Basics
Description
- Given that women often become pregnant without intending to, preconception care is a critical aspect of primary care for all women of reproductive age.
- Preconception care should be tailored to meet the needs of the individual woman. Plans for conception should be addressed with the woman at her annual wellness visit. If pregnancy is not desired, contraception options should be discussed and implemented (see "Contraception " ).
- Counseling should not be limited to women, as there are contraception options for men as well as health optimization opportunities to reduce risks for conception (i.e., treatment of chronic disease and STIs, updating immunizations).
- With regard to pregnancy ambivalence, it is important for the provider to help clarify feelings about pregnancy, which can empower both women and men to actively participate in reproductive decision making or more consistent contraception use (1).
- For women who desire pregnancy, a general approach to preconception care includes optimization of chronic disease state (if applicable), ensuring immunizations are up-to-date, reviewing medications for teratogenic effects, improving diet, assuring folic acid, and encouraging exercise (2).
- It is important to deliver preconception services in a culturally competent manner while addressing the needs of adolescents, lesbian, gay, bisexual, transgender, or those questioning their sexual identity.
Epidemiology
- According to the CDC, 49% of pregnancies are unintended (3).
- A large number of young adults express pregnancy ambivalence, so good health habits should be encouraged for everyone who may become pregnant.
- Risk factors for poor pregnancy outcome often are present before the start of prenatal care:
- Unintended conception
- Chronic disease
- Teratogenic exposures
- Short interpregnancy interval
Etiology and Pathophysiology
- Approximately 10% of birth defects are caused by exposure to teratogens in the environment. These include maternal illness, infectious agents, physical agents, and drugs and chemical agents.
- The embryo is most vulnerable to teratogenic insults because organ development occurs at this time (end of the 10th week of gestation, 8th week postconception) (4).
- Most congenital anomalies result from an interplay of the embryo 's genetic predisposition and environmental insults during embryogenesis.
General Prevention
- Given that many pregnancies are unplanned, providers should have an ongoing, patient-centered discussions with their patients about desire to conceive.
- For women not desiring pregnancy, counseling should be offered on all options for contraception (and emergency contraception) such as long-acting reversible contraception (intrauterine devices, contraceptive implants) as well as the vaginal ring, the patch, oral contraceptives, hormonal injections, male/female condoms, diaphragm, and withdrawal. The effectiveness of these methods should be provided (see "Contraception " ).
Diagnosis
History
For women who desire pregnancy, complete a well-woman history including the following (2,5,6):
- Reproductive profile
- Desires and timing for future pregnancy
- Current and past use of contraception
- Evaluating for infertility (7)
- Failure to conceive >12 months of regular unprotected intercourse
- Failure to conceive >6 months of regular unprotected intercourse in women age >35 years
- History of infrequent menstruation, history of uterine/tubal disease or endometriosis
- Those with a partner who is subfertile
- Previous pregnancies
- Unintended versus intended
- Pregnancy spacing
- Maternal complications
- History of normal spontaneous vaginal delivery (NSVD), cesarean section, miscarriage, stillbirth
- Fetal/neonatal/infant outcomes (i.e., history of neural tube defect in previous pregnancy)
- History and prior workup if she experienced multiple miscarriages
- Intimate partner violence: Providers should screen women of childbearing age for intimate partner violence and refer women who screen positive for intervention services (8).
- Genetic/inherited conditions
- Autosomal recessive disease
- Sickle cell
- Thalassemia
- Cystic fibrosis
- Tay-Sachs disease
- Fragile X syndrome
- Down syndrome
- Muscular dystrophy
- Familial hearing or vision loss
- Diabetes
- Optimization of chronic disease management with special consideration to teratogenic medications
- Diabetes
- Polycystic ovarian syndrome (PCOS)
- Hypertension
- Thyroid disease
- Autoimmune disease
- Metabolic disorders
- Hematologic disorders
- Kidney disease
- Psychiatric disorders including depression, anxiety
- Testing/preventing infectious diseases
- Vaccine-preventable diseases: rubella, hepatitis B, varicella, influenza, tetanus
- HIV/AIDS
- Syphilis
- Chlamydia/gonorrhea
- History of herpes, need for chronic suppressive therapy
- Periodontal disease (encouraging dental care)
- Toxoplasmosis (Although routine screening is not advised, risk assessment and counseling can be done.)
- Nutrition/exercise
- Discussing optimal weight, especially in patients with BMI <19 or >29
- Folic acid supplementation
- Encouraging continuation of exercise
- Initiating healthy exercise routine
- Assessing for exposures
- Tobacco use/exposure
- Alcohol use/exposure
- Drug use/exposure
- HIV serodiscordant relationship
- Perception of safety at home and work
- Screening for domestic violence
- Work/environmental exposures
- Social support
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Rubella titer
- Varicella titer
- Hepatitis B surface antigen
- HIV
- Rapid plasma reagin (RPR)
- Chlamydia and gonorrhea
- Postpartum depression (PPD) if woman is high risk
- Screening for prediabetes if woman is obese or at risk for diabetes
- Consider screening thyroid-stimulating hormone (TSH) if clinically relevant.
- Cervical cancer screening per guidelines
- For women at high risk or for per patient request, genetic carrier testing can be done:
- Hemoglobin electrophoresis
- Cystic fibrosis, Tay-Sachs disease, fragile X syndrome
Treatment
General Measures
- For women of reproductive age, assess for desire to conceive in short term and long term at routine well-woman visit; for women not desiring pregnancy, contraception should be addressed and implemented.
- By asking women the "one key question " " "Would you like to become pregnant in the next year? " can best initiate discussion regarding women 's reproductive health desires (9)[C].
- For women and men who are ambivalent or not sure about pregnancy and contraceptive use, evaluating these attitudes and engaging in patient-centered discussions may help with informed decision making (10)[A].
- For men and women who are ambivalent toward pregnancy and/or engaged in inconsistent contraception use, an approach toward generalized health promotion should be taken.
- Provide contraception options with men and address male contraception (condoms, vasectomy, withdrawal) as indicated.
- For women who desire pregnancy
- Discuss optimal pregnancy interval of 2 " 5 years for women younger than age 35 years and 12 months for women older than age 35 years (11,12)[A].
- Recommend that woman of reproductive age planning to conceive take a prenatal vitamin with 400 Όg folic acid, as it is most beneficial if taken at least 3 months prior to conception (13)[A].
- A woman with history of neural tube defect or other defect linked to folic acid deficiency in prior pregnancy should take 4 mg folic acid. These defects include oral facial cleft, structural heart disease, limb defect, urinary tract anomaly, and hydrocephalus. Women with history of epilepsy, taking antiepileptic medications for other indications (i.e., migraine headache prophylaxis), with insulin-dependent diabetes, BMI >35, and family history of neural tube defect should also take this higher dose (13)[A].
- Discuss BMI and refer to services as deemed appropriate (i.e., nutritionist, exercise and weight loss programs) (14)[C].
- Update vaccinations (15)[C].
- Discuss smoking cessation with motivational interviewing and provide appropriate interventions (16)[A].
- If the woman has high-risk conditions, such as diabetes, hypertension, epilepsy, rheumatoid arthritis, assure that these conditions are well controlled with nonteratogenic medications; weigh risks versus benefits of continuing potentially teratogenic medications, including over the counter and herbals (17)[C].
- If the woman has HIV or her partner has HIV, preexposure prophylaxis should be discussed as an option for risk reduction in the seronegative partner while trying to conceive (18)[C].
- If patient has elevated risk for genetic conditions, testing for genetic carrier status and/or referral to genetic specialist should be considered.
- The woman (or couple) should be counseled on how to maximize fertility.
- Vaginal intercourse every 1 " 2 days after menstrual period ends, with particular attention to period of ovulation where cervical mucus becomes slippery, stretchy
- Optimizing BMI and minimizing caffeine intake
- Minimizing smoking, drug, and alcohol use as well as vaginal lubricants
- If suspecting infertility, both partners should be evaluated at the same time (7)[C].
Issues for Referral
In vitro fertilization, artificial insemination, gestational carrier, acupuncture for fertility
Ongoing Care
Patient Education
- Preconception Health. https://www.womenshealth.gov/pregnancy/before-you-get-pregnant/preconception-health.html
- Preconception Health and Health Care. http://www.cdc.gov/preconception/freematerials-health-edu.html
References
1.Higgins JA, Popkin RA, Santelli JS. Pregnancy ambivalence and contraceptive use among young adults in the United States. Perspect Sex Reprod Health. 2012;44(4):236 " 243.
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2.Gavin L, Moskosky S, Carter M, et al; Center for Disease Control and Prevention. Providing quality family planning services: recommendations of CDC and U.S. Office of Population Affairs. MMWR Recomm Rep. 2014;63(RR-04):1 " 54.
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3.Fine LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478 " 485.
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4.Shepard TH. "Proof " of human teratogenicity. Teratology. 1994;50(2):97 " 98.
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5.Farahi N, Zolotor A. Recommendations for preconception counseling and care. Am Fam Physician. 2013;88(8):499 " 506.
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6.Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care " United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006;55(RR-6):1 " 23.
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7.Practice Committee of the American Society for Reproductive Medicine. Optimal evaluation of the infertile female. Fertil Steril. 2006;86(5)(Suppl 1):S2647.
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8.US Preventive Services Task Force. Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2013. http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm. Accessed October 30, 2014.9.
The One Key Question Initiative. Oregon Foundation for Reproductive Health. http://www.onekeyquestion.org/. Accessed on May 27, 2014.10.Bruckner H, Martin A, Bearman PS. Ambivalence and pregnancy: adolescents ' attitudes, contraceptive use and pregnancy. Perspect Sex Reprod Health. 2004;36(6):248 " 257.
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11.World Health Organization. Report of a WHO Technical Consultation on Birth Spacing. Geneva, Switzerland: World Health Organization; 2005.12.Conde-Agudelo A, Rosas-Berm Ίdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295(15):1809 " 1823.
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13.US Preventive Services Task Force. Folic Acid to Prevent Neural Tube Defects. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspsnrfol.htm. Accessed October 30, 2014.14.Siega-Riz AM, Siega-Riz AM, Laraia B. The implications of maternal overweight and obesity on the course of pregnancy and birth outcomes. Matern Child Health J. 2006;10(5 Suppl):S153 " S156.
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15.Coonrod DV, Jack BW, Boggess KA, et al. The clinical content of preconception care: immunizations as part of preconception care. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S290 " S295.
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16.U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women. http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm. Published 2009. Accessed October 30, 2014.17.Cragan J, Friedman JM, Holmes LB, et al. Ensuring the safe and effective use of medications during pregnancy: planning and prevention through preconception care. Matern Child Health J. 2006;10(5)(Suppl):S129 " S135.
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18.
Aids Info. Preconception counseling and care for HIV-infected women of childbearing age: reproductive options for HIV-concordant and serodiscordant couples. http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/153/reproductive-options-for-hiv-concordant-and-serodiscordant-couples. Updated March 28, 2014. Accessed April 23, 2014.
Codes
ICD09
- V26.9 Unspecified procreative management
- V26.49 Other procreative management counseling and advice
- V25.8 Other specified contraceptive management
- V26.41 Procreative counseling and advice using natural family planning
ICD10
- Z31.9 Encounter for procreative management, unspecified
- Z31.69 Encounter for other general counseling and advice on procreation
- Z30.9 Encounter for contraceptive management, unspecified
- Z31.61 Procreative counseling and advice using natural family planning
SNOMED
- 406224006 Reproductive care (regime/therapy)
- 406225007 Reproductive technology management (regime/therapy)
- 389095005 Contraception care (regime/therapy)
- 397619005 Family planning education (procedure)
Clinical Pearls
- By asking women of reproductive age, "Would you like to become pregnant in the next year? " primary care clinicians better understand women 's reproductive health needs, whether it be preventing unintended pregnancy or ensuring for a healthy pregnancy.
- Preconception counseling should not be limited to women.
- Health optimization should be the general approach to both men and women of reproductive age.