Primary Care Reports June 2, 1997

A Primary Care Approach to Preconceptional Care

Author: Elmar P. Sakala, MD, MA, MPH, Professor of Gynecology & Obstetrics, Loma Linda University School of Medicine, Loma Linda, CA.

Peer Reviewer: William Michael McCullough, Jr., MD, FACOG, Assistant Clinical Professor, Wright State University School of Medicine, Dayton, OH.

Editor s Note—Most physicians providing obstetric care can recall seeing a patient on the first prenatal visit with a maternal complication or fetal abnormality that might have been prevented by appropriate counseling and intervention prior to the pregnancy. Some patients are ignorant of the following impacts on the developing embryo: 1) medical conditions they are suffering from; 2) medications they are taking; 3) occupational hazards they are exposed to; or 4) social practices they are engaging in. With organogenesis beginning as early as 17 days after conception, it is easy to understand why waiting until the onset of prenatal care may have little effect on providing the ideal environment for the developing conceptus.

Preconceptional counseling seeks to optimize pregnancy outcome by identifying individuals with risk factors, then providing interventions to prevent the development of a condition or disease that could jeopardize the mother, fetus, or neonate. Preconceptional care should be an integrated component of all primary care services, particularly as part of initial and annual visits for family planning services. Preconceptional care and counseling should be offered by primary care physicians to all women in their reproductive years as well as to their partners.

Primary care physicians provide the first contact between the patient and the health-care system. The majority of health-care visits of patients in their reproductive years are through primary care providers. The bulk of preventive care services occurs within the framework of the primary care health system. It is understandable then that the partnership between primary care doctors and their patients holds the key to optimal health-care outcomes, including pregnancy.

The Value of Prenatal Care

The achievement of optimal outcomes of pregnancy has been attributed, to a great degree, to the early enrollment of pregnant women into prenatal care. Prenatal care is traditionally initiated once pregnancy has been detected and seeks the following basic aims: 1) to identify known risks to either the mother or the fetus (e.g., women with Rh negative blood types); 2) to prevent the actualization of risks identified (e.g., administering prophylactic Rh immune globulin to Rh negative women); 3) to diagnose latent problems early enough to treat and thereby prevent any morbidity or mortality (e.g., obtain cultures and treat promptly if positive: cervical [for gonorrhea and chlamydia]; vaginal [for bacterial vaginosis and group B -hemolytic strep]; urine [for asymptomatic bacteriuria]); 4) to limit the adverse sequelae of problems that cannot be detected and treated early (e.g., prompt delivery of a patient with severe preeclampsia or timely administration of maternal corticosteroids to induce surfactant production in preterm fetuses).

These aims parallel the three tiers of preventive care in the health care system. Aims 1 and 2 above illustrate the most basic tier, which is primary prevention—identification of risk factors and provision of interventions so that the condition or disease never develops. Aim 3 illustrates secondary prevention, the next tier of preventive care—early identification of a problem and prompt treatment to prevent disability. Aim 4 is the third tier, which is tertiary prevention—the treatment of a major problem after it has developed to prevent disability.

Many studies support the premise that the interventions involved in such an organized prenatal care sequence contribute to decreasing maternal and perinatal morbidity and mortality. Maternal mortality rates in the United States have indeed fallen precipitously over the last 50 years. Perinatal mortality rates have similarly fallen significantly, even though U.S. perinatal mortality lags behind those of other industrialized countries in the Western world.

Limitations of Prenatal Care

Some perinatal mortalities and morbidities occur unpredictably. For these cases, no risk factors were present to suggest a problem would develop prior to the adverse event. Accordingly, corrective action was not possible. Examples include pre-eclampsia, umbilical cord accidents, and fetal anomalies arising from new mutations.

However, other adverse pregnancy outcomes potentially could have been prevented. Examples include intrauterine fetal death from abruptio placenta in a cocaine user and fetal macrosomia in a woman with poorly controlled adult-onset diabetes mellitus. The relevant risk factors were clearly present, but they were either not identified or appropriate intervention was not provided in a timely fashion.

But even if the sequence of risk identification and preventive intervention is initiated after pregnancy has occurred, optimal maternal and perinatal outcomes may still not be realized. Reasons for this inadequacy of prenatal care may be any of the following:

1. Many of the risks identified during prenatal care may already have had their destructive effect on the fetus by the time prenatal care starts. Waiting to address the existing pregnancy risks until after conception may be like closing the barn door after the horse is already out. An example is the development of neural tube and cardiac anomalies in the fetus of a woman with juvenile-onset diabetes mellitus whose blood glucose values were out of control during early embryogenesis.

2. The process of modification of maternal lifestyle behaviors that are harmful to the fetus may be of such an intensity and lengthy duration that their adverse effect will have already occurred by the time the behaviors are finally changed. Examples include the development of fetal alcohol syndrome in heavy-drinking women and the growth-restricted newborns of tobacco-smoking women.

3. Counseling for genetic risks after conception has occurred precludes avoiding pregnancy by seeking permanent sterilization and the consideration of artificial insemination by donor. An example is informing a woman who is already pregnant that she is a carrier for hemophilia and that 50% of her sons will be affected and 50% of her daughters will be carriers.

Thus, it makes intuitive sense to advance the preventive aspects of prepregnancy planning far enough before conception that the risks identified can be eliminated or at least modified as much as possible before pregnancy occurs. This lays the theoretical basis for the focus of preconceptional counseling.

Preconceptional Care is Primary Prevention

While prenatal care focuses on all three tiers of prevention (primary, secondary, and tertiary), preconceptional care is uniquely and distinctively primary prevention in nature. Its singular focus is on identification of risks to mother and baby, followed by health promotion to eradicate those risks. The focus of the following specific aspects of comprehensive preconceptional care is fundamentally on the adoption of behaviors that enhance the health of the mother and baby along with the discontinuance of behaviors hazardous to them.

The Focus of Preconceptional Care

Discontinue Harmful and Addictive Habits. Alcohol use among pregnant women is common in the United States. It is the most commonly abused psychoactive drug during pregnancy, with use rates of 6-20% depending on the population studied. Women in the childbearing age group are the most likely to use alcohol. Fetal exposure to alcohol is associated with major perinatal problems. Severe birth defects, facial malformations, growth retardation, central nervous system dysfunction, as well as learning and behavioral problems are noted. In heavy drinkers (2-3 drinks per day), the incidence of miscarriage doubles to 30%, and the rate of low birth weight doubles to 25%. Fetal alcohol syndrome is the primary cause of mental retardation in children.1 The risk of some abnormality in the fetus exposed to heavy alcohol use is approximately 50%. Since no safe level of alcohol consumption has been established, advise your patients to avoid all alcohol prior to conception and throughout pregnancy.

Smoking in pregnancy is associated with infertility, preterm labor, low birthweight babies, and higher perinatal morbidity and mortality. A dose-response relationship has been shown between the number of cigarettes smoked during pregnancy and newborn birthweight reduction. Long-term adverse neonatal physical, emotional, and intellectual effects from prenatal nicotine exposure have been documented.2,3 The U.S. Office of Smoking and Health states that smoking is an important preventable cause of adverse pregnancy outcomes.4,5 It is essential to advise women to modify smoking habits and to aim at quitting smoking prior to pregnancy.6-8

Cocaine use in pregnancy is widespread. This habit, even if limited to only the first trimester, can result in spontaneous abortion, placental abruption, premature birth, intrauterine growth restriction (IUGR), and fetal anomalies. These anomalies are thought to have a vasospastic etiology resulting from cocaine constriction of fetal blood vessels that leads to decreased regional circulation. Neonatal central nervous system dysfunction has been well described as a consequence of maternal cocaine use. Women who stop cocaine use by the second trimester have a normal incidence of premature delivery and IUGR.9 Inform your patients that stopping cocaine use prior to pregnancy has major perinatal benefits.

Discontinue Teratogenic Prescription Medications. The following section details a number of commonly used systemic pharmacological preparations that have been associated with serious teratogenic effects on the developing embryo.

Lithium. The use of this antidepressant drug during the first trimester may be related to an increased incidence of congenital defects, particularly of the cardiovascular system. One-third of the heart defects noted are that of the rare Ebstein’s anomaly.10 Consider using antidepressants other than lithium for your depressed female patients prior to conception and during the first trimester.

Phenytoin. Epileptic women taking phenytoin, either alone or in combination with other anticonvulsants, have a 2-3 times greater risk over the general population for delivering a child with congenital defects. Fetal hydantoin syndrome, first described in 1968 by Meadow, is found in 10% of infants exposed to phenytoin in utero.11 Findings noted include craniofacial dysmorphism, prenatal and postnatal growth delay, mental retardation, congenital heart defects, cleft lip and palate, and distal digital hypoplasia.12 If possible, prescribe anticonvulsants other than phenytoin to epileptic women prior to them attempting pregnancy.

Valproic acid. This is another anticonvulsant with significant teratogenic potential. The prevalence of meningomyelocele related to valproic acid monotherapy in pregnancy is estimated to be 2.5% when used between day 17-20 after conception.13 A characteristic pattern of minor facial defects has also been described, along with defects involving digits, urogenital tract, and mental and physical growth. Since valproic acid readily crosses the placenta, avoid prescribing it to epileptic women considering pregnancy.14

Isotretinoin. This vitamin A isomer is used for the treatment of severe, recalcitrant cystic acne. A high percentage of isotretinoin users are women in their childbearing years; up to 40% are women aged 13-19 years. This agent is a potent teratogen when taken orally but not topically. It has a characteristic anomaly pattern involving the central nervous, craniofacial, and cardiovascular systems.15 Current recommendations are that you advise patients that systemic isotretinoin should be stopped at least one month prior to conception.16

Warfarin. This oral anticonvulsant was first described in 1966 as causing fetal embryopathy.17 The critical period of exposure appears to be between the 6th and 9th weeks of gestation, with 30% of exposed fetuses developing fetal warfarin syndrome.18 Common characteristic findings include nasal hypoplasia (due to failure of nasal septum development) and stippled epiphyses. Exposure after the first trimester carries the risk of central nervous system defects, probably from fetal hemorrhage.19 Change women on warfarin anticoagulation therapy to subcutaneous heparin prior to conception.

Adoption of Healthy Dietary Habits. Neural tube defects (NTD) may be more frequent in lower socioeconomic groups and in women with diets lacking in certain vitamins. Incidence is higher in subsequent pregnancies of women who had a previous fetus with a NTD. Folic acid supplementation initiated at least 28 days prior to conception appears to reduce the rate of recurrent NTDs in subsequent pregnancies.20 Recent studies suggest that if you prescribe 4 mg/d of folate preconceptionally to your at-risk patients, their serious anomaly rate can be reduced by 70%.21 Low maternal prepregnancy weight, especially when combined with low pregnancy weight gain, is associated with increased perinatal mortality and morbidity.22,23 High maternal prepregnancy weight is associated with hypertension, fetal macrosomia, glucose intolerance, and difficult labor and delivery.24 Encourage your preconception patients to normalize their body weight, thereby improving their pregnancy outcome.

Anorexia and bulimia are psychiatric conditions with major nutritional consequences, particularly for the pregnant woman and her fetus. Therapy is complex, prolonged, and unpredictable in outcome.25,26

Identification of Risk for Preventable Perinatal Infectious Diseases. Hepatitis B virus (HBV) is a significant perinatal problem due to the risk of vertical transmission from mother to baby. The prevalence of surface antigen carriers in the United States is less than 1% but approaches 20% in individuals from the Far East as well as in the Alaskan Eskimo.27 Up to 10% of these infected individuals will develop a chronic carrier state with long-term risks including liver failure, cirrhoses, and liver cancer. Neonates born to women who are hepatitis B "c" antigen positive have a 90% chance of becoming chronic carriers. If your preconception female patients do not know their HBV status, order a simple blood screening test to identify whether they have the HBV antigen. For patients who are negative but at risk for HBV, recommend the series of preconception vaccinations thereby protecting not only themselves but also their future newborns.28

Rubella infection in pregnancy, although mostly benign for the mother, may cause spontaneous first trimester loss, fetal demise, or congenital rubella syndrome in the newborn. The widespread use of attenuated live rubella virus vaccine has almost abolished congenital rubella syndrome. Recommend immunization to your non-pregnant rubella-susceptible preconception patients to protect their future offspring.

Primary maternal toxoplasmosis infection in pregnancy can result in IUGR, stillbirth, and severe neonatal central nervous system sequelae including mental retardation and deafness. The earlier in gestation the infection, the more severe the fetal effects. It is transmitted to humans by ingestion of the sporozoa oocytes contained in raw meat or in infected cat feces. Currently, no immunization against toxoplasmosis is available, but you can identify seronegative women prior to pregnancy. Then, counsel them about appropriate preparation of meat and handling of cat litter.

Human immunodeficiency virus (HIV) infection is increasing most rapidly in heterosexual women of childbearing age. Acquired immunodeficiency syndrome (AIDS) is the fifth leading killer of American women between the ages of 15 and 45.28a Vertical transmission of HIV from an infected mother to her fetus and neonate occurs at a rate of 30%, with an extremely rapid progression in the newborn to AIDS. Immunization against HIV is nor currently available. All women should be offered HIV testing and should be asked regarding sexual partners and sexual practices. All primary physicians should be actively educating their patients regarding safer sex practices and the hazards of HIVto the newborn.

Normalization of Blood Nutrient Substrates. Glucose. Congenital malformations are the most frequent cause of neonatal death in infants of overt diabetic mothers. Anomalies are seen at a rate up to three times that of the general population. These anomalies, occurring with an incidence of 6-9%, involve skeletal, cardiovascular, genitourinary, and central nervous system defects.29 The mechanism of anomaly establishment has been shown to be substantially due to elevated plasma glucose levels. The critical gestation age for development of these malformations is before the seventh week of gestation, when most women have not even enrolled for prenatal care. Encourage overt diabetic women to achieve euglycemia before and during early pregnancy because repetitive studies show their congenital anomaly rates can be reduced to the same level as the general population.30-32

Phenylalanine. Phenylketonuria (PKU) is an autosomal recessive inborn error of metabolism in which blood levels of the amino acid phenylalanine are markedly elevated due to phenylalanine hydroxylase deficiency. Untreated PKU in infants and developing children results in mental retardation. The affected fetus of a woman who is only a carrier is not at risk in utero. However, the affected fetus of a pregnant woman with overt PKU is at high risk for mental retardation, microcephaly, and IUGR if the mother eats a phenylalanine unrestricted diet. If you place your PKU patients on a low-phenylalanine diet prior to conception and continue it throughout the pregnancy, fetal damage from high phenylalanine levels can be significantly reduced.33

Iron. Iron deficiency anemia is eight times more common in women than in men, mostly due to menstrual blood losses and pregnancy demands. The reduction in circulating red blood cell hemoglobin does not occur until the bone marrow stores are completely depleted. If a woman’s iron stores are marginal prior to conception, even though she may not be manifestly anemic, the increased iron demands of pregnancy may drain whatever bone marrow stores remain, making her overtly anemic. While maternal iron deficiency does not affect the fetus, due to active transport of iron across the placenta to meet fetal requirements, it clearly adversely affects the oxygen-carrying capacity of the woman leaving her tired and weak. Asses women planning pregnancy for evidence of iron deficiency anemia, then place them on iron supplementation to restore bone marrow stores before pregnancy occurs.

Modification of Psychosocial Risk Factors. Epidemiologic studies have identified psychosocial conditions associated with increased perinatal mortality as well as morbidities such as preterm birth.34 Preconception risk assessment by a sensitive interviewer provides an opportunity to identify such adverse conditions. Examples of psychosocial risk factors under the general category of lack of social support include: living in an abusive relationship, living alone, single marital status, and being a single parent. Examples of conditions with high stress and anxiety include: psychiatric condition, lack of employment, low income, inadequate housing, and limited formal education. Any efforts on your behalf that can successfully modify or correct the psychosocial condition prior to conception would appear to enhance the outcome of pregnancy once it occurs.35

Genetic Counseling. Genetic counseling involves advising a family regarding the risk of adverse consequences from the occurrence or risk of occurrence of a genetic disorder within the family. The family at risk is advised of what is known; the severity, anticipated course, prognosis, and management of the disorder; the risk of occurrence; and the choices available for avoiding recurrence.36 Much genetic counseling occurs retrospectively, after the birth of an affected infant.

The increased risk of aneuoploidy associated with advanced maternal age is the most common indication for invasive perinatal testing. While the risk is progressive throughout adult life, the curve begins to accelerate at about 35 years of age. The primary reason for this increased risk is a higher incidence of nondisjunction events, resulting in trisomies (-21, -18, -13) and 47,XXX and 47,XXY.36a

Set up your initial patient history forms to ask screening questions to identify risk for the most common disorders, then provide counseling to detected carriers. Examples are screening for Tay-Sachs disease in Ashkenazy Jews or French Canadians, and for sickle-cell anemia in people of African, Mediterranean, Middle Eastern, or Caribbean descent. Screening for cystic fibrosis may be offered to patients with a family history of the disease.

Provide preconceptional identification of carrier status, and it will allow women and their partners to understand autosomal recessive risks outside of the emotional context of pregnancy. This allows both informed decision-making about conception and planning for further desired testing should pregnancy occur.

Although genetic counseling can often provide a quantifiable risk of occurrence or recurrence, it is limited in actual primary prevention. Most often, the options available are: 1) get pregnant and take a chance followed by early prenatal diagnosis with possible pregnancy termination if the fetus is affected; 2) avoid pregnancy by male and/or female sterilization; 3) achieve pregnancy through artificial and/or assisted reproduction with donor sperm and/or donor ovum; or 4) adopt a child. For an overview of the focus of preconceptional care, see Table 1.

Predictors of Success in Preconceptional Counseling

While it is relatively easy to distinguish which risk factors are associated with perinatal mortality and morbidity, the likelihood of successfully changing or modifying those risk factors prior to conception is variable. The following considerations will heavily affect the probability of successful preconception behavior change.37 (See Tables 2 and 3.)

1. Who initiated the preconception counseling? The patient or the clinician?

2. How many decisions by the patient are required? A single decision, or multiple and repetitive decisions?

3. What is the duration of behavior change required by the patient? Short or prolonged?

4. What is the nature of the targeted behavior change? Restricted or complex?

5. Does the target of the recommendation involve addictive substances?

6. Is the adverse behavior the consequence of psychiatric conditions?

7. Does the recommended behavior change have the support of the patient’s family, cultural, and social group?

8. Is the rationale behind the recommendation understood by the patient?

9. How extensive is the economic cost of the recommendations to the patient?

Highest Success Counseling Scenarios. The following characteristics identify situations that have the highest chance for successful preconception primary prevention. Unfortunately, they represent a relatively small fraction of the total opportunities that exist for preconceptional interventions. All health-care professionals, regardless of their interest or training, whether nursing aides or subspecialist physicians, need to ensure that the following opportunities for preconceptional counseling are not missed.

a. Counseling is initiated by the patient. Most often this occurs if the patient has experienced an unfavorable outcome with a previous pregnancy. Examples include: an overt diabetic woman delivers a baby with caudal regression syndrome; a child is born with a previously undiagnosed spina bifida. The motivation for behavior change by the patient is maximal; thus, the likelihood of following through with recommendations for preconception glycemic control or folate supplementation is greatest. The main causes of failure in patient-initiated encounters are default on the part of the clinician to either provide the needed information and management or failure to refer the patient to a professional who does have the required interest and expertise.

b. Intervention requires only a single decision by the patient. The best example is immunization against serious perinatal infectious diseases, such as rubella and hepatitis B. The practice of administering rubella immunization immediately postpartum to susceptible women prior to discharging them from the maternity unit has been an extremely effective preconception intervention. Equally efficacious has been the identification of hepatitis B surface-antigen positive gravidas and the administration to their newborn of active vaccination as well as passive immunization with hepatitis B immunoglobulin. The limiting steps in such cases are: 1) failure to identify the risk status of the patient by not performing an appropriate prenatal screening test; or 2) failure to set up or implement protocols, thereby not administering immunizations when they are indicated.

Moderate Success Counseling Scenarios. The following characteristics identify the situations that have a significant chance for successful preconception primary prevention. These represent a somewhat larger fraction of the total opportunities that exist for preconceptional interventions. Even though these cases call for a greater degree of time spent in health education and promotion with the patient, the likelihood of seeing a successful outcome is good. With the increasing emphasis placed on primary care by changes in the health-care system, a strong case can be made for primary care physicians of all disciplines to pursue the following preconceptional counseling scenarios.

a. The duration of the behavior change is short. If an adverse intrauterine environment can be modified during a relatively short but critical period of embryogenesis, major congenital anomalies could potentially be prevented. An example is the achievement of euglycemia by an overt diabetic woman at the time of conception and for the first eight post-conceptional weeks. The interval of time required to obtain the benefit is only a few months, which makes the possibility of patient compliance reasonable. The limitations in implementing this intervention are both patient and clinician related.

Patient-related limitations include failing to take the initiative to control blood glucoses early enough to achieve eu-glycemia prior to conception. The initial motivation may be present, but, since conception seldom occurs when planned or desired, the level of drive may dwindle over time. Glucose control, even though of relatively short duration, does involve complex behaviors including: frequent monitoring of blood glucose levels, selection of appropriate food-mix, timing of eating, timing and regularity of exercise, as well as adjustment of insulin dosages. The more complex the behavior change, the more challenging the implementation.

Clinician-related limitations may be related to primary prevention not being as exciting to many specialists as acute care. The physician’s focus is often on the pressing chief complaint rather than the less urgent, but just as important, preventive activity. Additionally, preventive activities are often not well reimbursed by third-party payers.

b. The nature of the targeted behavior requires limited but multiple patient decisions. Taking pharmacologic preparations at critical periods of the pregnancy can potentially prevent congenital anomalies. An example is folate supplementation preconceptionally and in the early post-conceptional weeks. The target behavior is restricted in scope, limited to a single daily tablet of folic acid. However, the behavior must be repeated daily over a period of months. The same patient and physician limitations apply here as in the previous section.

c. The economic cost to the patient is limited. Changes that have no cost to the patient have the highest probability of successful implementation. If additional cash outlay is required, the lower the dollar amount required, the more likely the recommended change will take place. An example is the recognition of an epileptic woman considering pregnancy of the need to substitute a non-teratogenic (more expensive) anticonvulsant medication for a teratogenic (less expensive) anticonvulsant.

Limited Success Counseling Scenarios. The following situations have limited probability for successful preconception primary prevention. However, they have the greatest potential for improving maternal and perinatal outcomes since they represent the greatest proportion of total challenges that exist for preconceptional interventions. Because of the inherent nature of these circumstances, these patient encounters can be exceptionally challenging, demanding, and frustrating. Special skills in communication, motivation, and education are called into play in these situations. Not all primary care physicians have the time, the interest, or the training to deal with these challenging cases. However, all physicians should be familiar with other health-care professionals, specialists, or community resources that are able to assist the patient in behavior change.

a. The targeted behavior involves addictive substances. Smoking during pregnancy has numerous adverse perinatal consequences. Yet, efforts to enhance smoking cessation are complicated by the addictive properties of nicotine. Successful intervention will often require the skills of professionals specially trained in addiction medicine. In spite of the limited response rate, your effort to decrease preconception use of addictive substances is well justified.

b. The recommended behavior change is not endorsed by the patient’s family, cultural, or social group. This is a key limitation of many approaches to treatment of dependency conditions such as cocaine use. The patient may, within an isolated rehabilitation setting, stay "clean" for a prolonged period of time. However, when she returns to her previous social and cultural milieu, where cocaine use is part of the accepted and promoted lifestyle, the old habit may well be resumed.

c. The nature of behavior change is extensive and pervasive. Many of the hazards to the developing embryo and fetus are the consequence of lifestyle habits that are deeply ingrained into the everyday life of the woman. The limited success in motivating a change in such aspects of lifestyle is because change requires an extensive alteration in the woman’s behavior and how she experiences her life. Examples of such behaviors include: smoking cigarettes, consuming alcohol, ingesting an unhealthy diet, and experiencing excessive physical or emotional stress. Changes in each of these behaviors have the potential to improve the outcome of pregnancy.

Although such behaviors are recognized to be statistically associated with less than optimal pregnancy outcomes, the majority of babies born to women practicing these behaviors have no grossly identifiable abnormalities. The hope that such anecdotal "satisfactory" outcomes will somehow repeat often underlies the half-hearted efforts by both patients and health-care providers in modifying these harmful behaviors. Don’t wait until after pregnancy to encourage patients to start changing extensive and pervasive behavior. Begin addressing them now, before conception takes place.

Who Should Perform Preconceptional Counseling?

One would expect physicians providing pregnancy care would be tuned in to the importance of providing this service. Since many OB/GYN physicians and some family practitioners provide the major part of obstetrical care, it would seem appropriate to expect them to be in the forefront of preconceptional counseling. However, all primary care practitioners who provide family planning information or services have a significant role to play, whether they be internists, family doctors, pediatricians, nurse practitioners, nurse midwives, or physician assistants. Preconceptional care should be made available to all women and their partners as an integrated part of primary care services, particularly as part of initial and annual family planning service visits.8 Ideal opportunities for discussing pregnancy planning are visits when patients: 1) present for premarital examinations, 2) come for discontinuance of contraceptive methods, 3) are found to have a negative pregnancy test, or 4) seek infertility care. (See Table 4.) Patients receiving such services indicate an overwhelmingly positive response to the counseling. These avenues may serve to meet most of the high success scenarios and many of the moderate success ones.

However, broad changes in lifestyle habits and patterns (such as smoking tobacco, drinking alcohol, and poor nutritional habits) will not come about by health-care professionals waiting for patients to come to them. Such lifestyle changes include the challenging and difficult issues involved in the limited success scenarios. And yet, the greatest benefit of preconceptional change can arise from these, since women participating in these adverse behaviors number in the millions.

Helping professionals from all aspects of society should participate in preconceptional counseling in its broadest sense. School health personnel need to work with the teaching staff. Clergy need to be educated to discuss these principles in premarital counseling. The broadcast and print media need to be employed through public service messages on a wider scale to alert families at risk regarding the significance of making healthy choices.


1. Prenatal care often starts too late to interrupt injurious events and harmful influences to the developing embryo, many of which may antedate the pregnancy or be present at the time of conception.

2. Preconceptional care is mostly primary prevention in that it identifies women with risk factors and provides interventions so the adverse condition is removed and the harmful effect is never actualized.

3. Health education and motivation of behavior change are crucial to preconceptional counseling.

4. The focus of preconceptional care includes: discontinuing harmful and addictive habits, discontinuing teratogenic prescription medications, adopting healthy dietary habits, identifying risk for preventable perinatal infectious diseases, normalizing blood nutrient substrates, modifying psychosocial risk factors, and providing genetic counseling.

5. Characteristics can be identified that distinguish high vs. low likelihood of success in behavior change. Physicians are more likely to participate in preventive scenarios initiated by the patient or those involving a single decision by the patient. Physicians may not always be adequately trained or interested in dealing with the low success scenarios that involve addictive substances or require extensive and pervasive lifestyle change.

6. Preconceptional care should be part of all initial and annual primary care encounters.

7. Helping professionals from all aspects of society should participate in preconceptional counseling in its broadest sense.


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36a. Ferguson-Smith MA, Yates JRW. Maternal age-specific rates for chromosome aberrations and factors influencing them: Report of a collaborative European study on 52965 amniocentesis. Prenatial Diag 1984;4:5-7.

37. Sakala EP, Ho E. Preconception counseling: Improving pregnancy outcomes by starting before prenatal care. Clin Consult in Obstet Gynecol 1994;6:244-251.

Physician CMEQuestions

49. Which of the following statements best describes the theoretical basis of preconceptional care?

a. Encourage the use of non-steroidal contraceptive methods.

b. Identify risk factors and providing intervention before pregnancy.

c. Diagnose latent problems early enough to treat before morbidity occurs.

d. Limit the adverse sequelae of problems that cannot be detected early.

50. Preconceptional care focuses on which of the following levels of prevention?

a. Primary prevention

b. Secondary prevention

c. Tertiary prevention

d. Comprehensive prevention

51. For which of the following teratogenic agents is the etiology of anomalies suspected to be constriction of fetal blood vessels that leads to decreased regional circulation?

a. Tobacco

b. Alcohol

c. Phenytoin

d. Cocaine