RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in irinn

OG 1.3 Preconception and Prenatal Care

Class Senior Cycle 1

Course Obstetrics and Gynaecology
Code SC1 Obs
Title Preconception and Prenatal Care
Date January 2015
KNOWLEDGE AND SKILL OBJECTIVES

To understand the role of general preconception counselling

To ascertain how pregnancy affects certain maternal medical

conditions and to counsel patients accordingly

To become familiar with the different models of prenatal care

available

To understand the indication for standard prenatal laboratory tests

To describe the processes and procedures that constitute a Booking

Visit

To gain insight into the role of patient education in pregnancy

PRACTICAL OBJECTIVES

To attend at least one booking clinic and specialised

antenatal clinic (e.g. Obstetric Diabetes clinic/ Medical
Clinic/ Renal Clinic) plus regular team antenatal clinics

To perform abdominal examination, BP and urinalysis on

patients at the clinics
PRECONCEPTION CARE
Pre-pregnancy counseling; Offered under the following circumstances:

1. General considerations- apply to any woman contemplating

pregnancy
2. Medical disorders- particular medical disorders may influence the
course of pregnancy or pregnancy itself can have a deleterious
effect on the natural history of a medical condition
3. An obstetric complication in a prior pregnancy, or a gynaecologic
condition, may have implications for a future pregnancy. Under
such circumstances, preconception counseling may have a role in
addressing specific issues that need to be considered.
GENERAL PRECONCEPTION
COUNSELLING
Usually takes place at the GP surgery for the majority of
women who have no previous medical problems
Often arises when contraceptive requirements are being
reviewed
Review family history, gynaecological history, medical
history
Clinical examination to exclude cardiovascular,
respiratory, renal, neurological disease
Investigations:
Standard: Cervical Smear if due, Rubella Immunity, Varicella Zoster
Immunity
Targeted: e.g.Thyroid panel if history of thyroid dysfunction or if
clinical indication, Hepatitis screen if at risk (may require
immunization)
GENERAL PRECONCEPTION
COUNSELLING
1. Preconception folic acid 400mcg orally daily for 3 months prior to
conception and continue up until 12 weeks gestation to reduce the
risk of neural tube defects

2. Smoking Cessation: smoking associated with increased risk of low

birth weight and preterm labour. Link the patient in with local
smoking cessation intervention programmes

3. Alcohol: Avoid, especially in 1st trimester

4. Recreational Drug Use: should be avoided in pregnancy

5. Dietary advice with regard to weight reduction and also how to avoid
food- acquired infections such as listeriosis and salmonella in
pregnancy
MEDICAL DISORDERS IN PREGNANCY

Preconception care in this group involves a multidisciplinary

approach involving GP, Hospital Physician and Obstetrician
Each patient should have a specific plan discussed with them for
preconception, pregnancy and postpartum care
It is particularly important to optimize the patients health prior to
pregnancy
Medications should be reviewed to minimize risk if a patient is taking
potentially teratogenic medications (eg warfarin may be substituted
by low-molecular weight heparin, antiepileptic medications may
need to be adjusted to ensure that epilepsy is controlled on the
lowest-dose of the lowest number of therapies)
It is essential to highlight the importance of compliance with
essential medication that may need to be continued and indeed
increased during pregnancy
The impact of pregnancy on the chronic course of a medical
condition should be discussed and also the effect of the medical
disorder on pregnancy
EXAMPLES OF MEDICAL DISORDERS
PARTICULARLY RELEVANT TO PREGNANCY

1. Diabetes
2. Epilepsy
3. Cardiac Disease: pregnancy may be particularly
hazardous in some conditions, eg pulmonary
hypertension (30% maternal mortality)
4. Rheumatology: SLE, rheumatoid arthritis
5. Renal Disease
6. Infections: HIV, Hepatitis
7. Respiratory (e.g. cystic fibrosis)
8. Gastrointestinal: Crohns, Ulcerative Colitis

These will be discussed further in the Medical Disorders

in Pregnancy lecture
PRECONCEPTION CONSULTATION
PROMPTED BY PRIOR OBSTETRIC ISSUE
Women who have had a serious obstetric problem in the
past such as pre-term labour or severe pre-eclampsia
are counseled by their obstetrician on recurrence risk,
likelihood of success in a future pregnancy, possible
impact on maternal health with future pregnancy, and
any therapeutic options available to reduce risk

Women who have had a child with a previous congenital

anomaly or genetic disorder should be referred to a
specialist in fetal medicine or a geneticist for
preconception counselling
PRENATAL CARE

Commonly delivered through a Combined Care system

with GP, Obstetrician, and midwifery care
Care is initiated by GP who confirms the pregnancy and
writes to the hospital to request a registration or booking
appointment at the hospital.
BOOKING VISIT

Ideally in the First Trimester

Involves a discussion with the midwife, followed by
history-taking and examination by the Obstetrician
Obstetrician performs a risk assessment to determine
the degree of pregnancy risk (low- or high-risk)
Taking into account the patients views, a decision is
made on the type of antenatal care appropriate:
Midwifery-led care
Combined care with GP + Hospital
High Risk consultant-led care
Plan for any additional specialist input/ scheduled
consultations that may be required during pregnancy
(see slide 16)
BOOKING VISIT EXAMINATION
Baseline BP/ urinalysis/ BMI (weight and height)

Cardiovascular: exclude underlying cardiac condition (note: flow

murmur associated with hyperdynamic circulation characteristic of
pregnancy is very common)

Breast examination (opportunistic screening for breast disease; may

be appropriate for select women (e.g. positive family history/ older
women))

Abdominal examination is effectively replaced by ultrasound

evaluation of the pregnancy

Pelvic examination/ speculum: only in specific circumstances (e.g.

bleeding)
BOOKING VISIT: LABORATORY TESTS
STANDARD
Full Blood Count: exclude
anaemia. Hb< 11g/dl at first
contact or < 10.5 g/dl at 28weeks
should be investigated and iron
supplementation considered
Blood group and red cell
alloantibody screen:
RhD status clearly documented.
Rubella IgG
Syphilis (VDRL/TPHA)
HIV
Hepatitis B
Varicella Zoster IgG
Screening for fetal aneuploidy
discussed
FOR SELECT PATIENTS
Haemoglobin electrophoresis for
certain ethnicities at risk for
thallassaemia/ sickle cell disease
Hepatitis C
Thyroid panel if personal history/
family history of thyroid
dysfunction
Fetal aneuploidy screening if
patient opts of same
Parvovirus immunity if high risk/
epidemic (e.g. creche worker)
Toxoplasmosis immunity if high
risk
BOOKING VISIT ULTRASOUND

Early Ultrasound examination

at 8-14 weeks
Confirms ongoing intrauterine
pregnancy
Determines gestational age
Detects multiple gestation
18-22 weeks: women usually
scheduled for a detailed
ultrasound to confirm fetal
anatomic normality
SAMPLE SCHEDULE OF PRENATAL VISITS
GESTATIONAL AGE VENUE OBJECTIVE
< 12weeks Hospital Booking visit, confirmation of fetal viability, History,
Risk assessment, Standard panel of Booking bloods
16 weeks GP General well-being
20 weeks Hospital Fetal anatomy scan
24 weeks GP Screen for early-onset PET
28 weeks Hospital Fetal growth assessment, Gestational diabetes
screen if required, Repeat RBC alloantibody screen if
Rh negative and for routine antenatal anti-D
(prevention of Rh sensitization)
30 weeks GP BP/ urinalysis/ general review
32 weeks Hospital Evaluation of interval fetal growth. BP/ urinalysis
34 weeks GP BP/ urinalysis/general review
Alternating weekly from Hospital/ GP BP/ urinalysis/ general review/ fetal size evaluation/
36 weeks fetal presentation and station
41 weeks Hospital Delivery plan
ADDITIONAL CARE REQUIRED DURING
PREGNANCY:
Medical Problems

Cardiac: Cardiology consultation; Depending on severity of cardiac

condition, specialist input may be required throughout pregnancy
Renal: Nephrology consultation; Depending on severity of renal condition,
specialist input may be required throughout pregnancy
Diabetes: Combined care with Endocrinology
HIV: Combined care with Infectious Diseases consultant
Epilepsy: Combined care with Neurology
Psychiatric disorder: Psychiatry consultation; Depending on severity of
psychiatric condition, specialist input may be required throughout pregnancy

Note, for a variety of high-risk issues, prenatal consultation with the

Anaesthesia team is considered, given that options for regional
analgesia/ anaesthesia are sometimes impacted by a medical issue (for
example anticoagulation). Furthermore, the Anaesthesia team is
invariably involved in the care of a critically ill perinatal patient, such that
prenatal consultation and planning of perinatal care can be invaluable.
ADDITIONAL CARE REQUIRED DURING
PREGNANCY:
Problems in previous pregnancy:

Preterm labour
Severe PET/ HELLP
Rhesus Isoimmunisation or other red cell antibodies that may pose a risk for
haemolytic disease of the newborn
Still birth/ Neonatal death
Previous small for gestational age infant (<5th centile)
Previous large for gestational age infant (>95th centile)
Baby with a congenital anomaly/ genetic disorder
Puerperal Psychosis

The above list represents examples of conditions that may be highlighted at

the Booking Visit as requiring a specific surveillance plan to be put in place
ADDITIONAL CARE REQUIRED DURING
PREGNANCY:

Women with complications arising in index pregnancy; e.g:

Multiple gestation
Rhesus Isoimmunisation or other blood group antibodies
Small for gestational age fetus, or ultrasound evidence of
uteroplacental insufficiency
Large for gestational age fetus
Suspected or confirmed fetal congenital anomaly (structural or
chromosomal)
Placenta Praevia
Women who are particularly vulnerable or lack social support

The above represent examples of groups that merit hospital-based

consultant-led prenatal care
SUMMARY
Prenatal care is multidisciplinary
Much effort is directed towards ensuring patients are
educated about pregnancy and care during and after
delivery, and alerted to the symptoms/ concerns that
would require hospital attendance
While risk-assignment/ risk recognition is important at
the first prenatal visit, it is imperative that this exercise is
repeated as pregnancy progresses, as a patients risk
status may require revision.
Healthcare providers should remain alert to signs and
symptoms of common conditions that confer maternal
and fetal risk (e.g. preeclampsia/ diabetes)
Obstetric care providers should equally recognize
circumstances that require input from other specialties.