PRECONCEPTIONAL COUNSELING A NEED OF THE HOUR IN INDIA

1. PRECONCEPTIONAL COUNSELING
A NEED OF THE HOUR IN INDIA
…Caring hearts, healing hands
Dr. Sharda Jain
Dr. Jyoti Agarwal

2. Health Indicators
• Maternal Mortality (MMR)
2011 – 2013 167 / 1 lac births
Kerala 61 / 1 lac births
Assam / UP 300 / 1 lac births
• Infant Mortality (IMR)
40 / 1000 live births
Significant Improvement in MMR / IMR

3. Preconception counseling Importance

4. Definitions
• Pre-conception counseling (pre-conceptual counseling) is a
meeting with a health-care professional (generally a physician or
midwife) by a woman before attempting to become pregnant
Should start 6 months before getting pregnant
• Perinatal care : occurring during or pertaining to the phase
surrounding the time of birth, from the twentieth week of
gestation to the twenty-eighth day of newborn life
• Prenatal care - Is the care a women gets during pregnancy
beginning in the first trimester
Oxford Dictionary

5. Difference
Preconception care
During planning phase
Prenatal care
Is pregnancy related
care beginning in
the first trimester

7. What is Preconception counseling ???
Pre - Conception care is 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
Centre for Disease Control (CDC) and
Prevention 2006

8. Preconception Counseling Involve

9. Components of PCC
• Risk Assessment
• Health promotion
• Interventions
CDC, 2007

10. Preconception care
‘an integral part of primary care for women of
reproductive age’
• While preconception counseling is routine in
western countries, they are still in infancy
stage in India
• Indian women usually visit their doctors only
when they are already pregnant ignoring the
basic concept of pre-conception care

11. Planned babies are more healthy than
unplanned babies
• Globally 38% pregnancies unplanned & unintended
• In India the number crosses over 50%
• For this reason all women of childbearing age
should be offered preconception care & counseling
“Planned” pregnancies are seldom
planned with a health care provider

12. Global View

13. ACOG 1995: First technical
bulletin on Preconception Care

14. Aboubakr Elnashar

15. Has a positive impact on
maternal & child health

16. Importance
Adverse pregnancy outcomes remain a
prevalent health problem
• 12-15% of babies are born premature
• 25 -30 % are low birth weight
• 3% have major birth defects
• 31% of women suffer pregnancy
complications

17. Importance

18. Early ANC is too late to
Prevent Birth Defects

19. 4 Goals as endorsed by CDC
• Goal should be realistic
• Identify pre-existing
conditions that may
affect an anticipated
pregnancy
• Interventions that could
lead to more favorable
outcome

20. Goal no 1
Improve Knowledge ,
Attitude & Behavior of both
men & women related to
preconception health

21. Goal no 2
Assure all women of
childbearing age receive
evidence based risk screening &
interventions so as to enable
them to enter pregnancy in
optimal health

22. Goal no 3
Reduce risks indicated by a previous
adverse pregnancy outcome through
interventions during interconception
period so as to prevent or minimise
problems both for mother & her
future children

23. Goal no 4
Reduce disparities in adverse
pregnancy outcome

24. All this is to ensure
that the woman is
as healthy as
possible before
conception to
promote her
health and the
health of her baby

25. Target of preconception care
Preconception care
should be provided
to all reproductive
age individuals

26. Preconception health assessment ‘Tools’

27. Medical Record #:
Patient name:
Preconception Health Screening/Counseling
Date
Done
Pending Action Comments/Provider’s Initials
Family Planning
Pregnancy planning and spacing
Pregnancy prevention
Social History
Social support (safety, resources)
Alcohol use
Tobacco use
Illicit drug use
Exercise
Teratogen exposure (e.g. lead,
chemicals at work)
Nutrition History
Special diet
Eating disorder
Adequate vitamin/mineral intake (e.g.
Ca, folate)
Medical History
Diabetes
Thyroid disease
Asthma
Cardiovascular Disease
Hypertension
Deep Venous Thrombosis
Kidney Disease
Autoimmune Disease
Neurologic Disease
Hemoglobinopathy
Other medical or surgical problems
Infectious Disease History
STD’s including HIV
Hepatitis B (immunize if at high risk)
Rubella (test, if nonimmune,
immunize)
Toxoplasmosis
Medications
Over the counter medications
Prescription medications
Reproductive History
Uterine abnormalities
2 or more first trimester SAb’s
One or more 2nd trimester losses
Any fetal deaths
Preterm deliveries
Any infants admitted to NICU
Family History
Birth defects
Hemoglobinopathies
Mental retardation
Cystic fibrosis
Tay-Sachs disease
Consanguinous marriage
Bernstein, Merkatz
J Repro Med, 2000

28. Nutritional considerations
Weight < 85% or > 135% of the ideal for height

29. Preconception Folate Supplementation
• Folate metabolism impacts embryogenesis
• Neural tube , heart , orofacial tissue are folate
sensitive regions
• Neural tube closes around 28 days post conception
• Folic acid supplements reduces neural tube defects
by nearly 75 %
Nutritional sources often inadequate

30. Preconception health assessment
“Folic acid”

31. Each year more than 4000 pregnancies are
complicated by NTDs
“All women of childbearing
age who are capable of
becoming pregnant should
consume 0.4 mg of folic
acid per day 6 wks prior for
the purpose of reducing
their risk of spina bifida or
other neural tube defects ”
US Public Health Service (USPHS) Recommendation

32. In high risk women folate
supplementation
• Women taking folic acid
antagonists
• Herself had or a family h/o of
neural tube defect
• Insulin dependent DM
• Epilepsy
• Obesity (BMI > 35 kg/m2 )
5 mg / day
to be started
3 months
before
conception and
continued until
12 weeks post
conception

33. What We Know: Obesity
• 26% of women 20 to 39 years of age are
overweight (BMI 25 - 29.9 )
• 29% are obese (BMI 30 or more )
• These women are at risk of diabetes,
hypertension, preeclampsia,eclampsia
macrosomia, shoulder dystocia, operative
delivery, congenital anomalies, spontaneous
abortion & stillbirth

34. What can we do about it?
Fat is not inert
Weight loss
programs

35. Bariatric Surgery
• 20,000 bariatric surgeries in 2016
• 50 % were performed in women of
reproductive age
• Advised to prevent pregnancy for 12 to 18
months after surgery
• Oral contraceptives may be less effective
after malabsorptive bariatric surgery

36. Bariatric Surgery
• There is little evidence-based data to guide
preconception care of women who have had
bariatric surgery
• These patients are at risk of nutrient
deficiencies, including vitamins A, D, E, K, C,
B1, B6, B12; folic acid; and iron
Appropriate Nutritional Suplementation

37. It’s not healthy to be seriously
underweight either
• Women who are too thin (BMI <
18.5) are at risk of becoming
anemic , experiencing fertility
problems, giving birth to a low
birth weight baby & preterm
delivery
• Neonates born to these mothers
are at higher risk of gastroschisis
• Women with low BMI should be
assessed and counseled for eating
disorders

38. Preferred Medications For Chronic
Diseases And Those To Avoid
During Pregnancy

39. Acne
Isotretinoin
should be
avoided
Isotretinoin is
associated with
miscarriage and
birth defects

40. Asthma (6%)
• Preconception care
should focus on
identifying & reducing
exposure to allergens
• Patients should be
counseled to quit
smoking and secondhand
smoke exposure
• Oral corticosteroids are
associated with low birth
weight, increased risk of
oral cleft, and higher
rates of preeclampsia
Inhaled corticosteroids and beta
agonists are preferred

41. Diabetes Mellitus
• Affects nearly 10% of women of reproductive age
• Glucose is teratogenic at high levels
• Good glycemic control during organogenesis
reduces rates of congenital malformations
Good glycaemic control Assessment of comorbidities
Discontinue unsafe Rx Stop Smoking

43. Achieve HbA1c close to normal
7 % or Lower

44. Diabetes Mellitus
• Most oral
antidiabetic agents
should be
discontinued and
insulin started
• Metformin may be
continued in the
preconception
period
• ACE inhibitors
• ARBs
• Statins
should be avoided
as they are
associated with fetal
renal anomalies and
fetal death

45. First treat retinopathy
Conceive only when it
is stabilized
Retinopathy Present
Patient Counselling
For Risk Of Worsening
DETAILED OCULAR ASSESSMENT
OCULAR CARE

46. Satisfactory
BP Control
<130/80 mm Hg
Preconceptional
Uncontrolled HTN
Management of
Hypertension (3-5%)
↑ chances of Adverse
outcomes
Treating Severe Hypertension Improves
Pregnancy Outcomes
With long-standing hypertension always assess for
retinopathy, renal disease, and ventricular hypertrophy

47. SAFER ALTERNATIVES :
1. Methyldopa
2. Labetalol
3. Diltiazem
4. Clonidine
5. Prazosin
ACE Inhibitors or
Angiotensin-
receptor blockers
Management of
Hypertension
A Cochrane review of antihypertensive
treatment in pregnancy
Atenolol is associated with lower birth weight

48. Women with systemic
lupus erythematosis (SLE)
should conceive when in
remission

49. Thyroid disease can significantly
impact pregnancy outcome
• Both hypothyroidism & hyperthyroidism can
result in significant maternal and neonatal
morbidity
• Guidelines recommend achieving euthyroidism before
pregnancy
• TSH should be kept at 2.5 in women who want to
become pregnant
During pregnancy, thyroid replacement dosages
need to be increased by 30% or more

50. Hyperthyroidism
• Propylthiouracil is
preferred in the first
trimester
• Methimazole is
preferred in the
second and third
trimesters
• Methimazole
teratogenic in the
first trimester
• Propylthiouracil can
cause hepatotoxicity
in subsequent
trimesters

51. SEIZURE DISORDERS
• Both the disease and its treatment can
adversely affect pregnancy in the form of
miscarriage, low birth weight, developmental
disabilities, microcephaly, neural tube defects
and hemorrhagic disease of the newborn
• One-third of women with a seizure
disorder will experience more frequent
seizures in pregnancy

52. Majority Of Antiepileptic Drugs Are
Teratogenic
Sodium valproate
• NTD’S
• Cleft palate
• Hypospadius
• Autism
• Learning & memory
disabilities
Phenobarbital & phenytoin
Cardiac malformation
Phenytoin & carbamazipine
Cleft palate
Lamotrigine & carbamazepine monotherapy have the
least risk of major malformations in the foetus

53. Rate of congenital anomalies depends o
Type,Number & Dose of antiepileptic drug
• Risk of congenital malformations is highest
with sodium valproate & is 10 % as
compared to a women who is not taking any
drug
• Risk increases to 16 % if there is a previous
child with major congenital malformation
• Risk also increases to 16 % with polytherapy

54. Dictum for Epileptic Women
• Women should be seizures free for atleast 1
year , preferably 2 years
• Monotherapy should be used when possible
at the lowest effective dosage
• Should take high dose of folic acid (5 mg /
day) starting 3 months prior to pregnancy &
to be continued in the first trimester
Lamotrigine - not more than 300 mgm/day
Carbamazepine - not more than 400 mgm/day

55. Irreversible worsening
Renal dysfunction ↑ Risk of adverse Maternal
& Fetal outcomes
Mild Preconceptional
Renal dysfunction
Mod-Severe
Preconceptional
Renal dysfunction
Reversible worsening
Chronic Kidney Disease

56. Medical Review of CKD- A New Insight
Key drugs are
• Angiotensin
converting enzyme
(ACE) inhibitors
• Angiotensin II receptor
blockers
Thumb rule
Associated with growth
restriction, oligo-
hydramnios, renal
dysplasia , fetal renal
failure , death
ACE Inhibitors
Angiotensin-
receptor blockers

57. • Dyslipidaemia seldom poses threat during pregnancy
• Unproven safety of statins, fibrates and niacin during
pregnancy
Management of
Dyslipidemia
Do not use Statins , Fibrates or Niacin
Bile acid-binding resins may be
used to treat hypercholesterolemia

58. Women with Cardiac Disease
• In India 90 to 95% have Rheumatic heart
disease
• They have to be assessed well before they
are given GO HEAD signal
• Should be advised to have delivery in
tertiary care hospital

59. Vaccination against Rubella, Hepatitis
B virus ,Varicella,Tdap,HPV ,Influenza
• Routine testing for rubella IgG antibodies &
Hepatitis B prior to planning pregnancy is
recommended
• All susceptible patients should be immunized
and advised against attempting pregnancy for
subsequent one month

60. HIV
Helps couple make informed
reproductive decisions

61. If the man is HIV positive ……
The risk of transmission to the female partner is
negligible if
• The man is compliant with highly active
antiretroviral therapy
• Plasma viral load is less than 50 copies / ml
for more than 6 months
Unprotected intercourse at the time of ovulation
Sperm washing does not further reduce the risk
of infection

62. If the man is HIV positive …….
But not compliant
offer sperm washing

63. Insufficient evidence to
recommend that HIV negative
women needs pre – exposure
prophylaxsis …….
Hence NOT
recommended

64. Genetic Screening
Screen & counsel based
• Family history
• Ethnic background
• Age
- Thalassemia
- Sickle cell disease
- Haemophilia
- Cystic fibrosis

65. Screening for inborn errors
of metabolism
Phenylketonuria
Diet low in
phenylalaline prevents
babies from being born
with PKU-related
mental retardation

66. Alcohol ,Tobacco, Substance Use
Leading preventable cause of low birth
weight & mental retardation
No threshold has been identified for “safe”
use in pregnancy

67. Physical , Emotional Domestic abuse and
violence in Pregnancy
Two million women each year are abused by her
partner
29% of abused women report escalation of abuse
during pregnancy
Screen for
• Depression, anxiety,
• Domestic violence
• Major psychosocial stress

68. Should be screened for inherited & acquired
Thrombophilia's & anti-phospholipid antibody
syndrome
Parental karyotyping
balanced translocation is
performed if karyotype of
POC is abnormal
Recurrent Miscarriage
bad obstetric history

69. What about Preconception counseling for men !!!
Men as Partners in Reproductive Health

70. Why Preconception care for
men is important ???
• Preparing men for
fatherhood
• Improve pregnancy outcome
& family planning
• Offer an opportunity for
disease prevention and
health promotion in men

71. To conclude …..
• PCC is a part of preventive medicine
• PCC ensures that a woman enters
pregnancy with an optimal state of health
which would be safe both for mother and
baby
• It includes risk assessment and education
• Needs to be proactive
It is hoped it becomes done thing in
INDIA too

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