2

Preconceptional counseling
Rahat Khan and Hassan Shehata

INTRODUCTION • Attempt to identify the risks of pregnancy

for the mother and her fetus, educate
Preconceptional counseling is different from ante- about these risks, and institute proper
natal care and should not be confused with it. In interventions including referral to special-
particular, it is more important than antenatal ists before conception.
care, as 30% of pregnant women begin tradi-
tional antenatal care in the second trimester Depending on their personal choice, women
and after the period of maximal organogen- can go to any of the following health care pro-
esis (between 3 and 10 weeks’ gestation)1. viders for preconceptional counseling:
Preconception care refers to interventions that aim • Local doctor (general practitioner or fam-
to identify and modify biomedical, behavioral and ily physician)
social risks to women’s health or pregnancy outcome
through prevention and management. • Private obstetricians and gynecologists,
To date, the evidence as to the best means specialists and obstetric physicians.
for delivering preconception care is limited. • Maternity hospital clinic, preconception
The Preconception Care Work Group of the health clinics or organizations
Centers for Disease Control USA recom-
mends that preconception care should be an • Family planning, community health center
essential part of primary and preventive care, or women’s health nurse.
which involves good communication and liai- Health care providers can dispense preconceptional
son between the primary and secondary care
care and counseling during any encounter involving
providers2–4.
contraception, infertility, pregnancy testing, evalu-
Preconceptional evaluation and counseling:
ation for sexually transmitted disease or vaginal
• Begin with attitudes and practices that infection, or periodic health examination, especially
value pregnant women, children and fami- if the woman has pre-existing medical problems.
lies, and respect the diversity of people’s
lives and experiences
• Incorporate informed choice, thus encour- FACTORS ADVERSELY INFLUENCING
aging women and men to understand PRECONCEPTION CARE
health issues that may affect conception
and pregnancy • Unplanned pregnancy In one US study,
• Encourage women and their partners to 40% of the mothers surveyed within
prepare actively for pregnancy, enabling 3–6 months after delivery reported that
them to be as healthy as possible their pregnancy was unplanned; of these,

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PRECONCEPTIONAL MEDICINE

two-thirds had one or more indications COMPONENTS OF PRECONCEPTIONAL

for preconceptional counseling (smoking COUNSELING
and drinking within 3 months of preg-
The three integral components of pre-preg-
nancy, low body mass index (BMI) or late
nancy counseling are:
booking)5.
• Identification of risk factors related to
• Financial issues A number of women with pregnancy
low income may have difficulties with
• Patient education regarding pregnancy
child care and transportation, or may be
risks, management options and reproduc-
reluctant to seek pre-pregnancy counsel-
tive alternatives
ing. In the USA, on the other hand, pre-
conceptional counseling often is not fully • Initiation of interventions, when possible,
reimbursed by third-party payers. It is for to provide optimum pregnancy outcome.
this reason that it was proposed that it be
included in a variety of otherwise routine
Risk identification
encounters (see above).

• Inadequate training of health care provid- Thorough history taking is the key to risk
ers All women’s health care providers assessment in any woman planning a preg-
nancy. This can be accomplished at the pri-
should be trained to provide adequate
mary or specialist care level after referral.
assessment of risk factors in pregnancy
and offer appropriate recommendations
for interventions. Physical examination
• Lack of co-ordination between primary and
A preconceptional health check does not nec-
secondary care providers As lack of co-­
essarily involve a ‘hands-on’ physical check;
ordination can represent an important
rather, it focuses on obtaining information and
barrier to optimum pre-pregnancy care,
discussing health issues to help the woman
health care systems should develop poli- and her partner make informed decisions. A
cies for timely referrals to specialists and routine periodic health examination is all that
timely appointments. is needed, documenting maternal BMI, assess-
ment of breasts, thyroid, heart, skin, cervical
• Risk factors for adverse outcome These
smear and, if indicated, screening for Chlamydia
include advancing maternal age, genetic
and gonorrhea. As dental caries and other oral
history, infertility, fetal aneuploidy, ges- diseases are common and may be associated
tational diabetes, pre-eclampsia and prior with preterm delivery, inspection of the oral
stillbirth, among others. cavity should be included in any examination
• Lack of knowledge and education about health protocol, thus, prompting referral to a dentist
when appropriate.
and pregnancy Basic patient education
should be an integral part of all women’s
health care provider systems, as numer- Laboratory assessment and screening
ous women have multiple risk factors and
are unaware of the adverse pregnancy out- The choice of laboratory tests depends upon
come associated with them. the general guidelines recommended for all

20
 Preconceptional counseling

pregnant women and the individual’s personal Medical conditions

medical history.
Routine laboratory testing includes: Data from clinical trials demonstrating
improved outcome with preconceptional
• Rubella and varicella titer, the latter being
intervention exists for many chronic condi-
particularly important in women with a
tions, including diabetes mellitus, autoim-
negative history of varicella
mune conditions, hypertension, renal disease,
• Screening for hepatitis B, syphilis and HIV thyroid disease and cardiac problems6,10–12. It
in all antenatal pregnant women is important to clarify the following points in
• Complete blood count with red cell indi- history on the record:
ces (mean corpuscular volume (MCV) less • All medical and surgical conditions for
than 80 may indicate hemoglobinopathy). which a woman has been treated, as it is
useful for discussing the effect of preg-
nancy on these conditions and the effect
Interventions of such disorders on pregnancy

Preconceptional interventions are directed • Contact details for present and past spe-
at educating the patient, providing optimum cialist care providers.
therapy for medical disorders and, when
appropriate, referral for specialized care.
Pre-existing diabetes mellitus (see Chapters 5
and 32)
Age-related risk • For women with pre-existing diabetes,
pre-pregnancy tight glycemic control is
Women should be clearly informed that associated with enhanced pregnancy out-
advanced maternal age is associated with an come; pre-pregnancy counseling provides
increased risk of conditions such as infertility, an opportunity for assessment of diabetic
fetal aneuploidy, stillbirth, gestational diabe- retinopathy, nephropathy and neuropathy.
tes and pre-eclampsia, among others. Poor control of diabetes increases the risk
The risk of fetal chromosomal anomalies, in of major fetal congenital abnormalities
particular Down’s syndrome, increases sharply and miscarriage6.
with increasing maternal age. The estimated • Referral should be made to a specialist who
risk of having a baby with trisomy 21, 18 and cares for patients with diabetes (if contact
13 is 6 per 1000 live births at age 35 years, has not been previously established) and,
15 at age 40 years and 54 at age 45 years. if available, to a diabetic preconceptional
There is also an increased risk of miscarriage, counseling clinic.
twins, fibroids, hypertension, gestational dia-
• The safety of oral hypoglycemic agents is
betes, labor problems and perinatal mortality,
now well established, and patients should
although it is equally true that most pregnan-
be informed that outcomes are improved
cies in older women who do not have underly-
in women taking oral agents and compa-
ing diseases are uneventful.
rable to those of insulin.
Couples should be told that the probability
of conception is highly dependent on maternal • Women should receive preconceptional
and, to a lesser extent, paternal age and they folic acid (5 mg/day) up to 3 months into
should take this into account in family and pregnancy as well as in the months pre-
career planning. ceding conception26,27.

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PRECONCEPTIONAL MEDICINE

Chronic hypertension (see Chapter 12) • In known hypothyroidism, thyroid func-

• The goal should be to control blood pres- tion tests (TFTs) permit evaluation of ade-
sure prior to conception for any woman quacy of treatment and, if needed, support
on angiotensin converting enzyme (ACE) referral to specialist care.
inhibitors; the health care practioner
• In newly diagnosed hypothyroidism, spe-
should be satisfied with control, and effec-
cialist advice should be sought about
tive contraception is advisable.
the levothyroxine starting dose and the
• All women with hypertension should be woman should be referred for specialist
referred to a specialist for advice on drug management.
manipulation and to organize shared care
monitoring.
• ACE inhibitors should be avoided during Cardiac problems (see Chapter 3)
pregnancy (fetal growth restriction, oligo- • Women with a history of cardiac problems
hydramnios, renal failure in fetus). Meth- should be referred to a cardiologist for
yldopa or labetalol are the drugs of choice baseline cardiac assessments and discus-
in pregnancy. sion of potential pregnancy risks.
• Adequate diagnosis and functional assess-
ment of the severity are necessary to pre-
Asthma (see Chapter 4) dict maternal and fetal risks.
• Patients should be advised to use their
peak flow meters regularly. • Women advised against pregnancy should
be given appropriate contraception.
• Women with repeated asthmatic attacks
or severe disease should be referred to a
specialist in asthma therapy and not man- Epilepsy (see Chapter 11)
aged by the local doctor. • Women should be referred to a neurolo-
• If necessary, the use of steroids (inhaled gist for a thorough discussion of the risk
and systemic) in pregnancy is generally of anticonvulsant medications, ­adjustment
safe. of drug regimen and close monitoring dur-
ing pregnancy.
• Polytherapy should be avoided to minimize
Thyroid disease (see Chapter 6)
the teratogenic effects of anticonvulsants.
• Severe and untreated thyrotoxicosis
should prompt referral to an endocrinolo- • Preconceptional folic acid (5 mg/day) is
gist during the preconceptional period, advised for women on anticonvulsants28,29.
as this condition can lead to anovulation, • Prescription of an oral contraceptive pill
miscarriage, growth restriction and pre- with 50 μg of ethinylestradiol should be
term delivery7. Patients with elevated thy- considered.
roid stimulating antibodies who become
pregnant have the risk of neonatal/fetal
thyrotoxicosis. Chronic renal disease (see Chapter 8)
• There is insufficient evidence to recom- • Blood pressure and baseline renal function
mend for or against routine screening of tests should be performed; any woman
thyroid function and antibodies in women with renal disease planning a pregnancy
planning a pregnancy8. should be referred to a specialist.

22
 Preconceptional counseling

• Women should be informed that the out- • Women on warfarin planning a pregnancy
come of pregnancy and any adverse effects should be referred to a specialist for advice.
on underlying renal disease are influenced Warfarin is teratogenic and stopping or
by the presence and degree of renal impair- switching over to low molecular weight
ment, hypertension (10% risk of fetal loss heparin, before the 6th week of pregnancy
if pre-existing) and proteinuria. may minimize this risk.
• Renal disease during pregnancy is asso- • Inherited or acquired thrombophilia may
ciated with risk of prematurity, growth also be responsible for recurrent fetal
restriction and deterioration in maternal loss, pre-eclampsia and fetal growth
renal function. retardation.
• Women with renal transplants should
be asked to avoid pregnancy for a mini-
mum of 2 years until renal function Hemoglobinopathies
is optimized on a reduced amount of • All women with sickle cell syndrome or
immunosuppressants. thalassemias should be referred to a spe-
cialist/hematologist. Partners should be
screened appropriately and advice sought
Autoimmune disorders (see Chapter 7) if the trait is identified.
• Most autoimmune conditions improve • Hemoglobin electrophoresis detects beta
in pregnancy, except systemic lupus thalassemias, but alpha thalassemias can
erythematosus. only be confirmed by globin chain synthe-
• Referral should be made to an obstetric sis. Ethnic minorities should be screened
physician, as preconceptional counseling for particular traits (Asians and Cypri-
involves knowledge of anti-Ro/La, lupus ots for beta thalassemia; Africans, Afro-­
anticoagulant, renal and blood pressure Caribbeans, Afro-Americans and Asians
status. for sickle cell).

• Maternal medications may need to be

changed because of potential risks to the
Review of medications
fetus.
(see Chapters 22 and 23)
• Pregnancy outcome is improved if preg-
nancy occurs in remission period; the It is important to minimize exposure to all
increased risks of pre-eclampsia, miscar- non-essential drugs, including self-medication
riage, fetal death and growth restriction with over-the-counter drugs.
are related to the presence of anticardio-
lipin antibodies or lupus anticoagulant,
lupus nephritis and hypertension. Dietary evaluation (see Chapter 22)

• Vegetarians are at risk of various nutri-

Venous thromboembolism (see Chapter 9)
tional deficiencies and may benefit from
• Specialist advice should be sought for
nutritionist referral.
women who have a past history of deep
venous thrombosis (DVT) or pulmonary • Asian women are at risk of vitamin D
embolism (PE), or with an abnormal deficiency and may benefit from a specific
thrombophilia screen. supplement.

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PRECONCEPTIONAL MEDICINE

• Eating habits should be reviewed, and • Maternal obesity (BMI more than
women should be asked to avoid cat and 30 kg/m2) is associated with infertility,
sheep litter; uncooked meat, fish and eggs; reduced in vitro fertilization (IVF) success
and unpasteurized milk and soft cheese rates, miscarriage and several pregnancy
because of dangers of toxoplasmosis and complications, such as gestational diabe-
listeriosis. tes, pre-eclampsia, stillbirth, congenital
anomalies in the fetus and postpartum
• Undiagnosed or untreated celiac disease complications.
in both men and women may cause sub-
fertility, which resolves after adoption of a • The overall health benefits of achiev-
gluten-free diet. ing a normal BMI pre-pregnancy are
well described. Obesity-related hor-
• Megavitamins, non-essential dietary sup- monal changes appear to adversely affect
plements and herbal preparations should sperm parameters and can cause erectile
be discontinued, as their risk to the fetus dysfunction.
has not been evaluated. Multivitamins
• Obese women should be referred to a
containing more than 5000 IU of vitamin
weight management clinic and dietician;
A should be avoided.
women with polycystic ovaries should be
• Women with phenylketonuria are at a referred to a gynecologist.
high risk of having a baby with men-
tal ­retardation and should be placed on
a ­special diet to reduce levels prior to Past obstetric and gynecological history
conception.
Past obstetric and gynecological history is
• All women planning a pregnancy should important for identifying factors that may con-
be on 400 μg/day of folic acid at least 3 tribute to infertility or pregnancy complica-
months prior to conception to reduce the tions in the future.
incidence of neural tube defects, such as
spina bifida, by 72%. • History of irregular menstrual cycles,
abnormal cervical smear, ectopic preg-
nancy, pelvic surgery or uterine fibroids
(associated with miscarriage and preterm
Body mass index (see Chapter 30)
birth) should be sought.
• Past history of sexually transmitted dis-
• Approximately, 60% of American women
eases, including the date and types of
are overweight and 33% are obese. Women
treatment should be noted.
who are underweight or overweight are at
risk of subfertility and may need referral • Previous reproductive history should
to a pre-pregnancy weight management be taken including any recurrent mis-
clinic and dietician. Problems with obe- carriages, stillbirths, low birth weight,
sity and low weight are not confined to preterm births, congenital anomalies,
the American population, and obesity is antenatal problems and the mode, place,
almost as prevalent in the UK and in parts complications of delivery and type of
of Europe. In the UK, the prevalence of contraception.
obesity among women of reproductive age • All women who have had three consecu-
is expected to rise from 24.2% in 2005 to tive miscarriages should be referred to
28.3% in 201530. a gynecologist or recurrent miscarriage

24
 Preconceptional counseling

specialist for identification and manage- conditions necessitating referral are

ment of any treatable cause (see Chapter depression, bipolar affective disorder and
17 on recurrent miscarriages). schizophrenia, and history of postnatal
• The recurrence risk of an adverse outcome depression21 (see Chapter 13).
(e.g. miscarriage, intrauterine growth • Women should be reassured that there
restriction, pre-eclampsia, congenital
is no indication to routinely stop tricy-
anomaly, perinatal death) should be dis-
clic antidepressants or selective serotonin
cussed with women who have a history of
re-uptake inhibitors prior to or in early
these specific pregnancy complications.
pregnancy.
• Genetic screening should be advised for
couples who have had a previously abnor- • Women who are on mood stabilizing anti-
mal fetus, three recurrent fetal losses epileptic drugs should be on 5 mg/day of
or have a personal or family history of a folic acid preconceptionally and during
genetic problem. first 3 months of pregnancy28,29. This dose
is higher than that universally recom-
mended to other women.
Family history (see Chapter 31)
• Lithium is highly teratogenic if taken in
the first 12 weeks of pregnancy (risk of
• Enquiries should be made about family Ebstein’s anomaly 4–12%) and should
history of Tay Sachs disease (Ashkenazi
be given only if necessary by close moni-
Jews), sickle cell disease (Africans/Afro-
toring of lithium levels. Schizophrenic
Caribbeans, Afro-Americans, Asians),
women may be advised to continue main-
thalassemia (Mediterranean and Middle
Eastern origins), cystic fibrosis, epilepsy, tenance therapy and discuss the relative
thrombophilia, hemophilia, congenital risks/­benefits of the selected agents.
abnormalities, metabolic disorders and
mental disorders.
Illicit drug use
• Certain ethnic minorities have a high
prevalence of being heterozygous carriers
of certain autosomal recessive disorders • Cocaine use in pregnancy is associated
and both partners should be screened as with miscarriage, abruption, premature
this allows them to make informed deci- birth and low birth weight; opiate use is
sions about having children. associated with growth restriction and
preterm birth14,17,19,25.
• All women addicted to heroin should
Psychosocial problems
be encouraged to enter a detoxification
program.
• It is important to screen for domestic vio-
lence, work-related issues, lack of support • Intravenous drug abusers should be
and financial issues that can be a barrier to screened for hepatitis B, C and HIV, alco-
preconception care20. hol and tobacco use.

• Women with mental health issues should • A multidisciplinary approach is essential

be identified and actions taken to ensure as is screening for sexually transmitted
they are under specialist care. Common diseases.

25
PRECONCEPTIONAL MEDICINE

Alcohol use pregnancy are less likely to relapse. Data

on the use and relative risks of nicotine
replacement therapy (NRT) in pregnancy
• It is important to elicit a detailed his-
are lacking.
tory of alcohol consumption in terms of
amounts, duration and the propensity to • Bupropion should not be prescribed in
binge drinking. Causes of subfertility in pregnancy because of the lack of data on
these women include reduced ovulation its safety in pregnancy.
and endometriosis.
• Maternal consumption of 15 units/week is
Caffeine
associated with a reduction in birth weight
and in excess of 20 units/week is associ-
ated with intellectual impairment in the • According to many publications, caffeine
child. is the most widely consumed substance of
abuse worldwide. The safe limit in preg-
• High levels of alcohol consumption during
nancy is thought to be 300 mg/day, which
pregnancy result in the fetal alcohol syn-
is equivalent to three cups of brewed cof-
drome (FAS), which includes growth retar-
fee. Caffeine is present in chocolate, cola
dation, mental retardation, facial anoma-
and energy drinks as well as in coffee
lies and behavioral problems9,13,15,16,18. It is
and tea. Approximately 20% of Ameri-
seen in 33% of babies born to mothers who
can adults consume more than 300 mg of
drink 18 units/day. There is no clear safe
caffeine per day. Caffeine consumption
level of consumption. All women should
of more than 250 mg/day is associated
be advised to reduce their alcohol intake
with a modest, but statistically significant
if they are planning a pregnancy, although
decrease in fertility 9,19,22.
it has been posited that one or two drinks,
once or twice a week, is unlikely to harm
the fetus9.
Exercise
• It is important to identify women who
drink heavily and are likely to continue
• Women who exercise regularly should be
drinking throughout pregnancy so that
advised to continue such activity. On the
appropriate help and support can be
other hand, those who are inactive should
offered.
start a gentle exercise program. Inadequate
levels of exercise associated with obesity
Smoking may be a more common cause of anovula-
tion than exercise associated anovulation.
• Approximately, 23% of women smoke in • In some epidemiological studies, more
pregnancy, and they should be informed of than 7 h/week of aerobic exercise is asso-
the risks associated with smoking, which ciated with ovulatory infertility and could
include miscarriage, stillbirth, growth be related to reduced progesterone levels
restriction, preterm delivery and sudden and changes in the gonadotropin releasing
infant death syndrome9,13,19. hormone (GnRH), luteinizing hormone
• All women who smoke should be coun- (LH) and follicle stimulating hormone
seled on the benefits of smoking cessa- (FSH) secretion9. Initiation of strenuous
tion and offered resources to help them exercise in pregnancy should be avoided,
quit smoking. Women who quit before including hot tubs and saunas.

26
 Preconceptional counseling

Immunizations and infections as working with organic solvents, X-rays,

radioactive substances, toxoplasmosis
• Women of childbearing age should be (from changing cat litter boxes) and using
asked for a history of any illness or lead paint or solder used for decorating22–24.
immunizations. • Risks from potential hazards at home
• Non-pregnant women of childbearing (e.g. pets), at work and from farm animals
age should receive all clinically indicated should be assessed.
immunizations, preferably 1 month prior
• Any woman who thinks that her occupa-
to conception.
tion may pose a risk to pregnancy should be
• Having a clearly documented immunity advised to discuss this with her employer
to rubella is important, as primary rubella or occupational health department, if pos-
infection in the first 8–10 weeks of preg- sible, before getting pregnant.
nancy can result in mental handicap, cata-
ract, deafness, cardiac abnormalities and
growth restriction in the fetus.
SUMMARY AND RECOMMENDATIONS
• Varicella infection in the mother during
first 20 weeks of pregnancy can cause con-
• All women of childbearing age should be
genital varicella syndrome in the fetus.
offered preconceptional counseling and
Varicella vaccine must not be given to
evaluation.
pregnant women.
• Pregnant women are at increased risk of • The goals of preconceptional counseling
influenza infection complications. It is are to identify risks to the woman and her
recommended that women who become pregnancy, educate the patient and initiate
pregnant during the influenza season appropriate interventions.
receive the influenza vaccine, regardless of
• Good communication between primary
the stage of pregnancy. Pregnant women
and secondary care providers is vital to
are also being encouraged to have swine
optimize a woman’s health prior to con-
flu vaccine.
ception and ensuring timely referral.
• Patients at risk for hepatitis B infection
(women with multiple sexual partners, • A thorough history will help in identify-
parenteral drug users, household contacts, ing risk factors to the woman and her
health care workers) should be offered pregnancy.
hepatitis B vaccine. • A pregnant woman with a BMI of greater
• Women of childbearing age who are HIV 30 kg/m2 should be referred to dietician
positive should be offered preconceptional and specialist clinic.
counseling with a HIV specialist.
• Women who are planning a pregnancy
should be on folic acid 400 μg/day. Women
Occupational and environmental exposure who are diabetic or on anti­epileptic medi-
cations should be on 5 mg of folic acid/
day26–29.
• Questions about the woman’s work, hob-
bies, pets and home environment can • An up-to-date cervical smear should have
identify potential toxic exposures, such been taken.

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PRECONCEPTIONAL MEDICINE

• All women should be screened for hepa- References

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