SUJNANENDRA MISHRA, M.D.(OBGYN)

Beautiful Lines In “Old Testament”
“And the angel of the Lord appeared unto the
woman, and said unto her, ‘Behold now thou
art barren, and bearest not: but thou shalt
conceive and bear a son. Now, therefore
beware, I pray thee, and drink not wine and
strong drink, and eat not any unclean thing.’ ”

Intervention delayed = Little done
 The heart
starts beating
at 22 days
after
conception
 – The neural
tube closes by
28days after
conception
 – The palate
fuses at
56days after
conception

Absence of Preconception care has Negative health
outcomes:
Maternal and Child Morbidity and Mortality RAISED
• Birth defects • Low birth weight
• Preterm birth • Macrosomia
• Cesarean Section • Mental retardation
• Goiter • Cretinism
• Hypothyroidism • Childhood cancers
• Congenital and Neonatal
infections
• Type 2 diabetes & cardiovascular
disease In later life
• Vertical transmission of HIV / STI • Underweight and stunting
• Reduced breastfeeding • Diarrhea

Traditional Thinking:
Healthy Mothers Healthy Babies
Healthy Women Healthy Conception Healthy Pregnancy Healthy Mothers & Babies
FROM
T
O
Health Promotion and Prevention

PRESENT DAY “PREGNANCY CARE”
(Conceptual)
Pre
Conception
Period
• ZERO
TRIMESTER
0 to 3
MONTHS
• FIRST
TRIMESTER
4 TO 6
MONTHS
• SECOND
TRIMESTER
7 TO 9
MONTHS
• THIRD
TRIMESTER
3 MONTHS
POSTPARTUM
• FOURTH
TRIMESTER

Definition of PCC
A set of interventions that aim to identify and modify biomedical, behavioral,
and social risks to a woman’s health or pregnancy outcome through prevention
and management, emphasizing those factors which must be acted on before
conception or early in pregnancy to have maximal impact.
CDC’s Select Panel on Preconception Care, June 2005

Evidence-
PCC Is An Integral Part Of Pregnancy Care
Cardiac Disease 3%
Hypertension 3%
Asthma 6%
Diabetes 9%
On teratogenic drugs 2.6%(Chemo, HU, antiepileptic, etc.)
Overweight or Obese 50%
Not taking folic acid 69%
Dental caries/oral disease (Women 20-39) >80%
Prevalence Of Risk Factors Among Women Prior To Pregnancy

Evidence-
PCC Is An Integral Part Of Pregnancy Care
Nearly 4 out of 10 pregnancies are Unplanned.
Adolescent Pregnancies have higher rate of perinatal complications & poor Outcome.
Early Abortions are much higher than expected.
Up to 10% of the pregnant women have prior untreated STI.
Pre-pregnant Maternal Undernutrition and anemia contributes to Maternal Mortality.
Sickle Cell Disease status is not known to many before getting pregnant resulting in
adverse outcome.
Absence of interventions rate of Peripartum Transmission of HIV to child is higher.
Poor knowledge of newborn and childcare results in many Infant deaths.

PCC- Objectives
 Prior Reproductive awareness
 Positive Reproductive life plan
 100% Planned pregnancies
 Full Health coverage
 Early Risk screening
 Intensive inter-conception care

Projected Outcome of PCC
Minimize unintended pregnancy
Prevent birth defects
Prevent LBW and prematurity
Prevent poor pregnancy outcomes and high recurrence
Promote healthy behaviors and reduce risk-taking behaviors
Prepares and reinforces parents for parenting
Promote family planning

Barriers in PCC
Women most in need of preconception care are the least likely to receive counseling
Fragmented health care service delivery system
Lack of treatment services for high-risk behaviors
Inadequate physician reimbursement providing counseling services
Lack of efficacy of counseling provided to unmotivated patients and their partner
Limited number of conditions with evidence-based preconception interventions
Lack of emphasis on risk assessment/health promotion in training programs.
Johnson, K., et al.,
Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR
Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep, 2006. 55(Rr-6): 1-23.

01
RISK ASSESSMENT
02
HEALTH PROMOTION
03
INTERVENTIONS
Components:- Preconception Care

RISK ASSESSMENT
Reproductive
Medical
Medication
Substance Abuse
Toxins & teratogenic
agents
Nutritional Status
 Anthropometric
e.g. BMI)
Biochemical factors
(e.g., anemia)
Clinical factors
Dietary risks
Focused
Anemia
Diabetes
Hypertension
Renal diseases
Tuberculosis
Thyroid
01– Reproductive
Need
02 - HISTORY
03 – Physical
Examination
Infections - STDs
Genetic screening
(racial, ethnic, familial):
Sickle cell anemia
Cystic fibrosis
Thalassemia
 Tay-Sachs disease
Psychosocial Screening
depression, anxiety,
domestic violence
Laboratory Invest.
04 – Screening
Is the couple rightly
planning to have her
1st Pregnancy.
If timing of
subsequent
pregnancy is in
compliance to HTSP.
Availability of
Contraceptives.

HEALTH PROMOTION
I. NUTRITION
Ideal Weight
◦ BMI 20 to 26 Kg / M²
Nutrition
◦ Balance Diet
◦ Macronutrients
◦ Micronutrients
◦ Five a day Fruits and Vegetables
Supplementation
◦ Folic Acid
◦ No history of NTD: 0.4 mg. daily
◦ Prior infant with NTD: 4.0 mg. daily
◦ Woman with NTD: 4.0 mg. daily
◦ Deficient nutrients e.g. Iron
◦ Avoid overuse of:
◦ Vitamin A (limit to 3,000 IU per day)
◦ Vitamin D (limit to 400 IU per day)
◦ Caffeine (limit to two cups of coffee
or six glasses of soda per day)

Based on the patient’s reproductive life plan
◦ Knowledge about Contraception Methods
◦ Availability of basket of choice.
Effective contraceptive use
Usage of emergency contraception
HEALTH PROMOTION
II. CONTRACEPTION

HEALTH PROMOTION
III. Healthy behaviors
ENCOURAGE HEALTHY BEHAVIOR
Nutrition
Exercise,
Safe sex
Effective contraceptive use
Dental flossing
Preventive health services
DISCOURAGE HARMFUL BEHAVIOR
Tobacco in any form
Smoking [Ask, Advise, Assess, Assist, Arrange]
Alcohol
Substance Use

HEALTH PROMOTION
IV. Healthy Surroundings
AT HOME
No Domestic abuse and violence
No Intimate partner violence
No smoke
OUT OF HOME
Exposures Environmental and occupational
◦ ionizing radiation,
◦ lead,
◦ mercury,
◦ hyperthermia,
◦ herbicides,
◦ pesticides

INTERVENTIONS: Females
Behavioral Nutritional
Reproductive
Health
Genetic Medication Vaccination Infections

Interventions
BEHAVIORAL
Avoidance of lifestyle risk factors
Addiction
◦ Alcohol
◦ Smoking
◦ Tobacco
Domestic Violence
Drug Abuse
Psychological Issues
NUTRITIONAL
Screening for anemia
Supplementing iron and folic acid
Supplementing energy- and nutrient-dense food
Salt iodization
Information, education and counselling and Monitoring
nutritional status
Screening, Counselling and Management of diabetes mellitus
Monitoring blood glucose (also in pregnancy)
Promoting exercise

Interventions: Females
REPRODUCTIVE HEALTH
Keeping girls in school measures to prevent early marriage and
coerced sex
Educating girls and boys about sexuality, reproductive health
and contraceptive use
Enabling adolescents to obtain contraceptive services
Empowering girls to resist coerced sex
Engaging men and boys to critically assess norms and practices
regarding gender-based violence and coerced sex
Educating women and couples about the dangers to the baby
and mother of short birth intervals
Providing contraceptives
GENETIC
Taking a thorough family history
Screening for Sickle Cell anemia
Family planning in parents with Genetic
diseases
Genetic counselling
Population Carrier screening and testing
Providing community-based education
Community-wide or national premarital
screening among populations at high risk

Interventions: Females
MEDICATION
• Isotretinoins: If used in pregnancy to treat
acne, it can result in miscarriage and birth
defects. Pregnancy prevention should be
practiced in women of reproductive age taking
these drugs.
• Anti-Epileptic Drugs: Certain types of these
drugs are teratogens (e.g. valproic acid).
• Oral Anticoagulants: Drugs for management
of blood clotting such as Warafin have shown
to be teratogenic. Early exposure during
pregnancy could be avoided pre-
conceptionally by switching drugs.
VACCINATION
Human Papillomavirus: Category B- to be avoided during
pregnancy. Ideal for females aged 9–26 years preconceptionally.
Influenza: Women who will be pregnant during the flu season
should be vaccinated with the influenza vaccine.
Rubella : The rubella vaccine is a live attenuated virus and is not
recommended during pregnancy. Avoid pregnancy one month
following immunization this vaccine should be administered to
all susceptible women pre-conceptionally.
Varicella: Preconceptional immunization of women to prevent
disease in the offspring, when practical, is preferred to
vaccination of pregnant women with certain vaccines.

Interventions: Females -- INFECTIONS
All pregnant women should be
routinely tested for all these
infections during an early prenatal
visit (e.g. first trimester) in each
pregnancy even if previously
vaccinated or tested.

Preconception Interventions for Men

INTERVENTIONS: Males
Alcohol
◦ May be associated with physical and emotional abuse may decrease fertility
◦ May lead to Domestic Violence.
Genetic Counseling
Occupational exposure
◦ Lead
◦ Other Heavy Metals,
Sexually transmitted diseases
◦ syphilis,
◦ herpes,
◦ HIV

Diet
Nutritional requirements including folic acid
supplementation
Advice on a healthy diet
Weight
Measurement of body mass index and appropriate advice
Exercise
Advise 150 minutes of exercise per week or 30 minutes on
most days
Pregnancy history
Screen for any modifiable risk factors
Genetic screening
If indicated from personal/family history or ethnic
background
Smoking/alcohol/illicit drugs
Assess of intake and provide appropriate advice
Psychosocial aspects
Screen for domestic violence
Screen for mental health conditions
Medical conditions
Review current disease status and medications
Referral/correspondence with specialist if required
Environmental
Assess work, home and recreational environments
Contraception/family planning
Offer appropriate contraception advice for those not desiring
pregnancy
Breast examination
Dental health check
Screening for sexually transmissible infections and other
infectious diseases
Measles, mumps, rubella, varicella zoster, hepatitis B
Human immunodeficiency virus and hepatitis C with
appropriate pre-test counselling
Cervical screening
Preconception care checklist