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Preconceptional Counseling

Preventive medicine for Obstetrics

Involves:
o Identification of factors that affect perinatal
outcome
o Information of risk to mother
o Information of strategy to reduce or eliminate
the influence of risk factors
Prior to conception
Benefits:

Unintended pregnancy - counseling for continued


contraceptive use, lifestyle

Chronic medical disease


o DM
o Epilepsy
o Renal disease
o Hypertension
o Cardiac disease
o Thrombophilia & thromboembolism
o Connective tissue disease
o Psychiatric symptoms
Genetic disease
o Neural tube defect
o PKU
o Tay Sachs disease
o Thalassemia
Preconceptional counselors:
Knowledgeable on:
Medical & surgical disease
Reproductive disorder
Genetic condition
Questions:
1. How will pregnancy affects the pregnancy?
2. How will the condition affects the pregnancy?
Components:
Advice regarding
o Diet
o Alcohol use
o Smoking
o Illicit drug use
o Vitamin intake
o Exercise
Patient history
o Medical & genetic disease
o Reproductive history
- Outcomes of prior pregnancy
o Medication used & drug allergies
Family history
o Medical & genetic disease
o Reproductive abnormalities
Racial & ethnic origin
Social risk factors
Lifestyle & work habits
Diabetes glucose metabolic abnormalities
Maternal risks
o Retinal, renal & cardiac damage
o UTI
o DKA (diabetic ketoacidosis)
Fetal risks
o Malformations
o Growth disturbance
o Iatrogenic preterm delivery
o Neonatal metabolic instability
o Increased perinatal mortality
Maternal Counseling resulted to:
Earlier start of prenatal care

Lower HbA1c levels


Less likely to smoke during pregnancy
None delivered prior to 30 weeks (vs 17%)
Few macrosomia ( 23% vs 40%)
No IUGR ( vs 85%)
No neonatal death (vs 6%)
Fewer NICU admissions ( 17% vs 34%)

Hyoerglycemia is teratogenic to the embryo:


Neural tube defect
Cardiac anomalies & renal anomalies
Sacral agenesis
Holoprosencephaly
Each pregnancy visit should include a review of glucose
control
Emphasis on patient education
Renal

disease
Exacerbation of renal hypertension
Superimposition of preeclampsia
Pregnancy increases progression of renal damage in
severe disease
Fetal risk related to associated vascular dysfunction
Best predictor of perinatal outcome is serum creatinine
level
ACE inhibitors are contraindicated

Hyoertension
May worsen during pregnancy
May need additional drug therapy
Assessment of renal & cardiac function
Fetal risks : related to maternal BP control
Maternal risk: related to superimposition of
preeclampsia
Epilepsy
Increased seizure activity during pregnancy
Related to reduce drug level
Offspring of epileptic women at increased risk for
o Structural malformation
- Related to anti-epileptic meds
- Monotherapy is advocated
o Seizure disorder
Monotherapy significantly fewer malformations than
multitherapy
Cardiac disease
Pregnancy associated mortality related to the type of
cardiac lesions
Highest mortality risks:
o Pulmonary risk
o Complicated aortic coarctation
o Marfans syndrome w/ aortic involvement
Cyanotic heart disease: increased risk
o Obtain a pedigree analysis to quantify the fetal
risk
Thromboembolism/Thrombophilias
Maternal risks
o Pulmonary embolism
o Cerebral infarction
o Early preeclampsia
o Increase risk of recurrence
Fetal risks
o Preterm
o Stillbirth
o Abortion
o Fetal growth restriction
Connective tissue disease
Pregnancy associated risk vary w/ the type of CTD

o Rheumatic arthritis improve during pregnancy


but relapse within 6 months of deliveries
o Ankylosing spondylitis: increase back pain
o Scleroderma: improvement of Reynauds
phenomenon
o SLE most serious
SLE
Maternal risk factors
o Worsening hypertension & proteinuria
o Worsening renal function
Fetal risks
o Preterm birth
o IUGR
o Exposure to medication
o Stillbirth
Counseling
o Review of clinical course
o Assessment of organ damage
Psychiatric Disorder
Increased risk relapsed or return of dysmorphic
symptoms
Incidence of postpartum depression high for women
with bipolar disorders, major depression or
premenstrual symptoms
Fetal risks
o Risk of heritable mental illness
- Schizophrenia (0.8%)
from parent: 12%
two parents : 40%
siblings : 10%
- Bipolar disease (0.5 %-1.0%)
from either parents: 15%
mother was affected: higher
- ADHD
Counseling
Genetic diseases
Primary prevention avoidance of causal factors
Secondary prevention identification and termination
of affected pregnancies
Tertiary prevention surgical correction of structural
defects
Neural Tube defects
Mutation in the Methylene Tetrahydrofolate Reductase
gene
Overcome by periconceptional folic acid
o 4 mg/day for women w/ a prior baby w/ NTD
o 0.4 mg/day reduction of the prior risk of first
occurrence
Phenylketonuria (PKU)
Example of a disease the fetus cannot inherit but is
affected because of a maternal genetic
predisposition
Primary prevention
o
Adherence to a phenylalanine restricted
diet
o
Lower incidence of microcephaly
Tay sachs disease
Autosomal recessive neurodegeneration disorder
Jewish decent most often affected
Identification of carriers and avoidance of pregnancy
Thalassemias
Most common single gene disorder
Hemoglobinopathies
Primary and secondary prevention
Immunizations

Immunity to rubella, varicella, Hep B


Immunization with toxoid or killed bacteria allowed
during pregnancy
Live virus vaccine: no t allowed during pregnancy
- Ideally given 3 months after conceiving
Screening tests:
Rubella, varicella, Hep B
CBC
Hemoglobin Elcetrophoresis
Summary:
Preventive medicine of OB
Strategy to quantify the risk of the mother & fetus in relation
to a risk factor
Questions:
How will the risk factor affect the pregnancy?
How will pregnancy affect the associated disorder?
Prenatal Care
A comprehensive antepartum care programs that
involves a coordinated approach to medical &
psychosocial support that optimally begins before
conception & extends throughout the antepartum
period
Components
Preconceptional care
Initial prenatal evaluation
Subsequent prenatal visits
Ancillary prenatal tests
Nutritional advice
Preconceptional care
Aims to reduce the risk of women desiring pregnancy
by:
o Penetrating healthy lifestyle
o Improving readiness of pregnancy
Diagnosis of Pregnancy
Signs and symptoms:
o Cessation of menses
- Implantation bleeding
o Changes in the cervical mucus
- Beaded cervical pattern low levels of NaCl
o Changes of breasts
o Chadwick sign
o Skin changes increased pigmentation
o Changes in uterus
- Hegar sign
o Changes in the cervix
o Fetal heart action
- Funic souffl versus uterine souffl
Funic souffl passage of blood through
umbilical vessels
Uterine souffl maternal blood flow always
coincident with maternal pulses
o Perception of fetal movement
o Chorionic gonadotropin
o Ultrasonic recognition
Initial

Prenatal Evaluation
Initiated as soon as there is likelihood of pregnancy
Should be no later than the 2nd missed period
Goals:
o Determine the health status of the mother and
fetus
o Determine the gestational age of the fetus
o Formulation of a plan for continuing obstetrical
care

Components of the initial prenatal care visit


Risk assessment
a) Preexisting medical illness
b)Previous poor pregnancy outcome

o Perinatal mortality
o Preterm delivery
o Fetal growth restriction
o Fetal malformations
o Placental accidents
o Maternal hemorrhage
c) Evidence of maternal undernutrition
Estimated due date
General physical examination
Laboratory tests
Patient education

Definitions:
Parity number of pregnancies reaching viability ( 20
weeks, 500 gm) and not number of fetuses deliverd
Primipara woman who has delivered only once of a
fetus or fetuses who have reached viability
Multipara a woman who has completed two or more
pregnancies to viability
Nullipara a woman who has never completed a
pregnancy beyond an abortion
Gravida a woman who is or has been pregnant regardless
of outcome
Nulligravida a woman who is not now , and never has
been pregnant
Primigravida a woman who is or has been pregnant
only once
Multigravida a woman who is or has been pregnant
more than once
Parturient a woman in labor
Puerperal a woman who has just given birth
Obstetric index series of digits connected by dashes that
denotes past obstetrical history
Obstetrical index (a-b-c-d)
First digit (a) number of term infants
Second digit (b) number of preterm infants
Third digit (c) number of abortions, ectopic or molar
pregnancies
Fourth digit (d) number of children currently alive
Ex. G9P7 (6-1-2-6)
9 pregnancies
7 deliveries
6 term deliveries
1 preterm delivery
2 pregnancies not reaching viability
6 currently alive children
Normal duration of pregnancy
280 days or 40 weeks, calculated from the first day of
the last normal menstrual period
Estimated date of delivery (EDD)
o Calculated using Naegeles rule
o Add 7 days to the first day of LMP; count back 3
months
Trimesters of pregnancy
3 equal period consisting of 3 calendar months
1st trimester: up to 14 weeks
2nd trimester : 14 weeks 1 day up to 28 weeks
3rd trimester : 28 weeks 1 day up to 42 weeks
Gestational age
Expressed in weeks
Computed from
o LMP
o Ultrasound
Correlate with uterine size, quickening and detection of
FHT
Ascertained by a carefully done clinical examination
coupled with an accurate knowledge of the tie of
onset of the last menstrual period

If clinical parameters and fundic height are in temporal


agreement, duration of gestation can be established
Limiting Factors in AOG determination
Unsure menses
Irregular menses
Implantation bleeding
Use of any form of contraception
Ultrasonography
Recommended when clinical parameters do not agree
and estimation of gestational age cannot be clearly
identified
History
Detailed information about past obstetrical history
Concise menstrual history
Inquiry about contraceptive methods
Psychosocial screening
Smoking during
Alcohol intake
Use of illicit drugs
Domestic violence screening
Physical and Obstetrical Examination
Standard physical examination procedures
Obstetrical examination:
o Abdominal examination : assessment of fundal
height, fetal heart tones, uterine contractions
o Speculum examination
o Digital pelvic examination
o Inspection of the vulva and contiguous
structures
o Digital examination
Fetal Heart sounds
First heard at 16 to 19 weeks using a DeLee fetal
stethoscope
Depends on:
o Patient size
o Examiners hearing acuity
Heart sounds audible by 22 weeks in all patients
Fundal Height
Height in centimeters of the uterine fundus from the
superior border of the symphysis pubis
Gestational age equal to the fundal height between 20
to 31 weeks
Bladder must be empty
Laboratory and ancillary examinations
Hemoglobin/hematocrit
Urine culture and
sensitivity
Urinalysis
Rubella status
Blood group and Rh typing
Syphilis screen
Pap smear
Offer HIV testing
HbsAg screening
Ultrasound
Subsequent prenatal visits
Every 4 weeks until 28 weeks; every 2 weeks until 36
weeks; weekly thereafter
Complicated pregnancies:
o 1 to 2 weeks interval
o Often dictated by gravity of existing
complication
Prenatal Surveillance
Fetal
o Heart rate(s)
o Size (actual and rate of change)
o Amount of amniotic fluid

o Presenting part and station (late in pregnancy)


o Activity
Maternal
o Blood pressure actual and extent of change
o Weight actual and amount of change
o Symptoms headache, altered vision, abdominal
pain, nausea and vomiting, bleeding, fluid from
vagina, dysuria, bleeding
o Fundal height
o Vaginal examination late in pregnancy:
- Presenting part
- Station
- Pelvic capacity and configuration
- Consistency, effacement and dilatation of
the cervix
Leopolds Maneuver
LM1 fetal pole occupying the fundus
LM2 fetal position
LM3 fetal presentation/ attitude (if cephalic)
LM4 cephalic prominence
Subsequent laboratory tests
Ned not be repeated if initial results normal
Hemoglobin or hematocrit and syphilis serology ( if
prevalent in population) repeated at 28 to 32 weeks
Maternal serum AFP at 16-18 (or 15-20) weeks
Cystic fibrosis carrier screening
Ancillary prenatal tests
Gestational diabetes : high-risk women
o
50-grams OGCT at 24-28 weeks
Chlamydia trachomatis and gonorrhea: depending on
risk
Fetal fibronectin: not recommended
GBS : vaginal and rectal cultures at 35- 37 weeks
Summary
History
o Menstrual
o Obstetrical
o Medical/family/psychosocial
Determine gestational age / risk assessment
Physical examination
o Vital signs
o Abdominal and pelvic examinations
Initial laboratory examinations
Subsequent prenatal visits
Subsequent ;laboratory examinations
Patient education
Not necessary to limit exercise
Should not become excessively fatigued
No contraindication to exercise
Shorter active labor, fewer C/S deliveries
No effect on spontaneous abortion
Alter early neonatal behavior
Less meconium stained AF
Less fetal distress
ACOG recommendation
Women who are accustomed to aerobic exercise before
pregnancy should be allowed to continue this during
pregnancy
Caution against starting new aerobic exercise programs
or intensifying training efforts
Can benefit from sedentary exercise:
o Women w/ hypertensive disorder due to
pregnancy
o Women pregnant w 2 or more fetuses
o Women suspected of having a growth restricted
fetus
Standing job cashier, bank teller, dentist

Standing >3 hours/day


Active jobs physicians, waitresses, real estate agents
Continue or intermittent walking
Sedentary jobs librarian, bookkeeper,
Less than 1 hour standing/day
Employment
An occupation that involves severe physical strain
should be avoided
Adequate periods of rest
Minimize physical work for mothers with recurring
obstetrical complications
Uncomplicated pregnancies
o Can continue work until onset of labor
o 4-6 weeks from delivery before returning to work
Travel
No harmful effect
Air travel:
o Allowed if the woman feels well and not within 7
days of EDD
o Every 2 hours ambulation
Seatbelts
Should wear a properly positioned 3-point seat restraint
o Lap belt position: under her abdomen and across
upper thighs
o Shoulder belt : positioned between her breasts
Bathing and clothing
Increased danger of slipping during bathing in 3rd
trimester
Comfortable and non constricting clothing
o Well fitting, supporting brassiere
o Constricting leg wear avoided

Bowel Habits
Constipation common
o Prolonged transit time
o Compression of the lower bowel by uterus or the
fetal presenting part
Greater frequency of hemorrhoids
Coitus
Not harmful until the last 4 weeks or so of pregnancy
Avoided when there is a risk for abortion or preterm
labor
Care of teeth
Pregnancy is rarely a contraindication to dental
treatment
Dental carries aggravated by pregnancy is unfounded
Immunizations
Live virus vaccines
o Measles
o Mumps
o Varicella Zoster
Live bacterial vaccines
o Typhoid : risks vs benefit
o Poliomyelitis : no longer recommended
o Yellow fever : high-risk areas only
Inactivated virus vaccine:
o Influenza : after 1st trimester request
o Rabies : same as non pregnant
o Hepatitis A and B : same as non pregnant
o Enhanced poliomyelitis : risk of exposure
o Japanese encephalitis : risk vs. benefit
Inactivated bacterial vaccines
o Pneumococcal : same as non pregnant
o Meningococcal : same as non pregnant

o Hemophilus : same as non pregnant


o Cholera : risk vs. benefit
Toxoids
o Tetanus diphtheria ; same as non pregnant
Hyperimmuneglobulin:
o Hepatitis B : post exposure prophylaxis
o Rabies : post exposure prophylaxis
o Tetanus : post exposure prophylaxis
o Varicella : consider post exposure prophylaxis
within 96 hours
Pooled immune serum globulin
o Hepatitis A : post exposure prophylaxis
o Measles: post exposure prophylaxis
Smoking
Results to:
o Fetal injury
o Premature birth
o Low birth weight
Nicotine medications : allowed if prior attempts to quit
have failed or if smoking > 10 cigarettes per day
Alcohol
Ethanol is a potent teratogen
Fetal alcohol syndrome
o Growth restriction
o Facial abnormalities
o Central nervous system dysfunction
Caffeine
No evidence that it increases teratogenic nor
reproductive risks
More than 5 cups per day increase abortion rate
Illicit Drugs
Opium derivatives, amphetamines and barbiturates
Harmful : fetal distress, low birth weight, neonatal drug
withdrawal symptoms
Medications
With rare exceptions, drugs that exert a system effect
can cross the placenta
Advantages must outweigh any inherent risks
Dictated by the FDA category of the drug
FDA categories
A: human studies show no fetal risks
e.g. prenatal multivitamins
B: animal studies show no risk but no human studies
available or adverse effects demonstrated in animal
but no well controlled human studies
e.g. penicillins
C: no adequate animal or human studies; or there are
adverse animal fetal effects but no available human
data
D: there is evidence of fetal risk, but benefits outweigh
risks
e.g carbamazepine
phynetoin
X: proven fetal risks outweigh any benefits
e.g. isotretinoin