Care plan
on Management Level of Level of care
personnel
I – IV ● Refer to appropriate MO/ FMS/ Health Clinic /
– IV disciplines – Physician/ Hospital ±
specialist
multidisciplinary Cardiologist
approach
● Management
according to Clinical
Practice Guideline
Heart Disease in
Pregnancy 2016
● Family counselling
sessions with
emphasis on
contraception must be
given.
● Discuss and educate
risk of pregnancy with
cardiac disease
rnal death. Pregnancy increases cardiac workload by approximately 30%
tum period. Diseased hearts may not be able to withstand this load.
of foetal congenital heart disease is approximately 4%. This is significantly
low-up at cardiology clinics should be given pre pregnancy counselling.
l stenosis, severe aortic stenosis)
6 Released May 2023
e. Non-resolved peripartum cardiomyopathy of pr
Since termination of pregnancy should be considered
specialists should be made.
5. Therapeutics:
a. Antiarrhythmic and anti-coagulation drugs shou
i. Most antiarrythmic drugs are well-tolera
ii. Warfarin use is associated with an incre
foetal loss (approximately 10%). Wom
miscarriage and foetal demise
b. Anti-failure medication (e.g., digoxin and diuret
c. ACE inhibitors are contraindicated in pregnanc
d. Statins are generally contraindicated howev
hypercholesterolemia, hydrophilic agents shou
i. Lipophilic: Atorvastatin, lovastatin, and s
ii. hydrophilic: pravastatin, rosuvastatin, an
(*Lipophilic statins cross the blood-brain barrie
However, this is rare.)
e. Low dose aspirin (100 – 150 mg OD) is safe in
usually higher. Dose may need to be lowered
bleeding and transfusion
f. Beta blockers are the gold standard treatmen
instances, they should be continued. However,
47
regnancy
d in unplanned pregnancy in the above conditions, early referral to O&G
uld be thoroughly discussed
ated and generally safe
eased risk of foetal anomalies (estimated at 5-10 %) and a high risk of late
men requiring lifelong warfarin therapy should be counselled on risk of
tics) can be continued in pregnancy
cy but are safe during breastfeeding
ver if it is necessary for patients with coronary artery disease and
uld be preferred over lipophilic ones
simvastatin
nd fluvastatin
er more readily, which may lead to central nervous system complaints.
n pregnancy and breastfeeding. However, the dose for cardiac disease is
d during pregnancy towards term (36 weeks) due to increased risk of
nt for fixed output lesions such as mitral and aortic stenosis. In these
, prophylaxis beta blockers should be discontinued.
7 Released May 2023
SOP 4: THYROID DISEASE
Assessment Lab investigations Classific
and PE findings
● Hypothyroid and ● FBS ● Euthyr
hyperthyroid ● Lipid profile ● Hypert
symptoms ● TSH/free T4/free ● Hypoth
● Stability of thyroid T3
disease on ● ECG
treatment ● Blood pressure
● FBC
● Neck ultrasound (if
indicated)
1. When disease is well-controlled, pregnancy is usually unc
preterm labor and intrauterine foetal death (IUD)
2. Antibody positive hyperthyroidism can cause foetal thyrot
3. Complications of pregnancy such as UTI, labour or Cae
disease
4. If conception occurs in uncontrolled disease, therapy suc
disease may take months and pose risk to the feotus
5. Women who have been treated for years with antith
consideration for radioactive iodine (RAI) or surgical ma
advised to await resolution of disease and weaning off of
6. If unable to wean off medications, RAI can be considered
to the feotus
7. Weigh the risk and benefits of therapeutic agents of choic
detrimental to foetal and maternal health.
8. Explain increased vigilance is required in pregnancy w
combined clinics and fetomaternal specialists
48
Care plan
cation Management Level of Level of care
personnel
roid ● Refer to appropriate MO/FMS/ Health Clinic/
thyroid disciplines – MDT Physician/ Hospital ±
hyroid approach Endocrinologist/ specialist
surgeon
● Management
according to Clinical
Practice Guidelines
Management of
Thyroid Disorders
2019 and other
relevant guidelines
● Family planning
complicated. Uncontrolled disease are associated with miscarriage, IUGR,
toxicity as IgG can pass through placenta, but it is rare
esarean section may precipitate thyroid storm especially in uncontrolled
ch as beta-blockers can increase risk of SGA/IUGR. Achieving control of
hyroid drugs should be referred to the endocrinologist/ physician for
anagement. Women who wish to avoid foetal exposure to drugs can be
f treatment.
d to make women euthyroid/hypothyroid. Thyroxine carries negligible risk
ce. Continuation of drugs in pregnancy is vital as uncontrolled disease is
with increased frequency of antenatal visits with shared care between
8 Released May 2023
SOP 5: EPILEPSY
Assessment Lab investigations and PE Classific
findings
Controlled
Seizure-free ● Neurological examination uncontroll
interval ● EEG test
● Regular blood test : FBC,
LFT [depends on types of
anti-epileptic drugs (AED]
● Therapeutic drug
monitoring level if not
compliant or poorly
controlled seizure, or
suspect overdose
49
Care plan
cation Management Level of Level of care
● All women in the personnel
d/ MO/ FMS/ Hospital with
led specialist
reproductive age who are Physician/ /Health
diagnosed to have epilepsy Neurologists Clinics
and plan to conceive should
be referred to the pre
pregnancy service.
● Refer to appropriate
disciplines for
multidisciplinary approach
● Management according to
Consensus Guidelines on
the Management of Epilepsy
2017 and other relevant
guidelines.
● Family planning counselling
– Refer WHO Medical
Eligibility Criteria for
Contraceptive Use 2015 for
drug interaction between
AEDs and hormonal
contraceptives.
● Folic acid 5mg daily for at
least 3 months prior to
conception continue at least
until the end of first trimester
9 Released May 2023
1. Ideally, women should be advised against getting pr
various personal, cultural or religious reasons, this i
potential, the risk of teratogenicity while on AEDs an
discussed long before they wish to conceive. The lat
and tapering is done gradually.
2. If AED withdrawal is impossible, effort to achieve
conception. Switching to a less teratogenic AED shou
not beneficial because most teratogenic effects take p
practised till AED adjustment is achieved.
3. Shared decision should be made with the patient rega
risk to the feotus and control of seizures.
4. Enzyme-inducing AEDs can increase the chance of c
5. Teratogenicity risks depend on types of AED and dos
▪ Monotherapy : 4-8%
▪ Polytherapy : 15%
▪ Combination of valproate, carbamazepine and phe
▪ Phenytoin monotherapy : not related to increased
▪ Valproate >1000mg daily: high risk for foetal malfo
50
to reduce the incidence of
major congenital
malformations and to reduce
the risk of AED-related
cognitive deficits
regnant until they become seizure-free and are off AEDs. However, for
is seldom possible or practical. Hence, in all women with childbearing
nd the risk of recurrent seizures if AEDs were to be withdrawn must be
tter risk is low if the patient has been seizure-free for more than 2 years
monotherapy and lowest effective dose should be attempted before
uld be done before conception; switching during pregnancy is likely to be
place in the first trimester. For the above reason, contraception should be
arding the choice and dose of Anti-epileptic Drugs (AEDs), based on the
combined oral contraceptive failure.
se:
enytoin : 50%
d risk of major foetal malformation
ormation
0 Released May 2023
SOP 6: BRONCHIAL ASTHMA
Assessment Lab Classificatio
investigations
Assessment of asthma ● Well-control
control according to and PE ● Partly contro
guidelines (i.e., GINA, findings ● Uncontrolled
Asthma Control Test ● PEFR
Scoring) ● Spirometry
● CXR (if
indicated)
1. The natural history of asthma during pregnancy is e
during pregnancy.
2. Asthma is more likely to become severe or worsen du
3. During PPC counselling, the following should be emp
▪ patient education on good asthma control
▪ frequent monitoring (4 – 6 weeks)
▪ maintenance, reliever and anti-leukotriene should
▪ stepping down medication should be done after de
4. Asthma medications are safe in pregnancy. There i
These include all inhalers – reliever and preventer, an
51
Care plan
on Management Level of Level of
personnel care
lled ● Refer to appropriate MO/FMS/Physician Health
olled disciplines – / Respiratory Clinics/
d physicians Hospital ±
multidisciplinary specialist
approach
● Management according
to Clinical Practice
Guidelines Management
of Asthma in Adults
2017 or other related
guideline
● Family planning
extremely variable. Asthma may worsen, improve or remain unchanged
uring pregnancy in women with pre-existing severe asthma.
phasised:
be continued
elivery if asthma is well controlled
is a greater risk to both mother and baby if asthma is poorly controlled.
nd steroid tablets.
1 Released May 2023
SOP 7: SYSTEMIC LUPUS ERYTHEMATOSUS
Assessment Lab investigations and Classifi
PE findings
● Disease activity
● Autoantibody ● Renal profile N/A
profile ● Auto-antibodies test
● Comorbidities
(anti-Ro, anti-La, anti-
cardiolipin, lupus
anticoagulant)
● Urinalysis
● ESR
1. Assessment of the risk of pregnancy including:
▪ Disease activity and major organ involvement
▪ Hypercoagulability state
▪ Other concurrent medical disorders that may impa
▪ Previous obstetric outcome
2. Pregnancy is allowed if:
▪ Disease is quiescent for ≥ 6 months
▪ BP well controlled
▪ eGFR> 60ml/min
▪ proteinuria <1g/day (proteinuria 2+)
3. Use of hydroxychloroquine (HCQ) is recommende
Discontinuation of HCQ is related to an increased risk
52
Care plan
ication Management Level of Level of
personnel care
● Refer to appropriate MO/ FMS/
disciplines – Physician/ Health
Clinics/
multidisciplinary Rheumatologist Hospital ±
approach specialist
● Management according
to guidelines (i.e. EULAR
Recommendations 2016)
● Family planning
● Review medications –
the goal is to maintain
disease control on
medications with best
safety profile during
pregnancy
act pregnancy
ed in women with SLE preconceptionally and throughout pregnancy.
k for SLE exacerbations during pregnancy
2 Released May 2023
SOP 8: RENAL DISEASE
Assessment Lab Investigations and Cla
PE findings
● CKD Staging (CKD 1 ● FBS ●C
– 5 with or without ● Lipid profile –
proteinuria) ● Renal profile ●R
● Assessment for other ● Microalbuminuria w
concurrent medical ● 24hrs urine protein/ c
conditions albumin-to-creatinine
ratio (ACR)
● eGFR
● Ultrasound KUB
● ECG
● CXR (if indicated)
● lupus anticoagulant,
ANA
● HIV, VDRL, Hep B/C
(for women on dialysis)
Maternal Risk
1. Renal workload is tremendously increased in pregnan
2. Rate of renal function deterioration and worsening of p
● Renal function deteriorates more in CKD stage 3/4
● Doubling of proteinuria as CKD stage progresses
3. Women with severe impairment need daily dialysis d
mortality. The only risk modifying intervention is rena
accordingly.
4. All women with unexplained proteinuria/hematuria sh
pre pregnancy clinic
5. Adverse maternal outcomes (pre-eclampsia, hyperten
advances.
6. Risks of preterm delivery and IUGR correlate with ma
53
assification Management Care plan Level of care
Level of
CKD Stage 1 ● Refer to personnel Health Clinic/
Hospital ±
– 5 appropriate MO/ FMS/ specialist
Physician/
Renal disease disciplines – Nephrologist
with multidisciplinary
comorbidity approach
● Management
according to
Clinical Practice
Guidelines
Management of
Chronic Kidney
Disease 2018
● Family planning
ncy with an increased GFR and a physically enlarged kidney
proteinuria during pregnancy correlates significantly with CKD stages.
4 compared with stage 2 (60% vs 14.3%)
are 20.5%, 86.5% and 70% in stage 1, 3 and 4 – 5 respectively
during pregnancy, which is associated with increased morbidity and
al transplantation. Realistic options should be offered and counselled
hould have a referral to medical for renal work-up and be referred to the
nsion and caesarean delivery) are significantly higher as CKD stage
aternal renal function and level of proteinuria.
3 Released May 2023
7. Pregnancy may be considered in women with mild r
pressure and without significant proteinuria (<1 g/day)
8. Pregnancy should be avoided in women with either:
a. moderate to severe renal impairment
b. poorly controlled hypertension
c. heavy proteinuria
d. active systemic disease
9. Aim to conceive when:
a. Cause of renal impairment has been optimised
b. Doses of drugs for treatment are minimised
c. Hypertension (if present) is well-controlled
10. Women with moderate to severe impairment should b
11. Safety of treatment:
a. Calcium: safe in pregnancy
b. Activated Vitamin D: data is scarce but reassur
c. Erythropoietin is safe
54
renal impairment (serum creatinine <125 μmol/L), well controlled blood
).
d
be advised for more permanent methods of contraception.
ring
4 Released May 2023
SOP 9: THALASSAEMIA MAJOR
Assessment Lab investigations and Clas
PE findings
● Review of ● FBP ● Mi
● Mo
transfusion ● Renal profile ● Se
● Sy
requirements ● LFT
as
● Assess compliance ● Iron studies
with chelation ● Hb electrophoresis for
therapy and body both women and
iron burden partner
● Screen for end-organ ● DNA analysis (if
damage indicated)
● TFT
● Family screening
● Look for
organomegaly
1. Aggressive chelation in the preconception stage
▪ reduce and optimise body iron burden
▪ reduce end-organ damage
2. As diabetes is common in patients with thalassaemia
SOP for PPC in Diabetes for such women)
▪ Serum fructosamine is preferred for monitoring (ta
months pre-conception)
3. Assessment by a cardiologist
▪ Echocardiogram, electrocardiogram (ECG) and T2
4. Assessment of liver iron concentration using a FerriSc
55
Care plan
ssification Management Level of Level of care
● Counselling on personnel
ild MO/FMS/ Health Clinics
oderate Hospital ±
evere risk of pregnancy Physician/ specialist
ymptomatic/ – she needs to Paediatrician
symptomatic
be fully informed
about how
thalassaemia
affects
pregnancy and
vice versa
● Family planning
● Refer for genetic
counselling if the
need arises
● Transfusion
where indicated
a, women with diabetes should be referred to endocrinologists (Refer
arget serum fructosamine concentrations < 300 nmol/l for at least 3
2* cardiac MRI Released May 2023
can® or liver T2* (if it is available)
5
▪ Ideal liver iron should be < 7 mg/g (dry weight)
5. Bone density scan to document any pre-existing osteo
6. Serum vitamin D concentrations to be optimised with
7. To measure ABO and full blood group genotype and a
8. Iron chelators should be reviewed. Deferasirox or defe
9. Offer genetic counselling if the partner is a carrier of
genotype
10. Consider in vitro fertilisation/intracytoplasmic sperm in
the presence of haemoglobinopathies in both partners
11. Hepatitis B vaccination is recommended in HbsAg ne
12. Hepatitis C status should also be determined.
13. Offer penicillin prophylaxis for all women who have un
14. All women who have undergone a splenectomy shou
B
15. Folic acid (5 mg) is recommended to all women who a
56
oporosis.
supplements.
antibody titres
eriprone should be ideally discontinued 3 months before conception
f a haemoglobinopathy that may adversely interact with the woman’s
njection (IVF/ICSI) with a pre-implantation genetic diagnosis (PGD) in
s to avoid a homozygous or compound heterozygous pregnancy
egative women who are transfused or may be transfused.
ndergone a splenectomy.
uld be vaccinated for pneumococcus and Haemophilus influenzae type
are planning to conceive to prevent neural tube defects.
6 Released May 2023
SOP 10: MALIGNANCY
Assessment Lab Diagnostic
investigations criteria and
● Stage of disease and PE findings Differential
● Disease activity – diagnosis
Refer specific Refer specific
remission/active guidelines guidelines
1. Even though the incidence of malignancy occurring d
pregnancy is a challenge to the clinicians. The lis
(1:2,000−1:10,000), breast cancer (1:3,000−1
(1:75,000−1:100,000), lymphoma (1:1,000−1:6,000), c
2. With appropriate treatment of the cancer, pregnancy
Pregnant women diagnosed with breast cancer can r
similar survival when matched for stage at diagnosis.
Foetal Risk
1. The risk of miscarriage and congenital anomalies doe
cases after abdominal surgery and peritonitis
2. The risk of major malformations, spontaneous abort
instituted during the first trimester and it is advisable th
3. Even though no evidence of teratogenic effect was de
trimester, the risk for low birth weight and foetal grow
from exposure to chemotherapy in the second and t
reported for the general population. Chemotherapy exp
in the second and third trimester does not cause terat
such as docetaxel (D) and paclitaxel (P), demonstrated
complications when used in the second and third trim
57
Care plan
Management Level of personnel Level of care
Refer to multidisciplinary MO/ FMS/ other Secondary
team (oncology, primary related specialist care
team, O&G team) if
planning for pregnancy
during pregnancy is low ranging from 0.02-0.1%, diagnosing it during a
st of common cancers occurring in pregnancy are cervical cancer
1:10,000), ovarian cancer (1:10,000−1:100,000), leukaemia
colon cancer (1:13,000) and malignant melanoma (1:1,000−1:10,000).
itself does not appear to be associated with worse cancer outcomes.
receive treatment comparable with non-pregnant women leading to a
es not increase with surgery. Preterm deliveries usually occurred in
tions, and foetal death may be increased when chemotherapy is
hat the chemotherapy should be delayed until 14 weeks of gestation.
emonstrated from chemotherapy exposure in the second and third
wth restriction may be increased. The reported foetal malformation
third trimester rates range from 1.3% to 3.8%, similar to the rate
posure of 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC)
togenic effects. Few studies that evaluated the use of taxanes (T),
d no increase in the occurrence of foetal defects and other maternal
esters of pregnancy.
7 Released May 2023
4. However, trastuzumab is associated with oligohydram
trimesters and not recommended in pregnancy.
5. Methotrexate is teratogenic. The most common abnor
a few case studies are skull, hand, and limb deformitie
micrognathia, microcephaly, hypertelorism, low set ea
proximal limbs, low set ears, small chin and mouth, m
6. Women who stopped taking methotrexate even up
spontaneous abortion.
7. The foetal central nervous system during 8 to 25 weeks
dose of >0.1 Gy could decrease the intelligence quoti
carcinogenic effects within the first decade of life, suc
Pre pregnancy management
1. A woman with malignancy who considers pregnan
consideration the balance of effect on maternal and fo
2. In view of the effect of treatments on feotus, women wit
being hindered by pregnancy, the need to delay the in
radiotherapy to postpartum, the reduced options of ch
3. Even though, therapeutic abortion does not provide a
termination of pregnancy should be considered when
in abdominal and pelvis malignancy.
4. In women who wish to be pregnant, a concurrent folic
of women taking methotrexate.
58
mnios and anhydramnios, even when given in the second and third
rmalities following methotrexate exposure in utero demonstrated by
es such as hydrocephalus, hypoplasia of frontal and orbital bones,
ars and upsweep of the frontal hairline, dysmorphic features, short
mongoloid slant and a systolic heart murmur.
to 6 months prior to conception are still at risks of developing
s after conception is sensitive to radiation, and a radiation exposure
ient. Radiation in the second and third trimesters is correlated with
ch as the development of solid tumours and leukaemia.
ncy has to be managed by multidisciplinary teams taking into
oetal health.
th malignancy have to consider the problems of diagnostic activities
nstitution of chemotherapy to the second or third trimester and also
hemotherapy.
a better outcome when appropriate treatment for cancer is given,
n there is a need for immediate treatment of the disease especially
acid may be helpful to reduce the neural tube defects in the feotus
8 Released May 2023
SOP 11: RETROVIRAL DISEASE
Diagnostic
Assessment Lab investigations and criteria and
PE findings Differential
diagnosis
● Asympt ● FBC WHO clinical
omatic ● LFT classification
● Sympto ● HBV/HCV criteria of severit
matic ● CD4/CD8 ratio
● Viral load
● VDRL & other STI
screening
● Renal profile
● Physical examination
for opportunistic
infections/ AIDS
defining complex
● STI workup
● In general, the existing ART is to be continued throug
● Special effort must be made to determine the current
● Consultation with an infectious-disease physician is s
● Dual protection contraception should be advised
● Look for evidence of opportunistic infections, HIV-rela
● Counsel regarding risk of transmission to the feotus
59
Care plan
Management Level of Level of care
personnel
● Antiretroviral MO/FMS/ Health Clinic/
therapy (ART) as Infectious Disease Hospital ±
ty indicated in Physician/ General specialist
accordance to the Physician
Malaysian
Consensus
Guidelines on
Antiretroviral
Therapy 2017
● Family Planning:
Emphasise on dual-
protection
ghout pregnancy and after delivery.
CD4 and viral load during the early stage of pregnancy.
strongly recommended if the patient is experiencing virological failure.
ated illnesses and evaluation for possible STIs
9 Released May 2023
SOP 12: POST TRANSPLANT SURGERY
Lab Diagnost
Investigations criteria a
Assessment and PE Different
findings diagnos
● Transplanted organ ● Renal profile N/A
function ● LFT
● Graft rejection ● Lung
● Dosage and teratogenicity function
of immunosuppressive tests
drugs ● EEG, ECG
● Foetal and maternal risks ● Urine
protein
● Blood sugar
profile
1. Counselling on family planning and pregnancy includ
timing.
2. Timing of pregnancy: avoid pregnancy during the first
rejection is greatest and immunosuppressive therapy
3. Contraception should be emphasised during first year
medications): Long-acting reversible contraception is
intrauterine device (IUCD), and levonorgestrel-releasi
4. For renal transplant patients, vaginal delivery should
birth canal in most patients. The obstetrician should re
location of the allograft and ureter. A renal ultrasound
placed in the prenatal record to guide the surgeon if a
5. In post-transplant patients, offer advise on mediations
impaired
6. The American Society of Transplantation consensus c
a. No rejection in the past year
b. Adequate and stable graft function
c. No acute infections that might impact the foetu
60
tic Care plan
and Level of Level of
tial Management personnel care
sis
● Multidisciplinary MO /FMS /O&G Tertiary
team approach specialist/ hospitals
● Family planning Transplantation unit
ding individualised maternal and foetal risks, alternatives, and
t year post-transplantation (preferably 2 years) when the risk of
is most aggressive.
r post-transplant (fertility is not affected by immunosuppressive
effective and options include the etonogestrel implant, copper
ing IUCD.
d not be impaired, as the pelvic allograft does not obstruct the
eview operative notes from the transplant procedure to confirm
d might also aid in precise location. This information should be
a caesarean delivery is performed.
s and assisted reproductive technology if reproductive ability is
criteria for timing of pregnancy :
us
0 Released May 2023
d. Maintenance immunosuppression at stable dos
7. Review medications for teratogenic risk. Immunosupp
mammalian target of rapamycin (mTOR) inhibitors
pregnancy given its high risks of adverse foetal e
Glucocorticoids (e.g. prednisolone), calcineurin inhib
inhibitors such as azathioprine are considered safe in
8. Vaccination against influenza, pneumococcus, hepati
61
sing
pressants like mycophenolic acid (eg, mycophenolate mofetil),
(e.g.; sirolimus and everolimus) should not be used during
effects and should be stopped 6 weeks before conception.
bitors (e.g.; cyclosporine and tacrolimus) and purine synthesis
n pregnancy.
itis B, and tetanus should be administered before conception.
1 Released May 2023
SOP 13: DEPRESSION AND ANXIETY
Lab Diagnostic
investigations criteria and
Assessment and PE Differential
findings diagnosis
● Disease Status: TFT (if it has not Common Types
Acute/Remission been done Depression
● Functionality e.g before) ● Major
work, interpersonal depressive
and activity of daily disorder
living ● Persistent
● Comorbidities: other depressive
psychiatric illness or disorder
with medical (dysthymia)
illnesses Anxiety
● Psychosocial risks ● Generalised
e.g unemployment, anxiety
poor social support disorder
● Suicidal risks ● Panic disord
● Other anxie
disorder
Severity:
● Mild
● Moderate
● Severe w
psychosis
suicidality
1. Depression and anxiety are common mental disorders
2. Depression is the leading cause of disability worldwid
disease.
3. Depression can lead to suicide and devastating psych
4. Suicide is classified as direct maternal mortality in Ma
62
Care plan
Management Level of Level of
personnel care
s: ● Counsel on risk-benefit MO/ FMS/ Health
of treatment options in Psychiatrist Clinic/
pregnancy. Hospital ±
● For mild-moderate specialist
depression/anxiety with
low risk of relapse, aim
to achieve remission
and complete treatment
before pregnancy.
● For moderate-severe
d depression and/or high
risk of relapse, counsel
on risk-benefit of
der medications.
ety ● If medication is
indicated but the patient
refuses, offer adequate
support, refer to FMS or
psychiatrist, or offer
with intensive psychotherapy
or if available.
s.
de and is a major contributor to the overall global burden of
hosocial adverse effects.
alaysia.
2 Released May 2023
5. Educate patients on the risk of untreated depression a
6. Emphasise on the importance of recognizing symptom
a. Feeling depressed or loss of interest
b. Disturbed sleep and appetite
c. Poor concentration
d. Feeling lethargic
e. Hopeless, excessive guilt and having suicidal id
7. Counsel on the risk-benefit analysis of treatment optio
f. Risks of medication i.e. Selective Serotonin Re
risks of miscarriage, premature delivery, neona
g. Risk of untreated depression: miscarriage, pr
interpersonal conflict, functional impairment, m
initiation, long term behavioural problems in off
h. Assess previous history of depression and anx
8. Aim to complete treatment before getting pregnant if t
depression/anxiety with low risk of relapse). Maintena
9. If medication is indicated for severe depression/anxie
FMS or psychiatrist, or offer intensive psychotherapy
10. Arrange for psychological intervention:
a. Provide counselling and emotional support in prim
b. Arrange for brief psychological interventions (eg bri
care
c. Referral to tertiary centre for psychological interve
11. Baseline psychosocial investigations: corroborative hi
12. Early booking when pregnant
63
and anxiety on pregnancy and feotus
ms of depression and anxiety
deation
ons to reach a shared decision on a treatment plan.
euptake Inhibitor (SSRI): no risk of teratogenicity, low absolute
atal adaptation syndrome and primary pulmonary hypertension
remature delivery, low birth weight, poor antenatal self-care,
mother-baby bonding/attachment difficulties, low breastfeeding
fsprings, suicide and infanticide.
xiety (how many episodes and severity) and medication history
that is possible (only for mild and moderate
ance treatment of 6-9 months after remission
ety but the patient refuses, offer adequate support, refer to
if available.
mary care or O&G setting
ief cognitive behaviour therapy) by trained personnel in primary
ention
istory from social support
3 Released May 2023
SOP 14: SEVERE MENTAL ILLNESS
Assessment Lab Diagnostic
● Disease status: in investigation criteria and
remission or
presence of ongoing s and PE Differential
symptoms
findings diagnosis
● medication side ● FBS
effects ● Lipid profile Types:
● Schizophre
● Functionality and
capacity to consent nia
● Bipolar
● Comorbidities:
metabolic syndrome Disorder
and substance use ● History of
● Psychosocial risk: postpartum
Social support and
treatment adherence psychosis
● Other
● Risk of self-neglect,
aggression and self- psychotic
harm
disorders
Remarks
1. Severe mental illness includes psychotic disorders, sc
2. Schizophrenia and bipolar disorder have a prevalence
psychosis has a prevalence of 1 in 1,000 pregnancies
64
Care plan
Management Level of Level of
personnel care
● Refer to FMS or MO/ FMS/ Health
Psychiatrist Psychiatrist Clinic/
● Multidisciplinary team Hospital ±
involving psychiatrist, specialist
O&G, FMS and social
worker
● Counsel on risk-benefit of
treatment options in
pregnancy.
● Counsel patient and
family for compliance,
monitoring and social
support
● Continue medication if
patient is stable and
medications are not
contraindicated in
pregnancy
● If patient refuses
medication or switching is
required, refer immediately
to FMS or Psychiatrist
chizophrenia and bipolar disorder.
e of around 1 in 100 in the general population. Postpartum
s.
4 Released May 2023
3. There is an increased risk of relapse of pre-existing m
cessation of medication.
4. Preconception planning should start as soon as possi
conceive. Contraception is important if they are not pl
5. Detailed counselling regarding the risk-benefit of med
effects to the feotus must be given to the woman and
discussion on types of medication used if she plans to
6. Medication:
a. Continue medication if patient is stable and me
b. Valproate and carbamazepine should not be us
c. Lithium should not be used in the first trimester
d. Patients on Clozapine should be referred to ps
e. Continue depot antipsychotic if patient is respo
oral medication.
f. Avoid benzodiazepine unless for short-term tre
g. Choose the drug with the lowest risk profile for
response to medication.
h. Use the lowest effective dose, aiming for a sing
medication.
i. Start patient early on folate supplements
7. Educate patients and partner on risk of relapse, risk-b
8. Emphasise the importance of follow-up and complianc
9. Optimise patient’s mental state
a. Optimise medication or switch to low impact m
b. Offer psychological support
c. Close monitoring for relapse
10. Assist in substance abstinence
11. Advise on early booking when pregnant
65
mental disorders during the perinatal period, usually following
ible for women with severe mental illness that plan to
lanning to conceive.
dication during the pregnancy, the possibility of relapse and
her partner. Preconception planning will also involve
o breastfeed.
edications are not contra-indicated in pregnancy
sed in women who plan to conceive.
r of pregnancy.
sychiatrist for management
onding well and has a previous history of non-adherence with
eatment of severe anxiety and agitation
r the woman, feotus and baby, taking into account previous
gle drug regime but taking into account response to
benefit of continuing or starting medication
ce
medication
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SOP 15: SUBSTANCE USE DISORDER
Assessment Lab Diagnostic
investigations
and PE findings criteria an
● Obtain thorough and ● Urine for Differentia
adequate history: drugs (rapid diagnosis
substance, alcohol, test) Types:
● Alcohol
tobacco ● Infectious ● Nicotine
● Cannabis
● Comorbidities: disease ● Ampheta
medical and screening ne-type
psychiatric conditions stimulant
● Complications: bio- ● Opioid
psycho-social
● Psychosocial history:
History of partner or
spouse taking
substances. History of
forensic/criminal
history
1. Preconception planning should start as soon as po
conceive.
2. Contraception is important if they are not planning to c
3. Detailed counselling regarding the risk-benefit of rep
possibility of relapse and effects to the feotus must be
4. Preconception planning will also involve discussion o
plans to breastfeed.
5. Replacement Therapy and Medication:
a. Nicotine replacement therapy is safe during p
cognitive behavioural therapy and counselling w
to achieve smoking cessation during pregnanc
66
c Care plan Level of care
nd
al Management Level of Health Clinic or
s personnel Hospital with
Psychiatrist/
● Brief MO/ FMS/ Psychiatrist with
Psychiatrist subspeciality
psychological addiction
intervention e.g
s Brief
ami Motivational
Interviewing
t ● Nicotine
replacement
therapy
● Methadone
replacement
therapy
● Refer to
appropriate
discipline
ossible for women with substance use disorder who plan to
conceive.
placement therapy and medication during the pregnancy, the
e given to the woman and her partner.
on types of replacement therapy and medication used if she
pregnancy under supervision of a clinician. A combination of
with nicotine replacement therapy is the most effective strategy
cy.
6 Released May 2023
b. Methadone Replacement Therapy in pregnanc
and foetal outcomes associated with untreated
typically require treatment for withdrawal sy
continued during pregnancy.
6. Counsel patients on the risk of substances on pregna
7. Counsel patients and family on risk-benefit of starting
8. Emphasise the importance of recognizing symptoms o
9. Inform patients on the potential risks of substances
pharmacological intervention.
10. Emphasise on the importance of follow-up and adhere
11. Aim of treatment is to reach substance abstinence be
12. Offer counselling and psychological support in primar
13. Arrange for brief psychological interventions e.g brief
14. Referral to tertiary centre for psychological interven
primary care
15. Close monitoring for relapse
16. Early booking when pregnant
Reference
1. Mental Health Care in the Perinatal Period. Australian
2. NICE Antenatal and postnatal mental health. Decembe
3. Clinical Practice Guidelines on Major Depressive Disor
4. Guidelines for the identification and management of su
(WHO 2014)
5. Mental Health Gap Action Programme Intervention Gu
6. Guidelines for the Psychosocially Assisted Pharmacolo
7. The ASSIST Project-Alcohol, Smoking and Substance
2009
67
cy improves many of the adverse consequences of maternal
d opioid use. Infants exposed to methadone during pregnancy
ymptoms after delivery. Methadone is recommended to be
ancy and feotus.
g or continuing replacement therapy
of withdrawal for each substance.
and the availability of non-pharmacological intervention and
ence
efore pregnancy.
ry care or O&G setting
motivational interviewing by trained personnel in primary care
ntion and pharmacological intervention which not available in
Clinical Practice Guideline. October 2017
er 2014
rder, Ministry of Health Malaysia 2020 (work in progress)
ubstance use and substance use disorders in pregnancy
uide Version 2.0 (WHO 2016)
ogical Treatment of Opioid Dependence (WHO 2009)
Involvement Screening Test. (World Health Organization
7 Released May 2023
APPENDIX 1-8
PRE PREGNANCY HEALTH EDUCATION
1. Towards a healthy and happy family
A healthy married couple is the basic foundation for a happy family. Factors which
influence the health of an individual, family and the community include:
● Lifestyle
● Genetics/familial factors
● Environmental factors
2. Practising a healthy lifestyle
Balanced diet A diet which contains all the necessary nutrients in the right
Social interactions proportions according to caloric needs and right proportion.
Ensure adequate fluid intake.
Good daily living habit
Relaxation Husband and wife must be supportive and actively
Adequate rest and sleep participate in enhancing each other’s health.
Couples should practice mutual respect and consent for a
satisfying and equitable sexual relationship.
All men and women in reproductive age should have a
healthy lifestyle; avoid unhealthy habits like smoking,
consuming alcohol and other types of drug abuse.
Regular exercise decreases stress and lowers the risk of
heart disease, stroke and hypertension.
Six to eight hours of sleep a day to ensure adequate rest.
3. Genetic factors
Couple, men and women with:-
• Consanguineous marriage (e.g., autosomal recessive disorders)
• Previous child with genetic disorders (e.g., thalassaemia)
• Family history of genetic disorders (e.g., autosomal recessive disorders)
• Women at risk for aneuploidy or chromosomal anomaly (e.g., Down’s Syndrome)
• Male disorders (e.g., X-linked disorders – Duchenne Muscular Dystrophy,
Haemophilia)
• Unexplained/uninvestigated foetal loss should be counselled for possible genetic
problems.
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4. Family Planning
It is encouraged for couples to plan their pregnancy in order to contribute positively to
the eventual maternal and foetal outcome especially if the women’s condition is not
yet optimised. Health care providers should be consulted regarding the appropriate
and effective contraceptive method.
5. Pregnancy and Birth
• Physical maturity and age of the mother
The appropriate age for a woman to get pregnant is at the legal age 18 and above.
Women above 40 years are at higher risk of pregnancy complications.
• Preventing infections
Men and women in reproductive age group are advised about infections such as
sexually transmitted diseases as well as lifestyle diseases which can affect
reproductive potential and the unborn child. Hepatitis B, varicella and rubella
vaccinations may be advised to all women who are not immune.
• Antenatal health care
Couples who are planning to start a family should be in optimal health. A pregnant
woman and her partner should attend an antenatal clinic before 12 weeks of
gestation.
• Supplementation
Folic acid supplementation should be emphasised to all women at least 3 months
prior to a pregnancy.
• Breastfeeding
Breast milk is the best option for the newborn as it contains all the necessary
nutrients, in the right proportions, for the optimum health and growth of the
newborn. Exclusive breastfeeding for the first 6 months of the newborn and
encouraged to continue for at least 2 years.
• Childbirth
Each pregnant woman must be advised on the appropriate place of delivery.
• Child care
Every child must be immunised according to the recommended schedule.
6. Screening
• Cervical cancer screening (i.e.; pap smear, HPV DNA test) according to national
guideline
• STI (sexually transmitted infection) screening as indicated
• Clinical breast examination
• Diabetes and hypertension screening should be offered at least annually
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7. Vaccination
• Check for rubella status.
If the mother is not rubella immune, offer rubella vaccination together with
contraception, as pregnancy is contraindicated for three months following
vaccination. If the mother is unsure of her status, check for Rubella IgG to
confirm immunity.
• Hepatitis B vaccination
Enquire regarding the patient’s Hepatitis B vaccination. If the women has
not been vaccinated, offer Hepatitis B vaccination
• Varicella (chickenpox)
Offer and discuss benefits of vaccination pre pregnancy if the mother has
never had a varicella Infection. If unsure, check for varicella IgG to confirm
immunity.
• COVID-19 vaccination
If the woman have not received COVID-19 vaccination, offer and discuss
the benefit of vaccination.
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APPENDIX 1-9
PRE PREGNANCY COUNSELLING
A recommendation for pre pregnancy counselling should be given to all men and
women with risk of pregnancy complications. Such counselling can reduce the
incidence of maternal and foetal mortality and morbidity.
A. Objectives of pre pregnancy counselling include:
1. Conducting an initial assessment
• full history (medical, surgical, past obstetric, psychiatric, family, social and
substance use history)
• general physical examination
• identification of appropriate screening tests if necessary
• discussion on pregnancy planning
2. Allaying or reducing anxiety
It is necessary to reduce anxiety in women with chronic medical illness. Counselling
should include:
• The effect of pre-existing disorder on pregnancy and pregnancy on the disorder.
• The likelihood of possible recurrence of previous complications and how this may
possibly be reduced (e.g., intrauterine or neonatal death, hypertension, deep vein
thrombosis, miscarriage or preterm labour, mechanical problems of labour or
delivery).
3. Determining fitness for pregnancy
Pregnancy should be deferred and contraception should be offered to allow further
evaluation and management of known disorders or new findings (e.g., anaemia, heart
disease, diabetes and hypertension). Treatment and optimisation of medical and
surgical disorders may be required. Reproductive issues should be managed
appropriately.
4. Follow up
• Follow-up interval : 6 -12 monthly (based on patient’s condition)
• Until patient has no risk for pregnancy
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B. Factors Affecting Pregnancy
1. Social behaviour
• Common social behaviours affecting pregnancy:
Smoking - Miscarriage, low birth weight, placenta previa, placenta
abruption, infant respiratory tract infection, sudden infant
Alcohol - death syndrome, impaired fertility
Miscarriage, foetal alcohol syndrome, placenta abruption,
Cocaine - foetal intrauterine growth restriction (IUGR), low birth
weight, central nervous system abnormalities
Caffeine - Abortion, premature birth, placental abruption, IUGR,
congenital anomalies, neonatal central nervous system
(CNS) dysfunction
Low birth weight, IUGR
• Any form of substance abuse can affect pregnancy and its outcome.
2. Medication
A potential preventable group of disorders are drug-induced anomalies. Medications
during pregnancy should be avoided as far as possible.
Table 1.1: Effects of medications on pregnancy
AGENTS EFFECTS
Anti-convulsions
Incidence of congenital malformations in children born to
Sodium valproate epileptic mothers is about 6%. This appears to be largely due
Lithium carbonate to teratogenic effects of anticonvulsant. Combining drugs
Warfarin increases the incidence of congenital defects
Alcohol
Androgens Increase risk of neural tube defect to about 1/1000
Atropine pregnancies. Long term neurological implication to the baby
Increase in cardiovascular abnormality
Various congenital malformations including abnormalities of
the central nervous system, nose and bony epiphyses
Low birth weight, microcephaly, congenital heart disease and
mental retardation
Teratogenesis in first trimester, virilisation of female feotus
Foetal tachycardia
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AGENTS EFFECTS
Beta–blockers IUGR
Diazepam
Cyclophosphamide Respiratory depression
Diuretics
Diethyl-stilboesterol Teratogenesis in first trimester
Methadone
IUGR
Methotrexate
Genital anomalies, male infertility, female may develop clear
cell carcinoma of the vagina many years later
Maternal symptoms of withdrawal inducing foetal compromise
and abruption
Foetal complications are smaller-than-normal head size, low
birth weight, IUGR, preterm delivery, unspecified structural
anomalies and foetal withdrawal syndrome
Neural tube defects
Mycophenolate mofetil Multiple congenital malformations including facial, heart, renal,
(Immunosuppressive ear, eye and tracheo-esophageal malformations
drug)
Embryopathy includes dysmorphic facial features,
Phenytoin microcephaly and motor and intellectual retardation
Tooth enamel hypoplasia and cataract
Tetracycline
Terbutaline Hypoglycaemia
Thalidomide Phocomelia
Angiotensin converting Oligohydramnios, bone malformation, prolonged hypotension
enzyme inhibitor (ACE-i) and renal failure
and angiotensin receptor
blocker (ARB)
3. Nutritional status
Nutritional deficiency in women of reproductive age affects not only the general health
but also the fertility capacity. Folic acid supplementation is essential to prevent neural
tube defects.
4. Medical history
Pre-existing medical conditions may adversely affect mother and feotus. Pre
pregnancy intervention is important in counselling regarding risk and in optimising
medical management.
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