What are the key components of pre-conception counseling for women?

Preconception Counseling for Women

All women of reproductive age should receive comprehensive preconception care as an integral part of primary care, focusing on reproductive life planning, folic acid supplementation, chronic disease optimization, medication review for teratogens, immunization updates, and screening for infections and psychosocial risks. 1

Core Components of Preconception Counseling

Reproductive Life Planning

• Assess pregnancy intentions at every visit and provide contraceptive counseling tailored to the patient's reproductive goals 1
• Discuss optimal birth spacing of 18-24 months between deliveries to reduce maternal and fetal complications 2
• Review previous pregnancy history including adverse outcomes (fetal loss, birth defects, preterm birth, preeclampsia) to assess recurrence risks 1

Folic Acid Supplementation (Critical for Neural Tube Defect Prevention)

• Prescribe 400 mcg (0.4 mg) daily folic acid to all women of reproductive age, starting at least 1-3 months before conception 1, 2
• Increase to 4-5 mg daily for high-risk women: those with previous neural tube defect, epilepsy on antiepileptic drugs, insulin-dependent diabetes, obesity (BMI >35), or family history of neural tube defects 2
• Counsel on consuming folate-rich foods in addition to supplementation 1

Weight and Nutritional Optimization

• Target ideal BMI of 19.8-26.0 kg/m² before conception 1
• Counsel women with BMI ≥30 kg/m² or <18.5 kg/m² about infertility risks and pregnancy complications 1
• Recommend "five-a-day" (two servings fruit, three servings vegetables) and balanced nutrition 1
• Assess for nutritional deficiencies using the ABCDs: anthropometric (BMI), biochemical (anemia screening), clinical factors, and dietary risks 1

Chronic Disease Management (Essential for Reducing Congenital Anomalies)

Diabetes Mellitus

• Achieve A1C <6.5% (48 mmol/mol) before conception to minimize risk of congenital anomalies, preeclampsia, and preterm birth 1
• Refer to multidisciplinary team including endocrinologist and maternal-fetal medicine specialist when available 1
• Counsel about increased risks: miscarriage, stillbirth, congenital malformations, macrosomia 1

Hypertension

• Switch to pregnancy-safe antihypertensives before conception: discontinue ACE inhibitors and angiotensin receptor blockers 1
• Optimize blood pressure control with lifestyle modifications and appropriate medications 1

Thyroid Disease

• Ensure adequate thyroid hormone replacement with appropriate levothyroxine dosing, as requirements increase in early pregnancy 2
• Measure thyroid-stimulating hormone levels as part of preconception laboratory testing 1

Mental Health Disorders

• Screen for depression and anxiety disorders using validated tools 1
• Counsel about risks of untreated illness versus medication risks in pregnancy 1
• Adjust psychotropic medications before conception when appropriate, individualizing treatment based on severity 1

Seizure Disorders

• Review antiepileptic medications and switch to safer options when possible, using the fewest medications at lowest effective doses 1

Medication Review (Critical to Avoid Teratogenic Exposures)

• Systematically review all current medications, including over-the-counter drugs, herbs, and supplements 1
• Discontinue FDA pregnancy category X medications and most category D medications unless maternal benefits clearly outweigh fetal risks 1
• Stop statins before conception 1
• Use the fewest medications at the lowest dosages needed to control disease 1

Infectious Disease Screening and Immunizations

Laboratory Screening

• Complete blood count and urinalysis 1
• Blood type and Rh screen 1
• Screen for sexually transmitted infections (gonorrhea, chlamydia, syphilis, HIV, hepatitis B) based on risk assessment 1
• Consider rubella immunity testing if vaccination history uncertain 1

Immunization Updates (Complete Before Conception)

• Hepatitis B, influenza, measles-mumps-rubella (MMR), Tdap, varicella, and HPV vaccines as indicated 1
• Administer live vaccines (MMR, varicella) at least 1 month before conception 2
• Review immunization status annually 1

Genetic Screening and Family History

• Assess risk based on maternal age, ethnic background, and family history 1, 2
• Offer carrier screening for cystic fibrosis and other conditions based on ethnicity and family history 1, 2
• Provide genetic counseling for women ≥35 years due to increased chromosomal abnormality risk 2

Lifestyle and Behavioral Modifications

Substance Use Screening and Cessation

• Screen all women for tobacco, alcohol, and drug use using CAGE or T-ACE questionnaires 1
• Counsel complete abstinence from alcohol when attempting conception 2
• Provide smoking cessation interventions using the "5 A's" approach (Ask, Advise, Assess, Assist, Arrange) 1, 2
• Address substance abuse with appropriate referrals and treatment 1

Environmental and Occupational Exposures

• Assess workplace and home exposures to heavy metals, solvents, pesticides, and endocrine disruptors 1, 2
• Review Material Safety Data Sheets for occupational hazards 1
• Counsel about avoiding mercury by limiting large fish consumption 2
• Advise avoiding hyperthermia (hot tubs) 1

General Health Behaviors

• Recommend regular moderate exercise 1
• Promote dental hygiene and screen for periodontal disease 1
• Counsel on safe sex practices and seatbelt use 1

Psychosocial Assessment

• Screen for intimate partner violence, domestic violence, and childhood abuse at every visit 1, 2
• Assess for major psychosocial stressors that may affect pregnancy 1, 2
• Provide appropriate referrals and resources when violence or abuse identified 1

Physical Examination

• Focus on periodontal, thyroid, heart, breast, and pelvic examinations 1, 2
• Assess for signs of chronic disease or conditions affecting fertility 1

Common Pitfalls to Avoid

• Failing to ask about pregnancy intentions at routine visits: Nearly 50% of pregnancies are unintended, making universal preconception care essential 1, 3
• Delaying folic acid supplementation: Neural tube closure occurs at 5-8 weeks gestation, often before pregnancy recognition 1
• Continuing teratogenic medications: ACE inhibitors, ARBs, statins, and certain antiepileptics must be stopped before conception 1
• Inadequate diabetes control: Organogenesis occurs primarily at 5-8 weeks, requiring optimal glycemic control before conception 1
• Missing genetic screening opportunities: Advanced maternal age and ethnic-specific carrier screening should be addressed preconceptionally 2