Applied Evidence

Preconception counseling: Make it part of the annual exam

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Addressing lifestyle issues, managing chronic conditions, updating immunizations, and screening for genetic disorders before pregnancy pay big dividends in positive outcomes.



Practice recommendations
  • Supplementing women’s diets with 400 mg folic acid every day reduces the incidence of neural tube defects in their offspring by up to 72% (A).
  • Optimizing diabetic glucose control prior to conception is linked to a reduction in birth defects and pregnancy loss (B).
  • Limiting caffeine consumption to no more than 200 mg per day may reduce the risk of miscarriage (B).

Strength of recommendation (SOR)

  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented evidence, case series

In the United States most women do not seek out prenatal care until the 8th to 12th week of pregnancy, when the crucial period of organogenesis (4 to 10 weeks after fertilization) has already passed. In addition, women whose pregnancies are unintended—up to half of all pregnancies—may delay seeking care even longer.1 Given these realities, family physicians should consider all visits during the reproductive years—especially yearly exams—as opportunities for preconception counseling.

Preconception health care is essential to the health of our nation. Data from the Centers for Disease Control and Prevention (CDC) are cause for concern:2,3

  • 12% of infants are born prematurely.
  • 31% of pregnancies are complicated by maternal health issues.
  • 11% of women smoke during pregnancy.
  • 10% drink alcohol during pregnancy.
  • 69% of women do not take folate supplements.
  • 31% of women are obese.
  • 3% of women take medications and supplements that are known teratogens.

The Healthy People 2000 initiative set a goal of 60% of primary caregivers providing preconception care at routine medical visits, but thus far, only about 25% do so.2,3

As a primary care provider, you can have a huge impact on fetal and maternal health by counseling women to choose healthier lifestyles, helping them to manage their chronic conditions, updating their immunizations, and screening for genetic disorders before they become pregnant.

Start with the hard part: Lifestyle modification

Changing the way patients go about their lives—how they eat, how much they exercise, whether they use alcohol or tobacco—has 2 salient characteristics: It’s the most difficult thing to get patients to do, and it has the biggest payoff in improving maternal and fetal health. Lifestyle issues of greatest significance for the preconception patient include:

Folic acid supplementation. If your patients are like most women, they may not be aware of the importance of folic acid supplementation. Yet by neglecting to supplement their diet with folates, women are passing up an opportunity to reduce the incidence of neural tube defects (NTDs) such as anencephaly and spina bifida by up to 70%.4

4D ultrasound of an open neural tube defect in a developing fetus

Women considering conception or those who do not use contraception should take 400 mg folic acid, a dosage found in most prenatal vitamins, every day. All women of reproductive age should consider folate supplementation because of the high rate of unplanned pregnancies. Women who have previously had a child with an NTD and women who take anti-epileptic drugs should take 4 mg folate per day.5

Use routine office visits as an opportunity to counsel patients about folic acid supplementation, whether via prenatal vitamins or, if a higher dosage is necessary, by prescription. One group has reported that preconception counseling increases folate use in women planning pregnancy.6

Safer sex counseling. Counseling patients about safer sexual practices may reduce the incidence of human immunodeficiency virus (HIV), herpes, gonorrhea, chlamydia, and syphilis—conditions that may increase the incidence of preterm delivery, fetal malformations, neonatal infection, or developmental abnormalities.3

Identification of patients with HIV is essential, as early treatment with zidovudine (azidothymidine [AZT], Retrovir), reduces the risk of vertical transmission from mother to neonate by up to 70%.7

Infection prevention. Infections with the potential to harm the fetus include parvovirus B-19, cytomegalovirus, toxoplasmosis, and hepatitis B. Vaccinations are available for hepatitis B but not for the others, so it is particularly important to warn patients about avoiding exposure.

Women who work in child care, for example, should avoid direct contact with children who have parvovirus infection (“Fifth disease”) or other viral exanthems. Health care workers should use universal precautions at all times, and all pregnant women should avoid direct exposure to cat feces and consumption of uncooked meats.

Weight control. Obesity is an increasingly serious health problem in the United States. Obesity poses significant risks for pregnant women and their fetuses, including NTDs, diabetes, venous thromboembolism (VTE), premature labor or cesarean delivery, preeclampsia, and macrosomia.8,9 The time to start a program of exercise and weight loss is before conception, because some of the adverse effects of obesity can occur during the first few months of pregnancy.


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