Preconception Care:

Providing Fetal/Maternal
Health Risk Assessments
Lecture 4

Preconception Planning
Important because:
Offers best protection against low birth-weight &
other poor pregnancy outcomes.
1989 - federal panel advised women planning to
conceive to visit health care provider at least once before
conception.
Healthy pregnancy closely related to womans health
before conception.
Improves chances for healthy baby.

Preconception counseling:
Assess risks of medical & non-medical factors:
GDM, HTN, heart disease, psychiatric disorders,
domestic abuse, depression, Genetic disorders.
Discuss nutrition, meds, exercise, tobacco,
alcohol, drug use, family support,
unemployment, work-related hazards
Most critical time for fetus is day 17 56 when
organs, limbs, skeletal, CNS forming.
Exposure to environmental risks harmful to
embryo when woman may not realize she is
pregnant.
Pre & Post-Pregnancy Planning

Considerations for Potential Parents:
Financial Responsibility:
Cost of prenatal care, delivery, loss of work (both),
child care (home or day care center), childrearing.
Leaving workforce - does she plan to return ?
Employment benefits -are they adequate to support
maternal/infant pre & post natal care ?
IMPORTANT COMPONENTS OF PRECONCEPTION CARE
See a health care provider. Get physical exam.
Discuss risks. Maintain follow-up care. Update
Immunizations


Prenatal High-Risk Factors

Social/Personal: Low income level, poor diet,
multiparity > 3, weight < 100lb; weight > 200
lb; age <16; age >35; smoking, addictions
Pre-existing medical hx: Diabetes mellitus,
cardiac disease, anemia, hypertension, thyroid
disorder, renal disease.
Obstetric: Previous stillborn, habitual abortion,
cesarean delivery, Rh or blood group
sensitization. [ABO or Rh incomp.]

TORCH special group of infections
Toxoplasmosis, Hepatitis B, Syphilis, Varicella, Rubella,
Rubeola, Cytomegalovirus, Herpes simplex O = other

TORCH applies to pregnant women, unborn child,
newborn, children. Common cause of birth defects.
Can cause stillbirth.

Infection causes few symptoms in pregnant woman.
In infants - serious birth defects result if infections
contracted during pregnancy/delivery.
1
st
trimester more severe defects
Current pregnancy: Check titers: vaccines available but
most not during preg.
Toxoplasmosis rare; toxoplasma gondii [protozoal infec]
transmitted to mom thru raw meat or exposure to
infected cats feces. Severity > in 1st trimes.
Varicella - member of herpesvirus; worse in 1st trimes.
Infant may have life-threatening disease.
Hep.BsAg + Hepatits B in mom; infant gets Hep.B
vaccine & Immunoglobulin @ delivery; followed by 2
more Hep.B vaccines in 1st yr.
Syphilis untreated can cause fetal death. Tx PCN
Repeat VDRL > tx.
Rubella
(1st trimester) 50% rate of malformation.
(2
nd
tri) 6% rate of damage
If non- immune, avoid anyone w. active disease.
NO vaccine while pregnant but immunize > del.
No preg. for 3 mos.
Defects: Hearing loss, Deafness, Blindness, Heart
& Neuro defects, Mental Retardation

Cytomeglovirus part of herpesvirus family.
Defects: Mental retardation, hydrocephaly , microcephaly,
blindness; deafness.
May be picked up during 1
st
year or > 1 yr of age.
If 1st trimes.infection, may consider AB.

HSV 2 [genital ]. Valtrex - suppress lesions; C/S if lesions @
time of del. Blindness, MR, death

Vaccines you can get during pregnancy:
Tetanus & influenza vaccine [flu]
Rubella vaccine: only after delivery
If equivocal [aka borderline] pt. gets vaccine.
MD order, consent signed by pt.
Explain risks of birth defects pregnant within 3
mos.of vaccine. Live virus. SC injection

HIV: test done in NYS to all newborns - Newborn
Screening Test


36% of HIV-infected women using illicit drugs during
pregnancy had no prenatal care.
# of infants with AIDS (d/t perinatal transmission)
declined from 122 in 2000 to 47 in 2004.
(CDC)

CDC, AWHONN, Institute of Medicine & ACOG
support policy of universal HIV testing as routine
component of prenatal care. [2001]
Retest for HIV in 3
rd
trimester (new practice)
Do ELISA (screen) then Western Blot (confirm).
Seroconversion: Usually by 12-22 days after infection.
All by 6 mos.
Offer HIV test @ initial visit. Mom can refuse.
Discuss risk of not taking test .
HIV+ - treat with ZVD (zidovudine) in 2-3rd trimesters.
Transmission ~ 25% without Rx; with tx ~ 8.3 %.
If Rx begun @ del. or only to newborn, rate = 15%.
Treat in antepartum, intrapartum & infant x 6 weeks.
Monotherapy (ZVD) for viral load < 1,000.
New (2003): 3 drug tx reduces rate to 1-2 %. Start in
2
nd
trimester. For viral load > 1,000.
Woman must deal with guilt, depression, stigma.
Common Discomforts of Pregnancy

1
st
Trimester

Nausea & vomiting
Causes: hormonal, fatigue, changes in carb
metabolism
Interventions: sm. freq. meals; eat slow; dry
toast ; deep breaths.
Ends by 2
nd
trim; if severe, hospitalize &
hydrate

Nasal Stuffiness:
Causes: edema of nasal mucosa d/t ^ estrogen levels

Interventions: saline drops; humidifier.
Pseudafed 2
nd
/ 3rd trimester.


Breast Enlargement & Tenderness [cold weather]
Causes: ^ estrogen & progesterone levels

Interventions: Support bra with wide shoulder straps;
jacket/sweater.
Urinary Frequency & Urgency
Causes: pressure of uterus on bladder; lasts 3 mos. &
disappears; reappears in late preg. when head is
engaged. + blood/burning on urination - signs of UTI.
Interventions: UA & urine Cx & Tx with AB.
Reduce caffeine. Do Kegels. Plan frequent BR stops.

Increased vaginal discharge: leukorrhea
Causes: ^ estrogen & ^ blood supply to vagina;
hyperplasia of vag.mucosa.
Interventions: daily bath; sanitary pads OK but no
tampons, tight pants or underwear > infection.
Pruritis/erythema - poss. fungal infection.
Common Discomforts Of 2nd & 3rd Trimesters


Heartburn
Causes: Relaxation of cardiac sphinter, GI
mobility; progesterone & gastric displacement.
Food backs up from stomach into esophagus,
irritates lining; burning.
Interventions: Small, freq. meals; chew slowly;
avoid extra weight gain, avoid tight fitting clothes,
avoid fried & fatty foods; sleep with HOB ^;
Take antacid if all else fails.


Hemorrhoids [varicosities rectal veins]
Causes: Pressure on pelvic veins; in ^ 3rd trimes
Interventions: modified Sims position; stool softeners;
witch hazel/cold compresses.


Constipation
Causes: oral iron supplements; peristalsis;
displacement of bowels by fetus.
Interventions: No mineral oil; interferes with vitamin
metabolism. ^ po fluids; ^ roughage; attempt regular
BMs.

Backache: *R/O UTI 1st
Causes: Posture changes during preg.d/t ^
uterine enlargement
Interventions: Low heels; walk with pelvis
tilted forward; squat when lifting; dont bend.
Firm mattress; heat therapy; Tylenol.

Leg Cramps
Causes:Pressure from enlarging uterus, poor
circulation; fatigue, Ca & Phosphorus
Interventions: dorsiflex affected foot; elevate
legs.
Aluminum hydroxide [Amphogel] binds
phosphorus & reduces it in circulation.


Shortness of Breath : Dyspnea
Causes: pressure of uterus on diaphragm &
compression of lungs; more @ night when flat.
Interventions: 2-3 pillows @ night; sitting upright.


Ankle Edema
Causes: fluid retention & poor venous return from
lower extremities; aggravated by prolonged sitting or
standing & warm weather. Occurs near term.
Interventions: ^ legs, avoid tight fitting pants
CONTROLLABLE RISK FACTORS

Nutrition: Know ideal weight for your height. Instruct
client to keep food diary. Examine food choices in daily
diet.
If underweight/overweight before conception, counsel about
proper nutrition.
Calcium/zinc - beneficial for long-term health needs &
growth/development of baby.
Folic acid: protects against neural tube defects aka spina bifida.


GOOD SOURCES:
Folic acid: broccoli, collard greens, dried peas,
beans, citrus fruits and juices.
Zinc: whole grains, oats, wheat, barley, peas, beans.
Calcium: milk, yogurt, cheese, tofu, sardines with
bones, soy milk, OJ, legumes.
US Public Health Service & March of Dimes recommends all
women of childbearing age - 0.4 mg [400mcg] of folic acid
daily - reduce risk of neural tube defects. No more than 1 mg.
Supplement Folic Acid intake if you are:
Of child bearing age
Planning pregnancy
800-1000 mcg daily during pregnancy
PNV contain all requirements needed for pregnancy
including folic acid & iron.


Nutrition

RDA: add 300 kcal in 2
nd
& 3
rd
trimester.
Total Calories = 2500kcal/day (pregnant); 2200 non-
pregnant
Underweight clients >300 kcal. increase. (~ 2800
kcal/day)
RDA for protein/minerals/vitamins: ^ 60 g./day
Daily iron requirement doubles in preg. (15 to 30 mg)
Minerals (Ca, phos, iodine, Fe, Z) from fruits/veg.
Calcium/phosphorous stays same if client follows daily
recommended intake; * teens < 19 need 1300mg./day.
Vegetarianism
Vegen diet no food from animal sources (eggs,
fish, chicken) most challenging for health care
providers.
Adequate pure vegan diet: nuts, grains,
vegetables, fruits, legumes, rice, soy milk.
May be anemic & not get enough calories.
FISH: up to 12 oz/wk of low mercury fish. Canned
light tuna, shrimp, salmon, catfish is ok.
No swordfish, shark, tilefish, king mackerel (high
mercury)


Lactose intolerance or cultural avoidance can lead
to lowered calcium intake; recommend yogurt, cheese,
sardines, beans, collard greens, figs, OJ, tofu, Lactaid.
(commercial lactose).
* Few demands placed on maternal nutrition in 1
st

trimester.
RDA fluids = 6-8 glasses (1500-2000 ml); water, milk,
juices.
> 200mg caffeine daily doubles risk for miscarriage
1 cup ~ 100 mg ~ 250ml

Weight Gain (new slide)
Women of Normal weight: 25 - 35 lbs. (11.5 - 16 kg)

Underweight women: 28 - 40 lbs. (12.6 - 18 kg)

Overweight women: 15 - 25 lbs. (7 - 11.5 kg)

Twins or Multifetus: woman should gain 4 to 6
lbs. in 1st trimester, 1.5 pounds per week in 2nd
and 3rd trimester, for total of 35 to 45 lbs.
PICA: eating non-food substances (dirt, clay, laundry
starch, paint chips) or foods of low nutritional value (ice,
cornstarch)
In US, most common in African Americans, women
from rural areas, or women with family hx pica.
Interferes with normal consumption of nutrients;
causes anemia in mom. Possible lead poisoning.
In depth diet analysis nutrition counseling
RN discusses cravings. 24 hr. diet re-call.
Follow up done @ prenatal visits.
Folic Acid for ^ RBC production. 50% more in
pregnancy (800 ug/day); enriched grain products.
Controllable Risk Factors: Drug, Alcohol,
Tobacco Use

Alcohol:. Avoid all alcohol during time
attempting conception/pregnancy.
No known safe level during pregnancy. Associated
with malformation, slow fetal growth, fetal death, low
birth-weight, CNS abnormalities, neurologicaldefects,
spontaneous abortion, abruption.

Tobacco: Associated with spontaneous abortion,
ectopic pregnancy; low birth-weight, infant mortality.
Can potentially decrease fertility. Vasoconstriction
restricts blood flow to fetus & reduces % of oxygen
& nutrients carried by blood.


Illicit or Street Drugs: May be associated with
severe medical & developmental problems in
newborns.

1. Marijuana, most common - tend to have babies
earlier & may be smaller than term babies.
2. Cocaine: associated with miscarriage, abruption, low
birth-weight, premature birth, brain damage.
3. Heroin - IV drug users - evaluate for AIDS & Hep
B. In HIV + women, studies show treatment with
AZT reduces ransmission to baby from ~ 25% to
8%.

Exercise in Moderation

Boosts self-image, reduces tension, decreases
physical discomfort.
Get medical clearance before starting exercise
program.
Dont exercise in hot/humid weather or to point of
exhaustion.
Avoid exercise with risk of traumatic injury:
downhill skiing, horseback riding, water skiing,
tennis, etc.
Recommended: walking, cycling on stationary bike,
swimming




Avoid High Internal Body Temp

During early pregnancy, can interfere with
normal embryonic development.

Study published August 1992: use of hot tubs
& saunas found to raise body temperature to
102F if women stayed in tubs for up to 15
minutes. ^ risk of neural tube defects in
offspring.

Stress Management Techniques
Relaxation & deep breathing. Planning
pregnancy can be stressful.
Stress reduction enhances chances of
conception.
Excessive stress can lead to premature birth & low
birth weight. Sleep 8-10 hr.with frequent rest periods a
day.



Common STDs & effects to baby if untreated:

Chlamydia: Ear/eye infections, pneumonia.
Genital Herpes: Active infection - baby born thru
vaginal opening with open sores leads to severe skin
infections, nervous system damage, blindness, mental
retardation, death can occur.
Genital Warts: (If infection is active during delivery):
Warts can grow in voice box & block windpipe.
Gonorrhea: Eye Infections, blindness.
Syphilis: Damage to bone, lung, liver, blood vessels
Other Infections that can cause PTL: UTI & BV


Exposure to Contraceptives
Controversial adverse effects on fetus. Do not use.

Prescription and Over-the-Counter Drugs
Often unsafe during pregnancy: Accutane (acne) birth defects.
Avoid drugs used for headaches/common colds.

Environmental Reproductive Hazards
Avoid unnecessary environmental risks at home/work.
Paint Thinners, Varnish Removers, Cleaning Solvents, Glue
X-rays, Radioactive materials, Cat litter (toxoplasmosis)
Leave job with questionable hazards.
Use protective equipment/safety protocols.


FDA Pregnancy Risk
Category for Drugs
Category A: no risk to fetus in any trimester
Category B: no adverse effects in animals; no
human studies available
Category C: Only prescribed after risks to fetus are
considered. Animal studies have shown adverse
reaction; no human studies available
Category D: Definite fetal risks, may be given in
spite of risks in life-threatening situations
Category X: Absolute fetal abnormalities. Do not
use anytime in pregnancy (Lithium, Accutane)
Male Role in Preparing for Pregnancy
Male planning to become father should:
Review family medical & genetic hx
Practice STD risk-reduction behaviors.
Avoid tobacco, alcohol, illicit/street drugs,
chemical exposure.
Assess financial status.
Be supportive of partner.
Play active role in pre-pregnancy planning.

Age is a Big Factor

Teenagers and Women over 40 years - greatest
risk.
Women over 40 years
Have decreased fertility.
Have increased risk for Downs Syndrome
& hypertension.
Should talk with health care provider about
Prenatal testing.
Healthy pregnant women > 40 yrs who follow
recommended practices have about same
chances as younger women for healthy
pregnancy outcome.






TEENS: more likely [than women in 20s] to have
labor, delivery & low-birth-weight problems.

Almost half of all pregnant teens do not get prenatal
care in 1st trimester of pregnancy.

Teens less likely to gain appropriate weight & often
practice unhealthy eating habits.