Preconceptional care- Dr. Archana Asok.pptx

PRECONCEPTIONAL CARE

1. GARBHADHANA VIDHI PRECONCEPTIONAL CARE Dr. ARCHANA ASOK

2. CONTENTS 1. WHAT? 2. WHY? 3. HOW? 4. WHEN? What is PCC? Why is PCC practiced? How is PCC practiced? When to do PCC?

3. 1. What is PCC ? Definition and scope GOALS: Importance of preconceptional health for both partners and goals of PPC

4. Preconceptional care is the provision of biomedical,behavioural and social health interventions to women and couples before conception occurs. Preconceptional care - Definition

5. 4 out of 10 women report that their pregnancies are unplanned Perinatal deaths are 50% higher among babies born to adolescent mothers Up to 10% of pregnancies among women with untreated gonococcal infections result in perinatal death Maternal undernutrition and iron-deficiency anemia account for at least 20% of maternal mortality Female genital mutilation increases the risk of neonatal death by 15% - 55% In the absence of interventions, rates of HIV transmission from mother to child are between 15 and 45%

6. NEED OF PRECONCEPTIONAL CARE: By 1st antenatal visit ,organogenesis would have started. There lies the importance of preconceptional care and pregnancy planning. Dr. David Barker first popularized the concept of fetal origins of adult disease (FOAD) . Since its inception, FOAD has received considerable attention. The FOAD hypothesis holds that events during early development have a profound impact on one’s risk for development of future adult disease. Low birth weight, a surrogate marker of poor fetal growth and nutrition, is linked to coronary artery disease, hypertension, obesity, and insulin resistance. The ‘Developmental Origins of Health and Disease (DOHaD) ’ hypothesis, a rather more recent term for the concept initially proposed and called ‘Fetal Origins of Adult Disease’ in the 1990s, postulates that exposure to certain environmental influences during critical periods of development and growth may have significant consequences on an individual’s short and long-term health.In this concept, the developing fetus, if exposed to a hostile uterine environment (caused by insults such as poor nutrition, infections, chemicals, metabolite or hormonal perturbations) responds by developing adaptations (predictive adaptive responses—PARs) that not only foster its immediate viability, but also its survival if a similar environment is encountered later in life.

7. GOALS OF PCC Health Assessment: Preconceptional care begins with a thorough assessment of the individual's health status. This includes evaluating medical history, current health conditions, medications, and lifestyle factors that may affect fertility or pregnancy outcomes. Health Promotion: Preconceptional care emphasizes health promotion and disease prevention strategies to optimize fertility and pregnancy outcomes. This includes promoting healthy lifestyle behaviors such as proper nutrition, regular exercise, weight management, and avoidance of harmful substances like tobacco, alcohol and recreational drugs. Risk Identification: Healthcare providers identify potential risk factors that could impact the individual's ability to conceive or carry a pregnancy to term. These may include chronic medical conditions (such as diabetes or hypertension), genetic factors, lifestyle habits (such as smoking or substance abuse) and environmental exposures.

8. Screening and Vaccinations: Individuals may undergo screenings for infectious diseases (such as HIV, hepatitis B, and rubella) and receive vaccinations to prevent certain infections that could harm the mother or baby during pregnancy. Genetic Counseling and Testing: Preconceptional care may involve genetic counseling and testing to identify genetic conditions that could impact the health of the future child. This allows individuals to make informed decisions about family planning and potential interventions. Partner Involvement: Recognizing that reproductive health involves both partners, preconceptional care encourages the involvement of both individuals in the planning process. This may include discussions about family planning goals, shared decision-making and support for each other's health and well-being. Education and Counseling: Preconceptional care provides education and counseling on various topics related to pregnancy planning, including fertility awareness, prenatal vitamins (such as folic acid supplementation), the importance of prenatal care and strategies for a healthy pregnancy.

9. 2. Why is PCC practiced ? I mpact of preconceptional care on fertility

10. IMPACT OF PRECONCEPTIONAL CARE ON FERTILITY Preconceptional care has a significant impact on maternal health by improving overall health before pregnancy and addressing specific risk factors that can affect maternal well-being. Reduction of Maternal Complications: Preconceptional care aims to identify and manage chronic conditions such as diabetes, hypertension and obesity before pregnancy. By optimizing these conditions, the risk of complications during pregnancy such as gestational diabetes, preeclampsia and preterm birth can be reduced. Improvement of Reproductive Health: Preconceptional care includes screening for reproductive health issues such as sexually transmitted infections (STIs) and addressing them before pregnancy. Treating STIs can prevent complications such as pelvic inflammatory disease (PID) which can lead to infertility or increase the risk of ectopic pregnancy. Promotion of Healthy Pregnancy Weight: Achieving a healthy weight before pregnancy reduces the risk of complications such as gestational diabetes, preeclampsia and cesarean delivery. Preconceptional care encourages weight management strategies such as healthy eating and regular physical activity to support maternal health.

11. Prevention of Neural Tube Defects and Other Birth Defects: Preconceptional care includes recommendations for taking folic acid supplements before pregnancy to reduce the risk of neural tube defects such as spina bifida. Addressing other risk factors, such as exposure to teratogenic substances can also help prevent birth defects Improvement of Mental Health: Preconceptional care acknowledges the importance of mental health in maternal well-being. Addressing mental health concerns before pregnancy, such as anxiety or depression, can reduce the risk of postpartum depression and improve overall maternal health outcomes.

12. 3. How PCC is practiced ?

13. PRECONCEPTIONAL CARE AND COUNSELLING

14. Fear of incoming pregnancy is removed Preconceptional counselling is a part of preventive medicine Women should be urged to stop smoking, taking alcohol and abusing drugs. Addicted women is given specialised care. Educational classes include discussion as regard delivery, timing, method and possible interventions( Ventouse/forceps/ caesarean delivery) Counselling should be done by primary health care providers Help of an obstetrician, physician, geneticist may be required and should be extended PRECONCEPTIONAL EDUCATION

15. GENETIC DISEASES ACOG recommends counseling and offering to test for the following conditions in patients desiring pregnancy: Cystic fibrosis (everyone) Spinal muscular atrophy (everyone) Hemoglobinopathies (everyone, per an ACOG Practice Advisory from August 2022) Fragile X syndrome (anyone with a family history of fragile X-related disorders, including those with premature ovarian insufficiency younger than 40 years and those with intellectual disability suggestive of fragile X syndrome) Canavan disease and Familial dysautonomia (Ashkenazi Jewish descent) Tay-Sachs disease (Ashkenazi Jewish, French-Canadian, or Cajun descent or those with a family history) Other known genetic disorders in the patient or her family (individualized)

16. Families with histories of genetic disorders should be referred to a genetic counselor to discuss the risks of passing the condition on to their newborns. The genetic counselor can also educate the family on disorders that might impact fertility. Additionally, affected patients should be informed that reproductive technologies, such as preimplantation genetic diagnosis before in vitro fertilization are available options that may reduce the risk of passing abnormal genes to offspring. Referral to a reproductive endocrinology and infertility (REI) specialist is often appropriate d for interested couples in these cases.

17. यस्य यस्य हि अंगावयवस्य बीजे बीजभागे उपतप्तो भवति तस्य तस्य अंगावयवस्य विक्रुतिरुच्यते :न उपजायते च अनुपतापात् । (चशा ३/१७) GENETIC DISORDERS IN AYURVEDA

18. Patient or partner has a family history of a genetic condition Patient has had a previous pregnancy or child born with a genetic condition Patient or partner is a carrier for a genetic condition Patient or partner has a genetic condition that could be passed down to a child Patient or couple would like screening for genetic conditions prior to becoming pregnant Patient and partner are related by blood Patient has a history of recurrent miscarriages Patient is at an increased risk for specific age-related genetic conditions Women who are pregnant or are planning pregnancies who are aged above 35. GENETIC COUNSELLING For whom this is done?

19. Components of Preconception Genetic Counseling Genetic counseling has been defined by the Ad Hoc Committee on Genetic c ounseling of the American Society of Human Genetics as: A communication process that deals with the human problems associated with the occurrence, or the risk of occurrence of a genetic disorder in a family. Preconception genetic counseling is the process of genetic risk identification, patient education and patient empowerment. Its goal is to provide individuals and families with a specific genetic risk assessment and to furnish them with disease-related information and management options before conception. This knowledge may allow individuals and their providers to better plan and pursue various reproductive options. The process of genetic counseling involves communication, empathy, and respect for patient autonomy. Because the hypothesized end point of preconception genetic counseling is empowerment of the patient, accurate risk assessment, the provision of unbiased medical information and support for the patient's decisions.

20. PREGNANCY SPACING AND PLANNING Spacing between two pregnancies should be atleast 24 months which can lead to health benefits for the mother and baby. Spacing births allows the mother to recover physically and emotionally before she gets pregnant again and faces the demands of pregnancy, birth and breastfeeding. Limiting the number of children in a family means more resources for each child and more time for the parents to dedicate to each child. Family planning can also help couples in a sexual relationship not to be worried about the woman getting pregnant. STIs including HIV/AIDS can also be prevented with correct and consistent use of condoms. Younger women (adolescents) can delay pregnancy until their bodies are mature and they are ready in terms of their life course. Older women (over 35) can prevent unwanted pregnancies that are often risky for their health and can lead to complications for both mothers and infants.

21. Research suggests that beginning a pregnancy within six months of a live birth is associated with an increased risk of: Premature birth P lacental abruption Low birth weight Congenital disorders Schizophrenia Maternal anemia

22. निवत्तप्रसवायास्तु पुनः षड्भ्यो वर्षेभ्य ऊर्ध्वं प्रसवमानाया नार्याः कुमारोऽल्पायुर्भवित / PUNARGARBHA GRAHANA / SUBSEQUENT PREGNANCY The woman who has been relived of pregnancy (now) if she conceives again and delivers a child after a lapse of six years, such a child will be short lived (has short span of life) . This is a suggestion not to postpone the second pregnancy unduly long, beyond 6 years .

23. Patient with medical complications should be educated about the effects of the disease on pregnancy and also the effects of pregnancy on the disease. In extreme situations pregnancy is discouraged Pre existing chronic diseases (HTN, DM, Epilepsy) are stabilised in an optimal state by intervention Patients with chronic conditions such as seizure disorders, diabetes, cardiac or renal disease, autoimmune disorders, and other long-term illnesses should be referred to a high-risk obstetrical specialist (eg, Maternal-Fetal-Medicine) to discuss possible changes in medical management during pregnancy. MEDICAL HISTORY

24. DRUG HISTORY Drugs used before pregnancy are verified and changed if required, so as to avoid any adverse effect on the foetus during the period of organogenesis. For ex: Anti convulsant drugs are checked Warfarin replaced with Heparin Oral anti diabetic drugs replaced with insulin

25. Advanced maternal age describes a pregnancy where the birthing person is older than 35. Pregnant people over age 35 are more at risk for complications like miscarriage, congenital disorders and high blood pressure. MATERNAL AGE Complications of advanced maternal age: Preeclampsia. Gestational diabetes. Premature birth or low birth weight. Expecting twins. Miscarriage. Down syndrome or other genetic disorders. Cesarean section (c-section). Stillbirth.

26. AGE OF MARRIAGE AND CONCEPTION - AYURVEDA SUSRUTHA AH AS MARRIAGE MALE 25 20 21 FEMALE 16 16 12 CONCEPTION MALE 25 25 FEMALE 16 16 Consequences of Conception at VeryYoung/Old Age Very young or old women should not be impregnated. If a woman below 16 is impregnated by a man of below 25 either she will not conceive or intrauterine death of the foetus / If the child is born, it would not live long or will have weak organs, ill health, deformed body parts etc. 1. Early pregnancy increases the risk of NTD’S, IUGR, Preterm birth, Still birth etc. 2. Late pregnancy increases the risk of Down’s syndrome, Eclampsia, Macrosomia, Hydramnios etc.

27. Weight: Obese and Underweight Individuals Obesity is associated with multiple pregnancy-associated risks, including an increased risk for infertility, early pregnancy loss, gestational diabetes, hypertension, congenital birth defects, fetal macrosomia, cesarean delivery, delivery complications, endometritis, and venous thromboembolic events.Additionally, people who are obese have higher risks for chronic diseases outside of pregnancy, such as hypertension, pregestational diabetes, heart disease, and stroke, all of which can lead to additional complications in pregnancy. Women with a BMI greater than 30 should be considered for referral to a dietician ( 26.1- 29 kg/m 2 over weight above 29 obese ) Women with malnutrition and abnormally low BMIs ( <19.8kg/m 2 ) may be at risk for nutrient deficiencies that increase the risk for low birth weight infants and preterm labor. They should be given dietary counseling and considered for referral to a dietician.

28. ALL FOODS SHOULD BE FRESH AND ORGANICALLY GROWN/FED WHENEVER POSSIBLE so food is higher in nutritional value and lower in toxins. A healthy diet rich in fruits, vegetables, and whole grains should be encouraged. Patients should also be counseled to avoid excessive vitamin intake during pregnancy, especially with the fat-soluble vitamins A, D, E, and K, levels of which can build up in tissues and become toxic. Excess iodine is also associated with congenital goiter. PROTEIN: an average sized serving (equivalent to the palm of your hand) of protein-providing food at least 2x a day before conception and 3x a day during pregnancy. PROTEIN PROVIDING FOODS FISH – 3 times weekly- tuna, king mackerel, shark, sardines POULTRY – Trim the skin to avoid fats. EGGS – are an excellent source of protein. Limit their consumption only if they cause gastro-intestinal problems such as bloating & constipation or other allergy symptoms. DAIRY – Natural cultured non-flavoured yoghurt is good (unless hypersensitive to cows’ milk). Goats’ or sheep’s milk/cheese preferred. DIET GUIDELINES FOR PRECONCEPTION

29. LEGUMES/PULSES – Split peas, lentils, chickpeas, beans. NUTS/SEEDS – raw/unsalted/fresh CARBOHYDRATES Keep consumption to moderate levels and choose low glycaemic carbohydrates where possible (most non-starchy vegetables, pulses, whole (not refined) grains.) High glycaemic foods (eg. sugar, white/refined grains) can disrupt hormones. Refined carbohydrates also leach nutrients from your body’s stores which in turn increases your desire for these foods. VEGETABLES – lots every day. Should make up minimum 40% of total food intake. Organic whenever possible. Wide variety, especially dark green leafy / red and orange / avocado. Eat both raw and cooked regularly. Juices - carrot/celery/beetroot as a base (great way of ensuring adequate vegetable intake). Salads - use a wide variety of vegetables. FRUIT - 2 - 3 pieces daily, maximum (because of high sugar content). No dried fruit. GRAINS - Whole grain/ red rice PHYTO-OESTROGENS - If suffering from endometriosis, fibroids or hormone imbalance / eat regular ly/ moderate amounts of phyto-oestrogenic foods e.g. soy , cucumber , whole grain s, fennel , asparagus sprouts.

30. FOODS TO BE AVOIDED: SUGAR – avoid excessive intake of sugar ALCOHOL - avoid alcohol . Alcohol significantly lowers conception rates, is toxic to the foetus (Foetal alcohol syndrome) and leaches nutrients. SMOKING - Low birth weight(SGA), Abruptio placenta, preterm labor, miscarriage BEVERAGES COFFEE/TEA - avoid. Related to fertility/pregnancy/foetal health problems, including miscarriage. DAIRY – Avoid cows’ milk/cheese/ as it is linked to endometriosis/creates mucus in tubes and malabsorption.

31. Adequate folic acid supplementation before conception reduces the risk of a fetus having a neural tube defect (NTD). For individuals at average risk, 400 micrograms daily initiated at least 1 month before conception is recommended. Individuals at higher risk for having a fetus with an NTD include those with a medical history of seizure disorders or NTD, a previous pregnancy with an NTD. For pregnancies at higher risk of NTD, 4 mg of folic acid once daily starting 3 months before conception and continued through 12 weeks of gestation is recommended S ome studies have shown high-dose supplementation reduce the risk of NTD by as much as 70%. FOLIC ACID SUPPLEMENTATION

32. IMMUNIZATIONS Measles-Mumps-Rubella (MMR): rubella vaccines should be given at least 28 days before conception. Varicella: vaccine should be given at least 28 days before conception. Because this is a 2-dose course, vaccination should begin 2 months before attempting conception. Hepatitis B Meningococcus Pneumococcus (if appropriate) Human papillomavirus (HPV): vaccine should not be delayed while attempting to conceive; if a person becomes pregnant during their HPV series, the series can be paused and resumed after pregnancy. Annual influenza vaccination Rubella, also called German measles, during pregnancy this disease can severely affect the developing fetus with possible blindness, heart defects, hearing defects, musculoskeletal defects and mental retardation. Varicella infection in pregnancy can cause bacterial infections of the skin and soft tissues in children, including Group A streptococcal infections. Infection of the lungs (pneumonia) Infection or swelling of the brain (encephalitis, cerebellar ataxia) Bleeding problems (hemorrhagic complications)

33. STI and Cervical Cancer Screening Patients should be screened for STIs and cervical cancer according to standard guidelines. Based on patient age and other risk factors, consider screening patients for chlamydia, gonorrhea, syphilis, HIV, and hepatitis B and C. Chlamydia has been linked to preterm labor, low birth weight and eye and lung infections. Gonorrhea can lead to miscarriages, premature birth and low birth weight. Syphilis has also been linked to premature birth, as well as stillbirth and problems with multiple organs including the baby's brain, heart, skin, eyes, ears, teeth, and bones

34. REGIMES TO BE FOLLOWED Exercise Woman should be advised to exercise regularly to improve overall health, reduce cardiovascular risks, and help maintain a healthy weight. ACOG recommends moderate-intensity exercise / at least 30 minutes a day / 5 days per week / before, during, and after pregnancy. Meditation Meditation is one of the tools widely used to release hormones that help during the fertility journey, pregnancy and birth. One of these hormones is cortisol, the hormone “guilty” for creating stress. By meditating the level of cortisol can be reduced.

35. Preconceptional Yoga &Pranayam In the way to regulate apaan a vayu some pranayam and aasan are indicated for both male and female. Pranayam - kapal bhati, naadi Shoshana,bhramari. Aasana for female- paschimottanasana, pavan mukadama, shavasana, bhujangasana, hastapadasana etc. Aasana for male - sarvangasana, matsyasana, ardha- matsyendrasana, bhujang asaan,adhomukhdehavasan etc.

36. INVESTIGATIONS

37. Physical exam ination – A detailed exam measures height, weight, blood pressure as well as checks all your systems such as your cardiovascular system, your lungs, abdomen and looks for signs of any medical condition in any other system. Gynaecological exam ination – This will include a genital examination for signs of any sexually transmitted infection (STI) or growths. Also a PAP smear test will be advised to screen for cervical cancer and an HPV test. A pelvic exam may also be done to check for any lumps, masses or tenderness. Urine test – Routine examination of the urine will reveal the presence of urinary tract infection. Blood test – H aemoglobin count , vitamin D levels , Rh factor, rubella titre, varicella titre, tuberculosis, hepatitis B titres ( health care worker), cytomegalovirus titres, toxoplasmosis titres , thyroid function, and sexually transmitted diseases. GENERAL INVESTIGATIONS

38. An Ultrasound (USG) of the abdomen will be advised to check for growths or cysts in the ovaries and uterine size or the presence of fibroids. Other tests that may be requested depending on your clinical examination may include an ECG or 2D Echo Genetic disorder screening – a genetic disorder screening may be recommended. This will help determine if you face the risk of passing on a genetic disorder, such as Fragile X syndrome, cystic fibrosis or sickle cell disease.

39. Karyotyping is a test to examine chromosomes in a sample of cells. This test can help identify genetic problems. KARYOTYPING

40. 4. When to do PCC ?

41. Preconception care covers the period before first pregnancy occur s and between two pregnancies. The preconception period (3 to 6 months prior to pregnancy) is the time to make life changes that can help boost fertility, reduce problems during pregnancy and assist in recovery from birth.

42. In 2012 WHO organised a meeting to develop global consensus on preconception care to reduce maternal and childhood mortality and morbidity. The meeting report provides information and perspectives on alternative definitions, sensitive issues, target groups, delivery mechanisms and specific regional considerations. Maximizing the gains for maternal and child health - GENEVA 2012 Preconception care can make a difference

43. The report most importantly provides the evidence based package of interventions addressing 13 various areas as below:

44. PROGRAMMES RELATED TO PCC

45. The National Preconception Health and Health Care Initiative (PCHHC) is a public-private partnership of over 70 organizations focused on improving the health of young women and men and any children they may choose to hav e. Preconception health and health care (PCHHC) has gained increasing popularity as a key prevention strategy for improving outcomes for women and infants, both domestically and internationally. Ministry of Health and Family Welfare launched the India Newborn Action Plan (INAP) in September 2014, which included PCC

46. GARBHADHANA VIDHI स्त्रीपुंसयोरव्यापन्नशुक्रशोणितगर्भाशययोः श्रेयसी प्रजामिच्छतो । (C.Sha. 8:3) Atulya-Gotriya Acharya Charak describes -For marriage the women should be belong to the same community but of different gotra (different family lineage) only then an intelligent and healthy child is born. The reason for this might be to reduce the risk of hereditary disease and to avoid congenital anomalie s.

47. RAJASWALA CHARYA Follicular development starts from the 1st day of the bleeding phase. Thus our RAJASWALA CHARYA is of atmost important in preconceptional health. ततः पुष्पेक्षणादेव कल्याणध्यायिनी त्र्यहम् ॥ २३॥ मृजालङ्कारराहिता दर्भसंस्तरशायिनी | क्षैरेयं यावकं स्तोकं कोष्ठशोधनकर्षणम् ॥ २४॥ पर्णे शरावे हस्ते वा भुञ्जीत ब्रह्मचारिणी। कल्याणध्यायिनी - should be in pleasant mood (saumanasyam garbhadharananam srestam) thus do not disrupt the hormonal mechanism मृजालङ्कारराहिता - She should not adorn herself with ornaments to avoid sexual attraction. दर्भसंस्तरशायिनी - darbha is nidra janaka, sramahara and facilitate easy flow of blood कोष्ठशोधनकर्षणम् - Food should be laghu, sitam, vatanulomana (sodhana) Food should be taken in पर्णे / शरावे / हस्ते - This is the restrict the amount of food. Thus kapha dosha do not aggravate(PCOS)

48. GARBHADHANA VIDHI 1st in 16 samskaras. PURVA SAMYOGA VIDHI: This is to ensure that the couple enters into pregnancy with an optimal stage of health It is the time to identify the risk factors that could affect the pregnancy or perinatal outcome अथाप्येतौ स्त्रीपुंसौ स्नेहस्वेदाभ्यामुपपाद्य, वमनविरेचनाभ्यां संशोध्य, क्रमेण प्रकृतिमापादयेत् । संशुद्धौ चास्थापनानुवासनाभ्यामुपाचरेत्; उपाचरेच्च मधुरौषधसंस्कृताभ्यां घृत- क्षीराभ्यां पुरुषं, स्त्रियं तु तैलमाषाभ्याम्'| Sneha sweda followed by vamana and virechana, then peyadi krama done. After elimination of dosas couples should be given asthapana and anuvasana types of enema. Man should be given ghrta and kshira with sweet drugs and women fed with taila masha.

49. 2 type of sodhana Bahya sodhana: sneha sweda followed by vamana virechana vasti Abhyanthara sodhana: soumanasyam etc DIET: MALE : SHALI + KSHEERA + GHRTA Shali: tridosa shamaka, vrishya, madhura vipaka and rasa snigda Ksheera : madhura rasa and madhura vipaka, shleshmala. Thus increase sukra Ghrta : रस शुक्र ओजयो hitam, rasayanam Thus these diets increase sukra in male partner FEMALE: TAILA + MASHA Taila : tridosha shamaka, yoni vishodhanam Masha : pitta kara property and ushna virya of masha increase arthava It contains vitamins B, folic acid, magnesium, iron & calcium which are all essential factors for conception

50. PSYCHOLOGICAL MAKEUP Sadhvrtachara Mano anukula kadha sravana su vadhya ghosham Avoid krodha, shoka, bhaya etc Anyonya and abhikamata Sumana and kalyana kamana Sukla vastra- tranquility, satwa guna pradhana Favourable external environment and sound interpersonal relations described in our classics prove well in dealing with sexual dysfuctions.

51. Abnormal coitus position: Left lateral position (Vamam) –pitta gets aggravate. Right lateral position (Dhakshinam) –kapha gets aggravate. Nyubjam: Vata gets aggravated Normal: Supine position (Uthana) –all doshas in equilibrium. ACHARYA DAYS SU 1st 3 days + 13th day AS 1st 3 days + 11 and 13th day AH 1st 3 days + 11th day DAYS TO AVOID COITUS

52. Preconception care: a means of prevention

53. THANKS