PERINATAL CARE MANUAL 4th Edition 2020 released June 2022 2

Care plan

n Management Level of Level of care
personnel
– IV Health Clinic /
– IV ● Refer to appropriate MO/ FMS/ Hospital ±
disciplines – Physician/ 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

ternal death. Pregnancy increases cardiac workload by approximately
apartum period. Diseased hearts may not be able to withstand this load.
risk of foetal congenital heart disease is approximately 4%. This is

of 2%
ow-up at cardiology clinics should be given pre pregnancy counselling.

stenosis, severe aortic stenosis)

6 Released June 2022

e. Non-resolved peripartum cardiomyopathy of pre
Since termination of pregnancy should be considered
specialists should be made.
5. Therapeutics:

a. Antiarrhythmic and anti-coagulation drugs shoul
i. Most antiarrythmic drugs are well-tolerate
ii. Warfarin use is associated with an incre
late foetal loss (approximately 10%). Wo
miscarriage and foetal demise

b. Anti-failure medication (e.g., digoxin and diuretic
c. ACE inhibitors are contraindicated in pregnancy
d. Statins are generally contraindicated howeve

hypercholesterolemia, hydrophilic agents should
i. Lipophilic: Atorvastatin, lovastatin, and si
ii. hydrophilic: pravastatin, rosuvastatin, and

(*Lipophilic statins cross the blood-brain barrier
However, this is rare.)
e. Low dose aspirin (100 – 150 mg OD) is safe in p
usually higher. Dose may need to be lowered
bleeding and transfusion
f. Beta blockers are the gold standard treatment
instances, they should be continued. However, p

47

egnancy
in unplanned pregnancy in the above conditions, early referral to O&G

ld be thoroughly discussed
ed and generally safe
eased risk of foetal anomalies (estimated at 5-10 %) and a high risk of
omen requiring lifelong warfarin therapy should be counselled on risk of
cs) can be continued in pregnancy
y but are safe during breastfeeding
er if it is necessary for patients with coronary artery disease and
d be preferred over lipophilic ones
imvastatin
d fluvastatin
r more readily, which may lead to central nervous system complaints.
pregnancy and breastfeeding. However, the dose for cardiac disease is
d during pregnancy towards term (36 weeks) due to increased risk of
t for fixed output lesions such as mitral and aortic stenosis. In these
prophylaxis beta blockers should be discontinued.

7 Released June 2022

SOP 4: THYROID DISEASE

Assessment Lab investigations Classifica
and PE findings

● Hypothyroid and ● FBS ● Euthyro
hyperthyroid ● Lipid profile ● Hyperth
symptoms ● TSH/free T4/free ● Hypothy

● Stability of thyroid T3
disease on ● ECG
treatment ● Blood pressure
● FBC
● Neck ultrasound (if

indicated)

1. When disease is well-controlled, pregnancy is usually u
IUGR, preterm labor and intrauterine foetal death (IUD)

2. Antibody positive hyperthyroidism can cause foetal thyroto
3. Complications of pregnancy such as UTI, labour or Caes

disease
4. If conception occurs in uncontrolled disease, therapy such

disease may take months and pose risk to the feotus
5. Women who have been treated for years with antithy

consideration for radioactive iodine (RAI) or surgical man
advised to await resolution of disease and weaning off of t
6. If unable to wean off medications, RAI can be considered
to the feotus
7. Weigh the risk and benefits of therapeutic agents of choice
detrimental to foetal and maternal health.
8. Explain increased vigilance is required in pregnancy wi
combined clinics and fetomaternal specialists

48

Care plan

ation Management Level of Level of care
personnel
oid ● Refer to appropriate MO/FMS/ Health Clinic/
hyroid disciplines – MDT Physician/ Hospital ±
yroid approach Endocrinologist/ specialist
surgeon
● Management

according to Clinical

Practice Guidelines

Management of

Thyroid Disorders

2019 and other

relevant guidelines
● Family planning

uncomplicated. Uncontrolled disease are associated with miscarriage,

oxicity as IgG can pass through placenta, but it is rare
sarean section may precipitate thyroid storm especially in uncontrolled

h as beta-blockers can increase risk of SGA/IUGR. Achieving control of

yroid drugs should be referred to the endocrinologist/ physician for
nagement. Women who wish to avoid foetal exposure to drugs can be
treatment.
to make women euthyroid/hypothyroid. Thyroxine carries negligible risk

e. Continuation of drugs in pregnancy is vital as uncontrolled disease is

ith increased frequency of antenatal visits with shared care between

8 Released June 2022

SOP 5: EPILEPSY

Assessment Lab investigations and PE Classifica
findings
Controlled
Seizure-free ● Neurological examination uncontrolle
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

ation Management Level of Level of care
● All women in the personnel
/ MO/ FMS/ Hospital with
ed 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 June 2022

1. Ideally, women should be advised against getting pre
various personal, cultural or religious reasons, this is
potential, the risk of teratogenicity while on AEDs and
discussed long before they wish to conceive. The latte
and tapering is done gradually.

2. If AED withdrawal is impossible, effort to achieve m
conception. Switching to a less teratogenic AED should
not beneficial because most teratogenic effects take p
be practised till AED adjustment is achieved.

3. Shared decision should be made with the patient regar
risk to the feotus and control of seizures.

4. Enzyme-inducing AEDs can increase the chance of co
5. Teratogenicity risks depend on types of AED and dose

▪ Monotherapy : 4-8%
▪ Polytherapy : 15%
▪ Combination of valproate, carbamazepine and phen
▪ Phenytoin monotherapy : not related to increased r
▪ Valproate >1000mg daily: high risk for foetal malfor

50

to reduce the incidence of
major congenital
malformations and to reduce
the risk of AED-related
cognitive deficits
egnant until they become seizure-free and are off AEDs. However, for
s seldom possible or practical. Hence, in all women with childbearing
d the risk of recurrent seizures if AEDs were to be withdrawn must be
er risk is low if the patient has been seizure-free for more than 2 years

monotherapy and lowest effective dose should be attempted before
d be done before conception; switching during pregnancy is likely to be
place in the first trimester. For the above reason, contraception should

rding the choice and dose of Anti-epileptic Drugs (AEDs), based on the

ombined oral contraceptive failure.
e:

nytoin : 50%
risk of major foetal malformation
rmation

0 Released June 2022

SOP 6: BRONCHIAL ASTHMA

Assessment Lab Classification
investigations
Assessment of asthma ● Well-controlle
control according to and PE ● Partly control
guidelines (i.e., GINA, findings ● Uncontrolled
Asthma Control Test ● PEFR
Scoring) ● Spirometry
● CXR (if

indicated)

1. The natural history of asthma during pregnancy is ex
during pregnancy.

2. Asthma is more likely to become severe or worsen dur
3. During PPC counselling, the following should be emph

▪ patient education on good asthma control
▪ frequent monitoring (4 – 6 weeks)
▪ maintenance, reliever and anti-leukotriene should b
▪ stepping down medication should be done after del
4. Asthma medications are safe in pregnancy. There is
These include all inhalers – reliever and preventer, and

51

Care plan

n Management Level of Level of
personnel care

ed ● Refer to appropriate MO/FMS/Physician Health

lled disciplines – / Respiratory Clinics/

multidisciplinary physicians Hospital ±
approach specialist

● Management according

to Clinical Practice

Guidelines Management

of Asthma in Adults

2017 or other related

guideline
● Family planning

xtremely variable. Asthma may worsen, improve or remain unchanged

ring pregnancy in women with pre-existing severe asthma.
hasised:

be continued
livery if asthma is well controlled
s a greater risk to both mother and baby if asthma is poorly controlled.
d steroid tablets.

1 Released June 2022

SOP 7: SYSTEMIC LUPUS ERYTHEMATOSUS

Assessment Lab investigations and Classific
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 impac
▪ 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 recommended
Discontinuation of HCQ is related to an increased risk f

52

Care plan

cation Management Level of Level of
personnel care

● Refer to appropriate MO/ FMS/ Health
disciplines – Physician/ 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

ct pregnancy

d in women with SLE preconceptionally and throughout pregnancy.
for SLE exacerbations during pregnancy

2 Released June 2022

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/ co

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 pregnanc

2. Rate of renal function deterioration and worsening o

stages.
● Renal function deteriorates more in CKD stage 3/4
● Doubling of proteinuria as CKD stage progresses a

3. Women with severe impairment need daily dialysis du

mortality. The only risk modifying intervention is renal

accordingly.

4. All women with unexplained proteinuria/hematuria sho

pre pregnancy clinic

5. Adverse maternal outcomes (pre-eclampsia, hypertens

advances.

53

assification Management Care plan Level of care
Level of
CKD Stage 1 ● Refer to Health Clinic/
personnel Hospital ±
5 appropriate MO/ FMS/ specialist
Renal disease disciplines – Physician/
Nephrologist

with multidisciplinary

omorbidity approach

● Management

according to

Clinical Practice

Guidelines

Management of

Chronic Kidney

Disease 2018

● Family planning

cy with an increased GFR and a physically enlarged kidney
of proteinuria during pregnancy correlates significantly with CKD

compared with stage 2 (60% vs 14.3%)
are 20.5%, 86.5% and 70% in stage 1, 3 and 4 – 5 respectively
uring pregnancy, which is associated with increased morbidity and

transplantation. Realistic options should be offered and counselled

ould have a referral to medical for renal work-up and be referred to the

sion and caesarean delivery) are significantly higher as CKD stage

3 Released June 2022

6. Risks of preterm delivery and IUGR correlate with mate
7. Pregnancy may be considered in women with mild re

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 be
11. Safety of treatment:
a. Calcium: safe in pregnancy
b. Activated Vitamin D: data is scarce but reassurin
c. Erythropoietin is safe

54

ernal renal function and level of proteinuria.
enal impairment (serum creatinine <125 μmol/L), well controlled blood
.

e advised for more permanent methods of contraception.
ng

4 Released June 2022

SOP 9: THALASSAEMIA MAJOR

Assessment Lab investigations and Class
PE findings

● Review of ● FBP ● Mild
transfusion ● Renal profile ● Mod
requirements ● LFT ● Sev
● Sym
● Assess compliance ● Iron studies
asy
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 (targ
months pre-conception)

3. Assessment by a cardiologist
▪ Echocardiogram, electrocardiogram (ECG) and T2*

4. Assessment of liver iron concentration using a FerriSca

55

Care plan

sification Management Level of Level of care
● Counselling on personnel
d MO/FMS/ Health Clinics
derate Hospital ±
vere risk of pregnancy Physician/ specialist
mptomatic/ – she needs to Paediatrician
ymptomatic
be fully informed

about how

thalassaemia

affects

pregnancy and

vice versa
● Family planning
● Refer for genetic

counselling if the

need arises
● Transfusion

where indicated

, women with diabetes should be referred to endocrinologists (Refer
get serum fructosamine concentrations < 300 nmol/l for at least 3

* cardiac MRI Released June 2022
an® 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 s
7. To measure ABO and full blood group genotype and an
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 neg
12. Hepatitis C status should also be determined.
13. Offer penicillin prophylaxis for all women who have und
14. All women who have undergone a splenectomy should

B
15. Folic acid (5 mg) is recommended to all women who ar

56

oporosis.
supplements.
ntibody titres
eriprone should be ideally discontinued 3 months before conception

a haemoglobinopathy that may adversely interact with the woman’s
njection (IVF/ICSI) with a pre-implantation genetic diagnosis (PGD) in

to avoid a homozygous or compound heterozygous pregnancy
gative women who are transfused or may be transfused.
dergone a splenectomy.
d be vaccinated for pneumococcus and Haemophilus influenzae type
re planning to conceive to prevent neural tube defects.

6 Released June 2022

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 du
pregnancy is a challenge to the clinicians. The list
(1:2,000−1:10,000), breast cancer (1:3,000−1:
(1:75,000−1:100,000), lymphoma (1:1,000−1:6,00
(1:1,000−1:10,000).

2. With appropriate treatment of the cancer, pregnancy it
Pregnant women diagnosed with breast cancer can re
similar survival when matched for stage at diagnosis.

Foetal Risk

1. The risk of miscarriage and congenital anomalies doe
in cases after abdominal surgery and peritonitis

2. The risk of major malformations, spontaneous abortio
instituted during the first trimester and it is advisable
gestation.

3. Even though no evidence of teratogenic effect was dem
trimester, the risk for low birth weight and foetal growt
from exposure to chemotherapy in the second and th
reported for the general population. Chemotherapy e
(FAC) in the second and third trimester does not ca
taxanes (T), such as docetaxel (D) and paclitaxel (P), d
other maternal complications when used in the second

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

uring pregnancy is low ranging from 0.02-0.1%, diagnosing it during a
of common cancers occurring in pregnancy are cervical cancer

:10,000), ovarian cancer (1:10,000−1:100,000), leukaemia
00), colon cancer (1:13,000) and malignant melanoma

tself does not appear to be associated with worse cancer outcomes.
eceive treatment comparable with non-pregnant women leading to a

es not increase with surgery. Preterm deliveries usually occurred

ons, and foetal death may be increased when chemotherapy is
e that the chemotherapy should be delayed until 14 weeks of

monstrated from chemotherapy exposure in the second and third
th restriction may be increased. The reported foetal malformation
hird trimester rates range from 1.3% to 3.8%, similar to the rate
exposure of 5-fluorouracil, doxorubicin, and cyclophosphamide
ause teratogenic effects. Few studies that evaluated the use of
demonstrated no increase in the occurrence of foetal defects and
d and third trimesters of pregnancy.

7 Released June 2022

4. However, trastuzumab is associated with oligohydramn
trimesters and not recommended in pregnancy.

5. Methotrexate is teratogenic. The most common abnor
by a few case studies are skull, hand, and limb defor
bones, micrognathia, microcephaly, hypertelorism, lo
features, short proximal limbs, low set ears, small chin

6. Women who stopped taking methotrexate even up t
spontaneous abortion.

7. The foetal central nervous system during 8 to 25 w
exposure dose of >0.1 Gy could decrease the intellig
correlated with carcinogenic effects within the first d
leukaemia.

Pre pregnancy management

1. A woman with malignancy who considers pregnanc
consideration the balance of effect on maternal and foe

2. In view of the effect of treatments on feotus, women
activities being hindered by pregnancy, the need to
trimester and also radiotherapy to postpartum, the redu

3. Even though, therapeutic abortion does not provide a
termination of pregnancy should be considered when t
in abdominal and pelvis malignancy.

4. In women who wish to be pregnant, a concurrent foli
feotus of women taking methotrexate.

58

nios and anhydramnios, even when given in the second and third
rmalities following methotrexate exposure in utero demonstrated
rmities such as hydrocephalus, hypoplasia of frontal and orbital
ow set ears and upsweep of the frontal hairline, dysmorphic
and mouth, mongoloid slant and a systolic heart murmur.
to 6 months prior to conception are still at risks of developing
weeks after conception is sensitive to radiation, and a radiation
gence quotient. Radiation in the second and third trimesters is
decade of life, such as the development of solid tumours and

cy has to be managed by multidisciplinary teams taking into
etal health.
n with malignancy have to consider the problems of diagnostic
o delay the institution of chemotherapy to the second or third
uced options of chemotherapy.
better outcome when appropriate treatment for cancer is given,
there is a need for immediate treatment of the disease especially
ic acid may be helpful to reduce the neural tube defects in the

8 Released June 2022

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 severity

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 through

● Special effort must be made to determine the current C

● Consultation with an infectious-disease physician is str

● Dual protection contraception should be advised

● Look for evidence of opportunistic infections, HIV-relate

● 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 ±

y indicated in Physician/ General specialist

accordance to the Physician

Malaysian

Consensus

Guidelines on

Antiretroviral

Therapy 2017
● Family Planning:

Emphasise on dual-

protection

hout pregnancy and after delivery.
CD4 and viral load during the early stage of pregnancy.
rongly recommended if the patient is experiencing virological failure.

ed illnesses and evaluation for possible STIs

9 Released June 2022

SOP 12: POST TRANSPLANT SURGERY

Lab Diagnosti

Investigations criteria an

Assessment and PE Differentia

findings diagnosis

● 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 includin

timing.

2. Timing of pregnancy: avoid pregnancy during the first

of rejection is greatest and immunosuppressive therap

3. Contraception should be emphasised during fi

immunosuppressive medications): Long-acting reve

etonogestrel implant, copper intrauterine device (IUCD

4. For renal transplant patients, vaginal delivery should n

birth canal in most patients. The obstetrician should

confirm location of the allograft and ureter. A renal ult

should be placed in the prenatal record to guide the su

5. In post-transplant patients, offer advise on mediations

impaired

6. The American Society of Transplantation consensus cr

a. No rejection in the past year

b. Adequate and stable graft function

c. No acute infections that might impact the foetus

60

ic Care plan

nd Level of Level of
al Management personnel care
s

● Multidisciplinary MO /FMS /O&G Tertiary

team approach specialist/ hospitals

● Family planning Transplantation unit

ng individualised maternal and foetal risks, alternatives, and

t year post-transplantation (preferably 2 years) when the risk
y is most aggressive.
irst year post-transplant (fertility is not affected by
ersible contraception is effective and options include the
D), and levonorgestrel-releasing IUCD.
not be impaired, as the pelvic allograft does not obstruct the
d review operative notes from the transplant procedure to
trasound might also aid in precise location. This information
urgeon if a caesarean delivery is performed.
and assisted reproductive technology if reproductive ability is

riteria for timing of pregnancy :

s

0 Released June 2022

d. Maintenance immunosuppression at stable dosi
7. Review medications for teratogenic risk. Immunosuppr

mammalian target of rapamycin (mTOR) inhibitors (
pregnancy given its high risks of adverse foetal eff
Glucocorticoids (e.g. prednisolone), calcineurin inhibit
inhibitors such as azathioprine are considered safe in p
8. Vaccination against influenza, pneumococcus, hepatiti

61

ing
ressants like mycophenolic acid (eg, mycophenolate mofetil),
(e.g.; sirolimus and everolimus) should not be used during
fects and should be stopped 6 weeks before conception.
tors (e.g.; cyclosporine and tacrolimus) and purine synthesis
pregnancy.
is B, and tetanus should be administered before conception.

1 Released June 2022

SOP 13: DEPRESSION AND ANXIETY

Lab Diagnostic

investigations criteria and

Assessment and PE Differential

findings diagnosis

● Disease Status: TFT (if it has Common Types:

Acute/Remission not 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

disorder

● Other anxiet

disorder

Severity:

● Mild

● Moderate

● Severe wit

psychosis o

suicidality

1. Depression and anxiety are common mental disorders.

2. Depression is the leading cause of disability worldwide
disease.

3. Depression can lead to suicide and devastating psycho

62

Care plan

Management Level of Level of
personnel care

: ● 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

depression and/or high

risk of relapse, counsel

on risk-benefit of

medications.

● If medication is

ty indicated but the patient

refuses, offer adequate

support, refer to FMS or

psychiatrist, or offer

intensive psychotherapy

th if available.

or

.
e and is a major contributor to the overall global burden of

osocial adverse effects.

2 Released June 2022

4. Suicide is classified as direct maternal mortality in Mala
5. Educate patients on the risk of untreated depression an
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 option
f. Risks of medication i.e. Selective Serotonin Reu

risks of miscarriage, premature delivery, n
hypertension
g. Risk of untreated depression: miscarriage, pre
interpersonal conflict, functional impairment, mo
initiation, long term behavioural problems in offs
h. Assess previous history of depression and anxie
8. Aim to complete treatment before getting pregnant if th
depression/anxiety with low risk of relapse). Maintenan
9. If medication is indicated for severe depression/anxiety
FMS or psychiatrist, or offer intensive psychotherapy if
10. Arrange for psychological intervention:
a. Provide counselling and emotional support in prima
b. Arrange for brief psychological interventions (eg
primary care
c. Referral to tertiary centre for psychological interven
11. Baseline psychosocial investigations: corroborative his
12. Early booking when pregnant

63

aysia.
nd anxiety on pregnancy and feotus
ms of depression and anxiety

deation
ns to reach a shared decision on a treatment plan.
uptake Inhibitor (SSRI): no risk of teratogenicity, low absolute
neonatal adaptation syndrome and primary pulmonary
emature delivery, low birth weight, poor antenatal self-care,
other-baby bonding/attachment difficulties, low breastfeeding
springs, suicide and infanticide.
ety (how many episodes and severity) and medication history
hat is possible (only for mild and moderate
nce treatment of 6-9 months after remission
y but the patient refuses, offer adequate support, refer to
f available.
ary care or O&G setting
brief cognitive behaviour therapy) by trained personnel in
ntion
story from social support

3 Released June 2022

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, sch
2. Schizophrenia and bipolar disorder have a prevalence
psychosis has a prevalence of 1 in 1,000 pregnancies.
3. There is an increased risk of relapse of pre-existing me

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

hizophrenia and bipolar disorder.
of around 1 in 100 in the general population. Postpartum
.
ental disorders during the perinatal period, usually following

4 Released June 2022

cessation of medication.
4. Preconception planning should start as soon as possib

conceive. Contraception is important if they are not pla
5. Detailed counselling regarding the risk-benefit of medic

effects to the feotus must be given to the woman and h
discussion on types of medication used if she plans to
6. Medication:

a. Continue medication if patient is stable and med
b. Valproate and carbamazepine should not be use
c. Lithium should not be used in the first trimester
d. Patients on Clozapine should be referred to psy
e. Continue depot antipsychotic if patient is respon

oral medication.
f. Avoid benzodiazepine unless for short-term trea
g. Choose the drug with the lowest risk profile for t

response to medication.
h. Use the lowest effective dose, aiming for a singl

medication.
i. Start patient early on folate supplements

7. Educate patients and partner on risk of relapse, risk-be
8. Emphasise the importance of follow-up and compliance
9. Optimise patient’s mental state

a. Optimise medication or switch to low impact me
b. Offer psychological support
c. Close monitoring for relapse
10. Assist in substance abstinence
11. Advise on early booking when pregnant

65

ble for women with severe mental illness that plan to
anning to conceive.
cation during the pregnancy, the possibility of relapse and
her partner. Preconception planning will also involve

breastfeed.
dications are not contra-indicated in pregnancy
ed in women who plan to conceive.
of pregnancy.
ychiatrist for management
nding well and has a previous history of non-adherence with
atment of severe anxiety and agitation
the woman, feotus and baby, taking into account previous
le drug regime but taking into account response to

enefit of continuing or starting medication
e
edication

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SOP 15: SUBSTANCE USE DISORDER

Assessment Lab Diagnostic
investigations
and PE findings criteria and

● Obtain thorough and ● Urine for Differential

adequate history: drugs (rapid diagnosis

substance, alcohol, test) Types:
● Alcohol
tobacco ● Infectious ● Nicotine
● Cannabis
● Comorbidities: disease ● Amphetam

medical and screening ne-type

psychiatric conditions stimulant
● Opioid
● Complications: bio-

psycho-social

● Psychosocial history:

History of partner or

spouse taking

substances. History of

forensic/criminal

history

1. Preconception planning should start as soon as pos
conceive.

2. Contraception is important if they are not planning to co
3. Detailed counselling regarding the risk-benefit of repl

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 pr
cognitive behavioural therapy and counselling
strategy to achieve smoking cessation during pr

b. Methadone Replacement Therapy in pregnancy

66

d Care plan Level of care
Management
Level of Health Clinic or
● Brief personnel Hospital with
psychological Psychiatrist/
intervention e.g MO/ FMS/ Psychiatrist with
Brief Psychiatrist subspeciality
addiction
mi Motivational
Interviewing

● Nicotine
replacement
therapy

● Methadone
replacement
therapy

● Refer to
appropriate
discipline

ssible for women with substance use disorder who plan to

onceive.
lacement therapy and medication during the pregnancy, the
given to the woman and her partner.
on types of replacement therapy and medication used if she

regnancy under supervision of a clinician. A combination of
g with nicotine replacement therapy is the most effective
regnancy.
y improves many of the adverse consequences of maternal

6 Released June 2022

and foetal outcomes associated with untreated
typically require treatment for withdrawal sym
continued during pregnancy.
6. Counsel patients on the risk of substances on pregnan
7. Counsel patients and family on risk-benefit of starting o
8. Emphasise the importance of recognizing symptoms o
9. Inform patients on the potential risks of substances a
pharmacological intervention.
10. Emphasise on the importance of follow-up and adheren
11. Aim of treatment is to reach substance abstinence befo
12. Offer counselling and psychological support in primary
13. Arrange for brief psychological interventions e.g brief m
14. Referral to tertiary centre for psychological interventi
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

opioid use. Infants exposed to methadone during pregnancy
mptoms after delivery. Methadone is recommended to be
ncy and feotus.
or continuing replacement therapy
of withdrawal for each substance.
and the availability of non-pharmacological intervention and
nce
ore pregnancy.
y care or O&G setting
motivational interviewing by trained personnel in primary care
ion 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 June 2022

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
Social interactions right 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

death syndrome, impaired fertility

Alcohol - Miscarriage, foetal alcohol syndrome, placenta abruption,

foetal intrauterine growth restriction (IUGR), low birth

weight, central nervous system abnormalities

Cocaine - Abortion, premature birth, placental abruption, IUGR,

congenital anomalies, neonatal central nervous system

(CNS) dysfunction

Caffeine - 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,
(Immunosuppressive renal, 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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