Preconception Counseling

Aka: Preconception Counseling, Preconception Management

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II. Evaluation: Tobacco, Alcohol, Caffeine and Substance Use

  1. See Substance Abuse in Pregnancy
  2. Caffeine
    1. Limit to 1-2 cups per day (<300 mg/day)
  3. Tobacco Cessation
    1. Most important single preventable U.S. risk:
      1. Low birth weight
      2. Perinatal mortality
      3. Ectopic Pregnancy
      4. Miscarriage
      5. Placental Abruption
      6. Orofacial Clefts
    2. Epidemiology
      1. Women (especially ages 25-44) who smoke: 25%
      2. Women who stop smoking in pregnancy: 21%
      3. Women who resume smoking within 1 year: 70%
    3. References
      1. (2020) Obstet Gynecol 135(5):e221-9 +PMID: 32332417 [PubMed]
  4. Alcohol abstinence
    1. Fetal Alcohol Spectrum Disorders
    2. Spontaneous Abortion
    3. Fetal Growth Restriction
  5. Cannabinoid abstinence
    1. Decreases male and female fertility
    2. Fetal Growth Retardation
    3. Neurodevelopmental disorders
    4. Lo (2022) Am J Obstet Gynecol 227(4):571-81 [PubMed]
  6. Cocaine abstinence
    1. See Cocaine Abuse in Pregnancy
  7. Opioid Use Disorder (e.g. Heroin)
    1. See Opioid Use Disorder in Pregnancy
    2. Use Buprenorphine or Methadone during pregnancy
  8. References
    1. Lassi (2014) Reprod Health 11(Suppl 3):S6 +PMID: 25415846 [PubMed]

III. Evaluation: Infectious Disease

  1. Evaluate risk and screen as indicated for Sexually Transmitted Diseases and other infections
    1. HIV Infection
      1. Discuss universal screening for age 15 years and older
      2. Discuss the risk of vertical transmission
    2. Syphilis
      1. Screen high risk women
    3. Hepatitis B
      1. Screen if risk, especially if not immunized
      2. Discuss risk of vertical transmission in Chronic Hepatitis B Carrier
    4. Hepatitis C
      1. Screen adults 18 years and older
    5. Gonorrhea
      1. Screen all women under age 25 years and those at increased risk
    6. Chlamydia
      1. Screen all women under age 25 years and those at increased risk
    7. Herpes Simplex Virus infection
      1. Discuss risk of vertical transmission and recognition of genital outbreaks during pregnancy
      2. Offer HIV Preexposure Prophylaxis to those at high risk and review safe medications at conception (e.g. Truvada)
    8. Tuberculosis
      1. Screen high-risk women
      2. Treat active and Latent Tuberculosis prior to pregnancy
  2. Immunizations (avoid conception within 4 weeks unless otherwise noted)
    1. RubellaVaccine
      1. Indicated if negative for Rubella IgG and not pregnant
      2. Avoid pregnancy for 1 to 3 months after RubellaVaccine (Live Vaccine)
      3. If pregnant and not immune, schedule RubellaVaccine for postpartum
    2. Varicella Vaccine
      1. Indicated if negative for Varicella IgG and not pregnant
      2. Avoid pregnancy for 1 month after Varicella Vaccine
      3. If pregnant and not immune, schedule Varicella Vaccine for postpartum
    3. Tdap Vaccine
      1. Vaccinate all pregnant women at 27-30 weeks gestation with each pregnancy
      2. Provides passive Immunity to the infant against Pertussis
    4. Pneumococcal Vaccine
      1. Indicated if high risk for Pneumococcus (e.g. Asplenic)
    5. Hepatitis B Vaccine
      1. Vaccinate all women prior to pregnancy if not already vaccinated
    6. HPV Vaccine
      1. Universal Vaccination at age 11 to 26 years old in U.S. (and consider for unimmunized <45 years)
      2. Avoid Vaccination during pregnancy (delay completing series until pregnancy completed)
    7. Influenza Vaccine
      1. Vaccinate all women pregnant during Influenza season (as well as those with other indications)
    8. Covid Vaccine
      1. Covid 19 infection doubles the risk of Preeclampsia
      2. May be given during preconception planning, pregnancy and Lactation
  3. Avoid Toxin or Infection Exposures
    1. See Teratogen Exposure for occupational, household product risk (Heavy Metals, solvents, Pesticides)
    2. Toxoplasmosis (cat litter, garden soil, raw meat)
    3. Cytomegalovirus, Parvovirus, Chicken Pox (child care)
    4. Listeria (cold cuts, undercooked or raw meats)
    5. Condoms or abstinence if partner has STD

IV. Evaluation: Miscellaneous Concerns

  1. Screen for Domestic Violence
    1. See Intimate Partner Violence Screening
    2. See Intimate Partner Violence
  2. Screen for Mood Disorder (esp. Major Depression)
    1. See Depression Screening Tools
    2. See Patient Health Questionaire 9 (PHQ-9)
  3. Avoid overheating (e.g. hot tubs, saunas)
    1. Increased risk of Neural Tube Defects
    2. Increased Miscarriage risk
  4. Recommend regular Exercise
    1. See Exercise in Pregnancy
    2. Target 150 minutes/week of moderate Exercise
  5. Wear Seat Belts (three point Seat Belt)
  6. Work toward ideal body before pregnancy
    1. See Weight Gain in Pregnancy
    2. See Pregnancy Risk Assessment
      1. Covers Obesity and underweight associated pregnancy risks
      2. Includes precautions regarding prior Bariatric Surgery
    3. In Obesity, before pregnancy, attempt weight loss of 10%
      1. Lowest risk at BMI 18.5 to 24.9 kg/m2
      2. Stop Weight Loss Medications (e.g. Topiramate, Phentermine, GLP1 Agonists) at least 2 months prior to pregnancy

V. Management: Diet and Supplements

  1. See Nutrition in Pregnancy
    1. Includes Teratogenic foods
  2. See Teratogen Exposure
    1. Includes Occupational Exposures in Pregnancy
    2. Includes Herbal Teratogens
  3. Prenatal Vitamins with 400 ug Folic Acid (600 Dietary Folate Equivalents or DFE) and 150 mcg Iodine
    1. See Folic Acid dosing for high risk populations
    2. See Iodine for pregnancy recommendations
    3. Start Folic Acid 1-3 months before pregnancy and continue for at least 12 weeks postconception
    4. High dose Folic Acid (4-5 mg daily) is indicated in women at high risk for Neural Tube Defect (e.g. Epilepsy)
  4. Assess Vitamin Deficiency or overuse
    1. Avoid Vitamin A in excess of 3000 IU per day
    2. Avoid Vitamin D in excess of 400 IU per day
    3. Ensure well balanced diet
    4. Assess for Iron Deficiency
  5. Avoid Herbals which are related to Miscarriage
    1. See Herbal Teratogens
  6. Avoid excessive foods with increased risk
    1. See Nutrition in Pregnancy
    2. See Mercury Content in Fish

VI. Management: Preimplantation Genetic Diagnosis

  1. See Pregnancy Risk Assessment
  2. Indicated for single gene disorder risks
  3. Protocol
    1. Isolate single blastomere from Embryo at day 3
    2. Developing Embryo tested for single gene disorders
    3. Normal Embryos then implanted

VII. References

  1. Wilkins in Ryan (1999) Kistner's Gynecology, p. 451
  2. Brundage (2002) Am Fam Physician 65(12):2507-14 [PubMed]
  3. Close (2023) Am Fam Physician 108(6): 605-13 [PubMed]
  4. Farahi (2013) Am Fam Physician 88(8): 499-506 [PubMed]
  5. Johnson (2006) MMWR Recomm Rep 55(RR-6): 1-23 [PubMed]
  6. Leuzzi (1996) Med Clin North Am 80:337-74 [PubMed]
  7. Morrison (2000) Prim Care 27(1):1-12 [PubMed]
  8. Ramirez (2023) Am Fam Physician 108(2): 139-50 [PubMed]

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