Focus on women's health: Preconceptual care

The aim of preconceptual care is to enable women to make decisions to optimise their health, and consequently the health of their baby, when planning a pregnancy

In general practice women often actively seek our advice to discuss how best to prepare themselves for pregnancy. Consultations for women’s health issues, sexual and reproductive health and cervical screening, for example, naturally lend themselves to discussing preconceptual care. However, we need to be equally aware of the specific issues and considerations for women of childbearing age who have additional health issues. Preconceptual care is also about managing long-term conditions specifically with pregnancy in mind to ensure the best possible outcome for maternal and child health. Women who have increased risk of inherited genetic disorder are not covered in this article although referral for genetic screening and counselling would be appropriate.

PRECONCEPTUAL ADVICE FOR ALL WOMEN

Table 1 outlines the general advice that should be raised with all women who are planning a pregnancy. Lifestyle choices such as smoking, drug and alcohol consumption, as well as poor nutritional intake, increase the health risk to both mother and baby. In addition to lifestyle advice, women should be advised about their menstrual cycle, the optimum time for ovulation and frequency of sex to increase their chances of conception. Approximately 80% of couples achieve pregnancy within 12 month of trying although fertility decreases and risk of chromosomal abnormalities increases as women get older.¹

Folic acid supplements taken in pregnancy significantly reduce the incidence of neural tube defects (NTD) in the infant, such as spina bifida, anencephaly and encephalocoele.² It is therefore recommended that all women take folic acid supplements prior to conceiving. Specific groups, as outlined in Table 1, are at increased risk of NTD and therefore a higher dose of folate supplement is recommended for these women.

LONGER TERM COMPLICATIONS

Women who have longer-term illnesses and chronic disease may be at greater risk of problems in pregnancy and additionally the health of the developing infant may be significantly compromised (Table 2). Specialist intervention is necessary to manage many of these higher-risk women in the preconceptual phase to ensure optimum health and safe medicine management. The list is not exhaustive, but the following have specific implications pre-conceptually of which practice nurses need to be aware.

• Obesity
• Mental health
• Cardiac disease
• Renal disease
• Diabetes
• Venous Thromboembolism (VTE)
• Epilepsy
• Asthma
• Sexually Transmitted Infections
• HIV
• Female Genital Mutilation
• Genetic haemoglobinopathies such as sickle cell disease and thalassaemia
• Metabolic disorders such as hypo- and hyperthyroidism
• Rheumatoid arthritis
• Recurrent miscarriage
• Increased risk of genetic congenital abnormalities
• Older women

Obesity

With 25% and 32% of the female population classed as obese and overweight, respectively, and 15.6% of women classified as obese at the start of their pregnancy, more and more women are putting themselves at risk of poor maternal health and adverse infant outcomes.^3,4 This is compounded by the risks of gestational hypertension and diabetes that obesity can bring in pregnancy. These risks also limit the choices women have in terms of where they can have their babies. Clearly, women who are overweight and obese need to be made aware of the risks and supported in losing weight through improvements in their diet and exercise. Even reducing weight by 5-10% would have significant benefits on their health and improve their chances of conceiving in the first instance.²

Mental Health

Women who have, or have had, mental illness may be concerned how a pregnancy is going to affect their health not only while they are pregnant but also in the postnatal period and their ability to cope with a newborn. Early support and intervention is important for women who suffer from depression and anxiety or who have previously had a history of postnatal depression. Women with severe mental illness are likely to need additional specialist input. Medication for depression, bipolar affective disorder or schizophrenia may need to be withdrawn or switched depending on the safety of specific drugs in pregnancy. It is a balance of taking into account potential risks to the fetus from medication compared with the risks of any deterioration of a woman’s mental health during her pregnancy. Specialist intervention would be appropriate to assess such risks and women advised to continue with contraception until their medication has been reviewed by a psychiatrist.

Hypertension

Women with hypertension who are considering a pregnancy should be referred to a cardiac specialist. Antihypertensives, such as ACE inhibitors and Angiotensin II receptor antagonists (AIIRAs), are contraindicated at all stages of pregnancy and are associated with congenital malformations. ACE inhibitors are also associated with intrauterine growth restriction (IUGR), hypoglycaemia, renal disease and premature deliver. Beta-blockers, hydrazine and methyldopa are deemed safer options in pregnancy.² Regular monitoring of women with hypertension is paramount and good control of blood pressure is required before stopping contraception and attempting to conceive.

Cardiac Disease

Heart disease is the commonest cause of maternal death in the UK and therefore any woman with chronic cardiac disease must be referred to a cardiac specialist so that a complete assessment of her condition can be undertaken to determine how safe a pregnancy would be to her wellbeing.² Women with pulmonary hypertension, aortic aneurysm, severe aortic stenosis and symptomatic ventricular dysfunction should be advised against pregnancy.

Chronic Kidney Disease (CKD)

Maternal and fetal risks are significantly increased for women with renal disease. The risk of intrauterine death in women with CKD is 6%, increasing to 12% if the mother has accompanying hypertension. Women with severe CKD stage 4 or 5 are likely to be unable to conceive. Moderate renal disease (CKD 3B and 4) can deteriorate during pregnancy thus further threaten the baby’s survival. CKD 1, 2 and 3A does not generally worsen although there remains a risk to the fetus. Referral to a renal specialist is therefore essential in the preconceptual phase and medication needs to be continued until the woman has been appropriately reviewed. Past history of renal transplant does not automatically preclude a woman trying to conceive although clearly this would be under the direction of the nephrologist.²

Diabetes

Again, referral to specialist care is essential for women with diabetes who are planning a pregnancy. The main aims are to gain optimal control for blood glucose and blood pressure to achieve the best possible outcomes for the mother and baby. Additionally, good control helps to reduce the risks of complications of diabetes, which can be significantly exacerbated during pregnancy. Practice nurses can support women to achieve their HbA1c targets with improvements in diet and exercise as well as instigate or increase blood glucose monitoring due to the additional risks of hypoglycaemia during pregnancy. NICE recommends a preconceptual target HbA1c of 48mmol/mol (6.5%) for women, if this can be achieved and maintained without complications of frequent hypoglycaemia.⁵ However, any improvements in HbA1c will be of benefit although the risks associated with pregnancy increase with the length of time the woman has had diabetes. Women should be persuaded against pregnancy if their HbA1c is greater than 86mmol/mol (10%) due to the serious increase in risks to their own health and congenital abnormalities with poorer control.⁵

In addition to reducing HbA1c, complications of diabetes should be assessed and any necessary management commenced pre-conceptually. Prior to stopping contraception, baseline assessment should be undertaken to determine additional risks for the woman, which can worsen during pregnancy, including:

• Retinopathy screening
• Renal function assessment
• Optimal blood pressure control
• Identification of neuropathy
• Cardiovascular assessment

Women planning a pregnancy are likely to have to make changes to their medications preconceptually following specialist advice:⁵

• Insulin should be the drug of choice and all other medicines for diabetes stopped
• Metformin may be used when the benefits of improving HbA1c outweigh the risks
• ACE inhibitors and AIIRAs should be stopped
• Safer alternative antihypertensive medications may be prescribed
• Statins should be discontinued

Venous Thromboembolism (VTE)

Pulmonary embolism (PE) accounts for a third of all maternal deaths and is the leading cause of maternal death in the UK.² Warfarin therapy is contraindicated in pregnancy due to its teratogenicity and risk of placental abruption and should be stopped prior to pregnancy. Following specialist intervention, the woman may be switched to heparin or low-dose aspirin. It is recommended that all women with a personal or family history of VTE are screened for inherited and acquired thrombophilia. Women who have had a DVT or PE in a previous pregnancy, following surgical procedures or while taking the combined hormonal contraceptive pill are deemed at being at greater risk in pregnancy. High BMI and increased maternal age also increases the risks of VTE in pregnancy.

Epilepsy

Women with epilepsy can have a normal healthy pregnancy. Specialist care is recommended to review a woman’s anti-epileptic drugs (AEDs) as it is the medications themselves that are associated with the increase risk of congenital abnormalities, specifically NTDs, orofacial defects, congenital heart abnormalities and hypospadias, rather than epilepsy itself.² In view of such risks, additional folic acid supplements are recommended (Table 1).

Sodium valproate is associated with a greater risk of congenital malformations and its use is discouraged in women of child-bearing age.⁶ Effective contraception needs to be continued in the preconceptual period until alternative treatments are commenced. If the use of sodium valproate is unavoidable then the smallest possible dose needs to be used with close monitoring of any pregnancy in view of the increased risks of fetal abnormality.

In general, the frequency of seizures is not increased in pregnancy, although for a minority of women it might be. However, women with epilepsy need to be aware that 1–2% are likely to have a tonic-clonic seizure during labour with a further 1–2% within the first 24 hours after delivery. The gravest consequence of this is sudden unexpected death in epilepsy (SUDEP), which can occur if AED therapy is inadvertently stopped.

Women considering pregnancy are encouraged to register with the UK and Irish Epilepsy and Pregnancy Register (UKEPR) which is a long-term study looking at the effects of AEDs on maternal and child health.

Asthma

Achieving good control with asthma is an important element of preconceptual care. Generally speaking asthma may improve, worsen or remain constant in pregnancy.⁷ Positively, risks of low birthweight, pre-term delivery and congenital malformations, are considered to be low in women with asthma and are more associated with poor control.² Women who are using long-acting and short-acting beta-2 agonists, inhaled corticosteroids, antimuscarinic bronchodilators, cromones or theophylline can continue to use these safely prior to and during pregnancy. The SIGN and British Thoracic Society UK asthma guideline supports the use of leukotriene receptor antagonists in pregnancy if essential to asthma management in that individual.⁷ Use of oral steroids may increase the risk of oral cleft lip/palate but the risk of not treating a potentially life-threatening disease outweighs the potential risk to the baby. Achieving good control of asthma reduces acute exacerbations and subsequent need for treatment. Women with poorly controlled asthma and those at risk of severe asthma should be referred to a respiratory physician.

SEXUAL HEALTH

Herpes

Women who have a history of recurrent genital herpes are often concerned about how this might affect their baby. However, the risk of neonatal herpes is very low and is not an indication for caesarian section.⁸ Reassurance can be given to women that there is no increase of congenital abnormalities or risk of preterm labour or IUGR with a history of genital herpes. There is limited evidence of the benefits of suppressive treatment during pregnancy but women may wish to discuss this with their obstetrician.¹⁰

Chlamydia

Chlamydia screening is not offered routinely as part of antenatal screening. However, women under 25 years should be signposted to the National Chlamydia Screening Programme. Taking a full sexual history can identify risks of infection for all women and therefore genital screening and blood tests for sexual transmitted infections (STIs) may be pertinent pre-conceptually. Women also need to be advised that they will be offered screening for syphilis, HIV, hepatitis B and C as well as rubella as part of antenatal care once they are pregnant.

Sexual Dysfunction

Discussion with women may reveal possible issues such as vaginismus, lack of libido or dyspareunia which will have implications for sex and thus the ability to conceive. Additionally, women may wish to discuss erectile dysfunction of their partners or men themselves may seek advice. Sexual dysfunction needs to be handled sensitively and appropriate referral may be necessary.

HIV

When either one or both partners have HIV, they must be referred to an HIV specialist for preconception counselling. Reducing the risks depends on the amount of viral load in the blood, the presence of other STIs that can increase the viral load in genital secretions, and managing anti-retroviral therapy (ART). Risks of mother to baby transmission and the effects of ART on the fetus should be discussed and consideration given to the possibilities of assisted conception techniques.⁹

Female Genital Mutilation (FGM)

It may be that during routine examination of a women, female genital mutilation is apparent. Clearly if a woman who has been subjected to FGM is planning a pregnancy, it has enormous implications. From a practical point of view, it is paramount that the woman is able to have a safe birth, as extensive lacerations resulting in damage to the urethra, bladder and rectum, can occur during delivery. Fetal asphyxia and neonatal death are also a significant risk. It may be that the woman needs to be referred for reversal, or ‘deinfibulation’, although she may be reluctant to undergo this procedure.¹⁰ Certainly, specialist involvement is vital for preconceptual counselling, adequate information, advice and support. Some areas of the country, where there is a greater incidence of FGM in some communities, have specialist midwives who would offer pre-conceptual guidance and support. Undoubtedly, this is a situation that needs treating with huge sensitivity but our awareness of the implications of FGM are so important for these women.

CONCLUSION

Advising women on preconceptual care is an important part of the practice nurse’s role. Where there are specific long-term health issues, practice nurses may need to seek support and guidance to be able to help women achieve optimum health for themselves, and consequently their babies. Reducing the risks of complications during pregnancy and labour and to the unborn child can be achieved through appropriate care and management prior to conception.

Awareness of risks, avoiding life-style hazards and taking the necessary measures to improve chronic medical conditions prior to conception will ultimately optimise the health of both mother and baby once pregnancy occurs.

REFERENCES

1. Guttinger A. Planning Pregnancy. Sexual and Reproductive Healthcare (e-SRH) eLearning for Healthcare. 2014 www.e-lfh.org.uk/home/

2. National Institute for Health and Care Excellent. Clinical Knowledge Summaries. Pre-conception Advice and Management. June 2012. cks.nice.org.uk/pre-conception-advice-and-management

3. Health and Social Care Information Centre. Statistics on obesity, physical activity and diet: England 2014. www.hscic.gov.uk/catalogue/PUB13648/Obes-phys-acti-diet-eng-2014-rep.pdf

4. National Institute for Health and Care Excellence. NICE Commissioning Guide 36. Weight management before, during and after pregnancy, March 2011. www.nice.org.uk/guidance/cmg36

5. National Institute for Health and Care Excellence. NICE Guideline 3. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period, February 2015. www.nice.org.uk/guidance/ng3

6. Medicines and Healthcare Products Regulatory Agency. Medicines related to valproate: risk of abnormal pregnancy outcomes, January 2015. www.gov.uk/drug-safety-update/medicines-related-to-valproate-risk-of-abnormal-pregnancy-outcomes

7. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. A national clinical guideline 141, 2014. https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/

8. British Association for Sexual Health and HIV and The Royal College of Obstetricians and Gynaecologists. Management of Genital Herpes in Pregnancy, October 2014. www.rcog.org.uk/globalassets/documents/guidelines/management-genital-herpes.pdf

9.British HIV Association. British HIV Association guidelines for the management of HIV infection in pregnant women, 2012 (2014 interim review) 2014. www.bhiva.org/documents/Guidelines/Pregnancy/2012/BHIVA-Pregnancy-guidelines-update-2014.pdf

10. Royal College of Nursing. Female genital mutilation. An RCN resource for nursing and midwifery practice (Second edition) Available at: www.rcn.org.uk/__data/assets/pdf_file/0010/608914/RCNguidance_FGM_WEB2.pdf

11. Public Health England. Immunisation against infectious disease. Contraindications and special considerations: the green book, chapter 6. Last updated April 2013. Available at: www.gov.uk/government/publications/contraindications-and-special-considerations-the-green-book-chapter-6