Presented By : Rehab alghamdi R3

Supervised by : Dr.Shadi banon

 ‫س ُكنُوا ِإلَ ْي َها‬ ‫س ُك ْم َأ ْز َو ً‬
‫اجا لِتَ ْ‬ ‫ق لَ ُك ْم ِمنْ َأ ْنفُ ِ‬‫﴿ َو ِمنْ َآيَاتِ ِه َأنْ َخلَ َ‬
‫َو َج َع َل بَ ْينَ ُك ْم َم َو َّدةً َو َر ْح َمةً ِإ َّن فِي َذلِ َك َآَليَا ٍ‬
‫ت لِقَ ْو ٍم‬
‫ون(‪﴾)21‬‬ ‫يَتَفَ َّك ُر‪َ 6‬‬

‫( سورة الروم )‬
‫‪Dr. Laila Aloufi‬‬
‫‪FM consultant‬‬
: Contents
o Pre-test .
o Introduction .
o Definitions .
o Premarital screening.
o Premarital counseling .
o Workshop.
o Family Physicians Role .
o MOH program .
PRE-TEST
5 minutes
 Overview
M
​ arriage is considered a remarkable event in
the individuals' lives .

 It works on building a new family, new

emotional, social, familial, and healthy
relationships.
 ​The injury to any members of the family with
hereditary and infectious diseases leads to
foul the pleasure of life and several
psychological, social, and economic problems.
 :Definition of Healthy Marriage

state of agreement and harmony between •

the marriage partners with regard to the
healthy, psychological, sexual and social
aspects, aiming at making a sound family
.and getting healthy, happy children
‫الزواج الصحي هو حق أساسي من حقوق الفرد وحدث مهم في حياته‬
 : Definition of premarital counseling

Premarital counseling is a type of therapy that

helps couples prepare for marriage to ensure a
strong, healthy relationship
 Through premarital counseling, couples are
encouraged to discuss topics related to
marriage, such as:
• Finances •Children and parenting
•Communication •Family relationships
•Beliefs and values •Decision-making
•Roles in marriage •Dealing with anger
•Affection and sex •Time spent together
Different types and Techniques of premarital
counseling :

• Online premarital counseling courses .

• One-one professional counseling .
• Compatibility tests or questionnaires.
• Group courses and discussion .
 : Definition of premarital screening

conducting examination for couples intending to marry;

in order to identify if there is any injury with :

 genetic blood diseases such as sickle-cell

anemia (SCA) and Thalassemia .
 some infectious diseases such as
hepatitis B, C and HIV "Aids".

 provide medical consultation on the

odds of transmitting these diseases to
the other marriage partner or the
children in the future .
: Objectives of Premarital Screening
 Limiting the spread of some genetic blood diseases: sickle-cell
anemia (SCA) and thalassemia, and some infectious diseases:
hepatitis B, C and AIDS/HIV.

 Reducing the financial burdens resulting from the treatment

of the injured in terms of the family and community.
 Reducing pressure over health institutions and blood banks.

 Avoiding the social and psychological problems for families

whose children suffer.

 Disseminating awareness with regard to the concept of the

comprehensive, healthy marriage .
 ‫من المنظور الشرعي‬
‫• إن الشريعة اإلسالمية مبنية على جلب المصالح ودرء المفاسد كما قال‬
‫ك إال َرحْ َمةً لِ ْل َعالَ ِم َ‬
‫ين)‬ ‫تعالى‪َ ( :‬و َما َأرْ َس ْلنَا َ‬

‫• قرر الفقهاء قاعدة (الدفع أولى من الرفع)‪ ،‬والمراد بالدفع منع حصول‬
‫الضرر قبل وقوعه‪ ،‬والمراد بالرفع إزالة الضرر (رفع الضرر) بعد‬
‫حصوله‪ ،‬وإجراء فحص الزواج الصحي يتم به منع األضرار المتوقعة‬
‫قبل حصولها فيكون أولى من ترك الناس يصابون بهذه األمراض ثم‬
‫نقوم بعالج تلك األمراض أو التخفيف من أضرارها‪.‬‬
 Case 1
Newly engaged Couple came for premarital
tests so they can get their premarital
screening certificate approval.

What screening tests will be done to

them?
 Premarital Screening test :
Genetic blood disease :
• Thalassemia  Basic Laboratory Test :
• Sickle cell anemia • CBC
• Hemoglobin electrophoresis
• Sickling test
Infectious disease :
• Hepatitis B virus  Basic Laboratory Test :
• Hepatitis C virus • HBs Ag
• HIV , AIDS • HCV - ab
• HIV - ab
 Why to include hemoglobinopathies in
premarital Screening Program?

 These are autosomal recessive inheritable

haemoglobinopathies which are common in some regions
of Saudi Arabia.

 These are incurable disorders and causes significant

morbidity and mortality.

 This imposes a heavy financial burden on the society

Why to include HIV / HBV /HCV in
?premarital Screening Program
 These diseases are now prevalent in epidemic proportion.

 They can be easily transmitted to sexual partners and to

newborns.

 They are not curable.

 The mortality and morbidity rates are high.

 Analysis of HB electrophoresis results
• 92% of adult hemoglobin Hb A

• 2-3% of adult hemoglobin.

• Increased In βThalassemia.
Hb A2

• less than 1% of hemoglobin in adults.

• Comprises Normal Hemoglobin in Fetus
Hb F
from 3-9 months of life
• Increased In β-Thalassemia
• found in α-Thalassemia Hb H
• mild to moderate anemia
• found in α-Thalassemia Hb Barts
• severe form of anemia
• infants are stillborn or die immediately
after birth (hydropsfetalis)
• presents as Sickle cell Anemia Hb S
• In homozygous state both genes are abnormal
presents as SCA Sickle Cell
• Hb is 6-8 gm /dl Anemia
• Reticulocyte count :10-20%.
• Hb electrophoresis : Hb A : 0 %
Hb SS :95%
Hb F : 2-20%
• Sickling Solubility test: precipitation of Hb S gives a
turbid appearance
• Sickle cell trait Hb AS
• heterozygous state only one chromosome carries
the gene effected and one normal gene
• No symptoms of sickle cell disease but can pass the
trait on to their children
• Hb electrophoresis: Hb A: 60 %
Hb SS:40%
Hb F:2%
Hepatitis B virus

susceptible

Immune due to natural

infection
Immune due to hepatitis B
vaccination

Acutely infected

chronically infected

Four interpretations
Hepatitis C virus
 HIV virus
1- serum HIV enzyme-linked immunosorbent assay
(ELISA)

2- A positive result should be confirmed with a

Western blot or second ELISA.
What will happen after the tests ?
Consultation
 Case 2
24 years old female patient come to you
for premarital counseling as her wedding
will be this year

How can we counsel her ?

 Establish rapport
History
 Sociodemographic data as age, education, occupation,
consanguinity to the partner, sequence of marriage.

 Medical / surgical history :

a. Ask about systemic illness such as:
hypertension, diabetes mellitus, heart problems, epilepsy, etc.
b. Ask about previous surgical history
(date, type, where it was done).
c. Ask about history of blood transfusion
d. Ask about history of STI or genital lesions.
 History
 Ask about current medications.

 psychological histories / ICEE

 Family history of chronic or genetic diseases.

 assess risky behaviors such as smoking, alcohol consumption

or substance abuse.

 explore if she previously married, have any children and history

of baby with congenital abnormality
 Physical Examination
1- assess general appearance.

2- obtain baseline measurements and vital signs.

3- explore relevant general examination details depending on

client(s) history.
 Laboratory Tests
· CBC.
· Blood grouping and Rh.
· Hb electrophoresis.
· Sickling test.
· Rubella antibodies IgG (for females).
· VDRL test for syphilis
· HIV test.
· HBsAg.
· Anti HCV antibodies.
 counseling
premarital educational materials which includes the
following information:

Concept and aim of premarital screening.

Common haemoglobinopathies in KSA .
Sexually Transmitted Infections (STIs).
Healthy lifestyle.
Contraception?
vaccinations if indicated.
medications
schedule for revisit or referral accordingly
 Vaccination
Human Papillomavirus

• HPV vaccine recommended for females aged 9–26

years.

• The HPV vaccine has been classified by the FDA as

pregnancy category B. Thus, vaccination use during
pregnancy is not recommended.
 Vaccination

Influenza
• Women who will be pregnant during the influenza season
should be vaccinated with the influenza vaccine.

• This intramuscular, inactivated vaccine may be used in all

three trimesters.

• It should be noted that the intranasal vaccine spray contains

a live, attenuated virus and should not be used during
pregnancy.
 Vaccination

MMR & varicella

• It is a live attenuated vaccine.

• Administered to all susceptible women

preconceptionally or at post partum period.

• Contraindicated during pregnancy and women should

be advised to avoid conception for one month
following immunization.
 Vaccination

Tdap

• Tetanus vaccination may protect against neonatal tetanus.

• Administer 1 dose of Tdap during each pregnancy, preferably

in the early part of gestational weeks 27–36 to reduce the
risk of neonatal pertussis.
  Folic acid :

 Pre-conceptional folic acid supplementation decreases

the occurrence and recurrence of neural tube defects
(NTDs).
 It is recommended for all women planning pregnancy
or capable of becoming pregnant( Grade 1A )

 low risk women , 400-800microgram daily

 moderate risk ,1 mg daily
 high risk , 4 mg daily
 Case 3
After Premarital tests of couple the results
showed :
Both of them found to be carriers of sickle cell
anemia
Negative for Hep B, Hep C and HIV

What are their options?

?In case of carrier for hemoglobinipathies
o The future couple should be advised that after marriage
your children could suffer from Sickle Cell anemia or
Thalassemia.

o The physician will not issue the premarital fitness

certificate.

o The decision will be for the future couple whether to go

ahead with the marriage or not.
 Available choices after positive
Test results ?

1) Avoidance of marriage.
2) In-vitro-Fertilisation 
 In case of infection with HIV or Hepatitis
?viruses
o The physician will repeat the test before confirming the
diagnosis.
o If still positive; will not issue premarital fitness
certificate.
o HIV & HCV Positive are encouraged to avoid marriage.
o In HBV Carriers, the healthy partner is advised to be
vaccinated.
o The HIV, HCV patient will be informed and referred to a
Specialty Clinic for Follow-up
 What Ethical issues can arise ?

usually premarital screening comes too late for

couples to change their opinions ABOUT
marriage. By this time they are already
committed for this relationship.
Which Spouse would be affected the Most ?
  Is it a stigma or dilemma for female? 

Rejecting marriage on these ground for female

may effect her social life .Sometimes this stigma
may prevent her from ever getting married .
• In Saudi Arabia , 90% of couples detected as carriers
did not follow the advice and went ahead with their
marriages. Social and familial commitments make it
difficult to ask partners to undergo pre marital
testing.

• Wrong religious beliefs could be obstacles to

premarital screening success regardless of education
level. 
 
? What is the Family Physicians Role
• Psychosocial preparation for both male and female ?

• Discuss Genetic counseling :

Encourage individual or family to obtain information about a genetic condition
that may effect them.
They can make appropriate decisions about marriage , reproduction and health
management.

• Discuss Consanguinity :
Relationships by blood , in which the chances of offspring inheriting a recessive
allele for a disease are increased .The closer the relationship , the greater the
risk.
MOH PROGRAM
‫برنامج الزواج الصحي‬

‫‪ ‬نبذة عن البرنامج‬
‫‪ ‬مراكز الفحص الطبي المعتمدة‬
‫‪ ‬خطوات الفحص الطبي‬
‫‪ ‬أنواع شهادات الفحص الطبي‬
‫‪ ‬خطوات اصدار شهادة الفحص الطبي‬
 ‫برنامج الزواج الصحي‬

‫‪ ‬بدأ منذ عام ‪ 1425‬هـ ‪:‬‬

‫‪ o‬أطلقت عليه وزارة الصحة اسم ( برنامج فحص المقبلين على الزواج )‬
‫‪ o‬يستهدف فقط فحص أمراض الدم الوراثية ‪.‬‬
‫‪ ‬في عام ‪ 1429‬هـ ‪:‬‬
‫‪ o‬أطلق عليه اسم ( برنامج الزواج الصحي )‪.‬‬
‫‪ o‬إضافة فحص األمراض المعدية ‪.‬‬
 ‫أن تكون المملكة نموذجا يحتذي به في تطبيق‬
‫الرؤية‬
‫برنامج الزواج الصحي بمفهومه الشامل‪.‬‬
‫‪ ‬‬

‫المحافظة على سالمة األجيال القادمة من خالل‬

‫تطبيق البرنامج يقوم به فريق مؤهل يلتزم‬ ‫الرسالة‬
‫بمعايير الجودة العالية‬
‫‪ ‬‬

‫* الخصوصية والسرية‬
‫‪ ‬‬ ‫القيم‬
‫* الدقة والمصداقية‬
‫‪ ‬‬

‫* الشمولية والشفافية‬
‫‪ ‬‬
 ‫توزيع مراكز الفحص ما قبل الزواج بالمملكة‬
‫‪20‬‬
‫‪20‬‬
‫‪18‬‬ ‫استقبال‬
‫‪16‬‬
‫‪16‬‬ ‫‪131‬‬
‫‪14‬‬
‫‪11‬‬ ‫‪12‬‬
‫‪10‬‬ ‫مختبر‬
‫‪9 9‬‬ ‫‪10‬‬
‫‪8 9‬‬
‫‪9‬‬ ‫‪8‬‬ ‫‪93‬‬
‫‪5 5‬‬ ‫‪6‬‬
‫‪4 5 6‬‬
‫‪4 3‬‬ ‫‪4‬‬
‫‪4‬‬ ‫عيادة‬
‫‪1 1 2‬‬ ‫‪2‬‬
‫‪0‬‬ ‫مشورة‬
‫ا‬
‫ل‪6‬ق‪6‬نف‪66‬‬
‫ا‬
‫ج‪6‬ده‬ ‫ي‪6‬شة‪6‬‬
‫ب‪6‬‬
‫ل‪6‬جو‪6‬‬
‫ا‬
‫ئ‪6‬ل‪6‬‬
‫ح‪6‬ا‪6‬‬ ‫‪6‬‬‫و‬‫ت‪6‬ب‪6‬‬ ‫ل‪6‬شر‪6‬‬ ‫م‬ ‫ال‪6‬‬
‫ج‪6‬ا‪6‬ز‬ ‫ريا‪66‬‬
‫ال‪6‬‬
‫‪80‬‬
‫ذة‬ ‫ف‬ ‫ك‬ ‫قي‪6‬ة‬ ‫دي‪6‬ن‪6‬‬ ‫ن‬‫ا‬
‫ة ا مل‬
‫‪6‬‬ ‫ض‪6‬‬
‫ر‬‫ن‪6‬و‪6‬‬
‫ة‬
‫‪Accredited Premarital Screening Centers‬‬

‫مستشفى‬ ‫مستشفى حراء‬ ‫مستشفى الوالدة‬ ‫مستشفى النور‬

‫الكامل‬ ‫العام‬ ‫واألطفال‬ ‫التخصصي‬

‫عيادة المشورة‬
‫الطبية‬
‫برنامج الزواج الصحي‬

‫اقسام مركز الفحص الطبي قبل الزواج ‪:‬‬

‫‪ o‬قسم االستقبال‬
‫‪ o‬قسم المختبر‬
‫‪ o‬قسم المشورة الطبية‬
 ‫برنامج الزواج الصحي‬

‫خطوات الفحص الطبي ‪:‬‬

‫‪ o‬اعطاء بعض البيانات مثل اإلسم والعمر والعنوان ‪.‬‬
‫‪ o‬يفضل أن يجري الطرفين الفحص في نفس المركز ‪.‬‬
‫‪ o‬هذه الفحوصات ال تتطلب الصوم ‪.‬‬
 ‫برنامج الزواج الصحي‬

‫• ننصح المقبلين على الزواج بإجراء الفحص الطبي قبل موعد‬

‫الزواج‪ ‬بمدة ال تقل عن ثالثة أشهر‪ ‬ليتسنى للزوجين التخطيط لحياتهم‬
‫بشكل أفضل‪ ،‬حيث‪ ‬إن صالحية شهادة الزواج الصحي تستمر لمدة‬
‫ستة أشهر ويمكن‪ ‬فقط إعادة فحص األمراض المعدية‪ ‬عند الحاجة‪ .‬‬
 ‫برنامج الزواج الصحي‬
‫وفي حال ما إذا كان أحد األطراف خارج المملكة فيجب اتباع الخطوات‬ ‫•‬
‫التالية‪ :‬‬
‫أهمية التأكد من إجراء كافة النتائج المخبرية لألمراض المشمولة‬ ‫•‬
‫بالبرنامج (ثالسيميا‪ ،‬األنيميا المنجلية‪ ،‬التهاب الكبد الفيروسي ب‪/‬ج‪،‬‬
‫ونقص المناعة المكتسبة)‪.‬‬
‫وضوح كافة المعلومات الشخصية للمقبل على الزواج‪.‬‬ ‫•‬
‫يشترط أن يكون المركز الطبي معترفًا به‪ ،‬وتتم مصادقة النتائج من قبل‬ ‫•‬
‫السفارة السعودية‪.‬‬
 ‫برنامج الزواج الصحي‬

‫‪ o‬ظهور نتائج الفحوصات واصدار شهادات الفحص تتطلب ‪ 10‬ايام ‪.‬‬

‫‪ o‬بعض االحيان في حالة احتياج للتأكيد تصل المدة الى اسبوعين ‪.‬‬
 ‫نتيجة الفحص‬

‫مرض االلتهاب الكبدي‬ ‫مرض االيدز‬ ‫مرض وراثي‬ ‫سليم‬

‫االحالة الى عيادة‬
‫مكافحة االيدز‬
‫ال يرغب بإتمام العقد يرغب في إتمام العقد‬ ‫يرغب في اتمام العقد ال يرغب بإتمام العقد‬

‫عدم اصدار شهادة‬ ‫‪ -‬حضور الخطيبين وولي‬

‫امرها لعيادة المشورة الطبية‬
‫الطرف المصاب‬ ‫الطرف االخر سليم‬ ‫‪ -‬التوقيع بالعلم والموافقة على‬
‫‪ -‬االحالة لعيادة االمراض‬ ‫‪ -‬الحضور لعيادة المشورة‬ ‫اتمام العقد‬
‫المعدية للمتابعة‬ ‫مع ولي االمر‬
‫‪ -‬التوقيع بالموافقة على‬ ‫‪ -‬التوقيع بالعلم والموافقة‬
‫ابالغ الطرف األخر ومتابعة‬ ‫‪ -‬االحالة لعيادة الصحة‬ ‫اصدار شهادة الفحص قبل الزواج‬
‫اتمام العقد‬ ‫العامة للتطعيم مع‬
‫‪ -‬التعهد بإكمال الجرعات‬
 ‫أنواع شهادات الفحص‬
‫في حالة أمراض الدم الوراثية‬ ‫‪‬‬
‫تعطي شهادة متوافق او غير متوافق مع الحرية التامة للطرفين بعد ذلك ‪.‬‬ ‫‪‬‬
‫معنى متوافق ‪ :‬ان نتائج كال الطرفين سليمة او ان احدهم سليم واالخر حامل ‪.‬‬ ‫‪‬‬
‫متوافق ‪ :‬حامل أي ال تظهر عليه األعراض ويعتبر هذا الزواج آمن لعدم وجود احتمالية والدة طفل مصاب ‪.‬‬ ‫‪‬‬
‫معنى غير متوافق ‪ :‬نتائج كال الطرفين غير سليمة أي كالهما حاملين او مصابين او احدهما حامل واالخر مصاب‬ ‫‪‬‬

‫في حالة األمراض المعدية ‪:‬‬ ‫‪‬‬

‫ال توجد شهادة توافق او عدمه ‪.‬‬ ‫‪‬‬
‫الحاالت االيجابية ال تعتبر غير متوافقة ‪.‬‬ ‫‪‬‬
‫تصدر الشهادة عند الرغبة في اتمام الزواج ‪.‬‬ ‫‪‬‬

‫ايجابية الفحص لألمراض المستهدفة ال تمنع اقتران الخطيبين ‪.‬‬

 ‫انواع شهادات الفحص‬

‫شهادة توافق‬ ‫شهادة عدم توافق‬

‫تعطى ألمراض الدم الوراثية‬ ‫تعطى فقط ألمراض الدم الوراثية‬

‫تعطى لحاالت‬ ‫سليم –حامل ‪/‬مصاب‬ ‫‪ -1‬حامل – حامل‬
‫تعطى لاللتهاب الكبدي ب و ج‬ ‫‪ -2‬مصاب ‪ -‬مصاب‬
‫سليم – سليم‬ ‫‪ -1‬الطرفان مصابان ‪ /‬حامالن‬ ‫‪ -3‬حامل – مصاب‬
‫‪ -2‬احدهم مصاب ‪ /‬حامل واالخر‬
‫سليم‬

‫تطبع بقسم االستقبال‬ ‫تطبع بعيادة المشورة الطبية‬

‫ال تمنح أي نوع من الشهادتين الى حالة نقص المناعة المكتسب‬

 ‫شهادة توافق‬

‫ال تشير شهادة الفحص الى‬

‫نوعها أو نتائج الفحص‬
 ‫شهادة عدم توافق وراثيا‬

‫ال تشير شهادة الفحص الى‬

‫نوعها أو نتائج الفحص‬
References
1-Which one of the following screening tests is NOT
included in the “program of healthy marriage “ of
Saudi Arabia:

a-Hemoglobin electrophoresis
b-Anti-HCV.
c-HBs Ag
d-PCR detection of HPV DNA
Answer : D
2-Mohammed is a 27 years old Saudi gentleman who
loves his 23 year old cousin, went to hospital for pre-
marital blood testing. 2 weeks later the results, knowing
that both of them are carriers of Sickle Cell Anemia.
The probability of giving birth to a sickle cell anemic
baby is:
a-25%
b-50%
c-75%
d-100%
Answer : A
3-According to the previous question what
should we do after telling them the possibilities:

a-He should repeat the blood test

b-Courage them to get married.
c-He should not issue the premarital fitness
certificate
d-Telling the couples that they have no right to
go ahead with this marriage.
Answer : C
4-Which of the following is the direct influencer
of increased incidence of autosomal recessive
disorders in Saudi Arabia :

a-Low social and healthcare awareness

b-Consanguineous marriages
c-Some wrong religious beliefs
d-All of the above

Answer : B
5-A successful pre-marital counseling approach
is considered successful when it provides:

a-Active involvement of policy makers.

b-Raising awareness through educational
programs.
c-Targeting the young males and females just
before they get married.
d-Both A&B
Answer : D