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PRE PREGNANCY CARE (PPC)

DR ALIFAH MOHD ZIZI

KAPIT O&G UPDATES

+DEFINITION…

Identify and modify biomedical,

behavioural and social risks to a

woman health or pregnancy through

prevention and management

+GOALS….

1. Help the mother to maintain her well-being

2. Obstetrician & physician have ultimate time to

assess, manage and treat many conditions or

complications before conception

3. Help the mother to achieve a healthy outcome

for herself & also her unborn fetus

4. Reduce maternal or neonatal morbidity and

mortality

+COMPONENTS…

1. Identification of pregnancy related risks

2. Patient’s education and informed choice regarding pregnancy risks, management options and reproductive alternative

3. Identifying couples who are at increased risk of having babies with a genetic malformation.

4. Initiation of interventions, when possible to provide optimum pregnancy outcome

5. Women and their partners being encouraged to prepare actively for pregnancy, and be as healthy as possible

+WHO????

Any women who wish to embark on

pregnancy, especially those who are at

risk

+WHEN??

Anytime… OR

At least 3 months before getting pregnant

+WHAT TO EXPECT ??

1.Complete history- medical, surgical, drug,

family history, social

2.Physical examination

3.Laboratory investigations

+Pre-pregnancy Counselling

Age related risk

Body Weight (BMI)

Chronic diseases

Infections (STIs)

Medication review

Immunisation status (Rubella)

Genetic counselling

Diet

Exercise

Smoking

Alcohol

Elicit drug abuse

Psychosocial –relationship/stress/ financial/mental health

+ AGE- RELATED RISKS

Most pregnancies are uneventful and have a good outcome

The risk of fetal chromosomal abnormalities, particularly trisomy 21 (Down's syndrome) increases sharply with maternal age

There is also an increased risk of infertility, miscarriage, twins, fibroids, hypertension, gestational diabetes, labour problems, and perinatal mortality with increasing maternal age.

+

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Teenage pregnancy also associated with

1.Nutritional issue

2.Anaemia / Hypertension

3.Emotional

4.Social issue

+WEIGHT (BMI)

+ A healthy weight reduces the risk of

Infertility

Neural Tube Defect (NTD)

Miscarriage

Preterm delivery

Gestational diabetes

Hypertension

Thromboembolic disease

Caesarean delivery & intrapartum complication

Consultation with a dietician may be helpful

Aim to reduce weight to normal BMI.

+CHRONIC DISEASES

Many chronic diseases and their

treatments may have implications

for fetal health and development

Similarly pregnancy and labour

may worsen pre-existing maternal

conditions

+

Heart Disease

Chronic HPT

DM

Epilepsy

Thyroid Disease

Connective Tissue Disease

Mental Health Illness

Infection

+1. Chronic Hypertension

Woman with chronic hypertension may have

impact on the pregnancy (eg Pre- eclampsia,

IUGR or worsening of any end organ

damage)

Aims

1.To ensure BP stable

2.To identify if any complication (end organ)

3.To adjust anti-hypertensive to a safer choice

Women should take 75 mg aspirin from 12

weeks' gestation to delivery

+ STOP!!

1) Angiotensin-

converting enzyme

(ACE) inhibitors or

angiotensin-II

receptor blocker

(ARB)

2) Chlorothiazide

-Increased risk of

congenital abnormalities

Drugs of choice

Methyldopa

Labetolol

Nifedipine

+2. Diabetes Mellitus

Aims..

Ensure good control of blood

sugar

HbA1c < 7%

Reduce Weight

Screen for complications

Baseline Renal Function

Opthalmologist referral

+ Impact of Pregnancy to DM

-Worsening retinopathy and nephropathy

-Difficulty in controlling blood sugar

Impact of DM to pregnancy

- MOTHER- PE, Intrapartum complications, Operative morbidity, PPH

- FETUS- Miscarriage, congenital malformations, stillbirth and neonatal death, macrosomia, polyhydramnions, shoulder dystocia,

Convert OHA to insulin

Metformin safe to be used in pregnancy

Folic acid 5mg a day should be started to reduce the risk of child having neural tube defect

+3.Heart Disease

All women with congenital or acquired heart disease

should discuss future pregnancies with a cardiologist

and obstetrician

Need detail assessment of cardiac status (ECHO)

The ability to tolerate pregnancy is related to

1.Presence of pulmonary hypertension

2.Haemodynamic significant of any lession

3.Functional class (NYHA)

4.Presence of cyanosis (Spo2 <80%)

+ Pregnancy is contra-indicated

1) Pulmonary hypertension

2) Marfan's syndrome with a dilated aortic root

3) Severe aortic or mitral valve stenosis

4) Any patient with poor ventricular function

5) Eisenmenger’s syndrome

HIGH MORTALITY

1.Eisenmenger's syndrome or cardiomegaly

- mortality may be as high as 25% to 50%.

2.Primary pulmonary hypertension and cyanotic disease

-maternal mortality of 50%

+ If the woman takes warfarin, this

should be converted LMWH

Those with rheumatic heart

disease should continue their

penicillin

Angiotensin-converting enzyme

(ACE) inhibitors and angiotensin

receptor blocker (ARB) are both

severely teratogenic.

Statins are contra-indicated in

pregnancy .

+4.Epilepsy

Referral for Neuromedical specialist before conception to reduce or

change drug treatment if possible

Assess fit free period (preferably 6 months – 1 year)

More concern on the effect of AED (anti-epileptic drugs to developing

fetus)

Counsel about the balance between the possible harm done by

medication compared with against the risk of developing seizure in

pregnancy

+AEDs (anti-epileptic drugs)

Phenytoin, phenobarbitone, carbamazepine, sodium

valproate, lamotrigine, Keppra (Levetiracetam) all

cross placenta and teratogenic

The risk increases if using sodium valproate and

also with the number of drugs use (polytheraphy)

MAJOR ABNORMALITY MINOR ABNORMALITY

-Neural tube defect

-Orofacial cleft

-Congenital heart defects

-Dysmorphic features

-Hypoplastic nails

+ Use monotheraphy if possible

DO NOT CHANGE the drugs if the epilepsy well controlled

with that particular medication

Recommend folic acid 5 mg per day before conception and

up to 12 weeks following conception

Arrange for detail scan during 2nd trimester

Educate family members regarding care if patient

develop seizure

+5.Thyroid Disease

Check TFTs if not done in the last 6 months

Need to liase with ENDOCRINOLOGIST

Those with subclinical hypothyroidism, should commence

treatment

Those on treatment for hypothyroidism, should be reviewed to

ensure optimum control. The requirement for thyroid

replacement therapy increases in pregnancy.

Hyperthyroid individuals should be reviewed and may wish to

consider treatment with radio-active iodine or surgery prior to

pregnancy.

Need to assess for any complications from the thyroid disease

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Impact on the disease to pregnancy

-THYROTOXICOSIS- miscarriage, IUGR, thyroid

storm

-HYPOTHYROID- miscarriage, IUGR, neonatal

kernicterus

Carbimazole, PTU and thyroxine are safe in

pregnancy

If underwent RAI (radio-iodine ablation) need to

delay pregnancy at least 1 year

+6.Infections (STIs)

Includes – HIV, Hepatitis B, Herpes, Genital warts,

Syphillis

Any active sexually transmitted illness (STIs) are not

advice for pregnancy

Need to liase with ID physician (infectious disease)

or GUM (genito-urinary medicine) specialist for

treatment before embark on pregnancy

Risk of transmission to the developing fetus if

untreated

+MEDICATION REVIEWS

It is good practice to minimise exposure to all drugs, including those bought over the counter

There is little data on herbal preparations in pregnancy, and they should also be avoided

+IMMUNISATION STATUS

Ensure that the immunisation status (esp Rubella) is

up to date

Those who is never vaccinated is succeptible for

Rubella infection in pregnancy and will put baby at

risk of Congenital Rubella Syndrome (cataract,

deafness, heart, lung, brain anomalies)

Live vaccine should be given more than 1 month

before embark to pregnancy

+GENETIC COUNSELLING

This is recommended for those

1) Who have had a previous child with an inherited disease such as Down's syndrome or cystic fibrosis

2) Have a family history of a genetic disorder.

Couples need to know what the risk of having an affected child is and whether screening, genetic testing, pre-natal or pre-implantation is available.

+NUTRITION

In healthy women on a normal diet, advice on

eating 5 portions of fruit and vegetables per

day and consuming dairy products to raise

stores of vitamins, iron and calcium is

reasonable.

Dietary changes to optimise growth and

development

Vegetarian diets lack adequate amounts of

amino acid, iron, vitamin B12, complex lipids

+SMOKING & ALCOHOL

Smoking in pregnancy :

Intrauterine growth retardation

Miscarriage and stillbirth

Premature delivery

Placental problems

Fetal alcohol syndrome- facial anomalies, mental

retardation, behavioural problems

Smoking & alcohol cessation during pregnancy will improve pregnancy outcome

+ILLICIT DRUGS

Advise to stop using illicit drugs if

a pregnancy is desired

Offer referral where the woman

is planning a pregnancy and is

unable to stop using without

support

Methadone clinic

+CAFFEINE

Limit 300mg/day

Consumption of > 250mg/day can decrease fertility

>500mg/day increase miscarriage, stillbirth, IUGR

+ENVIRONMENTAL EXPOSURE

Avoid organic solvents

Mercury associated with ADHD

Lead miscarriage, stillbirth, IUGR, premature birth

Work place environment

+EXERCISE

Mild to moderate exercise while pregnant is not

harmful if done on a regular basis prior to pregnancy

Do not initiate strenous exercise regime during

pregnancy

Low impact routine

+PSYCHOSOCIAL

Assess marital or relationship status

Any stressor – financial, support (may need social

worker involvement)

Any mental health need to liase with psychiatric

team

THANK YOU

!