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Pre Pregnancy Care (PPC)

What is Pre-Pregnancy Care?

Pre-Pregnancy Care (PPC) is a set of healthcare and interventions given to women in their reproductive age before conception occur. Centre for Disease Control and Prevention in 2006 defined Pre Pregnancy Care as A set of intervention that aim to identify and modify biomedical, behavioural and social risks to a woman’s health or pregnancy outcome through prevention and management, emphasizing those factors that must be acted on before conception or early in pregnancy to have maximal impact (CDC 2006)’

Women in their reproductive age with medical problems should receive pre-pregnancy care in order to achieve optimization of the health risk before conception at least 3 months prior to conception. Pre-pregnancy care should also encompasses women at high risk of getting overt medical condition example obesity and anaemia.

What are medical conditions or medical risk factors indicated for pre-pregnancy care?

Examples of medical conditions and medical risk factors that need optimization before conception taking place are :

  • Diabetes Mellitus
  • Hypertension
  • Cardiovascular disease
  • Congenital Heart Disease
  • Thyroid disease
  • Obesity
  • Connective tissue disease
  • SLE
  • Chronic Kidney Disease
  • Anaemia
  • Substance Abuse
  • Genetic conditions example thalassemia
  • History of giving birth to an abnormal baby (congenital anomalies)

Women with any medical risk factors or medical conditions should be offered pre-pregnancy care even before conception is planned and the service should be provided by the nearest health clinic or hospital.

What’s the importance of pre-pregnancy care?

Medical conditions or risk factors are capable of determining the outcome of the pregnancy. It can affect maternal and foetal outcome. The negative effect can occur as early as the first 4 weeks of pregnancy. Subsequently the adverse effect can alter the normal process of organogenesis during the first trimester of conception for as long as the condition is not optimized.

For example, hyperglycaemia leads to disturbances to the normal organogenesis of the growing foetus (Keirse; JPOG 2010). Optimization of blood glucose level minimizes or abolishes the adverse effects of hyperglycemia on the growing foetus.

Pre-pregnancy counseling, aimed at protecting the fetus during embryogenesis, may indeed be the most effective strategy available for promoting a safe environment for the developing foetus4

What is the objective of pre-pregnancy care?

The objectives of pre-pregnancy care are to deliver pre-conception services to women and their partners as follows :

  1. To achieve a conducive physical and mental condition prior to pregnancy so that the foetus develops in an optimized environment to promote normal and healthy growth.
  2. To screen the woman for any medical conditions or risk factors and initiate intervention.
  3. To manage medical conditions and achieve optimization according to the recommended guidelines (WHO).
  4. To promote women and their partner to plan their pregnancy by means of counselling, health promotion and education.
  5. To promote healthy life changes in order to achieve positive maternal and foetal outcome.

Woman with medical condition that is planning a pregnancy must receive appropriate medical care from the pre-pregnancy care services and plan the timing of conception. Example of optimizations are to achieve diabetes control of HbA1c below 6.5%1, blood pressure control of below 140/902 and haemoglobin level of below 11 g/dl (WHO).

Standards of care for optimization are recommendations provided by the clinical up-to-date practice guidelines endorsed by Ministry of Health Malaysia. Recommended therapy includes treatment for specific medical conditions (example diabetes and hypertension) and hormone replacement therapy (example hypothyroidism).

What are the benefits gained from pre-pregnancy care?

The most important benefits gained from pre pregnancy care are the reduction of complications during pregnancy resulting to positive outcome3. Complications can be divided into maternal and foetal complications.

Examples of foetal complications :

  • Miscarriages
  • Pre-term delivery
  • Congenital anomalies mainly congenital heart disease
  • Intra Uterine Growth Retardation and Low Birth Weight (birth weight less than 2.5 kg)
  • Macrosomia (birth weight more than 4.0 kg)
  • Intra Uterine Death

Examples of maternal complications :

  • Uncontrolled High Blood Pressure that could lead to eclampsia and stroke
  • Kidney impairment or kidney failure
  • Heart failure
  • Obstructed labour
  • Prolonged labour
  • Haemorrhage
  • Obesity
  • Unstable thyroid function
  • Smoking and substance abuse
  • Symptomatic anaemia or anaemia needing transfusion

Medical conditions must be treated intensively and aggressively before pregnancy is planned by giving individualized therapy. Once optimization achieved, the woman is allowed to conceive. The process of optimization may take more than 3 months and meanwhile the woman must be put on effective family planning measures.

Husband or partner must be empowered on the benefit of pre-pregnancy care in order to give maximum support to the woman. Their role in supporting the woman is essential in order to enhance outcome. Financial and psychosocial support are the 2 main components vital to the success of the pre-pregnancy care and pregnancy outcome.

Components of pre-pregnancy care

  • Screening for medical conditions and medical risk factors
  • Management and optimization of medical conditions and risk factors
  • Nutrition and Supplementations
  • Family Planning

What are the supplements encouraged?

Apart from specified medical therapies, nutrition and supplementation is another component of pre pregnancy care essentials to promote healthy pregnancy. Proper nutrition and supplementations help to provide vital minerals and vitamins that are needed to enhance normal organogenesis and brain development.

Nutrient or supplements in this context of discussion are mainly folic acid, calcium and iron supplements. Folic acid prevents from neural tube defects (abnormal development of spinal cord)3. Calcium helps to reduce eclampsia (severe hypertension leading to seizures and cerebral haemorrhage or infarction)3. Iron supplement reduce the incidence of anaemia3.

Screening and optimizations of medical conditions have been mentioned earlier. However family planning component will be discussed in another topic.

Who should receive pre-pregnancy care?

In general and ideally all women in their reproductive age whom plan to conceive should receive pre-pregnancy care. However, a certain group of woman are highly recommended for pre-pregnancy care are :

  • Woman confirmed with medical conditions
  • Woman with familial genetic conditions
  • Woman with congenital anomalies
  • Woman who has a child with genetic condition
  • Woman who has a child with congenital anomalies

Pre-pregnancy care starts as early as 6 weeks post-partum especially in very high-risk woman. Every woman attending the health clinic or hospital should be given pre-pregnancy care services regardless of the reason for the clinic visit.

Opportunistic screening identifies risk factors and referral to the doctor if needed. If pre-pregnancy care indicated the woman will be registered and regular pre-pregnancy care follow-up will ensue. Every woman must be made aware of the importance of pre-pregnancy care before conception to prevent complications.

Who are responsible in providing pre-pregnancy care services?

All medical and health personnel from health clinics and hospitals are responsible in providing the service. A dedicated pre pregnancy care team focuses on the care and long term planning. Networking between health clinics and hospitals is essential in providing holistic and comprehensive care. Private medical centres and general practitioner clinics must also provide pre pregnancy care services for women who seek private medical care.

Health care professionals must be trained on the pre pregnancy care protocol provided by Ministry of Health Malaysia3. The training is comprehensive and holistic thus ensuring professionalism and empowerment. Confidence and skills will develop as they get involved in direct patients care.

Paramedics are involved in screening and initial counselling3. Medical officers and specialists are involved in more specialized care4. Health clinics provides pre-pregnancy care services to most women. However complicated medical conditions with co-morbidities requiring subspecialist care will be referred to the respective hospitals.

Where do pre-pregnancy care services provided?

Currently all government health premises (health clinics and hospitals) provide the service. Pre-pregnancy care services at health clinics are led by Family Medicine Specialists and Obstetrics & Gynaecologist lead the services at hospital level. A woman need to approach the medical staff to enquire on the service availability and its procedures.

It is the aspiration of Ministry of Health Malaysia in making sure the program is successful and all women are given the opportunity to optimize health issues prior to conception in order to form a healthy nation in the future.

References

  1. Clinical Practice Guidelines on Management Type 2 Diabetes Mellitus 2009
  2. Clinical Practice Guidelines on Hypertension 3rd edition 2010
  3. Perinatal Care Manual KKM section 1 2010
  4. Jack, B.W., and Culpepper, L. Preconception care: Risk reduction and health promotion in preparation for pregnancy. JAMA,1990

 

Last Reviewed : 14 April 2015
Writer/Translator : Dr. Sri Wahyu bt. Taher
Accreditor : Dr. Fuziah bt. Paimin