Interconception Care for Mothers During Well-Child Visits With Family Physicians: An IMPLICIT Network Study.

PURPOSE: Interconception care (ICC) is recommended to improve birth outcomes by targeting maternal risk factors, but little is known about its implementation. We evaluated the frequency and nature of ICC delivered to mothers at well-child visits and maternal receptivity to these practices. METHODS: We surveyed a convenience sample of mothers accompanying their child to well-child visits at family medicine academic practices in the IMPLICIT (Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques) Network. Health history, behaviors, and the frequency of the child's physician addressing maternal depression, tobacco use, family planning, and folic acid supplementation were assessed, along with maternal receptivity to advice. RESULTS: Three-quarters of the 658 respondents shared a medical home with their child. Overall, 17% of respondents reported a previous preterm birth, 19% reported a history of depression, 25% were smoking, 26% were not using contraception, and 58% were not taking folic acid. Regarding advice, 80% of mothers who smoked were counseled to quit, 59% reported depression screening, 71% discussed contraception, and 44% discussed folic acid. Screening for depression and family planning was more likely when the mother and child shared a medical home (P <.05). Most mothers, nearly 95%, were willing to accept health advice from their child's physician regardless of whether a medical home was shared (P >.05). CONCLUSIONS: Family physicians provide key elements of ICC at well-child visits, and mothers are highly receptive to advice from their child's physician even if they receive primary care elsewhere. Routine integration of ICC at these visits may provide an opportunity to reduce maternal risk factors for adverse subsequent birth outcomes.

Diagnosis and management of ectopic pregnancy.

Ectopic pregnancy affects 1% to 2% of all pregnancies and is responsible for 9% of pregnancy-related deaths in the United States. When a pregnant patient presents with first-trimester bleeding or abdominal pain, physicians should consider ectopic pregnancy as a possible cause. The patient history, physical examination, and imaging with transvaginal ultrasonography can usually confirm the diagnosis. When ultrasonography does not clearly identify the pregnancy location, the physician must determine whether the pregnancy is intrauterine (either viable or failing) or ectopic. Use of the beta subunit of human chorionic gonadotropin (ß-hCG) discriminatory level, the ß-hCG value above which an intrauterine pregnancy should be visualized by transvaginal ultrasonography, may be helpful. Failure to visualize an intrauterine pregnancy when ß-hCG is above the discriminatory level suggests ectopic pregnancy. In addition to single measurements of ß-hCG levels, serial levels can be monitored to detect changes. ß-hCG values in approximately 99% of viable intrauterine pregnancies increase by about 50% in 48 hours. The remaining 1% of patients have a slower rate of increase; these patients may have pregnancies that are misdiagnosed as nonviable intrauterine or ectopic. After an ectopic pregnancy has been confirmed, treatment options include medical, surgical, or expectant management. For patients who are medically unstable or experiencing life-threatening hemorrhage, a surgical approach is indicated. For others, management should be based on patient preference after discussion of the risks, benefits, and monitoring requirements of all approaches.

Adult vaccination.

Immunization has effectively decreased the burden of disease on society. Nevertheless, over 50,000 deaths occur annually in the United States from vaccine-preventable disease, and nearly all of these occur in adults. It is essential for primary care physicians to be knowledgeable about the unique immunization-related needs of adults and to be aware of the factors that determine the need for vaccination.

The future of cancer screening.

Lung and ovarian cancers are two of the most common and deadly cancers affecting men and women in the United States. The potential impact of an effective screening modality for early detection of these cancers is enormous. Yet, to date, no screening tool has been proven to reduce mortality in asymptomatic individuals, and no major organization endorses current modalities for screening for these cancers. Novel approaches, potentially relying on genomics and proteomics, may be the future for early detection of these deadly cancers.

Preconception and prenatal care.

Advances in preconception and prenatal care have been successful in reducing risk in a number of areas. Folic acid supplementation, abstinence from alcohol, tight glycemic control in pre-gestational diabetics, and the administration of rhogham all have been successful in reducing individual risks. Unfortunately, overall perinatal morbidity and mortality has not decreased in the past two decades. In light of this, clinicians must remain abreast of the latest research and technological advances, and adopt those practices that improve outcomes. Continued critical appraisal of persistent racial and ethnic disparities may be useful in understanding and reversing current trends. Additionally we must continue to creatively develop instruments of quantifying those aspects of high quality prenatal care, which are unmeasurable. Furthermore, we must advocate on a local, state, and national level for improved services for our prenatal patients not just in the office and the hospital, but in their homes and communities.