Midterm Pregnancy Loss When to Get Pregnant Again Acog

Abstract: Interpregnancy care aims to maximize a woman's level of wellness not just in betwixt pregnancies and during subsequent pregnancies, simply also forth her life course. Considering the interpregnancy period is a continuum for overall health and wellness, all women of reproductive age who have been pregnant regardless of the issue of their pregnancies (ie, miscarriage, abortion, preterm, full-term delivery), should receive interpregnancy care as a continuum from postpartum care. The initial components of interpregnancy care should include the components of postpartum care, such every bit reproductive life planning, screening for depression, vaccination, managing diabetes or hypertension if needed, didactics nigh future health, assisting the patient to develop a postpartum care team, and making plans for long-term medical intendance. In women with chronic medical conditions, interpregnancy intendance provides an opportunity to optimize health before a subsequent pregnancy. For women who will not take whatsoever future pregnancies, the period subsequently pregnancy also affords an opportunity for secondary prevention and improvement of future health.

Background

Efforts to reduce maternal morbidity have led to an increased focus on improving maternal health before a future pregnancy and across the lifespan. One proposed intervention is improving interpregnancy intendance. Long understood as an intervention to better neonatal outcomes, the part of interpregnancy care recently has been recognized for its role in maternal health. This document reviews the existing information on interpregnancy care and offers guidance on providing women with interpregnancy care.

Prepregnancy, Postpartum, Interpregnancy, and Well-Adult female Care: The Intersection

Prepregnancy, postpartum, interpregnancy, and well-woman intendance are interrelated and can exist defined by their relationship to the timing of pregnancy Figure one. For women who become pregnant, pregnancy is recognized as a window to future health because complications during pregnancy, such as gestational diabetes mellitus, gestational hypertension, preeclampsia, and fetal growth restriction, are associated with gamble of health complications later in life 1 2 iii four. The interpregnancy period is an opportunity to address these complications or medical issues that take developed during pregnancy, to appraise a woman's mental and physical well-being, and to optimize her health forth her life course. The yield of this effort is improved maternal health at the offset of the next pregnancy, which leads to improved health outcomes for the infant. The proposed long-term yield is improved long-term health for the woman. Therefore, interpregnancy care aims to maximize a woman'southward level of health not just in between pregnancies and during subsequent pregnancies, merely also along her life form. Because the interpregnancy period is a continuum for overall health and health, all women of reproductive historic period who have been pregnant regardless of the outcome of their pregnancies (ie, miscarriage, abortion, preterm, total-term commitment), should receive interpregnancy care every bit a continuum from postpartum care (see the American Higher of Obstetricians and Gynecologists' [ACOG] Committee Opinion Optimizing Postpartum Care or the For More Information section). Even so, it should exist best-selling that not all women will desire to or will take subsequent pregnancies or children.

The wellness care providers of that intendance for women of reproductive historic period include obstetrician–gynecologists, chief intendance providers, subspecialists who care for chronic illnesses, advanced practice professionals, and mental wellness providers. Some models have included pediatricians and dentists caring for the babe or other children. Creative partnerships such every bit these every bit well as policies that promote access to and coverage of interpregnancy care can ensure that the woman'south health is addressed.

Definition of Interpregnancy and Well-Woman Intendance

Interpregnancy care is the intendance provided to women of childbearing age who are betwixt pregnancies with the goal of improving outcomes for women and infants 5. When reviewing international recommendations for birth spacing, the World Wellness Organization identified iv intervals: one) "interpregnancy interval" indicates the time a woman is non meaning between i live birth or pregnancy loss and the side by side pregnancy; 2) "nascency-to-birth interval" is the fourth dimension between a alive nascence and the subsequent live nascency (this interval does not take into account any pregnancy losses in between births); iii) "interoutcome interval" describes the fourth dimension between the outcome of 1 pregnancy and the outcome of the previous pregnancy; and 4) "nascence-to-formulation interval" is the fourth dimension between a live birth and the start of the next pregnancy 6. This document discusses interpregnancy care , defined hither as the intendance that addresses a woman'southward wellness care needs during the interval between 1 live nascency or pregnancy loss and the start of the next pregnancy; specifically, it will focus on this interval later on a woman has transitioned from postpartum care.

Existing Recommendations

The concept of interpregnancy care is well established and multiple organizations have put along their own distinct set of interpregnancy intendance recommendations 5 seven 8 9. However, many of these recommendations are focused solely on improving neonatal outcomes of future pregnancies. This document will focus on interpregnancy care to improve maternal and neonatal outcomes of futurity pregnancies, as well as long-term women'southward health outcomes.

Clinical Considerations and Direction

To optimize interpregnancy care, anticipatory guidance should begin during pregnancy with the evolution of a postpartum intendance plan that addresses the transition to parenthood and interpregnancy or well-woman intendance 4 Table 1. The initial components of interpregnancy care should include the components of postpartum care 10, such equally reproductive life planning, screening for depression, vaccination, managing diabetes or hypertension if needed, instruction almost futurity wellness, assisting the patient to develop a postpartum care team, and making plans for long-term medical care Box 1. Timing of visits should consider any changes in insurance coverage predictable subsequently delivery.

Central Steps in Interpregnancy Intendance*

During Prenatal Care

• Make up one's mind who will provide primary intendance after the immediate postpartum period

• Discuss reproductive life planning and preferences for a method of contraception

• Provide anticipatory guidance regarding breastfeeding and maternal health

• Discuss associations between pregnancy complications and long-term maternal health, as advisable

During the Maternity Stay^†

• Hash out the importance, timing, and location of follow-up for postpartum intendance

• If desired by the patient, provide contraception, including long-acting reversible contraception or surgical sterilization

• Provide anticipatory guidance regarding breastfeeding and maternal health

• Ensure the patient has a postpartum medical home

At the Comprehensive Postpartum Visit^‡

• Review any complications of pregnancy and birth and their implications for future maternal wellness; discuss appropriate follow-up care

• Review the reproductive life plan and provide a commensurate method of contraception

• Ensure that the patient has a primary medical dwelling house for ongoing intendance

During Routine Health Care or Well-Woman or Pediatric Visits^§

• Assess whether the adult female would like to become significant in the side by side year

• Screen for intimate partner violence and depression or mental health disorders

• Assess pregnancy history to inform decisions about screening for chronic conditions (eg, diabetes, cardiovascular disease)

• For known chronic conditions, optimize illness control and maternal health

• Pediatric colleagues to screen during child health visits for women's wellness issues such as smoking, low, multivitamin employ, and satisfaction with contraception (IMPLICIT Toolkit)^‖

*Timing should take into account any changes in insurance coverage anticipated later delivery.

^†See Guidelines for Perinatal Care , Eighth Edition, for more information.

^‡See Committee Opinion 736, Optimizing Postpartum Care, for more information.

^§Come across Committee Opinion 755, Well-Woman Visit, and www.acog.org/wellwoman for more than information.

^‖Implicit Toolkit Family Medicine Education Consortium. IMPLICIT interconception care toolkit: incorporating maternal adventure assessment into well-child visits to amend nascency outcomes. Dayton (OH): FMEC; 2016. Bachelor at: https://health.usf.edu/publichealth/chiles/fpqc/larc/∼/media/89E28EE3402E4198BD648F84339799C1.ashx . Retrieved September 12, 2018.

What Are the Clinical Components of Interpregnancy Care?

Breastfeeding and Maternal Health

Health care providers should routinely provide anticipatory guidance and support to enable women to breastfeed equally an important role of interpregnancy health 11 12. Multiple studies take shown that longer duration of breastfeeding is associated with improved maternal health, including lower risks of diabetes 13 14 xv, hypertension 15 sixteen, myocardial infarction 17, ovarian cancer 15 18, and breast cancer fifteen 19. For women with gestational diabetes, longer duration of breastfeeding is associated with decreased adventure of metabolic syndrome 20 and type 2 diabetes 21. A contempo simulation study found that if ninety% of women were to breastfeed optimally, this would prevent 5,023 cases of breast cancer, 12,320 cases of type 2 diabetes, 35,982 cases of hypertension, and 8,487 cases of myocardial infarction 22.

Although ACOG recommends exclusive breastfeeding for the first half dozen months of life, obstetrician–gynecologists and other health intendance providers should back up each woman's informed decision about whether to initiate or continue breastfeeding eleven, recognizing that she is uniquely qualified to decide whether sectional breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant. Additionally, obstetrician–gynecologists and other health care providers tin provide information and resources that might help women improve understand their workplace breastfeeding rights 23. Additional guidance tin be found at world wide web.acog.org/breastfeeding .

Interpregnancy Interval

Women should exist advised to avoid interpregnancy intervals shorter than 6 months and should be counseled most the risks and benefits of repeat pregnancy sooner than 18 months. Most of the data from observational studies in the United States would suggest a small increase in risk of agin outcomes associated with intervals of less than 18 months and more than significant risk of agin outcome with intervals of less than six months betwixt nascency and the start of the adjacent pregnancy 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40. More recent studies, however, accept called into question the methodologies common to much of the literature, and the question remains open as to the causal upshot of brusk interpregnancy intervals on some outcomes 41 42. Interdelivery (from ane delivery to the next) intervals of less than 18 months take been associated with increased risk of uterine rupture among women undergoing trials of labor after cesarean 43 44. Interpregnancy intervals of greater than 5–10 years also may be associated with increased risk of adverse outcomes 25.

Considering the interpregnancy interval is a potentially modifiable risk factor, there has been enthusiasm for providing guidance to women and their families about the benefits of intervals longer than 6 months between pregnancies. Women of lower socioeconomic status and women of color appear to be at hazard of the shortest interpregnancy intervals 45 46 47, which highlights the interpregnancy interval as a potential opportunity to accost inequities in adverse outcomes.

Interventions to Increase Optimally Spaced Pregnancies

Family planning counseling should begin during prenatal care with a chat nigh the woman's interest in hereafter childbearing 48. In the Us, 45% of pregnancies are unplanned 49, and i in 3 women become pregnant before the recommended eighteen-month interpregnancy interval 50. Contraceptive access and patient and health care provider knowledge are important enablers of adequate birth spacing 51 52, and woman-centered family unit planning counseling enables each adult female to select a family unit planning method that is acceptable to her and is commensurate with her desires for future childbearing. Starting this conversation past request, "Would you like to become pregnant in the next year?" or, for women in the immediate postpartum catamenia, "When would yous similar to become meaning again?" allows the health care provider and the woman to heart discussions of contraception on the woman's priorities. The counseling should include a word about nascency spacing and its role in providing sufficient fourth dimension to optimize wellness before the adjacent pregnancy. This optimization tin can amend outcomes for the subsequent pregnancy also as across the woman's lifespan 53.

Counseling should include a give-and-take of all contraceptive options (including implants, intrauterine devices, hormonal methods, barrier methods, lactational amenorrhea, and natural family unit planning). The Centers for Illness Command and Prevention'southward (CDC ) U.S. Medical Eligibility Criteria for Contraceptive Apply and U.S. Selected Do Recommendations for Contraceptive Use 54 55 tin be used to facilitate show-based contraception counseling to meet an private patient's family planning and pregnancy spacing needs. Counseling should utilise a shared controlling approach, which acknowledges that there are two experts in the conversation (the health care provider every bit an good in clinical intendance and the patient equally an skilful on her own experiences and preferences) 48 56 so that the adult female can make an autonomous and informed decision. Health care providers also should inquire what methods women have plant to be constructive and acceptable in the past. Family planning counseling may be perceived differently by women who historically have been marginalized and who accept experienced coercive counseling and social policies 57 58. Wellness care providers should be witting of implicit biases against childbearing among marginalized women and ensure that counseling addresses the individual woman's needs and desires 57.

Every woman should have access to all contraceptive methods when needed (including immediately subsequently giving birth) without financial or logistical barriers, and obstetrician–gynecologists and other obstetric care providers can assistance advocate for policies that support this 59. This includes, but is non limited to, long-interim, reversible contraceptive methods because they may be particularly helpful in reducing unplanned pregnancy and, therefore, optimizing birth spacing sixty 61. For more data on long-acting, reversible contraceptives, see the For More Information department.

Few other interventions have proven efficacy in reducing the occurrence of short interpregnancy intervals. Other interventions that may have do good include dwelling visitation programs and enhanced social supports 62 63 64.

Low

All women should exist screened for depression in the postpartum period and and so as part of well-adult female care during the interpregnancy period. Such screening should exist implemented with systems in place to ensure authentic diagnosis, constructive treatment, and appropriate follow-up. Postpartum depression screening also may occur at the well-kid visit with procedures in place to accurately convey the information to the maternal care provider. Perinatal depression and anxiety affect i in 7 women, with devastating consequences for women and children 65. Screening for symptoms with a validated instrument, such equally the Patient Health Questionnaire-nine or the Edinburgh Postnatal Low Scale, is recommended by the U.Due south. Preventive Services Chore Force 66 and by all major medical organizations that care for women and infants 65 67 68. The American University of Pediatrics recommends postpartum depression screening at the time of well-child visits at i, 2, 4, and 6 months of age 67. Although screening alone has been demonstrated to be of benefit 65, ideally screening would exist paired with available and accessible mental health interventions. A recent systematic review found that only 22% of women who screened positive for depression attended a mental health visit in the absence of an intervention to facilitate referral 69. Health care providers should be prepared to initiate treatment or refer women to a qualified caregiver, or both.

Managing Other Medical Conditions

In women with chronic medical conditions, interpregnancy care provides an opportunity to optimize wellness earlier a subsequent pregnancy. For women who will not have whatever hereafter pregnancies, the period after pregnancy also affords an opportunity for secondary prevention and improvement of future health. Recommendations for counseling and goals can be found in Table 2 , with recommendations for the most common conditions expanded on in the following sections.

Reducing Weight

Women should be encouraged to reach their prepregnancy weight by 6–12 months postpartum and ultimately to achieve a normal body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 18.5–24.9. Ideally, a woman's weight should be optimized earlier she attempts to become meaning seventy, although the health benefits of postponing pregnancy need to be balanced against reduced fecundity with female aging 71. Postpregnancy weight retentivity and gain take been associated with subsequent adverse obstetric consequences such every bit gestational diabetes, hypertensive disorders, stillbirth, large-for-gestational historic period neonates, cesarean commitment, longer-term obesity 72 73 74 75 76 77 78, and possibly built anomalies 79. Reduction of BMI betwixt pregnancies is associated with improved perinatal outcomes 78, which makes achieving ideal torso weight an important component of interpregnancy care.

Health care providers should offer specific, actionable advice regarding nutrition and physical activity, using proven behavioral techniques 70 80. Health care providers are referred to ACOG's Obesity Toolkit for more resources 81. Several randomized controlled trials take been conducted to encourage weight loss in the postpartum period, with mixed results 82. The most constructive means by which to achieve weight loss goals are non clear, but most likely include a program of diet alone or diet in combination with exercise 83 84. In that location is insufficient show on whether breastfeeding is associated with postpartum weight modify 15.

For women with a BMI greater than or equal to xl or greater than 35 with at least i serious obesity-related morbidity, referral to a bariatric surgery program may be considered because bariatric surgery is associated with improved metabolic health 85. Studies that compared outcomes among women with pregnancies before and afterward undergoing bariatric surgery have found lower rates of gestational diabetes and hypertension in the postprocedure pregnancy but higher rates of small-for-gestational-age infants 86. Women should be counseled that weight loss later bariatric surgery is associated with improved fertility, and it is recommended to delay pregnancy for 12–24 months after the procedure 87. During the postoperative menstruum, the risk of oral contraceptive failure in patients who take bariatric surgery with a malabsorptive component is increased 54. See the For More Information department for additional resources on reducing weight.

Substance Employ and Use Disorders

Tobacco Cessation. Nonpregnant developed smokers should exist offered smoking cessation support through behavioral interventions and U.Southward. Food and Drug Administration-approved pharmacotherapy 88. Tobacco employ is a modifiable hazard factor for a host of adverse pregnancy outcomes and longer-term health outcomes. The U.S. Preventive Services Task Force and ACOG recommend medications, behavioral interventions, or both in nonpregnant adults 89 ninety. For lactating women, nicotine replacement therapy is compatible with breastfeeding because the amounts of nicotine and cotinine transferred with breast milk are more often than not the same or lower using replacement therapy compared with smoking 91. Specific tools are available to assist health care providers in enabling women to cease smoking afterward pregnancy 89 92. Wellness care providers should reassess tobacco utilize (smoked, chewed, electronic nicotine commitment systems, vaped) at the postpartum visit 4 and continue to provide, or refer to, assistance with ongoing efforts at abeyance 93.

Substance Utilize Disorder. In the interpregnancy period, all women should be routinely asked about their employ of alcohol and drugs, including prescription opioids, marijuana, and other medications used for nonmedical reasons and referred equally indicated. Substance use disorder and relapse prevention programs also should be fabricated available iv 48 94. Untreated substance utilize disorders have implications for long-term maternal wellness and increase the run a risk of adverse pregnancy outcomes. Moreover, psychiatric disorders such as low, anxiety, bipolar disorder, and posttraumatic stress disorder are prevalent amongst women with substance use disorders. Women with substance use disorder take higher rates of unintended pregnancies and lower rates of use of reliable contraception 95. Therefore, it is particularly important to ensure continuation of treatment or to identify and initiate handling for substance use disorder during the interpregnancy catamenia.

Women who are planning to get pregnant in the immediate future should be encouraged to discontinue recreational substance utilise and should be counseled that there is no safe level or type of alcohol apply during pregnancy. Women who are unable to quit before or during pregnancy likely have a substance utilize disorder and should exist referred to treatment as indicated, if this has non already been done. Come across the For More Information section for boosted resources on substance use.

Social Determinants of Health and Racial and Ethnic Disparities

Health care providers should inquire about and certificate social and structural determinants of wellness and maximize referrals to social services to help amend patients' abilities to access health intendance 96. Social determinants of health (eg, stable housing, access to food and rubber drinking water, utility needs, safety in the home and customs, immigration condition, and employment conditions) chronicle closely with health outcomes, health-seeking behaviors, and health care 96 97. Many of the resources available to women and families with specific needs are provided through state departments of wellness, insurers, or community health organizations, only individual health care providers and practices should engage in evaluation and referral as well. Estimates of the benefit of such programs are derived largely from observational cohort and preintervention and postintervention designs, but many demonstrate improved health outcomes 98 99 100 101.

Health care providers should be aware of prevailing disparities in health care and outcomes in order to empathize the risks faced by the populations they intendance for, but no current evidence guides variation in intendance by race or ethnicity that may be needed to ameliorate outcomes. Women of color and of low socioeconomic status are at hazard of adverse pregnancy and overall poor health outcomes 102. These women may exist least likely to receive prepregnancy and interpregnancy care despite their disproportionate need seven 103. Although some interpregnancy interventions (eg, dwelling visits, social supports) accept been demonstrated to be of do good within specific populations at take chances, information on differential furnishings of interventions past population are scarce.

If available, health care providers should consider patient navigators, trained medical interpreters, health educators, and promotoras (lay community health care workers who work in Spanish-speaking communities [104]) to facilitate quality interpregnancy care for women of low-wellness literacy, with no or limited English proficiency, or other advice needs.

Intimate Partner Violence

Women of childbearing age should be screened for intimate partner violence (IPV), such as domestic violence, sexual coercion, and rape and referred for intervention services if they screen positive. Sample questions to brainstorm the chat and guidance on how to appropriately and safely screen for IPV are provided in ACOG Commission Opinion Intimate Partner Violence 105. Given the high incidence of IPV, screening for IPV should occur during all encounters (postpartum, well-woman, and at the kickoff prenatal visit and at least once per trimester for meaning women) 48 106. During a lifetime, more than one in iii women feel rape, physical violence, or stalking by an intimate partner 105. Intimate partner violence has a period prevalence of 17% in the first yr postpartum 107. Some women experience IPV as reproductive coercion, including pregnancy pressure, pregnancy coercion, and sabotaging contraception 108.

Sexually Transmitted Infections

Women with histories of STIs before or during pregnancy should have thorough sexual and behavioral histories taken to determine take a chance of repeat infection or current or subsequent infection with human immunodeficiency virus (HIV) or viral hepatitis. All women should be encouraged to engage in prophylactic sex activity practices; partner screening and treatment should be facilitated as advisable. Equally office of interpregnancy intendance, women at high take chances of STIs should be offered screening, including for HIV, syphilis, and hepatitis. Screening should follow guidance fix forth past the CDC 109. Sexually transmitted infections have articulate implications for a woman'south overall health, fertility, and pregnancy outcomes. Unrecognized and untreated infections may have of import sequelae. Women with history of prior STIs are at increased risk of recurrent STIs 110 and, thus, should exist considered for rescreening.

Immunizations

The interpregnancy period is platonic to initiate or consummate advisable adult vaccinations that are contraindicated during pregnancy or were not completed during pregnancy but are medically indicated 111 Tabular array ane in ACOG's Committee Opinion on Maternal Immunization ). The current recommended immunization schedule for adults 19 years or older can exist plant on the CDC's website. The American College of Obstetricians and Gynecologists reviews these schedules annually for endorsement. Immunizations are a proven way to prevent and, in some cases, eradicate affliction. Attention to vaccines needed during the interpregnancy period can play a major role in reducing morbidity and mortality from a range of preventable diseases, including pertussis, influenza, man papillomavirus, hepatitis, and rubella for nonimmune women.

Other Components of the Well-Adult female Visit

The periodic well-woman visit every bit a component of interpregnancy intendance provides the opportunity for women to receive necessary preventive services. This may include multiple well-woman visits for women who have an interpregnancy interval that lasts for more one year. Guidance for the components of the well-woman exam can exist establish in ACOG's Committee Opinion on Well-Woman Visit , and at www.acog.org/wellwoman 112 113.

What Is Role of Interpregnancy Care in Specific Populations?

The provision of interpregnancy care may be particularly effective when targeted to high-risk and special populations. In add-on to the same universal recommendations listed in this document, the following recommendations should be considered for specific populations. More details on each topic are provided in the For More than Data section.

History of High-Run a risk Pregnancy

Preterm Nascence

For women who delivered early, obstetrician–gynecologists and other obstetric care providers should obtain a detailed medical history of all previous pregnancies and offer women the opportunity to discuss the circumstances that led to the preterm nativity. Ideally this would occur within half-dozen–8 weeks of delivery in guild to facilitate record review and accurate data gathering; a suggested plan for management of subsequent pregnancies (eg, 17α-hydroxyprogesterone, cervical cerclage, cervical length surveillance) based on current bachelor evidence should be provided to the patient and documented in an accessible location in the medical record. Women with a history of preterm birth, whether indicated or spontaneous, are at increased risk of recurrence 114 115 and at risk of longer-term maternal morbidity 116. A prior preterm birth is associated with an increased risk of subsequent cardiovascular disease 117. Although women with obstetric complications such equally preterm birth may need greater health care services than women with normal delivery outcomes, some evidence suggests that women with obstetric complications are no more probable to admission interpregnancy services 118.

Women with prior preterm births should be counseled that short interpregnancy intervals may differentially and negatively affect subsequent pregnancy outcomes and, as such, the birth spacing recommendations listed earlier are particularly important 119. Given insufficient evidence of benefit, screening and treating asymptomatic genitourinary infections in the interpregnancy period in women at high adventure of preterm birth is not recommended 120 121.

Fetal Anomalies

For women who have had pregnancies affected by congenital abnormalities or genetic disorders, wellness care providers should review postnatal or pathologic information with the women and offer genetic counseling, if appropriate, to estimate potential recurrence risk. Approximately 2–iv% of live births are affected by congenital abnormalities. The strongest risk factors, such as age, family unit history, and a previously affected child, are usually nonmodifiable. In some cases, the finding of a malformation may take implications for maternal wellness. For case, maternal obesity and pregestational diabetes mellitus are risk factors for congenital anomalies 122 123. In these cases, interventions to forestall a recurrence should focus on improvement in the underlying maternal medical conditions.

Modifiable run a risk factors for congenital birth defects too can be identified and addressed in the interpregnancy period. All women who are planning a pregnancy or capable of becoming pregnant should accept 400 micrograms of folic acid daily. Supplementation should begin at least one month before fertilization and continue through the first 12 weeks of pregnancy. All women planning a pregnancy or capable of becoming meaning who have had a kid with a neural tube defect should take 4 mg of folic acid daily. Supplementation should begin at to the lowest degree three months before fertilization and keep through the commencement 12 weeks of pregnancy. A thorough review of all prescription and nonprescription medications and potential teratogens and environmental exposures should be undertaken before the next pregnancy.

The responsibility of caring for a medically fragile infant may deter women from accessing interpregnancy care. Novel strategies, such equally embedding screening and referral services within pediatric follow-upwardly clinics 124, may assistance women to address their own health needs.

Genetic Testing

The interpregnancy menstruum is an ideal time for genetic counseling and carrier screening if they have not been previously completed, which allows for informed planning of the subsequent pregnancy 125 126. Family unit history and carrier status are important considerations. A genetic and family history of the patient and her partner should be obtained 126 127 128. This may include family history of genetic disorders; nascence defects; mental disorders; and breast, ovarian, uterine, and colon cancer. Farther guidance on carrier screening and counseling tin be establish in ACOG's Committee Opinion on Carrier Screening in the Age of Genomic Medicine 125, ACOG'southward Committee Opinion on Carrier Screening for Genetic Conditions 126, and ACOG's Technology Assessment on Modern Genetics in Obstetrics and Gynecology 128.

Infertility

Underlying conditions that may contribute to subfertility (eg, polycystic ovary syndrome, infections, obesity, and thyroid dysfunction) should be evaluated and treatments optimized earlier a woman attempts to become pregnant. Generally, recommendations for the length of the interpregnancy interval should not differ for women with prior infertility compared with women with normal fertility. Women with histories of infertility or subfertility may need to rely on assisted reproduction to become pregnant; the timing of the next pregnancy attempt is, therefore, often more readily influenced by wellness care providers than information technology might be for other women.

Prior Cesarean Delivery

Women with prior cesarean deliveries, and specially those who are considering a trial of labor after cesarean commitment, should be counseled that a shorter interpregnancy interval in this population has been associated with an increased risk of uterine rupture and gamble of maternal morbidity and transfusion. Evidence exists of increased adventure of uterine rupture after cesarean delivery following delivery-to-delivery intervals of 18–24 months or less 43 129. Evidence also indicates that there is increased risk of maternal morbidity and blood transfusion among women with interpregnancy intervals of less than six months 44 130. Furthermore, women should be counseled that the incidence of placenta accreta spectrum increases with the number of prior cesarean deliveries 131.

For More Data

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this certificate that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/InterpregnancyCare .

These resource are for data but and are non meant to be comprehensive. Referral to these resources does non imply the American College of Obstetricians and Gynecologists' endorsement of the system, the organization'southward website, or the content of the resource. The resources may alter without notice.

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Source: https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2019/01/interpregnancy-care

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