Preconception Counseling and Care

PRECONCEPTION COUNSELING AND CARE

Preconception counseling and care is intended to optimize a woman’s health for pregnancy, ideally commencing before conception, with a preconception visit. During this visit a thorough family and medical history of both parents is obtained, as well as a physical examination of the prospec-tive mother. The goal of this visit is to minimize adverse health effects for the mother and fetus and to promote a healthy pregnancy. Preexisting conditions that may affect conception, pregnancy, or both are identified and addressed. For example, neural tube defects (NTDs) are associated with folic acid deficiency. Discussion about folic acid sup-plementation is an essential component of preconcep-tion. In addition, women with conditions such as maternal phenylketonuria or diabetes can reduce the risks of adverse fetal effects by establishing strict metabolic control before conception and continuing it throughout the pregnancy. Establishing metabolic control of these conditions during pregnancy is believed to be of lesser benefit.

All health encounters during a woman’s reproductive years, particularly those that are a part of preconception care, should include counseling about appropriate medical care and behaviors to optimize pregnancy outcomes. The following maternal assessments may serve as the basis for this counseling:

·            Family planning and pregnancy spacing

·            Family history

·            Genetic history

·            Medical, surgical, psychiatric, and neurologic histories

·            Current medications

·            Substance use

·            Domestic abuse and violence

·            Nutrition

·            Environmental and occupational exposures

·            Immunity and immunization status

·              Risk factors for sexually transmitted diseases

·  Obstetric and gynecologic history

·  Physical examination

·  Assessment of socioeconomic, education, and culture context

Vaccinations should be offered to women found to be at risk for or susceptible to rubella, varicella, and hepatitis B. All pregnant women should be tested for HIV infection, unless they decline the test. A number of other tests can be performed for specific indications:

·  Screening for sexually transmitted diseases

·  Testing for maternal diseases based on medical or repro-ductive history

·  Mantoux test with purified protein derivative for tuberculosis

·  Screening for genetic disorders based on racial and ethnic background:

·         Sickle hemoglobinopathies (African Americans)

·         Beta-thalassemia (individuals of Mediterranean and Southeast Asian descent; African Americans)

·         Alpha-thalassemia (individuals of Southeast Asian and Mediterranean descent; African Americans)

·         Tay-Sachs disease (Ashkenazi Jews, French Canadians, and Cajuns)

·         Canavan disease and familial dysautonomia (Ashkenazi Jews)

·         Cystic fibrosis (while carrier frequency is higher among Caucasians of European and Ashkenazi descent, carrier screening should be made available to all couples)

·         Screening for other genetic disorders on the basis of family history

Patients should be counseled regarding the benefits of the following activities:

·  Exercise

·      Reducing weight before pregnancy, if obese; increasing weight, if underweight Avoiding food faddism

·      Avoiding pregnancy within one month of receiving a live attenuated vaccine (e.g., rubella)

·      Preventing HIV infection

·      Determining the time of conception by an accurate menstrual history

·      Abstaining from tobacco, alcohol, and illicit drug use before and during pregnancy

·      Taking 0.4 mg of folic acid daily while attempting pregnancy and during the first trimester of pregnancy for prevention of NTDs; women who have had a prior NTD-affected pregnancy should consume 4 mg of folic acid per day in the preconception period. This amount can be achieved by adding a separate supple-ment to a single multivitamin tablet to provide a total of 4 mg of folic acid while avoiding excessive intake of fat-soluble vitamins, which may have adverse fetal effects if taken in high doses.

·      Maintaining good control of any preexisting medical conditions (e.g., diabetes, hypertension, asthma, systemic lupus erythematosus, seizures, thyroid disorders, inflam-matory bowel disease).