The primary aim of preconception and interconception care is to improve maternal health and birth outcome for mother, infant and family through prevention and interventions.

1. Preconception, Antenatal and
Antepartum Care
(IL)
„Dr. Elhadi Miskeen, MBBS, MD
„Head Department of Obstetrics and
Gynecology
„College of Medicine, University of Bisha, KSA

2. SLOs
Communicate
• Communicate the patients on appropriate interventions to optimize
preconception health
Describe
• Describe typical care of the pregnant patient, including accurate
diagnosis of pregnancy, medication safety, risk factors for poor
outcome
Discuss
• Discuss the assessments for fetal well-being, and nutritional needs
Discuss
• Discuss the antepartum patient education including employment,
exercise, nutrition and weight gain, breast feeding, sexual activity,
travel and teratogens
List
• List the common symptoms of pregnancy

3. Clinical Case
A 36-year-old nulliparous woman presents to your office for her
first prenatal visit. She is unsure of her last menstrual period as
she recently discontinued her birth control pills, but thinks it
was 2 months ago.
In addition to worrying about her baby having abnormalities
related to her age, she is an early elementary school teacher
and is concerned about exposure to childhood illnesses.
Since she is“older,” she is concerned that she may not have
other children and really wants to optimize the outcome of this
pregnancy.
What will you do during her first obstetric visit? What screening
will you offer her? How will you counsel her regarding her goal
for a healthy pregnancy?

4. INTRODUCTION
The primary aim of preconception and
interconception care is to improve maternal health
and birth outcome for mother, infant and family
through prevention and interventions.
Preconception care is defined by interventions that
aim to identify and modify biomedical, behavioral,
and social risks to a woman’s health through
prevention and management.
These interventions focus on risk factors that can be
modified and/or eliminated prior to conception or
in early pregnancy in order to impact overall
pregnancy health and birth outcome.

5. The essential elements of preconception
health promotion
and intervention
1. Screening for medical and social risk factors
2. Counseling based on age, race, medical,
and/or genetic history
3. Providing appropriate immunizations such
as rubella and varicella
4. Prescribing intervention aimed at improving
overall pregnancy outcome and adult health
such as achieving a healthy weight, diabetes
control, eliminating inappropriate
prescription and non-prescription
medications and habits (smoking)
5. General health education

6. The CDC
Preconception
Health and Health
Care
Recommendations
Each woman, man, and couple should be encouraged
to have a reproductive life plan.
Increase public awareness of the importance of
preconception health behaviors and services by using
information that is relevant across various age groups,
literacy levels, and cultural/ethnic groups.
As a part of primary care visits, provide risk assessment
and educational and health promotion counseling to all
women of childbearing age to reduce reproductive
risks and improve pregnancy outcome.

7. The CDC Preconception Recommendations
4. Increase the proportion of women who receive interventions as follow-up to
preconception risk screening, focusing on high priority interventions (i.e. those
with evidence of effectiveness and greatest potential impact).
5. Use the interconception period to provide additional intensive interventions to
women who have had a previous pregnancy that ended in an adverse outcome
(i.e. infant death, fetal losses, birth defects, low birth weight, or preterm birth).
6. Offer, as a component of maternity care, one prepregnancy visit for couples and
persons planning a pregnancy.

8. The CDC
Preconception
Recommendation
s
Increase public and private health insurance coveragefor women with low
incomes to improve access to preventive women’s health and preconception
and interconception care.
Increase
Integrate components of preconception health into existing local public
health and related programs, including an emphasis on interconception
interventions for women with previous adverse outcomes.
Integrate
Increase the evidence base and promote the use of the evidence to improve
preconception health.
Increase
Maximize public health surveillance.
Maximize

10. Major
components of
PCC

11. A 37-year-old P0 has Type
II diabetes for five years
that is under fair control
with Metformin.
She has a body mass index
(BMI) of 35 cmm−3 and is
considering infertility
treatment because of
ovulatory dysfunction.
• Key components to be considered in
her preconception care include the
following:
a. Maternal age
b. Pregestational diabetes
c. Obesity
d. Medications
CLINICAL

12. A 24-year-old G2 P1102
recently delivered a term
female
infant with an open neural
tube defect (NTD) that was
diagnosed late in pregnancy.
A prior delivery three years
ago was delivered at 33
weeks after preterm
premature
rupture of membranes.
Key components of interconception
counseling should include the following:
a. Recurrence risk for NTDs
b. Folic acid recommendations
c. Recurrence risk for preterm delivery
d. Progesterone recommendations

13. A number of other
tests can be
performed for
specific indications:
• All health encounters during a woman’s
reproductive years, particularly those that
are a part of preconception care, should
include counseling about appropriate
medical care and behaviors to optimize
pregnancy outcomes.

14. Screening for STDs Testing
for maternal diseases based
on medical or reproductive
history
Mantoux test with purified
protein derivative for
tuberculosis by epidermal
injection technique and not
by use of “tine” instruments
Screening for genetic
disorders based on racial and
ethnic background.

15. Patients should
be counseled
regarding the
benefits of the
following
activities:
Maintaining good control of any preexisting medical conditions
Taking 0.4 mg of folic acid daily while attempting pregnancy and
during the first trimester of pregnancy for prevention of NTDs;
Determining the time of conception by an accurate menstrual
history
Reducing weight before pregnancy, if obese; increasing weight, if
underweight
Exercise
Avoiding food faddism
Avoiding pregnancy within 1 month of receiving a live attenuated
vaccine (e.g., rubella)
Preventing HIV infection
Abstaining from tobacco, alcohol, and illicit drug use before and
during pregnancy

16. ANTEnatal
CARE
The goals of obstetric care are to
1)provide easy access to care,
2) promote patient involvement, and
3) provide a team approach to ongoing
surveillance and education for the patient and
about her fetus.

17. Complete antenatal
care includes the
following:
Diagnosing pregnancy and determining gestational age
Diagnosing
Monitoring the progress of the pregnancy with periodic
examinations and appropriate screening tests
Monitoring
Assessing the well-being of the woman and her fetus
Assessing
Providing patient education that addresses all aspects of
pregnancy
Providing
Preparing the patient and her family for her management
during labor, delivery, and the postpartum period
Preparing
Detecting medical and psychosocial complications and
instituting indicated interventions
Detecting

18. DIAGNOSIS
OF
PREGNANCY
• For a woman with regular menstrual cycles, a
history of one or more missed periods
following a time of sexual activity without
effective contraception strongly suggests early
pregnancy.
• Symptoms” Fatigue, nausea/vomiting, and
breast tenderness
• On physical examination, softening and
enlargement of the pregnant uterus becomes
apparent 6 or more weeks after the last
normal menstrual period.
• The patient’s initial perception of fetal
movement (called quickening) is not usually
reported before 16 to 18 weeks of gestation
and often as late as 20 weeks in first-time
mothers.

19. Investigations
• A pregnancy test
• Serum pregnancy tests
Human chorionic gonadotropin (hcG)
Detection of fetal heart activity (fetal heart tones)

20. THE INITIAL PRENATAL VISIT
At the initial prenatal appointment, a
comprehensive history, focusing on:
• past pregnancies, gynecologic history,
medical history with attention to chronic
medical issues and infections,
• information pertinent to genetic screening,
and information about the course of the
current pregnancy.
social circumstances

21. Patients should be questioned
about the following aspects of their lifestyle that could pose a risk and receive appropriate
counseling, if indicated:
Nutrition and weight
gain counseling
Sexual activity Exercise Smoking
Environmental and
work hazards
Alcohol
Traditional and home
medications; OTC
medications (for
example, cough
medications)
Illicit/recreational
drugs
Domestic violence Sexual abuse Seat belt use

22. Initial Assessment of Gestational Age: Estimated Date of Delivery
Gestational age is the number of weeks that have
elapsed between the first day of the LMP (not the
presumed time of conception) and the date of delivery
Ultrasound examination can detect pregnancy early in
gestation. (TVS)

23. SUBSEQUENT
ANTENATAL
VISITS
Blood pressure
Weight
Obstetric
physical
findings
ULTRASOUND
SCREENING
TESTS –
(Routine and
specific)
ANTEPARTUM
PATIENT
EDUCATION

24. Clinical
Follow-Up
The patient is 8 weeks pregnant based on your bedside vaginal
sonogram.
You perform a thorough history and physical examination, obtaining
the appropriate prenatal screening blood work and cervico-vaginal
cultures.
You discuss available screening for genetic conditions, including fetal
chromosome abnormalities, as well as screening for immunity to
more common infectious diseases. The patient is educated on the
importance of regular prenatal care, appropriate exercise, nutrition,
and weight gain, and how to manage common complaints in
pregnancy.

25. Which is a common symptom of pregnancy?
Symptoms of early pregnancy include:
missed periods, nausea and vomiting, breast changes, tiredness
and frequent urination.
Many of these symptoms can also be caused by other factors such as
stress or illness.
If pregnancy suspect advice for seeking medical care ASP.

26. Antenatal care (ANC)
• ANC is defined as the complex of interventions that a pregnant woman receives
from organized health care services.
• The purpose of ANC is to prevent, identify and treat conditions as well as help a
woman approach pregnancy and birth as a positive experiences.
• The care should be appropriate, cost-effective and based on individual needs of
the mother.
• Antenatal care is a key entry point for pregnant women to receive a broad range of
health promotion and preventive health services.

27. Focused antenatal care
• Focused antenatal care (FANC) is personalized care provided to a pregnant
woman which emphasizes on the women's overall health status, her preparation
for child-birth and readiness for complications or it is timely, friendly, simple safe
services to pregnant women.

28. Impoertance of ANC
• Antenatal care is a key entry point for pregnant women to receive a broad
range of health promotion and preventive health services.
• ANC is an opportunity to advice women and their families on how to
prepare for birth and potential complications and promote the benefit of
skilled attendance at birth and to encourage women to seek postpartum
care for themselves and their newborn.
• It is also ideal time to counsel women about the benefits of family planning
and provide them with options of contraceptives.
• In addition, ANC is an essential link in the house – to – hospital care
continuum and helps assure the link to higher levels of care when needed.

29. Objectives of Focused ANC
• The new approach to ANC emphasizes the quality of care rather than the quantity.
For normal pregnancies WHO recommends only four antenatal visits.
• The major goal of focused antenatal care is to help women maintain normal
pregnancies through:
• Health promotion and disease prevention
• Early detection and treatment of complications and existing diseases
• Birth preparedness and complication readiness planning.

31. The first visit
The first ANC visit should occur in the first trimester, around or
preferably before 16 weeks of gestational age.
Objectives of first visit:
To determine patients’ medical and obstetric history with a view to collect evidence of the woman's eligibility to follow the
basic component or need special
care and/or referral to a specialized hospital (using the classifying form).
To do pregnancy test to those women who come early in pregnancy,
To identify and treat symptomatic STI
To determine gestational age
To provide routine Iron supplementation
Provide advice on signs of pregnancy-related emergencies and how to deal with them
To provide simple written instructions that gives general information about pregnancy and delivery, as well as any
specific answers to the patient’s questions.
To provide routine Provider-initiated HIV counseling and testing using the optout approach

32. Component of the first visit
1. History
2. Examination
3. Laboratory tests
Urine analysis preferably multiple dipstick test for bacteriuria and test for proteinuria
Blood: syphilis (rapid test - RPR if available or VDRL) result while waiting in the clinic.
Blood-group typing (ABO and rhesus).
Hemoglobin (Hb) or hematocrit.
Stool exam
Perform HIV test
Additional investigation that can be considered include: urine culture and sensitivity, ultrasound,
Pap smear, HBsAg.

33. Interventions:
Iron and folate supplements
Iron
If rapid test for syphilis is positive: treat, provide counseling on safer sex, and arrange for her partner’s
treatment and counseling.
Treat
Tetanus toxoid: give first injection.
Give
In malaria endemic areas provide insecticide treated nets (ITN).
Provide
Refer clients that need specialized care, according to diagnosis
Refer

34. The second visit
The second visit should be scheduled at 24-28 Weeks. It is expected to take 20 minutes.
Objectives of the second visit is to:
address complaints and concerns
perform pertinent examination and laboratory investigation
assess fetal well being
design individualized plan
advice on existing social support
decide on the need for referral based on updated risk assessment
address complaints and concerns

35. The third visit
The third visit should take place around 30 – 32 weeks and is expected to take 20 minutes.
The objective of the third visit:
address complaints and concerns
perform pertinent examination and laboratory investigation
review individualized birth plan and complication readiness including advice on skilled attendance at birth
advice on family planning, breastfeeding
decide on the need for referral based on updated risk assessment

36. The fourth visit
• The fourth should be the final visit of the basic component and should take place between
weeks 36 and 38.
• Objectives of the 4th visit:
• review individualized birth plan
• complication readiness
• re-inform women and their families of the benefits of breastfeeding and contraception
• perform relevant examination and investigations

37. Common Complaints of Pregnancy.

38. Danger Signs During Pregnancy
• Vaginal bleeding
• Sudden gush of fluid or leaking of fluid from vagina
• Severe headache not relieved by simple analgesics
• Dizziness and blurring of vision
• Sustained vomiting
• Swelling (hands, face, etc.)
• Loss of fetal movements
• Convulsions
• Premature onset of contractions (before 37 weeks)
• Severe or unusual abdominal pain
• Chills or fever

39. Qs
hadimiskeen19@gmail.com

40. THANKS