Preconception care

By: Dajane N.(BSc, MSc)

11/26/2023 DAJANE N.(BSc, MSc) 1

Presentation Outline

Definition or concept of preconception care

Terminologies

Strategies of preconception care

Components of preconception care

Preconception care counseling

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Pre-conception Care

Concepts of pre-pregnancy care

• Definition: Is “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.”(CDC 2015)

• This care has also been called pre-pregnancy, inter-pregnancy care, or

periconceptional medicine.
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Terminologies

Preconception
The period of time before the fertilization of an ovum

Pre-pregnancy
Sometimes used in place of preconception as it is considered to be
easier for the general public to understand.
It refers to the period of time before a person becomes pregnant

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Terminologies

Periconception period:

• Is the time window of 14weeks prior to conception until 10 weeks

after conception.

the gametes maturate and are epigenetically programmed

the embryonic tissues, organs and trophoblast (placenta) are

formed.
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Terminologies
Preconception health
The health of women and men during their reproductive years,
which are the years they can become pregnant.
All women and men can benefit from preconception health,
whether or not they plan to have a baby 1 day.
Part of preconception health is about people getting and staying
healthy overall, throughout their lives

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Terminologies
Preconception health …
Good preconception health encompasses two main concepts:
i. Planning pregnancy
 Enabling women and their partners to choose if and when to start
or grow their families
ii. Fit for pregnancy
 Recognizing that many pre-pregnancy health behaviours and risk
factors are amenable to change
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Terminologies
Preconception health …
Good preconception health encompasses two main concepts:
i. Planning pregnancy
 Enabling women and their partners to choose if and when to start
or grow their families
ii. Fit for pregnancy
 Recognizing that many pre-pregnancy health behaviours and risk
factors are amenable to change
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Terminologies
Inter-conception care
Is the provision of preconception care in between the birth of one
child and the conception of the next child

• Is an opportunity to :assess risk, promote healthy, assess lifestyle

behaviors;
• identify and treat medical and psychosocial issues that could
impact pregnancy outcome.

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Aim : Preconception care

Improve knowledge, attitudes, and behaviors of men and women

related to pre-conceptional health

Assure that all childbearing-aged women receive pre-conceptional

care services

including evidence-based risk screening, health promotion, and

interventions will enable them to enter pregnancy in optimal

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 Aim: cont’d

 Reduce risks indicated by a previous adverse pregnancy outcome through

inter-conceptional interventions to prevent or minimize recurrent adverse

outcomes

 Reduce the disparities in adverse pregnancy outcomes

 potentially modifiable condition(factors)

 pregnancy outcomes are dependent on the interaction of various maternal, fetal,

and environmental factors

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 During the inter-conception period:
 intensive interventions are provided to women who have had a
previous adverse pregnancy outcome
• fetal loss
• preterm birth (PTB)
• low birthweight (LBW)
• birth defects, or infant death.

• Specifically, for those planning pregnancy

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 Interconception period

 Addressing the health of women and their partners prior to

pregnancy

 recognised as an essential element to achieve healthy outcomes

for mothers and their children

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Pre-conception Care: Goal
Is to identify and modify biomedical, behavioral, and social risks to the

woman's health or pregnancy outcome through prevention and management. Or

Generally, its goal is to enhance pregnancy outcomes and improve child health.

Preconception care can help reduce the risk of complications during pregnancy

and childbirth, improve the health of the mother and baby, and increase the

chances of having a healthy baby.

The interventions include education, counseling, and assessment.

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Pre-conception Care
• Education includes topics such as smoking, alcohol abuse, and
other drug use, folic acid supplementation, and healthy diet.

• Counseling includes topics such as sexually transmitted

infections, family planning, and pregnancy spacing.

• Assessment includes physical examination, medical and family

history, and carrier screening.

• Preconception care is beneficial for all people, whether or not

they plan to have a baby one day.
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 Inter-conception period

 Addressing the health of women and their partners prior to

pregnancy

 Recognized as an essential element to achieve healthy outcomes

for mothers and their children

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 PCC involves a range of strategies including:
Reproductive planning
• the use of effective contraception before conception is desired
counseling regarding substance use in pregnancy
• avoidance of smoking and alcohol consumption
folic acid and iodine supplementation
weight reduction in those overweight or obese and
Medication adjustments.
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 Why is the preconception care?

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Why PCC…

• There is a growing recognition that adolescent pregnancies and poorly

spaced pregnancies contribute to maternal, perinatal and infant

mortality, and the vicious cycle of ill-health and poverty.

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Why PCC..
Globally four out of 10 women report that their pregnancies are
unplanned.

Perinatal deaths are 50% higher among babies born to adolescent

mothers

Women with epilepsy are at increased risk of having babies with

congenital anomalies.

Maternal malnutrition plays great role in maternal mortality

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Why PCC..

Preconception care

provides a full range of effective interventions

• focused primarily on the health of women of reproductive age, and

• their partners, prior to or between pregnancies,

promote the opportunity for safe motherhood and the birth of a healthy

infant with the expectation of healthy longevity

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Why PCC..

brings attention to the missing component in the existing health

system

addressing the needs of adolescents, young women and their partners

before pregnancy is planned or occurs

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Why PCC..

Has positive impact

reduce maternal and child mortality

prevent unintended pregnancies

prevent complications during pregnancy and delivery

prevent stillbirths, preterm birth and low birth weight

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Why PCC..
prevent birth defects

prevent neonatal infections

prevent underweight and stunting

 prevent vertical transmission of HIV/STIs

lower the risk of some forms of childhood cancers

lower the risk of type 2 diabetes and cardiovascular disease later in

life.
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Pre-conception care completes the coverage across the life course

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# Why is the preconception period important?

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Why is PC period…

The periconception environment is critically important for the

developmental process

Poor maternal health and diet before and in the early stages of pregnancy

can lead to;

impaired fetal or infant growth

poor birth outcomes

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long-term effects on cardiovascular
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Why is PCC…
Fetal programming:
 the intrauterine environment is understood to have a profound impact on
one’s entire lifetime health
i.e. is known as the developmental origins of health and disease
(DOHAD).

• E.g. The offspring of mothers who are obese at the time of conception are
more likely to be overweight and develop cardiovascular and metabolic
disease
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Critical periods of development

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Components /packages of PCC

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Areas addressed by preconception care package

Nutritional condition Sexually transmitted

Vaccine preventable intection
disease Human immuno
Genetic condition deficiency virus

Female genital Interpersanal violence

mutilation Psychoactive substance
Too early, unwanted and use
successive pregnancy Tubacco
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use
023
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Pre-pregnancy health and Planning for pregnancy

• Pre-pregnancy planning:

o It is essential to ensure a healthy pregnancy and promote the well-

being of both you and your future baby.

• Here are some steps to consider before getting pregnant: find the next

slides.

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Pre-pregnancy health and Planning for pregnancy
• Schedule a Preconception Visit:
• As soon as you’re ready to try for pregnancy, visit your healthcare
provider for a preconception checkup.
• During this visit, discuss on:
• medical history
• family’s medical history
• current health issues, diet, vitamins,
• lifestyle, safety of medications, and mental health.
• dental checkup to address any
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N.(BSc, MSc)disease before pregnancy 33
Cont’d…

• Genetic Counseling:

• Consider meeting with a genetic counselor if you have

concerns about genetic conditions or family history.

• Genetic counseling helps assess your risk and provides

information about potential genetic disorders.

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 Cont’d…
• Start Taking Prenatal Vitamins:
• Begin taking prenatal vitamins that contain folic acid before
conception.
• Folic acid helps prevent birth defects of the brain and spine.

• Give Up Bad Habits:

• If you smoke, drink alcohol, or use recreational drugs, seek help to quit.
• These substances can harm your health and affect fetal development.

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Cont’d…
• Eat Well:
• Focus on a balanced diet rich in fruits, vegetables, whole grains, lean
proteins, and dairy products.
• Proper nutrition supports your health and prepares your body for
pregnancy.
• Aim for a Healthy Weight:
• Achieve and maintain a healthy weight before pregnancy.
• Being underweight or overweight can impact fertility and pregnancy
outcomes.

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Cont’d…
• Establish a Regular Exercise Routine:
• Engage in moderate exercise to improve overall fitness.
• Consult your healthcare provider for exercise recommendations.
• Mental Health:
• Manage stress, practice relaxation techniques, and seek emotional
support.
• Mental well-being is crucial during preconception and pregnancy.
• Remember that pre-pregnancy care helps identify any issues that could
affect your pregnancy, allowing you to take preventive steps.
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Time to initiate preconception care

• The time that people should start caring for a pregnancy is before conception.

• Preconception care should occur any time any health care provider sees a
reproductive-age patient

• occur opportunistically when women of childbearing age attend their health

care professional for;
 contraception or for baby and toddler checks
attend their specialist for review of their medical disease or
if they are referred to infertility clinics.
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Time to initiate preconception care

 Here are some key points to consider:

• Planning Ahead:
• Preconception care involves preparing for a healthy pregnancy.
• It’s beneficial to start thinking about it at least three months before
actively trying to conceive.
• However, even if a woman is already pregnant, it’s never too late to
begin preconception care.

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Time…cont’d

• Before Conception:

• Optimal health before pregnancy significantly impacts the health

of both the mother and the baby.

• Starting preconception care early allows time to address any health

issues, make lifestyle changes, and optimize overall well-being.

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Time…cont’d

• Key Considerations:

• Medical Conditions: If a woman has any existing medical

conditions (such as diabetes, hypertension, or thyroid disorders),

managing them before pregnancy is crucial.

• Medications: Review medications and adjust them if necessary.

Some medications may need to be changed during pregnancy.

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Time…cont’d
• Key Considerations:
• Nutrition: Ensuring adequate folic acid intake and a balanced diet is
essential.
• Lifestyle Factors: Addressing factors like smoking, alcohol
consumption, and substance use is vital.
• Immunizations: Checking immunization status and getting necessary
vaccines (e.g., rubella) is important.
• Genetic Screening: Assessing genetic risks and considering carrier
screening if relevant.
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Time…cont’d
• Consulting a Healthcare Provider:

• Women planning pregnancy should schedule a visit with their

healthcare provider.

• The provider will assess overall health, discuss family history, and

provide personalized recommendations.

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Time…cont’d
• Early Pregnancy Care:

• If a woman suspects she might be pregnant, she should seek prenatal care

promptly.

• Early prenatal visits help monitor the pregnancy and address any issues.

• Note: preconception care sets the foundation for a healthy pregnancy and a

healthy baby.

• Open communication with a healthcare provider is essential throughout the

process.
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# What PCC interventions improve maternal and fetal outcomes?

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 women and their partners who receive PCC are more likely to have

improved knowledge and show positive health behaviours:

Decreased smoking and consumption of any substance abuse

 increased use of folic acid and

greater engagement in antenatal care

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 Elements of preconception care actions and counseling

Reproductive planning

• Reproductive planning helps to prevent unintended pregnancy, age-related

infertility and fetal teratogen exposure.

• It may also improve health and pregnancy outcomes.

• Arrange preconception visit schedule for those desiring pregnancy

• Offer appropriate contraception advice for those not desiring pregnancy or

until chronic medical conditions are stabilized.

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 Key Elements of preconception care and counseling
Maternal age
 > 18 up to 34 yrs
Ideal age group
 Teenage pregnancy(< 18 yrs old)
Associated with adverse maternal and familial consequences
Increased risk of preterm birth
mental health problems
depression, substance abuse, and
posttraumatic stress disorder (PTSD)
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 Elements of preconception care actios and counseling

 Advanced Maternal Age(> 35 yrs old)

delaying childbirth is associated with worsening reproductive outcomes

• infertility, miscarriage

medical co-morbidity or chronic medical disease

an increase in maternal and fetal morbidity and mortality

Increased genetic risk, increased risk of CS

pregnancy complication or obstetrics morbidity and mortality

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Elements of preconception care actions and counseling
Nutritional Intervention
• Focus on a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and dairy products.
• Proper nutrition supports your health and prepares your body for pregnancy.

 Folic acid supplementation

 Enhances cell division, fetal neurodevelopment

 prevent congenital anomaly

• E.g. Neural tube defect(NTD)

 400µg-500µg daily for at least four weeks prior to conception and for the first 12 weeks of gestation

 to all women of preconception

 Reduce risk of developing NTD by 72%

 Reduce risk of recurrence by 68%

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Nutritional supplementation….
 Folic acid supplementation

5 mg daily for at least four weeks prior to pregnancy and for the first 12
weeks of gestation for high risk

High risk
previous NTD

anticonvulsant medication

GDM
malabsorption

BMI >30 kg/m2

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Nutritional supplementation….
 Iodine
Advice all women to consume iodine content diet
150 μg daily while pregnant and breastfeeding
Production of maternal thyroid hormone
fetal brain and CNS development

 Calcium
 Women with inadequate dietary intake (<1000 mg daily)
At least 1000 mg daily
Prevention
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 Nutritional supplementation….
 Vitamin D

Women with vitamin D deficiency identified by blood tests

1000 IU/day (vitamin D 30–49 nmol/L)

2000 IU/day (vitamin D <30 nmol/L)

 Benefit:

Reduces risk of small-for gestational-age babies

Prevent impaired fetal skeletal development

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 Nutritional supplementation….
 Iron
Women with iron deficiency identified by blood tests
Oral supplement with at least 60 mg of elemental iron daily

 Vitamin B12
Specificially for Vegans and vegetarians
2.6 μg/day or intramuscular injection
1000 μg/ampoule
Prevent Infant neurological sequelae
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Nutritional restrictions
 Vitamin A

Dietary sources do not pose a risk at normal levels

Limit vitamin A supplements to 3000 IU per day

All synthetic derivatives of retinol should be ceased at least one month

prior to conception

Increased risk of miscarriage and CNS malformations

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Nutritional restrictions…

 Mercury containing fish

All women

Avoid fish containing high levels of mercury (shark, billfish)

Consume 1-2 serve

Increased risk of negative effects on fetal brain and CNS (over-

conception or high level of mercury )

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 Nutritional restrictions…

 Caffeine

Moderate caffeine consumption(200mg/day)

• High consumption increases the risk of;

Miscarriage and preterm

fetal growth restriction

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Management of Medical condition

 Screening for Chronic Disease,

 Optimizing Care, and

 Managing Medication Exposure

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Medical history…

Medical disease management before conception can positively

influence pregnancy outcome.

Medical management to normalize the intrauterine biochemical

environment should be discussed with the patient,

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 Medical history…

Appropriate management plans should be outlined before

conception;

 advice can also be given about avoiding specific medications in the

first trimester

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Medical history

Diabetes Mellitus

Pre-gestational diabetes is associated with increased risks of

adverse fetal, neonatal, and maternal outcomes during pregnancy

The risk of adverse fetal and neonatal outcomes correlates largely

with the degree of maternal glycemic control

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Medical history

Diabetes Mellitus

Crucial points to be address include:

Potential fetal, neonatal, and maternal risks of diabetes in pregnancy.
The importance of planning a pregnancy, and the increased risks
associated with an unplanned pregnancy.
How to access preconception care.
Contraception and family planning.
What to do should an unexpected pregnancy occur.
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 Medical history
Diabetes Mellitus

• Preconception counseling should include:

weight loss
exercise,
appropriate diet, and
optimization of blood sugar control.
• Normalization of glucose levels (hemoglobin A1c <6%) prevents most, if
not all, of the complications of diabetes in pregnancy.
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Medical history…

 Diabetes Mellitus

Components of preconception care in women who are actively planning

pregnancy

A) Glycemic control
Optimize glycemic control with goal Hgb A1c <6.5%
fasting glucose <95 mg/dL and
2-hour postprandial ≤120 mg/dL or
1-hour postprandial ≤140 mg/dL)
This achieved with diet, exercise,
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DAJANE N.(BSc, MSc) insulin therapy as necessary 64
Medical history…

 Diabetes Mellitus

Components of preconception care in women who are actively planning pregnancy

B) Medication optimization

 Optimization of glucose-lowering medications

 Cessation/substitution of potentially teratogenic medications

 Folic acid supplementation

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Medical history…

 Diabetes Mellitus

C) Screening and management of diabetes-related complications

 Diabetic retinopathy

 Diabetic nephropathy

 Cardiovascular disease

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Medical history…

 Diabetes Mellitus

D) Assessment for and management of co-existing medical conditions

 Hypertension

 Hyperlipidemia

 Thyroid disorders

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Medical history…

 Diabetes Mellitus

E) Weight management and nutrition

• Nutritional requirements are adjusted on the basis of maternal body mass

index (BMI);

women with normal BMI require 30–35 kcal/kg/day

30–35 kcal/kg/day (usually 2000–2400 kcal/day)

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3 meals and 3 snacks DAJANE N.(BSc, MSc) 68
Medical history…

 Diabetes Mellitus

E) Weight management and nutrition

• Composition

Carbohydrate (complex) 45%

Protein 20%

Fat (<10% saturated) 35%Weight loss

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 Medical history…
 Diabetes Mellitus

E) Weight management and nutrition

• Exercise

Moderate exercise decreases the need for insulin therapy in type

II diabetics

increasing the glucose uptake in skeletal muscle,

should be strongly encouraged for diabetic patients

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Medical history…
Hypertension

Chronic hypertension affects 3% of women of reproductive age

Chronic hypertension associated with higher rates of

preterm birth,

placental abruption,

 intrauterine growth restriction,

preeclampsia, and fetal death

Risk of worsening hypertension and organ damage

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Medical history…
Hypertension
Caring for women of reproductive age with hypertension should include:
• Educating them about the risks of hypertension during pregnancy
and
• Their medication regimen may need to be changed before
conception.
• Women with long-standing hypertension
assessed for retinopathy,
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Medical history…

Hypertension

Angiotensin converting enzyme inhibitors and angiotensin receptor blockers

• should be avoided in pregnant women and in the preconception period

associated with neonatal renal failure, oligohydramnios, and death

For the same reasons, they should not be considered first-line

treatment for hypertension in women of childbearing age in general.

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Medical history…
Hypertension

 The following have good safety profiles and are effective for treatment.
• Short-acting β-blockers- labetalol
• calcium channel blockers- nifedipine, and
• Α-blockers-methyldopa

 Diuretics do not have a teratogenic effect but are not first-

line treatment for hypertension
• exacerbate the intravascular volume depletion that accompanies preeclampsia.
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Medical history…

Heart disease
• Pre-pregnancy counselling
The risk of pregnancy depends on the specific heart disease
clinical status of the patient.
 Individual counselling by experts is recommended
• Adolescents
advice on contraception,
 pregnancy issues should be discussed as soon as they become
sexually active
• High risk patients should be managed by an expert multidisciplinary team

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Modified WHO classification of maternal cardiovascular risk: principles

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Modified WHO classification of maternal cardiovascular risk: application

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WHO classification…

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WHO classification…

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WHO classification…

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Cardiac….

• multi-disciplinary cardio-obstetrics team

to facilitate shared decision making with the patient at every stage of
the process.

• Risk categories range from I to IV

A) Class I: being isolated atrial or ventricular ectopic complexes which do not

portend an increased risk

B) Class IV: significant pulmonary hypertension from any cause

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Cardiac….
• Prohibitive conditions: include

severe left ventricular dysfunction

severe left-sided heart obstruction

significant aortic aneurysms associated with bicuspid aortic valve and

Marfan syndrome

• Most women with these high risk conditions are recommended to avoid pregnancy,

contraceptive planning is also advised in these high risk patients.

• Review all cardiovascular medications for contraindications

E.g. teratogenic angiotensin converting enzyme inhibitors that will require alternatives.
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Medical hx…

Epilepsy

• The risk of fetal abnormality increases with the number of different

anticonvulsant medications being taken and women considering pregnancy

should, therefore, have the number minimized.

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Medical hx…

Epilepsy

• All epileptics on medication should also be given 5 mg folic acid daily from

3 months preconception

to counteract the folate-antagonist effect of the drugs thus reduce the

chance of a neural tube defect in the fetus.

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Medical hx…

• Many major antiepileptic drugs

• e.g. valproate [Depacon], phenytoin [Dilantin], carbamazepine (Tegretol),

phenobarbital) are teratogenic

• Rates of congenital anomalies are related to higher doses and polytherapy

• Monotherapy should be used when possible at the lowest effective dosage

11/26/2023 DAJANE N.(BSc, MSc) 87

Medical hx…

Epilepsy

• Treatment goals:

to achieve seizure control with monotherapy and with medications

considered less teratogenic

11/26/2023 DAJANE N.(BSc, MSc) 88

Epilepsy…

• Anti-seizure medication discontinuation before pregnancy in suitable

candidates
a. have been seizure-free for 2 to 5 years
b. display a single seizure type
c. have a normal neurological examination and normal intelligence
quotient, and
d. electroencephalogram results that have normalized with treatment.

11/26/2023 DAJANE N.(BSc, MSc) 89

Epilepsy…
the risk of seizure relapse is greatest in the first 6 months after discontinuing AEDs,
withdrawal should be accomplished before conception.

If withdrawal is not possible

monotherapy should be attempted to reduce the risk of fetal malformations

AEDs- increased the risk

intrauterine growth restriction,
congenital malformations that include craniofacial and digital anomalies, and co
gnitive dysfunction

11/26/2023 DAJANE N.(BSc, MSc) 90

Medical hx….
Thyroid disease
• significantly impact pregnancy outcomes

A) Hypothyroidism affects 2.5% of women of reproductive age

first trimester cause cognitive impairment in children
clinical and subclinical : can cause;
preterm birth
 low birth weight
placental abruption, and fetal death
 infertility, miscarriage, pre-eclampsia
11/26/2023 DAJANE N.(BSc, MSc) 91
Medical hx….

TSH and FT4 levels should be checked

• levothyroxine supplementation in hypothyroid women of reproductive

age

11/26/2023 DAJANE N.(BSc, MSc) 92

Medical disorder: Hypothyroidism
Inadequately treated maternal hypothyroidism:
Decreased fertility,
miscarriage,
anemia,
impaired cognitive function in the offspring
 pregnancy complications including
gestational hypertension,
low birth weight,
placental abruption,
preeclampsia,
preterm birth and fetal death.
11/26/2023 DAJANE N.(BSc, MSc) 93
Medical hx…
B)Hyperthyroidism

• result in significant maternal and neonatal morbidity

• inadequately treated is associated with:

maternal heart failure,

placental abruption,

preeclampsia, preterm delivery and

fetal goiter, intrauterine growth restriction,

small for gestational age, and stillbirth.

11/26/2023 DAJANE N.(BSc, MSc) 94
Medical: Hyperthyroidism

Women with overt hyperthyroidism, should be counseled prior to pregnancy re

garding treatment options (medications, radioactive iodine ablation, or

subtotal thyroidectomy)

Goal of treatment: maintain serum free thyroxine (T4

) levels in the high normal to slightly above normal range.

• Free T4 levels: measured every 2–4 weeks and doses adjusted accordingly.
11/26/2023 DAJANE N.(BSc, MSc) 95
Medical: Hyperthyroidism

Achieving eu-thyroidism before pregnancy

Propylthiouracil is preferred in preconception and first trimester;

methimazole (Tapazole) is preferred in the second and third trimesters

Possible teratogenicity in the first trimester with methimazole and liver

failure with PTU after first trimester

11/26/2023 DAJANE N.(BSc, MSc) 96

ASTHMA
• Is a prevalent chronic condition, affecting approximately 4% to
9% of all pregnancies(USA)
one third of women with asthma maintain control similar
one third worsen, and
one third improve
• Maternal and fetal complications are associated with poorly
controlled maternal asthma
preterm birth
low birth weight (LBW)
increased perinatal mortality, and
 maternal preeclampsia
11/26/2023 DAJANE N.(BSc, MSc) 97
Asthma…

• inadequate control of asthma is a greater risk to the fetus than asthma

medications are

• Ideally, asthma control should be optimized prior to conception

• poor asthma control prepregnancy

 increased risk of intrauterine growth retardation and

 hypertension during pregnancy

11/26/2023 DAJANE N.(BSc, MSc) 98
 Asthma…

 During pregnancy:

One third of women experience improvement in symptoms

One third experience a worsening of symptoms, and

One third remain unchanged

11/26/2023 DAJANE N.(BSc, MSc) 99

Asthma…

• If left uncontrolled, can be associated with:

premature birth

Preeclampsia

low birth weight and growth restriction,

increased need for cesarean section, and

increased maternal morbidity and mortality.

11/26/2023 DAJANE N.(BSc, MSc) 100
Asthma…
• The goals for symptom control in pregnancy are the same as in the nonpregnant

state: use of rescue inhalers less than twice a week, nighttime

awakenings less than twice per month, and lack of activity impairment due to sy

mptoms.

• A stepwise approach to treatment is recommended

 use the lowest amount of drug necessary to control symptoms, but it is safer for pregnant

women to be treated for asthma than to experience exacerbations and hypoxia.

11/26/2023 DAJANE N.(BSc, MSc) 101

Asthma…
 Management
• Inhaled Corticosteroids

• The 2018 Global Institute for Asthma have suggested that all ICS products are
safe during pregnancy.

• Women with well controlled asthma should be continued on their

current ICS regimen to avoid the potential for a break in therapy and
loss of asthma control related to a drug change.

11/26/2023 DAJANE N.(BSc, MSc) 102

Thrombophilias
 Assess the need for thromboprophylaxis during pregnancy: ACOG-
recommended management guidelines.
oLow risk for thrombophilia if testing is positive for any of the following:
heterozygous factor V Leiden mutations, heterozygous prothrombin
G20210A mutations, protein C deficiency, protein S deficiency
oHigh risk for thrombophilia if testing is positive for any of the following:
homozygous factor V Leiden mutations, homozygous prothrombin
G20210A mutations, heterozygosity for both factor V Leiden and
prothrombin G20210A mutations, antithrombin deficiency
11/26/2023 DAJANE N.(BSc, MSc) 103
Thrombophilias

• Consider initiating low molecular weight heparin (LMWH) or

unfractionated heparin (UFH) if indicated

• Except in cases of mechanical heart valves, warfarin is

contraindicated in pregnancy

• Monitor patients for thromboembolic events due to increased risk

during pregnancy
11/26/2023 DAJANE N.(BSc, MSc) 104
Reproductive history

• Prior preterm birth infant

evaluation of remediable causes is recommended for a next pregnancy

• Prior cesarean delivery

advise women to wait at least 18 months for a subsequent pregnancy.

• Prior miscarriage

• Prior stillbirth

• Uterine anomalies

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Vaccination(Immunization)

Evaluation of a woman’s immune status should occur in the

preconception period.

Optimally, immunization with indicated vaccines should occur prior to

pregnancy.

For the reproductive age female, preconception evaluation of

immunity to rubella, varicella, and hepatitis B are particularly
beneficial for the health of the woman and her offspring

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Vaccination(Immunization
• Maternal vaccination
Provides protection of the neonate through passive immunization
Maternal antibodies (IgG) are transmitted transplacentally, particularly in
the last 4–6 weeks of gestation.
An additional benefit may occur with the passage of antibodies (IgA) via
breast milk.
In addition, by immunizing close contacts of a newborn, the risk of
exposure to disease is reduced, a strategy known as cocooning.
11/26/2023 DAJANE N.(BSc, MSc) 107
 Vaccination/Immunizations

includes assessment of immunity against common pathogens

depending on health status, travel plans, and time of year

Vaccines that contain toxoids such as tetanus are suitable before or

during gestation

11/26/2023 DAJANE N.(BSc, MSc) 108

Vaccination/Immunization…

Vaccine containing killed bacteria or viruses(Inactivated vaccine)

are not associated with adverse fetal outcomes

are not contraindicated preconceptionally or during pregnancy

• E.g. influenza, pneumococcus, hepatitis B, meningococcus, and

rabies vaccines

11/26/2023 DAJANE N.(BSc, MSc) 109

Vaccination/Immunization…
Live, attenuated vaccines:

are contraindicated in pregnancy

 If live, attenuated vaccines are administered, the patient should avoid pregnancy for
4 weeks because of the theoretical concern for transplacental infection of the fetus

 E.g.varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow fever

• 1 month or longer pass-between vaccination and conception attempts

• immunize the susceptible patient against influenza and tetanus, diphtheria and
pertussis

11/26/2023 DAJANE N.(BSc, MSc) 110

Vaccination/Immunization…
Typhoid immunization is recommended on travel to an endemic region.

Cholera immunization should be given only to meet travel requirements.

Tetanus-diphtheria immunization should be given if a primary series has

never been administered or if 10 years has elapsed without the patient
receiving a booster.

Immunization for yellow fever is recommended before travel to a high

risk area.

11/26/2023 DAJANE N.(BSc, MSc) 111

 Summary of vaccination/mmunization
Recommended for All Women of Childbearing Age
(Preconception, Postpartum, and Considered Safe in Not Recommended in Pregnancy
Pregnancy)
• Varicella
• Influenza
• Tetanus/diphtheria Td • MMR (measles-mumps-

• Tdap rubella)

• Hepatitis B • BCG
• COVID-19-mRNA • Smallpox
• Human papilloma (HPV)-
recombinant(contraindicated in pregnancy)
11/26/2023 DAJANE N.(BSc, MSc) 112
Genetic and Family History

• The time to screen appropriate populations for;

genetic disease-carrier status

multifactorial congenital malformations

familial diseases with major genetic components

11/26/2023 DAJANE N.(BSc, MSc) 113

Genetic …
Neural-Tube Defects
Incidence: 0.9 per 1000 live births
2nd most frequent structural fetal malformation next to cardiac
anomalies
Pre-conceptional folic acid therapy -reduces risk recurrence by 72%
Since > 90% of neonates with NTDs are born to women at low risk, all
women should take daily 400 to 800 μg of folic acid orally before
conception and through the first trimester
11/26/2023 DAJANE N.(BSc, MSc) 114
Genetic…
Phenylketonuria
It results from a deficiency of phenylalanine hydroxylase (PAH)

• Complication
Developmental delay (92%), Microcephaly (73%), Fetal-growth restriction
(40%), Spontaneous abortion (24%), Congenital heart disease (12%)

Phenylalanine concentration is ideally normalized 3 months before conception and

then maintained throughout pregnancy

The target phenylalanine blood concentration is 120 to 360 μmol/L

11/26/2023 DAJANE N.(BSc, MSc) 115

Genetic…

Phenylketonuria

• Management

Dietary restriction

Pharmacotherapy:

• Tetrahydrobiopterin/sapropterin, Phenylalanine ammonia lyase

11/26/2023 DAJANE N.(BSc, MSc) 116

Pre-conception counseling
A ) Environmental Toxins Household chemicals (avoid paint

Smoking cessation, thinners/strippers, other solvents,

Screen for alcoholism pesticides),

use of illegal drugs Radiation exposure

Occupational exposures

 Material Safety,

11/26/2023 DAJANE N.(BSc, MSc) 117

A) Smoking

Women should be advised to stop smoking prior to pregnancy

 Discussion and advice on risk of smoking on pregnancy adverse outcome

• miscarriage,
• placental abruption,
• placenta praevia,
• premature rupture of membranes,

11/26/2023 DAJANE N.(BSc, MSc) 118

 A) Smoking…

 Adverse pregnancy outcome…

• preterm delivery,
• low birthweight,
• cleft lip and cleft palate,
• perinatal mortality,
• sudden infant death syndrome and
• impaired cognitive development

11/26/2023 DAJANE N.(BSc, MSc) 119

Smoking…

Discussion often provides

• a strong motivation to pregnant women to stop smoking.

• helps to reduce fetal and infant death by 10%( smoking cessation)

• Nicotine replacement therapy including nicotine patches and e‐

cigarettes, can help wean women off tobacco

11/26/2023 DAJANE N.(BSc, MSc) 120

Smoking…
• Healthcare providers can provide structured counseling: 5A's
intervention, which includes:
1. Asking about tobacco use
2. Advising patients quit
3. Assessing willingness to quit
4. Assisting patients with quitting through appropriate medications,
counseling, referrals, and support groups.
5. Arrange follow-up and support
11/26/2023 DAJANE N.(BSc, MSc) 121
Alcohol

No time during pregnancy is safe to drink alcohol

 harm can occur early, before a woman has realized that she is or might be

pregnant.

 if women cease intake of alcohol before conception adverse pregnancy

outcome can be prevented

Fetal alcohol syndrome and other alcohol-related birth defects can be

prevented
11/26/2023 DAJANE N.(BSc, MSc) 122
B)Exercise

 Recommend regular moderate exercise or moderate-intensity physical

activity
Advise 150 minutes of exercise per week or 30 minutes on most days

no data suggest that exercise is harmful during pregnancy

But, certain forms of exercise, such as high-contact sports and scuba

diving, are contraindicated.

Avoid hyperthermia (hot tubs)

11/26/2023 DAJANE N.(BSc, MSc) 123
C) Counsel to maintain a healthy weight

Total weight gain recommended in pregnancy

Normal weight (BMI: 18.5 up to 24.9kg/m2)

 11 to 16 kg (25 to 35 lb)

Underweight( BMI: < 18.5kg/m2)

up to 18 kg (40 lb), but

11/26/2023 DAJANE N.(BSc, MSc) 124

Overweight(BMI: > 24.9kg/m2)

limit weight gain to 7 kg (15 lb),

Advice them to lose 5–10% of their body weight prior to conception.

avoid foods that are high in fats and carbohydrates, to limit sugar

intake, and to increase their physical activit

Morbidly obese

they do not need to gain any

11/26/2023
weight
DAJANE N.(BSc, MSc) 125
Overweight are at risk of:
 diabetes gestational diabetes, and hypertension.

• These conditions are associated with adverse pregnancy outcomes

macrosomia
shoulder dystocia
operative delivery
congenital anomalies
intrauterine growth restriction
spontaneous abortion
stillbirth
preeclampsia, and eclampsia
11/26/2023 DAJANE N.(BSc, MSc) 126
They should be educated on the risks of obesity,

referred to a dietitian and

encouraged to exercise

• For women classified as underweight

dietary advice and behaviour techniques should also be provided to

help them achieve a target weight range.

• Inadequate weight gain

is associated with an increased risk of an LBW infant

11/26/2023 DAJANE N.(BSc, MSc) 127
D) Assess risk of nutritional deficiencies:
Vegan
Pica
Milk intolerance
Calcium or iron deficiency

• Avoid over use of:

Vitamin A
Vitamin D
Caffeine
11/26/2023 DAJANE N.(BSc, MSc) 128
 E) Counsel on the use of OTC:

 Medications

 Nutritional supplements, and

 Naturopathic substances.

11/26/2023 DAJANE N.(BSc, MSc) 129

PC Counseling: Exposure

Occupational exposures

threaten both male and female fertility

Threaten pregnancy, and the health of the unborn child

e.g. by causing menstrual irregularities,

• reducing the number

• deteriorating quality of maturing eggs and sperm, etc

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PC Counseling: Exposure
 Occupational exposure agents are divided into:
i. chemical
ii. Physical
iii. biological exposures

• Exposure may occur at work by;

a. Inhalation
b. through the skin or
c. through the gastrointestinal tract.
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PC Counseling: Exposure
A) Chemical exposure agents
Some chemical exposure agents can damage:
sperm formation in the testicles in exposed men - infertility.
exposure agents to organic solvents- miscarriages
Exposure to toxic substance
Death to developing embryo
Structuran malformation e.g. teratogenicity

11/26/2023 DAJANE N.(BSc, MSc) 132

PC Counseling: Exposure
 Example of chemical exposure agents
heavy metals lead and mercury
organic solvents
anaesthetic gases
Chemotherapy(e.g. Cytostats)
Pesticides
 tobacco smoke from environment.

11/26/2023 DAJANE N.(BSc, MSc) 133

PC Counseling: physical Exposure
• Radiation

• Shock

• vibration or movement

• heavy lifting (risk for the back)

• Noise

• ionizing and non-ionizing radiation

• extreme cold or heat

• movement; and postural issues

• mental and physical fatigue

11/26/2023 DAJANE N.(BSc, MSc) 134
PC Counseling: Exposure
C) Biological exposure agents

• Any pathogen, bacteria, viruses, or parasites in the mother’s body can

pass through the placenta to the fetus.

 severity of the infection depends on;

a. the pathogen
b. the mother’s immunity and
c. the stage of pregnancy.

11/26/2023 DAJANE N.(BSc, MSc) 135

• Screening for STIs and other infectious diseases
Screening for immunity to measles, mumps, rubella, varicella zoster and
hepatitis B should be performed.
• recommended vaccinations
diphtheria, tetanus and pertussis (dTpa), and influenza
• Delay conceiving for at least 28 days after receiving any live attenuated
vaccinations he
measles, mumps and rubella (MMR) vaccine.

11/26/2023 DAJANE N.(BSc, MSc) 136

• Screening for STIs for women and men
Chlamydia
Gonorrhea
Herpes simplex virus infection
HIV infection
Syphilis
Tuberculosis
Hepatitis B virus

11/26/2023 DAJANE N.(BSc, MSc) 137

• Screening for STI
• Screen all women younger than 25 years women who are at risk of
infection
• Screen high-risk women
• Universal screening
• Counsel about the risk of vertical transmission
• Partner notification
• Treat infected patients

11/26/2023 DAJANE N.(BSc, MSc) 138

• Cervical screening should be performed

women over 25 years of age having a cervical screen for human

papillomavirus every five year

11/26/2023 DAJANE N.(BSc, MSc) 139

Preconception care for Men

Like women, preconception health is also important for men.

Preconception care for men offers a number of benefits:

• opportunities for disease prevention and

• health promotion

• the improvement of family planning and pregnancy outcome

11/26/2023 DAJANE N.(BSc, MSc) 140

Preconception care for men
• Do preconception care important for men? Yes.

• Immunizations:
• Men should ensure they are up-to-date on certain vaccines to protect their health and the health
of their future child.
• Recommended immunizations include:
• Hepatitis B: Ensures protection against hepatitis B virus.
• Rubella (German Measles): Prevents rubella infection, which can be harmful during
pregnancy.
• Varicella (Chickenpox): Protects against chickenpox.
• Tdap (Tetanus, Diphtheria, and Pertussis): Ensures immunity against these diseases.
• Influenza (Flu): Annual flu vaccination is advisable.

11/26/2023 DAJANE N.(BSc, MSc) 141

PCC for men…
• Sperm Health and Fertility:

• Keeping testicles cool is crucial for healthy sperm production. Men can:

• Wear loose-fitting underwear (such as boxer shorts) to maintain

optimal testicular temperature.

• Avoid prolonged sitting to prevent heat buildup.

• Lifestyle factors like quitting smoking, reducing alcohol intake, and

avoiding recreational drugs positively impact fertility.

11/26/2023 DAJANE N.(BSc, MSc) 142
PCC for men…
• General Health Check-up:
• Men should have a general medical check-up before attempting to
conceive.
• Discuss any existing medical conditions with a healthcare provider.
• Address any health issues that may affect fertility.

• Sexually Transmitted Infections (STIs):

• Men should be screened for STIs, as they can lead to infertility.
• Testing before conception reduces the risk of passing infections to a
partner.
11/26/2023 DAJANE N.(BSc, MSc) 143
 Summary: Overview of preconception care and influence on
the life course

11/26/2023 DAJANE N.(BSc, MSc) 144

 U.S. Food and Drug Administration Pregnancy Risk
Categories for Medications

11/26/2023 DAJANE N.(BSc, MSc) 145

 Category Definition
A Controlled studies in pregnant women fail to demonstrate a risk
to the fetus in the first trimester, there is no evidence of risk in
later trimesters, and the possibility of fetal harm appears remote.
Medications in this class are considered safe to use in pregnancy

B Either animal-reproduction studies have not demonstrated a fetal

risk but there are no controlled studies in pregnant women, or
animal-reproduction studies have shown an adverse effect (other
than a decrease in fertility) that was not confirmed in controlled
studies in women in the first trimester (and there is no evidence
of a risk in later trimester
Medications in this class are generally considered safe.
C Either studies in animals have revealed adverse effects on the
fetus (teratogenic or embryocidal or other) and there are no
controlled studies in women, or studies in women and animals
are not available. Drugs should be given only if the potential
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benefit justifies the potential risk to the fetus.
DAJANE N.(BSc, MSc) 146
 Category Definition
D There is positive evidence of human fetal risk, but the
benefits from use in pregnant women may be acceptable
despite the risk (e.g., if the drug is needed in a life-
threatening situation or for a serious disease for which safer
drugs cannot be used or are ineffect

X Studies in animals or humans have demonstrated fetal

abnormalities or there is evidence of fetal risk based on
human experience, or both, and the risk of the use of the
drug in pregnant women clearly outweighs any possible
benefit. The drug is contraindicated in women who are or
may become pregnant.

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11/26/2023 DAJANE N.(BSc, MSc) 148