Ten years of experience in periconceptional care

Family Planning and Preconception Care Service Management: The Key Role of Bulgarian GPs

Assisting women in attaining their reproductive goals is crucial for improving the well-being of families and children. As the first point of contact for healthcare, general practitioners (GPs) are ideal for family planning (FP) and preconception care (PCC). However, primary care interventions' efficacy is unclear. The aim of this study was to examine GPs' knowledge, attitudes, and perspectives on FP and PCC service management. Most GPs were aware of FP and PCC services and held a firm conviction that they should be primarily accountable together with obstetrician-gynaecologists. However, it is worth noting that less than 50% of respondents reported receiving thorough and comprehensive knowledge of their respective specialities. Those with general medicine qualifications demonstrated a high level of commitment to providing such services. The women's GPs and those with training in general medicine prescribed birth control pills and emergency contraception three times more frequently than the other doctors who suggested condoms or traditional methods or referred patients to another specialist (p < 0.05). In conclusion, PCC is of the utmost importance, and its effective implementation demands the collaboration of policymakers, healthcare providers, and individuals. GPs are essential in managing FP and PCC. They must incorporate more in-depth PCC into their clinical practice.

Addressing reproductive health needs across the life course: an integrated, community-based model combining contraception and preconception care

Prevention of pregnancy (contraception) and preparation for pregnancy (preconception care) are services that most people need during their reproductive life course. Despite increased attention, and growing recognition that health before pregnancy is crucial to addressing disparities in maternity outcomes, service provision is far from routine. We bring together evidence from the literature, new quantitative and qualitative data on women's preferences, and case studies of existing practice, to develop an integrated, community-based model that synthesises reproductive life planning, contraception, and preconception care. Our model provides a holistic, life course approach, encompassing school-based education, social media, and national campaigns, and highlights the need for training and system-level support for the range of health-care professionals who can deliver it. This high-level model can be adapted across settings, leading to a step change in the provision of preconception care in the community with consequent improvements in health and wellbeing, and reductions in inequalities at population level.

Review of Evidence for Environmental Causes of Uveal Coloboma

Uveal coloboma is a condition defined by missing ocular tissues and is a significant cause of childhood blindness. It occurs from a failure of the optic fissure to close during embryonic development,and may lead to missing parts of the iris, ciliary body, retina, choroid, and optic nerve. Because there is no treatment for coloboma, efforts have focused on prevention. While several genetic causes of coloboma have been identified, little definitive research exists regarding the environmental causes of this condition. We review the current literature on environmental factors associated with coloboma in an effort to guide future research and preventative counseling related to this condition.

Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes

Preconception health care is heralded as an essential method of improving pregnancy health and outcomes. However, access to health care for low-income US women of reproductive age has been limited because of a lack of health insurance. Expansions of Medicaid program eligibility under the Affordable Care Act (as well as prior expansions in some states) have changed this circumstance and expanded health insurance coverage for low-income women. These Medicaid expansions provide an opportunity to assess whether obtaining health insurance coverage improves prepregnancy and pregnancy health and reduces prevalence of adverse pregnancy outcomes. We tested this hypothesis using vital statistics data from 2011-2017 on singleton births to female US residents aged 15-44 years. We examined associations between preconception exposure to Medicaid expansion and measures of prepregnancy health, pregnancy health, and pregnancy outcomes using a difference-in-differences empirical approach. Increased Medicaid eligibility was not associated with improvements in prepregnancy or pregnancy health measures and did not reduce the prevalence of adverse birth outcomes (e.g., prevalence of preterm birth increased by 0.1 percentage point (95% confidence interval: -0.2, 0.3)). Increasing Medicaid eligibility alone may be insufficient to improve prepregnancy or pregnancy health and birth outcomes. Preconception programming in combination with attention to other structural determinants of pregnancy health is needed.

Preconception care practices in Nigeria: a descriptive qualitative study

Background

Preconception care is a specialized care targeted at women of reproductive age before pregnancy to detect, treat or counsel them about pre-existing medical and social conditions that may militate against safe motherhood and positive pregnancy outcome. In spite of the known need for preconception care in Nigeria, routine preconception care services are not available in the country. This study explores existing preconception care practices in the country in order to encourage building on it and formalising it for inclusion in routine maternal and child health services in the country.

Methods

Forty-one in-depth interviews and 10 focus group discussions were conducted in this descriptive qualitative study to explore the existing preconception care services from the perspectives of community members (women and men in the reproductive age group), community and religious leaders, health care professionals as well as policy makers. Thematic analysis was carried out using MAXQDA 2018.

Results

Participants stated that there are no defined preconception care services in the health care system nor are there any structures or guidelines for preconception care in the country. Preconception care services are however provided when health workers perceive a need or when clients demand for it. The services provided include health information, education and counselling, treatment modification, medical check-up and screening. Outside of the health system, there are some traditional, religious and other practices with similar bearing to preconception care which the participants believed could be included as preconception care services. These include premarital counselling services by religious bodies, family life and HIV education within the secondary school system and some screening and outreach services provided by non-governmental and some governmental agencies.

Conclusion

There is a need to provide structure and guidelines for preconception care services in the country so that the services can be properly streamlined. This structure can also involve practices that are currently not within the health system.

Profile of Mothers of Children with Fetal Alcohol Spectrum Disorder: A Population-Based Study in Canada

Objective: To compare the characteristics of mothers of children with Fetal Alcohol Spectrum Disorder (FASD) with mothers of typically developing control children. Methods: The study utilized a cross-sectional, observational design, using active case ascertainment. Biological mothers were interviewed using a standardized retrospective questionnaire to collect data on demographics, living environment, pregnancy history, nutrition, alcohol and other drug use prior to and following pregnancy recognition. Results: A total of 173 mothers were interviewed. Of these, 19 had a child who was diagnosed with FASD, five had a child who had received a deferred FASD diagnosis, and 37 had children who were selected into the control group as typically developing children. The remaining 112 mothers had children who did not meet diagnostic criteria for FASD. The mothers of children with FASD did not differ significantly from mothers of the control group children with respect to age, ethnicity, marital status, and employment status at the time of pregnancy. However, mothers of children with FASD had lower levels of education (p < 0.01) and were more likely to have received financial support (p < 0.05) at the time of pregnancy, to have smoked tobacco (p < 0.001), and to have used marijuana or hashish (p < 0.01) prior to pregnancy recognition, compared with mothers of control children. All mothers of children with FASD reported alcohol consumption prior to pregnancy recognition; however, only 10.5% reported alcohol consumption following pregnancy recognition. None of the mothers interviewed reported any drug use following pregnancy recognition. Conclusions: Population-based preventive interventions, including repeated screening, monitoring, and education regarding the effects of alcohol use, as well as other substances, before and during pregnancy, are needed to eliminate risk for FASD and other negative consequences on child and maternal health.

Physical Exertion Immediately Before Early Preterm Delivery: A Case-Crossover Study

BACKGROUND

Occupational exertion is associated with a higher risk of preterm delivery, although studies of leisure time activities generally document reduced risks. Less is known about the risk of preterm delivery immediately following episodes of moderate or heavy physical exertion.

METHODS

We conducted a case-crossover study of 722 women interviewed during their hospital stay for early preterm delivery, defined by a gestational age before 34 weeks, and after 20 weeks. Interviews occurred between March 2013 and December 2015 in seven hospitals in Lima, Peru.

RESULTS

The incidence rate ratio (RR) of early preterm delivery was 5.82-fold higher (95% confidence interval [CI] = 4.29, 7.36) in the hour following moderate or heavy physical exertion compared with other times and returned to baseline in the hours thereafter. The RR of early preterm delivery within an hour of physical exertion was lower for exertion at moderate intensity (RR = 2.43; 95% CI = 1.50, 3.96) than at heavy intensity (RR = 23.62; 95% CI = 15.54, 35.91; P-homogeneity < 0.001). The RR of early preterm delivery was lower in the hour following moderate physical exertion among women who habitually engaged in physical exertion >3 times per week in the year before pregnancy (RR = 1.56; 95% CI = 0.81, 3.00) compared with more sedentary women (RR = 6.91; 95% CI = 3.20, 14.92; P-homogeneity = 0.003).

CONCLUSIONS

Our study showed a heightened risk of early preterm delivery in the hour following moderate or heavy physical exertion.

Preconception counselling for low health literate women: an exploration of determinants in the Netherlands

Background

Women from lower socioeconomic groups tend to be at greater risk of adverse perinatal outcomes, but are less likely to participate in preconception counselling compared to higher socioeconomic groups. This could be partly because of their limited skills to assess, understand and use health related information in ways that promote and maintain good health (health literacy skills). In this study we explored determinants of participation in preconception counselling among women with low health literacy in The Netherlands.

Methods

Potential determinants of participation in preconception counselling were derived from the literature, and mapped onto a theoretical framework, which was tested for perceived relevance and completeness in an expert review (n = 20). The framework was used to prepare face-to-face interviews with women with low health literacy and a wish to conceive (n = 139). In the interviews we explored preconception counselling awareness, knowledge, considerations, subjective norms, self-efficacy, attitude, and intention. Linear regression analyses were used to test associations with intention to participate in preconception counselling.

Results

Most women (75%) were unaware of the concept of preconception counselling and the provision of counselling, even if they lived in areas where written invitations had been disseminated. Common considerations for participation were: preparation for pregnancy; perceived lack of information; and problems in a previous pregnancy. Considerations not to participate were mostly related to perceived sufficient knowledge and perceived low risk of perinatal problems. Respondents generally had a positive attitude towards participation in preconception counselling for themselves, and 41% reported that they would participate in preconception counselling.

Conclusion

Women with low health literacy were generally unaware of the concept and provision of preconception counselling, but seemed to be interested in participation. Further research should investigate how to effectively reach and inform this group about preconception counselling. This knowledge is essential for evidence-based development of interventions to increase the accessibility and understanding of preconception counselling.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0617-1) contains supplementary material, which is available to authorized users.

General practitioners' knowledge, attitudes and views of providing preconception care: a qualitative investigation

BACKGROUND

Preconception health and care aims to reduce parental risk factors before pregnancy through health promotion and intervention. Little is known about the preconception interventions that general practitioners (GPs) provide. The aim of this study was to examine GPs' knowledge, attitudes, and views towards preconception health and care in the general practice setting.

METHODS

As part of a large mixed-methods study to explore preconception care in England, we surveyed 1,173 women attending maternity units and GP services in London and interviewed women and health professionals. Seven GPs were interviewed, and the framework analysis method was used to analyse the data.

FINDINGS

Seven themes emerged from the data: Knowledge of preconception guidelines; Content of preconception advice; Who should deliver preconception care?; Targeting provision of preconception care; Preconception health for men; Barriers to providing preconception care; and Ways of improving preconception care. A lack of knowledge and demand for preconception care was found, and although reaching women before they are pregnant was seen as important it was not a responsibility that could be adequately met by GPs. Specialist preconception services were not provided within GP surgeries, and care was mainly targeted at women with medical conditions. GPs described diverse patient groups with very different health needs.

CONCLUSION

Implementation of preconception policy and guidelines is required to engage women and men and to develop proactive delivery of care with the potential to improve pregnancy and neonatal outcomes. The role of education and of nurses in improving preconception health was acknowledged but remains under-developed.

Effects and safety of periconceptional oral folate supplementation for preventing birth defects

BACKGROUND

It has been reported that neural tube defects (NTD) can be prevented with periconceptional folic acid supplementation. The effects of different doses, forms and schemes of folate supplementation for the prevention of other birth defects and maternal and infant outcomes are unclear.

OBJECTIVES

This review aims to examine whether periconceptional folate supplementation reduces the risk of neural tube and other congenital anomalies (including cleft palate) without causing adverse outcomes in mothers or babies. This is an update of a previously published Cochrane review on this topic.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015). Additionally, we searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 August 2015) and contacted relevant organisations to identify ongoing and unpublished studies.

SELECTION CRITERIA

We included all randomised or quasi-randomised trials evaluating the effect of periconceptional folate supplementation alone, or in combination with other vitamins and minerals, in women independent of age and parity.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy and assessed the risk of bias of the included studies. We assessed the quality of the body of evidence using the GRADE approach.

MAIN RESULTS

Five trials involving 7391 women (2033 with a history of a pregnancy affected by a NTD and 5358 with no history of NTDs) were included. Four comparisons were made: 1) supplementation with any folate versus no intervention, placebo or other micronutrients without folate (five trials); 2) supplementation with folic acid alone versus no treatment or placebo (one trial); 3) supplementation with folate plus other micronutrients versus other micronutrients without folate (four trials); and 4) supplementation with folate plus other micronutrients versus the same other micronutrients without folate (two trials). The risk of bias of the trials was variable. Only one trial was considered to be at low risk of bias. The remaining studies lacked clarity regarding the randomisation method or whether the allocation to the intervention was concealed. All the participants were blinded to the intervention, though blinding was unclear for outcome assessors in the five trials.The results of the first comparison involving 6708 births with information on NTDs and other infant outcomes, show a protective effect of daily folic acid supplementation (alone or in combination with other vitamins and minerals) in preventing NTDs compared with no interventions/placebo or vitamins and minerals without folic acid (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.17 to 0.58); five studies; 6708 births; high quality evidence). Only one study assessed the incidence of NTDs and showed no evidence of an effect (RR 0.07, 95% CI 0.00 to 1.32; 4862 births) although no events were found in the group that received folic acid. Folic acid had a significant protective effect for reoccurrence (RR 0.34, 95% CI 0.18 to 0.64); four studies; 1846 births). Subgroup analyses suggest that the positive effect of folic acid on NTD incidence and recurrence is not affected by the explored daily folic acid dosage (400 µg (0.4 mg) or higher) or whether folic acid is given alone or with other vitamins and minerals. These results are consistent across all four review comparisons.There is no evidence of any preventive or negative effects on cleft palate (RR 0.73, 95% CI 0.05 to 10.89; three studies; 5612 births; low quality evidence), cleft lip ((RR 0.79, 95% CI 0.14 to 4.36; three studies; 5612 births; low quality evidence), congenital cardiovascular defects (RR 0.57, 95% CI 0.24 to 1.33; three studies; 5612 births; low quality evidence), miscarriages (RR 1.10, 95% CI 0.94 to 1.28; five studies; 7391 pregnancies; moderate quality evidence) or any other birth defects (RR 0.94, 95% CI 0.53 to 1.66; three studies; 5612 births; low quality evidence). There were no included trials assessing the effects of this intervention on neonatal death, maternal blood folate or anaemia at term.

AUTHORS' CONCLUSIONS

Folic acid, alone or in combination with vitamins and minerals, prevents NTDs, but does not have a clear effect on other birth defects.

The effects of preconception interventions on improving reproductive health and pregnancy outcomes in primary care: A systematic review

BACKGROUND

Reproductive health and pregnancy outcomes may be improved if the reproductive risk assessment is moved from the antenatal to the preconception period. Primary care has been highlighted as an ideal setting to offer preconception assessment, yet the effectiveness in this setting is still unclear.

OBJECTIVES

To evaluate the effectiveness of preconception interventions on improving reproductive health and pregnancy outcomes in primary care.

METHODS

MEDLINE, CINAHL, EMBASE and PsycINFO databases were searched from July 1999 to the end of July 2015. Only interventional studies with a comparator were included, analysed and appraised systematically, taking into consideration the similarities and differences of the participants, the nature of interventions and settings.

RESULTS

Eight randomized controlled trials were eligible. Preconception interventions involved multifactorial or single reproductive health risk assessment, education and counselling and the intensity ranged from brief, involving a single session within a day to intensive, involving more than one session over several weeks. Five studies recruited women planning a pregnancy. Four studies involved multifactorial risks interventions; two were brief and the others were intensive. Four studies involved single risk intervention, addressing folate or alcohol. There was some evidence that both multifactorial and single risk interventions improved maternal knowledge; self-efficacy and health locus of control; and risk behaviour, irrespective of whether brief or intensive. There was no evidence to support reduced adverse pregnancy outcomes. One study reported no undue anxiety. The quality of the studies was moderate to poor.

CONCLUSION

The evidence from eligible studies is limited to inform future practice in primary care. Nevertheless, this review has highlighted that women who received preconception education and counselling were more likely to have improved knowledge, self-efficacy and health locus of control and risk behaviour. More studies are needed to evaluate the effects on adverse pregnancy outcomes.

[Relationships between psychological well-being, lifestyle factors and fertility]

INTRODUCTION

10 to 15% of the Hungarian fertile age population struggles with reproductivity problems. Previous researches have shown that psychological well-being and lifestyle factors play a pivotal role in overall health status, which is closely related to fertility.

AIM

The aim of the study was to examine fertility-related psychological and lifestyle factors in a Hungarian sample.

METHOD

194 women (115 infertile and 79 fertile) took part in the study. Standardized, validated questionnaires were used for the assessment of psychological factors and self-administered questions were used for exploring lifestyle factors.

RESULTS

The results show that infertile women are younger (33.98±4.89 vs. 36.43±5.81 years, p<0.005) and their psychological status is significantly worse compared to their fertile counterparts. The number of their depressive (BDI 14.00±12.21 vs. 7.79±9.17, p<0.005) and anxiety symptoms is higher (STAI-T 48.53±10.56 vs. 40.25±10.65, p<0.005) compared to fertile women. Findings related to lifestyle factors show that lower level of fluid consumption (1.71±0.67 vs. 1.95±0.68, p<0.05) and diet (31.30% vs. 18.42%, p<0.05) is significantly related to infertility. In this sample higher level of fluid consumption was associated with the fertile group (OR = 1.65, CI = 2.58-1.06), independently of body mass index and age.

CONCLUSIONS

The results confirm the findings of international researches showing that women struggling with infertility are in worse psychological condition than their fertile counterparts. The authors conclude that the findings demand further investigations and follow-up studies in order to more specifically determine the relationship between fluid consumption and fertility.

Preconception healthcare delivery at a population level: construction of public health models of preconception care

A key challenge of preconception healthcare is identifying how it can best be delivered at a population level. To review current strategies of preconception healthcare, explore methods of preconception healthcare delivery, and develop public health models which reflect different preconception healthcare pathways. Preconception care strategies, programmes and evaluations were identified through a review of Medline and Embase databases. Search terms included: preconception, pre-pregnancy, intervention, primary care, healthcare, model, delivery, program, prevention, trial, effectiveness, congenital disorders OR abnormalities, evaluation, assessment, impact. Inclusion criteria for review articles were: (1) English, (2) human subjects, (3) women of childbearing age, (4) 1980–current data, (5) all countries, (6) both high risk and universal approaches, (7) guidelines or recommendations, (8) opinion articles, (9) experimental studies. Exclusion criteria were: (1) non-human subjects, (2) non-English, (3) outside of the specified timeframe, (4) articles on male healthcare. The results of the literature review were synthesised into public health models of care: (1) primary care; (2) hospital-based and inter-conception care; (3) specific preconception care clinics; and, (4) community outreach. Fifteen evaluations of preconception care were identified. Community programmes demonstrated a significant impact on substance use, folic acid supplementation, diabetes optimization, and hyperphenylalaninemia. An ideal preconception visits entail risk screening, education, and intervention if indicated. Subsequently, four public health models were developed synthesizing preconception care delivery at a population level. Heterogeneity of risk factors, health systems and strategies of care reflect the lack of consensus about the best way to deliver preconception care. The proposed models aim to reflect differing aspects of preconception healthcare delivery.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

Does preconception care work?

BACKGROUND

To date, there is a lack of evidence to suggest that a systematic and coordinated approach to prepregnancy care might make a difference.

AIMS

To evaluate whether women who receive preconception care through a structured approach will be more likely to be healthy around the time of conception compared with women who plan their pregnancy but have not been exposed to preconception care.

METHODS

A case control study was undertaken of women who attended the preconception care service and subsequently conceived, received maternity care and gave birth at Mater Health Services Brisbane between January 2010 and January 2013. Pregnancy information and birth outcomes for each woman who attended the service were matched with those of three women who reported that they had planned their pregnancy but did not attend the service. Records were matched for prepregnancy BMI, age, parity, prepregnancy smoking status and number of health conditions.

RESULTS

Pregnant women who attended preconception care were more likely to have received adequate peri-conceptual folate, to report being vaccinated against influenza and hepatitis B, to have consulted with a specialist with the specific aim of optimising a pre-existing health condition and to report less weight gain up until booking. Preterm birth and hypertensive disorders of pregnancy were less common amongst women who had attended preconception care, and there were trends towards a decreased incidence of gestational diabetes, LGA and fetal anomalies.

CONCLUSION

These preliminary data provide some optimism that a comprehensive preconception care service may positively influence maternal and neonatal outcomes.

WITHDRAWN: Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome

This review has been replaced by the protocol 'Preconception counselling for women with epilepsy' (Winterbottom 2014). The full review is expected to be published by 1st July 2014.

The editorial group responsible for this previously published document have withdrawn it from publication.

Maternal nicotinamide supplementation causes global DNA hypomethylation, uracil hypo-incorporation and gene expression changes in fetal rats

Recent evidence shows that excess nicotinamide can cause epigenetic changes in developing rats. The aim of the present study was to investigate the effects of maternal nicotinamide supplementation on the fetus. Female rats were randomised into four groups fed a standard chow diet (control group) or diets supplemented with 1 g/kg of nicotinamide (low-dose group), 4 g/kg of nicotinamide (high-dose group) or 4 g/kg of nicotinamide plus 2 g/kg of betaine (betaine group) for 14-16 d before mating and throughout the study. Fetal tissue samples were collected on the 20th day of pregnancy. Compared with the control group, the high-dose group had a higher fetal death rate, and the average fetal body weight was higher in the low-dose group but lower in the high-dose group. Nicotinamide supplementation led to a decrease in placental and fetal hepatic genomic DNA methylation and genomic uracil contents (a factor modifying DNA for diversity) in the placenta and fetal liver and brain, which could be completely or partially prevented by betaine. Moreover, nicotinamide supplementation induced tissue-specific alterations in the mRNA expression of the genes encoding nicotinamide N-methyltransferase, DNA methyltransferase 1, catalase and tumour protein p53 in the placenta and fetal liver. High-dose nicotinamide supplementation increased fetal hepatic α-fetoprotein mRNA level, which was prevented by betaine supplementation. It is concluded that maternal nicotinamide supplementation can induce changes in fetal epigenetic modification and DNA base composition. The present study raises the concern that maternal nicotinamide supplementation may play a role in the development of epigenetic-related diseases in the offspring.

Folate deficiency and folic acid supplementation: the prevention of neural-tube defects and congenital heart defects

Diet, particularly vitamin deficiency, is associated with the risk of birth defects. The aim of this review paper is to show the characteristics of common and severe neural-tube defects together with congenital heart defects (CHD) as vitamin deficiencies play a role in their origin. The findings of the Hungarian intervention (randomized double-blind and cohort controlled) trials indicated that periconceptional folic acid (FA)-containing multivitamin supplementation prevented the major proportion (about 90%) of neural-tube defects (NTD) as well as a certain proportion (about 40%) of congenital heart defects. Finally the benefits and drawbacks of three main practical applications of folic acid/multivitamin treatment such as (i) dietary intake; (ii) periconceptional supplementation; and (iii) flour fortification are discussed. The conclusion arrived at is indeed confirmation of Benjamin Franklin's statement: "An ounce of prevention is better than a pound of care".

Born too soon: care before and between pregnancy to prevent preterm births: from evidence to action

Providing care to adolescent girls and women before and between pregnancies improves their own health and wellbeing, as well as pregnancy and newborn outcomes, and can also reduce the rates of preterm birth. This paper has reviewed the evidence-based interventions and services for preventing preterm births, reported the findings from research priority exercise, and prescribed actions for taking this call further. Certain factors in the preconception period have been shown to increase the risk for prematurity and, therefore, preconception care services for all women of reproductive age should address these risk factors through preventing adolescent pregnancy, preventing unintended pregnancies, promoting optimal birth spacing, optimizing pre-pregnancy weight and nutritional status (including a folic acid-containing multivitamin supplement) and ensuring that all adolescent girls have received complete vaccination. Preconception care must also address risk factors that may be applicable to only some women. These include screening for and management of chronic diseases, especially diabetes; sexually-transmitted infections; tobacco and smoke exposure; mental health disorders, notably depression; and intimate partner violence. The approach to research in preconception care to prevent preterm births should include a cycle of development and delivery research that evaluates how best to scale up coverage of existing evidence-based interventions, epidemiologic research that assesses the impact of implementing these interventions and discovery science that better elucidates the complex causal pathway of preterm birth and helps to develop new screening and intervention tools. In addition to research, policy and financial investment is crucial to increasing opportunities to implement preconception care, and rates of prematurity should be included as a tracking indicator in global and national maternal child health assessments.

[Effect of a new dietary supplement on sperm quality]

INTRODUCTION

There is a decline in male fertility thus new treatments are needed.

AIMS

To test the efficacy of a new dietary supplement developed in the USA and registered as a drug of cure in Hungary (OGYI).

METHODS

In a clinical trial 100 men with low sperm quality (spermium count 5-20 M/ml, good motility 10-40%, and adverse shape 30-50%) were examined.

RESULTS

Sperm parameters were measured before and after a 3-month treatment and after another 3-month without treatment. This dietary supplement statistically and clinically significantly improved sperm count and motility. In 74 cases this dietary supplement demonstrated a beneficial effect on sperm quality (more than 10% increase in sperm count, or quality of motility, or shape); in 16 cases the improvement exceeded 30%. No adverse effect could be accounted for this treatment.

CONCLUSIONS

This new dietary supplement may contribute to the treatment of male infertility.

Experience of the Hungarian Preconception Service between 1984 and 2010

The objective of this historical account is to summarize the concept, objectives, methods, results and general experience of the Hungarian Preconception Service, Budapest, based on 27 years (1984-2010) and 25,313 women and couples. The service includes counseling and care (examinations and medical interventions) based on three steps: (1) preconception screening for reproductive risk factors ("reproductive health check-up"), (2) a 3-month preparation for conception, because conception is when some major developmental events, such as the sex of the conceptus and the foundation of health and many diseases, are determined, and (3) achievement of optimal conception and better protection of the embryo in early pregnancy. With normal prenatal care, pregnant women visit clinics between the 7th and 12th gestational weeks, but the embryo has passed through his/her most vulnerable period before the 10th week, and thus prenatal care is too late to reduce the risk of congenital abnormalities. The new primary health care infrastructure for preconception care is performed by qualified and trained nurses and midwifes. Couples at risk are selected and are referred to specialists who can reject or confirm the supposed risks and treat the couples if necessary as part of their secondary health care. The most important results of the Hungarian preconception service were (i) a significant reduction in the rate of preterm births (5.0% vs. 9.2%) which has been linked mainly to preconception screening of sexually transmitted infections of female participants followed by appropriate treatment, (ii) a very significant reduction of congenital abnormalities (2.9% vs. 4.0%), particularly neural-tube defects and cardiovascular malformations, due to periconception multivitamin supplementation, (iii) reduction of smoking among female participants, (iv) involvement of male partners in the family planning health system, (v) much improved identification of couples at high risk and greater access to the secondary care of specialists. In conclusion, the Hungarian experience demonstrates the feasibility and usefulness of preconception care in the prevention of adverse birth outcomes including congenital abnormalities and preterm births.

Prevention of neural-tube defects with periconceptional folic acid, methylfolate, or multivitamins?

BACKGROUND/AIMS

To review the main results of intervention trials which showed the efficacy of periconceptional folic acid-containing multivitamin and folic acid supplementation in the prevention of neural-tube defects (NTD).

METHODS AND RESULTS

The main findings of 5 intervention trials are known: (i) the efficacy of a multivitamin containing 0.36 mg folic acid in a UK nonrandomized controlled trial resulted in an 83-91% reduction in NTD recurrence, while the results of the Hungarian (ii) randomized controlled trial and (iii) cohort-controlled trial using a multivitamin containing 0.8 mg folic acid showed 93 and 89% reductions in the first occurrence of NTD, respectively. On the other hand, (iv) another multicenter randomized controlled trial proved a 71% efficacy of 4 mg folic acid in the reduction of recurrent NTD, while (v) a public health-oriented Chinese-US trial showed a 41-79% reduction in the first occurrence of NTD depending on the incidence of NTD.

CONCLUSIONS

Translational application of these findings could result in a breakthrough in the primary prevention of NTD, but so far this is not widely applied in practice. The benefits and drawbacks of 4 main possible uses of periconceptional folic acid/multivitamin supplementation, i.e. (i) dietary intake, (ii) periconceptional supplementation, (iii) flour fortification, and (iv) the recent attempt for the use of combination of oral contraceptives with 6S-5-methytetrahydrofolate (methylfolate), are discussed. Obviously, prevention of NTD is much better than the frequent elective termination of pregnancies after prenatal diagnosis of NTD fetuses.

Primary prevention of neural-tube defects and some other congenital abnormalities by folic acid and multivitamins: history, missed opportunity and tasks

The history of intervention trials of periconception folic acid with multivitamin and folic acid supplementation in women has shown a recent breakthrough in the primary prevention of structural birth defects, namely neural-tube defects and some other congenital abnormalities. Recently, some studies have demonstrated the efficacy of this new method in reducing congenital abnormalities with specific origin; for example, in the offspring of diabetic and epileptic mothers, and in pregnancy with high fever. The benefits and drawbacks of four possible uses of periconception folate/folic acid and multivitamin supplementation are discussed: we believe there has been a missed opportunity to implement this preventive approach in medical practice. The four methods are as follows: (i) dietary intake of folate and other vitamins, (ii) periconception folic acid/multivitamin supplementation, (iii) food fortification with folic acid, and (iv) the combination of oral contraceptives with 6S-5-methytetrahydrofolate ('folate').

Is there a reduction of congenital abnormalities in the offspring of diabetic pregnant women after folic acid supplementation? A population-based case-control study

The objective of the present study was to estimate the preventive effect of folic acid for structural birth defects (i.e. congenital abnormalities [CAs]) in the offspring of pregnant women with diabetes mellitus type 1 (DM-1). The occurrence of medically recorded DM-1 in pregnant women who had malformed fetuses/newborns (cases) and delivered healthy babies (controls) with or without folic acid supplementation was compared in the population-based Hungarian Case-Control Surveillance System of Congenital Abnormalities. The case group included 22,843 offspring, and there were 79 (0.35%) pregnant women with DM-1, while the control group comprised of 38,151 newborns, and 88 (0.23%) had mothers with DM-1. Case mothers with DM-1 associated with a higher risk of total rate of CAs in their offspring (OR with 95% CI: 1.5, 1.1-2.0) compared to the total rate of CAs in the offspring of non-diabetic case mothers. This higher risk can be explained by four specific types/groups of CAs: isolated renal a/dysgenesis; obstructive CA of the urinary tract; cardiovascular CAs; and multiple CAs, namely caudal dysplasia sequence. However, there was no higher rate of total CAs in the children of pregnant women with DM-1 after folic acid supplementation; in addition, neural-tube defect and renal a/dysgenesis did not occur. However, this benefit cannot be explained by the CA reduction effect of folic acid during the critical period of major CAs. In conclusion, there was a certain reduction in maternal teratogenic effect of DM-1 after folic acid supplementation during pregnancy, but the explanation of this effect requires further study.

Efficacy of medical care of epileptic pregnant women based on the rate of congenital abnormalities in their offspring

The objective of the present study was to check the efficacy of progress in the medical care of epileptic pregnant women on the basis of the reduction of different congenital abnormalities (CAs) in their offspring. First, the prevalence of medically recorded epilepsy was compared in 95 pregnant women who later had offspring with different CAs (case group) and 90 pregnant women who later delivered newborn infants without CA (control group) and matched to cases in the Hungarian Case-Control Surveillance System of Congenital Abnormalities, 1980-1996. Second, the rate of different CAs was compared in the offspring of epileptic pregnant women between 1980 and 1989 and 1990-1996. Cleft lip with or without cleft palate, cleft palate, cardiovascular CAs, oesophageal atresia/stenosis, hypospadias and multiple CAs showed a higher risk in the offspring of pregnant women with epilepsy treated with different antiepileptic drugs, explained mainly by polytherapy. There was no higher risk for total CAs after monotherapy. There was no significantly lower rate of total CAs in the offspring of epileptic pregnant women during the second period of the study. The efficacy of special medical care of epileptic pregnant women was not shown on the basis of decrease in the rate of CAs in the offspring of epileptic pregnant women.

Individual accumulation of heterogeneous risks explains perinatal inequalities within deprived neighbourhoods

Dutch’ figures on perinatal mortality and morbidity are poor compared to EU-standards. Considerable within-country differences have been reported too, with decreased perinatal health in deprived urban areas. We investigated associations between perinatal risk factors and adverse perinatal outcomes in 7,359 pregnant women participating in population-based prospective cohort study, to establish the independent role, if any, for living within a deprived urban neighbourhood. Main outcome measures included perinatal death, intrauterine growth restriction (IUGR), prematurity, congenital malformations, Apgar at 5 min < 7, and pre-eclampsia. Information regarding individual risk factors was obtained from questionnaires, physical examinations, ultrasounds, biological samples, and medical records. The dichotomous Dutch deprivation indicator was additionally used to test for unexplained deprived urban area effects. Pregnancies from a deprived neighbourhood had an increased risk for perinatal death (RR 1.8, 95% CI [1.1; 3.1]). IUGR, prematurity, Apgar at 5 min < 7, and pre-eclampsia also showed higher prevalences (P < 0.05). Residing within a deprived neighbourhood was associated with increased prevalence of all measured risk factors. Regression analysis showed that the observed neighbourhood related differences in perinatal outcomes could be attributed to the increased risk factor prevalence only, without a separated role for living within a deprived neighbourhood. Women from a deprived neighbourhood had significantly more ‘possibly avoidable’ risk factors. To conclude, women from a socioeconomically deprived neighbourhood are at an increased risk for adverse pregnancy outcomes. Differences regarding possibly avoidable risk factors imply that preventive strategies may prove effective.

Factors affecting the willingness of counselors to integrate preconception care into sexually transmitted disease clinics

BACKGROUND

The high rate of unintended pregnancy is an immediate barrier to providing preconception care (PCC). Failure to deliver additional PCC messages at sexually transmitted disease (STD) clinics might represent a major missed opportunity to target women at increased risk for unintended pregnancy for behaviors that also put them at risk for adverse pregnancy outcomes.

METHODS

Using a survey questionnaire, we assessed perceptions of PCC and factors influencing the willingness of STD counselors to integrate PCC as an intervention service provided by the STD clinics of 140 STD counselors. We used a cross-sectional design and selected survey participants with a minimum of 2 years' experience in providing HIV pretest and posttest counseling and syphilis interviewing using a nonprobability, purposive sample.

RESULTS

The level of occupational responsibility and the amount of time available seemed to affect counselor perceptions of the importance of PCC and whether it should be integrated as an intervention service provided by STD clinics. Findings suggested that, although most STD counselors reported that PCC was an important issue, there was significant variation in the perception of whether PCC should be delivered at STD clinics.

CONCLUSION

STD counselors perceived PCC to be an important intervention service that can be delivered at STD clinics. Additional study is needed to identify factors that might affect full integration into the STD clinic setting.

Effects and safety of periconceptional folate supplementation for preventing birth defects

BACKGROUND

It has been reported that neural tube defects can be prevented with periconceptional folic acid supplementation. The effects of different doses, forms and schemes of folate supplementation for the prevention of other birth defects and maternal and infant outcomes are unclear.

OBJECTIVES

This review updates and expands a previous Cochrane Review assessing the effects of periconceptional supplementation with folic acid to reduce neural tube defects (NTDs). We examined whether folate supplementation before and during early pregnancy can reduce neural tube and other birth defects (including cleft palate) without causing adverse outcomes for mothers or babies.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010). Additionally, we searched the international clinical trials registry platform and contacted relevant organisations to identify ongoing and unpublished studies.

SELECTION CRITERIA

We included all randomised or quasi-randomised trials evaluating the effect of periconceptional folate supplementation alone, or in combination with other vitamins and minerals, in women independent of age and parity.

DATA COLLECTION AND ANALYSIS

We assessed trials for methodological quality using the standard Cochrane criteria. Two authors independently assessed the trials for inclusion, one author extracted data and a second checked for accuracy.

MAIN RESULTS

Five trials involving 6105 women (1949 with a history of a pregnancy affected by a NTD and 4156 with no history of NTDs) were included. Overall, the results are consistent in showing a protective effect of daily folic acid supplementation (alone or in combination with other vitamins and minerals) in preventing NTDs compared with no interventions/placebo or vitamins and minerals without folic acid (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.15 to 0.52). Only one study assessed the incidence of NTDs and the effect was not statistically significant (RR 0.08, 95% CI 0.00 to 1.33) although no events were found in the group that received folic acid. Folic acid had a significant protective effect for reoccurrence (RR 0.32, 95% CI 0.17 to 0.60). There is no statistically significant evidence of any effects on prevention of cleft palate, cleft lip, congenital cardiovascular defects, miscarriages or any other birth defects. There were no included trials assessing the effects of this intervention on maternal blood folate or anaemia at term.We found no evidence of short-term side effects.

AUTHORS' CONCLUSIONS

Folic acid, alone or in combination with vitamins and minerals, prevents NTDs but does not have a clear effect on other birth defects.

Lifestyle factors in people seeking infertility treatment - A review

BACKGROUND

Clinical infertility is a prevalent problem with significant financial and psychosocial costs. Modifiable lifestyle factors exist that may affect a person's time to conception and their chance of having a healthy, live birth. However, no guideline delineates what preconception advice should be offered to people presenting for infertility treatment.

AIM

The aim of this article is to review the literature regarding modifiable lifestyle factors in people seeking infertility treatment.

RESULTS

A person's time to pregnancy and their chance of having a healthy, live birth may be affected by factors such as weight, vitamin and iodine intake, alcohol and caffeine consumption, smoking, substance abuse, stress, environmental pollutants, vaccinations and oxidative stress.

CONCLUSIONS

Advice on modifiable lifestyle factors should be given to people presenting for infertility treatment to help them make positive changes that may improve their chances of pregnancy and delivering a healthy, live baby. Developing a guideline for this would be a prudent step towards helping clinicians to implement this aspect of preconception care.

Congenital abnormalities in the offspring of pregnant women with type 1, type 2 and gestational diabetes mellitus: a population-based case-control study

To estimate the risk of structural birth defects (i.e. congenital abnormalities [CA]) in the offspring of pregnant women with type 1 (DM-1), type 2 (DM-2) and gestational diabetes mellitus (GDM) and to check the efficacy of recent specific care of diabetic pregnant women in the reduction of DM-related CA. Comparison was made of the occurrence of medically recorded types of diabetes mellitus in pregnant women who had malformed fetuses/newborns (cases) and who delivered healthy babies (controls) in the population-based Hungarian Case-Control Surveillance System of Congenital Abnormalities, 1980-1996. In the case group, which included 22 843 offspring, there were 79 (0.35%) pregnant women with DM-1, 77 (0.34%) pregnant women with DM-2 and 120 (0.53%) pregnant women with GDM. The control group comprised 38 151 newborns, and 88 (0.23%), 141 (0.37%) and 229 (0.60%) pregnant women with DM-1, DM-2 and GDM, respectively. The total rate of cases with CA was higher only in the DM-1 group (adjusted OR with 95% CI: 1.5, 1.1-2.0) and within four specific types/groups: isolated renal a/dysgenesis, obstructive CA of the urinary tract, cardiovascular CA and multiple CA; namely, caudal dysplasia sequence. The risk of total CA was lower in the present study compared to the risk in previous studies and the DM-1-related spectrum of CA was also different. There was no higher risk of total CA in the offspring of pregnant women with DM-2 and GDM. The certain part of maternal teratogenic effect of DM-1 is preventable with appropriate periconceptional and prenatal care of diabetic women.

Routine pre-pregnancy health promotion for improving pregnancy outcomes

BACKGROUND

A number of potentially modifiable risk factors are known to be associated with poor pregnancy outcomes. These include smoking, drinking excess alcohol, and poor nutrition. Routine health promotion (encompassing education, advice and general health assessment) in the pre-pregnancy period has been proposed for improving pregnancy outcomes by encouraging behavioural change, or allowing early identification of risk factors. While results from observational studies have been encouraging, this review examines evidence from randomised controlled trials of preconception health promotion.

OBJECTIVES

To assess the effectiveness of routine pre-pregnancy health promotion for improving pregnancy outcomes when compared with no pre-pregnancy care or usual care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2009).

SELECTION CRITERIA

Randomised and quasi-randomised trials examining health promotion interventions which aim to identify and modify risk factors before pregnancy. The review focuses on all women of childbearing age rather than those in high-risk groups. We have excluded trials where interventions are aimed specifically at women with established medical, obstetric or genetic risks or already receiving treatment as part of programmes for high-risk groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and carried out data extraction.

MAIN RESULTS

Four trials (2300 women) are included. The interventions ranged from brief advice through to education on health and lifestyle over several sessions. For most outcomes, data were only available from individual studies. Only one study followed up through pregnancy and there was no strong evidence of a difference between groups for preterm birth, congenital anomalies or weight for gestational age; only one finding (mean birthweight) reached statistical significance (mean difference -97.00, 95% confidence interval (CI) -168.05 to -25.95). This finding needs to be interpreted with caution as pregnancy outcome data were available for only half of the women randomised. There was some evidence that health promotion interventions were associated with positive maternal behavioural change including lower rates of binge drinking (risk ratio 1.24, 95% CI 1.06 to 1.44). Overall, there has been little research in this area and there is a lack of evidence on the effects of pre-pregnancy health promotion on pregnancy outcomes.

AUTHORS' CONCLUSIONS

There is little evidence on the effects of pre-pregnancy health promotion and much more research is needed in this area. There is currently insufficient evidence to recommend the widespread implementation of routine pre-pregnancy health promotion for women of childbearing age, either in the general population or between pregnancies.

Pregnancy complications and birth outcomes of pregnant women with urinary tract infections and related drug treatments

Maternal urinary tract infections in pregnancy showed an association with a higher rate of preterm birth in previous studies. The aim of this study was to check this relationship, and in addition to evaluate the efficacy of recent medical treatments. The population-based large control (without any defects) data set of the Hungarian Case-Control Surveillance System of Congenital Abnormalities was evaluated. Of 38,151 newborn infants, 2188 (5.7%) had mothers with urinary tract infections during pregnancy, and 90% of these maternal diseases were prospectively and medically recorded. The prevalence of pre-eclampsia and polyhydramnios showed an association with urinary tract infections during pregnancy. Pregnant women with urinary tract infections in pregnancy had a somewhat shorter gestational age (0.1 week) and a higher proportion of preterm births (10.4% vs 9.1%). These differences were correlated with the severity of urinary tract infections. However, the preterm-inducing effect of maternal urinary tract infections is preventable by some antimicrobial drugs such as ampicillin, cefalexin and cotrimoxazole. In conclusion, maternal urinary tract infections during pregnancy increase pre-eclampsia and polyhydramnios, and in addition the rate of preterm birth; however, the latter is preventable by appropriate drug treatments.

The effectiveness of preconception counseling to reduce adverse pregnancy outcome in women with epilepsy: what's the evidence?

OBJECTIVE

The purpose of this Cochrane review was to determine the effectiveness of delivering preconception counseling interventions to women with epilepsy (WWE) as a means of reducing adverse pregnancy outcomes, increasing knowledge, and increasing intentions to plan pregnancy.

METHODS

Two hundred twenty-five citations were retrieved from a systematic search of the Cochrane Library and electronic databases: Medline (OVID), Scopus, CINAHL, PsychINFO, and ASSIA, and hand searches of relevant epilepsy and obstetric journals.

RESULTS

The search strategy identified 11 studies for consideration for inclusion. However, none met the required criteria for inclusion.

CONCLUSIONS

There is no robust evidence to inform the content, methods of delivery, or likely effectiveness of preconception counseling to improve pregnancy outcomes for WWE and their offspring. The value of counseling WWE prior to conception remains uncertain and requires evaluation in well-designed studies, appropriately powered to detect changes likely associated with both maternal and infant outcomes.

A study of the potential teratogenic effect of large doses of promethazine used for a suicide attempt by 32 pregnant women

In Hungary, promethazine, a phenothiazine antihistamine, is the second most frequently used drug during pregnancy. The purpose of this study was to examine the effects of very large doses of promethazine that were used for a suicide attempt during pregnancy on embryo-fetal development. Self-poisoned pregnant women were identified from patients of the Department of Toxicology Internal Medicine, Korányi Hospital, Budapest, who were admitted from the three million people of Budapest and surrounding region. The rate of congenital abnormalities, intrauterine development (based on pregnancy age at delivery and birth weight), and cognitive-behavioral status of exposed children born to mothers who attempted suicide with promethazine alone or in combination with other drugs during pregnancy was compared with their sib controls. In all, 89 of the 1044 women with self-poisoning during pregnancy between 1960 and 1993 used promethazine for a suicide attempt. Of these 89 women, 32 delivered newborn babies. The dose of promethazine taken by these women for self-poisoning ranged between 125 mg and 1750 mg (mean of 544 mg, i.e., 21.8 tablets). Of the 32 promethazine-exposed children, nine (28.1 %) were affected with congenital abnormalities. However, of 11 pregnant women who attempted suicide with promethazine between the 3rd and 12th postconceptional week, that is, the critical period for production of most major congenital abnormalities, only three were affected with defects, and the critical periods for producing these defects did not overlap with the time of the suicide attempt during pregnancy. Of 34 unexposed sibs, five (14.7%) had congenital abnormalities; the difference in the total rate of congenital abnormalities between the exposed children and their sib controls was not significant. There also was no difference in pregnancy age-specific birth weight between exposed children and their sibs. Mean intelligence quotient was not reduced, and the incidence of behavioral deviation was not increased in the exposed children. The findings of this study did not indicate teratogenic or fetotoxic (including neurotoxic) effects of large doses of promethazine in children born to mothers who self-poisoned during pregnancy, although the total rate of congenital abnormalities was very high. Our experience shows the feasibility and benefits of using the self-poisoning model in estimating human teratogenic/fetotoxic risks of exposure to drugs.

No association between vulvovaginitis-bacterial vaginosis, related drug treatments of pregnant women, and congenital abnormalities in their offspring — A population-based case-control study

The possible association between prospectively and medically recorded vulvovaginitis-bacterial vaginosis (VV-BV) and different congenital abnormalities (CA) has not been studied. The data set of the population-based Hungarian Case-Control Surveillance of Congenital Abnormalities between 1980 and 1996 were evaluated, i.e. 22,843 pregnant women who had newborns or fetuses with congenital abnormality (cases) and 38,151 pregnant women who delivered newborn babies without any congenital abnormality (controls). The main outcome measures were different congenital abnormalities. Of 22,843 cases with CA, 1,536 (6.7%) had mothers with VV-BV, while of 38,151 matched controls without CA, 2,698 (7.1%) had mothers with VV-BV in the second and/or third gestational month of pregnancy. Nearly all pregnant women with VV-BV were treated during pregnancy, but a higher risk for the total group of CAs (adjusted POR with 95% CI: 0.95, 0.89–1.02) or any CA group was not found. In addition, the risk for total CAs was significantly lower in cases born to mothers with VV-BV and appropriate treatment than born to mothers with VV-BV but without treatment. Thus maternal VV-BV needs treatment during pregnancy as well, because it helps reduce the rate of preterm birth without a risk for CAs.

Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome

BACKGROUND

The provision of preconception counselling to women with epilepsy (WWE) has become established as recommended practice and includes a review of drug treatment and the provision of information and advice on both seizure and treatment-related risks to both mother and child. In this review we assess the evidence regarding the effectiveness of preconception counselling for WWE.

OBJECTIVES

To determine the effectiveness of preconception counselling for WWE, measured by a reduction in adverse pregnancy outcome in both mother and child; increased knowledge of preconception issues in WWE and increasing intention to plan pregnancy.

SEARCH STRATEGY

We searched the Epilepsy Group's Specialized Register (30/01/2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), and electronic databases: MEDLINE (OVID) (1950-February 2008); SCOPUS (1966-March 2008); CINAHL (1982-March 2008); PsyclNFO (1806-March 2008); ASSIA (1987-March 2008).

SELECTION CRITERIA

Randomised control trials; including cluster and quasi-randomised trials, prospective cohorts, controlled before and after studies, and interrupted time series that compared the outcomes in mothers with epilepsy and infants of mothers with epilepsy who received preconception counselling, to the outcomes of mothers with epilepsy and their infants who received standard care or no intervention.

DATA COLLECTION AND ANALYSIS

The methodological quality of potentially relevant studies were assessed to determine appropriate inclusion. Where necessary, study authors were contacted for additional information. No studies met the review inclusion criteria.

MAIN RESULTS

The search strategy identified 11 studies for consideration of inclusion. However, none met the required criteria for inclusion.

AUTHORS' CONCLUSIONS

There is no evidence to inform the content, methods of delivery or effectiveness of preconception counselling to improve pregnancy outcomes for WWE and their offspring. The value of counselling delivered to WWE prior to conception, with the intention of reducing the risks of adverse outcome in mother and child, requires evaluation in well-designed studies, appropriately powered to detect changes in both maternal and infant outcome.

Use of folic acid supplements, particularly by low-income and young women: a series of systematic reviews to inform public health policy in the UK

OBJECTIVE

To provide a basis for making recommendations on the potential to improve use of folic acid supplements in the UK, particularly among low-income and young women.

DESIGN

Systematic reviews of relevant research from 1989 to May 2006 in Europe, the USA, Canada, Australia and New Zealand.

RESULTS

Twenty-six systematic reviews and/or meta-analyses were identified from the wider public health literature, and eighteen studies on the effectiveness of preconception interventions were included. Ninety studies were identified which were directly relevant to folic acid supplement intake. There were factors that are particularly associated with lower rates of use of folic acid supplements. One of the most important of these is the link with unintended pregnancy, followed by age, socio-economic and ethnic group. Integrated campaigns can increase the use of folic acid supplements to some extent. Research trials indicated that: (i) printed resources and the mass media used in isolation are not effective in the longer term; and (ii) health-care-based initiatives can be effective and are more likely to be successful if they include making supplements easily available.

CONCLUSIONS

Campaigns and interventions have the potential to exacerbate socio-economic inequalities in folic acid use. One way of addressing this is to include elements that specifically target vulnerable women. To achieve and maintain an effect, they need to be based on good health promotion practice and to be sustained over a long period. However, even high-quality campaigns that increase use result in under half of women in the target group taking supplements.

Pre-conception counselling in primary care: prevalence of risk factors among couples contemplating pregnancy

The outcome of pregnancy can be influenced by several risk factors. Women who are informed about these risks during pre-conception counselling (PCC) have an opportunity to take preventive measures in time. Several studies have shown that high-risk populations have a high prevalence of such risk factors. However, prevalence in the general population, which is assumed to be low risk, is largely unknown. We therefore provided a systematic programme of PCC for the general population and studied the prevalence of risk factors using the risk-assessment questionnaire which was part of the PCC. None of the couples reported no risk factors at all and only 2% of the couples reported risk factors for which written information was considered to be sufficient. Therefore, 98% of all couples reported one or more risk factors for which at least personal counselling by a general practitioner (GP) was indicated. Many of these factors were related to an unhealthy lifestyle. Women with a low level of education reported more risk factors than women with a high level of education. There is a great need for PCC as shown by the fact that almost all couples reported risk factors for which personal counselling was indicated. Pre-conception counselling may reduce the risk of adverse pregnancy outcome by enabling couples to avoid these risks. PCC can be provided by GPs, who have the necessary medical knowledge and background information to counsel couples who wish to have a baby.

[Antimicrobial therapy associated with preterm birth]

The effect of 51 antimicrobial drugs was evaluated for the reduction of preterm birth.

STUDY DESIGN

Newborn infants without birth defects were selected from the population-based large data set of the Hungarian Case-Control Surveillance of Congenital Abnormalities, 1980-1996, for the study. Medically recorded gestational age and the proportion of preterm birth were the primary outcomes of the study and newborn infants born to mothers with or without a given antimicrobial drug were compared.

RESULTS

The use of 51 antimicrobial drugs in the mothers of 38 151 newborn infants including at least ten pregnant women was evaluated. Only two: ampicillin and clotrimazole showed an obvious preterm birth preventive effect, mainly after the use during the first trimester of pregnancy.

CONCLUSIONS

Our findings suggest that ampicillin and particularly clotrimazole may be effective for the reduction of preterm birth associated with infectious diseases of pregnant women.

A study of the potential teratogenic effects of large doses of drugs rarely used for a suicide attempt during pregnancy

The available data set regarding pregnant women who attempted suicide during pregnancy was evaluated to estimate the teratogenic effect of very large doses of drugs based on the rate and distribution of congenital abnormalities of exposed children. These pregnant women were identified from patients of central toxicological inpatients clinic, Budapest, Hungary, 1960–1993. Of 1044 women with self-poisoning during pregnancy, 411 delivered live-born babies; 367 of these children were examined in this study. Data for 12 frequently used (10 or more times) drugs were published previously; this paper presents 77 medicines (58 drugs and 19 medicinal products including multiple components) that were rarely used for a suicide attempt by 197 pregnant women. Although 23 (11.7%) exposed children had congenital abnormalities (CAs), in general, a causal relationship of the CA and the drug taken by the pregnant woman cannot be assumed. This is because the suicide attempt often did not occur during a critical period for producing the CA. Of 67 pregnant women who attempted suicide between the 3rd and 12th postconceptional week, that is, the critical period of most major CAs, 7 (10.5%) children were affected with CAs. This high rate of CAs in exposed children can be explained by the intensive medical examinations, including diagnosis of mild CAs and minor anomalies, or the low socioeconomic status and hazardous lifestyle of mothers. None of the rarely used drugs was identified as a potential human teratogen. Experience of the authors shows the feasibility and benefits of using the self-poisoning model in estimating human teratogenic/fetotoxic risks of exposure to drugs.