The Importance of Preconception Care

In this episode, Dr. Kimberly Turner and Dr. Natalia Colón-Guzmán discuss the critical role of preconceptual visits in maternal health. They explore the importance of medical history, genetic testing, vaccinations, and lifestyle factors in ensuring healthy pregnancies. Dr. Colon-Guzman shares her journey in medicine and highlights the significance of cultural competence in providing care to diverse populations. The conversation also addresses barriers to accessing preconceptual care and emphasizes the need for mental health considerations in pregnancy planning.

Catch full episodes of the Moms, Minds, and Medicine (M3): Inside Maternal Health Research Podcast here on YouTube: https://youtube.com/playlist?list=PLv4qXQ6sECQPdkBvXPng5RXOvh3rUrbLY&si=MerdAjUvSdJQLVQr 📺

—

Subscribe to our YouTube channel here: https://www.youtube.com/channel/UCbCKCKG5N4ZWZMF0oGzIeyA

—

Follow our social media accounts to keep up with the Maternal Health Research Collaborative:

Instagram: https://www.instagram.com/maternalhealthrc/

Facebook: https://www.facebook.com/maternalhealthRC

Transcript

Introduction to Moms, Minds, & Medicine: Inside Maternal Health Research

SPEAKER_01 0:00

Hi, I'm Dr. Kimberly Turner, and welcome to Mom's, Minds, and Medicine inside maternal health research. This podcast is your trusted companion on the pregnancy journey, where we break down the latest insights, answer the real questions, and empower you to make informed decisions every step of the way.

Welcome Dr. Natalia Colón-Guzmán

SPEAKER_01 0:36

I'm your host, Dr. Kimberly Turner, and I'm so proud to welcome my colleague and friend, Dr. Natalia Cologne Guzman, to our podcast. Good morning. Good morning, Dr. Turner. I am so excited to be here.

Understanding the Pre-Conceptional Visit

SPEAKER_01 0:52

Well, thank you for um agreeing to join us to talk about a really underutilized part of prenatal care, which is the pre-conceptual visit. Can you explain to the audience what in general the preconceptual visit is?

SPEAKER_00 1:08

Absolutely. So when people are starting to think about beginning a family or starting a family, many patients uh visit their OBGYN regularly, about once a year, for annual checkups, or sometimes they have a problem visit or whatnot. And sometimes at those visits, um, either the patient or the doctor can approach the conversation about starting a family. Um, and when that happens, you can actually set aside a whole new visit for um preconception counseling. Essentially, the goal is to get the patient as ready as they can be. Sometimes there's no perfect ready, but we try our best to ensure that we optimize everything in terms of health and um what you can do to ensure a successful pregnancy. So preconceptual visits start with obviously a good um history, good physical exam, and then there are plenty of discussions that can happen afterwards, um, starting from a family history of genetic conditions, because some of these things can be inherited and passed on. So we ensure that we ask them all those questions and see actually if the patient could be at risk for that. Uh these days, and this day and age, there's actually uh great testing uh back when Dr. Turner um started. It was definitely not as simple as it is today. We have these tests that offer testing for over a hundred mutations, sometimes, I think even more these days. I haven't checked recently, but I know that they have definitely a vast um majority of diseases out there that can be tested. So that's one thing, for example. We can do uh genetic testing for that. Besides that, there are many other things that can happen in that visit. Um, like I said, we take a good history, we um assess the patient for medical problems. So patients have anything from, you know, diabetes, high blood pressure, thyroid issues. And you definitely want to make sure that those conditions are all well controlled before you head into a pregnancy. Dr. Turner and I well know that um sometimes if patients are not in great control of those conditions, uh, the conditions can definitely become more of a problem during the pregnancy and can definitely impact the outcome that the pregnancy has. And unfortunately, sometimes those those outcomes can be uh detrimental to baby or mom. So we definitely want to address that, especially if the patient is high risk with comorbidities. For example, just to give you an idea, if you have diabetes, you want to make sure that your A1C is well controlled, ideally under six to six point five, good choice. Just the A1C for those that don't know. Oh, that's right. Yes. So the hemoglobin A1C is a blood level that we check. What it essentially does, to put it in simple terms, is it measures the average of your blood sugar in three months in your bloodstream. So if your blood sugars have been running high, say, I don't know, over 200 for the most part, that A1C is going to be really high. And then that's basically how we know that we need to tweak medications or help you with your medications so that we can bring those numbers down. So that is definitely a very important part of that conversation, for example, in terms of the diabetes aspect. That's just one example. Patient can have high blood pressure. We want to make sure that you're on the proper medications, that those medications are the ones that you know you could potentially continue to take while you're pregnant. Not every medication is safe. And speaking of that, when we go over your medications, we also want to make sure that all the medications that you take are safe, whether it's for diabetes, for your thyroid, for high blood pressure, or for any other medical condition, for example. For sure.

SPEAKER_01 4:55

Um, I do want to back up because I didn't talk about your background. Oh, that's right. And how you got into this auspicious career of gynecology. I know that you're a third-generation doctor. Yeah. And I just think the human interest there is so I think your history is really amazing. Can you give our viewership a little bit of your background? Absolutely. And we'll jump right back into the pre-conceptual.

SPEAKER_00 5:21

No problem. Um, so I'm born and I was born and raised in Puerto Rico. Um, therefore, Spanish is actually my uh first language. Um, English is my second. Very proud and always love to say that I am a third-generation Obi Guayan. My grandfather on my father's side um actually was uh an Obi Guayan who started his own practice many decades ago. And when my um uncle and my father um became doctors, they both chose to do obstetrics and gynecology as well, and actually started um or joined my grandfather in their practice. Um I grew up surrounded by these men, constantly hearing their stories, or even, you know, going to the office just to hang out and see or play doctor there, or going to the hospital with my dad. And always had that. I don't know, there was always something special about those deliveries that he would take me on, or you know, even just seeing a patient in, I don't know, the grocery store and my dad being stopped and said, Oh my God, you delivered my daughter 18 years ago and how special. And, you know, we always will remember you for that and how authentic and fantastic and great you were at the time of the delivery. Um it was always something that I looked up to and thought that maybe one day that could be me. So, you know, that and obviously many other factors. I just love uh taking care of women, women's health issues, and honestly, obviously uh delivering babies is definitely a very exciting and important part of it. Um, so I chose that career path for myself as well. And here we are.

SPEAKER_01 7:00

What an amazing legacy you have. And thank you for continuing this sometimes challenging but always rewarding work of obstetrics. Can you also talk a little bit about your current role? Um, I don't know that many people understand how obstetrics has changed from you see one doctor for every visit, they deliver your baby, and then you go on. And now it's more of a hospital-based model.

SPEAKER_00 7:24

So, Dr. Turner and I have actually known each other for a really long time because for 12 years I worked with her at the more traditional office type model, where basically we would go into the office and see all these lovely patients every day. We would do G Y N and O B. And then about once a week, we would go to the hospital and take call. And we would take call and be in charge of all the patients of the practice that were there that day. We would do their deliveries, their C-sections, round on them postpartum, um, circumcisions, even that kind of thing. Um, that is what many OBGYans um still do this day, but due to changes in simply healthcare and um systems and just personal lifestyle choices, um, more doctors are gravitating towards this newer model, the hospital-based model or the hospitalist-based model, where essentially a hospital can hire doctors to work there, uh hospital-based and hence called hospitalist, and take care of patients that come in from either a clinic that can be attached to the hospital, or patients that don't have prenatal care and simply come to the hospital store for care, um, either for delivery or for problems, and or patients that have a doctor elsewhere, but happen to just be closer to your hospital and then just come in to deliver at your hospital. So, this um currently is my job. I am a hospitalist. I um do five shifts, uh, five, 24-hour shifts actually every month, and have some time off in between where I devote my time to my family and other activities. So it has been uh a big change in terms of what I used to do. And um, Dr. Turner knows very well how big of a change it has been. But I continue to love what I do because obstetrics has always been my passion and hospitalist work is obstetrics heavy.

SPEAKER_01 9:17

Sure, sure. So a big change over what your grandfather did and your father and even what I did in my clinical years. But I agree it's it's a nice model because it does allow for some more work-life balance, and the patients are still getting outstanding care in your current role, and particularly as somebody that was born in Puerto Rico and that lived there for a lot of their life. How do you see your role currently with that population of Hispanic women? And how do you help them navigate, or are you able to help them navigate this preconceptual space? Yes.

SPEAKER_00 9:57

Excellent question. Um, I have the great fortune of being Puerto Rican and speaking a second language. Um, as you and I know, language barriers are unfortunate, unfortunately, a big barrier to patient care. And as part of this role, I um work at a practice where we take care of mostly um Hispanic patients. And um I pride myself in that because I can go there, see them in um their own language, right? And um make them comfortable and welcomed. And honestly, some patients um come early enough where you don't necessarily get to do a preconception counseling visit, but you can do a lot of education early on in the pregnancy. And with my language being Spanish and actually our staff being mostly um Spanish speaking, we are able to um really connect with these patients and be able to provide resources that they may otherwise not be able to uh find. Um,

The Importance of Provider-Patient Connection

SPEAKER_00 10:55

yeah, really it's a great opportunity. I really love it.

SPEAKER_01 10:59

I love my thought. And I don't know if all the viewers know, but there is a lot of data now saying that when your provider is like you, whether that's gender, race, and you have that connection, the care is better on both ends. Absolutely.

SPEAKER_00 11:16

And that's why it's so good that I I just love that I'm able to speak Spanish and just communicate and take care of them and deliver them and all in their language. I think there's always a special connection. There's always a special connection, and I think patients just feel like the care is beyond what they could otherwise maybe get elsewhere. So sure, sure. Well, thank you again.

SPEAKER_01 11:41

That's great work. I hope that you continue that for many more years. I hope so. And speaking of data, there's also data that says that less than 50% of women know about and utilize this preconceptual visit. So why do you think that is, and what should we be doing about that as doctors in this field?

SPEAKER_00 12:01

So I think a lot of it could be lack of education, unfortunately. Um, I think that when patients come in, and you know, we you and I did this, right, for many years. When they would come in for an annual, we would sometimes focus just on the annual, right? On getting their PAPS mirror done, on talking about birth control, on talking about a mammogram if they were of age, or talking about it, you know, other issues, sexual health issues and that kind of thing. And then truly sometimes we never did ask for the young ones, are you interested in starting a family in the next year? So I think some of that could be provider uh dependent. Like we we needed to do or we needed to be more upfront about offering them that. Another big problem, as you and I know also, is access, access to care is it's a huge problem, as we know. Uh, lack of insurance is a barrier. Or sometimes, you know, we have uh the Medicaid law in Maryland where patients can get um Medicaid for pregnancy care, but unfortunately, sometimes they can't get there right before, so we can discuss those issues or problems or medical problems that they have um before they get pregnant. So I think, you know, language barrier, for example, that's another, that's another issue. So it's it's a multi-system um, not failure, but a multi-system problem that, you know, if we fix the different aspects, we could probably make a whole lot better. But I agree, I mean, not many patients come for those appointments, and and I think it can be initiated like that preconceptual talk could be initiated by either the patient or ourselves, you know, we just have to approach it and actually do it.

SPEAKER_01 13:44

So

Raising Awareness About Pre-Conceptional Visits

SPEAKER_01 13:45

yeah, I think some of that, you and I both have daughters, so some of that comes with uh teaching our children and hopefully their friends, maybe not at a young age, but at a certain age, that it's important to think about your reproductive health and that these visits are available, they're covered by insurance. And sometimes during the preconceptual visit, they would come knowing their problems, and other times we would uncover the problems based on some testing. Absolutely. That's the yeah, this is our big plug, and now I'm working on the public health side. So for the viewers, this is a really nice way to A, meet a provider, B, get great information, C get health screenings, D, catch up on your vaccinations, which is my next topic. Yes. Why is it important for women who are planning pregnancy to get vaccines? We're in respiratory season right now, so flu and COVID are on the rise. And why is it important for pregnant women

Vaccinations and Their Role in Maternal Health

SPEAKER_01 14:43

or even before pregnancy to think about this?

SPEAKER_00 14:46

So, absolutely a very important issue. We definitely want to be able to maximize prevention of diseases that we have vaccines for. Why? Because many of these uh vaccine-preventable diseases are very bad for your health or can make you very ill. If a young lady gets um COVID, for example, in the beginning of the pregnancy or later on in the pregnancy, um you and I have seen how um they can be admitted to the hospital, they can um get pneumonia, they can be dependent on oxygen, things that normally would not happen if you um had, you know, if you hadn't acquired the disease, it's it can put put a challenge on your body, it could put a challenge on your baby. Because if you get less less oxygen, for example, just to put COVID as an example, same thing with the flu. If you get COVID or the flu and you have a need for oxygen because your oxygen levels are low in your blood, your baby could potentially be impacted by that. So vaccines like the flu, COVID, and then of course, you know, you have your hepatitis vaccine, varicella, those illnesses can be transferred, transmitted to the baby. So, say, for example, that you never had varicella, you never got your varicella vaccine, and for some weird reason you come in contact with somebody who had uh who has varicella and you're pregnant, your baby can suffer anomalies and consequences. Um because of you getting the illness. Same with the measles. So these are important vaccines that prevent important diseases that we know can be almost eradicated with the use of vaccines. So um we want to make sure that mom stays healthy, and of course, mom can pass things on to baby, so we want to make sure that baby stays healthy. That's why vaccines are so important. I agree. Healthy mother, healthy baby.

SPEAKER_01 16:42

Yes. You're talking about Varacella, I just want to clarify that that's chicken pox. Correct. Um, and sometimes in the preconceptual visit, is it not accurate that we would draw blood? Because you can tell um the vaccine levels or the antibody to the vaccine levels.

SPEAKER_00 17:00

Exactly. So that's actually when uh patients come in, and um, apart from history physical and all that, we can draw blood work and check what we call titers to see um if you have responded to those vaccines or you if you've had had that illness before. And there are illnesses um like rubella or measles and uh chicken pox slash varicella hepatitis that we can test for. And if you have not been exposed to the vaccine or the illness, we can try to go ahead and get you vaccinated before you get pregnant. Right and try to prevent that um very preventable disease um during pregnancy. So exactly extremely

Advancements in Genetic Testing

SPEAKER_00 17:40

important.

SPEAKER_01 17:40

So preconceptual visit to screen for medical problems, to potentially check blood and get vaccinated if you need to, and some are seasonal and some are once in a lifetime, and then genetics. We alluded to the fact that genetics has come a long way in the beginning of my career. To know if your baby had a genetic test, you had to have a needle placed in the amniotic sac to draw fluid, which was called an amniosynthesis is still called an amniocentesis. And sometimes that's still necessary, but now we have like finger pricks and blood tests. And can you talk a little bit about that?

SPEAKER_00 18:17

I mean, it's incredible how far science has come in terms of offering patients testing, not only preconceptually, but also during the pregnancy. I mean, way back when, uh, you know, 30 years ago, we didn't have these incredible resources that we have now. Like we mentioned before, preconceptually, um, there are uh several tests that can be offered to the patient where you can be tested to see if you carry genes for hundreds of conditions. Because if mom carries one gene and then gets together with a partner that carries the other gene, sometimes baby can be affected by a particular illness. For example, sickle cell disease, um, which is quite common. The trait can be quite common in African American patients. Um we would talk about sickle cell, yes. So then we can test mom to see if she carries the gene. And if she does, we can do proper counseling, test the partner, and see what the chances are of potentially a baby come um being born with this um disease. And also, so we have that preconceptually, but when the patient gets pregnant, there is a very early test that one can do also to check for um trisomies. Um, so major genetic uh disorders like Down syndrome, trisomy 13 and 18. A lot of people get excited because they also can find out gender with that test.

SPEAKER_01 19:39

Yeah.

SPEAKER_00 19:39

But um the test is yes, everybody's always excited, but the test is also so incredibly important because it reveals information about potential major illnesses um or major disorders that uh unfortunately sometimes are not compatible with life. Not every trisomy. Trisomy 21 uh patients can live or babies can live, but some other trisomies they um they could um pass. So uh it's incredible that we have um these tools um this day and age to test people

Lifestyle Factors for a Healthy Pregnancy

SPEAKER_00 20:07

for that.

SPEAKER_01 20:07

Right. And another just trisomy 21 is the disorder that causes Down syndrome. And um, if we know that the baby is going to be affected, we can intervene, give resources, many, many options open up. So knowledge is power and getting all of this preconceptual knowledge, early pregnancy knowledge is so important. And even with sickle cells, if you have the traits, knowing if your partner has a trait and the one-fourth chance your baby can be affected, and you can be tested. And if the baby has it, we're even getting to the point where we might even be able to change some of that in utero, offer treatments through cord blood. I mean, it's just fantastic where all of this research is going. So thank you for that. So we've talked a lot about screening patients for medical conditions and how screening for genetic conditions can help women, even before they're pregnant, have healthier pregnancies and better outcomes. But what we didn't talk about is what other things can women do in their lifestyle in terms of nutrition, exercise. Don't smoke. Give us a little bit of your knowledge and your counseling on those types of things.

SPEAKER_00 21:22

So when patients come in for a preconceptual visit, we definitely look at BMI and we need to have an honest and frank conversation about that. Not everybody's slender, not everybody can have a normal BMI for different reasons. Um, sometimes people have conditions that just don't allow them to get down there. Um, and essentially, we want to have an honest conversation about the importance of a normal BMI because that can impact, once again, it can impact your pregnancy outcome. Patients that are obese are known to be, amongst other things, a higher risk for C section or having a bigger baby. Um, those are uh probably two of the top things that I can think about right now. But essentially, we want to work, even if we don't have that perfect BMI, we want to be eating right and exercising. That's all to your benefit always. Keeping your body healthy, clean, and exercising is one of the best things you can do for yourself. We all know that that just leads you to healthier habits, healthier lifestyle, and definitely a healthier pregnancy. So I always recommend trying to achieve the best BMI that you can. Um, working out at least 30 minutes, five to six times a week. That's also super important. Um, this day and age, we know that um uh lifting and weightlifting has become a very big thing because we know that it does our health wonders as well, especially for women, you know, in terms of long-term um effects of osteoporosis and things like that. Um, so we definitely go over that. And I always try to go over, you know, you can't do a whole nutrition counseling class because there's so much to talk about, but just in general, things to avoid, things to do, alcohol intake, definitely avoidance of smoking. Those are always main points that I want to review with patients when they come in.

Mental Health Considerations Before Pregnancy

SPEAKER_01 23:08

And one thing that's getting a lot of focus these days, too, is mental health. So, can you speak briefly about what we as obstetricians talk about when we tell patients who have had depression, anxiety, particularly postpartum depression, what do they think about before pregnancy?

SPEAKER_00 23:27

So definitely so common. I mean, so many patients that we see come in, so many patients that we see come in and say they have anxiety, depression, that take medications. It's it's the more patients we see, the more I see it. Um so essentially, one good thing that we do is we screen everybody. There are tools and um like a quiz, dare I say, where we give a patient a questionnaire and they can actually answer that for us in the office, even when they're not pregnant. And we can kind of get an assessment of how they're doing emotionally and um mentally. Um and if you see a high score, it's a great time for intervention, right? Um, we know that we can ask for help. We know that there are psychologists, therapists, um, and psychiatrists, of course, that can help patients. Not everything involves medication. Sometimes therapy can actually um help the patient, but it is in it is so important to ensure that your mental well-being is in a good uh state before you get pregnant, because unfortunately, pregnancy can sometimes make things worse. And like you mentioned, um, we can see patients who suffer from terrible anxiety and depression during the pregnancy and afterwards. And we definitely don't want to get to uh a point of no return where mom is so sick that she's just not even functional. Um, so early intervention is always best. If patients take medications, we review those once uh again, like I said before, we review medications. We want to make sure what you're taking is safe. There are medications that are safe. A lot of people think it's a stigma that, you know, oh, people are gonna think I'm crazy because I take Zolaf. No, we don't. We know that some people need this medication because they have an imbalance of particles in their brain that triggers these symptoms, and people need to take these medications to function and do well. So we will ensure to review that and ensure that you're an appropriate regimen and you have the appropriate follow-up so that you keep your mental health in in the best shape that you can while you're pregnant.

The Significance of Prenatal Care

SPEAKER_01 25:29

Sure, sure. Well, thank you. I think to wrap up, I'd just like you to discuss a little bit why prenatal care is such an important part of what we think about as OBGYN physicians. And we are so blessed in the state to have coverage for pregnancy, insurance coverage for pregnancy, that it's not all that common that we see people with no prenatal care, but compare and contrast a little bit a good prenatal care regimen and what can happen when there's no prenatal care.

unknown 26:00

Yeah.

SPEAKER_00 26:01

Prenatal care is so important. I mean, we we know that not everybody can access it. Luckily, like you said, we live in a in a state that um recently, I believe it's been now a couple of years, um, has adopted this law so that patients can actually get insurance for their pregnancy and even some months afterwards. I it covers up to four months, I believe. But the reason why prenatal care is so important is because we want to be able to provide the mother and the baby with the best possible healthy outcome that we can. We want to ensure that mom does well. We want to ensure that that baby is as healthy as possible. And the way that we can do that is through the course of these 14 to 16 visits, depending on um who you see and how it works, is seeing you, making sure that you're okay, checking your blood pressure, checking your urine, listening to your baby, ordering tests, ordering ultrasounds. That is the way that we make sure that baby is well and that you are well as well. So unfortunately, we know that um some patients are not able to access prenatal care. And unfortunately, we also know via studies and data that sometimes when you can't access prenatal care, it doesn't mean every time you will, but people can have what we call bad outcomes. They can have uh preterm labor or complications from pregnancy that can unfortunately lead to mother or baby not doing well. Um, and we definitely want to uh grasp as many of those patients as we can to try to prevent um those bad outcomes.

Conclusion and Call to Action

SPEAKER_00 27:30

Exactly.

SPEAKER_01 27:31

Exactly. So, yes, I think we've covered just about everything. You can never cover everything, but just the importance again to reiterate to reiterate to the audience there is a visit that you can have before pregnancy that's covered by insurance that can help make sure that you are healthy, physically healthy, mentally healthy, that we review medications and our risk factors for pregnancy. It's called the preconceptual visit. And we hope that our work here, you and I, is helping to reach the masses so that they know it's available. I just want to thank you so much for your time and your friendship and your collegiality through all these many years. And we look forward to bringing you back to the Moms Minds and Medicine podcast.

SPEAKER_00 28:19

Thrilled to be here, Dr. Turner, and um, I would love an invite to come back.