Preconceptional Care and Counseling

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Chapter 180 Preconceptional Care and Counseling

THE CHALLENGE

In many ways, prenatal care is the prototypical example of preventive medicine. Preconceptional care is directed toward ensuring the optimal health of the prospective mother and doing those things that will remove preventable impediments to a healthy outcome for the pregnancy. The care these women receive during this and the prenatal phase of their lives is critical to both their health and the success of the pregnancy.

Scope of the Problem: In the United States, roughly 4.1 million women give birth each year, and >90% of American women will bear children during their lifetime. Twenty percent or more of women have one or more risk factors that could adversely affect a pregnancy if not addressed. Therefore, women who receive delayed (after 12 weeks of pregnancy) or no prenatal care are at risk for having undetected or preventable complications of pregnancy that can result in significant maternal or fetal morbidity or mortality.
Objectives of Management: To protect the health and well-being of mother, fetus, and neonate through screening and optimizing a woman’s health and knowledge before conceiving a pregnancy.

TACTICS

Relevant Pathophysiology: The initiation of folic acid supplementation at least 1 month before pregnancy has been shown to reduce the incidence of neural tube defects such as spina bifida and anencephaly. (Because organogenesis begins early in pregnancy, starting folic acid supplementation after neural tube closure [28 days after conception] has no demonstrated benefit in reducing neural tube defects.) Similarly, adequate glucose control in a woman with diabetes before conception and throughout pregnancy decreases maternal morbidity, spontaneous abortion, fetal malformation, fetal macrosomia, intrauterine fetal death, and neonatal morbidity. Reducing the risk of infectious diseases that can have adverse effects on the mother or fetus if contracted during pregnancy, through vaccination (e.g., rubella) or avoidance (e.g., toxoplasmosis), is a proven preventive strategy.
Strategies: Ideally, obstetric care should commence before pregnancy with a preconception visit, during which a thorough family and medical history for both parents is taken and a physical examination of the prospective mother is performed. Both before and between pregnancies, pre-existing conditions that may affect conception, pregnancy, or both should be identified, and appropriate management plans should be formulated with the goal of a “healthy” subsequent pregnancy. Unfortunately, nearly half of all pregnancies in the United States are unintended, making the challenge of preconception care more difficult. As a result, effective preconceptional care must address pregnancy planning for women who seek care in anticipation of a planned pregnancy and, just as importantly, for all women with childbearing potential.
General evaluations are directed toward establishing optimal maternal health, providing nutritional counseling, and instituting appropriate prophylaxis. This generally takes the form of genetic screening or the detection of maternal diseases that will alter or be altered by the future pregnancy. Based on age, ethnic origin, race, or family history, couples may be identified who are at increased risk of chromosomal or enzymatic abnormalities, such as sickle cell trait, thalassemia, or Tay-Sachs disease carrier state. A family history that is positive for certain diseases, such as cystic fibrosis and congenital hearing loss, indicates the need for additional screening.
The evaluation should focus on many aspects of the woman’s life that can adversely influence the outcome of the pregnancy: undiagnosed, untreated, or poorly controlled medical conditions; immunization history; medication use; occupational and environmental exposures; nutritional issues; tobacco and substance use; and any other high-risk behaviors. Social and mental health issues that may affect the woman’s ability to access and participate in prenatal care should also be addressed.
Before pregnancy is the optimal time for immunizing against hepatitis B, rubella, and varicella; screening for human immunodeficiency virus and syphilis infections; and, if found, beginning treatment to prevent the transmission of disease to the fetus. The patient should be counseled on ways to prevent infection with toxoplasmosis, cytomegalovirus, and parvovirus. Anemia, hypothyroidism, urinary tract infections, and other conditions may be identified; nutritional counseling and weight reduction may be effected before pregnancy; and admonitions about the risks of using medications, drugs, alcohol, and tobacco and avoidance of chemicals such as solvents and pesticides during early pregnancy may be given.
Patients considering pregnancy in the immediate future should be prescribed prenatal vitamins, folic acid supplements, or both. (Prenatal vitamins should include at least 400 μg of folic acid and 30 mg of elemental iron for patients at average risk. The dosage of folic acid should be increased to 1 mg per day for women with diabetes mellitus, epilepsy, or hemoglobinopathies; patients who have given birth to a child with neural tube defects should take 4 mg of folic acid per day for subsequent pregnancies. Higher levels of supplementation should not be achieved by taking excess multivitamins because of the risk of vitamin A toxicity.)
Patient Education: American College of Obstetricians and Gynecologists Patient Education Booklet AP056 (Good Health Before Pregnancy: Preconceptional Care), AB012 (Planning Your Pregnancy), AP001 (Nutrition During Pregnancy), AP0103 (Having a Baby [Especially for Teens]), AB005 (You and Your Baby: Prenatal Care, Labor and Delivery, and Postpartum Care), AP060 (Later Childbearing), AP104 (Drugs and Pregnancy), AP032 (Especially for Fathers).

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IMPLEMENTATION

Special Considerations: If the patient has significant medical problems, the impact of pregnancy on these problems, and the implications for the pregnancy, may be determined and, where possible, the risks may be reduced before conception. Medications for hypertension, epilepsy, thromboembolism, depression, and anxiety should be reviewed and changed, if necessary, before the patient becomes pregnant.

REFERENCES

Level II

Jack BW, Campanile C, McQuade W, Kogan MD. The negative pregnancy test. An opportunity for preconception care. Arch Fam Med. 1995;4:340.

Milunsky A, Jick H, Jick SS, et al. Multivitamin/folic acid supplementation in early pregnancy reduces the prevalence of neural tube defects. JAMA. 1989;262:2847.

Level III

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care, 5th ed. Elk Grove Village, IL: AAP, 2002. Washington, DC, ACOG,

American College of Obstetricians and Gynecologists. Perinatal viral and parasitic infections. ACOG Practice Bulletin 20. Washington, DC: ACOG, 2000.

American College of Obstetricians and Gynecologists. Access to women’s health care. ACOG Statement of Policy. Washington, DC: ACOG, 2003.

American College of Obstetricians and Gynecologists. Neural tube defects. ACOG Practice Bulletin 44. Obstet Gynecol. 2003;102:203.

American College of Obstetricians and Gynecologists. Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. ACOG Committee Opinion 304. Obstet Gynecol. 2004;104:1119.

American College of Obstetricians and Gynecologists. Pregestational diabetes mellitus. ACOG Practice Bulletin 60. Obstet Gynecol. 2005;105:675.

American College of Obstetricians and Gynecologists. The importance of preconception care in the continuum of women’s health care. ACOG Committee Opinion 313. Obstet Gynecol. 2005;106:665.

American College of Obstetricians and Gynecologists. Update on carrier screening for cystic fibrosis. ACOG Committee Opinion 325. Obstet Gynecol. 2005;106:1465.

American College of Obstetricians and Gynecologists, American College of Medical Genetics. Preconception and prenatal carrier screening for cystic fibrosis. Clinical and laboratory guidelines. Washington, DC: ACOG, 2001.

American Diabetes Association. Preconception care of women with diabetes. Clinical Diabetes. 2000;18:124.

Botto LD, Moore CA, Khoury MJ, Erickson JD. Neural-tube defects. N Engl J Med. 1999;341:1509.

Centers for Disease Control and Prevention. Entry into prenatal care—United States, 1989–1997. JAMA. 2000;283:2924.

Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J Med. 1992;327:1832.

Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect. 1998;30:24. 46.

Institute of Medicine. Preventing low birthweight. Washington, DC: Institute of Medicine, National Academy Press, 1985.

Iqbal MM. Prevention of neural tube defects by periconceptional use of folic acid. Pediatr Rev. 2000;21:58.

Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care—United States. MMWR Recomm Rep. 2006;55:1.

Leuzzi RA, Scoles KS. Preconception counseling for the primary care physician. Med Clin North Am. 1996;80:337.

Lu MC, Kotelchuck M, Culhane JF, et al. Preconception care between pregnancies: the content of internatal care. Matern Child Health J. 2006;10:107.

Mustard CA, Roos NP. The relationship of prenatal care and pregnancy complications to birthweight in Winnipeg, Canada. Am J Public Health. 1994;84:1450.

Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet. 1991;338:131.

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