Pre-conception care - Dr. Otieno Gwer

Many couples approach major family projects with careful planning. Take for example the construction of a home. A lot of background checking goes into place. They ensure that the piece of land they intend to use is the best their money can afford and is not entangled in other legal issues, they counter check mortgage details with a lawyer, and consult an architect or two. After all the facts are in, then the construction begins.

One would assume that having a baby is a major family project that deserves similar diligence in planning. However indications are that this is not the case. Half the pregnancies in America are unplanned and though no studies have been conclusively done my guess is that the situation in Kenya is worse.

In ideal circumstances a couple should approach pregnancy after pre conception counseling and where necessary intervention. This will optimize the result of the pregnancy and is known to be the best preventive medicine in Obstetrics. By the time most women realize they are pregnant, the fetal heart is beating and the spinal cord is formed. This may be too late to intervene, unless one thinks of termination.

Some of the factors to consider before pregnancy are outlined below.

Age

Teenage pregnancies (15 -19) are more likely to be complicated by low blood levels (anaemia), low weight babies, and preterm labour, and are generally at a higher risk of infant mortality. The teenager is still growing and will need additional supplementation compared to a fully grown woman.

Elderly gravida was a term previously referring to pregnant women above 35yrs but now appears tactless as many women are getting pregnant at this age. It has also been found that the risks of pregnancy at this age were previously exaggerated. Nonetheless, women at this age are at a higher risk of pregnancy related complications and maternal deaths compared to younger post-pubertal women. Their babies have a higher risk of being malformed or have chromosomal disorders. However women in this age group have better health seeking behavior, and are more likely to afford specialized care to ameliorate the effects of age.

Older age of the father is also associated with an increased incidence of genetic diseases, but this is usually so low that it is of little concern to many doctors.

Smoking

Prior to conception, one should stop smoking. Smoking affects the growth of the fetus in a proportionate manner to the amount of cigarettes smoked; it not only reduces the fetal weight and size, but also increases the chance of premature delivery. Babies born to smokers have a high chance of having attention-deficit/hyperactive disorder, in addition to behavioural and learning disorders that manifest at school age. Smoking also increases the complications related to blood vessel damage including the potentially fatal detachment of the placenta.
Cigarette smoke has many toxins beyond nicotine that cause these effects; this makes the nicotine patch a much safer substitute. Even where the woman is not a smoker, passive smoking has similar effects and should be equally discouraged. Ideally, one should quit smoking before conception.

Alcohol

Ethyl alcohol, found in all alcoholic drinks, is the most potent teratogen (agent that can hamper the development of an embryo or fetus) known. Its effect on the baby were described in the 1800s. It is a frequent cause of learning difficulties (referred to as mental retardation in other literature) and causes a wide variety of birth defects which include, but are not limited to, heart defects, brain defects, spinal defects, a characteristic skull and facial defect, and behavioral problems. The effects of alcohol are dose dependent (are worse with greater doses), and no doubt there is a safe threshold, but this has never been established and it probably varies from person to person.
Women who are considering conception are best advised to stop alcohol intake, prior to and during the pregnancy. Other recreational drugs (e.g. heroin, marijuana and cocaine), without going into the details of each, are also discouraged.

Diet

Vegetarian diet being protein deficient can be corrected with increasing the consumption of milk products and eggs. Strict vegetarians are advised to take supplements with consultation as some of them may be detrimental. All women should approach pregnancy with good blood levels and adequate iron stores.
Obesity is associated with many complications in pregnancy e.g. high blood pressure, gestational diabetes, fetal malformation and a higher incidence of cesarean delivery.
The fetus is an efficient parasite that can extract adequate nutrients from undernourished mothers; however extreme deficiency as seen in anorexia and other eating disorders can lead to a less than optimal outcome in a contemplated pregnancy.

Domestic Abuse

A pregnancy can worsen a difficult relationship, and many times creates a risk for violence amongst those who have abusive partners. Before pregnancy one should evaluate her social circumstances and ensure they will have adequate support through-out this period

Immunization

Rubella infection(German measles) is dangerous to pregnancy. Those who are susceptible to the infection should consider immunization, then wait a latent period of three months before conceiving. However one should not be alarmed if she conceives before the time is over as the vaccine is safe. Varicella (Chicken pox) and Hepatitis B should be similarly tackled.
Tetanus toxoid immunization is also recommended but it should not preclude conception.

Past Reproductive Performance

How one performed in her previous pregnancies is a predictor of how her future pregnancies are going to be like. If her conceptions have previously been difficult and require medical assistance, or she has had recurrent early pregnancy losses, there is need for evaluation before another conception is attempted. Some complications of pregnancy and delivery also recur in subsequent pregnancy and one should take advice before conceiving.

Chronic (long standing) Medical Conditions.

Ideally a couple should approach pregnancy in optimal health in order to secure the best possible outcome. However some have incurable illnesses or longstanding illnesses some of which preclude pregnancy.

Diabetes Mellitus is associated with many health complications which can be avoided if conception is attained when the blood sugar control is optimal. Stopping contraception in a diabetic to facilitate conception can lead to alteration in blood sugar that will first have to be monitored. Pregnant diabetic women are not advised to use oral medicine for blood sugar control; pre conception change to insulin with attainment of control is preferable to changing medicine and trying to control sugars when the woman is already pregnant. Diabetic women who receive pre-conception care have been shown to have better sugar control, lower chances of pre-term delivery, fewer macrosomic babies, and fewer growth retarded babies. They are also less likely to have obstetric complications or hospitalization. They spend fewer post-partum days in the hospital and have lower health care costs.

Epilepsy - Women with epilepsy are 2 to 3 times more likely to have children with anomalies. These anomalies are in most of the cases related to the medication they are taking, and occur within the first weeks after conception. Preconception care therefore aims to change medication to one drug that is least likely to lead to malformations at the least dose at which it is effective. These women should also take preconception folic acid to reduce the risk of malformations.

Other diseases that require pre-conception counseling and control include; high blood pressure, Kidney diseases, thyroid diseases, asthma and heart diseases. The above two are just illustrations. Women with diseases like the heart and lung disease condition known as Eisenmenger's complex are strongly advised not to conceive.

Genetic Diseases

These are diseases that occur in individuals due to errors that they have in their genes and can thus be passed to their offspring. The most common of such diseases in East Africa is Sickle Cell Anemia. A couple should seek pre-conception counseling where their pedigree and genetic make up is assessed and the mathematical possibility of transmission of the disease to their offspring is calculated. A decision is made on what action should be taken in early pregnancy in case of the eventuality.

Child bearing is an important part of the human life cycle, the experience of pregnancy is a profound life altering physiological event, that converts a woman to a mother with many other irreversible physiological, anatomical, social and psychological changes. It should thus be approached with maximal preparation.

Dr.Otieno Gwer is a consultant obstetrician and gynaecologist based at the Coast of Kenya