EDUCATION

Planning a pregnancy is the time when women are arguably the most interested they have ever been in optimising their health, in the interests of having a healthy baby. It is also an opportunity to discuss the potential father’s lifestyle and general health. The advice provided at the preconception consultation may be the last chance to see the patient before she becomes pregnant, so this consultation needs to address issues that will be important in the early stages of pregnancy, even before she knows she is pregnant.

Women can be informed that the optimum biological age for pregnancy is between 20 and 35 years. Beyond that age, the risk of infertility, miscarriage, multiple pregnancy, pregnancy complications and fetal abnormalities increases statistically. However, many women are delaying conception until their late thirties and early forties, and deliver healthy babies.

Advice should include avoiding any prescribed or over-the-counter medications likely to affect early pregnancy, exercising regularly and avoiding alcohol, tobacco and illicit drugs. Any household members should be encouraged to stop smoking.

Preconception education will involve answering the questions posed, but also providing information to assist in optimising the health of the parents and opening a discussion about parenting ideas and philosophies.

STRESS MANAGEMENT

Because the mother’s stress hormones (including cortisol and catechols) cross the placenta, maternal stress also affects fetal neurological, physiological and metabolic development. For example, significant and prolonged maternal stress,¹,² particularly in the first trimester, is associated with poorer fetal growth, developmental problems, an increased risk of mental illness and a higher risk of cardiovascular disease in the offspring.

The work and home environment will have a significant impact on the potential mother’s stress levels.

Planning a pregnancy brings with it many anxieties about whether the woman will be able to become pregnant, inevitable life change, financial pressure, changes to career path and more. Information and an opportunity to talk through these concerns is helpful. Therefore, putting in place effective strategies for managing stress is an important part of preparing for pregnancy. Stress management activities such as regular sleep patterns, reducing reliance on substances and practising yoga, T’ai chi, meditation and relaxation exercises, as well as planning staged modifications to the mother’s work schedule, can provide benefits to emotional health. Counselling, cognitive behaviour therapy and mindfulness-based stress management may be helpful for some women where needed.

SPIRITUALITY

Starting a family affects a woman, her family and her work in profound ways. Asking about what all this means for her and how she will adjust may be an important conversation. A preliminary discussion of a patient’s religious or spiritual beliefs may be appropriate, particularly if there is a problem with fertility, if the pregnancy fails to proceed or if antenatal testing reveals a fetal abnormality.³ A discussion of the parents’ religious views about circumcision, should they have a male child, may be appropriate in the planning stages.

EXERCISE

Optimum fitness is a desirable goal prior to conception. Pregnancy adds a significant physical and physiological load, so aerobic and resistance training to help build fitness and muscle strength, and a back care program, will help her to cope with the pregnancy and childbirth far more effectively. She will also be able to reduce the risk of hypertension and diabetes during pregnancy, improve immunity and mental health and minimise complications. It should also be remembered that exercising to excess during pregnancy can be as much of a problem as being inactive.

Stretching and yoga improve flexibility. Patients with low back problems can be referred for back rehabilitation programs such as those supervised by physiotherapists or exercise physiologists.

Once the patient is pregnant, she can continue or adjust her current exercise program (Box 54.1).

NUTRITION

Assess the patient for possible nutritional risk, especially if the patient is vegan, lactose-intolerant, has coeliac disease or other gut problems or an eating disorder likely to affect nutritional status. If the woman’s body weight is in the normal range, then dietary advice will focus on the quality and balance of foods she is eating.

However, women who are either significantly overweight or underweight need to address this risk factor. Obese women are 2.7 times more likely to be infertile than women in the healthy weight range. Obesity in women can also increase the risk of miscarriage and impair the outcomes of assisted reproductive technologies and pregnancy.⁴ It is also associated with an increased rate of caesarean section.⁵

Being underweight is associated with reduced conception rates among nulliparous women and increased likelihood of conception among parous women.⁶

Some foods are to be avoided because of the risk of listeriosis, which causes a risk of miscarriage. These foods include raw seafood, pre-prepared (salad bar) salads, delicatessen meats, leftovers, soft cheeses and pâté. All fruit and vegetables should be washed in filtered water before eating.

Eating a fresh, varied and healthy diet is important during pregnancy, as it is at any other time. Supplementation, particularly for those with poor vegetable intake, with a multivitamin containing 500 μg folate should commence prior to conception. Iron, zinc, vitamin D, calcium and iodine are all essential nutrients that may be lacking, and should be included in the choice of a high-quality antenatal supplement. A good intake of omega-3 fatty acids is also important for fetal development, and supplements of 3 g daily should be considered for those with a poor intake.

Some women think that ‘if one supplement is good, then more is better’. Check the contents of any supplements or over-the-counter preparations that are being taken, and be sure to avoid excess. This may particularly be the case for substances such as vitamin A.

CONNECTEDNESS

Relationships and social support are important not only for practical reasons but also because they have such a profound effect upon maternal emotional wellbeing and coping. Discuss the social connections the patient has with family and friends. Encourage development of a network of parents with babies, particularly if there are no family members likely to be around once the baby arrives.

ENVIRONMENT

The patient should be advised to avoid contact with household or occupational chemicals. Clear any toxic chemicals out of the house and replace with non-toxic alternative cleaning products.

If the family has a cat, advise that someone other than the pregnant (or intending to be pregnant) woman should empty the litter tray, to minimise the risk of toxoplasmosis. She should avoid contact with garden soil, wash all fruit and vegetables before consumption and avoid undercooked or raw meat or unpasteurised milk products. She should also limit the consumption of large fish likely to contain higher levels of mercury.

Discuss the potential for transmission of parvovirus B19 and cytomegalovirus. Childcare workers should wear gloves when changing children’s nappies and wash their hands frequently. Regular, moderate sun exposure will also be helpful for adequate vitamin D levels.