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

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

3. 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

4. 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

5. 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

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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. Thank you