Charlotte Porter GP Update NUHSHS, March 2019 Preconception advice Charlotte Porter GP Update NUHSHS, March 2019

Reducing risk in pregnancy Alcohol Smoking Drugs Family/pregnancy spacing Medical/obstetric history Medication

Pre pregnancy: positive interventions Folate * Vitamin d Weight optimisation (pcos, miscarriage, obesity* and stillbirth) Stop smoking Listeria/brucella avoidance Iron supplements Mood assessment/ domestic violence STI/ cervical cytology/ hep b/c FGM

Pre pregnancy planning Epilepsy* Diabetes* Thyroid disease Hypertension Cardiac disease Renal disease Asthma Previous/FH VTE Rheumatological conditions/ connective tissue disorders Inflammatory bowel* Haemaglobinopathy* depression

Other questions? Travel plans (Zika, malaria) Risk of genetic disorder (age, FH, consanguinity) Rubella and chickenpox vaccination Drug use, OTC, prescribed and illegal Work related risk

Obstetric history Nullip? Previous termination of pregnancy Previous miscarriage Previous caesarean section Previous pregnancy complications Reduced maternal and perinatal mortality and morbidity with 18-59 month interpregancy interval

Prescribing in pregnancy- general principles Avoid teratogenesis (1st trimester week 3-11) Avoid fetal effects- eg on growth, brain development, renal function Avoid effects on labour, eg uterine relaxation Avoid effects on neonate (eg respiratory supression) Remember altered physiology, and necessity for altered doses/schedules related to cardiovascular/renal and hepatic changes

Prescribing in pregnancy Less than 10% of commonly prescribed medications have enough known about them to truly determine risk in pregnancy Most women avoid medication Sometimes the risk of stopping medication has to be balanced against the risk to the fetus Treating for two! (or three)

Prescribing in pregnancy But up to 90% of women will use OTC medication during pregnancy, and 70% will have prescribed medication (Am J O&G 2008) There are large gaps in the evidence base BUMPS website UK national teratology database Valproate, retinoids, carbimazole

Effects (K=known, P=potential) Drug Uses Effects (K=known, P=potential) SSRI- paroxetine Depression (up to 25% ,25s) ? Swap to sertraline, liase with mother and baby team Intellectual delay, (P) autism (P) cardiac defects (K, x2 increase- not sertraline), craniosynostosis (K, x3 increase) paracetamol Simple analgesia Use at low dose for short time Asthma (P) Adhd (P) neurofen Avoid if possible Cardiac risks, fetal renal function- avoid after 30w – premature closure of the ductus arteriosus, PPHN, bleeding risk in labour Hepatitis b vaccine Prevention of infection No good evidence for harm acyclovir Hsv, varicella No good evidence of harm azithromicin chlamydia carbamezepine Epilepsy, bipolar disorder Lowers folate levels, assocated with neural tube defects and facial cleft, hypospadias (all K) Neonatal haemorrhage (give additional vit K) Sodium valproate Intellectual impairment (K) clotrimazole candida No good evidence for harm, possible increase in miscarriage risk, but confounding factors fluconazole Candida, use single dose Fallot tetraology, transposition, hypoplastic left heart, increased risk assocated with prolonged use metranidozole Anaerobic infection

Epigenetics? Heritable changes in gene expression (DNA methylation, histone modification) Alteration in phenotype without change in genotype Age of parents Lifestyle Environmental exposure Fertility treatments War babies/ famine in pregnancy increases risk of cvd and schizophrenia in offspring Pollution exposure and asthma

Thank you