Prepregnancy Care Update April 2019

3. Identify and modify biomedical,
behavioural and social risks to a woman
health or pregnancy through prevention and
management.

4. 1. Help the mother to maintain her well-being
2. Obstetrician & physician have ultimate time to
assess, manage and treat medical 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

5. 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

6. Any woman who wish to
embark on pregnancy,
especially those who are
at risk.

7.  Anytime…
OR
 At least 3 months
before getting pregnant

8. 1.Complete history- medical, surgical, drug, family
history, social
2.Physical examination
3.Laboratory investigations

9. General
 Age: < 18 & > 35 years
 Lifestyle:
- Smoking, Alcohol
- Substance abuse
- Obesity / Underweight
 Consanguinity
 Familial or genetic
disorders
 Congenital
abnormalities
(Structural /
chromosomal)
Family History

10. Obstetric
 Recurrent Miscarriage
 Intrauterine death
 Previous abnormal baby
 Early neonatal death
 APH / PPH history
 Instrumental delivery
 Macrosomia / SGA
 ABO/ Rhesus incompatibility
 Grandmultipara
 Preterm delivery
 Retained placenta
 3rd/4th degree perineal tear
 Hypertension
 Diabetes Mellitus
 Heart disease
 Thyroid disease
 Epilepsy
 Bronchial asthma
 Connective tissue disorders
 Renal disorders
 Anaemia
 Haematological disorders
 Malignancy
 Communicable disease L(HIV,
Malaria, TB)
Medical History

11. Surgical History
 Caesarean Section
 Uterine surgery
 Pelvic Surgery
 Abdominal Surgery
 Domestic Violence
 Single Mother
Social History

12.  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.

14. 1. Nutritional issue
2. Anaemia / Hypertension
3. Emotional
4. Social issue

16. BMI
UNDERWEIGHT < 17.5 KG/M2
NORMAL 17.5- 22.99 KG/M2
OVERWEIGHT 23- 27.99 KG/M2
OBESE > 28 KG/M2

17. A healthy weight reduces the risk of
 Infertility
 Neural Tube Defect (NTD)
 Miscarriage
 Preterm delivery
 Gestational diabetes
 Hypertension
 Thromboembolic disease
 Caesarean delivery & intrapartum
complication

18.  Refer to dietitian
 Refer to obesity clinic
 Advice for regular exercise
Aim: To reduce Weight to Normal BMI.

19.  Many chronic diseases and their treatments may have implications for
pregnancy, fetal health and development
 Similarly, pregnancy and labour may worsen pre-existing maternal
conditions
MEDICAL
CONDITIONs
Maternal / Neonatal
Morbidity / Mortality

20.  Chronic Hypertension
 Diabetes Mellitus
 Heart Disease
 Epilepsy
 Thyroid Disease
 Connective Tissue Disease
 Mental Health Illness
 Infection

21.  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

22. Drugs of choice
 Methyldopa
 Labetolol
 Nifedipine
STOP!!
1) Angiotensin-converting enzyme (ACE) inhibitors
or angiotensin-II receptor blocker (ARB)
2) Chlorothiazide
 Increased risk of congenital abnormalities

23.  Optimize BP control
 Change to safer drug in pregnancy
 Regular monitoring of Renal
function & UFEME
 Women should take aspirin from 12
weeks' gestation and calcium
carbonate from 20 weeks’ gestation
to delivery

24. Aims:-
 Ensure good control of blood sugar
 HbA1c < 6%
 Reduce Weight
 Screen for complications
 Baseline Renal Function
 Ophthalmologist referral

25.  Impact of Pregnancy to DM
-Worsening retinopathy and nephropathy
-Difficulty in controlling blood sugar
 Impact of DM to pregnancy
- MOTHER- PreEclampsia, Intrapartum complications,
Operative morbidity, Postpartum Haemorrhage
- FETUS- Miscarriage, congenital malformations, stillbirth
and neonatal death, macrosomia, polyhydramnions,
shoulder dystocia

26.  Convert OHA to insulin
 Metformin safe to be used in pregnancy
 Screen for end organ complications
 Folic acid 5mg/day (pre-conception)
should be started to reduce the risk of
child having neural tube defect

27.  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%)

28.  Pregnancy is contraindicated in:-
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%

29.  If the woman takes warfarin, this should be converted
LMWH (depending on the dosage of warfarin)
 Those with rheumatic heart disease should continue their
oral penicillin prophylaxis
 Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor blocker (ARB) are both severely
teratogenic.

30.  Combine care with cardiologist
 Echo assessment
 Change to the drugs that can be
used in pregnancy
 If contraindicated for pregnancy, to
use proper contraception

31.  Referral for Neuromedical specialist before conception
to reduce dosage 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

32.  Effect of pregnancy on epilepsy:
- Risk of seizure highest in peripartum period
- Deterioration in seizure control due to: poor compliance to AEDs as
fear of teratogenesis, decreased drug levels related to early pregnancy
nausea/vomiting, lack of GIT absorption of AEDs, lack of sleep near
term / labour/ postpartum.
 Effect of epilepsy on pregnancy:
- Teratogenicity / fetal anticonvulsant syndrome
- Neonatal withdrawal symptoms
- Vitamin K deficiency due to liver enzyme inducing drugs that causes
haemorrhagic disease of newborn.

33.  Phenytoin, phenobarbitone, carbamazepine, sodium
valproate, lamotrigine, Keppra (Levetiracetam) all
cross placenta and teratogenic
 Sodium valproate: associated with higher risk (twice)
compare to other AEDs. Doses greater than 1mg/day
have higher risk.
MAJOR ABNORMALITY MINOR ABNORMALITY
-Neural tube defect
-Orofacial cleft
-Congenital heart defects
-Dysmorphic features
-Hypoplasia of mid face

34.  Use monotheraphy if possible
 DO NOT CHANGE the drugs if the epilepsy well controlled
with that particular medication
 Aim: lowest dose of anticonvulsants that protects against
seizures.
 Educate family members regarding care if patient develop
seizure

35.  Combine care with neurologist
 Avoid unplanned pregnancy
 Appropriate choice of contraception (efficacy
of hormonal contraception is reduced in
women on enzyme-inducing anticonvulsants)
 Continue Anti-Epileptic Drug
 Folic acid 5 mg/day before conception and up
to 12 weeks following conception
 Arrange for detail scan during 2nd trimester

36.  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

37.  Impact of 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

38.  Combine care with endocrinologist
 Ensure thyroid status normal
 Continue medications

39.  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

40.  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

41.  Ensure that the immunization status (esp Rubella) is up to
date
 Those who is never vaccinated is susceptible 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

42. 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 test is available.

43.  In healthy women on a normal diet, advice on
eating 5 portions of fruits 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

44. Possible Complications:
 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

45.  Advise to stop using illicit drugs if
pregnancy is desired
 Offer referral where the woman is
planning a pregnancy and is unable
to stop using without support
eg. Methadone clinic
 Psychiatric referral for substance
dependence / counsellor referral

46.  Limit 300mg/day
 Consumption of > 250mg/day can
decrease fertility
 >500mg/day increase miscarriage,
stillbirth, IUGR

47.  Avoid organic solvents
 Mercury  associated with ADHD
 Lead  miscarriage, stillbirth, IUGR, premature birth
 Work place environment

48.  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

49.  Assess marital or relationship status
 Any stressor – financial, support (may need social worker
involvement)
 Any mental health need to liase with psychiatric team

50. THANK YOU !