Pre conceptional counselling and Antenatal care
Dr. Esraa Al- Qassab
C.A.B.O.G.\F.I.C.O.G.
Pre-conceptional care
1.Medical history:
DM:-
Optimize glycemic control to decrease risk of miscarriage and congenital anomaly.
Treat nephropathy, retinopathy.
Folic acid supplementation 5mg daily \3months.
HbA1C less than 6.5%
HT:-
Assess RFT.
Change ACEIs & thiazide diuretic to methyldopa or Ca channal blocker.
Epilepsy:-
Risk of congenital anomaly in offspring of epileptic mother is 2-3 times higher than general
population, so optimize control, avoid multiple agent.
Folic acid supplementation.
If no seizure for 2 years perform EEG than withdraw drug over 3 mon, with involvement of
neurologist.
Thrombo embolism:- test for thrombophilia, if pt on warfarin change to heparin.
Asthma:-
optimize control, fewer medication & offer influenza vaccine.
Cardiac disease:-
counsel pt about morbidity and mortality during pregnancy , involvement of
cardiologist.
Depression & anxiety:-
avoid benzodiazepine cause cleft lip& withdrawal symptoms in neonate.
2.Gyaenecological &reproductive hx:
if irregular cycle investigate for PCOS & treat.
hx of PTL, IUGR, PE high RR assess before pregnancy.
hx of PID test for tubal patency.
hx of EP advice pt to see Dr as soon as she believe that she is pregnant.
3. Livinng environment
Drugs:-
are classify to A,B,C,D,X, x should never taken when trying to conceive or in pregnancy e.g folic
acid antagonist, isotretinion, warfarin. avoid vit A more than 5000 IU daily.
Smoking:-
stop bf pregnancy because increase risk of EP, PTL& placental abruption.
Folic acid 1-2 months bf conception &continue for 1
st
3 mon. Of pregnancy(low risk 1mg, high risk e,g
epilepsy or DM 4mg).
Diet
----women trying to conceive should have diet rich in iron, vit.B, Ca.
Caffeine
----high intake increase risk of miscarriage (2 cup coffee &6 glasses of cola).
Fish
----large fish contain excessive amount of mercury that harm the developing fetus.
Weight
---both extreme of wt decrease fertility, try to reach optimal BMI bf pregnancy(20-25)kg\m2
Exercise:
avoid vigorous exercise to avoid increase in core temperature because hyperthermia associated
with NTD , also avoid long time spent in hot tubs.
4. Fetility review: assess regular cycle & ovulation, discuss fertility after contraception. Ovulation occure 2
wk after pills , seek medical care if regular cycle not occur 2-3 m after pill, review frequency &timing of
intercourse
5.Medical examination & testing:
a-full medical examination for lung, breast & abdomen, gynaecological examination including pap smear
and if mammography is indicated best time is bf pregnancy.
b-screen for infectious disease: e.g
1. HIV(both partners) 2. syphilis(both) 3. GC & chlamydia (both) 4. hepatitis B Ag & Ab
5. test immunity for rubella if –ve vaccinate bf pregnancy because live attenuated vaccine is
contraindicated in pregnancy and avoid pregnancy for 1 mon after vaccine, test also for varicella.
6. Test for toxoplasma: if –ve,no immunization for toxo, but advice should be given about hygeine
e.g avoid under cooked meat, avoid contact with cat faeces, wear gloves while gardening.
7. CMV
8. Dental hygiene, gum disease increase the risk of PTL, so should be treated bf pregnancy & during
pregnancy to improve out come.
6. Male preconceptional counselling:
--Avoid smoking ,alcohol at least 3 months bf conception , because it takes 10-12 weeks for sperm
to produce.
-Avoid exposure to heat ,avoid tight under wear.
-Offer SFA because in large proportion of subfertile couple there is male problem and can be
detected bf spending long time in vain
Antenatal care
Aims of ANC:
1.To prevent, detect & manage those factors adversely affecting the health of mother and baby.
2.To provide advice, reassurance, education and support for women &her family.
3.To deal with minor problems of pregnancy.
4.To provide general health screening.
1
.
Booking visit: is the 1
st
ANC visit during which history, examination & of investigation are
performed to provide appropriate care and to determine whether risk factors are present or not.
1
st
step in booking is confirmation of pregnancy: by symptoms of pregnancy e.g amenorrhea, breast
tenderness, nausea.
2
nd
step is dating the pregnancy:-
Dating by LMP: the EDD is calculated by taking date of LMP, counting forward by 9 months &adding 7 days
provided cycle is regular.
Dating by US: dating by US is more accurate especially if there is menstrual irregularity, so all women
should offer US between 10-14 weeks (late 1
st
&early 2
nd
TMS). CRL is used up to 13 wk+6d, HC from 14 -20
week, after 20 wk the effect of environmental factors will cause variation in fetal size, so dating the
pregnancy becomes less accurate as pregnancy advance .
Benefits of dating US
1.Accurate dating in women with irregular cycle or poor recollection of LMP
2. Reduce incidence of induction of labour for prolonged pregnancy.
3.Maximizing potential for serum screening to detect fetal abnormalities
4. Early diagnosis of multiple pregnancy.
5. Detection of asymptomatic failed IUP.
Booking history;
1)past medical 4)gynaecological
2)past surgical 5)family &social hx
3)Obstetric 6)Age and race *
The booking examination:
Accurate measurement of blood pressure.
Abdominal examination to detect size of uterus.
Detection of abnormal scar indicative of previous surgery.
Measurement of Ht & Wt to calculate BMI*
Urine dip testing for protein, glucose, WBCs, nitrate,& blood.
Booking investigation
FBC : as screen for anaemia & TCP. Hb level 11 g per dl or more considered normal in pregnancy.
Blood group & red blood cell antibody: if RH –ve prophylactic dose given as single dose at 28 wk or in
divided doses at 28 & 34 wk, or given after sensitizing events e.g threartened miscarriage, APH, &
delivery of baby will require additional anti –D.
3.Urine analysis : MSU should be examine in early pregnancy to detect asymptomatic bacteriuria.
4.Rubella : rubella infection in 1
st
TMS cause serious congenital abnormalities, so if there is no previous
hx of rubella infection ,should be advised to avoid contact with infected person &to undergo rubella
immunization after current pregnancy to protect future pregnancies
5.Hepatitis B: HBsAg +ve indicate recent infection or carrier state, if HBsAB +ve indicate previous infection
or immunization. vertical transmission occur in labour , immunization for baby after birth by Ig & vaccine
decrease rate of infection.
6.HIV.
7.Syphilis : transmission to fetus cause serious anomalies which can be prevented by simple antibiotic
treatment.
8. Hb studies; in high risk women screened for haemoglobinopathy.
Screening for fetal anomaly
1. Screening for down s syndrome: nuchal translucency at 11-14 wk, serum biochemistry at 15-20 wk.
2. screening for NTD e.g spina bifida & anencephaly: by maternal serum alpha feto protein at 15-20 wk,
detailed anomaly scan at 18-20 wk.
3. Screening for congenital structural anomalies : by US 18-20 wk
Screening for clinical conditions:
1.Gestational diabetes; all women should be assessed for risk factors for GDM at booking visit, if risk
factors are present ,women should be offered 2hr 75 g OGTT at 24-28 wk. A previous hx of GDM should
prompt glucose monitoring or OCTT at 16-18 wk ,if results are normal ,test should be repeated at 24-28
wk. *
2. pre-eclampsia & preterm labour: all women should be screened for PE at each visit by BP
measurement and testing for protein in urine , if risk factor for PE identified at booking visit, extra visits
should be arranged.
Women with hx of PTL should offer screening for bacterial vaginosis, UTI, &cervical length by US.
3. Fetal growth & wellbing: SFH should be checked at each visit. Listen to FH at each visit in 2
nd
& 3
rd
TMS by pinard stethoscope or Doppler US
No need for growth scan in absence of risk factors.
Follow –up visit:
Subsequent visits have been scheduled at intervals of 4 weeks until 28 weeks, then every 2 weeks until
36 weeks, and weekly thereafter. Women with complicated pregnancies require return visits at 1-2
week intervals.
at each visit from 24 wk: BP & protein in urine, SFH.
at 36 wk: fetal presentation & engagement.
at 28 wk anti D for Rh –ve women a single dose or in divided doses at 28 & 34 wk
Work – A woman with an uncomplicated pregnancy who is employed, may continue to work without
interruption until the onset of labor.
Postpartum, the patient may resume working 4-6weeks after an uncomplicated delivery.
Working during pregnancy should be limited or contraindicated in:
Vaginal bleeding
Short (<3 cm) or dilated cervix before
36 weeks gestation
Uterine malformation
Pregnancy-induced hypertension
Fetal growth restriction
Multiple gestation
Prior history of preterm birth
Polyhydramnios
maternal medical disorders that are associated with impaired placental perfusion
Airline travel – Most airlines allow women to fly up to 35-36 wks of gestation, Because of the lack of
availability of emergency care, certain precautions should be taken regarding airline travel:
Women with complicated pregnancies (eg, sickle cell anemia, high risk of preterm delivery,
preeclampsia) should avoid air travel.
All airline travelers should maintain hydration.
periodically move their lower extremities to avoid stasis and potential venous thrombosis.
continuously wear seat belts to protect against unexpected turbulence.
Supplemental oxygen should be administered to pregnant who may not tolerate the hypoxic
environment of high altitude flying.
Sama Adeeb