BY

DEPARTMENT OF OBTETRICS AND GYNAECOLOGY BMC, SAKI.

Outline INTRODUCTION

TIMING (WHEN)

COMPONENTS

CONCLUSION

INTRODUCTIONThere were about 4million birth in the U.S

in 2003,with almost all born healthy but, the infant mortality rate in the U.S ranked 28th

that year.

Preconception care has been advocated as a measure to improve pregnancy outcomes i.ehealthy child/children and mother with happy family

TIMINGThe appropriate time for preconception care

include:

Routine health maintenance visits

Pre-appointment examination

Pre-marital or family planning visit

After negative pregnancy test

Pre-school examination

COMPONENTSComponents of preconception care

parallels that of prenatal care i.e :

Risk assessment

Health promotion

Medical intervention

Psychosocial intervention

NUTRITION A woman’s nutritional status may have a profound effect on

reproductive outcome The two forms of malnutrition are : over nutrition (obesity) and

under nutrition Obesity

poses the following risks: hypertensive disorders gestational diabetes UTI LGA babies Intrapartum complications

Obese patients should be advised to loose weight before pregnancy

NUTRITION CONT’D Undernutrition

Effects of under- nutrition include:

.LBW babies .SGA babies

.Anaemia .DM

.Cardiovascular diseases

NUTRITION CONT’DAt preconception visit patient’s weight and

height should be measured and inquiries should be made about Bulimia, Anorexia , Pica, Vegetarian eating habits , Megavitamins supplements e.g. vitamin A is a known teratogen at high doses(>5000 iu/d).However , it should be noted that retinol not B-carotene which is found in fruits and vegetables is the teratogenic form.

Folic acid supplementation 4000 pregnancies are affected in the U.S. by

neural tube defects(NTDs);spinal bifida,anencephaly and encephalocele.Spinalbifida is usually complicated with disabilities like paraplegia, bowel incontinence,bladderincontinence,hydrocephalus,and intellectual impairment.

Studies have shown a 72% reduction in recurence of NTDs with 4mg daily dose of folic acid.

Folic acid contdCDC recomends that all women of

childbearing age who are capable of becoming pregnant take 0.4mg of folic acid daily starting 1-3 month prior to planned conception and through the 1st trimester.

EXERCISE Available data suggest that moderate

exercise is safe for pregnant women who have no medical or obstetric complication

Advantages of exercise include:

decrease pregnancy related discomfort

improve maternal fitness

improve maternal self-esteem

MEDICAL CONDITIONSDiabetes mellitus

congenital anomalies is 2-6 times commoner in pregnant diabetic patients compared with non-diabetic pregnant women.

RBS goal in pregnant diabetic is 110mg/dl while 2hpp should not exceed 115mg/dl

Medical condition contdHypertention

preconception hypertention should be adequately managed

Epilepsy

Epilepsy is the commonest neurological problems in pregnancy. It leads to menstrual irregularity ,ovulatorydysfunction and infertility.

PhenylketonuriaMost common in-born error of

metabolism that leads to mental retardation, seizures, microcephaly, delayed speech, eczema and autistic-like behavior.

Genetic counseling

The ideal time for genetic counseling is before a couple attempt to conceive especially in advanced maternal age, consanguinity or family history of genetic diseases. e.g. Ashkenazi Jews have 1/25 chance of carrying gene for Tay sach ‘s disease

The U.S whites have 1/22 chance of caring gene for Cystic fibrosis.

Africans ----------------Sickle cell diseases

Mediterranean -----------β- thalasemia

S/E Asia----------------------&-thalasemia

IMMUNIZATIONS.

The following vaccine are recommended in pre-conception period:

• T.T • Rubella• Varicella• Chicken Pox • Hepatitis B among others.

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LIFE STYLE CHANGES CAFFEINE

Caffeine is present in most beverages, in chocolates and in over -the - counter, medications such as cold and headache medicine. 1 cup of coffee contains only 120mg, a cup of tea has 40mg and coke has 45mg per 12-02. consumption of caffeine during pregnancy is quite common, but its metabolism is slow. Cigarette smoking increases caffeine metabolism leading to high intake.

EFFECTS.• Decreased fertility • Increased spontaneous abortion• Decreased birth rate.

TOBACCO

12 -20% of woman smoke during pregnancy, subjecting themselves and their infants to a number of adverse effect. Woman contemplating pregnancy should be advised to quit smoking.

LIFE STYLE CHANGES CONTD. ALCOHOL

The most severe consequence of exposure to alcohol during pregnancy is Fetal Alcoholic Syndrome (FAS) consisting of a trial of prenatal or postnatal growth retardation, Neuro-developmental abnormalities and facial abnormalities. It is the largest preventable cause of birth defect and mortality rate in western world. Intending mothers should be counseled that there is no safe level of alcohol consumption during pregnancy. Effects include: Infertility, spontaneous abortion, hypertension, stroke, breast cancer.

ILLICIT DRUGS

At preconception visits, inquiry should be made about drugs used and counseling, referred and access to recovery program me should be offered as the case may be. Examples of drugs are: Marijuana, Heroine, Cocaine. Their effects are: Hyperactivity, Inattention syndrome in older years, LBW, IUGR, Preeclampsia, Abruptio Placenta, Fetal distress, sudden infant death syndrome, GI dysfunction.

STI

The preconception visit is a good opportunity to screen for genital infections such as: Chlamydia, Gonorrhea, Syphilis, HIV. EFFECTSChlamydia – Inclusion Conjunctivitis, PneumoniaSyphilis – Spontaneous abortion, non-immune hydrops, still birth, neonatal deathGonorrhea – Ophthalmia Neonatorium.HIV

LIFESTYLE CHANGES CONT’D

• MEDICATION

Antihypertensive - ACEI (Renal impairment), Diuretics (decreases maternal plasma volume).

Anticoagulants ---warfarin is a teratogen and it crosses placenta.Heparin is better sustitute because it does not cross placenta.–

Antithyroid drugs

Hypoglycaemics – oral hypoglycaemics should be switched to Insulin.

LIFE STYLE CHANGES CONTD OCCUPATIONAL EXPOSURES

Increasing no of women are entering the workforce world-wide and most in their reproductive years. The preconception visit is the best time to identify and control exposure that may affect parental health and pregnancy outcome.

The 3 most common occupation exposure reported to affect pregnancy are:

.Organic solventse.g.painting,printing,varnishing,plastic etc .Lead e.g.smelting,printing,battery. .Video display terminals

DOMESTIC VIOLENCEDomestic violence is increasingly recognized

as a major public health issue. Findings from the 1998 National Violence Against Women Survey showed that in the United States 1.5 million women are raped or physically assaulted by an intimate partner every year. Domestic violence crosses all socioeconomic, racial, religious, and educational boundaries. :

Domestic violence cont’d Even physicians are not immune. In a survey, 17%

of female medical students and faculty had experienced abuse by a partner in their adult life, an estimate comparable to that of the general population. Victims of domestic violence should be identified preconceptionally, because the pattern of violence may escalate during pregnancy. The prevalence of domestic violence during pregnancy ranges from 0.9% to 20.1%, with most studies identifying rates between 3.9% and 8.3%.

DOMESTIC VIOLENCE CONT’DSWhereas violence in nonpregnant women is

directed at the head, neck, and chest, the breasts and the abdomen are frequent targets during pregnancy. Physical abuse during pregnancy is a significant risk factor for low birth weight and maternal complications of low weight gain, infections, anemia, smoking, and alcohol or drug usage.

If it is identified that a patient is the victim of domestic violence, the physician should assess her immediate safety and make timely referrals to local community resources and shelters.

CONCLUSIONPreconception care has been

advocated and is being practiced in some developed countries,thesituation however is different in this part of the world.Thereforeawareness and education should be encouraged.

THANK YOU