Question

Sarah is contemplating becoming pregnant. She and her husband are at the clinic to conduct preconception counseling. What teachings would you include?

Answer 1

Issues of Concern

In anticipation of future childbearing years, every individual benefit from education about pregnancy readiness and the role of family and parenting with age-appropriate education. As children enter puberty, both boys and girls must be educated about the delay in sexuality, pregnancy prevention, and prevention of sexually transmitted infections. Although education may not correlate with delayed sexual activity, it is important to educate young males about their responsibilities in reproductive health. Every couple must have the opportunity to choose when they are ready to reproduce. Family planning and pregnancy prevention is key to pregnancy readiness. [1] Unplanned and unintended pregnancy results in late prenatal care which can subsequently contribute to adverse events during pregnancy and poor perinatal outcomes. Both the woman and man must be assessed for risks and educated about the risks associated with poor perinatal outcomes. This risk assessment must include evaluation of overall well-being, medical history, surgical risks, social and behavioral risks, medication risks, occupational risks, education risks, and any other barriers that may pose an undue risk on fertility or pregnancy. A few important items to discuss during preconception counseling include:

Management of Chronic Disease

Any woman with a chronic disease should review her desire to become pregnant with the primary care physician or provider and her family. Pregnancy can increase risks for both the mother and the child requiring additional visits, changes in routine care, and possible prolonged hospital stays if the perinatal period and pregnancy outcomes are not optimal. Preconception counseling must focus on optimizing both primary and secondary prevention, treatment compliance, and improving overall well-being prior to becoming pregnant. Any identified risks including disease history and status, current medications, social barriers, and limited support systems or financial barriers must also be reviewed. Patients with diseases or health issues associated with progression during pregnancy such as severe depression and anxiety, seizure disorders, diabetes[2], cardiac, renal disease, and other long-term illnesses should be referred for further counseling with a high-risk provider to discuss possible changes in medical management during pregnancy.

Genetic Disorders and Carrier States

Families with histories of genetic disorders should be referred to a genetic counselor to discuss the risks of passing the disorder to the newborn. The genetic counselor can also educate the family on disorders that might impact fertility.

Folic Acid

Early use of Folic acid prevents neural tube defects. Women of reproductive age should be prescribed folic acid during the preconception period and throughout pregnancy.

Short Interval Pregnancy (less than 18 months)

Short interval pregnancies are associated with preterm deliveries, premature rupture of membranes, maternal morbidity, and mortality, third trimester bleeding, myometritis, and anemia. Counseling about short interval pregnancy and the negative impact would likely reduce the number of short interval pregnancies .

Smoking Cessation

Tobacco use is associated with preterm labor, intrauterine growth retardation, low birth weight, and placental abruption. Smoking cessation can reduce perinatal mortality and low birth weight by at least 20%. Smoking cessation should be offered to the woman and her partner before and during early pregnancy .Women should be counseled that secondhand smoke can impact both fertility and the perinatal period.

Alcohol Use

Alcohol use in pregnancy is associated with fetal alcohol syndrome and fertility problems. Women should be advised to avoid alcohol if they are planning a pregnancy. The literature is unable to recommend a safe level of alcohol use (Level A). The use of alcohol during pregnancy can result in neuropsychologic adverse outcomes in the newborn. Preconception counseling should include addressing this issue prior to pregnancy.

Obesity

Obesity is associated with multiple perinatal risks including increased risk for gestational diabetes, hypertension, congenital heart diseases in the fetus, and a higher risk of difficult deliveries, cesarean section, and complications of delivery. Women with a BMI > 40 should be counseled to see a dietician. Women who are obese have higher risks for chronic diseases such as hypertension, diabetes mellitus, heart disease, and stroke all of which can lead to additional complications in pregnancy. Obesity is an independent risk factor in pregnancy with a higher chance of developing pregnancy-associated hypertension, insulin-dependent gestational diabetes, and macrosomic infants.

Underweight

Women with malnutrition may be at risk for nutrient deficiencies that increase the risk for low birth weight in the fetus and preterm labor.

Substance Use

Use of drugs in pregnancy is associated with neonatal abstinence syndrome, placental abruption (cocaine), low birth weight, maternal morbidity such as hemorrhage, and fetal and infant mortality. Women should be advised to discontinue use of substances. Education must include both perinatal risk and risk to mother and neonate long-term.

Toxin Exposure

Women should be counseled to avoid toxic substances. Toxins with potential impact on reproductive health include lead, arsenic, fluoride, toluene, flame retardants, plastics, and pesticides.

Environmental Exposures

Preconception assessment of home environment, community, and occupational hazards are important to recognizing and reducing potential risks during pregnancy especially during the organogenesis period. The assessment must include exposure history and duration of exposure. Education and counseling must include the warnings of birth defects and potential transmission of toxins in breastfeeding. Exposure to chemicals in the community and work environment may be linked to birth defects, fetal loss, and low fertility. Couples should be encouraged to inquire about potential hazards in the workplace.

Medication Exposures

Preconception counseling must include careful evaluation of medications taken by the women prior to pregnancy. Allowing adequate time for the transition to less harmful medicines and optimizing dosing can lead to both improved perinatal outcomes and avoidance of anomalies and poor outcomes for the fetus.

Diabetes Management

Uncontrolled diabetes is associated with congenital heart defects, intrauterine growth retardation, and miscarriage. In the neonate, it can be associated with hypoglycemia, respiratory distress syndrome, hyperbilirubinemia. For the mother, it is associated with an increased risk of hypertension, visual problems, and infections. Women who can maintain A1C level less than 7, will have a lower risk of complications including congenital heart defects (Level A). Counseling during the preconception period must focus on disease management and education, optimal control, weight management, and education about the potential risks to mother and fetus during the perinatal period.

Infectious Diseases Management

Couples should receive counseling about treatment and potential risks to the mother and baby. Infections with known adverse effects or long-term sequelae in the perinatal period are listed below.

• Hepatitis B - Preconception counseling should include a review of a risk factor for hepatitis B and any history of treatment of a prior diagnosis of the virus. Literature supports vaccinating women who are at high risk for hepatitis B during the preconception period. Women with positive hepatitis B status must be educated about risks to the newborn and associated risks of hepatocellular carcinoma for chronic hepatitis B carriers.
• Human Immunodeficiency Virus (HIV) - Prior to pregnancy, parents should be evaluated for risk of HIV and those with known positivity must be treated. Women at high risk for HIV should be counseled on prevention and guided on the risk of transmission to the newborn if they should become positive during pregnancy. Those with known HIV status must be educated about the risk of transmission, educated about the reduction in transmission with proper treatment, and encouraged to adhere to medical management throughout the pregnancy. Proper treatment of HIV during pregnancy can reduce transmission as much as 75 percent (Level A).
• Tetanus - The World Health Organization recommends that all women of childbearing age be protected against tetanus. The mortality rate of tetanus is as high as 1 in 10 people when Tetanus is diagnosed. Women at high risk should be vaccinated prior to pregnancy. It is safe to administer tetanus vaccine (Td) during pregnancy in any trimester. It is standard practice in the United States to administer tetanus vaccine along with pertussis (Tdap) between 27 and 36 weeks gestation.
• MMR -Preconception counseling should include a vaccination history that includes measles, mumps, and rubella. These viruses can have moderate to severe effects during pregnancy or increase the risk of miscarriage. It is important to vaccinate before pregnancy if the woman has not been vaccinated. The Centers for Disease Control recommend waiting at least 28 days after receiving a rubella-containing vaccine before pregnancy.

Clinical Significance

Preconception counseling must include communication to the potential mother and father. During preconception counseling, the provider has the opportunity to perform the risk assessment. Risk assessment includes reviewing a thorough history of medical, surgical, psychosocial, genetic, nutrition, and behavioral risks. These include screening for alcohol and drug use. Couples should be reminded about the importance of vaccination for the mother and early access to prenatal care if pregnancy occurs. Women with behavioral health issues should be counseled to see their provider for medication management and changes if needed. Early preconception counseling and intervention has the potential to reduce perinatal morbidity and mortality. Pregnancy readiness and a planned pregnancy is the optimal goal. Families seeking future pregnancies should be counseled to seek primary care to address any identified risks and to discuss pregnancy planning. The overall goal is preconception wellness and optimal management of chronic health and behavioral issues.