Before, during and after your maternity

The best time to begin eating a healthy diet is before you become pregnant. Balanced and safe food supplement will help you and your baby start out with the nutrients you both need.

Pregnancy is a critical period during which good maternal nutrition is a key factor influencing the health of both mother and child. Risk of complications during pregnancy or delivery is lowest when prenatal weight gain is adequate.

I trimester: gynecological examination, blood pressure and weight check colposcopy, Pap test, cervical and vaginal smear tests ultrasonic examination laboratory analysis (biochemical, urine, blood, blood group and Rh factor)

II trimester: gynecological examination for potential placement of cerclage, blood pressure and weight check ultrasonic examination biochemical screening, AFP control (alpha fetoprotein) for pregnant women older than 35 for Rh negative mothers, antibody control 23 ng Doppler ultrasonic examination laboratory analysis (blood sugar, urine culture)

III trimester: blood pressure and weight check ultrasonic examination cardiotocography (CTG), Doppler if necessary laboratory analysis (blood sugar, urine culture)

Proper nutrition is important after delivery to help the mother recover and to provide enough food energy and nutrients for a woman to breastfeed her child. Women having serum ferritin <= 70 μg/L may need iron supplements to prevent iron deficiency anaemia during pregnancy and postpartum.

Immunization

Human papillomavirus (HPV)

Women should be screened routinely for HPV-associated abnormalities of the cervix with cytologic (Papanicolaou) screening. Recommended subgroups should receive the HPV vaccine for the purpose of decreasing the incidence of cervical abnormalities and cancer.
By avoiding procedures of the cervix because of abnormalities caused by HPV, the vaccine could help maintain cervical competency during pregnancy.

Hepatitis B

All high-risk women who have not been vaccinated previously should receive hepatitis
B vaccine before pregnancy; women who are chronic carriers should be instructed on ways to prevent transmission to close contacts and how to prevent vertical transmission to their babies.

Varicella

Because the varicella vaccine is contraindicated during pregnancy, screening for varicella immunity (by either a history of previous vaccination, previous varicella infection verified
by a healthcare provider, or laboratory evidence of immunity) should be done as part of a preconception visit. All nonpregnant women of childbearing age who do not have evidence of varicella immunity should be vaccinated against varicella.

Measles, mumps, and rubella

All women of reproductive age should be screened for rubella immunity. Immunization should be offered to women who have not been vaccinated or who are not immune and who are not pregnant. Women should be counseled not to become pregnant for 3 months after receiving vaccination. This vaccination will provide protection against measles, mumps, and rubella.

Influenza

Influenza vaccination is recommended for women who will be pregnant during influenza season and for any woman with increased risk for influenza-related complications, such as cardiopulmonary disease or metabolic disorders, before influenza season begins.

Diphtheria-tetanuspertussis vaccination

Women of reproductive age should be up-to-date for tetanus toxoid, because passive immunity is probably protective against neonatal tetanus. The diphtheria-tetanuspertussis vaccine is recommended for women who might become pregnant or immediately after delivery to avoid complications of pertussis in the newborn infant.

Infectious disease

Hepatitis C

There are no data that preconception screening for hepatitis C in low-risk women will improve perinatal outcomes. Screening for high-risk women is recommended. Women who are positive for hepatitis C and desire pregnancy should be counseled regarding the uncertain infectivity, the link between viral load and neonatal transmission, the importance of avoiding hepatotoxic drugs, and the risk of chronic liver disease. Women who are being treated for hepatitis C should have their reproductive plans reviewed and use adequate contraception while on therapy.

Toxoplasmosis

There is no clear evidence that preconception counseling and testing will reduce
Toxoplasma gondii infection or improve treatment of women who are infected. However, if preconception testing is done, women who test positive can be reassured that they are not at risk of contracting toxoplasmosis during pregnancy; women who are negative can be counseled about ways to prevent infection during pregnancy. For women who convert during pregnancy, treatment should be offered.

Chlamydia

All sexually active women ≤ 25 years and all women at increased risk for infection with Chlamydia (including women with a history of STI infections, new or multiple sexual partners, inconsistent condom use, sex work, and drug use) should be screened at routine encounters before pregnancy

Herpes simplex virus

During a preconception visit, women with a history of genital herpes should be counseled about the risk of vertical transmission to the fetus and newborn child; women with no history should be counseled about asymptomatic disease and acquisition of infection. Although universal serologic screening is not recommended in the general population, type-specific serologic testing of asymptomatic partners of persons with genital herpes is recommended.

Medical conditions

Diabetes mellitus

All women with diabetes mellitus should be counseled about the importance of diabetes mellitus control before considering pregnancy. Important counseling topics include maintaining optimal weight control, maximizing diabetes mellitus control, selfglucose monitoring, a regular exercise program, and tobacco, alcohol, and drug cessation, along with social support to assist during the pregnancy. In the months before pregnancy, these women should demonstrate as near-normal glycosylated hemoglobin level as possible for the purpose of decreasing the rate of congenital anomalies. Women with poor control of their diabetes mellitus should be encouraged to use effective birth control. Testing to detect prediabetes and type 2 diabetes in asymptomatic women should be considered in adults who are overweight or obese (BMI ≥ 25 kg/m²) and who have 1 or more additional risk factors for diabetes, including a history of gestational diabetes mellitus.

Thyroid disease

Women with hypothyroidism should be counseled about the risks of this condition to pregnancy outcomes and the importance of achieving optimal replacement therapy before conception. All women with symptoms of hypothyroidism should be screened for thyroid disease; if there is hypothyroidism, adequate therapy should be initiated.

Hypertension

Women of reproductive age with chronic hypertension should be counseled about the risks associated with hypertension during pregnancy for both the woman and her offspring and the possible need to change the antihypertensive regimen when she is planning a pregnancy. Women with hypertension for several years should be assessed for ventricular hypertrophy, retinopathy, and renal disease before pregnancy. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are contraindicated during pregnancy; women who could become pregnant while taking these medications should be counseled about their adverse fetal effects and should be offered contraception if they are not planning a pregnancy. Women who are planning a pregnancy should discontinue these medications before pregnancy

Thrombophilia

Providers may consider screening women of childbearing age for a personal or family history of venous thrombotic events or recurrent or severe adverse pregnancy outcomes. Women with a personal or family history suggestive of thrombophilia may then be offered counseling and testing for thrombophilias if they are contemplating pregnancy. Screening for thrombophilias with laboratory testing in routine care is not recommended. Women of reproductive age with a known genetic thrombophilia should be offered preconception genetic counseling to address the risk of the condition to the offspring. Women of reproductive age with a thrombophilia whose treatment regimen involves warfarin should be counseled about its teratogenic nature; whenever possible, the treatment should be changed to a less teratogenic anticoagulant before conception.

Psychiatric condition

Depression/anxiety

Providers should screen and be vigilant for depression and anxiety disorders among women of reproductive age because treating or controlling these conditions before pregnancy may help prevent negative pregnancy and family outcomes. Women of reproductive age with depressive and anxiety disorders who are planning a pregnancy or who could become pregnant should be informed about the potential risks of an untreated illness during pregnancy and about the risks and benefits of various treatments during pregnancy.

Parental exposure

Alcohol

All women of childbearing age should be screened for alcohol use, and brief interventions should be provided in primary care settings, which should include advice regarding the potential for adverse health outcomes. Brief interventions should include accurate information about the consequences of alcohol consumption, which should include the effects of drinking during pregnancy, information about effects beginning early during the first trimester, and warnings that no safe level of consumption has been established. Women who show signs of alcohol dependence should be educated about the risks of alcohol consumption; for women who are interested in modifying their alcohol use patterns, efforts should be made to identify programs that would assist them in achieving cessation and long-term abstinence. Contraception consultation and services should be offered and pregnancy should be delayed until it can be an alcohol-free pregnancy.

Tobacco

All women of childbearing age should be screened for tobacco use. Brief interventions should be provided to all tobacco users and should include brief counseling that describes the benefits of not smoking before, during, and after pregnancy; discussion of medication; and referral for more intensive services (individual, group, or telephone counseling) if the woman is willing to use these services. For pregnant women, augmented counseling interventions should be used

Illicit substances

A careful history should be obtained to identify use of illegal substances as part of the preconception risk assessment. Men and women should be counseled about the risks of using illicit drugs before and during pregnancy and offered information on programs that support abstinence and rehabilitation. Contraception services should be offered, and pregnancy should be delayed until individuals are drug free.

Family and genetic history

All individuals

All women who are considering pregnancy should have a screening history in the preconception visit. Providers should ask about risks to pregnancy on the basis of maternal age, maternal and paternal medical conditions, obstetric history, and family history.
Ideally, a 3-generation family medical history should be obtained for both members of the couple, with the goal of identifying known genetic disorders, congenital malformations, developmental delay/mental retardation, and ethnicity. If this screening history indicates the possibility of a genetic disease, specific counseling should be given, which may include referral to a genetic counselor or clinical geneticist.

Family history

Individuals identified as having a family history of developmental delay, congenital anomalies, or other genetic disorders should be offered a referral to an appropriate specialist to better quantify the risk to a potential pregnancy.

Previous pregnancies

If at least 1 member of a couple has a known chromosomal anomaly, in vitro fertilization with preimplantation genetic diagnosis should be discussed.

Known genetic conditions

Suspected genetic disorders may require further work-up prior to conception. Known or discovered genetic conditions should be optimally managed before and after conception.

Risk factors for depressive symptoms during pregnancy⁽¹⁷⁾

Depression is one of the most common complications in pregnancy. As many as 12.7% of pregnant women experience a major depressive disorder. Several professional organizations now recommend routine screening for antepartum depression. In fact, the American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression during each trimester of pregnancy.

Maternal anxiety

In the general population, depression and anxiety are highly comorbid, with almost 60% of individuals with major depression also meeting criteria for an anxiety disorder. In this review, 11 studies evaluated the relationship between maternal anxiety and depression. Anxiety showed one of the strongest associations with antepartum depressive symptoms. On average, anxiety during pregnancy had a medium-tolarge correlation with depressive symptoms in bivariate analysis.

Life stress

Eighteen studies assessed life stress as a potential predictor of antepartum depression. When considering all measures of stress, increased stress showed a medium association with depressive symptoms in bivariate and multivariate analyses. For example, in 1 study of 3011 women, those with ≥2 stressful life events within the past year were 3 times as likely to have an elevated Edinburgh Postnatal Depression Scale score. Stress can be measured in a variety of ways, and the most common conceptualizations of stress in our sample were life events (n = 15 studies) and daily hassles (n = 5 studies). Life events refer to psychologically significant events that occur in a person’s life, such as a divorce or death in the family. In addition, life events may be perceived as positive or negative. When considering all types of life events, there was a small-to-medium association in bivariate analysis but inconsistent results in multivariate analysis. However, negative life events were significantly associated with an increase in depressive symptoms in both bivariate and multivariate analyses.

Social support

In total, >20 articles addressed the relationship between social support and depressive symptoms during pregnancy Seventeen studies assessed total social support from any source. On average, these studies demonstrated a medium correlation between a lack of social support and depressive symptoms. In multivariate analysis, the average effect size was small. In addition, 9 studies specifically addressed intimate partner support. These studies demonstrated that a lack of partner support is also significantly associated with increased risk of depressive symptoms during pregnancy. In fact, lack of partner support showed 1 of the strongest associations in bivariate and multivariate analyses (medium-to-large effect).

Socioeconomic status

Five studies assessed measures of composite SES, such as the Hollingshead Index (which considers occupation and education). In bivariate and multivariate analyses, there was no significant association between SES and depressive symptoms. Inconsistent results were found for 3 subcomponents of SES: income, employment, and education. Lower income had a small correlation with depressive symptoms in bivariate analysis. However, only 2 studies addressed income in multivariate models. Lower educational attainment demonstrated a small association in bivariate studies, but it was not significantly associated with depressive symptoms in our multivariate analysis. Finally, unemployment was not significantly associated with depressive symptoms in bivariate analysis, and the research was inconsistent among multivariate studies.