Preconception care is a critical component of reproductive care that can significantly influence maternal pregnancy outcomes and have a lifelong impact on a child’s health. Appropriate care can reduce the risks of gestational diabetes, hypertension, preterm birth, impaired fetal growth, poor birth outcomes and congenital anomalies.
Both underweight and overweight women are at increased risk of adverse pregnancy outcomes. Overweight or obese women should be encouraged to lose 5-10% of their body weight before conception as this reduces rates of fetal abnormalities, miscarriage, preeclampsia, gestational diabetes, preterm delivery, macrosomia and stillbirth.
This may require referral to a dietitian, education regarding a healthy and balanced diet with supplementation for any identified nutritional deficiencies, guidance on exercise and in some cases referral for bariatric surgery.
Educate women regarding the limiting of caffeine consumption to < 300 mg/day (2-3 cups a day) as this increases the risk of fetal growth restriction and the cessation of smoking, alcohol and illicit drug use as applicable.
Male partners also require counselling as obesity, smoking, excessive alcohol consumption, illicit drug use and poor diet may affect their fertility and influence pregnancy outcomes.
Folic acid supplementation is vital in preventing neural tube defects. A Cochrane review demonstrated a 72% reduction in defects compared to no intervention, placebo or supplements without folic acid.
A dose of 400-500 mcg is recommended for at least one month prior to conception and continued for the first 12 weeks of pregnancy. A higher dose of 5mg is recommended for women with pre-pregnancy diabetes mellitus, a previous affected child or family history of neural tube defects, a BMI over 30 or those using anti-epileptic medications.
Also recommended is 150 mcg of iodine for all pregnant and breastfeeding women to aid with the development of the fetal brain and central nervous system.
History and medications
Chronic conditions (e.g. diabetes, hypertension, thyroid disorders, epilepsy, renal disease, autoimmune conditions and cardiac conditions) should be optimised before conception. Achieving optimal glycaemic control in diabetes reduces the risk of congenital malformations, miscarriage, preterm birth and birth weight abnormalities.
Women may require specialist input or input from maternal-fetal medicine specialists. They may also require contraception while being treated.
Mental health status should also be assessed and managed, as appropriate, before pregnancy.
Women should also be screened for domestic violence as this is associated with poor antenatal attendance and poor obstetric outcomes.
Review medications, over the counter preparations and vitamins as they may carry teratogenic potential and need to be ceased or changed before conception.
Genetic and other considerations
Review the woman and her partner’s ethnic background and family history as this may raise concerns for inheritable genetic disorders. Referral for genetic counselling may be needed.
All couples considering pregnancy should be offered reproductive carrier screening for conditions such as cystic fibrosis, spinal muscular atrophy and fragile X syndrome. Carrier rates are 1:25, 1:40 and 1:250 respectively.
The woman is tested (blood test) first and if positive, the partner is tested. Testing prior to pregnancy allows for genetic counselling and increased reproductive options including in vitro fertilisation with preimplantation genetic diagnosis, in vitro fertilisation with donor oocytes or sperm, or adoption.
A general examination should be performed including blood pressure, auscultation of heart sounds and where relevant, a breast examination and cervical screening.
Vaccination status should be reviewed. Advise immunisation for hepatitis B, rubella and varicella for women not immune. Women should not conceive for at least 28 days after receiving live, attenuated vaccines.
Women should also be screened regarding their risk of exposure to toxins or radiation in the home, workplace or during other activities and advised to avoid travelling to areas with high rates of infection while trying to conceive.
Key messages
- Preconception health greatly influences pregnancy outcomes and the child’s health lifelong
- Simple interventions including folic acid and iodine supplementation greatly impact fetal development
- Reproductive screening should be offered to all couples and a Medicare rebate is now available.
– References available on request
Author competing interests – nil