Every woman aged 15–49 years should be considered for pre-conception care ©. Pre-conception care is a set of interventions that aim to identify and modify biomedical, behavioural and social risks to a woman’s health or pregnancy outcome through prevention and management.42 This should include smoking cessation (A)43 and advice to consider abstinence from alcohol (especially in the early stages of pregnancy),44 folic acid and iodine supplementation (A),45, 46 review of immunisation status ©,47 medications (B)48 and chronic medical conditions, especially glucose control in patients with diabetes (B).49 There is evidence to demonstrate improved birth outcomes with pre-conception healthcare in women with diabetes, phenylketonuria and nutritional deficiency50 as well as benefit from the use of folate supplementation and a reduction in maternal anxiety.51 The information below lists all the potential interventions that have been recommended by expert groups in pre-conception care ©. What does pre-conception care include?
Medical issues
Reproductive life plan
Assist your patient in developing a reproductive life plan that includes whether they want to have children. If they do, discuss the number, spacing and timing of intended children. Reproductive history
Ask if there have been any problems with previous pregnancies such as infant death, foetal loss, birth defects particularly neural tube defects (NTD), low birthweight, pre-term birth, or gestational diabetes. Are there any ongoing risks that could lead to a recurrence in a future pregnancy? Medical history
Ask if there are any medical conditions that may affect future pregnancies. Are chronic conditions such as diabetes, thyroid disease, hypertension, epilepsy and thrombophilia well managed? Medication use
Review all current medications including over-the-counter medications, vitamins and supplements. Genetic/family history
Assess risk of chromosomal or genetic disorders, (e.g. cystic fibrosis (CF), fragile X, Tay–Sachs disease, thalassaemia, sickle cell anaemia and spinal muscular atrophy), by collection of data on family history and ethnic background. Provide opportunity for carrier screening for these and other more common genetic conditions. General physical assessment
Conduct Pap test and breast examinations before pregnancy if indicated or due. Also assess body mass index (BMI), and BP and ask about periodontal disease. Substance use
Ask about tobacco, alcohol and illegal drug use.Vaccinations
Vaccinations can prevent some infections that may be contracted during pregnancy. If previous vaccination history or infection is uncertain, testing should be undertaken to determine immunity to varicella and rubella. Women receiving live viral vaccines such as MMR and varicella should be advised against becoming pregnant within 28 days of vaccination. Recommended vaccinations are: • MMR • varicella (in those without a clear history of chickenpox or who are non-immune on testing) • influenza (recommended during pregnancy to protect against infection if in second or third trimester during influenza season) • diphtheria, tetanus, pertussis (DTpa) (to protect newborn from pertussis).
Lifestyle issues
Family planning
Based on the patient’s reproductive life plan (see above), discuss fertility awareness and how fertility reduces with age, chance of conception, and risk of infertility and foetal abnormality. For patients not planning to become pregnant, discuss effective contraception and emergency contraceptive options. Folic acid supplementation
Women should take a 0.4–0.5 mg supplement of folic acid per day for at least 1 month prior to pregnancy, and for the first 3 months after conception. In women at high risk (i.e. with a reproductive or family history of NTD, women who have had a previous pregnancy affected by NTD, women on anti-epileptics, and women who have diabetes) the dose should be increased to 5 mg per day. Healthy weight, nutrition and exercise
Discuss weight management and caution against being overweight or underweight. Recommend regular, moderate-intensity exercise and assess risk of nutritional deficiencies (e.g. vegan diet, lactose intolerance, calcium or iron and vitamin D deficiency due to lack of sun exposure). Psychosocial health
Provide support and identify coping strategies to improve your patient’s emotional health and wellbeing. Smoking, alcohol and illegal drug cessation (as indicated)
Smoking, illegal drug and excessive alcohol use during pregnancy can have serious consequences for an unborn child and should be stopped prior to conception. Healthy environments
Repeated exposure to hazardous toxins in the household and workplace environment can affect fertility and increase the risk of miscarriage and birth defects. Discuss the avoidance of TORCH infections: Toxoplasmosis, Other – such as syphilis, varicella, mumps, parvovirus and human immunodeficiency virus (HIV) – Rubella, Cytomegalovirus, Herpes simplex. • Toxoplasmosis: avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk products, and wash all fruit and vegetables. • Cytomegalovirus, parvovirus B19 (fifth disease): discuss importance of frequent handwashing, and child and healthcare workers further reducing risk by using gloves when changing nappies. • Listeriosis: avoid paté, soft cheeses (feta, brie, blue vein), pre-packaged salads, deli meats and chilled/smoked seafood. Wash all fruit and vegetables before eating. Refer to Australian food standards at www.foodstandards. gov.au/foodmatters/pregnancyandfood.cfm regarding folate, listeria and mercury. • Fish: limit fish containing high levels of mercury.