Preconception care: Clinical sciences

Preconception care involves optimizing health, addressing modifiable risk factors, and providing education prior to pregnancy. The goal of preconception care is to ensure that your patient's health is optimized to allow for a safe pregnancy. A simple question like, “Do you have a desire to become pregnant in the next year?” opens the door for preconception counseling if the answer is “yes;” it also helps facilitate a contraceptive counseling discussion if the answer is “no.” Preconception counseling can be completed during a specific scheduled visit or during any encounter with a patient who expresses interest in becoming pregnant.

Okay, when a patient presents for preconception care, you should start with screening and assessing for key components of preconception care. First, you’ll review any major medical conditions that can affect pregnancy. These include diabetes mellitus or DM; thyroid dysfunction; hypertension; thrombophilias; history of bariatric surgery; HIV; mood disorders; and previous pregnancy complications.

Now let’s go into details a bit. Counsel your patients with DM that the goal for pre-pregnancy hemoglobin A1c is less than 6.5%. This is to reduce the risk of congenital anomalies and pregnancy complications. Recommend vision screening for vasculopathy, urine protein testing for renal disease, and an electrocardiogram for cardiac disease screening. In addition, thyroid function screening is appropriate for patients with pregestational type 1 diabetes, a personal or family history of thyroid disease, age greater than 30, obesity, and history of pregnancy loss, preterm delivery, or infertility.

If your patient has long-standing or uncontrolled hypertension recommend similar testing as for diabetic patients including vision screening, urine protein evaluation, and an electrocardiogram. Also assess your patient’s current blood pressure medications as some are teratogenic, such as ACE inhibitors and angiotensin receptor blockers. Finally, counsel that those with chronic hypertension are at an increased risk of developing preeclampsia and intrauterine growth restriction in pregnancy; and start these patients on low-dose aspirin after 12 weeks of gestation to reduce their risk of preeclampsia.

Patients with thrombophilias are at higher risk of deep venous thrombosis or pulmonary emboli during pregnancy and postpartum. Focus your preconception counseling on discussing the risks and benefits of thromboprophylaxis, and loop in a hematologist if needed.

If your patient has had bariatric surgery, it’s recommended to avoid pregnancy in the first 12 to 24 months postoperatively, as the rapid weight loss during this time can affect fetal growth. Additionally, oral birth control may not be as effective due to decreased gastrointestinal absorption. Once pregnant, monitor for nutritional deficiencies and dumping syndrome, which is caused by rapid gastric emptying. Also keep in mind that pregnancy symptoms, like nausea and vomiting, can mask bariatric surgery complications leading to delays in diagnosis.

For patients with HIV, it’s important to discuss antiretroviral therapy to decrease the risk of vertical transmission. Recommend starting antiretroviral therapy prior to pregnancy and continuing it throughout with the goal of having an undetectable viral load at conception and beyond.

For those with mood disorders, such as anxiety and depression, discuss the risks and benefits of continuing medication while pregnant versus those associated with discontinuation. In general, untreated or undertreated conditions are associated with a risk of impaired maternal-infant bonding, maternal self-harm, and neglect. As such, be sure to discuss safe medications, and encourage your patients to establish care with a psychologist or counselor, if they haven’t already.

Now, for patients who have had previous pregnancies, obtain their obstetrical history and review any prior complications. If complications have occurred, discuss the risk of recurrence and possible interventions for future pregnancies. In addition, for patients with a history of pregnancy loss or preterm delivery, also consider screening for thyroid disease.

Okay, let’s switch gears and talk about general screening. This includes routine screening for tobacco, alcohol, cannabinoids, and other substance use disorders; sexually transmitted infection, or STI screening; teratogens including environmental and occupational exposures, like pesticides, lead paint, asbestos, and radiation; and risks for infectious diseases, such as Zika and toxoplasmosis. Specifically, recommend avoiding travel to areas with high rates of Zika, as well as staying clear of cat feces and not consuming raw or undercooked meat to minimize toxoplasmosis occurrence. Additionally, patients should be screened for intimate partner violence, continuing periodically to their postpartum checkup. Screenings can be accomplished through direct questions with your patient or a standardized questionnaire.