Need for pre-pregnancy counselling for all women
Pre-pregnancy counselling – Most of the pregnancies are unplanned. Hence some of the complications of pregnancy which occur early enough are difficult to avoid unless a pre-pregnancy health check up and counselling is done. This becomes especially important if you have chronic diseases like diabetes, hypertension, epilepsy, obesity etc. For example in diabetes if you have uncontrolled sugars, the risk for abortions and having a malformed baby is high. This risk can be minimized if the sugars are well controlled when planning for pregnancy.
Is there any ideal time for becoming pregnant?
There is no such ideal time for becoming pregnant. But because of the increased risk for complications after 35 years it is advisable to complete family before 35 years of age. The ideal gap between 2 pregnancies would be 2 years to allow for the complete care of the elder one including lactation and for full recovery of the health of the mother.
What happens during pre-pregnancy counselling?
At the Pre-pregnancy counselling visit, the doctor takes a detailed history and makes necessary examinations. If the lady has not undergone her routine pap smear, then pap smear for cervical cancer screening is also taken at the same visit. Basic blood investigations and any particular test based on the history and examination if required are sent during pre-pregnancy consultation.
Your BMI will be measured and your doubts regarding proper diet and exercise will be addressed during the pre-pregnancy consultation. The diet should be a well balanced one. Preferably home cooked meals are advisable to avoid stomach upsets. Any exercise programme which you have been doing can be continued. This may require slight modification once you are pregnant to avoid strain on the tummy.
The medicine which is usually prescribed is folic acid. This should be started at least 1 month prior to conception. Folic acid deficiency is associated with defects in development of the baby’s spinal cord, increased risk for abortions, anemia etc. Hence folic acid supplementation is advisable when trying for conception.
Pre-pregnancy counselling for older women
If your first conception is after 40 years, then definitely you should have a health check up and pre-pregnancy counselling before planning for pregnancy. This will tell whether you are healthy enough to carry a baby without causing grave complications to your health.
Age and Pregnancy
As age increases, people tend to be at increased risk for developing hypertension, diabetes etc. When you have such illnesses, pre-pregnancy counselling visit ensures the control of the disease, modification of the medicines being taken, folic acid supplementation etc. becomes absolutely necessary. During pregnancy, older women tend to have increased risk of developing pregnancy induced hypertension, diabetes, premature labour etc. It would be better to have pregnancy care at a secondary or tertiary centre where if required doctors from other specialties can also be involved in your care.
Fibroid in pregnancy
The problem older ladies who get pregnant for their first time faces is that they may have growths called fibroids in their uterus which are probably first detected in their first scan in pregnancy. Fibroids in pregnancy can cause abortions, premature labour etc.
Advancing age is also associated with fetal chromosomal abnormality like Down’s syndrome. These can be screened for by an ultrasound and blood tests at 12 weeks.
The Importance of pre-pregnancy counselling for a women with a history of miscarriage
Miscarriage is a very disappointing thing to happen and having recurrent miscarriages is very tragic. Having a single miscarriage does not lessen your chances of having a normal pregnancy, but having 2 or more miscarriages reduces your chances of having a normal pregnancy to some extent. In other words, a single abortion may occur by chance but if you have 2 or more abortions there may be a likely cause in 50% of the cases which needs to be treated to get a normal outcome. Miscarriages occurring early (<10 weeks) are more likely due to some genetic defect in the baby so that baby doesn’t grow well. The other reasons for early miscarriages may be uncontrolled sugars in the mother. Late pregnancy loss after 10 weeks could be due to antibodies in the mother causing abnormal clotting (APLA syndrome). It could also be due to structural problems in the uterus like presence of big fibroids inside the uterus, bands or walls inside the uterus or due to problems with mouth of the uterus (cervix) which gives way even before time.
Cases of two or more abortions
When you have two or more abortions, consult a doctor to check for any particular cause like this. If diabetes is found it can be controlled, fibroids can be removed before the next pregnancy, band or septums may be removed before next pregnancy. If antibodies are found (APLA), treatment with medicines for blood thinning markedly improves the pregnancy outcome. Sometimes a chromosome check of the parents may be required and if found abnormal a genetic counselling may be required. Sometimes no cause may be found and we may have to closely follow up the subsequent pregnancies.
Women with history of chronic diseases and pre-pregnancy counselling
Asthma and pregnancy
Mild asthmatic patients do not have many problems in pregnancy. Asthma improves in 1/3 of the people, remains the same in another third and worsens in other third. Even with severe asthma, pregnancy usually goes uncomplicated.
Most of the medicines used for asthma are safe during pregnancy. Hence you should not stop the medicines which you are taking already. Steroids may be sometimes required to control your disease. If steroids are used a sugar monitoring test may be required. The doctors may have to alter some medicines for pain relief or some medicines during labour which may trigger an attack of asthma.
Diabetes patient’s pregnancy
Uncontrolled diabetes is associated with lot of complications in pregnancy like abortions, fetal structural defects, recurrent infections in pregnancy, premature delivery, big sized baby, increased risk for operative deliveries etc.
But the good news is that all these complications can be minimized if there is optimum control of sugars at the time of conception and henceforth. A proper diet and exercise plan is the foundation on which sugar control can be built up. Along with this, certain medications may need to be changed and sometimes a shift over from oral medicines to insulin may be required for better control.
Planning your care at a centre where you can be cared for by team of gynecologist, diabetologist, dietician etc would be ideal. Pre-pregnancy counselling is the right choice of consultation before pregnancy for diabetes patients.
Chronic hypertension
If you are already a hypertensive patient, it will be better to have a pre-pregnancy counselling and health check up to ensure that none of your organs like kidneys, liver have been affected by hypertension. Some of the medicines are not safe in pregnancy, hence may need to be changed. As with diabetes, hypertension is also associated with certain complications in pregnancy like growth restriction, superadded hypertension of pregnancy etc. Hence a close watch for these complications is required.
Anomaly Scan and Fetal Echo for a pregnant lady with heart disease
If you are a heart patient, a green signal from your cardiologist is a must before you plan your pregnancy. Your pregnancy care should be in a hospital with a full time cardiologist. You should have a pre-pregnancy counselling with your obstetrician regarding the anticipated effects of pregnancy on your disease and how your disease can affect pregnancy.
Some heart conditions may increase the chances of heart disease for the baby. So a detailed anomaly scan and fetal echo may need to be done by a maternal-fetal medicine specialist.
Epilepsy
Epilepsy if well controlled is associated with uncomplicated pregnancies and normal children. Some of the medicines used can cause malformations for the baby (around 2% risk). Epileptic patients on certain antiepileptic medications, definitely benefit from folic acid supplementation at least 3 months prior to conception. Uncontrolled fits in pregnancy increases risk of complications, hence you should not stop your antiepileptic medications. A pre-pregnancy consultation from your neurologist would be preferred when you are planning to conceive, just to adjust your medicines. You will also be required to undergo detailed anomaly scan by a maternal-fetal medicine specialist.
Thyroid disease
If you have hypothyroidism (your body is not producing enough thyroid), you will be on thyroid supplements. A normal thyroid level is essential for the baby’s brain development. You may need to increase the dose of thyroxine once you are pregnant and will require regular monitoring of thyroid levels.
In case of hyperthyroidism, you will be on antithyroid medicines. Again the correct dose required need to be adjusted closely in pregnancy.