The Genome

CMECNE

NTDs and Pregnancy – Folic Acid Recommendations

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the use of folic acid to prevent neural tube defects
2. Restate the high risk factors that ACOG and CDC cite for the use of 4mg of folic acid

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

ACOG guidance provides the latest update on neural tube defects (NTDs) including recommendations related to screening, management and delivery. The USPSTF has reaffirmed its recommendation that folic acid supplementation prevents NTDs in offspring. Evidence of potential harms to mother or infant is no greater than small.

PROFESSIONAL RECOMMENDATIONS

USPSTF
- All women who are planning or capable of pregnancy should take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid
- Approximately 50% of pregnancies in the US are unplanned so it is best to already be on folic acid prior to pregnancy
ACMG
- Daily folic acid intake of 400 µg (0.4 mg) is recommended in all women of child-bearing age
  - If planning pregnancy, start at least 4 weeks prior to planned conception
- Women at High risk: 4,000 µg (4 mg) of daily folic acid supplementation at least 12 weeks prior to conception
  - Then continue with 400 µg (0.4 mg) after 12 weeks gestation

Note: ACMG highlights that folic acid supplementation reduces risk but not entirely prevent NTDs even among women who are fully compliant

ACOG, CDC, AAFP, AAP, Health and Medicine Division of the National Academies (formerly the Institute of Medicine), US Public Health Service, American Academy of Neurology
- Women who are capable of becoming pregnant should take at least 0.4 mg (400 µg) of folic acid daily

ACOG, CDC, and several other organizations
- Women with a history of neural tube defects, or has a partner with an NTD or a partner who has had a child with an NTD or other high-risk factors take 4 mg (4000 μg) of folic acid daily

Note: While USPSTF focuses on prevention of NTD, other organizations also stress the prevention of other birth defects such as heart defects, urinary tract anomalies and oral facial clefts

High risk factors include the following

Patient has a previously NTD-affected pregnancy
Patient herself is affected
Patient with a first- or second-degree relative with a NTD
Diabetes mellitus type 1
Obesity
Particular antiseizure medications (eg, valproic acid)

NOTE: Folic acid may not prevent NTDs in diabetic pregnancies, especially if not well controlled | Likewise regarding obesity and antiepileptic medications may also be folate-resistant

Learn More – Primary Sources:

USPSTF Statement: Folic Acid Supplementation for the Prevention of Neural Tube Defects

ACOG Practice Bulletin 187: Neural Tube Defects

ACOG Committee Opinion 720: Maternal–Fetal Surgery for Myelomeningocele

ACMG Policy Statement on folic acid and neural tube defects

ACMG Focused Revision: Policy statement on folic acid and neural tube defects

CDC Recommendations for the Use of Folic Acid to Reduce the Number of Cases of Spina Bifida and Other Neural Tube Defects

SOGC Guideline 410: Prevention, Screening, Diagnosis, and Pregnancy Management for Fetal Neural Tube Defects

Locate a Genetic Counselor or Genetics services:

Genetic Services Locator-ACMG

Genetic Services Locator-NSGC

Genetic Services Locator-CAGC

Locate a Maternal Fetal Medicine Specialist

Maternal Fetal Medicine Specialist Locator-SMFM

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