What is the recommended preconception plan for a woman planning to become pregnant?

Preconception Care Plan

Preconception care should begin at least 3 months before attempting pregnancy and must include folic acid supplementation, chronic disease optimization, medication review, immunization updates, and lifestyle modifications to reduce birth defects, pregnancy complications, and maternal mortality. 1

Core Components of Preconception Care

Folic Acid Supplementation (Start Immediately)

• Begin folic acid 400 mcg daily at least 3 months before conception to reduce neural tube defects by nearly 75% 1, 2
• Higher dose (4-5 mg daily) is required if you have epilepsy, insulin-dependent diabetes, obesity with BMI >35, or family history of neural tube defects 3, 2
• This intervention has the highest quality evidence (Grade A) and must start before pregnancy because neural tube closure occurs before 52 days' gestation, often before women know they are pregnant 1, 2

Medical History and Risk Assessment

• Review reproductive history including any previous adverse pregnancy outcomes (infant death, fetal loss, birth defects, low birth weight, preterm birth) to assess recurrence risks 1
• Screen for chronic conditions that affect pregnancy: diabetes, hypertension, thyroid disease, rheumatic heart disease, thromboembolism, autoimmune diseases 1
• Complete physical examination focusing on periodontal health, thyroid, heart, breast, and pelvic examination 3, 2

Chronic Disease Optimization (Critical for Reducing Birth Defects)

• Diabetes: Achieve A1C <6.5% (ideally <6%) before conception through intensive management—this reduces the three-fold increased risk of birth defects to near-normal levels 1, 2
• Hypothyroidism: Optimize Levothyroxine dosing now, as requirements increase during early pregnancy and proper levels are essential for fetal neurologic development 1, 3
• Hypertension: Switch to pregnancy-safe medications before conception 3, 2
• Epilepsy: Review anti-epileptic drugs with your physician—certain medications like valproic acid are teratogens and should be changed to lower-risk alternatives at lower dosages before conception 1

Medication Review (Prevent Teratogenic Exposures)

• Avoid all FDA pregnancy category X medications (e.g., isotretinoin/Accutane for acne) and most category D medications unless maternal benefits clearly outweigh fetal risks 1, 2
• Review all prescription medications, over-the-counter drugs, herbs, and supplements with your physician 1
• Common pitfall: Many women continue teratogenic medications because they don't realize they need to stop before conception—review this now 1

Immunizations (Complete Before Pregnancy)

• Rubella and varicella vaccines are essential if you lack immunity—these are live vaccines contraindicated during pregnancy, so you must receive them now and avoid pregnancy for 28 days after vaccination 1, 3
• Update hepatitis B, Tdap (if not received within 10 years), HPV, and influenza vaccines as needed 1, 2
• Rubella vaccination prevents congenital rubella syndrome, which causes severe birth defects 3

Infection Screening

• Screen for periodontal disease, urogenital infections, and sexually transmitted infections (HIV, syphilis, hepatitis B, gonorrhea, chlamydia) as indicated 1, 2
• Early identification and treatment prevent transmission to the fetus 1, 4

Genetic Screening and Counseling

• Assess risk based on age, ethnic background, and family history 1, 2
• Offer carrier screening for cystic fibrosis and other genetic disorders as indicated by your background 1, 3
• If you have known genetic disorders (e.g., phenylketonuria), discuss management strategies before and during pregnancy 1

Nutritional Assessment and Weight Optimization

• Target ideal BMI of 19.8-26.0 kg/m² through exercise and nutrition before conception 1, 2
• Consume "five-a-day" (two servings of fruit and three servings of vegetables) 1
• Take a daily multivitamin containing folic acid 1
• Assess for nutritional deficiencies including anemia 1

Lifestyle Modifications (Eliminate Teratogenic Exposures)

• Complete abstinence from alcohol—no time during pregnancy is safe to drink, and fetal alcohol syndrome can be prevented by stopping before conception 1, 3, 2
• Stop smoking immediately using the five A's approach (Ask, Advise, Assess, Assist, Arrange) 1, 2
• Eliminate all street drugs and substance abuse 1
• Avoid environmental toxins: workplace chemicals (solvents, pesticides, heavy metals), mercury in large fish 3, 2

Laboratory Testing

• Complete blood count, blood type and Rh status, urinalysis 3, 2
• Consider TSH measurement and diabetes screening as appropriate 2

Psychosocial Assessment

• Screen for depression, anxiety, domestic violence, and intimate partner violence 3, 2
• Assess major psychosocial stressors and provide appropriate referrals if needed 3, 2

Reproductive Life Planning

• Discuss optimal pregnancy spacing of 18-24 months between deliveries to reduce complications 3, 2
• Use effective contraception until all preconception optimization is complete 1

Critical Timeline

The preconception period must begin at least 3 months before attempting pregnancy because:

• Folic acid requires 3 months to achieve protective levels against neural tube defects 1
• Organogenesis occurs during the first 52 days of pregnancy, often before women know they are pregnant 1
• Chronic disease optimization (especially diabetes) takes time to achieve target control 1
• Live vaccines require 28-day waiting period after administration 3

Common Pitfalls to Avoid

• Do not wait until pregnancy is confirmed to start preconception care—by then it is often too late to prevent birth defects 1
• Do not assume "healthy" women don't need preconception care—approximately 50% of pregnancies are unplanned, making routine preconception counseling essential for all women of childbearing age 3
• Do not continue teratogenic medications (isotretinoin, certain anti-epileptics, category X drugs) while attempting conception 1
• Do not delay genetic counseling if you are ≥35 years old—chromosomal abnormality risk increases significantly with maternal age 3, 2