Preconceptional Counseling

Definition

• It is sets of intervention that aims to identify

and modify biomedical risk,
behavioral and social risk to a women ‘s
health or pregnancy outcome through
prevention and management
 Goals

• Improve knowledge ,attitude, behaviours of men

and women related to preconceptional
counselling (PC)
• To ensure all women in reproductive age receive
PC services
• Reduce risk associated with previous adverse
pregnancy outcomes through inter-conceptional
interventions to prevent and minimize recurrent
adverse outcomes
• Reduce disparities in adverse pregnancy
outcomes
To be successful - preventives strategies should
be made to so that potential pregnancy risk
can be avoided even before conception
Upto half of the pregnancy are unplanned,and
by the time she realize their pregnancy they
have crossed 1 to 2 weeks after missed period
 COUNSELING SESSION

• BEST TIME IS DURING PERIODIC HEALTH

MAINTENANCE EXAMINATION
• Negative pregnancy test is best time of
evaluation
• Counselors can be gynecologist ,family
practitioner ,pediatricians .
• They must have knowledge regarding relevant
medical disease , prior surgery, reproductive
disorders or genetics conditions
 MEDICAL HISTORY
• With specific medical condition ,general point
include how pregnancy will affection maternal
health and how high risk condition affect
fetus
• Later advice for improving outcome was
provided
 Diabetes mellitus
• Prototype condition where PC is beneficial
• PC is found to be beneficial as well as cost
effective in this case
• Previously healthy mother has 2 to 3 % risk
birth defect
• Already diabetics risk increases to 6 to 9 %
 Epilepsy
• MEDICATIONS
– ASSOCIATION WITH SOME MEDICATIONS WITH
SOME BIRTH DEFECTS
– SOME WOMEN ON ANTI-SEIZURE MEDICATIONS
FOR YEARS AFTER A SEIZURE AND MIGHT BE ABLE
TO DISCONTINUE
– LOWEST POSSIBLE EFFECTIVE DOSE
– SINGLE DRUG VERSUS MULTIPLE DRUGS
 INFECTIONS
• HEPATITIS B
– 90% CHRONIC CARRIERS ARE WITHOUT
SYMPTOMS

– IDENTIFY NEONATES FOR FULL VACCINATION AND

PROPHYLAXIS
– WOMEN WHO ARE HEP. NEG CAN BE
VACCINATED
 HIV

• HELPS INFECTED WOMEN MAKE INFORMED

REPRODUCTIVE DECISIONS
• BEGIN MATERNAL CARE PROGRAM
• HIGH RISK WOMEN CAN BE COUNSELED
REGARDING RISK REDUCTION
 IMMUNISATIONS
• TOXOIDS VACCINES LIKE FOR TETANUS
INFLUENZA ,PNEUMOCOSIS,HEP B, RABIES
ARE NOT ASSOCIATED WITH ADVERSE
OUTCOMES
• BUT LIVE VACCINES LIKE MMR ,VARICELLA
ZOSTER ,POLIO,CHICKEN POX ARE NOT GIVEN
DURING PREGNANCY AND ATLEAST 1 MONTH
GAP WITHIN VACCINATION AND CONCEPTION
SHOULD BE THERE
 GENETIC DISEASE
• FAMILY HISTORY –PEDIGREE CONSTRUCTION
HELPS FAMILY GENETIC SCREENING
• WOMEN WITH PRIVIOUS HISTORY OF BIRTH
DEFECT SHOULD BE DOCUMENTED
• HEALTH AND REPRODUCTIVE STATUS OF
EACH BLOOD RELATIVE SHOULD BE REVIEWED
FOR MEDICAL ILLNESS , MR,BIRTH DEFECTS
,INFERTILITY
 NEURAL TUBE DEFECT
• NTDS are seen in 0.9%of live births
• Folic acid administration reduces
risk on ntds by 72%
• >90%of infants with NTDs are born with low
risk
• Current recommendation all women who may
become pregnant should take folic acid 400ug
daily 3 months before the conception to 1st
trimester
 PHENYLKETONEURIA
• MOTHER WITH PHENYLKETONEURIA WHOSE
ON UNRESTRICED DIET WILL HAVE
ABNORMALLY HIGH LEVEL ,WHICH WHEN
CROSSES PLACENTA CAN AFFECT NEURAL AND
CARDIAC TISSUE OF BABY
• WITH PC ADVICING PHENYLKRTONEURIA
RESTRICED DIET BEFORE PREGNANCY
INCIDENCE OF DEFECT REDUCED
DRAMATICALLY
 THALASEMIAS
• MC SINGLE GENE DISORDER WORLD WIDE
• All high risk couples after PC remarkably showing
no affect on child born
• ACOG recommends that individual with high risk
ancestry be offered carrier screening to allow
them informed decision making regarding
reproduction and perinatal diagnosis

Method like pre-implantation genetic diagnosis is

avialable for patient at risk of certain thalassemia
syndrome
• Genetic diseases like Tay Sachs ,Gaucher
,cystic fibrosis, Canavans disease ,familial
dysautonomis,mucolipidosis IV,Neimann pick
disease type A,Fanconi anemia group C,Bloom
syndrome ACOG recommends
preconceptional counselling and screening
 Reproductive history
• PC USEFUL in women with past history of
• INFERTILITY,MISCARRIAGE,
• ECTOPIC PREGNANCY
• RECCURENT PREGNANCY LOSS
 PARENTAL AGE
• MATERNAL AGE -LESS , ADOLSCENT MOTHERS
Preeclampsia,preterm delivery,anemia risk
higher
MATERNAL AGE after 35 more likely to ask for
PC because –
1.Wishes to optimise her outcome
2.Baby planning after infertility treament
 FOR FETUS
Maternal Age risk primarily stem from
• Indicated preterm delivery in hypertension and
diabetes
• Spontaneous pre term
• Fetal growth disorder like chronic maternal
disease or multifetal gestation
• Fetal aneuploidy
• Pregnancy after assisted reproductive technology
ART leading increase mortality and morbidity by
multi-fetal gestation and preterm delivery
 PATERNAL AGE
• There is increase incidence of genetic disease
in offspring caused by new autosomal
dominant mutations in older men
• Incidence is low
 Social history
• Recreational drugs and smoking –first step in
preventing drug related fetal risk is for women
to honestly assess her use ,questioning should
be non judgemental
• Screening for at risk drinking can be
accomplised using a number of validated
tool,like we studied TACE questions
• TACE QUESTIONS –series of 4 questions
concerning
• Tolerence to alcohol
• Being annoyed by comments about drinking
• Attempts to cut down
• The eye opener history of drinking early in
morning
 Diet
• Pica –craving and comsuption of ice,laundry
starch,clay,dirt other non food items
• Vegitarian diet at protein deficient but also
can be corrected by increasing EGG and
cheese consumption
• Anorexia and bulimia increase maternal risk of
nutritional deficiences ,electrolyte imbalence
• Incontrast also obesity has severe maternal
complication
 Other social factors
• Enviromental exposure
• Exercise
• Intimate partner voilence
ANTENATAL CARE
 Definition of Antenatal care
Comprehensive antepartum program involves a
co ordinated apporoach to medical
care ,continuous risk assesment and
psychological support that optimally begins
before conception and extend throughout the
post partum periods and interconceptional
period
 Goals
• To reduce maternal and perinatal mortality
and morbidity rates

• To improve the physical and mental health of

women and children
 Importance of Antenatal Care
• To ensure that the pregnant woman and her fetus
are in the best possible health.

• To detect early and treat properly complications

• Offering education for parenthood

• To prepare the woman for labor, lactation and care of

her infant
 Schedule for Antenatal Visits:
The first visit or initial visit should be made as
early in pregnancy as possible.
Return Visits:
• Once every month till 28 w.
• Once every 2 weeks till the 36 w
• Once every week, till labor.
 WHO RECOMMENDATION
• AT LEAST FOUR VISITS
• 1ST AT 16 WEEKS
• 2ND AT 24 TO 28 WEEKS
• 3RD AT 32 WEEKS
• 4TH AT 36 WEEKS
 Frequency of antenatal appointments

• Nulliparous with an uncomplicated pregnancy, a

schedule of 10 appointments.

• Parous with an uncomplicated pregnancy, a schedule

of 7 appointments.
 PROCEDURE OF THE VISIT

Assessment

History Examination Investigation

 FIRST VISIT
NOT BEYOND SECOND MISSED PERIOD
 OBJECTIVES
• To assess health status of mother and fetus
• Assess the fetal gestational age and to obtain
baseline investigation
• To organise continued obstetric care and risk
assesment
 Vital statistics
• Name ,age ,Date of first examination
• Gravida and parity
• Duration of marriage
• Occupation of pateint and her husband
• Period of gestation
 History
• Personal history
• Family history
• Medical and surgical history
• Menstrual history
• Obstetrical history
• History of present pregnancy
 EXAMINATION
GENERAL EXAMINATION
BUILT ,NURITION, HEIGHT, WEIGHT ,PALLOR ,JAUNDICE,
TONGUE ,TEETH,GUMS ,AND TONSILS ,NECK
Breast examination
EDEMA OF LEG
PULSE RATE AND BLOOD PRESSURE

Systemic examination
OBSTETRIC EXAMINATION
ABDOMINAL
VAGINAL
 ROUTINE INVESTIGATION
• BLOOD –CBC+ABORH,SEROLOGY
• URINE FOR PROTEIN SUGAR AND PUS CELLS
• CERVICAL CYTOLOGY STUDY HAS BECOME
ROUTINE IN MANY CLINICS
SPECIAL INVESTIGATION

• FOR RUBELLA ,HIV ,HBSAG

• GENETIC SCREENING
 SPECIAL INVESTIGATION

• FOR RUBELLA ,HIV(WITH CONSENT) ,HBSAG

• GENETIC SCREENING :MSAFP,TRIPLE TEST AT
15TO 18 WEEKS (FOR NEURAL TUBE
DEFECT,DOWN’S )

UITRASOUND EXAMINATION TO DETECT

1.EARLY PREGNANCY 2.ACCURATE DATING 3.NUMBER OF FETUS 4.GROSS
FETAL ANOMALIES 5.ANY UTERINE OR ADNEXAL ANOMALY
 Fetal KICK count

–The pregnant woman reports at least

10 movements in 12 hours.

–Absence of fetal movements precedes

intrauterine fetal death by 48 hours.
 Physical Examinations
• Height of over 150 cm indication of an
average-sized pelvis
• The approximate weight gain during
pregnancy is 12 kg.; 2kg in the first 20 weeks
and 10 kg in the remaining 20 weeks (1.5 kg
per week until term).
• Symphysis–fundal height should be measured
and recorded at each antenatal appointment
from 24 weeks.
• Fetal presentation should be assessed by
abdominal palpation at 36 weeks.
 SUBSEQUENT VISITS
OBJECTIVES
• TO ASSES FETAL WELL BEING
• TO KNOW LIE, PRESENTATION,POSITION AND
NUMBER OF FETUS
• ANEMIA ,PRE ECLAMPSIA ,AMNIOTIC FLUID AND
FETAL GROWTH
• SPECIAL ANTENATAL CLINICS FOR CARDIAC AND
DIABETES
• TO SELECT TIME FOR USG AMNIOCENTESIS AND
CHORIONIC VILLIOUS BIOPSY WHEN INDICATED
 SUBSEQUENT VISITS
History for any new symptoms and quickening
Examination
General –pallor,Edema,weight gain
Abdominal examination
2nd trimester –fetal movement,fetal part palpation ,fetal
sound auscultation
3rd trimester palpation to identify lie,presentation
,position,growth pattern,volume of liquor
,engagement.
• Vaginal examination :best done on onset of
labour or before start of induction
• Assessment of pelvis for feto-pelvic
disproportion done
• Fetal heart sound is heard by sonic aid as early
as 10thweek of pregnancy.

• Fetal heart sound is heard by Pinard' s fetal

stethoscope after the 20thweek of pregnancy.
 Booking scan
• BOOKING SCAN AT (18 -20 WKS ) HAS GOT
ADVANTAGES IN ADDITION TO 1ST TRIMESTER
SCAN
• FETAL ANATOMY SURVEY AND TO DETECT ANY
STRUCTURAL ABNORMALITY INCLUDING
CARDIAC
• PLACENTAL LOCALISATION.
 REPETITON OF INVESTIGATION
• Haemoglobin estimation is repeated at 28th
and 36th weeks
• Urine tested for protein and sugar at every
antenatal visit
 Health Teaching
• Physiological changes during • Smoking :
pregnancy • Medications
• Weight gain
• Infection
• Fresh air and sunshine
• Irradiation
• Rest and sleep
• Diet
• Occupational and
environmental hazards
• Daily activities
• Travel
• Exercises and relaxation
• Hygiene • Follow up
• Teeth • Minor discomforts
• Bladder and bowel • Signs of Potential
• Sexual counseling Complications
Common Discomforts of Pregnancy, Etiology, and
Relief Measures :

Urinary frequency
RELIEF MEASURES:
• Decrease fluid intake at night.
• Maintain fluid intake during day.
• Void when feel the urge.
 Fatigue
RELIEF MEASURES:

• Rest frequency.

• Go to bed earlier.
 Sleep difficulties
RELIEF MEASURES:
• Rest frequency
• Decrease fluid intake at night
 Nasal stuffiness and epistaxis
ETIOLGY: Elevated estrogen levels
– RELIEF MEASURES :
• Avoid decongestants.
• Use humidifiers, and normal saline drops.
Ptyalism (excessive salivation)
ETIOLGY: Unknown
RELIEF MEASURES:

• Perform frequent mouth care.

• Chew gum.
• Decrease fluid intake at night.
• Maintain fluid intake during day.
 Nausea and vomiting

•most cases of nausea and vomiting in pregnancy

will resolve spontaneously within 16 to 20 weeks.
•that nausea and vomiting are not usually associated
with a poor pregnancy outcome.

•non-pharmacological:
•ginger
•P6 (wrist) acupressure
•pharmacological:
•antihistamines.
 Nausea and vomiting
– RELIEF MEASURES:
• Avoid food or smells that exacerbate condition.
• Eat dry crackers or toast before rising in morning.
• Eat small, frequent meals.
• Avoid sudden movements. Get out of bed slowly
• Breath fresh air to help relieve nausea.
 Heartburn
RELIEF MEASURES:
• Eat small, more frequent meals.
• Use antacids.
• Avoid overeating and spicy foods.
 Dependent edema
• Avoid standing for long periods.
• Elevate legs when laying or sitting.
• Avoid tight stockings.
 Varicosities
• Rest in sims' position.
• Elevate legs regularly.
• Avoid crossing legs.
• Avoid long periods of standing
 Hemorrhoids
RELIEF MEASURES:
• Maintain regular bowel habits.
• Use prescribed stool softeners.
• Apply topical or anesthetic
ointments to area.
 Constipation
RELIEF MEASURES:
• Maintain regular bowel habits.
• Increase fiber in diet.
• Increase fluids.
• Find iron preparation that is least
constipating
 Backache
RELIEF MEASURES:
• Wear shoes with low heels.
• Walk with pelvis tilted forward.
• Use firmer mattress.
• Perform pelvic rocking or tilting
 Leg cramps
– RELIEF MEASURES:
• Extend affected leg and dorsiflex the foot.
• Elevate lower legs frequently.
• Apply heat to muscles.
 Faintness

RELIEF MEASURES:
•Rise slowly from sitting to standing.
•Evaluate hemoglobin and hematocrit.
•Avoid hot environments
Screening
 Asymptomatic Bacteriuria
• Women should be offered routine screening
for asymptomatic bacteriuria by midstream
urine culture early in pregnancy. Identification
and treatment of asymptomatic bacteriuria
reduces the risk of pyelonephritis.
 Screening for fetal anomalies

• The 'combined test' (nuchal translucency, beta-human

chorionic gonadotrophin, pregnancy-associated plasma
protein-A) should be offered to screen for Down's
syndrome between 11 weeks 0 days and 13 weeks 6
days.
• For women who book later in pregnancy the most
clinically and cost-effective serum screening test (triple or
quadruple test) should be offered between 15 weeks 0
days and 20 weeks 0 days.
 Screening for gestational diabetes
• risk factors for gestational diabetes :

• body mass index above 30 kg/m2

• previous macrosomic baby weighing 4.5 kg or above
• previous gestational diabetes (refer to 'Diabetes in pregnancy
• family history of diabetes (first-degree relative with diabetes)
• family origin with a high prevalence of diabetes:
– South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)
– black Caribbean
– Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab
Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).
 Screening for haematological conditions

• Screening for sickle cell diseases and

thalassaemias should be offered to all women
as early as possible in pregnancy (ideally by 10
weeks).
 Anaemia
• Screening should take place early in pregnancy
(at the booking appointment).
• at 28 weeks when other blood screening tests
are being performed.
• At 36 weeks.
• Normal range:
• 11 g/100 ml at first contact and 10.5 g/100 ml
at 28 weeks) should be investigated and iron
supplementation considered .
 Blood grouping and red-cell alloantibodies

• Women should be offered testing for blood

group and rhesus D status in early pregnancy.
• To give anti-D at 28 weeks and post delivery if
the baby (+)
 Hepatitis B virus
• Serological screening for hepatitis B virus
should be offered to pregnant women so that
effective postnatal interventions can be
offered to infected women to decrease the
risk of mother-to-child transmission.
 Hepatitis C virus
• Pregnant women should not be offered
routine screening for hepatitis C virus because
there is insufficient evidence to support its
clinical and cost effectiveness.
 Rubella
• Rubella susceptibility screening should be
offered early in antenatal care to identify
women at risk of contracting rubella infection
and to enable vaccination in the postnatal
period for the protection of future
pregnancies.
Nutritional Supplements
 Folic Acid
• Start before conception and throughout the first 12
weeks.
• reduces the risk of having a baby with a neural tube
defect (for example, anencephaly or spina bifida).
• The recommended dose is 400 micrograms per day.
 Vitamin D
Women at greatest risk are following advice to take this daily supplement. These
include:

• women of South Asian, African, Caribbean or Middle Eastern family origin

• women who have limited exposure to sunlight, such as women who are
predominantly housebound, or usually remain covered when outdoors
• women who eat a diet particularly low in vitamin D, such as women who
consume no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast
cereal
• women with a pre-pregnancy body mass index above 30 kg/m2.
 Vitamin A

Vitamin A supplementation (intake above 700

micrograms) might be teratogenic and
should therefore be avoided
 Iron
• Iron supplementation should not be offered
routinely to all pregnant women. It does not
benefit the mother's or the baby's health and
may have unpleasant maternal side effects.
• THANK YOU