Pre Pregnancy Care (PPC) at health .pptx

PPC

1. Pre Pregnancy Care (PPC) Echo training Dr Denise Tan Suyin KK Selayang Baru

2. DEFINITION Penjagaan Pra Kehamilan = Pre pregnancy care Definisi: Preconception care provision of biomedical , behavioral and social health intervention to women and couples before conception occurs . Aims at improving their health status and reducing factors that could contribute to poor maternal and child health outcomes. The ultimate aim is to improve maternal and child outcome , in both the short and long term (Meeting to Develop a Global Consensus on preconception care to reduce maternal and childhood mortality and morbidity. Geneva, WHO, 2013)

3. Which would you prefer to see in your clinic: Unplanned pregnancy Planned and optimised pregnancy

4. Concept of PPC: Identify women in the reproductive age group with r isk factors and their wish to conceive or not If they want to have a baby: ensure they're at their optimal health If they do not wish/ unsuitable to conceive: Advise on suitable contraception Integrated in the chronic disease management of reproductive age group woman. (DM/ HPT clinic, TB clinic, JPL, OPD)

5. Kumpulan Sasar Wanita dalam linkungan umur reproduktif ( 15-49 tahun ) yang mempunyai masalah kesihatan : Masalah perubatan kronik Penyakit berjangkit Risiko gaya hidup Pengecualian bagi Wanita: Menopause Hysterectomy

6. BORANG PENILAIAN PERTAMA PENJAGAAN PRA-KEHAMILAN

7. Borang PPC DM Clinic HPT Clinic Asthma Clinic TB Clinic

8. PPC form

9. Documentation 05 Document in TPC ( Alert) : PPC counselling done Fill up borang PPC → OPD pass to Dr Fazilah/SN Saiyidatina Mariam → MCH pass to SN Umairah document on cover Buku Perancang

10. Some examples

11. PENGENDALIAN ‘COMMON CONDITIONS’ SEMASA PERKHIDMATAN PPC Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 1. Diabetes Mellitus Janin/bayi: Kecacatan kongenital pelbagai ( VSD, neural tube defect, skeletal malformation) Makrosomia Hypoglysemia Polycythemia Ibu: Pre-eclampsia UTI Vaginal candidiasis Sepsis HbA1c < 6.5% Sasaran HbA1c 6.5% harus mengambilkira risiko hypoglycemia Kehamilan harus dielakkan jika HbA1c > 10% Pemantauan HbA1c berkala Self monitoring blood glucose Jika DM tidak terkawal, insulin boleh dimulakan sebelum hamil ACEI/ARB dan Statin dihentikan bagi wanita yang ingin hamil atau apabila didapati hamil. Nasihat supaya datang segera ke klinik sekiranya disyaki hamil CPG: Management of type 2 Diabetes Mellitus (5 th edition 2015) CPG: Management of Diabetes in Pregnancy (2017) Diabetes in pregnancy: management from pre-conception to postnatal period, NICE (2015)

12. Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 2. Obesiti Janin/Bayi : Keguguran Kecacatan kongenital (kecacatan jantung, neural tube defects) Makrosomia Kelahiran pramatang   Ibu : Pre-eclampsia Gestational diabetes Meningkatkan risiko kelahiran caesarean Venous thromboembolism Jangkitan luka Risiko berkaitan anaesthesia BMI<27.5kgm 2   ATAU   Penurunan berat badan 10% daripada berat badan asal dalam tempoh 6 bulan   Saringan kardiovaskular setahun sekali Saringan masalah kesihatan berkaitan dengan obesity dan rujuk jika perlu: Obstructive sleep apnea Osteoarthritis Gastroesophageal reflux Polycystic ovarian syndrome Kemurungan Masalah pernafasan reaktif/asthma Orlistat boleh diberi semasa tempoh pra-kehamilan Semua ubat-ubatan obesiti perlu dihentikan apabila wanita hamil (FDA kategori X) Clinical Practice Guideline - Management of Obesity 2004 AACE/ACE Clinical Practice Guidelines for Comprehensive Medical Care of Patients with Obesity (2016)   PENGENDALIAN ‘COMMON CONDITIONS’ SEMASA PERKHIDMATAN PPC

13. Saya tak nak injection, takut naik berat badan!

14. Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 3. Hyperthyroidism Janin/Bayi : Thyrotoxicosis Keguguran Kerencatan janin (IUGR) Kurang berat lahir Kelahiran mati ( stillbirth )   Ibu: Thyroid storm Complications of pregnancy such as UTI, labour or Caesarean section may precipitate thyroid storm especially in uncontrolled disease   Euthyroid   Sasaran biokimia: TSH : 0.4-4.0µmol/L T4 : 9-22µmol/L (bergantung kepada makmal setempat)   Pastikan keadaan euthyroid atau klien stabil tanpa ubat atau keadaan euthyroid dengan dos ubat terendah Pemantauan klinikal – simptom dan tanda hypothyroidism / hyperthyroidism , krisis thyroid ( thyroid storm ) Serum T4 perlu diulang selepas 2-4 minggu ubat anti-thyroid dimulakan Pemantauan serum T4 setiap 4-6 minggu apabila telah mencapai tahap sasaran (paras normal T4 mengikut makmal setempat) Pemantauan kesan sampingan ubat antitiroid – demam/sakit tekak dan neutropenia (FBC), jaundis (LFT) Ultrasound leher untuk thyroid dan FNAC (jika perlu) Women who wish to avoid fetal exposure to drugs can be advised to await resolution of disease and weaning off of treatment. If unable to wean off medications, can be considered for RAI which converts women to euthyroid/hypothyroid. Thyroxine carries negligible risk to the fetus Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum (2017)

15. Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 4. Hypothyroidism Janin/Bayi : Keguguran IUGR Fetal goitre Cretinism   Ibu: Kurang subur Komplikasi hypothyroid   Euthyroid   Sasaran biokimia: TSH 0.4-4.0µmol/L T4 11-22µmol/L (bergantung atas rujukan paras normal makmal setempat)   Pastikan keadaan euthyroid dengan dos ubat terendah Pemantauan klinikal – gejala dan tanda hypothyroidism , kemurungan, krisis hypothyroidism ( myxedema coma ) Ultrasound leher untuk tiroid dan FNAC (jika perlu) Rawatan penggantian dengan L- thyroxine seumur hidup (dos maksimum 200mg/sehari): TSH 4.0-8.0mIU/L : L-thyroxine 25µg sehari TSH 8.0-12.0mIU/L: L-thyroxine 50µg sehari TSH >12.0mIU/L: L-thyroxine 75µg sehari (Peningkatan dos: 12.5-25µg sehari ) Jika klien memerlukan dos L- thyroxine >200mg sehari – perlu semak kepatuhan terhadap pengambilan ubat Kelebihan dalam memberi rawatan kepada wanita hamil dengan masalah subklinikal hipotiroidism (mengurangkan risiko keguguran dan masalah perkembangan otak janin) Temujanji susulan selepas permulaan rawatan: 4-8 minggu dengan serum TSH Clinical Practice Guidelines for Hypothyroidism In Adults , ATA/AACE (2012)

16. Special notes: target??? TSH upper reference limit of 4 mIU/L For hypothyroid women already treated with L- thyroxine 1)Before conception and 1st trimester Aim: TSH 2.5 mIU/L 2nd and 3rd trimester Aim: TSH 3.0mIU/L The TSH goal can be reverted to the normal reference range for non-pregnant women after delivery L- thyroxine dosage increased by 30%–50% upon conception

17. Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 5. Masalah jantung Janin/Bayi : Risiko kecacatan jantung bayi meningkat 5-10% jika ibu bermasalah jantung kongenital Risiko tinggi IUGR jika ibu bermasalah jantung cyanotic Fetal warfarin syndrome   Ibu : Risiko tinggi kematian ibu Risiko tinggi mendapat pulmonary embolism , subacute bacterial endocarditis dan strok dikalangan ibu dengan injap mekanikal. Tidak dibenarkan hamil ( absolute contraindication ): Primary pulmonary hypertension Eisenmenger syndrome Dilated cardiomyopathy Cyanotic heart disease Marfan syndrome Symptomatic obstructive lesion (AS/PS/COA) Severe heart failure ( NYHA III-IV) Pemantauan tanda/simptom kegagalan jantung Pemantauan tanda/gejala aritmia Echocardiogram dan ECG mengikut keperluan Teruskan ubat-ubatan sedia ada. Bagi wanita dengan injap mekanikal, dinasihatkan dos warfarin terendah untuk mencapai tahap terapeutik Perlu penjagaan bersama pakar jantung/pakar perubatan   Clinical Practice Guideline - Heart Disease in Pregnancy ( 2n d Edition , 2016)

18. Dangerous in pregnancy Considered safe in pregnancy Warfarin Increased risk of fetal anomalies (estimated at 5-10 %) high risk of miscarriage/ late fetal loss (approximately 10%). Anti-arrythmic drugs Most are well-tolerated and safe Anti-failure medication (e.g., digoxin and diuretics) can be continued in pregnancy 2. Statin generally contraindicated however if it is necessary hydrophilic agents preferred over lipophilic ones Lipophilic: Atorvastatin, lovastatin, and simvastatin hydrophilic: pravastatin, rosuvastatin, and fluvastatin (*Lipophilic statins cross the blood-brain barrier more readily, which may lead to central nervous system complaints. However, this is rare.) 3. Beta blockers the gold standard treatment for fixed output lesions such as mitral and aortic stenosis. In these instances, should be continued. However prophylaxis beta blockers should be discontinued 3. ACE inhibitors contraindicated in pregnancy but are safe during breastfeeding 4. Aspirin Low dose (100 – 150 mg OD) is safe in pregnancy and breastfeeding.

19. Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 6.Hipertensi Janin/Bayi : Placenta abruptio IUGR Ibu : Strok Kegagalan organ: buah pinggang, jantung Pre-eclampsia Tekanan darah SBP<140mmHg ± DBP<90mmHg   ACE-I, ARB, diuretik dan statin perlu dihentikan bagi wanita yang ingin hamil atau apabila didapati hamil Pilihan anti-hipertensif semasa pra-kehamilan adalah calcium channel blocker, beta blocker dan central acting agent ( methyldopa ) Clinical Practice Guideline - Management of Hypertension (5th Edition , 2018) 7. Bronchial asthma Janin/Bayi : Kelahiran pramatang Kurang berat lahir   Ibu : Serangan asthma yang teruk Pre-eclampsia Asthma terkawal: skor Asthma Control Test (ACT) ≥20 PEFR>80% predicted Simptom terkawal dan tiada serangan akut selama 3 bulan Definisi terkawal (GINA) adalah; Sepanjang 4 minggu yang lalu, wanita yang mempunyai penyakit asthma tidak mengalami simptom di bawah: Simptom asthma pada siang hari kurang daripada 2 kali seminggu. Gangguan tidur disebabkan oleh asthma Penggunaan ubat pelega lebih daripada 2 kali seminggu Limitasi aktiviti disebabkan oleh asthma Monitor skor ACT dan PEFR setiap kali lawatan klinik Pastikan teknik penggunaan inhaler dan kepatuhan rawatan asthma setiap kali lawatan klinik disemak Saranan imunisasi influenza setahun sekali ( inactivated influenza vaccine ) Clinical Practice Guideline - Management of Asthma in Adults (2017) Gobal Initiatives for Asthma (GINA) 2018

20. 1. Methyldopa is the safest choice of drug during pregnancy. Most women on anti-hypertensives before pregnancy will be switched to methyldopa 2. Prolonged use of beta-blockers has been found to be associated with small for gestational age (SGA) 3. Diuretics are associated with: i. reduction in utero-placental blood flow causing IUGR ii. increase in viscosity of maternal blood leading to VTE 4. ACE inhibitors are contraindicated in pregnancy associated with severe neonatal outcomes such as renal agenesis and pulmonary hypoplasia 5. Angiotensin receptor blockers (ARBs) are contraindicated in pregnancy and breastfeeding. increased risk of fetopathy (e.g. pulmonary hypoplasia, limb contractures, and calvarial hypoplasia) Choice of antihypertensive

21. PENGENDALIAN ‘COMMON CONDITIONS’ SEMASA PERKHIDMATAN PPC Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 8. Epilepsi Janin/Bayi : Kecacatan bayi: penyakit jantung, sumbing bibir dan lelangit, cacat anggota, sistem saraf, usus, saluran kencing dan genitalia Risiko tinggi mendapat epilepsy   Ibu : 30% peningkatan mengalami sawan   Tiada serangan sawan dalam tempoh 2 tahun Jika perlu ubat anti-epileptik, sebaiknya dengan monoterapi dos rendah yang efektif Pemeriksaan neurologi yang normal Pemeriksaan EEG (jika perlu) Ujian darah berkala : FBC, LFT (bergantung kepada jenis ubat) Therapeutic drug monitoring level jika kurang komplian dan sawan tidak terkawal atau disyaki toksik (overdose) Perlu penjagaan bersama dengan pakar perubatan neurologi/ medical Penukaran anti-epileptic drug (AED) yang kurang teratogenisiti perlu sebelum hamil contohnya: levetiracetam atau lamotrigine Risiko teratogenicity bergantung kepada jenis AED dan dos: Monoterapi: 4-8% Politerapi: 15% Kombinasi valproate, carbamazepine dan phenytoin: 50% Phenytoin monoterapi: tiada kaitan dengan peningkatan major fetal malformation Valproate >1000mg sehari: risiko paling tinggi untuk fetal malformation Nasihat pesakit yang merancang untuk hamil agar mengambil asid folik 5mg setiap hari 3 bulan amalan kontraseptif Consensus Guidelines on The Management of Epilepsy (2010) Epilepsy in Pregnancy, Green-top Guideline no.68, RCOG, 2016. Treatment for epilepsy in pregnant women and the physical health of the child. Cochrane Database of Systematic Reviews , 2016.

22. PENGENDALIAN ‘COMMON CONDITIONS’ SEMASA PERKHIDMATAN PPC Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 11. Anaemia Janin/Bayi : IUGR Kurang berat lahir Kelahiran pramatang Keguguran Terjejas perkembangan mental dan kognitif   Ibu : Risiko postpartum haemorrhage Lemah jantung   Hb > 11 g/dL Pantau simptom anaemia Kenalpasti punca anaemia dan rawat mengikut keperluan Bagi iron-deficiency anaemia : Nasihat pemakanan yang tinggi kandungan zat besi bagi pelanggan Iron supplementations Nasihat pelanggan kepentingan jarak kehamilan dalam memastikan anaemia dirawat terlebih dahulu     UK Guidelines on the Management of Iron Deficiency in Pregnancy

23. Masalah kesihatan Risiko kepada ibu dan janin/bayi Sasaran Intervensi pra-kehamilan Rujukan 15. Tuberkulosis dalam rawatan Janin/Bayi : Risiko keguguran Kurang berat lahir Risiko tuberculosis kongenital Risiko kecacatan kongenital kesan ubat untuk MDR-TB   Sempurna rawatan atau sembuh   Pastikan sempurna rawatan Kontraseptif: suntikan DMPA setiap 8 minggu atau dos estradiol minimum 50µg Garispanduan Kawalan dan Pencegahan Tibi dalam Kalangan Ibu Mengandung, 2018 Clinical Practice Guideline - Management of Tuberculosis (3 rd edition, 2012) PENGENDALIAN ‘COMMON CONDITIONS’ SEMASA PERKHIDMATAN PPC Rifampicin reduces plasma estrogen. Thus COCP is not reliable *this effect lasts up to 28days after stopping Rifampicin

24. Choosing contraception → Google playstore/ Apple appstore → WHO Contraception Tool → Download!

25. References

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