was observed in patients with prosthetic valves (adjusted OR 30; 95% CI: 1.5−616, p = 0.025) and with the use of acetylsalicylic acid (adjusted OR 14; 95% CI: 1.2–16, p = 0.030). Furthermore, the latter was associated with perinatal death (adjusted OR 9; 95% CI: 1.4−68, p = 0.021). Conclusionssevere complications were found during pregnancy and postpartum in patients with heart disease, which is why preconception evaluation and close surveillance are vital.

O-094 Management of subfertility in women with PCOS: expectations, problems and solutions

Abstract Polycystic ovarian syndrome (PCOS) is a common cause of subfertility particularly when anovulation is present. In this circumstance efforts are made to induce ovulation through lifestyle modification, medication, or a combination of both. Other patients with PCOS may be ovulatory but require IVF/ICSI for other causes, including male factor or tubal infertility. In all cases, attention needs to be placed on the underlying metabolic, psychological, and reproductive features that may complicate treatment and subsequent pregnancy. Pregnancy itself has a higher chance of complications and these can be reduced by adequate preconception evaluation and intervention. Recently, the international evidence-based guideline for evaluation and treatment of PCOS has been updated (1) and the infertility section subjected to a literature integrity check to exclude publications that did not meet the highest criteria for incorporation into clinical management. A recent individual patient data meta-analysis has also clarified the relative efficacy of fertility treatments (2). The following conclusions are recommended; 1. Letrozole is the first line drug of choice for ovulation induction based on its efficacy and lower multiple pregnancy rate 2. Clomiphene is an effective drug particularly given a long experience of use and its lower cost 3. Metformin may be valuable for some patients particularly if glucose intolerance is present 4. A combination of clomiphene and metformin may be effective, particularly in overweight individuals 5. Gonadotrophins are an effective treatment in experienced clinics which the resources to undergo adequate monitoring 6. Laparoscopic ovarian surgery may assist some patients and is associated with a lower multiple pregnancy rate and may have long term benefits 7. IVF may be safely conducted with appropriate safeguards to reduce ovarian hyperstimulation syndrome in those where ovulation induction has failed. It should be noted that some of these drugs are “off-label” in many countries and are not recommended in several healthcare systems.There are several areas where further information may lead to altered and improved practice: 1. IVF as a first line therapy may be more effective and allow better control of multiple pregnancy rates. 2. In vitro maturation (IVM) with IVF/ICSI shows increasing success with no or minimal FSH use (3). 3. Bariatric surgery is more readily available and may lead to significant weight loss related ovulation. 4. Newer GLP1 receptor agonists show dramatic weight loss and are being evaluated in PCOS. 5. First line gonadotrophin treatment has been advocated by some proponents. 6. Higher dose and longer use of standard oral agents may help in ovulation induction resistant patients. 7. Inositol and myoinositol are being evaluated as safe, low cost, over the counter alternatives. 8. Alternatives to hCG are available for ovulation induction in oral and IVF cycles. 9. Promising pharmacogenomic approaches may allow individualisation of treatment. While the genomic and environmental aetiology of PCOS remains uncertain, the increasing emphasis on evaluation and assessment of effective therapies for subfertility is advancing rapidly.

Malformações congênitas em uma cidade da região metropolitana de Curitiba-PR

Congenital malformations (CM) are structural/functional alterations that occur in the fetus, leading to a socio-economic and emotional impact. This is a retrospective, documentary study with a quantitative approach aiming at identifying the relationship of risk factors and maternal epidemiological profile with the occurrence of CM. It was based on the analysis of 37 medical charts of pregnant women in a municipality in the metropolitan region of Curitiba-PR, between 2019 and 2021. The data revealed a profile: pregnant, multiparous, obese women between 18 and 36 years old, with comorbidities, with no preconception evaluation. The most affected organic systems were the cardiovascular and the nervous systems or multiple systems. An increased risk of fetal malformations was observed in obese women over 25 years old, who used alcohol or tobacco. Although a single cause of CM in that period and place has not been identified, an association was established between maternal epidemiological factors and characteristics of fetal malformations, highlighting the need for preconception health education.

Pregnancy Outcomes Subsequent to Stillbirth—A Single Tertiary-Care Center Experience

Background: Currently, there is little evidence to guide clinical management of pregnancies after stillbirth. Our study aims to evaluate the pregnancy outcome in pregnant women with a previous stillbirth, by applying a standardized protocol for etiologic investigations and subsequent treatment of the underlying etiology. Methods: A retrospective cohort study on a group of 100 women with history of stillbirth, occurred in single pregnancy between 2005 and 2021, was performed. All patients were followed up in their subsequent pregnancies (n = 153) in a tertiary university hospital. During the preconception period causes of stillbirth were investigated and a correction of modifiable risk factors was encouraged with a multidisciplinary approach. Data about pregnancy management, obstetric complications, gestational age at delivery, mode of delivery and neonatal outcomes were collected. Results: The analysis of previous stillbirth revealed that, by using the ReCoDe classification, the most common identifiable causes of death were fetal growth restriction (21%), placental abruption (11%) and “other placenta insufficiencies” (26.7%), whereas 15.8% of stillbirth was unexplained. Out of 153 subsequent pregnancies, 131 (85.62%) resulted in live births, 15 (9.8%) in a first trimester miscarriage, and 7 (4.57%) in second trimester miscarriage; no cases of stillbirth recurrence occurred. Obstetric complications in subsequent pregnancies included gestational diabetes (21.4%), gestational hypertensive disorders (6.1%), intrahepatic cholestasis of pregnancy (3.8%), fetal growth restriction (7.6%) and preterm birth (19.8%). The mean gestational age at delivery was 38 weeks with a mean birth weight of 2886.63 g. Conclusions: Our experience is encouraging as reflecting good outcomes in terms of live birth rate in the subsequent pregnancies, with no cases of recurrence. These results are probably due to extensive preconception investigations with a multidisciplinary approach. A preconception evaluation is, thus, essential to improve maternal and fetal outcome in case of history of stillbirth, aiming to minimize the risk of recurrence.

Pregnancy After 40: Recommendations for Counseling, Evaluation, and Management From Preconception to Delivery.

Pregnant patients over age 40 often have unique risk factors and potential complications before and during pregnancy that play a role in their counseling and management. To provide practitioners an overview on how to approach preconception evaluation and counseling, prenatal care, and management of associated comorbidities, as well as potential complications, in pregnant patients over age 40. Literature review was performed using OVID and PubMed, with further relevant information queried from guidelines of professional organizations. Pregnant patients over age 40 should receive preconception evaluations by their obstetrician-gynecologist and other appropriate specialty care providers as they pertain to preexisting medical comorbidities. In the preconception period, attention should be given to managing and optimizing preexisting medical conditions and associated pharmacotherapeutics. Referral to specialists in assisted reproductive technologies or maternal-fetal medicine should be considered if indicated for appropriate evaluation and counseling. During pregnancy, accurate dating and counseling on aneuploidy screening, with consideration for early diabetes screening, should be performed in the first trimester. A detailed anatomy scan and fetal echocardiogram should be completed by 22 weeks' gestation, along with routine and high-risk (if indicated) prenatal care. Close attention should be given to the development of pregnancy-related complications associated with advancing age. Third-trimester fetal surveillance can be considered. Given that no contraindications exist, these patients should be encouraged to pursue a vaginal delivery with consideration for induction at 39 to 40 weeks' gestation. Pregnancy rates are increasing in persons over age 40. As a result, preconception evaluation and counseling tailored to that demographic are essential. In addition to standard prenatal care, they should have early screening and diligent monitoring for pregnancy-related comorbidities associated with advancing age. With the increased pregnancy-associated comorbidities in patients over age 40, providers should be familiar with how to evaluate, counsel, and manage them during the preconception and pregnancy periods.

INSULIN RESISTANCE & INFERTILITY: ASSESSING THE SIGNIFICANCE OF INSULIN RESISTANCE AMONG WOMEN SEEKING FERTILITY CARE

To assess prevalence and significance of insulin resistance (IR) among women seeking fertility care Retrospective cohort study A database query was performed on patients aged 18 to 47 of the Reproductive Endocrinology and Infertility division from 2014 to 2020 who had a hemoglobin A1c (A1c) value. All women who present to this office are screened with a A1c if their BMI is >25kg/m2. Data was correlated to in vitro fertilization (IVF) data. Insulin resistance was defined per the American Diabetes Association. Statistical analysis was performed using student’s T test, ANOVA, or chi square. Linear and logistic regression were used to adjust for confounding variables. 3170 women were included in the study. The prevalence of IR was 17.9% and diabetes was 2.7%. Mean A1c value was 5.4 +/- 0.58. After adjusting for age, a higher body mass index (BMI) (OR 1.12, 95% CI 1.11-1.14, P<.001) and a non-white race (OR 2.38 95% CI 1.97-2.89, P<.001) were predictive of an elevated A1c. IR was significantly associated with increased total gonadotropin dose (P = 0.02), but was not associated with worse IVF outcomes, such as number of oocytes retrieved, pregnancy or live birth rate after adjusting for age and anti-Mullerian hormone (AMH). IR was not associated with any particular diagnosis of infertility. Of the 464 women with IR who conceived and received care in our hospital system, 18% (102) developed gestational diabetes (GDM), compared to 6.9% (173/2345) of women without IR.Tabled 1Normal (A1c < 5.7)Insulin Resistance (A1c 5.7-6.4)Diabetes (A1c 6.5+)p-valueAge34.33 (+/- 4.40)34.86 (+/- 5.11)35.16 (+/- 5.51)0.02BMI26.18(+/- 6.18)32.39(+/- 8.12)34.32(+/- 9.77)<0.001Normal (18.5-24.9)1238 (90.6%)117(8.6%)12(0.9%)Overweight (25-29.9)662(82.9%)116(14.5%)21(2.6%)Obese (30+)514 (58.2%)319(36.1%)50(5.7%)Race0.00White1488(85.9%)214(12.4%)30(1.7%)Non-White629(66.7%)265(28.1%)49(5.2%)AMH4.00(+/- 4.28)3.89(+/- 3.88)2.90(+/- 2.74)NSTSH1.88(+/- 1.20)2.09(+/- 3.55)2.25(+/- 2.01)0.02Total Gonadotropins2661.92(+/- 1279.42)2898.40(+/- 1337.10)3359.09(+/- 1446.60)0.02Total Oocytes14.91(+/- 9.57)14.65(+/- 9.66)13.60(+/- 7.91)NSFrozen Blasts4.21(+/- 3.44)4.01(+/- 3.18)3.20(+/- 2.78)NSNS = non-significant Open table in a new tab Insulin resistance is a common finding among women seeking fertility treatment, especially when BMI is >30kg/m2, and should be considered during preconception evaluation. While IR was not associated with worse IVF outcomes, patients with IR may require higher doses of gonadotropins and have a higher risk of GDM. Preconception evaluation and lifestyle counseling provide a unique and motivational opportunity to improve pregnancy and long term health outcomes.

Systemic Lupus Erythematosus Treatment in Pregnancy: Case Study

Abstract Systemic lupus erythematosus is a chronic inflammatory autoimmune disease with high prevalence in female in reproductive age. In recent years the prognosis of pregnant patients with SLE has improved significantly. Even though the treatment options have improved, the risk of flares, preeclampsia, pregnancy loss, and premature labours remains high compared to healthy women. The aim of this article is to offer a review of current treatment options in pregnant patients with SLE and to present a case report of 32-year-old patient with newly diagnosed acute outbreak of SLE, who experienced a life-threatening multisystem flare at 24 weeks of gestational age. This case represents one of the most extreme manifestations of lupus disease activity associated with pregnancy that has been reported in literature and emphasizes the importance of preconception evaluation and counseling and amultidisciplinary management approach in cases with a complex and evolving clinical course.

Dietary patterns and ovarian reserve among women attending a fertility clinic

To investigate the associations between dietary patterns and antral follicle count (AFC), a marker of ovarian reserve. Prospective cohort study. Fertility center at an academic hospital. A total of 363 women seeking preconception evaluation and infertility care at the Massachusetts General Hospital who participated in the Environment and Reproductive Health Study. None. At enrollment, women reported diet through a food frequency questionnaire, from which we computed three dietary pattern adherence scores: the Mediterranean diet, the Fertility diet, and the Profertility diet. The AFC was assessed with a transvaginal ultrasound performed on the third day of an unstimulated menstrual cycle or on the third day of a P withdrawal bleed. Higher adherence to the three dietary patterns examined were unrelated to AFC. The multivariable adjusted AFC means and 95% confidence intervals for women in the highest compared with the lowest quartile of adherence score were 13.9 (13.0-14.9) and 13.5 (12.6-14.4) for the Mediterranean diet, 14.0 (13.2-14.9) and 13.5 (12.7-14.3) for the Fertility diet, and 12.5 (11.6-13.5) and 13.3 (12.5-14.2) for the Profertility diet. Dietary patterns were unrelated to AFC among a cohort of women presenting at a fertility center. Due to the limited and heterogeneous current evidence, it is important to evaluate this association in further studies, and in particular among women from the general population.

Serum 25 hydroxyvitamin D levels and affecting factors among preconception fertile women

BackgroundRecent study found that vitamin D before conception was considered as a potential additional determinant for achieving pregnancy and live births. The study aimed to evaluate the serum 25 hydroxyvitamin D (25(OH)D) levels and its affecting factors among preconception fertile women.MethodsThis cross-sectional study enrolled 410 women aged 22–44 years who attended a preconception genetic counseling clinic from January 2018 to May 2019. Sociodemographic characteristics and reproductive history of women were collected, and height and weight were measured. Serum 25(OH)D concentration was assayed with chemiluminescence immunoassay. Descriptive statistics were used to examine serum 25(OH)D concentration, and socio-demographic characteristics and reproductive history among preconception women. Determinants of vitamin D deficiency and its affecting factors were assessed using χ2 test and logistic regression.ResultsFindings showed 84.4% of women had serum 25(OH)D concentration below 20 ng/mL. Women working indoors as well as without a history of childbirth had significantly lower 25(OH)D levels compared with those non-working individuals and having delivered a previous child (both P < 0.05). The 25(OH)D levels were the lowest in winter among that in spring, summer, and autumn (all P < 0.001). Women in winter have significantly elevated OR of 5.00 (95%CI 1.75–14.25) to develop vitamin D deficiency. Seasonal variation in serum 25(OH)D levels was not present in non-working individuals and women aged 31–44 years.ConclusionsVitamin D deficiency is common among preconception women especially nulliparous women and working women, which propose to screen serum 25(OH)D on preconception evaluation and emphasize need vitamin D supplements and get sunshine exposure.

Preconception Evaluation Before In Vitro Fertilization.

Infertility poses a substantial public health problem for women of reproductive age, in the United States and globally. Infertility can be overcome with a variety of emerging assisted reproductive technologies (ARTs). In vitro fertilization (IVF) currently represents the most commonly utilized method of ART and is typically associated with the highest clinical pregnancy rate and live birth rate compared with other infertility treatment options. However, proper preconception evaluation and counseling is paramount for optimizing IVF and pregnancy outcomes. This article aims to outline current guidelines and recommendations for comprehensive preconception evaluation before initiation of IVF. Articles were obtained from PubMed, ACOG committee opinions 781 and 762, and relevant textbook chapters. A variety of recommendations and best practices exist for optimally managing patients seeking IVF. Special attention must be paid to the workup of certain patient populations, such as those with age older than 35 years, uterine abnormalities, comorbidities (especially hypertension, diabetes, and thrombophilias), and obesity. In addition, many lifestyle factors must be addressed before IVF initiation, such as smoking, illicit drug use, and inadequate nutrition. Preconception counseling and expectation management is key to optimizing pregnancy outcome. A myriad of patient and environmental factors impact the potential success rates of IVF in treating infertility. Providers must be equipped to provide data-driven, patient-centered counseling before initiation of IVF.

Fertility preservation with successful pregnancy outcome in a patient with transplanted heart and non-Hodgkin\u2019s lymphoma \u2013 a case report

Background: Fertility preservation must be discussed with reproductive age women before cancer treatment. Heart transplantation raises complex issues in pregnancy. Pregnancy in a heart transplant woman after pelvic irradiation involves close multidisciplinary follow-up to avoid complications in the mother and the foetus. We report the first live birth in a heart transplant woman after pelvic irradiation, chemotherapy and fertility preservation.Case presentation: A 36-year-old heart transplant woman with pelvic non-Hodgkin lymphoma spared her fertility, with cryopreservation of oocytes and embryos, before chemotherapy and pelvic irradiation. After multidisciplinary discussion and pre-conception evaluation, pregnancy was achieved. A close follow-up by a multidisciplinary team allowed a normal pregnancy without maternal or foetal complications and the delivery of a healthy infant.ConclusionsAchieving pregnancy in heart transplant women with iatrogenic ovarian failure after oncologic treatment including pelvic irradiation is possible and can be successful. Careful and close surveillance by a multidisciplinary team is mandatory due to increased risk of maternal and foetal complications.

Laparoscopic Relocation of the Ovaries After Prior Transposition

Video Objective To describe the indications, surgical approaches and expected outcomes for ovarian transposition and highlight a case of ovarian relocation to the pelvis in a patient who underwent prior transposition. Setting A 34 year old patient with a history of metastatic spinal ependymoma underwent laparoscopic ovarian transposition prior to craniospinal radiation. Eleven years after her transposition, she was seen by reproductive endocrinology and infertility for preconception counseling and evaluation. Her follicle stimulating hormone levels were within normal limits, but her hysterosalpingogram demonstrated bilateral tubal isthmic occlusion. She was referred to minimally invasive gynecologic surgery for surgical consultation. Interventions The patient was taken to the operating room for operative laparoscopy, ovarian relocation to the pelvis and evaluation of her fallopian tubes. Intraoperative findings were notable for transposition of the bilateral ovaries and fallopian tubes to the lateral abdominal peritoneum. Adhesiolysis was performed to mobilize each ovary on its vascular pedicle. Without compromise to the ovarian blood supply, and in a tension-free manner, each ovary was sutured to the ipsilateral round ligament. Conclusion Laparoscopic ovarian transposition is an important surgical technique to aid preservation of ovarian function in reproductive aged women undergoing pelvic radiation. Gynecologic surgeons should be aware of the techniques to perform ovarian transposition, as well as relocation of the ovaries to the pelvis for future spontaneous or assisted reproduction. Knowledge of abdominal and pelvic anatomy, as well as proficiency in laparoscopic suturing are essential to perform ovarian transposition and relocation in a minimally invasive fashion.

Subsequent Pregnancy in Peripartum Cardiomyopathy- Is the Answer Always No?

Background Peripartum cardiomyopathy (PPCM) is a rare form of heart failure (HF) afflicting 1 in every 968 pregnancies and one of the leading causes of maternal morbidity in the United States. Women with PPCM are often counseled to avoid subsequent pregnancy based on limited data. Preconception evaluation (PCE) with stress echocardiography (SE) may allow clinicians to risk stratify patients with cardiomyopathy (CM) and guide therapies to improve pregnancy outcomes. Methods 40 women with CM, including 24 with PPCM, were referred to our program for either PCE with SE or medical management during a subsequent pregnancy and were categorized as either low or high risk of developing recurrent HF. Serial resting echocardiograms and cardiology clinic evaluation was recommended, medical interventions, change in cardiac function, and maternal and fetal outcomes were monitored. Results 12 PPCM patients had PCE, 6 deemed high risk with close monitoring and medical intervention (initiation of beta blocker or digoxin therapy) for all except one patient who did not follow up as recommended, she subsequently developed recurrent HF within 6 months postpartum. Of the 6 low risk PPCM patients, one developed HF despite being asymptomatic during pregnancy. Four women were started on beta blockade, hydralazine, and digoxin as indicated during cardiology clinic visits, Among all patients with CM, initiation of digoxin during pregnancy was associated with a 67% incidence of augmented EF and 33% subclinical improvement or unchanged EF. None had reduced EF. Discussion PCE may have risk stratification utility not only for PPCM patients, but also other CM cohorts who seek a successful pregnancy. In women with unknown risk, initiation of appropriate medications such as digoxin resulted in improved function and lower risk of maternal or fetal complications.

Choosing Pre-conception Planning for Women/Families: Counselling and Informed Consent (Part 2) - Pre-conception Reproductive Planning, Lifestyle, Immunization, and Psychosocial Issues.

To inform reproductive and other health care providers about pre-conception evaluation, including considerations for reproductive planning, lifestyle modification, immunization status and attitudes, and psychosocial issues. This counselling information can be used for patient education and planning and possible pre-conception and/or prenatal testing. This information may allow for improved risk assessment when pre-conception counselling for individual patients and their families is used. CONSIDERATIONS FOR PRE-CONCEPTION CARE (PART 2) REGARDING PRE-CONCEPTION REPRODUCTIVE PLANNING, LIFESTYLE, IMMUNIZATIONS, AND PSYCHOSOCIAL ISSUES: CONSIDERATION FOR CARE STATEMENTS: For this review article, the Consideration for Care Statements use the Grading of Recommendations, Assessment, Development and Evaluations strength and quality principles because they are comparable for the clinician and the patient/public user. For example, "Strong" for clinicians is defined as "the recommendation would apply to most individuals. Formal discussion aids are not likely to be needed to help individuals make decisions consistent with their values and preferences." For patients/the public, "Strong" is defined as, "we believe most people in this situation would want the recommended course of actions and only a small number would not." Quality of evidence (High, Moderate, Low) is based on the confidence that the true effect lies close to that of the estimate of the effect. In addition, the Canadian Task Force on Preventive Health Care key to evidence statements and grading of recommendations are included. PubMed, Medline, and the Cochrane Database were searched until May 2017, using appropriate key words (i.e., preconception, reproductive planning, lifestyle modification, immunization risks and benefits, psychosocial pregnancy factors/issues). Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. The benefits for the patient and her family from receiving this pre-conception counseling would include an increased understanding of the relevant issues for both pre-conception and in early pregnancy as well as better pregnancy outcomes. Harm includes potential increased anxiety or psychological stress associated with the possibility of identifying maternal pregnancy risks.

Woman's Pre-Conception Evaluation: Genetic and Fetal Risk Considerations for Counselling and Informed Choice.

To inform reproductive and other health care providers about genetic and fetal risk information to consider during a woman/couples' pre-conception evaluation, including considerations for genetic risk assessment, genetic screening, or testing to allow for improved counselling and informed choice. This genetic information can be used for patient education, planning, and possible pre-conception and/or prenatal testing. This information may allow improved risk assessment for pre-conception counselling for individual patients and their families. PubMed or Medline and the Cochrane Database were searched in May 2017 using appropriate key words ("pre-conception," "genetic disease," "maternal," "family history," "genetic," "health risk," "genetic health surveillance," "prenatal screening," "prenatal diagnosis," "birth defects," and "teratogen"). Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. The benefits for the patient and her family include an increased understanding of relevant genetic risk pre-conception and in early pregnancy, and better pregnancy outcomes as a result of use of the information. The harm includes potential increased anxiety or psychological stress associated with the possibility of identifying genetic risks. The evidence obtained was peer-reviewed by the Genetics Committee of The Society of Obstetricians and Gynaecologists of Canada. Consideration for Care Statements For this review article, the Consideration for Care Statements use the GRADE strength and quality as it is comparable for the clinician and the patient/public user. [GRADE from the Canadian Task Force on Preventive Health Care (www.canadiantaskforce.ca). For clinicians, Strong = The recommendation would apply to most individuals. Formal discussion aids are not likely to be needed to help individuals make decisions consistent with their values and preferences. For patients/public, Strong = We believe most people in this situation would want the recommended course of actions and only a small number would not. Quality of evidence (High, Moderate, Low) based on the confidence that the true effect lies close to that of the estimate of the effect.] Conclusion Pre-conception planning is presently underutilized by both patients and providers. Pre-conception genetic assessment is only a part of the counselling, education, and health management change that can improve perinatal and maternal morbidity and mortality. A published literature review on pre-conception genetic counselling identified mainly clinical cohort studies, surveys, and expert opinion with no RCTs. There is strong support for pre-conception counselling and moderate quality based on the understanding that most individuals would support and use pre-conception counselling when choice, timing, and ease of access is considered.

Management of pregnancy in cardiomyopathies and heart failure.

Pregnancy exposes women with inherited cardiomyopathies to increased risk for arrhythmias and heart failure. In asymptomatic patients with inherited cardiomyopathies, pregnancy is generally well tolerated. Preconception evaluation, risk assessment and proper counseling by a team of experienced physicians are mandatory in managing women with inherited cardiomyopathies planning pregnancy. In this paper, we reviewed the clinical course, risk assessment and management during pregnancy of women with cardiomyopathies.

Reproductive Issues of Women with Epilepsy

There are about 10 million people with epilepsy in India and a quarter of them are women in reproductive age group. The social stigma of epilepsy has pervasive impact on the life of people with epilepsy particularly women. The cyclical hormonal changes during menstrual cycle and during pregnancy can influence the seizure pattern in women with epilepsy. Exposure to antiepileptic drugs (AEDs) can increase the risk of fetal malformations in the infants. This risk is higher with polytherapy and valproate in higher doses. A small proportion of children with antenatal AED exposure can have problems with cognitive development. All women with epilepsy need to have preconception evaluation to simplify the treatment of epilepsy. It is preferable to avoid valproate as an AED antiepileptic drug in women who are planning pregnancy.

Fetal outcome and recommendations of pregnancies in lupus nephritis in the 21st century. A prospective multicenter study

The aim of this multicenter study was to assess the present risk of fetal complications and the inherent risk factors in pregnant women with lupus nephritis.Seventy-one pregnancies in 61women (59 Caucasians and 2 Asians) with lupus nephritis were prospectively followed between October 2006 and December 2013. All patients received a counselling visit within 3 months before the beginning of pregnancy and were followed by a multidisciplinary team. At baseline mild active nephritis was present in 15 cases (21.1%).Six pregnancies (8.4%) resulted in fetal loss. Arterial hypertension at baseline (P = 0.003), positivity for lupus anticoagulant (P = 0.001), anticardiolipin IgG antibodies (P = 0.007), antibeta2 IgG (P = 0.018) and the triple positivity for antiphospholipid antibodies (P = 0.004) predicted fetal loss.Twenty pregnancies (28.2%) ended pre-term and 12 newborns (16.4%) were small for gestational age. Among the characteristics at baseline, high SLE disease activity index (SLEDAI) score (P = 0.027), proteinuria (P = 0.045), history of renal flares (P = 0.004), arterial hypertension (P = 0.009) and active lupus nephritis (P = 0.000) increased the probability of preterm delivery. Odds for preterm delivery increased by 60% for each quarterly unit increase in SLEDAI and by 15% for each quarterly increase in proteinuria by 1 g per day. The probability of having a small for gestational age baby was reduced by 85% in women who received hydroxychloroquine therapy (P = 0.023).In this study, the rate of fetal loss was low and mainly associated with the presence of antiphospholipid antibodies. Preterm delivery remains a frequent complication of pregnancies in lupus. SLE and lupus nephritis activity are the main risk factors for premature birth. Arterial hypertension predicted both fetal loss and preterm delivery.Based on our results the key for a successful pregnancy in lupus nephritis is a multidisciplinary approach with close medical, obstetric and neonatal monitoring. This entails: a) a preconception evaluation to establish and inform women about pregnancy risks; b) planning pregnancy during inactive lupus nephritis, maintained inactive with the lowest possible dosage of allowed drugs; c) adequate treatment of known risk factors (arterial hypertension, antiphospholipid and antibodies); d) close monitoring during and after pregnancy to rapidly identify and treat SLE flares and obstetric complications.

Fertility and Pregnancy in Turner Syndrome.

Turner syndrome (TS) occurs in one in 2500 live female births and is one of the most common chromosomal abnormalities in women. Pregnancies in women with TS, conceived with either autologous or donated oocytes, are considered high risk because of the associated miscarriages and life-threatening cardiovascular complications (aortic dissection, severe hypertension). Therefore, it is imperative to conduct a full preconception evaluation and counselling that includes cardiac assessment with Holter blood pressure monitoring, echocardiography, and thoracic MRI. Abnormal findings, such an aortic dilatation, mandate close monitoring throughout the pregnancy and the immediate postpartum period and could possibly contraindicate pregnancy. When invitro fertilization using donated oocytes is performed in these women, only a single embryo should be transferred. Women with a Turner mosaic karyotype appear to have a lower risk of obstetrical and cardiovascular complications but should nevertheless undergo the full preconception evaluation. In this article, we offer guidelines on the management of women with TS in the preconception period, during pregnancy, and postpartum.