Pre-conception care and counselling

In this modern era, we like to plan most of our things as much as possible. It is important that couples plan pregnancy with proper preconception care and counselling, which will optimize both maternal and fetal outcome. It should include informed choice, which helps them to understand health issues that may affect conception and pregnancy and then prepare actively for pregnancy.

It is primarily a pre-conception risk assessment for any potential complications of pregnancy. It involves taking a detailed history including past reproductive history, medical assessment, medication use, screening of infections, checking immunization status, identifying any genetic or psychological risks to the couple. Physical assessment should also include blood pressure, weight and BMI.

The general advises by Nice guidelines (UK) include correct BMI between 19 and 30, folic acid supplements, healthy lifestyle, to avoid smoking and drinking, rubella immunisation, sex every 2-3 days, medical review and cervical cytology if due.

A healthy weight reduces the risk of neural tube disease(NTD), preterm delivery, gestational diabetes, caesarean delivery, hypertension and thromboembolic disease and is also more likely to promote conception. Women should be advised regarding the increased risk of adverse pregnancy outcomes associated with their increased weight, particularly at BMIs >40. Consultation with a dietician and exercise will be helpful. If not responding, bariatric surgery can be considered. Similarly, women who are underweight may also find getting pregnant difficult and are at risk of preterm delivery and low birth weight.

Supplementation with folic acid is one of the most significant preventative interventions available in the preconception and antenatal period, 400 micrograms per day whilst trying to become pregnant and for at least the first three months of pregnancy to reduce the risk of NTD. Diet alone does not reliably supply adequate folic acid. Women at high risk of NTD should take a higher dose of 5 mg per day until 12 weeks of pregnancy. High risk is defined as where either partner has an NTD or has already had a pregnancy affected by NTD, family history of NTD, an anti-epileptic medication, coeliac disease, diabetes, thalassaemia trait, haemolytic anaemia particularly thalassaemia or sickle cell anaemia, women with a BMI >30 kg/m2

Cervical screening of the women who are due or nearly due for a cervical smear is encouraged to have their screening before becoming pregnant. Smears are not routinely taken during pregnancy as pregnancy-related inflammatory changes make them difficult to interpret. Many treatments cannot be carried out during pregnancy should an abnormality be detected.

Smoking in pregnancy is associated with a large number of adverse effects including intrauterine growth restriction, miscarriage, stillbirth, premature delivery and placental problems. Smoking around a baby increases the risk of sudden infant death and other respiratory diseases. Appropriate health education and if a required referral to a smoking cessation service for optimum outcome.

High levels of alcohol consumption during pregnancy may result in fetal alcohol syndrome. This syndrome has growth restriction, intellectual impairment, facial anomalies and behavioural problems. Advise women to avoid alcohol completely as there appears to be a small increased risk of miscarriage even with less level of alcohol. Advise to stop using illicit drugs if a pregnancy is desired. Offer referral to deaddiction centre where the woman is planning a pregnancy and is unable to stop using without support. Encourage the use of reliable contraception whilst drug use continues. Where injecting drugs, or with a past history of such behaviour, offer hepatitis B and C and HIV testing.

Immunization status should be checked for measles, mumps and rubella, if negative she should be immunized and delay conception for three months. If high risk, check for hepatitis B immunity and influenza for seasonal vaccination. Tetanus vaccination protects against neonatal tetanus. Vaccinate with Tdap during pregnancy to reduce neonatal pertussis also at the optimal time between 27 to 36 weeks of gestation. Varicella immunity can be checked, and if non-immune, vaccination may be offered. Patients should be counselled to avoid pregnancy for one month after vaccination.

Infections like chlamydia, tuberculosis, HIV, syphilis, herpes, gonorrhoea should be screened at high risk and treated. If the result is positive, then counselling for the risk of vertical transmission is recommended.

Consider referral for genetic screening for couples planning pregnancy who have a personal or family history of inherited genetic disorders, or who have had a previous pregnancy affected. Women at risk of an inherited genetic disorder for which they may request termination should be advised to present early in pregnancy for testing where relevant.

Diabetes affects nearly 10% of women of reproductive age, and about 1% of pregnancies are complicated by pregestational diabetes. Pregestational diabetes increases the risk of miscarriage, congenital fetal anomalies and perinatal death. Glucose is teratogenic at high levels, and rates of congenital fetal anomalies are directly related to glycemic control in the first trimester. Preconception HbA1C levels should be <6.5%. Pregnancy is associated with higher rates of hypoglycemia, decreased hypoglycemic awareness, increased rates of diabetic ketoacidosis and the progression of diabetic retinopathy and nephropathy. Preconception care should include educating women about the impact of diabetes on pregnancy outcomes and the impact of pregnancy on diabetes, optimizing glycemic control, screening for vascular complications of diabetes, evaluating medication use, encouraging effective family planning till ready for conceiving.

Women with renal impairment who are planning pregnancy should be referred to a physician for advice. Advise women to continue using contraception until they have discussed pregnancy with the specialist. Renal disease in pregnancy may be associated with intrauterine growth restriction, prematurity and deterioration in maternal renal function. Most women with severe renal disease are infertile, and if they do conceive, the risks are high. Women with progressive renal disease may be advised to complete pregnancies while renal function remains relatively good.

Seizure disorders are the most common neurologic disease to affect pregnant women, and both the disease and its treatment can adversely affect pregnancy. Approximately one-third of women with a seizure disorder will experience more frequent seizures in pregnancy. Seizure disorders are associated with miscarriage, low birth weight, developmental disabilities, microcephaly, and haemorrhagic disease of the newborn (induced by antiepileptic drugs). Most anti-epileptic drugs are teratogenic, although the risk is reduced if used as monotherapy. Sodium valproate is associated with a particularly high risk. Advise women to continue using contraception until a discussion with a specialist has taken place. Women should use 5 mg of folic acid per day from before conception until 12 weeks of pregnancy to reduce the risk of NTDs.

Chronic hypertension affects 3% of women of reproductive age. It is associated with higher rates of preterm birth, placental abruption, IUGR, preeclampsia, and fetal death. Women with chronic hypertension are at risk of worsening hypertension and end-organ damage.25% of women with hypertension develop superimposed preeclampsia during pregnancy. Caring for women of reproductive age with hypertension should include educating them about the risks of hypertension during pregnancy, their medication regimen may need to be changed before conception. Women with long-standing hypertension who are planning pregnancy should be assessed for retinopathy, renal disease and ventricular hypertrophy.

Asthmatic women with poorly controlled asthma before pregnancy are more likely to experience worsening symptoms during pregnancy. Poorly controlled asthma poses risks to the fetus such as neonatal hypoxia, intrauterine growth restriction, preterm birth, low birth weight and fetal and neonatal death. Preconception care should focus on optimizing asthma control with medications and reducing exposure to allergens. Patients should be counselled on smoking cessation and avoidance of second-hand smoke exposure.

Women with thrombophilia are more likely to develop venous and arterial clots during pregnancy and are at risk of preeclampsia. Effects on the fetus include placental infarction, intrauterine growth restriction, placental abruption, recurrent miscarriage, fetal stroke and fetal death.Warfarin is teratogenic. Preconception care allows women to change to a treatment regimen that is safer for the fetus before pregnancy. Heparin or low-molecular-weight heparin is preferred. Women with thrombophilia should be educated about the risks of pregnancy so that they can make informed decisions about conception. Genetic testing for inherited thrombophilia should be offered. Given increased rates of neural tube defects with many antiepileptic drugs, supplementation with 5mg of folic acid daily should be initiated at least one month before conception and continued in the first trimester.

Hypothyroidism affects 2.5% of women of reproductive age and even more have subclinical disease. Hypothyroidism in the first trimester is associated with cognitive impairment in children. Hypothyroidism (clinical and subclinical) in pregnant women increases the risk of preterm birth, low birth weight, placental abruption and fetal death. Women who are adequately treated before pregnancy and those diagnosed and treated early in pregnancy have no increased risk of perinatal morbidity. It is essential to monitor women on thyroid replacement therapy and educate them about its impact on pregnancy. During pregnancy, thyroid replacement dosages typically need to be increased by four to six weeks gestation, possibly by 30% or more. Hyperthyroidism can result in significant maternal, and neonatal morbidity and outcomes correlate with disease control. Guidelines recommend achieving euthyroidism before pregnancy.

Advanced age that is women over the age of 35 should be counselled about increasing difficulty in conceiving with age, increased risk of miscarriage, twins, fibroids, hypertension, gestational diabetes, labour problems and perinatal mortality. Most pregnancies are uneventful and have a good outcome. The risk of fetal chromosomal abnormalities, particularly Down’s syndrome, increases sharply with maternal age from 1in 800 at 30 years to 1 in 100 at 40 years of age.

Preconception care also involves taking a history from male partner including medical, sexual, surgical, personal and familial history. It will be beneficial to do a baseline semen analysis to pick up any abnormalities early. For the best maternal and fetal outcome, both husband and wife should be seen together in the clinic. Whenever needed, it is good practice to have a multidisciplinary approach by involving physician, endocrinologist, fetal medicine specialists, dietician etc. for optimum outcome.