Preconception and prenatal care
Now a days these terms are changed to the concept of inter-conception care as all health care interactions with reproductive age women are opportunities to assess risk, promote healthy lifestyle behaviours and identity, treat and optimise medical and psychosocial issues that could impact pregnancy and the lifetime health of the mother and child.
The evidence and rationale for providing these services are multiple. 1st increasing evidence suggests that human health status in adulthood is dictated by micro environmental and macro environmental conditions around the time of conception (fetal programming of adult disease) . Hence the 1st prenatal visit may be too late to address modifiable behaviours that could optimise not only pregnancy outcome but the health of the child and future adult. A second significant contribution to adverse pregnancy outcome is related to congenital anomalies, PTB, and LBW. Third almost half of the pregnancies are mistimed, unplanned or unwanted or unwanted such that women may not be at optimal health or practicing ideal health behaviours at the time of conception and this is particularly true for adolescents and low income women. Fourth the proportion of women who delay childbearing or get pregnant with significant medical conditions is increasing, and specific opportunities exist to optimise fertility and pregnancy outcomes as-it relates to medication management for those planning planning pregnancy. Data suggest couples planning pregnancy are more likely to change behaviours.
Topics for preconception / inter-conceptioncounselling
< 18 years- teenage pregnancy is associated with adverse maternal and familial consequences and increased risk of preterm birth
>35 years- with advancing maternal age comes an increased likelihood of pre-existing chronic medical diseases such as arthritis , hypertension and diabetes, and Increased genetic risk. Many nulliparous women aged 40 and above require the use of ART to become pregnant and they are more likely to undergo caesarean delivery and are at increased risk of preeclampsia , premature delivery , LBW , retained placenta.
Underweight: advise weight gain-before conceiving and greater weight gain with pregnancy.
Overweight: pre-gestational weight gain or obesity BMI > 30 and excessive gestational weight gain is an independent risk for miscarriages congenital anomalies, hypertensive disorders etc.
Women who become pregnant after Bariatric surgery are prone to severe micronutrient deficiencies. iron ferritinfolate calcium zinc magnesium iodine and vitamin A B12 D and K.
Maternal obesity is a potential risk factor for childhood obesity , asthma , cognitive deficits
The total weight gain recommended in pregnancy is 11 to 16 kg for women at healthy weight. Underweight women cam gain up to 18 kg but overweight women should limit weight gain to 7 kg.
If the patient doesn’t show a 4.5 kg weight gain by mid pregnancy her nutritional status should be reviewed.
When excess weight gain is noted patients should be counselled to avoid foods that are high in fats and carbohydrates to limit sugar intake and to increase their physical activity.
Dietary and lifestyle interventions can reduce maternal gestational weight gain and improve outcomes for both mother and baby. Weight gain and weight retention after pregnancy is a risk factor for subsequent obesity. Women who resumed their pregnancy weight by 6 months postpartum gained only 2.4 kg over the next 10 years compared with 8.3 kg for women who retained weight after delivery
3) psychiatric and neurologic health:
Depression, anxiety- adjust medication to those most favourable to pregnancy at the lowest possible dose, counsel about fetal echocardiography and neonatal withdrawal syndrome for some medication
Seizure disorders- start folic acid 4 mg when considering pregnancy to decrease risk of NTD . If no seizure in 2 years , consider trial off medication, adjust medications to those most favourableto pregnancy to avoid risk of dysmorphic structural malformation syndrome , close serum monitoring is required during pregnancy
Migraines- migraine pattern can change with pregnancy. Most migraine specific medications are not contraindicated.
Congenital cardiac disease or valve disease- coordinate with cardiologist , pregnancy may be contraindicated with some conditions depending on severity ( NYHA classification) or medications needed
Hypertension – adjust medication to optimise blood pressure . Discontinue ACE inhibitors and ARBs . These drugs are associated with congenital abnormalities
5)Respiratory : optimisetreatment regimen per stepped protocol , if steroid dependent use early ultrasound to evaluate fetal cleft, advise patients at increased risk for gestational diabetes that medications , including steroids , are not contraindicated , emphasise that benefits of treatment exceed risks
6)Gastrointestinal- optimise treatment regimen , advise that it is ideal to conceive while in remission some medications have absolute versus relative contraindications
7)Metabolic / Endocrine :
Diabetes- achieve euglycemia before conception ( hbA1 c <7% ) , dose dependent relationship regarding risk of congenital anomalies with medications, with type 1 and long-standing type 2 diabetes , insulin therapy is best , sulfonylureas are usually reserved for gestational diabetes mellitus
8)Genetic and family history:
The time to screen appropriate populations for genetic disease carrier status and multifactorial congenital malformations or familial diseases with major genetic components is before pregnancy. If patients screen positive , referral for genetic counselling is indicated and consideration of additional preconception options may be warranted including donor egg or sperm , ART after preimplantation selection, prenatal genetic testing after conception , or adoption. Hemoglobinopathies like sickle cell disease, thalassemia, Tay -Sachs disease , canavan disease and cystic fibrosis.
The age of father is also important because genetic , structural , behavioural or cognitive risks to the child may exist when the father is older.
9)Rheumatologic- it is ideal to conceive while SLE in remission. Some medications may be contraindicated
10)Infections and immunisations:
Screening and counsellingwomen about sexually transmitted infections such as syphilis, gonorrhoea, chlamydia and HIV in addition to TORCH( toxoplasmosis rubella CMV and herpes infection. It is also an ideal time to confirm and update immunisation status. All reproductive age women should be current with immunisation recommended by the Advisory Committee on immunisation practices (ACIP) and the CDC. If the woman conceives and expects to deliver during flu season , she should receive influenza vaccine. She should be given the tetanus , diphtheria and pertussis ( Tdap) vaccine between 27 to 36 weeks to provide passive immunity for the newborn.
11)Substance abuse and other hazards:
Smoking and use of alcohol and other drugs by pregnant women are all harmful to the developing foetus. By active and passive smoking most of the placental and fetal damage is done in the 1 st trimester , helping women to quit smoking before conceiving should be a primary object in preconception counselling and as part of prenatal care.
Alcohol is a well established teratogen , and alcohol used during pregnancy can lead to fetal alcohol syndrome ( FAS) which includes microcephaly and long term abnormal neuropsychologic outcomes.
Cannabis use is associated with increased risk for preterm delivery, IUGR, and withdrawal symptoms in the neonate, increased neonatal morbidity and mortality and has negative ffect on intellectual outcome.
Cocaine use can lead to spontaneous abortion , PTB , placental abruption and preeclampsia, numerous abnormalities in arousal, attention and neurologic and neurophysiologic functions, most such effects appear to be self limited and restricted to early infancy and childhood. Neonatal issues include poor feeding , lethargy and seizures.
Poor obstetric outcomes can be up to six times higher in patients who abuse opiates such as heroin and methadone.
Data regarding the accumulation of mercury in fish have led to warnings advising pregnant women to avoid or decrease fish consumption however the benefits of omega 3 fatty acids found in fish outweigh the risks.
If a patient works in a laboratory with chemicals or in agriculture around a lot of pesticides , she
Should be advised to identify potential reproductive toxins and limit her exposure.
Lead has historical significance but more recent concerns are related to mercury v, phthalates, per chlorates, pesticides and bisphenol A ( BPA) . These agents are considered endocrine disrupting chemicals that interfere with cellular proliferation and differentiation and result in altered metabolic hormonal or immunologic capabilities . For example BPA commonly found in plastics used for food and beverage products and packaging is associated with recurrent miscarriages and aggression and hyperactivity in girls
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It is important to individualise patient care. Therefore the initial visit should include a detailed history along with physical and laboratory examinations. A better history may be obtained if patients are asked to fill out a preinterview questionnaire or history form. Previous medical , surgical history , obstetric and reproductive history , family history is essential to optimise care.
Physical and laboratory examination:
Baseline height weight and vital signs are recorded
Basic laboratory tests include blood group and Rh type, screening for Rh antibody if mother is Rh negative, hematocrit, serological test for rubella and syphilis, urine routine and microscopy , blood sugar, screening for HIV , hepatitis B , hepatitis C and CMV , thyroid function test, anticonvulsant therapy requires measurement of blood levels of medication to determine if the appropriate dose is better used. Both thyroid medication and anticonvulsant medication levels are sensitive to physiologic expansion of blood volume and metabolic changes that occur during pregnancy.
Repeat prenatal visits: traditionally this has been every 4 weeks for the 1st 28 weeks, every 2 to 3 weeks until 36 weeks and weekly thereafter if the pregnancy progresses normally. Goal of subsequent visits is to assess fetal growth and maternal wellbeing. If the patient is Rh negative and unsensitised she should receive Rh immunoglobulin at 28 weeks . A glucose challenge test is performed at 24 to 28 weeks . Repeat haemoglobin done at 36 weeks . Group B streptococcus screening should be done at 35 to 36 weeks. If required urine culture and sensitivity should be done. Any asymptomatic UTI should be treated because asymptomatic bacteriuria is a risk factor for pyelonephritis and PTB.
Ultrasound during pregnancy: 1st scan is done to confirm viability and rule out ectopic pregnancy at 7 to 8 weeks. 2nd scan done between 12 to 15 weeks . It is called NT scan or 1 st trimester anomaly scan. With this double marker test is offered. 3 rd scan done at 18 to 22 weeks . It is called Target scan or 2 nd trimester anomaly scan. Thereafter growth scan is done at around 32 to 34 weeks .
Common patient centered issues:
Nutrition during pregnancy- patient should take a diet rich in protein , omega 3 fatty acids, vitamins like folate, vitamin A , vitamin C, minerals like calcium magnesium, iron, zinc etc.
Physical activity- ACOG recommends 30 minutes or more of moderate exercise daily if no medical or obstetric complications . A good rule of thumb to judge “moderate ‘’ exercise intensity is the “talk test” . If a woman cannot maintain a conversation while doing the activity , she is probably overexercising. If the woman’s job has no occupational health hazards she can work until delivery.
Travel– a pregnant woman should avoid prolonged sitting in car or aeroplane because of tge risk of venous stasis and possible thromboembolism
Nausea and vomiting in pregnancy –
It is the most common symptom of pregnancy . For this she is advised to eat small meals tgat favours protein over carbohydrates and liquids over solids. Vitamin B 6 reduces nausea, antihistamines, benzamides, phenothiazines, butyrophenonestype 3 serotonin receptor antagonists, corticosteroids , ginger and accupuncture all have been used in the treatment of hyperemesis( excessive vomiting leading to dehydration and weight loss).
Heartburn– it is a common complaint because of relaxation of oesophageal sphincter . Women are advised to eat smaller portions and to not eat immediately before lying . Pillows to prop up the upper body at bed time. Liquid antacids are more helpful than tablets
Backache– numerous physiological changes of pregnancy contribute to backache like ligament laxity due to relaxin and oestrogen , weight gain, hyperlordosis and anterior tilt if pelvis. Backache can be prevented by avoiding excessive weight gain and a regular exercise program before pregnancy, posture is important , sensible shoes , rest with elevation of the feet is helpful
Sexual activity– for women at risk of PTL or those with the history of previous pregnancy lossand who nite increased uterine activity after sex , avoidance of sexual activity is recommended.
A key element to ensure the optimal prenatal and preconception care is to see the patient approximately 3 to 6 weeks postpartum , sooner in case of complicated and caesareandelivery to educate woman for waiting at-least 24 months after delivery to conceive again.