INTRODUCTION
The health care offered before conception in order to optimize the outcome of a given pregnancy constitutes the preconception care. It is the preventive care for women of reproductive age and their partners, including assessment by history and physical examination, counseling, education and intervention. Achieving good health before conception helps women to have healthier pregnancies with fewer complications. The continuity of care and the close physician-patient relationship in primary care offers an opportunity for the physician to assess risk factors and to intervene and modify behaviors that increase pregnancy risk.1 Education of males is also important since they often influence health risks and behaviors in the female.2 Preconception care must begin at least 3 months before planning a pregnancy.3
EARLY TRENDS
Until 1941, the placental barrier was believed to protect the developing fetus from adverse exposure to environmental hazards. Studies of birth defects caused by rubella infection during pregnancy disproved this theory. Further progress toward protecting neonatal outcomes has included education and close management of insulin dependent diabetic women before and during pregnancy. This was later extended to various high-risk factors existing before pregnancy. The concept was then offered even to normal women as a primary preventive measure because it was realized that a woman's health prior to pregnancy is important for successful pregnancy outcome.
PRECONCEPTION VISIT4
A preconception visit should include:
- History including medical history, family's medical background, questions about diet and social habits, such as whether she drinks or smokes, past pregnancies, birth control use, medication and immunizations.
- General physical examination including height, weight, blood pressure, thyroid, dentition, heart, breasts and signs of asymptomatic underlying disease.
- Pelvic examination:
- Infection identification: (1) signs of condylomata or herpes (2) vaginal discharge evaluated for Candida, Trichomonas, and bacterial vaginosis, cervical discharge culture for gonococci and Chlamydia
- Cervical anomalies
- Pap smear
- Bimanual examination to rule out uterine and adnexal abnormalities
- Ultrasound assessment in case of any clinical suspicion.
- Laboratory evaluation: Complete blood count (CBC), blood group, Rh type. Infection profile [venereal disease research laboratory (VDRL), rubella, human immunodeficiency virus (HIV) and hepatitis B surface antigen], blood sugar, urine analysis and in indicated cases hemoglobin electrophoresis and cytomegalovirus (CMV) antibody titers.
Counseling Implications
Medical Disorders
Diabetes mellitus, epilepsy and hypertension are amongst diseases where it is worthwhile to bring the disease under optimal control before getting pregnant. In diabetes to prevent early pregnancy loss and congenital malformations, optimal medical care and patient education and training must begin before conception. This is best accomplished through a multidisciplinary team approach. The desired outcome of glycemic control in the preconception phase of care is to lower glycated hemoglobin so as to achieve maximum fertility and optimal embryo and fetal development.5 Acute complications, including history of infections, ketoacidosis and hypoglycemia, and chronic diabetic complications such as retinopathy, nephropathy, hypertension, atherosclerotic vascular disease, autonomic and peripheral neuropathy and associated thyroid disorders, need to be investigated. Diabetes management, including insulin regimen, prior or current use of oral glucose-lowering agents, self-monitoring of blood glucose regimens and results, medical nutrition therapy, calorie needs, diet and exercise, need to be discussed. Since the safety of currently available oral glucose-lowering agents in pregnancy is not well-established, women with type 2 diabetes who are taking such agents should be switched to insulin therapy for the preconception period and for pregnancy.6 Antihypertensive agents that are safe for pregnancy should be used. Angiotensin-converting enzyme inhibitors, β–blockers and diuretics are preferably avoided.
Age-related Factors
Pregnancy in an adolescent girl encompasses problems in education, medical and social risks. Pregnancy in elderly encompasses another set of problems. Older women are more likely to have health problems, which could adversely affect pregnancy. In addition, previous gynecologic conditions or abdominal surgery may affect the mother's ease in carrying or delivering the baby. For couples in their 30s and 40s considering parenthood, a common concern is the risk of having a baby with a genetic defect. The risk of chromosomal anomalies increases from 1 in 1,300 at 24 years to 1 in 100 at 40 years. The patient needs to be counseled regarding the need for invasive diagnostic procedures when pregnancy establishes.
Nutrition and Weight Gain
A balanced, nutritious diet is advisable before conception and throughout pregnancy. Studies of the Dutch famine during Second World War revealed the vital need for good preconception nutrition to ensure healthy newborns. Maternal nutrition 90–120 days prior to conception is believed to be as critical, if not more, as the early pregnancy nutrition.7 Special attention is required regarding intake of calcium and vitamins, and must include a folate supplement. Folate has been shown to reduce the rate of neural tube defects arising in the first few weeks of pregnancy often before a woman realizes she is pregnant.8 Similarly, pantothenate may help in decreasing the incidence of cardiac anomalies.
Young women in the current times are depriving themselves of sound nutritional habits to meet social images of feminine beauty. Primary care attempts to address this problem through education and counseling. However, poor nutrition due to poverty may be the single greatest risk factor for many future mothers. The role of client advocacy clearly comes into focus when the connection between poverty and at risk pregnancy or neonatal outcomes is made.
A woman should attempt to reach her ideal body weight (IBW) before conceiving. Women who weigh less than 90% IBW have increased risk for preterm or low birth weight infants.
Women who weigh more than 120% IBW have increased risk for gestational diabetes or hypertension. Reducing obesity before pregnancy increases the chances of having a healthy pregnancy.9
Eating disorders may cause nutrient deficiencies that should be corrected before pregnancy. The woman must also be informed that vitamin excesses, especially fat-soluble vitamins, may be toxic and possibly teratogenic.
Lifestyle Behaviors
Counseling regarding a woman's social habits, such as tobacco and alcohol use, is another crucial part of a preconception visit. Discontinuing behaviors, which can be harmful to the developing fetus, including quitting smoking at least 3 months prior to conception is important. Smoking has been shown to influence fertility, cause miscarriage, low birth weight, preterm delivery and is considered a risk factor for sudden infant death syndrome.
Birth defects and growth retardation are known risk factors with alcohol consumption. Drinking alcohol beverages can cause fetal alcohol syndrome, a pattern of birth defects that includes mental retardation, cardiovascular, skeletal and facial abnormalities.10 Lower birth weight has been associated with fathers who drank prior to conception and passive smoking is also harmful to the fetus. Hence, the father to be has to be involved in these lifestyle changes. Intake of caffeine containing beverages must also be reduced, as it may delay conception and increase risk of abortion.11 A discussion regarding illicit, prescription and over-the-counter drug use and understanding the harm is also important.9
Environmental Challenges
Studies of occupational hazards and their effects currently support a much larger environmental risk of birth defects. Hazard protection for the worker often fails to include the 5fetus.9 An example of this is the noise protection devices for workers exposed to high levels of noise. Testing of children exposed in utero revealed a threefold increase in development of a high frequency hearing loss greater than 4,000 decibels. The protective device the pregnant woman wears over her ears does not provide any protection for her developing fetus.
Another deficit is the safe levels of chemicals. Heavy metals like lead, copper and mercury, carbon disulfide, acids, and anesthetic gases can affect the developing embryo. With over 50,000 chemicals in the market, including household chemicals and insecticides, there are less than 100 animal studies to determine the effect of chemicals on human development. An adult's safe level of chemical exposure is believed to be five to ten times higher than fetal tolerances. Fetal vulnerability is due to a high rate of cell division and differentiation, a small relative size, a lack of enzymes to metabolize drugs, and a less efficient excretory system.12
Protection from radiation (X-rays and effect of electromagnetic radiation), including exposure to it by living near high tensions wires and by use of microwave ovens and video display terminals, needs to be discussed. Knowledge of the dangers of physical stresses and strains to pregnancy are also important. Modern amusement park rides can generate high negative G-forces, which cause shearing affects known to cause placental abruptions. The early pregnancy is largely protein embryonic cells. Proteins undergo great changes at increased temperature. Hence, tub bath and infrared heat exposure may be harmful.
Infections
Rubella infection can cause serious birth defects if contracted during pregnancy. If the patient is not immune to rubella due to a prior episode, she can be vaccinated before pregnancy, but pregnancy should be delayed for 3 months after vaccination.9 Toxoplasmosis can seriously affect the fetus. Serological testing to identify immunity is worthwhile in high prevalence areas. A pregnant woman can help to avoid contracting toxoplasmosis by not eating undercooked meat or handling cat litter before she becomes pregnant and during pregnancy. All women must be preferably screened for hepatitis B. Uninfected women, especially those at high risk (such as health care workers who handle blood), can get protection from this infectious disease by vaccination. Local infections must be identified and treated before pregnancy is planned. For example, treatment of condylomata acuminata by podophyllin is contraindicated during pregnancy and hence treatment has to be completed before pregnancy. It is particularly important to screen for and treat bacterial vaginosis since it is associated with an increased risk of premature rupture of membranes, preterm birth, and histologic choriomeningitis. Counseling of HIV-positive couples regarding pregnancy outcome, antiretroviral drugs, breastfeeding and long-term implications is extremely important.
Contraception Usage
Few couples are aware that birth control pills should be discontinued several months in advance of pregnancy to allow at least two regular menstrual cycles to occur before conception. Women who take oral contraceptive agents may gain excessive weight and have an increase in serum cholesterol. An intrauterine device should also be removed a few months prior to pregnancy. Limitations and failure rates of various contraceptive methods must be discussed with the couple.
Drug Usage
Medication use by adult population is extremely common.13 A review of data14 regarding 15,2531 women who delivered between 1996 and 2000 revealed that in 64% of women, a drug other than a vitamin or mineral supplement was dispensed in the 270 days period before delivery. This included category C drugs dispensed to 37.8% and category D drugs dispensed to 4.8% of women. Moreover, drugs which are absolutely contraindicated in women who are pregnant (category X) were given to 4.6% of study population. A planned pregnancy helps in averting problems due to drug usage.
Fertility Treatment
High rate of multifetal gestation in treatments incorporating exogenous gonadotropins and other associated complications and fallouts must be discussed.
Genetic Screening
Most couples do not require specific genetic screening before pregnancy. Information about background rate of birth defects needs to be given. However, some couples are at increased risk for genetic problems like thalassemia or Tay Sach's disease, because of a family history of inherited disease or because of their ethnicity or geographic background. Consanguinity, individuals with abnormal genetic test result and recurrent miscarriage also require genetic counseling. Prepregnancy counseling is quite important in educating couples and helping them make educated decisions about their risk for birth defects or genetic disorders.12
Advantages of Prenatal Care
- Identifying the optimal time to try to conceive.
- Explanation of appropriate testing and procedure options including risks, benefits and limitations.
- The importance of getting adequate folic acid, iron and other nutrients both while trying to conceive and in early pregnancy.
- The dangers of smoking, alcohol and drug use.
- A discussion of the patient's medical problems and/or those of her partner and its management by team approach.
- Accurate family and genetic history and identification of risk factors may reduce the incidence of birth defects.
- Updating woman's immunization status.
- A review of safe activities during pregnancy (e.g. moderate exercise, sex, travel) as well as unsafe ones (e.g. contact sports and first trimester travel).
- Individual participation in health care. The woman can maintain control over her life during the process of conception and pregnancy. Protective environment at work and short-term transfer from job-deemed harmful to pregnancy may be planned.
- Pregnancy planning allows women to optimize their reproductive future. The proportion of infants born with a health disadvantage is significantly lower if the pregnancy was intended than if it was mistimed or not wanted.
- Patient support—facilitation of informed decision- making is available. Assistance in coping with psychosocial issues, education and coordinated patient care is possible.
- Early and complete antenatal care becomes a reality because of the continuum of the care process.
Changing Dynamics of Responsibility
Realistically, although parents want a perfect baby, the physician cannot fulfill this goal every time. Preconception care shifts this responsibility back to the parents. Better reproductive outcomes may be achieved with increased education and intervention on many levels.12 Average first prenatal visit occurs 10 weeks after conception when most of fetal organogenesis has already been accomplished, greatly reducing chance for outcome intervention. Preconceptual counseling can help to increase the odds for a healthy pregnancy and healthy baby. Preconception planning and a risk screening profile at the initiation of care helps the physician to define the client base by risk level and also the ability to pay for medical care.
Current Status
Many studies9,12 have found that performance is poor in providing preconception counseling. Deficiencies are noted in providing a healthy woman with information on rubella immunization and family planning or counseling on sexually transmitted diseases and safer sex. This warrants correction. The four components necessary for the successful practice of preventive health care including preconception care, that is, attitude, organization, appropriate knowledge and management skills, needs to be emphasized during the training of the residents in the field of gynecology.
CONCLUSION
Preconception care consists of three main components: (1) risk assessment, (2) health promotion and (3) intervention. Preconception care and early pregnancy care are excellent opportunities to modify the medical, social and behavioral risks on pregnancy outcomes and should be an integral part of primary care practice. Because over 50% of all pregnancies are unplanned, it is imperative that all gynecologists think of themselves as preconception health providers. The benefits are not likely to be fully realized unless primary care physicians include preconception care as a routine intervention for all women of reproductive age in their practice. The need for such care is greater in hospitals that serve large numbers of poor women, since the women most likely to benefit from preconception care, are often those least likely to have access to it.
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- Yamey G. Sexual and reproductive health: what about boys and men? Education and service provision are the keys to increasing involvement. BMJ. 1999;319(7221):1315–16.
- Koonin LM, Wilcox LS, deRavello L, et al. Healthy pregnancies start with planning. Bus Health. 2001;19(1):55.
- Konchak PS. Preconception care “VITAL MOM”—a guide for the primary care provider. J Am Osteopath Assoc. 2001;101(2 Suppl):S1–9.
- Delgado Del Rey M, Herranz L, Martin Vaquero P, et al. Role of glycosylated hemoglobin of preconception stage in diabetic pregnancy outcome. Med Clin (Bare). 2001;117(2):45–8.
- Jaffiol C, Baccara MT, Renard E, et al. Evaluation of the benefits brought by pregnancy planning in type I diabetes mellitus. Bull Acad Natl Med. 2000;184(5):995–1007.
- Heslin JA, Natow B. Nutrition needs for the preconception period. Occup Health Nurs. 1984;32(9):469–73.
- Lumley J, Watson L, Watson M, et al. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database Syst Rev. 2000;(2):CD001056.
- Morrison EH. Periconception care. Prim Care. 2000;27(1):1–12.
- Floyd RL, Decouflé P, Hungerford DW. Alcohol use prior to pregnancy recognition. Am J Prev Med. 1999;17(2):101–07.
- Leviton A. Caffeine consumption and the risk of reproductive hazards. J Repro Med. 1988;33(2):175–78.
- Schrander-Stumpel C. Preconception care: challenge of the new millennium? Am J Med Genet. 1999;25;89(2):58–61.
- Kaufman D, Kelly J, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States. JAMA. 2002;287(3):337–44.
- Andrade SE, Gurwitz JH, Davis RL, et al. Prescription drug use in pregnancy. Am J Obstet Gynecol. 2004;191(12):398–407.