What are the Ministry of Health (MOH) guidelines for a pregnant woman's care?

Ministry of Health (MOH) Guidelines for Pregnancy Care

While the provided evidence does not contain specific MOH (Ministry of Health) guidelines, comprehensive international pregnancy care guidelines consistently recommend structured antenatal care with risk assessment, regular monitoring, and evidence-based interventions throughout pregnancy.

Essential Components of Antenatal Care

All pregnant women should receive routine antenatal care with a minimum of 8 antenatal contacts throughout pregnancy, ideally with midwife-led continuity of care. 1, 2

Initial Assessment and Risk Stratification

Before 20 weeks gestation, all women require comprehensive risk assessment for pregnancy complications, particularly pre-eclampsia. 1

Key risk factors requiring early specialist referral include: 1

• Previous pre-eclampsia
• Multiple pregnancy
• Pre-existing hypertension (diastolic BP ≥90 mmHg at booking)
• Pre-existing renal disease or proteinuria (≥+ on dipstick or ≥300 mg/24h)
• Pre-existing diabetes
• Antiphospholipid antibodies
• Any two additional moderate risk factors (nulliparity, age ≥40, family history of pre-eclampsia, BMI >30)

Preconception and Early Pregnancy Care

Women should receive preconception counseling addressing medication review, genetic screening, nutritional assessment, substance abuse screening, and immunization status. 1

Critical preconception interventions include: 1

• Folic acid supplementation (5 mg daily for high-risk women, standard dose for others) 3
• Avoidance of FDA pregnancy category X medications and most category D medications
• Screening for periodontal, urogenital, and sexually transmitted infections
• Update immunizations (hepatitis B, rubella, varicella, Tdap, influenza)
• Assessment of chronic medical conditions requiring optimization

Prevention Strategies

Pre-eclampsia Prevention

Low-dose aspirin (81-150 mg daily) should be started before 16 weeks gestation (optimally by 12 weeks) and continued until 37 weeks for women with major risk factors. 1, 2

Major risk factors warranting aspirin prophylaxis: 1

• Prior pre-eclampsia
• Chronic hypertension
• Pregestational diabetes
• BMI >30
• Chronic kidney disease
• Antiphospholipid syndrome

Calcium supplementation (1200 mg daily) is recommended if dietary calcium intake is low in the local population. 1

Venous Thromboembolism Prevention

All pregnant women require VTE risk assessment, with antepartum antithrombotic prophylaxis for those with hereditary thrombophilia and family history of VTE. 2

Trimester-Specific Monitoring

Second Trimester (13-27 weeks)

Detailed fetal anatomy ultrasound should be performed in the second trimester. 2

Women with pregestational diabetes require fetal echocardiogram in the second trimester. 2

Third Trimester (28+ weeks)

After 28 weeks gestation, pregnant women should observe more stringent precautions, particularly during infectious disease outbreaks. 2

Antepartum fetal surveillance starting at 32-34 weeks gestation is recommended for high-risk pregnancies. 2

Ultrasound for fetal growth assessment should be conducted for women with risk factors throughout the third trimester. 2

Blood Pressure Monitoring and Hypertension Management

Monitoring Schedule

After 20 weeks gestation, women require systematic blood pressure and proteinuria screening at each antenatal visit. 1

Two-tiered monitoring approach: 1

• Standard monitoring for low-risk women
• Enhanced monitoring for women with identified risk factors

Hypertension Thresholds and Treatment

For women with gestational hypertension with proteinuria, pre-existing hypertension with superimposed gestational hypertension, or hypertension with subclinical organ damage, initiate antihypertensive treatment at BP ≥140/90 mmHg. 1

For all other pregnant women with hypertension, initiate treatment at BP ≥150/95 mmHg. 1

Systolic BP ≥170 mmHg or diastolic BP ≥110 mmHg constitutes an emergency requiring immediate hospitalization. 1

First-line antihypertensive agents: 1

• Oral methyldopa
• Oral nifedipine
• Intravenous labetalol

Intravenous hydralazine is no longer the drug of choice due to increased perinatal adverse effects. 1

Special Population Management

Women with Obesity (BMI ≥30)

Women with obesity should receive counseling about pregnancy risks including gestational diabetes, hypertension, miscarriage, and stillbirth at the first prenatal visit. 2, 3

The goal is to control gestational weight gain within recommended limits, not to lose weight during pregnancy. 3

Management includes: 3

• Diet and exercise counseling based on IOM recommendations
• Target 30 minutes of moderate-intensity exercise daily or 150 minutes per week
• Nutritional consultation and dietitian referral
• Early screening for type 2 diabetes
• Aspirin ≥75 mg daily from 12 weeks if BMI ≥35
• Adequate folic acid (5 mg daily) and vitamin D supplementation

Anesthesiology consultation should be arranged during the antenatal period for women with BMI ≥30. 4

Women with Pregestational Diabetes

Strict glycemic control, screening for comorbidities, diagnostic testing, preeclampsia prophylaxis, fetal surveillance, and individualized delivery planning are required. 2

For women with good glycemic control and no vascular complications, delivery at 39 0/7 to 39 6/7 weeks is recommended. 2

For women with poor glycemic control, vascular complications, or prior stillbirth, delivery at 36 0/7 to 38 6/7 weeks may be appropriate. 2

Mental Health Screening

Health professionals should inquire about mental health during every consultation and connect women to relevant resources. 2

Laboratory Testing

Essential screening includes: 1

• Complete blood count
• Urinalysis
• Blood type and screen
• Rubella serology
• Syphilis screening
• Hepatitis B screening
• HIV screening
• Gonorrhea and chlamydia screening when indicated
• Diabetes screening
• Cervical cytology when due
• Thyroid-stimulating hormone levels when indicated

Common Pitfalls to Avoid

Do not delay aspirin prophylaxis beyond 16 weeks gestation in high-risk women, as efficacy decreases significantly with later initiation. 1, 2

Do not use methyldopa postpartum due to risk of postnatal depression; switch to alternative antihypertensive agents. 1

Do not assume obesity alone contraindicates exercise during pregnancy; regular physical activity reduces risks without adverse fetal outcomes. 3

Do not miss the opportunity for early specialist referral before 20 weeks for women with identified high-risk factors. 1