Preconception health assessment

1. Preconception health assessment Mrs. Mahida Samaha Alkony RN, RM, APN

2. Aims of preconception care: • Increase the health of the prospective parents. • Ensuring they are at the peak of their health potential at the point where conception occurs and throughout the period of organogenesis • Enhancing health of the developing baby.

3. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG)have classified the main components of preconception care into four categories of interventions: physical assessment, risk screening, vaccinations, and counseling. Eight areas of risk screening are 1) reproductive awareness; 2) environmental toxins and teratogens; 3) nutrition and folic acid; 4) genetics; 5) substance use, including tobacco and alcohol; 6) medical conditions and medications; 7) infectious diseases and vaccination; and 8) psychosocial concerns (e.g., depression or violence) (3,24,26--31,33).

4. Taking a Preconception history: • Detailed history must be obtained • The interview should be in an environment where the client feels at ease and confidentiality and privacy. • Time appointment should be available • All tests are explained in details • At some point each parent should be interviewed separately

5. Preconception care assessment Both the woman and her partner should be involved t discussion to provide the following information: • Health status, i.e. Rubella immunity, hepatitis B status, body mass index. • Sexual history, i.e. contraceptives, sexually transmitted disease or infertility • Family history to include genetic history, even if sperm or egg donors are used • Medical/surgical history

6. Preconception care assessment 5. Psychological history 6. Substance use, i.e. drugs, smoking, alcohol 7.history of infections 8. Obstetric and gynecological history 9. Contact with environmental hazards 10. nutritional history 11.Occupational history

7. Preconception care focuses mainly on the woman's health, but there are changes that the man can make as well. For example, men are advised to cut down on the amount of alcohol that they drink, and to avoid smoking. • This is because drinking and smoking have been shown to decrease the quality of a man’s sperm, which could reduce the chances of their partner conceiving.

8. Controlling pre-existing conditions • Another important part of preconception care is to ensure that any chronic (long-term) health problems that you have are controlled as effectively as possible before you become pregnant.

9. Areas of risk screening • 1) reproductive awareness; • 2) environmental toxins and teratogens; • 3) nutrition and folic acid; • 4) genetics; • 5) substance use, including tobacco and alcohol; • 6) medical conditions and medications; • 7) infectious diseases and vaccination; • 8) psychosocial concerns (e.g., depression or violence)

10. Risk factors for adverse pregnancy outcomes • Anti-epileptic drugs. Certain anti-epileptic drugs are known teratogens (e.g., valproic acid). Recommendations suggest that before conception, women who are on a regimen of these drugs should be prescribed a lower dosage of these drugs

11. Diabetes (preconception). The increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes • Folic acid deficiency. Daily use of vitamin supplements containing folic acid has been demonstrated to reduce the occurrence of neural tube defects by two thirds

12. Hepatitis B. Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus (HBV) infection. Preventing HBV infection in women of childbearing age prevents transmission of infection to infants and eliminates risk to the woman of HBV infection and sequelae, including hepatic failure, liver carcinoma, cirrhosis, and death • Hypothyroidism. The dosages of Levothyroxine® required for treatment of hypothyroidism increase during early pregnancy. Levothyroxine® dosage needs to be adjusted for proper neurologic development of the fetus

13. Maternal phenylketonurea (PKU). Women diagnosed with PKU as infants have an increased risk for delivering neonates/infants with mental retardation. However, this adverse outcome can be prevented when mothers adhere to a low phenylalanine diet before conception and continue it throughout their pregnancy • Obesity. Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Weight loss before pregnancy reduces these risks • Appropriate weight loss and nutritional intake before pregnancy reduces these risks.

14. Oral anticoagulant.Warfarin, which is used for the control of blood clotting, has been demonstrated to be a teratogen. To avoid exposure to warfarin during early pregnancy, medications can be changed to a nonteratogenic anticoagulant before the onset of pregnancy • STD. Chlamydia trachomatis and Neisseriagonorrhoeae have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STDs during pregnancy might result in fetal death or substantial physical and developmental disabilities, including mental retardation and blindness Early screening and treatment prevents these adverse outcomes.

15. Screening tests: *Physical examination to identify any medical or surgical conditions requiring referral to members of the multiprofessional team * Blood pressure measurement * Cardiac function * Thyroid function * Respiratory function * Review of gastrointestinal activity * Weight

16. Screening tests: * Sexual health status, i.e. vaginal, urethral or anal swabs * Cervical smear * Serum screening: - For haemoglobinopathies • Full blood count - Rubella status - Tuberculosis status

17. Screening tests: * Assessment of vitamin, zinc and lead levels * Hair analysis: - Nutritional state - Exposure to toxic metals * Urinalysis for protein, ketones, glucose and bacteriuria

18. Providing information to prospective parents: Results of screening tests should be given to clients as the information becomes available, taking care not to overload the couple with details. Verbal information is supported by documents, information via the Internet and referral to others in the multiprofessional team

19. NUTRITION • The aim is to ensure that women have a healthy body weight, sensible eating habits and suitable nutritional stores at the point of conception • Women with conditions that require specific diets or nutritional requirements should be referred or advised to seek specialist advice from their nutritionalist or dietician

20. Factors influencing diet: • Morning sickness • Hyper emesis • Pica (food cravings) • Dislike of certain foods

21. INFECTION Rubella virus: • Avoid contact with infected persons for 7 days before and 5 days after rash appears • Ask the Gp to check in immunity status and vaccinate prior to conception • Avoid pregnancy for 3 months following vaccination • Higher fetus risk in the first trimester • advise mothers on vaccinating children

22. INFECTION Toxoplasmosis • Caused by the parasite Toxopksma gondii • If tested prior to pregnancy and shown to carry the infection, then women are not at risk during pregnancy. • No risk to healthy women unless they have a compromised immune system • Advise on methods to minimize chance of infection • Wear gloves when dealing with cat Litter boxes • Wash hands thoroughly following gardening or contact with soil. • Ensure meat is thoroughly cooked • Raw or cured meat should be avoided • Wash hands after handling meat or fruit and vegetables (because of soil contamination)

23. INFECTION HIV/AIDS: • Continued unprotected sex results in an increased viral load • Sperm washing and artificial insemination is available but not on the NHS. • This is a safer option for conception although it has a relativity low success rate • If HIV infection is identified before conception, timely antiretroviral treatment can be administered, and women (or couples) can be given additional information that can help prevent mother-to-child transmission

24. Chicken pox virus (varicella zoster): • The majority of mothers have had chickenpox develop lifelong immunity which protects their baby during pregnancy. • Test for VZ antibody; if not present can receive varicella zoster immune globulin. • 1 in 3 women suffer spontaneous abortion following infection • Avoid pregnancy for 3 months following vaccination • At-risk groups include school teacher, child Care workers and nursery nurses. • Avoid infected individuals. If in contact and not immune. • Advise to use contraception until end of incubation period.

25. ENVIRONMENT AND LIFESTYLE Employment: • Advice varies with type of employment • Review employment details to protect from occupational hazards • Refer to health and safety representative at work for further information. Access standards or policies at work for information on Preconception and pregnancy-related issues

26. ENVIRONMENT AND LIFESTYLE: Employment: • Should avoid jobs which involve: • Vibrating machines • Toxic substances • Excessive cold or heat • Heavy lifting • Long traveling times! • Advise to discuss any concerns with employer • Remember to enquire about partner's employment

27. ENVIRONMENT AND LIFESTYLE Stress: • Avoidance of severe stress during the period of organogenesis • Reduce stress by listening and advising • Refer to psychologist, GP or other relevant organizations, such as employer's occupational hearth department

28. ENVIRONMENT AND LIFESTYLE Exercise: • Do not take up new exercise when pregnant; take it up before pregnancy and maintain • Avoid contact sports such as kickboxing • Marathon running can increase the core temperature and increase spontaneous abortions! • Physical work increases the blood flow to the legs reducing blood flow to the uterus! • Avoid hot saunas, steam rooms that increase core body temperature and are incompatible with conception anti carcinogenesis! • Discuss with fitness instructor

29. ENVIRONMENT AND LIFESTYLE Smoking: • Reduces sperm count in men • Both partners' should stop smoking 4 months prior to conception as cigarettes produce carbon monoxide and nicotine, reducing the oxygen supply to the fetus and causing vasoconstriction of spiral arterioles in the placenta. • Support women and their partners to cease smoking. • Refer to support groups. • Advise to keep away from smoky atmospheres

30. ENVIRONMENT AND LIFESTYLE Alcohol: • Alcohol readily crosses the placenta, only being metabolized by the fetus once Liver enzymes mature in the second half of pregnancy and thus is toxic in early pregnancy. • Decreases sperm count, impairs motility of sperm and causes sperm malformations. • A direct testicular toxin resulting in poor sperm production, abnormal sperm cells and sterility and impotence. • Abstain from consumption of alcohol for at Least 4 months prior to conception.

31. ENVIRONMENT AND LIFESTYLE Alternative Therapies • Therapies that include administration of herbals require careful monitoring of type and quantity. Treatment should be prescribed by a registered therapist, and therefore care should be taken when self-prescribing and administering. • Depends on the therapy, so need to consider each on individual basis

32. ENVIRONMENT AND LIFESTYLE Violence against women: • Advise women on support services • Refer parents to support organizations.

33. ENVIRONMENT AND LIFESTYLE Pets: • Special precautions should be taken when handling pets, their feeding or drinking bowels. • Direct contact is not necessary as cross infection can occur from the handler to another person or through pet equipment such as drinking containers. Toxoptasmosis is transmitted through cat faeces • Salmonella from birds, insects and mammals can result in meningitis or septicemia with death possible • Escherichia coif may result in food poisoning no and fetal death

34. ENVIRONMENT AND LIFESTYLE Hazardous substances: • Recommend organically grown foods • All foods should be thoroughly washed • Farmers should reduce contact with pesticides, insecticides. • Avoid using garden insecticides, and anti-Lice shampoos .

35. REPRUDCTIVE SEXUAL HEALTH • Barrier methods of contraception are recommended during the preparation phase for pregnancy. • These are non-invasive methods that have no direct influence on the body and thus conception. • However preconception care advice should be included in the packaging for distribution to women