INTRODUCTION
Preconception counseling is essential to give optimal outcome to any pregnancy, to correct wrong lifestyle habits, investigations to check and correct deficiencies, add routine supplementation, and plan pregnancy at the desired time. Women are often unaware that they are pregnant for the first few weeks of embryonic life, and promoting good health and nutrition before pregnancy is at least as important as during pregnancy.1
First Counseling
The first counseling include:
- Informed choice to women to make them understand health issues that may affect their pregnancy
- Optimizing chronic health issues
- Encouraging women and their partners to be as healthy as possible, to have healthy sperms and healthy eggs
- Identifying couples at risk for genetic problems, and counseling them accordingly
- Routine screening and encouraging immunizations to prevent infections in pregnancy
- Folic acid supplementation.
It has been seen that 25–50% pregnancies are unplanned or happen without prior visit to a doctor. In these cases, outcome may not be optimal, as by the first antenatal visit, organogenesis is well underway and neural tube defects (NTDs) due to folic acid deficiency can no longer be prevented. Also a high 2maternal glucose level would cause abnormalities at this stage of pregnancy which cannot be remedied later. The window of opportunity to vaccinate women may be lost, putting her and the unborn fetus at high risk to infections in pregnancy.
A routine history taking is very pertinent when a patient comes for preconception counseling. Understanding risky behavior in her lifestyle, past history of surgeries or illnesses, and family history of hypertension and diabetes are very important to elicit.
Overweight or underweight women should be counseled to approach optimal weight so that pregnancy outcome is favorable.
Cardiovascular and respiratory status should be documented.
A routine breast examination and a pap smear should be done at the checkup.
In India, all women should be recommended a thyroid screening investigation as it is almost endemic in our country and can lead to early miscarriage and even cretinism in new borns, if left uncorrected.
The couple needs to be assessed together and then counseled.
FOLIC ACID SUPPLEMENTATION
All women should be prescribed 400 µg folic acid while they are trying to conceive and in the first 3 months of pregnancy to reduce the risk of NTDs.2 Diet alone does not adequately supply folic acid. Women at a high risk of NTD should take a higher dose of 5 mg/day.3 High-risk group includes:
- Either partner has an NTD
- Previous pregnancy affected by NTD
- Family history of NTD
- Thalassemia trait
- Women with body mass index more than 30 kg/m2
- Diabetes
- Coeliac disease
- On antiepilepsy medicine.
- In healthy women, advice on healthy eating of 5 portions of fruits and vegetables and adequate dairy intake to increase stores of iron, calcium, and vitamins should be given.
- Lifestyle choices that women may have made including being vegan or keto diet may be at higher risk of nutritional deficiencies and need to be addressed.
- Women with prior history of bariatric surgery will need special attention as the absorption of nutrients may be suboptimal.
- Iron and calcium tablets are prescribed if the patient is anemic or has inadequate nutritional status.
- Vitamin D deficiency causes impaired fetal growth. Indian women are at particular risk of deficiency due to limited exposure to sunlight. Their diet does not include oily fish eggs and meat and hence counseled about the importance of maintaining adequate vitamin D stores during pregnancy and breastfeeding.
- Caffeine during pregnancy may cause intrauterine growth restriction and hence its consumption in pregnancy should be limited. NICE (National Institute for Health and Care Excellence) guidelines recommend limiting caffeine intake to 300 mg during pregnancy which is the equivalent of 4 cups of tea/3 mugs of instant coffee/2 mugs of instant coffee.
- Women should be cautioned against herbal preparations and teas as their use and safety in pregnancy has not been established.
EXERCISE
Women who exercise regularly should be advised to continue their fitness regime. Those who are inactive should start exercising regularly. Saunas and hot tubs should be avoided. Contact and high impact sports can be dangerous and should be warned against.
Smoking in pregnancy is associated with many complications including intrauterine growth restriction, musculoskeletal and limb defects,4 premature contractions and preterm labor, miscarriage and stillbirth, and placental issues. Passive smoking should also be avoided.
Alcohol in pregnancy can lead to deleterious effects in the fetus, these include facial abnormalities, growth restriction, intellectual problems, and behavioral issues.5 This is called “fetal alcohol syndrome”.
Illicit drugs like cocaine, opiates, and marijuana can cause serious problems in pregnancy, like miscarriage, stillbirth, placental abruption, and even sudden infant death. Women or their partners with history of drug usage should be screened for hepatitis and HIV prior to planning pregnancy.
All medication and drug use should be minimized. A special warning should be issued against herbal medication as the effects have not been documented in pregnancy.
IMMUNIZATION6
All women should be offered cervical cancer vaccination when they come for prepregnancy counseling, if they have not received it earlier. They should be reassured that in the event of pregnancy, the vaccinations can be continued after delivery.
Influenza vaccination should be offered to all women planning pregnancy if it has not been administered in the past 12 months.
All women should be screened for rubella as primary rubella can be disastrous for the unborn fetus. Birth defects like cleft lip and palate, cardiac defects, cataract, deafness, and intellectual impairment are seen in the infants. Infection in first 8–10 weeks of pregnancy can lead to up to 80% of pregnancies being affected.
5In the first 20 weeks of pregnancy, varicella infection can lead to congenital fetal varicella syndrome. Those afflicted have limb hypoplasia, growth restriction, skin scarring, cataract, and microcephaly. Mortality rate is high if it happens in early pregnancy so screening and vaccination, if required, is essential.
GUIDANCE ON FERTILE PERIOD
When a couple comes for preconception counseling, they are hopeful of conceiving soon. The menstrual cycle should be tracked and fertile period should be explained so that the couple can have positive results before anxiety builds up. In case the woman's cycles are irregular, investigations to rule out or treat hormonal imbalance should be a priority. History of previous abortions, pelvic pain or irregular bleeding should be elicited and investigated.
ADVANCED MATERNAL AGE
The NICE guidelines recommend that women over the age of 30 years should be informed about the increasing risk of Down syndrome with increasing age. The risk of fetal chromosomal abnormalities increase sharply with maternal age, being 1:1,500 at 20, 1:800 at 30, 1:270 at 35, 1:140 at 40, and 1:50 at 45 years of age.7 Current trend is for women to delay their pregnancy, and though women should be supported in their choices they should be aware that outcomes change with age. As age advances there would be increasing difficulty in conceiving, higher risk of miscarriage, fibroids, twins, and problems associated with hypertension and gestational diabetes. Though more older women will need assisted reproductive technique and are at risk of higher complications, they should be reassured that with good screening and care in their pregnancy the outcome of the pregnancy is favorable.
REFERENCES
- Inskip HM, Godfrey KM, Cooper C. Women's compliance with nutrition and lifestyle recommendations before pregnancy. BMJ. 2009;338:b481.
- De-Regil LM, Fernández-Gaxiola AC, Dowswell T, et al. Effects and safety of periconceptional folate supplementation for preventing birth defects. Cochrane Database Syst Rev. 2010;(10):CD007950.
- Cawley S, Mullaney L, McKeating A, et al. A review of European guidelines on periconceptional folic acid supplementation. Eur J Clin Nutr. 2016;70(2):143–54.
- Hackshaw A, Rodeck C, Boniface S. Maternal smoking in pregnancy and birth defects. Hum Reprod Update. 2011;17(5):589–604.
- Feldman HS, Jones KL, Lindsay S, et al. Prenatal alcohol exposure patterns and alcohol related defects and growth deficiencies. Alcohol Clin Exp Res. 2012;36(4):670–6.
- CDC. Pregnancy and vaccination. [online] Available from http://www.cdc.gov>vaccines>. [Last accessed September, 2019].
- NICE. (2008). Antenatal care for uncomplicated pregnancies: Clinical Guideline (CG 62). [online] Available from https://www.nice.org.uk/guidance/cg62 [Last accessed September, 2019].