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When the First Trimester is Too Late

My first patient of the day arrives. I open her chart to review and notice it’s an initial prenatal visit — my favorite. I’m thankful that the clinic I’m working at orders the initial set of prenatal labs in advance. I notice a hemoglobin level of 9.6 with an MCV of 74. The collection date was two weeks ago, and it doesn’t appear the clinician who signed these off recommended any follow-up testing. I make a mental note to order a hemoglobin electrophoresis.  

The patient is still getting her vitals taken so I decide to dig a bit deeper into her history. A procedure note three months earlier shows that her last visit was for an IUD removal. “Patient desires pregnancy,” is noted as the reason for removal. There is no mention that the clinician recommended a preconception visit, nor any mention that they recommended a prenatal vitamin. I feel my frustration growing at this classic failure of our health care system. This isn’t the first time we’ve missed an opportunity to provide preconception care, and I know it won’t be the last. I take a deep breath before I walk into the exam room. 

I make my way through the prenatal history taking component of our visit and discover her mother has a thyroid condition. The Endocrine Society recommends women with a familial thyroid history be screened as well. I make another mental note to add on a TSH. The gnawing annoyance that this wasn’t ordered at the time of her IUD removal returns. The Endocrine Society even makes a note about aggressive case-finding before pregnancy in their guidelines.  We all know how important normal thyroid hormone levels are in early pregnancy, right? Deep breath. Maybe not. 

Out of curiosity, I asked the patient whether she spoke to the clinician about her pregnancy plans at the last visit. She laughs a bit and responds, “Well of course, that’s why I asked to have my IUD removed!”

“What did she say when you told her that?” I asked.

“She removed my IUD and wished me luck!”

“Any mention of scheduling a preconception visit?” I asked.

She asked what that means. I took that as a no. 

I took another deep breath and moved onto reviewing her labs. The patient was unaware that she has anemia. I looked back at the call logs and realized one of the medical assistants made a single call attempt but couldn’t reach the patient and no voicemail was left. She never tried again. “Well, that’s two weeks wasted,” I thought to myself and took another deep breath. I explained to the patient my recommendation for additional testing per American College of Obstetricians and Gynecologists (ACOG)’s guidelines. In the meantime, I prescribed her iron pills. I mentally cringed as I remembered the article I read last year that showed an association between anemia in the first trimester and an increased risk of preterm labor. I said a silent prayer that she doesn’t suffer that outcome and finished up our visit with an exam.

I moved onto my next patient. Another initial prenatal visit. I review the labs — rubella non-immune.

In 1989, the NIH published the first national guideline that presented preconception care “as a normal part of women’s health care.” Developed by a panel of experts, the publication recommended that the first prenatal visit occur before conception and include risk assessment of any woman planning a pregnancy. In this guideline, risk assessment is specified to include three components: a history, a physical exam, and laboratory tests.

Since that time, a plethora of research has been published on the topic, including reference to the preconception period in several guidelines from major medical organizations. Yet few women can ever recall their clinician discussing preconception care with them, and a significantly smaller number ever receive preconception screening. 

While much of medicine in the 21st century has moved towards a patient-centered, preventative model, preconception care has been largely ignored in clinical practice. In fact, the ACOG presented a lecture on primary prevention of maternal and fetal complications at their annual meeting in 2018. They chose to highlight contraception as the method of primary prevention of pregnancy complications, much to the chagrin of women’s health advocates around the country. I wondered to myself how contraception fits into the picture of primary prevention for a woman who desires pregnancy. 

Today, we boast the highest rates of planned pregnancies in the history of the U.S. and yet, we have no mechanism in place as clinicians to actually support the planning of those pregnancies. We give false reassurances about a woman being “healthy” without any actual risk assessment to support that assumption. We tell women to start a prenatal vitamin as we run out to see another patient. Primary prevention of pregnancy complications is not birth control. It’s preconception care. Women now come to us because they realize this. So, why don’t we?

Kristy Goodman earned a B.S. in exercise science with a minor in health and wellness from the University at Buffalo, and completed a dual-degree program at the University of Medicine and Dentistry of New Jersey. She also earned an MS in PA studies and an MPH in health education and behavioral science. Kristy completed a postgraduate fellowship in ob/gyn and has worked in a variety of women's health settings providing preconception and prenatal care, emergency obstetric triage, labor and delivery services, and infertility evaluation and treatment. Conflict of interest: Kristy Goodman is the co-founder and CEO of PreConception Inc.

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