What is involved in preconception counselling?

Preconception Counseling Components

Preconception counseling should be integrated into routine primary care for all women of reproductive age and involves systematic assessment and optimization of health risks before pregnancy to reduce maternal and fetal morbidity and mortality. 1, 2

Core Assessment Areas

Reproductive Life Planning

• Ask directly at every visit: "Would you like to become pregnant in the next year?" to tailor counseling appropriately 3, 4
• Discuss contraceptive options and family planning goals based on the patient's reproductive intentions 1
• For multiparous women, counsel on optimal birth spacing of 18-24 months between deliveries to reduce complications 2

Folic Acid Supplementation (Grade A Evidence)

• All women of reproductive age should take 400 mcg of folic acid daily, starting at least 3 months before conception, to reduce neural tube defects by nearly 75% 1, 2
• Women with high-risk factors (epilepsy, insulin-dependent diabetes, BMI >35, family history of neural tube defects) require higher doses of 4-5 mg daily 2

Weight and Nutritional Assessment

• Assess BMI and counsel women with BMI <18.5 or ≥30 kg/m² about infertility risks and pregnancy complications 1
• Target ideal prepregnancy BMI of 19.8-26.0 kg/m² through exercise and nutrition 1
• Promote balanced diet including "five-a-day" (two servings of fruit, three servings of vegetables) 1

Chronic Disease Optimization

Diabetes Management (Grade A Evidence):

• Women with diabetes must achieve A1C <6.5% (ideally <6%) before conception to minimize congenital anomalies, preeclampsia, and preterm birth 1, 2
• Refer to multidisciplinary clinic including endocrinologist and maternal-fetal medicine specialist when available 1
• This is critical because organogenesis occurs at 5-8 weeks gestation, often before pregnancy recognition 1

Hypertension:

• Ensure blood pressure control using pregnancy-safe medications 1, 2
• Discontinue ACE inhibitors and angiotensin receptor blockers before conception 1

Thyroid Disease:

• Optimize thyroid function with appropriate levothyroxine dosing, as adjustments will be needed in early pregnancy 2

Seizure Disorders:

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

Psychiatric Conditions:

• Screen for depression and anxiety disorders 1
• Counsel about risks of untreated illness versus medication risks 1
• Adjust medications before conception if appropriate 1

Medication Review

• Systematically review all medications for teratogenic potential 1
• Avoid FDA pregnancy category X medications and most category D medications unless maternal benefits outweigh fetal risks 1
• Discontinue statins before conception 1
• Review over-the-counter medications, herbs, and supplements 1

Infectious Disease Screening and Immunizations (Grade C Evidence)

• Screen for sexually transmitted infections (gonorrhea, chlamydia, syphilis, HIV, hepatitis B) as clinically indicated 1, 2
• Screen for periodontal infections 1
• Update immunizations before pregnancy: hepatitis B, influenza, MMR, Tdap, varicella, and HPV as needed 1
• Counsel on preventing TORCH infections (toxoplasmosis, cytomegalovirus, parvovirus B19) 1, 5

Genetic Screening and Family History

• Assess risk based on maternal age, ethnic background, and family history 1, 2
• For women ≥35 years, provide genetic counseling regarding increased chromosomal abnormality risk 2
• Offer carrier screening for cystic fibrosis and other conditions as indicated by ethnicity and family history 1, 2

Substance Use Assessment

• Screen all patients for tobacco, alcohol, and drug use including prescription opioids used for nonmedical reasons 1, 3, 4
• Use CAGE or T-ACE questionnaires for alcohol screening 1
• Provide smoking cessation interventions using the "five A's" approach (Ask, Advise, Assess, Assist, Arrange) 1
• Advise complete abstinence from alcohol when attempting conception 2

Psychosocial Screening

• Screen for intimate partner violence, domestic violence, and coercive relationships 1, 2, 3
• Assess for depression, anxiety, and major psychosocial stressors 1, 2
• Provide appropriate referrals when needed 2

Environmental and Occupational Exposures

• Assess workplace and household exposures to toxins (heavy metals, solvents, pesticides, endocrine disruptors) 1, 2
• Review Material Safety Data Sheets for occupational hazards 1
• Counsel about limiting consumption of large fish to avoid mercury exposure 2

Physical Examination

• Focus on periodontal, thyroid, heart, breast, and pelvic examinations 1, 2

Laboratory Testing

• Complete blood count, urinalysis, blood type and screen 1, 2
• When indicated: rubella immunity, syphilis, hepatitis B, HIV, gonorrhea, chlamydia screening 1
• Consider TSH measurement 1
• Diabetes screening as appropriate 1
• Cervical cytology if due 1
• Creatinine and urinary albumin-to-creatinine ratio for women with diabetes 1

Ophthalmologic Assessment for Diabetic Patients

• Women with preexisting diabetes require dilated eye examination ideally before pregnancy or in first trimester 1
• Monitor every trimester and for 1 year postpartum based on retinopathy severity 1

Special Considerations

Previous Pregnancy History

• Review previous adverse outcomes (infant death, fetal loss, birth defects, low birth weight, preterm birth) 1
• Assess ongoing risks that could lead to recurrence 1

Post-Bariatric Surgery

• Counsel to prevent pregnancy during rapid weight loss phase 1
• Provide contraceptive assistance 1
• Address special nutritional requirements 1

Common Pitfalls to Avoid

The most critical pitfall is failing to ask about pregnancy intentions at routine visits, missing opportunities for preconception optimization. Since nearly half of pregnancies are unintended, this counseling should occur repeatedly throughout reproductive years, not just when pregnancy is actively planned 1, 3, 4. Another common error is inadequate glycemic control before conception in diabetic women—organogenesis occurs before most women recognize pregnancy, making preconception optimization essential rather than optional 1.