Preconception care: Clinical sciences

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Introduction0:00–0:53

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.

Screening and assessment 0:53–10:06

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. Next, let’s discuss diet and exercise.
A healthy diet that includes adequate daily allowances of vitamins, calcium, and iron is important both prior to and during pregnancy.
For example, if your patient is vegan, they need vitamin B12 supplementation. Additionally, all patients require approximately 350 additional calories per day in the first trimester, and 450 additional calories per day in the second and third trimesters.
Discuss initiation of folic acid supplementation prior to pregnancy to prevent neural tube defects. In fact, folic acid supplementation is encouraged in all reproductive-age patients, especially those considering pregnancy or those who are sexually active and not using contraception.
Finally, encourage regular exercise or physical activity for a minimum of 150 minutes of moderate exercise per week. Next up is reviewing your patient’s current medications.
This includes both prescription and non-prescription medications, along with supplements and herbal products. Each medication is discussed in the context of its safety in pregnancy.
If a patient is currently taking a teratogenic medication and desires pregnancy, that medication should be adjusted in partnership with the prescribing health care provider.
Remember that, whenever possible, it’s best to use the lowest effective dosage of safe medications to control symptoms. In regard to supplements and herbal products, discuss the risks and benefits of each; specifically low-dose ginger can be used for nausea and vomiting, however, most are not routinely FDA-approved and general guidelines on use are limited.
Next, review maternal carrier screening options. This is done by obtaining a full family and genetic history of your patient and their partner.
The goal is to identify if your patient is a carrier of an autosomal recessive disorder, which will prompt genetic counseling and likely testing for that specific disorder.
Basic genetic carrier screening includes cystic fibrosis and spinal muscular atrophy, which should be offered to all patients.
Additionally, there are some diseases that have a higher prevalence in certain populations, for example individuals of Ashkenazi Jewish descent.
This group is at increased risk of being carriers for certain diseases, such as Canavan disease, Familial dysautonomia, and Tay-Sachs disease, so carrier screening is offered to these patients.
Another component of preconception care is discussing optimal birth spacing. Short interpregnancy intervals, especially those of 6 months or less, are associated with risks; for example a lower chance of successful vaginal delivery after cesarean delivery.
The recommended interpregnancy interval is at least 18 months. Now, let’s review preventative care and ensure it’s up to date.

Preventative care10:06–11:36

This is done to further optimize pre-pregnancy health. Confirm that your patient’s cervical cancer screening is up to date and that they have had a mammogram or colonoscopy if indicated.
Next check your patient’s immunization status, and update if indicated for the following vaccines: Tdap, MMR, Hepatitis B, varicella, annual influenza, COVID-19 or SARS-CoV-2, and HPV.
Remember that live vaccines are not recommended during pregnancy, so if a booster for MMR or varicella is indicated, pregnancy should be avoided for at least one month thereafter.
Additionally, the HPV vaccine is not recommended during pregnancy. Next, encourage regular dental care with all patients, and vision care for those at high risk of eye disease, such as patients with diabetes or chronic hypertension.
Lastly, review the ideal weight or body mass index, or BMI. Encourage patients to take steps towards achieving an optimal BMI prior to pregnancy, as it has been shown that high and low BMIs are associated with infertility as well as maternal and fetal complications.
Let’s discuss a brief overview of your patient attempting to conceive. Recommend attempting to conceive after your patient has optimized their health and reduced modifiable risk factors.

Attempting to conceive11:36–12:58

Part of preconception counseling also includes a discussion about your patient’s menstrual cycle, optimal timing of intercourse, and when to seek a fertility evaluation if pregnancy does not occur.
Once your patient is ready to conceive, encourage regular unprotected intercourse during their estimated fertile window.
If pregnancy occurs, recommend establishing obstetrical care. On the flip side, if the pregnancy doesn’t occur, consider fertility evaluation.
Fertility evaluation is indicated if your patient is less than 35 years old and is not pregnant after 12 months of unprotected and timed intercourse, or if your patient is 35 years or older and not pregnant after 6 months.
Lastly, if your patient is anovulatory or has other clearly identifiable infertility factors, they should undergo a fertility evaluation sooner!
Alright, as a quick recap… Preconception care involves health optimization, addressing modifiable risk factors, and providing education prior to pregnancy.

Review12:58–13:51

Preconception care includes reviewing the patient’s history for major medical conditions, screening for substance use, STIs, teratogens and environmental and occupational exposures, risks for infectious diseases and intimate partner violence, and carrier screening options.
Preconception care also involves checking medications, counseling about family planning and birth spacing, encouraging a healthy diet and regular exercise; starting folic acid supplementation; and confirming that preventative care is up to date.