My name is Badenan Ibrahim Fathulla and I am delighted to be writing my second article for Nina. I am currently working as a specialist obstetrician and gynecologist at the Royal Free Teaching Hospital in London. You may remember in my introductory piece I shared that my vision is to help women in poorly resourced places to have a better quality of life. I feel passionately that creating practical guidance ‘sheets’, with information on what we women need to know and do to maintain better health is critical. The ultimate aim is to deliver an up to date information and advice section in a way that is accessible and relevant, as well as being beneficial to the wider family and community also.
In the first part, dealing with issues of preconception, I spoke about relationships, lifestyle choices and physical environment. In this, the second part, I am discussing medical issues, including necessary immunizations, medication and chronic health problems and how to deal with these when planning a healthy pregnancy.
Please note: All information contained in this article is based on best practice in the UK, with some modifications for women in Iraq, particularly taking in consideration the culture and available resources. Anything you read in my column is up to date and evidence based. However, please be aware that health practices and research are subject to change. I welcome questions, and you can find my Email contact to ask these below.
What is preconception health and why is it important?
Preconception health is a woman’s health before she becomes pregnant. It means knowing how health conditions and risk factors could affect you and your unborn child. These can include foods, lifestyle ‘habits’ and medicines. Certain existing health problems can also significantly affect pregnancy and you need to know how to deal with these.
Essentially, by the time you realize you are pregnant, much of the early development of the embryo (child in the womb) will already have happened; any intervention past these early weeks is therefore likely to be too late. By taking action on health issues and risks before pregnancy, you can prevent problems that might affect you or your baby later.
Half of pregnancies are unplanned and are therefore at greater risk of complications. By taking preconception health seriously and planning ahead, you promote your health as well as giving your child a good start. I, of course, believe that every woman should be thinking about her health whether or not she is planning a pregnancy. However, women are more motivated prior to pregnancy than any other time to achieve changes. I have put together some things you might like to consider in order to help you build a positive parenting future.
- Medication, Supplements
- Medication review
- It is important to minimize the exposure to all non-essential drugs.
- Do not use any medication unless needed and under medical supervision. The foetus is at its most vulnerable to the harmful effects of certain drugs and in the very early stages of pregnancy a woman is not always aware of her condition.
- Avoid herbal preparations as there is no available data to support safe use in pregnancy.
- Are vitamin and mineral supplements necessary?
If your diet is heathy and varied you should get all the vitamins and minerals your body needs. However, some vitamins and minerals are especially important for a healthy pregnancy; e.g. folic acid, vitamin D, iron, vitamin C, and calcium.
These are things to consider:
- You need to search and find the list of the foods, which are rich in the above vitamins and minerals.
- You need to take the recommended dose of folic acid, may need a vitamin D* supplement, and possible vitamin B12 if you are vegetarian.
- If you have had gastric surgery, have coeliac disease or are on restricted diet, you may need additional supplements. Discuss this with your doctor.
- Vitamin A supplement or any supplements containing more than 10.000 IU of vitamin A are dangerous, so ensure these are removed from any multivitamin supplements. You should also not be taking fish liver oil supplements.
*NB: If you are wearing a covered dress (Hijab) you will not have enough exposure to the sun. It is therefore more likely you will be deficient in vitamin D. Ensure you have a regular level checks and proper supplements.
Check your immunity – certain infections could harm your baby.
You should ask your family about your previous illness and immunization and record them. If you are not immunized, you should not get pregnant before receiving all the necessary and clinically indicated immunizations one month prior to the pregnancy.
You need to check your immunity to Rubella (German Measels) before getting pregnant. Rubella in pregnancy causes miscarriage and damages the baby.
- If you do not have a history of chicken pox or shingles check your immunity against Varicella. Infection in pregnancy may cause congenital fetal syndrome.
- If you are a health care worker with direct patient contact, take particular care to check your immunity. If you are not immune, ensure you receive varicella one month before attempting conception.
If you are a health care worker, have had multiple sexual partners, have been a visitor to endemic areas or have been an Intravenous drug user, you must ensure that you are tested for hepatitis B. If not infected get immunized!
- The Influenza Vaccine – and do you need it?
Pregnant women are at increased risk of influenza infections complications. It is recommended that women who become pregnant during the influenza season receive the vaccine; regardless of the stage of pregnancy. Pregnant women are also encouraged to have the swine flu vaccine where available.
- Existing medical conditions and their impact
You need to be as healthy as possible before pregnancy, especially if you have a chronic medical condition. Many medical conditions and their treatments might have implications for fetal well-being. Pregnancy can also cause some medical conditions to deteriorate further. You need to see specialist with a particular interest in problems in pregnancy. They will be able to give you evidence based advice. Your doctor will also need to review and even change some of your medication. You must therefore ensure continuation of contraception until you finish all your medical check-ups and medication control.
So that you know what to look out for, please find advice about some of the most common medical conditions and areas for consideration below.
Miscarriages are common and occur in 20%-30% of clinically diagnosed pregnancies. Even if you have miscarried previously, your chance to have a successful pregnancy is still very high. Even if you have had three or more consecutive miscarriages, your chance of a successful fourth pregnancy is still 60-75%. It is worth considering visiting a gynecologist who is especially interested in recurring miscarriages. They may be able to run some tests before your next pregnancy.
Avoid having unplanned pregnancy with diabetes; there are significant risks to you and your unborn child. Before any pregnancy educate yourself about your diabetes. You should be familiar with your medication, the blood sugar target concept, how to monitor your blood sugar and how to adjust your diet accordingly. You need to consider the following issues before getting pregnant:
- If your BMI is above 27 you must try to lose weight.
- You need to see a diabetic physician and an obstetrician. Both should be interested – and specialized in – looking after diabetic pregnant women.
- Although good diabetic control before pregnancy reduces the risks of miscarriage, congenital malformations, stillbirth and neonatal death they are not eliminated.
- You need to have an eye check and renal function check before getting pregnant.
- You should check your diabetic status before getting pregnant by doing a blood test called HbA1c. This test will show us how well controlled your diabetes has been over the previous two months. The figure should be kept below 6.1%. If HbA1c is above 10% you should avoid pregnancy as the risk of having congenitally abnormal baby is too high.
- Discontinue any oral hypoglycemic agent except Metformin, which has very good safety profile.
- You might need to use Insulin in pregnancy if your blood sugar remains poorly controlled. This chance is lower if you have well-controlled diabetes prior to pregnancy and a healthy life style, including healthy food and daily exercise.
- You need to check for co-existing thyroid disease and thyroid antibodies if you have type 1 diabetes.
- Review your medication with your doctor. Many diabetic women take ACE inhibitors, which need to be stopped prior to pregnancy. You also need to stop Statin medications.
- Ensure you take 5mg folic acid daily, three month prior to pregnancy.
- Hypertensive disorders(high blood pressure) in pregnancy
- Hypertension is a major cause of maternal, fetal, neonatal morbidity and mortality in both developing and developed countries. Hypertension is the most common medical problem in pregnancy and includes chronic HT, gestational HT, and Pre-eclampsia. However, most women with pre-existing mild to moderate hypertension (BP less than 160/110 mm Hg) are at low risk of perinatal complications. The risk of complications, are increased in severe hypertension.
- You need to have your medication reviewed as some of the antihypertensive medicines are not recommended in pregnancy and might cause congenital anomalies (birth defects). Calcium supplementation appears to reduce the risk of high BP in pregnancy, particularly for women at high risk of gestational hypertension and in communities with low dietary calcium intake.
- What you should know if you suffer from Epilepsy?
- Luckily anti-epileptic medication does not mean that you cannot enjoy a healthy pregnancy or normal labor. However, do be aware that there is a slightly higher risk of complication compared to women who do not have epilepsy.
- See your neurologist and review your medication with him. It is better to control your disease with just one type of medication, rather than many different preparations. You need to continue with your contraceptive method until the anti-epileptic dose has been adjusted.
- Don not stop your medication unless advised by your neurologist.
- You need to take 5mg of folic acid daily, three months prior to conceiving.
- Chronic cardiac disease
- If you have chronic heart disease you need to see the cardiologist for an accurate diagnosis and a functional assessment; this ensures that risks to you and your child can be identified.
- You need to continue your contraception until you finish all your assessments and investigations. Do not discontinue taking t heart medication unless advised by your cardiologist. The functional capacity of your heart prior to pregnancy is the best predictor for your heart’s ability to tolerate pregnancy.
- In very rare cases, such as severe heart disease or low heart capacity for example, your cardiologist might advise against pregnancy.
- Thyroid disease
- You need to check your thyroid if not done in the previous six months, and optimize your treatment before getting pregnant. Failure to achieve this will cause infertility, miscarriage and potentially a growth restricted and intellectually challenged baby. Your thyroid specialist might need to readjust your medication dosage, as the need for thyroid hormone is increased in pregnancy. If you start the early days of your pregnancy with thyroid doses that are lower than needed, your baby might be compromised.
- If you need to have radioactive iodine and surgery ensure this happens prior to pregnancy.
Continue your medications and contraception until you see your renal team and have an up to date assessment. Severe renal disease is associated with infertility and renal function might deteriorate in pregnancy, thus jeopardizing fetal survival. Renal disease during pregnancy is associated with risk of prematurity, intrauterine growth retardation. If you have progressive renal disease, it is better to complete childbearing whilst renal functions are preserved.
- Clot formation (venous thromboembolism)? How much you know about your family?
- If you, or member of your close family, have a history of clot formation you need a risk assessment prior to pregnancy. It may be that you need to start treatment as soon as possible – as pregnancy increases the risk of clot formation significantly.
- If you had clot in the past and are on Warfarin medication, you will need to see the hematologist who will change the Warfarin to another anti-clotting medication which is safe in pregnancy.
- You should not stop your medication unless advised by your doctor. Modern anticoagulant medication is safe in pregnancy and will not harm your baby
- Pregnancy does not influence the severity of asthma. In the majority of women asthma is well controlled and has no adverse effect on pregnancy. Asthma medications are safe in pregnancy.
- Poorly controlled asthma is more risky than the medication used to control it. Decreasing the medication or stopping it is a risk factor. If your symptoms are not well controlled you might need to either to increase the dose or the frequency of the inhaled steroid. If your asthma is not well controlled you must visit see a specialist to review your condition.
It is essential you see your rheumatologist to review your medication; you also need to continue using an effective contraceptive method whilst taking your medication. Some anti-rheumatic medication can continue to have physical effects long after you have stopped taking it and may therefore need to be discontinued several months before a planned conception.
- What you need to do if you have a history of mental health problems?
- You need to see your psychiatrist and express your wishes to get pregnant. He need to assess the safety of the current medication in pregnancy, and the possibility of switching to more appropriate for use during pregnancy. Continue your contraception until you are fully reviewed by your psychiatrist.
- Do not stop taking your medication unless otherwise directed by psychiatrist.
- Discuss your concerns, including any social and domestic issues, with your doctor.
- Ask for help!
- We might consider giving you a low dose of aspirin in pregnancy for other medical conditions like pre-eclampsia. This can cause breathing difficulties in a minority of women. If you ever had such aspirin sensitivity, inform your doctor before taking it.
As I said in my first column, starting today, here at nina-iraq, we have a platform we can speak from. We can use it to share the knowledge we do have. If you have any questions you can contact me directly. If you have anything you would specifically like me to address moving forwards please also get in touch at [email protected]. I look forward to hearing from you!