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Pre-pregnancy Considerations

“A woman’s health prior to conception is critical to the outcome of her pregnancy and may have a lifelong impact on her baby’s health. There is a lot that women can do prior to pregnancy to optimise their health including lifestyle changes such as a healthy diet and appropriate supplementation. Pre-pregnancy care helps find issues that may affect a woman’s pregnancy, so that steps can be taken to manage potential problems prior to pregnancy.”
RANZCOG Guideline Pre-Pregnancy Counselling”C-Obs 3(a) (July 2017)

For each of the following pre-pregnancy considerations, your GP is key to providing advice, guidance and is the link to future pregnancy care.

Medical Conditions and Medications

Some medical conditions may impact on your fertility, your health during pregnancy and the well-being of your baby during and after birth. Before you consider trying to fall pregnant it is important to visit your GP to discuss how your medical conditions and medications may affect your pregnancy, and vica versa, how any pregnancy may affect your medical conditions.

Medications may need changing, stopping, increasing or decreasing. Some medications may be risky to the baby, others innocuous, and some extremely important to continue and perhaps increase once a pregnancy is conceived.

It may be important to delay conception so that a medical condition can be optimised, in which case contraception is paramount as part of a healthy and safe short to medium-term plan to prepare for pregnancy.

Vaccinations

Prior to pregnancy you may need to consider vaccinations that protect you and your baby during the pregnancy period. These include the measles, mumps and rubella (MMR) vaccine, the chicken pox vaccine and hepatitis A/B vaccine. If you have had chicken pox in the past, you will be protected. However, if you have had a vaccination in the past for the above viruses, your immunity status should be checked, and a vaccination recommended if this is sub-optimal.

There are other vaccines important for your general health that should not be administered during pregnancy, but may be considered prior to pregnancy, including the meningococcal vaccine, and the HPV vaccine. A recently released vaccine protects you against nine of the most common HPV viruses that cause 90% of cervical cancers and genital warts. Your GP can advise you of your suitability for these vaccines.

Genetic Carrier Screening

You, your partner, children or relatives may have a heritable condition, or come from a racial background where particular conditions are common and can be passed from one generation to the next. Some genetically heritable conditions can also skip generations. It is reasonable to discuss the susceptibility of your unborn children to heritable conditions with your practitioner prior to pregnancy. You can expect to be provided advice about screening for conditions for which your children may be at increased risk, and the potential implications of conceiving a pregnancy and having a baby with the condition in question. In some cases referral to a genetic counselor may be required.

Lifestyle, diet and weight

A healthy weight is important not just from a general health point of view, but can have an important impact on the health of a woman and her baby in pregnancy, at delivery and for the lifetime of the child. Infants born to women of a healthy weight have a reduced risk of high blood pressure, metabolic, vascular and weight problems later in life.

A long-term plan for healthy eating and exercise can help contribute to a healthy pre-pregnancy weight and reduce risks of infertility, early pregnancy failure, blood pressure problems, diabetes in pregnancy, and birthing risks. There are a multitude of treatments for weight loss, and your GP is in a good position to discuss these with you.

Early review where there may be concerns about body weight or other risks for diabetes in pregnancy can make a huge difference to the health of your pregnancy. Your GP will discuss screening for diabetes earlier in your pregnancy and healthy eating and exercise to optimize the health of your pregnancy.

Alcohol, smoking and other illicit drugs have a negative impact on your baby during pregnancy and later in life. It is recommended to raise these concerns with your doctor before pregnancy so that you give yourself and any future children the best chance of good outcomes. There are many effective support and treatment programs available to help deal with addictions. Your GP is the best first person of contact to help point you in the right direction.

Supplements

0.4mg of folic acid, daily, at least four weeks prior to conception and during the first trimester of pregnancy has been proven to reduce the incidence of neural tube defects in early pregnancy. The neural tube is the structure that develops into the babies brain and spinal cord and is highly dependent on folate for normal development.

Some women will require a much larger supplement of folic acid. Nutritional deficiencies, some medical conditions and some medications can impair your folate levels. Furthermore a personal history of previous pregnancies affected by neural tube defects increases the risks in future pregnancies. In such cases women are recommended to increase this supplementation to 5mg of folic acid per day for one to three months prior to conception and for the entire pregnancy.

Your doctor can help to guide you where such an increase in the dose of folic acid is appropriate.

Women should consider taking a 150mcg daily of iodine supplementation in order to ensure there are the building blocks for adequate thyroid function in early pregnancy.

A reputable multivitamin for pregnancy will have the above constituents. Where an increase in folic acid supplementation is required, an additional preparation is needed.

Cervical screening

Routine cervical screening is considered good practice for the early detection of cervical disease to reduce the risk of cervical cancer. Unfortunately 80% of all cervical cancers in Australia are diagnosed in women who do not participate in, or have fallen out of, the cervical screening program.

For the majority of people, current recommendations for cervical cancer screening have recently changed from a 2-yearly PAP smear test where cervical cells are examined under a microscope, to a 5-yearly cervical screening test based on the detection of cancer-causing HPV viruses collected by using a cervical brush. Abnormal screening tests may require an earlier repeat cervical screening test or may need a colposcopy, where their cervix is examined under a microscope.

Women who have abnormal symptoms, such as abnormal vaginal bleeding or discharge, should see their doctor immediately and not wait for their next screening test.

Related Posts

Obstetrics, Patient Information

Letter to Obstetric Patients Regarding COVID-19

Dear Patients,

My thoughts are with you during this stressful time. At this moment of great joy, excitement, and anticipation, instead you may be experiencing worry and fears about how COVID-19 will affect your pregnancy care, and the health of yourself and your baby. Firstly I want to reassure you that the health of you and your baby is my highest priority, and I want to encourage you to contact my rooms if you have questions, symptoms, or worries. 

You may wish to read through some resources that have been put together by Queensland Health:

COVID-19 and pregnancy

COVID-19 and breastfeeding

I have had requests to provide advice about whether you should take early leave from your occupation to reduce your chances of a COVID-19 infection. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists is currently recommending that pregnant women work from home where possible. While there is currently no specific advice for pregnant women to stop working or take leave from work, there are general recommendations to avoid larger groups and practice social distancing, along with advice about hygiene practices.

My advice specifically for pregnant women is upgraded in order for you to stay as safe as possible and stay ahead of the wave of COVID-19 transmissions that seem to be escalating rapidly.

The following recommendations reflect my advice based on reading health guideline updates, my own observations, and after discussion with colleagues:

  • Work from home if at all possible. 
  • You are within your rights to request early leave from work especially where you may be exposed to large groups of people (at work or getting to/getting home from work); I would encourage you to negotiate this with your employer.
  • If you have children, whether or not to remove them from school is a controversial decision. School is a “large group” environment likely to accelerate spread. If you are trying to protect yourself, this would be an effective way to limit your exposure.
  • If you cannot stop attending your workplace, limit your exposure to colleagues and others by maintaining appropriate social distances >1.5m, wash hands regularly (especially before eating), avoid contact such as shaking hands, avoid touching your eyes/nose/mouth/face etc.
  • Partners and household family members are advised similarly as above in points 2, 3 and 4. Furthermore, household members are encouraged to be vigilant by heeding precautionary measures with social distancing, hygiene measures, and washing hands when arriving home. Isolation and seeking medical advice should be sought if partners or other members of your family develop worrying symptoms.

Contact me if you feel you have a confirmed exposure, or suspected/confirmed infection so I can help arrange appropriate care and follow up. I will be assessing antenatal appointments ahead of time from this week onwards to determine if we can look at the option of telephone consultations to reduce the need to attend the surgery in person. There will still be a requirement for reviews “in house” so that we can check baby’s ongoing growth and well being, the frequency of which will be determined on a case by case basis depending on your pregnancy and circumstances.

My hope is that by limiting your risk of exposure, you will continue to be safe in pregnancy, delivery and back at home afterwards.

Kind regards and yours sincerely,

Dr Matt Thyer 

Obstetrics, Pregnancy

Perinatal Anxiety and Depression

Pregnancy, childbirth and parenthood are exciting and special human experiences. However, it can be difficult to adjust to the pressures associated with these life-changing events. For those that have good supports, helpful family and friends and the good fortune of placid newborn this adjustment is made much easier. However, for some a difficult adjustment can turn to despair, anxiety and depression.

80 % of women will experience anxious and depressive symptoms shortly after giving birth. Commonly referred to as “the baby blues”, you may be teary, despondent and feel inadequate to care for your baby. These feelings are short-lived by most, but for a sizeable proportion of women they persist.

Up to 20% of women and 10% of men will experience perinatal anxiety or depression.

Depression is typified by one or more of the following symptoms and behaviours that persist for more than 2 weeks, can occur at any time during pregnancy and up to a year after delivery, and interferes with your normal function and relationships:

  • Depressed mood and persistently negative thoughts
  • Loss of interests or a sense of indifference or feeling numb
  • Difficulty concentrating, remembering things or getting things done Irritability, agitation or a “short fuse”
  • Feeling out-of-control
  • Feelings of guilt, shame, anger, inadequacy or hopelessness
  • Thoughts of harming oneself or the baby
  • Extreme lethargy and tiredness a lot of the time
  • Teary and upset a lot of the time
  • Social withdrawal
  • Sleeping problems; difficulty going to sleep or waking early
  • Change in appetite, weight gain or loss
  • Palpitations, headaches, sweaty hands

Anxious thoughts to some degree are a normal part of everyone’s life, however an anxiety disorder involves a persistent impairment of one’s normal function, relationships and work and may present in the following ways;

  • Generalized anxiety
  • Worry
  • Fears
  • Panic attacks

Anxiety and anxious behaviours in this case may be considered excessive or irrational to someone impartial.

These feelings should be taken extremely seriously, especially where they persist beyond two weeks an occur on a daily basis. It is a desperately sad fact that perinatal anxiety and depression are the leading causes of maternal mortality in the developed world. A parent in this state may lose hope and perspective, and this is a dangerous combination.

Several factors put people at higher risk of developing perinatal anxiety and depression including:

  • Past mental health illness including past perinatal depression/anxiety
  • Perfectionist and vulnerable personality type
  • Recent big life changes; financial pressure, loss of work, bereavement
  • Emotional stresses; estranged family or strained relationships
  • Social isolation: rural women, migrants and refugees
  • Domestic violence
  • History of physical or sexual abuse
  • Difficult birth

During and after pregnancy it is recommended to screen women for anxiety and depression. The Edinborough Post-Natal Depression Questionnaire produces a score (EDPS) that estimates your risk of being depressed. It is not diagnostic, but a screening tool. About 70% of women that screen positive to this questionnaire will be diagnosed with perinatal depression, so it is a reasonable screening tool. Equally however it is not 100% accurate and some people may screen negatively but still have depression. This is why a medical professional must be sensitive to these conditions and revisit screening on multiple occasions during and after pregnancy.

There are effective ways to treat perinatal anxiety and depression and they include a range of counseling modalities through to psychiatric and medical treatments. Your doctor is trained to help facilitate this where they can play a central role in directing you towards effective treatments that are appropriate given your conditions and circumstances.

There is no shame in seeking and receiving help for anxiety or depression as it shows you care about your pregnancy, baby, family, friends and yourself. That makes you a decent and caring person.

People do find their way through perinatal anxiety and depression. It is important to hold onto this fact during recovery.

The following helpful links are provided for your assistance in understanding more about perinatal anxiety and depression and the supports available to parents experiencing these conditions.

Life should be enjoyed.

The Gidget Foundation

Beyond Blue

Lifeline

PANDA – Perinatal Anxiety and Depression Australia

St John of God Raphael Services

Delivery, Obstetrics, Patient Information, Pregnancy, Uncategorized

Delivery planning

At some stage during your pregnancy it is worthwhile discussing your delivery planning and expectations about birth. Open channels of communication about your dreams and concerns are key to your sense of satisfaction about the events surrounding the birth of your child. You are encouraged to bring up this topic when you feel ready, otherwise it is discussed as a matter of routine as you progress toward your due date.

Vaginal birth after caesarean section (VBAC)

VBAC is supported by obstetric guidelines around the developed world provided it meets patient-based, institution-based and practitioner-based safety requirements. Decisions around whether or not to try for a VBAC can be highly emotive. A reasonable plan for one patient may be very different to another a the circumstances and risks can differ substantially. For this reason it is important to seek the advice of a practitioner that has seen the risks play out during pregnancy and labour, and knows how to deal with potentially life-threatening complications of a VBAC.

As a general approach, provided the risks are considered acceptable, every chance should be given to help you achieve a natural vaginal birth under the careful and watchful guardianship of your practitioner

Education and support including breastfeeding after delivery

Your midwife is invaluable in helping you to establish good breastfeeding habits after delivery. This will usually start with encouragement of skin-to-skin contact and breastfeeding as soon as possible after birth. Even at caesarean section it is possible to achieve this with the help of your midwife and other theatre staff. Occasionally your paediatrician may need to keep a very close eye on your baby in the nursery after delivery. However every effort is made to allow you a first contact as soon as possible after your delivery.

A strong focus on breastfeeding is currently adopted as there are evidence-based benefits to breast-feeding your child for at least 6 months. Breastfeeding reduces your child’s risk of developing metabolic and weight issues later in life, and there is early research showing breastfeeding can “reverse” these risks for babies that were “programmed” for metabolic impairment during the pregnancy. These are amazing benefits, however sometimes it feels like there is a lot of pressure around this issue after the birth. Again, open channels of communication with the team including your midwife, lactation consultants, obstetrician and paediatrician are key to working through these issues. Your voice is most important in this process and everyone is there to support you. It is worth remembering that breastfeeding is a partnership between you and baby, and it is not always the best thing for you both especially where the difficulties outweigh the benefits.

Analgesia in labour

There are some effective options for analgesia in labour that are supported by good evidence.

The epidural provides hands-down the best possible pain relief you can be offered in labour. Unfortunately, however, epidurals are not risk-free, they affect your mobility in labour, and can increase the duration of pushing and the risk of instrumental deliveries. They do not increase the risk of a caesarean section, and this detail is well supported by good evidence. The specific risks of an epidural should be discussed with you prior to labour so that you are not making decisions for the first time under the duress of labour.

Entonox or nitrous oxide (laughing gas) can provide some mild pain relief in labour. For some it is also a great distraction from labour. However many people experience intolerable effects including dizziness, nausea and sometimes vomiting. It is an option certainly worth considering for pain relief in labour where an epidural is considered undesirable.

Warm water immersion, or a warm shower, may provide good pain relief in labour. It is also relaxing. So where it is possible, is considered safe and does not pose a danger to yourself, baby or staff, it is a great option to consider.

Other than those above, there are no known reputable alternative sources of pain relief in labour. Some people have had good experience with morphine or pethidine, however overall it has not been shown to work well for the majority of people and is poorly supported by the evidence.

Analgesia at Caesarean Section

Caesarean sections require very effective and reliable pain relief. Spinal or epidural aneasthesia provide a regional nerve blockade so that your sensation is impaired below your waist thereby allowing your obstetrician painless access to deliver you child.

A spinal anaesthetic is introduced via a very fine needle through your lower spinal vertebrae and into the fluid bathing your spinal cord. The effect is very fast and effective. Conversely an epidural is introduced via a larger catheter, but stops short of entering the spinal canal, and relies on the diffusion of anaesthetic across tissue membranes to enter the spinal fluid that bathes the sensory nerves of your spinal cord. Occassionally your anaesthetist will combine these two methods to get a faster and more complete acting regional block, but also the benefit of an epidural catheter placement that can deliver anaesthetic following your operation. Each method has its benefits, limitations and risks and should be canvassed with the anaesthetist.

Sometimes a general anaesthetic will be required to provide adequate analgesia for a caesarean section where a spinal or epidural cannot be sited or where it is considered the safest means given the circumstances. In this situation you will be put to sleep and kept safe under the watchful eye of your anaesthetist while your baby is delivered. You are asleep for a short time and woken soon after your wound is closed and dressed. Recovery after a general anaesthetic can take some time as you may feel a bit drowsy, but generally after a few hours you are back to normal.

Recent Posts

  • Dr Matt Thyer’s Letter to Obstetric Patients Regarding COVID-19
  • Novel coronavirus (COVID-19) information for patients
  • Vaccinations
  • Gratitude to Mr James Harrison for his life-saving plasma donations
  • Perinatal Anxiety and Depression
  • Delivery Planning
  • After the first trimester of pregnancy
  • Early Pregnancy – The First Trimester
  • Pre-Pregnancy Considerations
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