Pre-conceptual counselling Dr.Bara'a Lukman Humo Al-Ibrahim Antenatal care & Pre-conceptual counselling Dr.Bara'a Lukman Humo Al-Ibrahim FABOG/FIBOG/DGO

Antenatal care Definition: Careful, systeamatic assessment and follow up of a pregnant patient to assure the best health of the mother and her fetus.

Aims of antenatal care The main aim of antenatal care is to have a healthy mother and a healthy baby at the end of the pregnancy: To prevent, detect, and manage those factors that adversely affect the health of the mother and baby. To provide advice, reassurance, education, and support for the woman and her family. To deal with the minor ailments of pregnancy. To provide general health screening. The main aim of antenatal care is to have a healthy mother and a healthy baby at the end of the pregnancy. Antenatal care thus becomes risk assessment - trying to identify from the patient's history and from examination whether there are any factors which may have an adverse effect on the patient or her fetus during the pregnancy and the correction of these problems, Pattern of antenatal care

Advice, Reassurance & Education Reassurance & explanation on pregnancy symptoms: Nausea Heartburn Constipation Shortness Of Breath Dizziness Swelling Back-ache Abdominal Discomfort Headaches Mostly these represent the physiological adaptation of her body to the pregnancy and are often called the ‘minor complaints’ of pregnancy

Information regarding smoking, alcohol consumption and the use of drug during pregnancy (both legal and illegal) is extremely important. Woman also need advice on work, exercise, sexual intercourse and maternity benefit. Parentcraft is the term used to describe formal group education of issue relating to pregnancy, labour and delivery and care of the newborn. The aim of this is to lessen anxiety and increase the sense of maternal control surrounding delivery.

Working during pregnancy The majority of women can be reassured that it is safe to continue working during pregnancy. A woman’s occupation during pregnancy should be ascertained to identify those at increased risk through occupational exposure. D GPP

Folic acid Dietary supplementation with folic acid, before conception and up to 12 weeks’ gestation, reduces the risk of having a baby with neural tube defects (anencephaly & spina bifida). The recommended dose is 400 micrograms per day. A

Few medicines have been established as safe to use in pregnancy. Prescribed medicines Few medicines have been established as safe to use in pregnancy. D

Prescription medicines should be used as little as possible during pregnancy and should be limited to circumstances where the benefit outweighs the risk. D

Smoking in pregnancy There are specific risks of smoking during pregnancy (such as the risk of having a baby with low birth weight and preterm). The benefits of quitting at any stage should be emphasized. Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking. A B

The booking visit The first risk assessment is usually made at the booking visit. Before risk assessment begins, the pregnancy should be confirmed and the expected date of delivery (EDD) should be calculated.

Confirmation of pregnancy Symptoms of pregnancy combined with a positive urinary or serum pregnancy test is sufficient confirmation of pregnancy. In many regions, all pregnant women are referred for US ‘dating scan’ which both confirm the pregnancy and accurately dates it. It may be possible to hear the fetal heart with the Doppler US from approximately 12 weeks onwards.

Dating of pregnancy Menstrual EDD Naegele´ s rule; EDD calculated by adding 7 days to the first day of the LMP and tacking away 3 months. This assume that: The cycle length is 28 days. Ovulation occurs generally on the 14th day of the cycle. The cycle was a normal cycle (i.e. not straight after stopping the oral contraceptive pill or soon after a previous pregnancy) If the cycle length is longer than 28 days, add the difference between the cycle length and 28, to compensate.

Dating by ultrasound Dating by an ultrasound scan in the first or early second trimester is more accurate, especially if there is menstrual irregularity or uncertainity regarding the LMP Before 15-16 weeks variation is little and the measurement of the crown-rump length CRL, biparietal diameter (BPD) and femur length (FL) is used for estimation of the gestational age. If the EDD predicted by the dating scan differ by more than 7 days from the menstrual EDD, the scan dating is usually chosen as the final EDD. After 20 weeks there is significant variation in fetal size, so dating pregnancy by ultrasound scan becomes less accurate

Ultrasonic estimation of EDC 1st trimester: - The best & most accurate. - Measure crown-rump (CRL ± 5 days).

BPD AC FL 2nd trimester: - (BPD, HC, AC, FL ± 10 days). 3rd trimester: - Much less accurate. BPD AC FL

Gestational age assessment: LMP and ultrasound Pregnant women should be offered an early ultrasound scan to determine gestational age and to detect multiple pregnancies. A

Ideally, scans should be performed between 10 and 13 weeks and crown–rump length measurement used to determine gestational age. GPP

Benefits of a dating scan: Accurate dating in women with irregular menstrual cycles or poor recollection of LMP Reduced incidence of induction of labour for prolonged pregnancy Maximizing the potential for serum screening to detect fetal abnormalities Early detection of multiple pregnancy Detection of asymptomatic failed intrauterine pregnancy

Booking History Past Medial History Past Obstetric History Previous Gynaecological History Family History Social History

Past medical history Taking a detailed history about any previous medical illness is important as: The disease and its treatment may adversely affect the growth of the fetus There may be an associated increased risk of placental dysfunction Pregnancy may cause improvement or deterioration in the medical illness

Major pre-existing diseases that impact on pregnancy: Diabetes mellitus Hypertension Renal disease Epilepsy Venous thromboembolic disease Human immunodeficiency virus (HIV) infection Connective tissue disease

Past obstetrical history 1. Details of previous pregnancy complications. The features that are likely to have impact on future pregnancies include: recurrent miscarriage (increased risk of miscarriage, intrauterine growth restriction (IUGR)), preterm delivery (increased risk of preterm delivery), early onset pre-eclampsia (increased risk of pre-eclampsia/ IUGR), abruption (increased risk of recurrence), congenital abnormality (recurrence risk depends on type of abnormality), macrosomic baby (may be related to gestational diabetes), IUGR (increased recurrence), Unexplained stillbirth (increased risk of gestational diabetes) 2. Details of previous labours and deliveries

Previous gynecological history: Previous history of infertility or recurrent abortion Previous history of cone biopsy as it may cause cervical incompetence or stenosis Previous history of myomectomy as it increase risk of uterine rupture during labour

Family history: Important areas are a maternal history of a first degree relative (sibling or parent) with: diabetes (increased risk of gestational diabetes), thromboembolic disease (increased risk of thrombophilia, thrombosis), preeclampsia (increased risk of preeclampsia), psychotic psychiatric disorder ( increased risk of puerperal psychosis). For both parents, it is important to know about any family history of baby with congenital abnormality and any potential genetic problems, such as haemoglobinopathies.

Social history: Smoking and drug abuse Social deprivation Domestic violence

The booking examination Historically, a full physical examination (CVS, RS, abdominal, pelvic and breast examination) was carried out at the booking visit. The value of this has been questioned, as the detection of significant pathology in the absence of focal symptoms is uncommon. For most healthy women without complicating medical problems, the booking examination will include the following:

Accurate measurement of blood pressure. Abdominal examination for the size of the uterus. Recognition of previous abdominal scars. Measurement of height, weight and estimation of BMI. Urine examination to look for asymptomatic bacteriuria Measure the blood pressure with the woman seated or semi- recumbent. Do not lie her in the left lateral position, as this will lead to under reading of Bp. Use an appropriately sized cuff. Convention is to use Korotokoff V (i.e. disappearance of sounds), as this is more reproducible than Korotkoff IV. Deflate the cuff slowly.

Booking investigation Full blood count; this Screens for anaemia and thrombocytopenia. Anaemia in pregnancy is most frequently caused by iron deficiency, however, other causes must be considered, especially if the Hb level is <9.0g/dl. Blood group and red cell antibodies,

Hepatitis B; vertical transmission to the fetus may occur, mainly during labour. human immunodeficiency virus syphilis haemoglobin studies; test for haemoglobinopathies for women with family history of it gestational diabetes; screening for gestational diabetes in those with risk factors at 28 weeks gestation

Screening for fetal abnormalities It is a routine aspect of antenatal care, offered to all pregnant women at 11 and 22 weeks gestation and includes: nuchal translucency scanning (11-13 weeks), or serum screening (15-19 weeks) for down's syndrome maternal serum alpha-fetoprotein (15-19 weeks) for neural tube defects detailed or anomaly ultrasound scan (19-22 weeks), for structural congenital abnormalities

Follow-up visits For those with normal pregnancy and normal past obstetrical history should have: 4 weekly appointment from 20 - 32 weeks Fortnight visits from 32 - 36 weeks Weekly visit from 36 weeks and on The minimum number of visits recommended by the royal college of obstetricians and gynecologist is 5, occurring at 12, 20, 28-32, 36, 40-41 weeks For high risk pregnancy more frequent visits

Contents of follow up visit In every visit the following should be carried out: Asking about maternal well being Fetal movements Measurement of blood pressure Urinanalysis for infection, protein, blood, and glucose Examination of oedema especially the face and hands Abdominal palpation for fundal height (symphysis fundal height assessment) Fetal heart auscultation

The following are carried out in addition to the above: Full blood count and red cell antibody screen → 28 and 36 weeks Gestational diabetes screening → 28 weeks The lie and presentation of the fetus → 36 weeks Iron supplementation to prevent iron deficiency anaemia Prophylactic anti-D for Rh negative women at 28 and 34 weeks

Pre-conceptual counselling Pre-conceptual counselling is helpful in a wide variety of circumstances. There is potential for general advice, an opportunity to plan care in those with background medical disease, a chance to review those with previous obstetric complications and a discussion with those at increased risk of fetal anomaly. In reality, what should ideally be preconceptual counselling is often carried out in the first trimester of the pregnancy.

Medical Chronic maternal disease may have a deleterious effect on fertility that may lessen as the disease process itself improves. Maternal disease can affect the fetus, and the pregnancy itself may affect the disease. E.g. SLE, Diabetes, HIV, Renal disorders, Thromboembolic disease and Thyroid disorders.

It is rare to advise against pregnancy in those with cardiac disease, although those with fixed pulmonary output may be advised that the risks to their own health are too great (e.g. in those with pulmonary hypertension). Those on warfarin for valvular problems or venous thromboembolic disease are at increased risk of teratogenic problems (particularly midfacial hypoplasia). Consideration should be given to timing of pregnancy and whether a change to heparin, at least in very early pregnancy, is appropriate. As anticonvulsants for epilepsy may also be teratogenic, seizure control with a single drug regime is ideal or, if seizure-free for 2-3 years, drug withdrawal may be considered (this may have implications for the patient's work and/or driving licence). Pre-conceptual folate supplements should be given because anticonvulsants lead to a reduction in serum folate.

It is also an opportunity to identify those with abnormal grief reactions who might benefit from further counselling before considering another pregnancy. Pre-eclampsia tends to improve with subsequent pregnancies, with the possible exception of severe pre-term disease. The incidence of proteinuric pre-eclampsia in a second pregnancy is 10-15 times greater if there was preeclampsia in the first pregnancy compared to those with a normal first pregnancy. It has been suggested that low-dose aspirin taken from early pregnancy (< 17 weeks and probably from the first trimester) may reduce the incidence of IUGR or perinatal mortality in those with previous severe disease. Studies in this area have provided conflicting evidence. Obstetrics

Those who have had a previous difficult instrumental delivery usually have a much more straightforward delivery next time around, but may occasionally request an elective caesarean section. This is controversial, and careful consideration of the advantages and disadvantages is required. In general, those with a previous caesarean section for a non-recurrent indication, e.g. breech, fetal distress or relative cephalopelvic disproportion secondary to fetal malposition, should be offered a trial of labour, but repeat elective caesarean section may be considered in certain circumstances. In situations where there has been previous IUGR or an intrauterine death, subsequent management depends on the cause and the estimated likelihood of recurrence. More intensive antenatal monitoring is usually offered and the outcome is usually good, particularly when the loss was 'unexplained'.

Risk of fetal anomaly Those who have had a previous baby with a fetal anomaly are often anxious to know the risk of this happening again and whether any prenatal testing can be carried out. This discussion has usually taken place after the problem pregnancy, but further discussion is sometimes welcomed. A couple who have had a previous Down's syndrome baby, or fetal loss from Down's syndrome, carry a risk of 0.75% above their baseline age-related risk. Down's, however, may rarely also be inherited from a parental translocation (e.g. 14 : 21) or mosaicism, which increases this recurrence risk significantly. The complexities of these issues often require specialist advice from a clinical geneticist.

This also applies to many other abnormalities, for example congenital heart disease: while in general the recurrence risk of this is ~ 5%, it is dependent on the family history, drug history and whether the anomaly was isolated or part of some other syndrome. Other structural abnormalities, for example Potter's syndrome or diaphragmatic herniae, usually carry a low recurrence risk. There may be a family history of certain conditions, and others have a racial predisposition, e.g. Tay-Sachs disease in Ashkenazi Jews or haemoglobinopathies in those of Mediterranean origin. Invasive fetal testing may be appropriate after parental gene testing if both partners are homozygous for a recessive condition.

Lifestyle education Smoking Alcohol and drug misuse Those whose work environment exposes them to radiation, hazardous gases or specific chemicals should be appropriately counselled. Moderate exercise is likely to be of benefit and should be encouraged, but should probably be avoided if there are complications, e.g. hypertension, multiple pregnancy, cardiorespiratory compromise, antepartum haemorrhage or preterm labour.