Preconceptional Care and Counseling

Published on 06/06/2015 by admin

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Last modified 06/06/2015

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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.

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