PRECONCEPTIONAL CARE Chapter 8

TOPICS
DEFINITION

CDC 2015 : “a set of interventions that aim to identify and modify biomedical,
behavioral, and social risks to a woman’s health or pregnancy outcome through
prevention and management”
COUNSELING SESSION
Gynecologists, internists, family practitioners, and pediatricians have the best
opportunity to provide preventive counseling during periodic health maintenance
examinations.

The occasion of a negative pregnancy test is also an excellent time

for education.
MEDICAL HISTORY - DM
Diabetes Mellitus
Komplikasi akibat DM dapat dihindari apabila kadar glukoksa dapat dikontrol
sebelum konsepsi.
Pada populasi ini juga banyak pengguna ACE inhibitors yang teratogenik
ACOG (2016)  preconceptional counseling untuk wanita pregestational DM
beneficial and cost effective dan should be encourage
Beberapa penelitian disebutin tapi intinya, komplikasi akkibat gula darah tidak
terkontrol lebih tinggi, nah kalo dialkukan preconceptional counseling bagus tu
glikemik kontrolnya, selain itu juga di kelommpok itu intake folat meningkat, dan lower
adverse outcome. Nah tapi dari 300 yg diabetic woman cuma setengah yang
preconcceptional counseling.
MEDICAL HISTORY - EPILEPSY
Compared with unaffected women, those with a seizure disorder carry an undisputed
augmented risk of having neonates with structural anomalies
Although more recent publications have largely failed to confirm this increased risk in
untreated women, it is difficult to refute entirely because women who are controlled
without medication generally have less severe disease (Cassina,2013; Vajda, 2015).
Treatment goals attempt to achieve seizure control with monotherapy and with
medications considered less teratogenic (Aguglia, 2009; Tomson, 2009).
Epileptic women should be advised to daily take a 4-mg folic acid supplement.
Even so, it is not entirely clear that folate supplementation reduces the fetal
malformation risk in pregnant women taking anticonvulsant therapy.
MEDICAL HISTORY - EPILEPSY
The American Academy of Neurology recommends consideration of antiseizure
medication discontinuation before pregnancy in suitable candidates (Jeha, 2005).
These include women who satisfy the following criteria:
(1) have been seizure-free for 2 to 5 years,
(2) display a single seizure type,
(3) have a normal neurological examination and normal intelligence, and
(4) show electroencephalogram results that have normalized with treatment.
MEDICAL HISTORY - IMMUNIZATIONS
Vaccines that contain toxoids such as tetanus are suitable before or during gestation.
Also, those containing killed bacteria or viruses—such as influenza, pneumococcus, hepatitis B,
Meningococcus, and rabies vaccines—are not associated with adverse fetal outcomes and are
not contraindicated preconceptionally or during pregnancy.
Conversely, live-virus vaccines are not recommended during pregnancy. Examples are vaccines
against varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow fever.
Moreover, 1 month or longer should ideally pass between vaccination and conception attempts.
That said, inadvertent administration of measles, mumps, rubella (MMR) or varicella vaccines
during pregnancy should not generally be considered indications for pregnancy termination.
Lost reports indicate that the fetal risk is only theoretical.
GENETIC DISEASES
Family History
Neural Tube Defect
 0,9 per 1000 live births
 Some NTDs, as well as congenital heart defects, are associated with specific
mutations. One example is the 677C → T substitution in the gene that encodes
methylene tetrahydrofolate reductase.
 Research Group (1991) showed that preconceptional folic acid therapy significantly
reduced the risk for a recurrent NTD by 72 percent.
 It is currently recommended, therefore, that all women who may become pregnant
take daily 400 to 800 μg of folic acid orally before conception and through the first
trimester (U.S Preventive Services Task Force, 2009).
GENETIC DISEASE
Phenylketonuria
Specifically, mothers with phenylketonuria (PKU) who eat an unrestricted diet have abnormally
high blood phenylalanine levels. This amino acid readily crosses the placenta and can damage
developing fetal organs, especially neural and cardiac tissues
Therefore, the phenylalanine concentration is ideally normalized 3 months before conception
and then maintained throughout pregnancy (American College of Obstetricians and
Gynecologists, 2017b). The target phenylalanine blood concentration is 120 to 360 μmol/L
(Camp, 2014).
Thalassemias
Intinya screening sebelum konsepsi, ada juga preimplantasi genetic diagnosis, biasanya
barengan dengan assisted reproductive technology
Individuals of Eastern European Jewish Descent
REPRODUCTIVE HISTORY
Miscarriage, ectopic pregnancy, and recurrent pregnancy loss; and obstetrical
complications such as cesarean delivery, preeclampsia, placental abruption, and
preterm delivery
Identification of a genetic abnormality in a stillborn can help determine the
recurrence risk and aid in the preconceptional or prenatal management in subsequent
pregnancies.
PARENTAL AGE
Maternal age
20-35 tahun the best
Asissted Reproductive Technologies
ART  kembar  komplikasi2 preterm, plasenta previa, abruption, preekklamsi,
major kongenital
Paternal Age
Finally, the incidence of genetic diseases in offspring caused by new autosomal-
dominant mutations in older men is increased. Still, the incidence is low
SOCIAL HISTORY
Recreational Drugs and Smoking
Environmental Exposures
excess exposure to methyl mercury or lead is associated with neurodevelopmental disorders.
Diet
Pica, Anorexia, Bulimia, Obesity  preeclampsia, gestational diabetes, labor abnormalities,
cesarean delivery, and operative complications
Exercise
woman is advised not to exercise to exhaustion, and she should augment heat dissipation and
fluid replacement. Further avoidances include prolonged supine position, activities requiring
good balance, and extreme weather conditions.
Intimate Partner Violence
PRENATAL CARE Chapter 9
CONTENT
PRENATAL CARE
Prenatal care undoubtedly contributed to the dramatic decline in this mortality rate
from 690 deaths per 100,000 births in 1920 to 50 per 100,000 by 1955 (Loudon,
1992).

In a study of almost 29 million births, the risk for preterm birth, stillbirth, early and
late neonatal death, and infant death rose linearly with decreasing prenatal care
(Partridge, 2012)
DIAGNOSIS OF PREGNANCY
Symptoms and Signs
 Amenorrhea;
 Fetal movements between 16 and 18 weeks’ gestation (Paritas >1; G1 = 20 weeks)

Pregnancy Tests
 Syncytiotrophoblast produces hCG in amounts that increase exponentially during the first trimester following
implantation. A main function of hCG is to prevent involution of the corpus luteum, which is the principal site of
progesterone formation during the first 6 weeks of pregnancy
 False-positive hCG test results are rare, (Elevated hCG levels may also reflect molar pregnancy and its
associated, exogenous hCG injection used for weight loss, (2) renal failure with impaired hCG clearance, (3)
physiological pituitary hCG, and (4) hCG-producing tumors that most commonly originate from gastrointestinal
sites, ovary, bladder, or lung cancers
 A gestational sac - transvaginal sonography by 4 to 5 weeks’ gestation
DIAGNOSIS OF PREGNANCY
Symptoms and Signs
 Amenorrhea;
 Fetal movements between 16 and 18 weeks’ gestation (Paritas >1; G1 = 20 weeks)

Pregnancy Tests
 Syncytiotrophoblast produces hCG in amounts that increase exponentially during the first trimester following
implantation. A main function of hCG is to prevent involution of the corpus luteum, which is the principal site of
progesterone formation during the first 6 weeks of pregnancy
 False-positive hCG test results are rare, (Elevated hCG levels may also reflect molar pregnancy and its
associated, exogenous hCG injection used for weight loss, (2) renal failure with impaired hCG clearance, (3)
physiological pituitary hCG, and (4) hCG-producing tumors that most commonly originate from gastrointestinal
sites, ovary, bladder, or lung cancers
 A gestational sac - transvaginal sonography by 4 to 5 weeks’ gestation
INITIAL PRENATAL EVALUATION
Prenatal care is ideally initiated early. Major
goals are to:
 (1) define the health status of the mother and fetus,
 (2) estimate the gestational age, and
 (3) initiate a plan for continued obstetrical care.
DEFINITION
1. Nulligravida—a woman who currently is not pregnant and has never been pregnant.
2. Gravida—a woman who currently is pregnant or has been in the past, irrespective of the pregnancy outcome. With the
establishment of the first pregnancy, she becomes a primigravida, and with successive pregnancies, a multigravida.
3. Nullipara—a woman who has never completed a pregnancy beyond 20 weeks’ gestation. She may not have been pregnant or may
have had a spontaneous or elective abortion(s) or an ectopic pregnancy.
4. Primipara—a woman who has been delivered only once of a fetus or fetuses born alive or dead with an estimated length of
gestation of 20 or more weeks. In the past, a 500-g birthweight threshold was used to define parity. This threshold is now controversial
because many states still use this weight to differentiate a stillborn fetus from an abortus (Chap. 1, p. 3). However, the -survival of
neonates with birthweights <500 g is no longer uncommon.
5. Multipara—a woman who has completed two or more pregnancies to 20 weeks’ gestation or more. Parity is determined by the
number of pregnancies reaching 20 weeks. It is not increased to a higher number if multiples are delivered in a given pregnancy.
Moreover, stillbirth does not lower this number. In some locales, the obstetrical history is summarized by a series of digits connected by
dashes. These refer to the number of term infants, preterm infants, abortuses younger than 20 weeks, and children currently alive. For
example, a woman who is para 2–1–0–3 has had two term deliveries, one preterm delivery, no abortuses, and has three living
children. Because these are nonconventional, it is helpful topecify the outcome of any pregnancy that did not end normally.
Trimester  14 minggu
 1  0-14
 214-28
 329-42
SUBSEQUENT PRENATAL VISIT
Sebulan 1x  sampai 28 weeks; 2 weeks  36 minggu; 1 minggu 1x pas aterm
Fundal Height  symphysis pubis  fundus, bladder must be emptied
Fetal Heart Sounds  10 minggu dengan USG, 20 minggu stetoskop
USG fetal anatomy, growth, and well-being
NUTRITIONAL COUNSELING

Weight gain
NUTRITIONAL COUNSELING
NUTRITIONAL COUNSELING
The Institute of Medicine (2006) recommends adding 0, 340, and 452 kcal/d to the estimated
nonpregnant energy requirements in the first, second, and third trimesters, respectively.
protein intake that approximates 1 g/kg/d is recommended
at least 27 mg of elemental iron be supplemented daily to pregnant women.
The pregnant woman may benefit from 60 to 100 mg of elemental iron per day if she is
large, has a multifetal gestation, begins supplementation late in pregnancy, takes iron
irregularly, or has a somewhat depressed hemoglobin level.
Perhaps more than half of all neural-tube defects can be prevented with daily intake of 400
μg of folic acid throughout the periconceptional period.
A woman with a prior child with a neural-tube defect can reduce the 2- to 5-percent
recurrence risk by more than 70 percent with a daily 4-mg folic acid supplement taken during
the month before conception and during the first trimester.
COMMON CONCERNS
Employment
 With physically demanding work, women had 20- to 60- percent higher rates of preterm birth, fetal-
growth restriction, or gestational hypertension.
 Occupational fatigue—estimated by the number of hours standing, intensity of physical and mental
demands, and environmental stressors—was associated with an increased risk of preterm premature
membrane rupture.

Exercise
 Pregnant women do not need to limit exercise
 placental size and birthweight were significantly greater in women who exercised
 regular, moderate-intensity physical activity for at least 150 minutes each week.
COMMON CONCERNS
Employment
 With physically demanding work, women had 20- to 60- percent higher rates of preterm birth, fetal-
growth restriction, or gestational hypertension.
 Occupational fatigue—estimated by the number of hours standing, intensity of physical and mental
demands, and environmental stressors—was associated with an increased risk of preterm premature
membrane rupture.

Exercise
 Pregnant women do not need to limit exercise
 placental size and birthweight were significantly greater in women who exercised
 regular, moderate-intensity physical activity for at least 150 minutes each week.
COMMON CONCERNS
Seafood Consumption
 If the mercury content of locally caught fish is unknown, then overall fish consumption should be limited to 6
ounces per week

Automobile and Air travel

 In general, air travel in a properly pressurized aircraft has no harmful effect on pregnancy (Aerospace
Medical Association, 2003). Thus, in the absence of obstetrical or medical complications, the American
Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2016a, 2017) have
concluded that pregnant women can safely fly up to 36 weeks’ gestation.
Coitus
 In healthy pregnant women, sexual intercourse usually is not harmful.
 Oral-vaginal intercourse is occasionally hazardous

Dental Care
 pregnancy is not a contraindication to dental treatment including dental radiographs
COMMON CONCERNS
Caffeine  kontroversi >500 mg caffeine (5 cups) slightly raises the
miscarriage risk ; rekomendasi <300 mg / d
Pica
Headache or Backache  acetaminophen
Varicosities and Hemorrhoids
Sleeping and Fatigue