Preconception Counseling: Purpose and Recommended Approach
Preconception counseling is essential for all women of reproductive age to identify and modify biomedical, behavioral, and social risks to optimize maternal health and pregnancy outcomes, reducing morbidity and mortality for both mother and child. 1
Core Purpose of Preconception Counseling
Preconception counseling serves to:
- Identify and modify health risks before conception
- Optimize maternal health status prior to pregnancy
- Reduce adverse pregnancy outcomes
- Provide education about healthy pregnancy
- Develop a reproductive life plan
Recommended Systematic Approach
1. Reproductive Life Planning
- Ask all reproductive-age women: "Would you like to become pregnant in the next year?" 2, 3
- Provide contraceptive counseling tailored to patients' intentions 1
- Encourage development of individual goals about childbearing 1
2. Nutritional Optimization
- Prescribe folic acid supplementation (400 mcg daily) to reduce neural tube defects risk by nearly 75% 1
- Recommend 4-5 mg daily folic acid for women:
- Taking folic acid antagonists
- With history of neural tube defect-affected pregnancy
- With obesity or diabetes 1
- Counsel about avoiding mercury exposure by limiting consumption of large fish 1
3. Weight Management
- Assess body mass index (BMI) 1
- Counsel women who are overweight, obese, or underweight about achieving healthy weight before conception 1
- Discuss appropriate weight gain goals for pregnancy 4
4. Infectious Disease Screening and Immunizations
- Screen for sexually transmitted infections and other communicable diseases 1
- Update immunizations before pregnancy:
- Hepatitis B
- Influenza
- Measles, mumps, rubella (MMR)
- Tetanus, diphtheria, acellular pertussis (Tdap)
- Varicella 1
5. Medication Review
- Check for teratogenic medications 1
- Change to safer alternatives when possible 1
- Use fewest medications at lowest effective doses 1
- Adjust medications for chronic conditions (e.g., diabetes, hypertension, seizure disorders) 2, 3
6. Chronic Disease Management
- Optimize control of chronic conditions before conception:
- Counsel women with diabetes about glycemic control, aiming for near-normal A1C levels to reduce congenital anomaly risk 1
- Manage hypertension with pregnancy-safe medications 1
- Optimize control of psychiatric illness 1
- Stabilize thyroid disease 2, 3
- For women with epilepsy, review antiseizure medications 5
7. Substance Use Assessment and Counseling
- Screen for alcohol use and provide referral for alcohol dependence 1
- Screen for tobacco use and provide smoking cessation treatment 1
- Screen for drug use, including prescription opioids 2, 3
- Provide brief behavioral interventions to reduce substance use 1
8. Environmental and Occupational Exposures
- Assess workplace exposures to toxicants (healthcare, dry cleaning, printing, manufacturing, agriculture) 1
- Evaluate household exposures to harmful agents (heavy metals, solvents, pesticides) 1
9. Genetic Risk Assessment
- Screen for personal or family history of congenital anomalies or genetic disorders 1
- Refer for genetic counseling when risk factors identified 1
- Offer carrier testing when appropriate 2, 3
10. Psychosocial Assessment
- Screen for depression and anxiety disorders 1
- Screen for intimate partner violence 1, 2, 3
- Evaluate patient safety and provide appropriate referrals 1
Special Considerations
Women with Previous Adverse Pregnancy Outcomes
- Evaluate women with history of:
- Preeclampsia
- Intrauterine fetal death
- Intrauterine growth restriction
- Recurrent miscarriages
- Preterm deliveries
- Congenital malformations 6
Women After Bariatric Surgery
- Counsel to prevent pregnancy during rapid weight loss 1
- Provide contraception assistance 1
- Address special nutritional requirements 1
Common Pitfalls to Avoid
Waiting until pregnancy is planned: Nearly half of pregnancies are unintended; preconception care should be integrated into routine primary care for all reproductive-age women 1
One-time counseling: Health status and risk factors change over time; preconception counseling should occur multiple times during a woman's reproductive lifespan 2, 3
Overlooking low-risk populations: Even in general populations assumed to be low-risk, 98% of couples report risk factors requiring personal counseling 7
Focusing only on women planning pregnancy: Preconception counseling is appropriate for all reproductive-age patients, whether currently using contraception or planning pregnancy 2, 3
Missing interpregancy interval counseling: Advise about optimal intervals between pregnancies to reduce future complications 2, 3