Preconception Care:

Providing Fetal/Maternal
Health Risk Assessments
Lecture 4

Preconception Planning
Important because:
Offers best protection against low birthweight &
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 & nonmedical factors: GDM, HTN, heart

disease, psychiatric disorders,
domestic abuse, depression, Genetic
disorders.
Discuss nutrition, meds, exercise,
tobacco, alcohol, drug use, family
support, unemployment, workrelated 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

Planning

Pre & Post-Pregnancy

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

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.

 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.

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 lifethreatening 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.

Rubella
(1st trimester) 50% rate of
malformation.
(2nd 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 1st year or > 1 yr of age.

If 1st trimes.infection, may consider AB.

HSV 2 [genital ]. Valtrex - suppress lesions; C/S

f 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 3rd trimester (new

 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.

Common Discomforts of
Pregnancy
1st Trimester
Nausea & vomiting
Causes: hormonal, fatigue, changes
in carb metabolism
Interventions: sm. freq. meals; eat
slow; dry toast ; deep breaths.
Ends by 2nd trim; if severe,
hospitalize & hydrate

Nasal Stuffiness:
Causes: edema of nasal mucosa d/t ^
estrogen levels
Interventions: saline drops; humidifier.
Pseudafed 2nd/ 3rd trimester.
Breast Enlargement & Tenderness [cold
weather]
Causes: ^ estrogen & progesterone
levels

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

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

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]

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

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 2nd & 3rd 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; *

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,

 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 1st 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

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.

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 birthweight, infant mortality. Can potentially
decrease fertility. Vasoconstriction

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

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

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,

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

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 lifethreatening situations

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

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

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