Ideally care of a pregnant woman should start many months before conceiving.

This means that you have to let your doctor know that you are planning to conceive. Many developed countries provide pre-pregnancy services in the form of clinics.

Why is it important to attend pre-pregnancy clinic or meet a doctor for pre-pregnancy advice?

The aim is to ensure that prospective parents are counseled about a woman being in a good state of health which will in turn ensure a well-grown healthy baby.

The most crucial time in the development of the fetus(Baby in the womb) is the first 8 weeks of pregnancy. During this time many pregnant women are not even aware that they are pregnant (after conception it can take anywhere between 2 to 5 weeks for the woman to realize that she has missed her period).

It is during the first four weeks that organogenesis (Formation of the various organs such as the heart, brain etc) takes place.It is important to realize that by the end of the eighth week of gestation(Pregnancy) most anomalies (Abnormalities in the baby) that are going to affect the fetus and newborn are already present.

Therefore it is the responsibility of the governments and health care workers (Nurses, Doctors, Midwives etc) to embark on a well planned health education campaign on the importance of pre-pregnancy counseling.Health education on pre-pregnancy counseling can be done via posters, printed media, health talk and can be introduced to secondary school curriculum.

Areas covered under pre-pregnancy counseling include:

1)Diet

A woman who is planning to conceive should have optimal nutritional status.

Some women may have deficiencies of vitamins, minerals and proteins calorie-malnutrition which has to be corrected in the pre-pregnancy clinic.Both obesity and malnutrition can have detrimental effects on pregnancy,therefore the bodyweight should be kept at average for height during the pre-pregnancy period.

Another important reason why women should have adequate nutrition in the pre-pregnancy state is the appearance of nausea and vomiting in the first three months( First trimester of pregnancy). This is also known as morning sickness and it can further deteriorate her nutritional status. Blood tests should be done during this period and treatment should be started if it is less than 12g/dl.

2)Folic Acid Supplementation

It is a well established fact that folic acid can prevent neural tube defects. All women should have folate rich foods and 0.4mg of folic acid daily( eg Preconceive).If there is a previous history of deliver of a baby with neural tube defects or if the pregnant woman is on anti-epileptic drugs she should take 5mg of folic acid per day.

There has been recent reports that folic acid supplementation can cause certain types of cancers. Please note that this risk is very small and can be reduced further if it is taken only up to 13 weeks of pregnancy.Patients who are at higher risk are those who already have a personal history  or family history of gastrointestinal tract malignancies such as colon cancer etc.The risk of the baby having neural tube defects can be almost eliminated by taking folate supplements.

The neural plate of the developing embryo closes to form the neural tube 24 to 48 days after conception. Incomplete closure in this process can cause Neural Tube Defects (eg Spina Bifida, Anencephaly).

The following are folate rich foods, but please bear in mind that taking folate rich foods alone is not enough to prevent neural tube defects. eg: Brussels sprouts,aspragus, spinach, blackeye beans, fortified break-fast cereals.

3)Medical Problems

Women who are diabetic must have their diabetes under best possible control before she enbarks on a pregnancy.

This is due to the fact that women who are diabetic have a much higher chance of having abnormal babies( Teratogenic effect).

It is also very important that women who are on oral hypoglycemic drugs (Oral drugs used in controlling diabetes) should change over to insulin before the pregnancy so that exposure of the fetus to these drugs within the first few weeks can be avoided.

All women who have a family history of diabetes mellitus and women who had gestational diabetes in a previous pregnancy should have her fasting blood sugar level checked.

Women who are already on drugs for other medical disorders such as epilepsy, hypertension, chronic asthma etc, should change over th the least teratogenic drugs.

4 Genetic Counseling

This is the provision of information to those at risk of having abnormal conception.

This is also the right time to screen women for thalassaemia and sickel cell disease in certain ethnic groups such as Asians and Blacks.

The patient can also be adviced to meet the clinical genetist if they had a previous history of a loss of baby due to congenital abnormality.

In women who are planning to have children after the age of 35years, the increased risk of having Down’s syndrome should be discussed.The risk of Down’s syndrome at the age of 35 years is about 1 in 350, at 40 years 1 in 100 and at the age of 45 years 1 in 30.The chance of recurrence of Down’s syndrome in a woman with a previous baby affected with downs is about 1.5%.

5)Vaccination

This is the ideal time to ensure that a pregnant woman is immune to Rubella and Chicken Pox prior to pregnancy.

The relationship between maternal rubella with congenital rubella syndrome is now well established. The risk to the fetus depends on the period of gestation at the time of infection . The greatest risk is in the first twelve weeks of pregnancy,where congenital rubella syndrome occurs in about 80% of the cases of maternal rubella and severe congenital abnormalities such as cardiac, cataract, deafness and cerebral palsy occur in upto 80% of those infected. The incidence of fetal infection decreases gradually thereafter.

Congenital rubella syndrome can be eradicated if protective levels of rubella antibodies are maintained among women of reproductive age.

Those with suceptible immunity levels and women who are non-immune should be vaccinated promptly. Since the vaccine used is a live vaccine, the patient should be properly adviced to refrain from getting pregnant for three months after vaccination and a proper contraceptive advice should be given.

6)Risk of radiation exposure

Any investigation requiring exposure to radiation in women of reproductive age should be done during the first half of the menstrual cycle to ensure that the woman is not pregnant at the time of the investigation.Common investigations which involves radiation include intra-venous urography or Ba enema.

Advice on contraception is very important till her medical problems are sorted out.

7)Cigarette Smoking

It is very important to ask for a history of smoking from a pregnant woman and her partner. Smoking can effect the pregnant woman , her partner. and even the unborn child.In men smoking can result in abnormal sperm production and reduction in sperm penetrating capacity.

Children born to smokers have shown reduced learning ability.

In pregnant women smoking is associated with a two fold increased rate of miscarriages, preterm labour and small for gestational age babies(Mean is 3376g in Non-smoker, Smoker: 3200g)

Both the pregnant lady and her partner should be encouraged to quit smoking.

However only 17% of smoking mothers stop before or during pregnancy, this should not discourage you to stop advising them to quit smoking.

8)Alcohol Consumption

Alcohol consumption is also associated with an increased risk of miscarriages.High levels of consumption can cause the fetal alcohol syndrome.Although mild to moderate alcohol consumption has not shown to adversely affect the fetus, alcohol should still be avoided because it does cross the placenta and reach the fetal blood where it can affect the development of the fetal brain.

Pre-Conception counseling becomes extremely important in the following groups of women:

If you had any of the following please make sure that you see a doctor several months before conceiving.

1)Previous history of abnormal baby.

2)Women with a family history of genetically transmitted diseases.

3)Women who are on regular medication for medical problems.

4)Women who marry late(Greater than 30 years).

5)History of previous still birth, miscarriage or neonatal death.

6) Pre existing medical condition such as diabetes mellitus, epilepsy and heart disease.

References

1) Essential Antenatal Care-A Guide for the Trainee-Deepal S. Weerasekera

2) Oxford Handbook of Clinical Specialties Judith Collier, Murray Longmore, Peter Scally- 6th Edition

3) Medical Disorders in Pregnancy- An Update-2006, Federation of Obstetric and Gynaecological Societies of India

No related posts.

 

You are welcome to discuss this post/related topics with Dr Shihaan and other experts from around the World in our Pregnancy, Gynaecology and Baby health Forums (www.askdrshihaan.org/forums/).