Midterm Pregnancy Loss When to Get Pregnant Again Acog

ABSTRACT: Interpregnancy care aims to maximize a woman's level of wellness not simply in between pregnancies and during subsequent pregnancies, simply besides along her life class. Because the interpregnancy period is a continuum for overall health and wellness, all women of reproductive age who have been meaning regardless of the outcome of their pregnancies (ie, miscarriage, abortion, preterm, full-term delivery), should receive interpregnancy care equally a continuum from postpartum care. The initial components of interpregnancy intendance should include the components of postpartum intendance, such as reproductive life planning, screening for depression, vaccination, managing diabetes or hypertension if needed, education about futurity health, assisting the patient to develop a postpartum intendance squad, and making plans for long-term medical care. In women with chronic medical conditions, interpregnancy care provides an opportunity to optimize wellness before a subsequent pregnancy. For women who will not accept any future pregnancies, the period after pregnancy besides 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 wellness before a time to come pregnancy and across the lifespan. One proposed intervention is improving interpregnancy care. Long understood as an intervention to improve neonatal outcomes, the part of interpregnancy care recently has been recognized for its role in maternal health. This document reviews the existing data on interpregnancy care and offers guidance on providing women with interpregnancy care.

Prepregnancy, Postpartum, Interpregnancy, and Well-Woman Care: The Intersection

Prepregnancy, postpartum, interpregnancy, and well-adult female care are interrelated and can be defined past their relationship to the timing of pregnancy Effigy 1. For women who get meaning, pregnancy is recognized equally a window to future health because complications during pregnancy, such as gestational diabetes mellitus, gestational hypertension, preeclampsia, and fetal growth restriction, are associated with hazard of health complications later in life 1 2 3 four. The interpregnancy menstruation is an opportunity to accost these complications or medical issues that accept developed during pregnancy, to assess a adult female's mental and physical well-existence, and to optimize her wellness along her life grade. The yield of this effort is improved maternal wellness at the start of the next pregnancy, which leads to improved health outcomes for the baby. The proposed long-term yield is improved long-term wellness for the woman. Therefore, interpregnancy care aims to maximize a adult female's level of wellness non simply in between pregnancies and during subsequent pregnancies, simply also along her life grade. Because the interpregnancy period is a continuum for overall health and health, all women of reproductive age who take been pregnant regardless of the consequence of their pregnancies (ie, miscarriage, abortion, preterm, full-term delivery), should receive interpregnancy intendance as a continuum from postpartum care (run across the American College of Obstetricians and Gynecologists' [ACOG] Committee Opinion Optimizing Postpartum Care or the For More Information department). However, it should be acknowledged that not all women will want to or will accept subsequent pregnancies or children.

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

Definition of Interpregnancy and Well-Woman Care

Interpregnancy care is the care provided to women of childbearing age who are between pregnancies with the goal of improving outcomes for women and infants five. When reviewing international recommendations for birth spacing, the World Wellness Organization identified four intervals: 1) "interpregnancy interval" indicates the time a adult female is non pregnant between one live nascency or pregnancy loss and the next pregnancy; ii) "birth-to-birth interval" is the time between a live birth and the subsequent live birth (this interval does not take into account whatsoever pregnancy losses in between births); three) "interoutcome interval" describes the time between the effect of 1 pregnancy and the outcome of the previous pregnancy; and 4) "birth-to-conception interval" is the time betwixt a live birth and the start of the next pregnancy 6. This document discusses interpregnancy care , defined here as the care that addresses a woman's health care needs during the interval betwixt ane live birth or pregnancy loss and the kickoff of the next pregnancy; specifically, it will focus on this interval subsequently a woman has transitioned from postpartum intendance.

Existing Recommendations

The concept of interpregnancy care is well established and multiple organizations have put forth their own distinct set of interpregnancy care recommendations v 7 8 nine. Still, many of these recommendations are focused solely on improving neonatal outcomes of future pregnancies. This certificate volition focus on interpregnancy intendance to better maternal and neonatal outcomes of future pregnancies, equally well as long-term women'due south 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 care iv Table 1. The initial components of interpregnancy care should include the components of postpartum care ten, such every bit reproductive life planning, screening for depression, vaccination, managing diabetes or hypertension if needed, educational activity virtually future health, profitable the patient to develop a postpartum intendance team, and making plans for long-term medical intendance Box ane. Timing of visits should consider whatsoever changes in insurance coverage anticipated after delivery.

Cardinal Steps in Interpregnancy Care*

During Prenatal Intendance

• Determine who will provide primary intendance after the immediate postpartum period

• Hash out 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 appropriate

During the Motherhood Stay^†

• Discuss the importance, timing, and location of follow-upwards for postpartum care

• If desired past the patient, provide contraception, including long-interim 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 whatsoever complications of pregnancy and birth and their implications for future maternal health; talk over appropriate follow-upwardly care

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

• Ensure that the patient has a chief medical home for ongoing care

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

• Assess whether the adult female would similar to become pregnant in the side by side year

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

• Assess pregnancy history to inform decisions about screening for chronic weather condition (eg, diabetes, cardiovascular illness)

• For known chronic conditions, optimize disease command and maternal wellness

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

*Timing should have into account any changes in insurance coverage predictable after delivery.

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

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

^§Run across Committee Opinion 755, Well-Woman Visit, and world wide web.acog.org/wellwoman for more information.

^‖Implicit Toolkit Family unit Medicine Education Consortium. IMPLICIT interconception intendance toolkit: incorporating maternal take chances assessment into well-kid visits to meliorate birth outcomes. Dayton (OH): FMEC; 2016. Available at: https://wellness.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 as an important part of interpregnancy health 11 12. Multiple studies have shown that longer elapsing of breastfeeding is associated with improved maternal health, including lower risks of diabetes 13 14 15, hypertension 15 16, myocardial infarction 17, ovarian cancer fifteen 18, and chest cancer 15 19. For women with gestational diabetes, longer duration of breastfeeding is associated with decreased run a risk of metabolic syndrome 20 and type ii diabetes 21. A recent simulation report institute that if ninety% of women were to breastfeed optimally, this would prevent 5,023 cases of breast cancer, 12,320 cases of type two diabetes, 35,982 cases of hypertension, and 8,487 cases of myocardial infarction 22.

Although ACOG recommends exclusive breastfeeding for the offset half dozen months of life, obstetrician–gynecologists and other wellness care providers should back up each woman's informed decision almost whether to initiate or continue breastfeeding 11, recognizing that she is uniquely qualified to determine whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant. Additionally, obstetrician–gynecologists and other wellness care providers can provide information and resources that might help women amend sympathize their workplace breastfeeding rights 23. Additional guidance can be plant at www.acog.org/breastfeeding .

Interpregnancy Interval

Women should exist advised to avoid interpregnancy intervals shorter than 6 months and should be counseled about the risks and benefits of repeat pregnancy sooner than 18 months. Virtually of the information from observational studies in the United States would suggest a small-scale increase in adventure of agin outcomes associated with intervals of less than 18 months and more significant risk of adverse upshot with intervals of less than 6 months betwixt birth and the commencement of the next pregnancy 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40. More recent studies, yet, have called into question the methodologies common to much of the literature, and the question remains open up as to the causal effect of brusk interpregnancy intervals on some outcomes 41 42. Interdelivery (from 1 delivery to the next) intervals of less than xviii months have been associated with increased risk of uterine rupture amid women undergoing trials of labor after cesarean 43 44. Interpregnancy intervals of greater than 5–10 years too may be associated with increased adventure of agin outcomes 25.

Because the interpregnancy interval is a potentially modifiable risk factor, in that location 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 announced to exist at take chances 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 conversation well-nigh the adult female's involvement in time to come childbearing 48. In the United States, 45% of pregnancies are unplanned 49, and one in three women become pregnant before the recommended 18-month interpregnancy interval 50. Contraceptive access and patient and health care provider cognition are important enablers of adequate birth spacing 51 52, and woman-centered family planning counseling enables each woman to select a family planning method that is acceptable to her and is commensurate with her desires for future childbearing. Starting this conversation by asking, "Would y'all like to go pregnant in the next yr?" or, for women in the immediate postpartum period, "When would you like to go pregnant again?" allows the health intendance provider and the woman to center discussions of contraception on the woman's priorities. The counseling should include a discussion well-nigh birth spacing and its function in providing sufficient time to optimize wellness before the side by side pregnancy. This optimization tin improve outcomes for the subsequent pregnancy also as across the adult female's lifespan 53.

Counseling should include a discussion of all contraceptive options (including implants, intrauterine devices, hormonal methods, barrier methods, lactational amenorrhea, and natural family planning). The Centers for Disease Control and Prevention's (CDC ) U.S. Medical Eligibility Criteria for Contraceptive Use and U.South. Selected Practise Recommendations for Contraceptive Use 54 55 can be used to facilitate testify-based contraception counseling to meet an individual patient's family unit planning and pregnancy spacing needs. Counseling should use a shared decision-making arroyo, which acknowledges that in that location are two experts in the chat (the health care provider every bit an practiced in clinical care and the patient every bit an expert on her ain experiences and preferences) 48 56 so that the woman can make an autonomous and informed decision. Health care providers too should ask what methods women have found to be effective and acceptable in the past. Family planning counseling may be perceived differently by women who historically have been marginalized and who take experienced coercive counseling and social policies 57 58. Wellness care providers should be conscious of implicit biases against childbearing among marginalized women and ensure that counseling addresses the individual woman's needs and desires 57.

Every adult female should have access to all contraceptive methods when needed (including immediately after giving nativity) without financial or logistical barriers, and obstetrician–gynecologists and other obstetric care providers can help advocate for policies that support this 59. This includes, just is non limited to, long-acting, reversible contraceptive methods considering 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 section.

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

Depression

All women should be screened for depression in the postpartum catamenia and then equally office of well-woman intendance during the interpregnancy menstruation. Such screening should be implemented with systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-upwardly. Postpartum low screening also may occur at the well-child visit with procedures in place to accurately convey the information to the maternal care provider. Perinatal depression and anxiety affect one in 7 women, with devastating consequences for women and children 65. Screening for symptoms with a validated musical instrument, such equally the Patient Health Questionnaire-ix or the Edinburgh Postnatal Depression Scale, is recommended by the U.Southward. Preventive Services Task Strength 66 and by all major medical organizations that intendance for women and infants 65 67 68. The American Academy of Pediatrics recommends postpartum low screening at the time of well-kid visits at i, 2, iv, and 6 months of age 67. Although screening alone has been demonstrated to be of do good 65, ideally screening would be paired with available and accessible mental health interventions. A contempo systematic review institute that only 22% of women who screened positive for depression attended a mental wellness visit in the absenteeism of an intervention to facilitate referral 69. Health intendance 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 weather condition, interpregnancy care provides an opportunity to optimize health before a subsequent pregnancy. For women who volition non take any future pregnancies, the period afterward pregnancy besides affords an opportunity for secondary prevention and improvement of future health. Recommendations for counseling and goals tin exist institute in Table two , with recommendations for the nigh mutual conditions expanded on in the post-obit sections.

Reducing Weight

Women should exist encouraged to accomplish their prepregnancy weight past 6–12 months postpartum and ultimately to achieve a normal body mass index (BMI; calculated as weight in kilograms divided past superlative in meters squared) of 18.5–24.nine. Ideally, a woman'south weight should exist optimized before she attempts to get pregnant 70, although the health benefits of postponing pregnancy need to exist balanced against reduced fecundity with female person crumbling 71. Postpregnancy weight retention and gain have been associated with subsequent agin obstetric consequences such equally gestational diabetes, hypertensive disorders, stillbirth, large-for-gestational age neonates, cesarean delivery, longer-term obesity 72 73 74 75 76 77 78, and maybe congenital anomalies 79. Reduction of BMI betwixt pregnancies is associated with improved perinatal outcomes 78, which makes achieving ideal body weight an important component of interpregnancy care.

Health intendance providers should offer specific, actionable communication regarding diet and physical action, using proven behavioral techniques lxx lxxx. Health care providers are referred to ACOG'due south Obesity Toolkit for more than resources 81. Several randomized controlled trials have been conducted to encourage weight loss in the postpartum period, with mixed results 82. The most effective means by which to reach weight loss goals are not articulate, only nigh probable include a program of diet alone or nutrition in combination with practice 83 84. In that location is insufficient evidence on whether breastfeeding is associated with postpartum weight change fifteen.

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 plan may exist considered because bariatric surgery is associated with improved metabolic health 85. Studies that compared outcomes among women with pregnancies before and after undergoing bariatric surgery accept establish 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 after bariatric surgery is associated with improved fertility, and it is recommended to delay pregnancy for 12–24 months subsequently the procedure 87. During the postoperative menses, the gamble of oral contraceptive failure in patients who have bariatric surgery with a malabsorptive component is increased 54. Encounter the For More Data department for additional resources on reducing weight.

Substance Apply and Utilise Disorders

Tobacco Cessation. Nonpregnant developed smokers should exist offered smoking cessation back up through behavioral interventions and U.S. Food and Drug Administration-approved pharmacotherapy 88. Tobacco use is a modifiable risk 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 90. For lactating women, nicotine replacement therapy is compatible with breastfeeding because the amounts of nicotine and cotinine transferred with chest milk are generally the aforementioned or lower using replacement therapy compared with smoking 91. Specific tools are available to assist wellness care providers in enabling women to cease smoking after pregnancy 89 92. Health care providers should reassess tobacco use (smoked, chewed, electronic nicotine delivery systems, vaped) at the postpartum visit 4 and continue to provide, or refer to, assistance with ongoing efforts at cessation 93.

Substance Use Disorder. In the interpregnancy period, all women should exist routinely asked about their use of alcohol and drugs, including prescription opioids, marijuana, and other medications used for nonmedical reasons and referred as indicated. Substance utilize disorder and relapse prevention programs also should be made available iv 48 94. Untreated substance use disorders have implications for long-term maternal health and increment the risk of adverse pregnancy outcomes. Moreover, psychiatric disorders such equally low, anxiety, bipolar disorder, and posttraumatic stress disorder are prevalent amid women with substance use disorders. Women with substance use disorder have 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 treatment for substance utilize disorder during the interpregnancy period.

Women who are planning to become significant in the firsthand futurity should be encouraged to discontinue recreational substance use and should be counseled that there is no safe level or blazon of alcohol utilise during pregnancy. Women who are unable to quit before or during pregnancy probable accept a substance utilize disorder and should be referred to treatment as indicated, if this has not already been done. Run across the For More than Data section for additional resource on substance use.

Social Determinants of Wellness and Racial and Ethnic Disparities

Health care providers should enquire about and document social and structural determinants of wellness and maximize referrals to social services to assist improve patients' abilities to access wellness intendance 96. Social determinants of wellness (eg, stable housing, admission to food and safe drinking water, utility needs, safe in the dwelling house and community, immigration status, and employment conditions) relate closely with health outcomes, health-seeking behaviors, and health intendance 96 97. Many of the resources bachelor to women and families with specific needs are provided through state departments of health, insurers, or community health organizations, merely private health care providers and practices should appoint in evaluation and referral equally well. Estimates of the do good of such programs are derived largely from observational accomplice and preintervention and postintervention designs, only many demonstrate improved health outcomes 98 99 100 101.

Health care providers should be enlightened of prevailing disparities in health intendance and outcomes in order to understand the risks faced past the populations they care for, but no current evidence guides variation in intendance by race or ethnicity that may be needed to improve outcomes. Women of color and of low socioeconomic status are at risk of agin pregnancy and overall poor wellness outcomes 102. These women may be least likely to receive prepregnancy and interpregnancy care despite their disproportionate need vii 103. Although some interpregnancy interventions (eg, home visits, social supports) have been demonstrated to be of benefit within specific populations at run a risk, data on differential effects of interventions by population are scarce.

If available, health care providers should consider patient navigators, trained medical interpreters, wellness educators, and promotoras (lay community wellness intendance workers who piece of work in Spanish-speaking communities [104]) to facilitate quality interpregnancy care for women of depression-health literacy, with no or limited English language proficiency, or other communication 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 begin the chat and guidance on how to accordingly and safely screen for IPV are provided in ACOG Committee Stance Intimate Partner Violence 105. Given the high incidence of IPV, screening for IPV should occur during all encounters (postpartum, well-woman, and at the showtime prenatal visit and at least once per trimester for pregnant women) 48 106. During a lifetime, more than one in three women feel rape, physical violence, or stalking by an intimate partner 105. Intimate partner violence has a flow prevalence of 17% in the outset 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 make up one's mind risk of repeat infection or current or subsequent infection with human immunodeficiency virus (HIV) or viral hepatitis. All women should be encouraged to appoint in safe sex activity practices; partner screening and treatment should be facilitated every bit advisable. As part of interpregnancy intendance, women at loftier risk of STIs should be offered screening, including for HIV, syphilis, and hepatitis. Screening should follow guidance set forth by the CDC 109. Sexually transmitted infections have clear implications for a woman'south overall health, fertility, and pregnancy outcomes. Unrecognized and untreated infections may have important sequelae. Women with history of prior STIs are at increased risk of recurrent STIs 110 and, thus, should be considered for rescreening.

Immunizations

The interpregnancy period is ideal to initiate or complete appropriate adult vaccinations that are contraindicated during pregnancy or were not completed during pregnancy only are medically indicated 111 Tabular array 1 in ACOG'southward Commission Stance on Maternal Immunization ). The current recommended immunization schedule for adults xix years or older tin can exist establish on the CDC's website. The American College of Obstetricians and Gynecologists reviews these schedules annually for endorsement. Immunizations are a proven way to forbid and, in some cases, eradicate disease. Attending to vaccines needed during the interpregnancy period can play a major role in reducing morbidity and bloodshed from a range of preventable diseases, including pertussis, influenza, human papillomavirus, hepatitis, and rubella for nonimmune women.

Other Components of the Well-Adult female Visit

The periodic well-woman visit equally 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 take an interpregnancy interval that lasts for more than than 1 yr. Guidance for the components of the well-woman examination can exist institute in ACOG'southward Committee Opinion on Well-Woman Visit , and at www.acog.org/wellwoman 112 113.

What Is Part of Interpregnancy Intendance in Specific Populations?

The provision of interpregnancy care may be especially constructive when targeted to loftier-hazard and special populations. In addition to the aforementioned universal recommendations listed in this document, the following recommendations should exist considered for specific populations. More than details on each topic are provided in the For More Information department.

History of High-Chance Pregnancy

Preterm Birth

For women who delivered early, obstetrician–gynecologists and other obstetric intendance 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 birth. Ideally this would occur inside half-dozen–8 weeks of delivery in guild to facilitate record review and accurate data gathering; a suggested programme for direction of subsequent pregnancies (eg, 17α-hydroxyprogesterone, cervical cerclage, cervical length surveillance) based on current available show 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 nascence is associated with an increased risk of subsequent cardiovascular disease 117. Although women with obstetric complications such as preterm nativity may need greater health care services than women with normal delivery outcomes, some prove suggests that women with obstetric complications are no more likely to access interpregnancy services 118.

Women with prior preterm births should exist counseled that brusque 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 risk of preterm nascency is not recommended 120 121.

Fetal Anomalies

For women who accept had pregnancies affected past congenital abnormalities or genetic disorders, wellness intendance providers should review postnatal or pathologic information with the women and offer genetic counseling, if advisable, to gauge potential recurrence risk. Approximately 2–4% of alive births are affected past congenital abnormalities. The strongest run a risk factors, such as historic period, family history, and a previously affected child, are usually nonmodifiable. In some cases, the finding of a malformation may have implications for maternal health. For example, maternal obesity and pregestational diabetes mellitus are risk factors for congenital anomalies 122 123. In these cases, interventions to prevent a recurrence should focus on improvement in the underlying maternal medical conditions.

Modifiable chance factors for built birth defects too tin can be identified and addressed in the interpregnancy catamenia. All women who are planning a pregnancy or capable of becoming significant should take 400 micrograms of folic acrid daily. Supplementation should brainstorm at least i month before fertilization and continue through the kickoff 12 weeks of pregnancy. All women planning a pregnancy or capable of becoming pregnant who have had a child with a neural tube defect should take 4 mg of folic acid daily. Supplementation should begin at least three months before fertilization and continue through the first 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 responsibleness of caring for a medically delicate infant may deter women from accessing interpregnancy care. Novel strategies, such equally embedding screening and referral services within pediatric follow-up clinics 124, may help women to address their own health needs.

Genetic Testing

The interpregnancy flow is an platonic time for genetic counseling and carrier screening if they have non been previously completed, which allows for informed planning of the subsequent pregnancy 125 126. Family history and carrier status are of import 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; birth defects; mental disorders; and chest, ovarian, uterine, and colon cancer. Farther guidance on carrier screening and counseling tin can be constitute 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 Engineering science Assessment on Modern Genetics in Obstetrics and Gynecology 128.

Infertility

Underlying atmospheric condition that may contribute to subfertility (eg, polycystic ovary syndrome, infections, obesity, and thyroid dysfunction) should be evaluated and treatments optimized before a woman attempts to get 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 endeavor is, therefore, ofttimes more readily influenced by health care providers than it might be for other women.

Prior Cesarean Delivery

Women with prior cesarean deliveries, and particularly those who are considering a trial of labor after cesarean delivery, should exist counseled that a shorter interpregnancy interval in this population has been associated with an increased adventure of uterine rupture and take chances of maternal morbidity and transfusion. Evidence exists of increased risk of uterine rupture after cesarean delivery following delivery-to-delivery intervals of 18–24 months or less 43 129. Show also indicates that there is increased risk of maternal morbidity and blood transfusion amid women with interpregnancy intervals of less than vi 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 than Information

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

These resource are for information but and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the organization, the organization's website, or the content of the resource. The resources may change 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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