Download 70) Preconception counseling INTRODUCTION — Preconception

70) Preconception counseling
INTRODUCTION — Preconception evaluation and counseling provide an opportunity
to inform women about fertility/pregnancy issues, identify some of the risks of
pregnancy for the mother and fetus, educate them about these risks, and institute
appropriate interventions, before conception.
Preconception care is very important for prevention of congenital anomalies since
many women initiate their prenatal care late during, or even after organogenesis ( the
development of organs which is completed by 8-10 weeks for the most part).
The key task in identifying risks to the woman and her pregnancy is to obtain a thorough
history. The following topics may pose risk to the pregnancy:
Maternal medical problems — A complete medical history is useful for discussing how
pregnancy can affect maternal medical conditions and the effect of a medical disorder
on the fetus and pregnancy. Optimal management of maternal medical conditions,
including changes in medications to incorporate medications known to be safer in
pregnancy, is an important step. Some common or serious medical conditions that
impact or are impacted by pregnancy are discussed briefly below, additional disorders
are reviewed separately

Hyperglycemia is probably the most important determinant of increased fetal
risk in pregnant women with diabetes. This conclusion is supported by
repeated observations that normalizing blood glucose concentrations before
and early in pregnancy can reduce the risk of miscarriage and congenital
malformations to nearly that of nondiabetic women.

For a patient with hypertension, the goal should be to control blood pressure
prior to conception. Certain agents, such as ACE inhibitors, should be
avoided in pregnancy, as their use at any stage of pregnancy is associated
with adverse effects on the fetus.

Asthma should be under good control prior to attempting conception. If
necessary, the use of steroids (inhaled and systemic) in pregnancy is
generally safe, particularly when compared with the risk of maternal acid
base disturbance and hypoxemia to the fetus.

Patients with thyroid disease require close monitoring of thyroid function tests
during pregnancy as the dose of medication to treat thyroid dysfunction
typically needs to be adjusted during pregnancy. Both hyper- and hypothyroidism can affect pregnancy outcome. In particular, neuropsychological
impairment in offspring may occur even in women with subclinical
hypothyroidism.

Women with a history of seizures and women taking antiepileptic drugs
should be referred to a maternal-fetal medicine specialist for a thorough
discussion of risks of pregnancy for mother and fetus, possible adjustments
in their drug regimen, and folic acid supplementation

Pregnancy can pose additional risks to women with cardiovascular disease
(congenital or acquired); a baseline cardiac assessment should be performed
and potential pregnancy risks should be discussed.

The prognosis for both mother and child is best when systemic lupus
erythematosus has been quiescent for at least six months prior to the
pregnancy, and the patient's underlying renal function is stable and normal or
near normal

Women with inherited thrombophilias are at higher risk of thromboembolic
complications during pregnancy because of pregnancy-associated changes
in several coagulation factors; in some cases, they are at increased risk of
adverse pregnancy outcome, as well
Age — Advanced maternal age is associated with increased pregnancy risks that
include infertility, fetal aneuploidy, gestational diabetes, preeclampsia, and stillbirth.
Women should be aware of these risks and the consequences of delaying conception
until they are over 35 years of age.
Reproductive history — The gynecologic and obstetric histories are important for
identifying factors that may contribute to infertility or complications in a future
pregnancy. Uterine anomalies, as an example, can be associated with recurrent
pregnancy wastage or preterm birth. The recurrence risk of an adverse outcome (eg,
miscarriage, preterm birth, intrauterine growth restriction, preeclampsia, congenital
anomaly, perinatal death) should be discussed with women who have a history of
pregnancy complications. In some cases, interventions to reduce or eliminate the risk of
recurrence are available.
Family history — Evaluation of the patient's family history helps to identify genetic risks
to the fetus and maternal medical risks that may not have been appreciated. As an
example, a woman may not be aware that a family history of thromboembolic disease
can put her at risk for thromboembolic and pregnancy complications.
Substance use — Exposure to tobacco, alcohol, and illicit drugs can be harmful to both
the mother and fetus [28-33]. Thus, it is important to screen women for use of these
substances.

Use of tobacco in pregnancy has been associated with several adverse
outcomes, including miscarriage, prematurity, and low birth weight.

A spectrum of birth defects related to alcohol intake during pregnancy may
occur, ranging from subtle growth retardation and neurobehavioral effects
with moderate alcohol intake, to the fetal alcohol syndrome with heavy use. It
has been estimated that more than half of women of childbearing age who do
not use contraception (and thus are at risk of getting pregnant) consume
alcohol, with approximately 2 percent engaging in binge or frequent alcohol
use. It is therefore important to elicit any history of alcohol consumption when
evaluating a woman of childbearing age.

Illicit drugs have variable effects on pregnancy outcome that may be related
to social disturbances in the mother, in addition to effects of the drugs
themselves.
Psychosocial issues — Psychosocial stress, mental health, and financial issues
should be identified and appropriate interventions taken with the help of a community
resource specialist. It is particularly important to screen for the presence of domestic
violence, lack of social support, and barriers to prenatal care.
Environmental exposures — Questions about the woman's work, hobbies, pets, and
home environment can identify potentially toxic exposure. Examples of such hazards
include organic solvents used in manufacturing processes, toxoplasmosis risk from
changing cat litter boxes or eating under-cooked meat, mercury from fish consumption,
and lead used in arts and crafts.
Weight — Maternal obesity has been linked to subfertility, having a child with a
congenital anomaly, and several other pregnancy complications (gestational diabetes,
preeclampsia, cesarean delivery, macrosomia, difficult delivery, and stillbirth/early
neonatal death).
Physical examination — The physical examination in the preconception evaluation is
the same as for the routine periodic health evaluation. Important aspects to highlight
include examination of the thyroid gland, breasts, heart, skin, and a pelvic examination.
The pelvic examination should include cervical cancer screening and, for patients in
whom it is indicated, screening for gonorrhea and chlamydia (see below). Dental caries
and other oral diseases (eg, periodontal disease) also are common and may be
associated with pregnancy complications, such as preterm delivery; thus, referral to a
dentist is appropriate.
Laboratory assessment/screening — The choice of laboratory tests depends upon
the general guidelines recommended for all pregnant women and the individual's
personal medical history. Routine laboratory examination includes:

Rubella titer

Varicella titer, in women with a negative history of varicella

Hepatitis B surface antigen

Complete blood count with red cell indices (MCV <80 may indicate
hemoglobinopathy). (See "Prenatal testing for the hemoglobinopathies and
thalassemias".)

HIV counseling and testing, with patient consent. (See "Prenatal evaluation
and intrapartum management of the HIV-infected patient in resource-rich
settings".)
In addition to these tests, further testing may be considered in those patients with
specific clinical indications.

Plasma glucose concentration for patients at increased risk of diabetes

Mantoux test for tuberculosis in high risk populations

Hepatitis C antibody in high risk populations

Toxoplasmosis titer in patients with occupational exposure, pet cats, or high
risk eating habits. Patients with a negative toxoplasmosis titer should be
counseled to avoid changing the cat litter, forgo eating under-cooked meat,
wear gloves when gardening, and frequently wash food, hands, and food
preparation areas.

Cytomegalovirus titer in women who work in child care facilities or dialysis
units or have children in day care.

Screening for sexually transmitted diseases including gonorrhea, chlamydia,
and syphilis.

Genetic carrier testing based upon a family history of heritable disease or
ethnic origin (eg, testing for cystic fibrosis gene mutations, hemoglobin
electrophoresis, hexosaminidase.

Serum phenylalanine level if maternal phenylketonuria is known or
suspected.

Lead level, if the patient is at high risk of lead exposure or an increased lead
level.
Exposure to ionizing radiation — In addition to the above, women who undergo
periodic screening tests (eg, mammogram, dental films, chest radiographs) involving
ionizing radiation should schedule these tests prior to attempts at conception.
Interventions — After the pregnancy risk assessment is performed, preconception
interventions are directed at preparing and educating the patient. These may include
preconception glycemic control in diabetics, folic acid supplementation, avoidance of
teratogens, and following a low phenylalanine diet in women with phenylketonuria .
Heritable diseases — For those with a positive history for a heritable disease, referral
to a specialist in genetic counseling is usually required to discuss carrier testing, the risk
of genetic disease in the fetus, options regarding prenatal diagnosis and intervention,
and the natural course of the disease
Cessation of substance use — Smoking cessation and reduction during pregnancy
improves pregnancy outcome. Women who are smokers should be counseled on the
benefits of smoking cessation and offered resources to help them quit smoking.
There are no data to establish a safe threshold for alcohol consumption during
pregnancy, thus the safest course of action is to abstain.
Patients who use illicit drugs should be strongly advised of the risks of this behavior and
referred to cessation programs in their area
Depression and psychotropic drugs — Patients with active symptoms of depression
should be treated, if necessary, with drug therapy.
Nutrition and supplements — A nutritionist may be consulted to evaluate restricted
diets or to offer advice on eating a well-balanced, healthy diet. A systematic review
concluded that provision of preconceptional nutritional counseling improved pregnancy.
All women planning pregnancy or capable of becoming pregnant should be counseled
to take a daily multivitamin with folic acid (400 to 800 mcg) to reduce the risk of neural
tube defects.
Women with phenylketonuria (PKU) and high blood phenylalanine levels are at risk for
having a baby with intellectual disability and congenital heart disease. Health care
providers should advise affected women of childbearing age to either stay on a PKU
diet or plan their pregnancies to occur after they have reinstituted such a diet.
The quantity and type of fish consumed should also be regulated and certain types of
fish should be avoided during pregnancy and the preconception period due to concerns
about possible teratogenic effects from environmental toxins. Only cooked fish should
be eaten
Exercise — Mild to moderate exercise is not harmful to the healthy pregnant woman or
her fetus.
Immunization — Ideally, a woman should be immune to or immunized against
infections that place her or her fetus at risk. These diseases vary by country and
personal risk factors (eg, pneumococcal vaccine after splenectomy). Nonpregnant
women of childbearing age who may become pregnant should receive all clinically
indicated immunizations, preferably at least one month prior to conception. In the United
States, this means immunity (as a result of immunization or disease) to measles,
mumps, rubella, tetanus, diphtheria, poliomyelitis, and varicella. Immunization issues
with respect to pregnancy are discussed in detail separately.

Pregnant women are at an increased risk of complications related to
influenza infection. It is therefore recommended that women who become
pregnant during the influenza season receive the influenza vaccine
regardless of stage of pregnancy.

Vaccination should be offered to a woman with a negative rubella titer and
she should be advised to wait one month before attempting conception since
this is a live attenuated virus vaccine.

Varicella infection during pregnancy can be associated with significant
maternal and fetal morbidity and mortality. Administration of anti-varicella
zoster immunoglobulin to the non-immune woman exposed during pregnancy
may not always be effective in preventing clinical disease, although it can
attenuate the risk to the fetus.

Patients at risk for hepatitis B infection (eg, women with multiple sexual
partners, household contacts of patients with hepatitis B, healthcare workers)
should be offered hepatitis B vaccine.
Precautions against infection — Some infections are potentially harmful in
pregnancy, particularly in the first trimester. Interventions exist to minimize the risk of
these infections .