Pre-pregnancy Counselling

GPs are sometimes consulted by women who state their intentions to "start a family" and ask for advice and a check-up. This provides a window of opportunity for health promotion as it is thought that women are very motivated to alter unhealthy life styles at this time.

There are currently no UK national guidelines for preconception care, although its importance in maximising the future chance of healthy pregnancy and good maternal and fetal outcomes is widely recognised.

Preconceptual care is distinct from antenatal care¹ and should include:²

• Informed choice, which helps women and men to understand health issues that may affect conception and pregnancy.
• Women and their partners being encouraged to prepare actively for pregnancy, and be as healthy as possible.
• Identifying couples who are at increased risk of having babies with a genetic malformation. Provide them with sufficient knowledge to make informed decisions.

A large number of pregnancies are unplanned - approximately a quarter in a recent study in Southampton.³ This, and the haphazard seeking of pre-pregnancy advice by many patients, means that many opportunities for pre-pregnancy counselling are missed. Folic acid supplementation before conception and during the first trimester reduces the risk of a neural tube defect (NTD) by 50-70%.⁴ However, often women may not be aware they are pregnant or only attend the first antenatal visit towards the end of this period. Similarly, diabetic women's glucose control appears to be most critical during the first 8-10 weeks of pregnancy in terms of preventing birth defects so targeted care needs to occur before and early in pregnancy.

Efforts need to be made to offer preconceptual care opportunistically as part of other consultations e.g. contraception, diabetic or epilepsy reviews. Any couple being referred for infertility assessment should have had a full preconception assessment prior to further investigation or treatment. School-based programmes, in the context of children's reproductive and sex education, might offer better public health coverage.⁵

• Consider potential hazards at home (e.g. pets or farm animals, domestic chemicals) or at work.
• Advise to wash hands after gardening and to avoid cleaning cat litter trays during pregnancy to avoid toxoplasmosis.
• Advise a woman who is planning pregnancy and is concerned about work exposure to hazardous substances, infections or radiation, to disclose her intention of becoming pregnant to her employer, if possible, so that a risk assessment may be carried out in advance of pregnancy.
• Where she does not feel able to disclose her intention of becoming pregnant to her employer, she can obtain information about the risk of exposure to specific substances by contacting the Health and Safety Executive.

• In healthy women on a normal diet, advice on eating 5 portions of fruit and vegetables per day and consuming dairy products to raise stores of vitamins, iron and calcium is reasonable.
• Because of the dangers of toxoplasmosis and listeriosis, women should avoid:
  • Uncooked meat, fish and eggs
  • Unpasteurised milk
  • Soft cheeses
  • Unwashed fruit and vegetables
• Vegetarians, and especially vegans, are at risk of various nutritional deficiencies and may need to be referred to a dietitian.
• Vitamin D deficiency causes impaired fetal growth. All women should be informed about the importance of maintaining adequate vitamin D stores during pregnancy and breastfeeding. Women at particular risk of deficiency include:
  • Women of South Asian, African, Caribbean or Middle Eastern family origin
  • Women with limited exposure to sunlight
  • Women who do not eat oily fish, eggs, meat or fortified margarine or cereals
  • Women with a pre-pregnancy BMI>30
  Supplementation of 10 mcg Vitamin D/day can be found in 'Healthy Start multivitamin supplements' (along with folic acid and Vitamin C).
• Caffeine during pregnancy may cause fetal growth retardation. A recent cohort study found an odds ratio of 1.2 for 100-199 mg of caffeine/day (1-2 cups of coffee, 2-4 cups of tea) and 1.6 for >300 mg caffeine/day (more than 3 cups of coffee or 6 cups of tea). A sensible approach would be to reduce caffeine consumption prior to pregnancy in heavy users.⁶
• However, women should be cautioned against substituting caffeinated drinks with herbal preparations and teas as their use and safety in pregnancy has not been studied or with sugar-heavy soft drinks.

Folic acid⁷

Supplementation with folic acid is one of the most significant preventative interventions available in the preconceptual/antenatal period:

• All women should take at least 400mcg/day whilst trying to become pregnant and for at least the first three months of pregnancy to reduce the risk of NTD.
• Where either partner has a NTD or has already had a pregnancy affected by NTD, or who are at a higher risk should be prescribed 5 mg/day. Higher risk of NTD is associated with:
  • Liver disease, malabsorption (e.g. coeliac disease)
  • Family history of NTD
  • Anti-epileptic medication
  • Renal dialysis
  • Diabetes (type 1 or 2)⁸
  • Sickle cell anaemia or thalassaemia
• Diet alone (e.g. green vegetables, fortified cereals) does not reliably supply adequate folic acid.
• The Southampton study found that only 2.9% women complied fully with pre-pregnancy advice regarding folic acid and alcohol.³

• Advise women who are overweight (BMI 25-29.9) or obese (BMI ≥30) to lose weight before becoming pregnant. A healthy weight reduces the risk of NTD, preterm delivery, gestational diabetes, Caesarean delivery, hypertension and thromboembolic disease and is also more likely to promote conception. Similarly, women who are underweight may find getting pregnant difficult and be at risk of more pregnancy-related complications.
• Whilst it is often impractical to achieve ideal body weight, women should be advised as to their increased risk of adverse pregnancy outcomes associated with their weight, particularly at BMIs>40. Consultation with a dietician may be helpful.

• Women who exercise regularly should be advised to continue to do so.
• Those who are inactive should start a gentle programme of regular exercise.
• Strenuous exercise in the first 3 months of pregnancy is inadvisable because of the possible risks to the fetus of overheating. Similarly, saunas and hot tubs should be avoided.
• Women should be advised of the potential dangers of certain activities during pregnancy, e.g. contact or high-impact sports, vigorous racquet sports and scuba diving.¹

• Smoking in pregnancy is associated with a large number of adverse effects in pregnancy including:
  • Intrauterine growth retardation
  • Miscarriage and stillbirth
  • Premature delivery
  • Placental problems
• Also ask regarding other smokers in the household since smoking around a baby increases risk of sudden infant death and other respiratory diseases.
• Give appropriate health education regarding the effect of smoking to pregnancy and more broadly. Offer referral to a smoking cessation service.
• There is little information on the use of nicotine replacement therapy (NRT) in pregnancy, but smoking gives a greater dose of nicotine and also exposes mother and fetus to other toxins. It is likely to be safer than smoking in mothers for whom non-pharmacological interventions have failed but risks and benefits should be fully discussed. NRT patches should be removed at night in pregnancy.¹⁰
• Bupropion should NOT be prescribed in pregnancy.

• High levels of alcohol consumption during pregnancy result in the fetal alcohol syndrome (FAS). There are various components including growth retardation, mental retardation, facial anomalies and behavioural problems.
• FAS is seen in approximately 33% of babies born to mothers who drink 18 units/day.
• Advise women planning a pregnancy to avoid alcohol completely during the first trimester as there appears to be a small increased risk of miscarriage associated with drinking alcohol.
• There is no clear safe level of consumption but if women choose to drink alcohol during pregnancy, particularly after the first trimester, they should be advised to drink no more than 1-2 units, no more than twice a week. At this low level there is no evidence of harm to the unborn baby.
• Advise to avoid becoming drunk and binge drinking.
• Where a woman is unable to reduce her alcohol consumption with support in primary care, offer specialist referral.

• It is good practice to minimise exposure to all drugs, including those bought over the counter.
• There is little data on herbal preparations in pregnancy, and they should also be avoided.
• Advise not to exceed 10,000 IU of vitamin A from vitamin supplements either prior to or during pregnancy as vitamin A is a potent teratogen.

In general:²

• Advise to stop using illicit drugs if a pregnancy is desired.
• Offer referral where the woman is planning a pregnancy and is unable to stop using without support. A multidisciplinary approach is essential. Most localities will have a clearly defined drug dependency service with a readily accessible entry point.
• Encourage the use of reliable contraception whilst drug use continues.
• Where injecting drugs, or with a past history of such behaviour, offer hepatitis B and C and HIV testing.

In particular:

• Cocaine use in pregnancy is particularly serious and has been associated with spontaneous abortion, placental abruption, premature birth, low birthweight and sudden infant death syndrome. There is conflicting evidence regarding fetal abnormalities.¹²
• Opiate use is associated with increased incidence of intra-uterine growth retardation and preterm delivery. This contributes to an increased rate of low birthweight and perinatal mortality. Women addicted to heroin who wish to become pregnant should be urged to enter a detoxification programme before conception and if not then at least stabilised on methadone.
• The direct effects of cannabis on the fetus are uncertain but may be harmful. Its use associated with smoking is known to be harmful and women should be counselled against smoking cannabis before and during pregnancy.

• Identify women who are due or nearly due a cervical smear and encourage women to have their screen before becoming pregnant.
• Smears are not routinely taken during pregnancy as pregnancy-related inflammatory changes make them difficult to interpret.
• Many treatments cannot be carried out during pregnancy should an abnormality be detected.

• Many chronic diseases and their treatments may have implications for fetal health and development. Similarly pregnancy and labour may worsen pre-existing maternal conditions.
• Women should have the opportunity to discuss these risks in order to make balanced reproductive choices and to optimise their health, disease control and medication prior to conception.
• Within primary care, encourage women to continue to use contraception and their regular medication until they have had a full review with their specialist team, as well as other routine pre-conceptual care.

Asthma

See Management of Adult Asthma.
A high level of control is essential during pregnancy and patients should be advised to use their peak flow meters and inhalers with extra care, especially the prophylactic steroids.

Diabetes^13,14

See Diabetes Mellitus in Pregnancy.

• From adolescence onwards, advise women about the risks of unplanned pregnancy, the effects of pregnancy on diabetes and vice versa.
• Both the diabetic and obstetric team need to be involved in preconceptual counselling.
• Structured educational programmes should be offered where women have not previously attended one.
• Provide advice on diet, exercise and weight loss (if BMI>27).
• Patients need to ensure very tight control of their blood glucose during pregnancy, including from preconception. Good glycaemic control reduces but does not eliminate the risks of miscarriage, congenital malformations, stillbirth and neonatal death. Currently 2/3rds of diabetic women have HbA_1c concentrations of over 7% in the first trimester.⁸
• Check for retinal and renal complications. Refer to nephrology where eGFR<45 ml/min.
• Blood glucose targets, monitoring and control should be discussed prior to pregnancy. Where safe, HbA_1c should be kept below 6.1%. Women with HbA_1c of above 10% should avoid pregnancy. HbA_1c should be measured monthly pre-conceptually. Individualised targets for self monitoring of blood glucose should be agreed, taking into account risk of hypoglycaemia (the risks of hypoglycaemia and hypoglycaemia unawareness are greater in pregnancy).
• Metformin can be used as an adjunct or alternative to insulin in type 2 diabetics but other oral hypoglycaemics should be discontinued prior to pregnancy. Many type 2 diabetics will be converted to insulin during this period..
• Aspart and lispro (rapid acting insulin analogues)are safe during pregnancy, whilst isophane insulin is the preferred choice for long acting insulin.
• Check for co-existing thyroid disease in type 1 diabetics (TSH, fT4 and thyroid peroxidase antibodies).²

Chronic Hypertension

See Hypertension in Pregnancy.

• Hypertension increases the risk of pre-eclampsia during pregnancy.
• ACE inhibitors and angiotensin II receptor antagonists are contraindicated and should be substituted with an alternative agent suitable for use during pregnancy. Women who become pregnant whilst taking ACEIs should be referred promptly to a specialist for medication switching. They should be advised not to stop their ACEI without a controlled switch because of the risk to mother and fetus of uncontrolled hypertension.¹⁵ ACEI taken in first trimester present only a small risk of fetal abnormalities.
• Methyldopa is the drug of choice.

Heart disease

See Congenital Heart Disease in Adults.

• All women with congenital or acquired heart disease should discuss future pregnancies with a cardiologist.
• Statins are contra-indicated in pregnancy and should be stopped prior to conception.

Epilepsy

See Epilepsy in Adults.

• Most anti-epileptic drugs (AEDs) are teratogenic although the risk is reduced if used as monotherapy.
• Referral to a specialist centre is required so that control can be maintained whilst minimising the risk to the fetus.¹⁶

Thyroid disease

See Thyroid Disease in Pregnancy.

• Check TFTs if not done in the last 6 months.
• Those with subclinical hypothyroidism, should commence treatment and be referred to an endocrinologist if contemplating pregnancy.
• Those on treatment for hypothyroidism, should be reviewed to ensure optimum control. The requirement for thyroid replacement therapy increases in pregnancy.
• Hyperthyroid individuals should be reviewed by the specialist team and may wish to consider treatment with radio-active iodine or surgery prior to pregnancy.

Mental health problems

See Antenatal Mental Health Problems.

• In mild to moderate depression, discuss stopping or switching anti-depressant (to that with the best safety profile in pregnancy) prior to conception.
• For individuals with severe depression, bipolar disorder or schizophrenia, advise continuing with contraceptive measures and normal treatment until a full review can be carried out by a psychiatrist.

Rubella

• Primary rubella infection can be disastrous for the fetus. Defects include mental handicap, cataract, deafness, cardiac abnormalities and intra-uterine growth retardation.
• Infection in the first 8-10 weeks of pregnancy results in damage in up to 90% of infants. Defects are rare after 16 weeks gestation. Whilst women are routinely screened during pregnancy for rubella, this cannot provide protection for the current pregnancy as immunisation must wait until immediately post-partum.
• With the downturn in rates of MMR vaccination and increasing numbers of births to women born outside the UK who may or may not have been offered rubella vaccination, increased vigilance is required.
• Test for immunity or vaccinate anyway in women without proof of vaccination. Advise woman not to get pregnant for a month after vaccination, although large numbers of studies have failed to show adverse effects of vaccination in early pregnancy.

Viral hepatitis

Those at risk (e.g. multiple sexual partners, visitors to endemic areas, healthcare workers, IV drug users) should be screened and vaccinated against hepatitis B if not infected.

Varicella

• In the first 20 weeks of pregnancy, varicella in the mother may cause congenital fetal varicella syndrome. This may cause limb hypoplasia, microcephaly, cataracts, growth retardation and skin scarring. It has a low incidence (less than 1% in the first 12 weeks) but the mortality rate is high.
  There have been very few case reports of fetal damage between 20 to 28 weeks gestation.
• The Department of Health recommends vaccinating the following people if seronegative¹⁷:
  • Healthcare workers with direct patient contact.
  • Healthy susceptible, close household contacts of immunocompromised patients.

• It is important to say that most pregnancies are uneventful and have a good outcome.
• The risk of fetal chromosomal abnormalities, particularly trisomy 21 (Down's syndrome) increases sharply with maternal age (1 in 1500 risk at 20 years, 1 in 270 at 35 years, 1 in 100 at 40 years).
• There is also an increased risk of infertility, miscarriage, twins, fibroids, hypertension, gestational diabetes, labour problems, and perinatal mortality with increasing maternal age.¹⁸

This is recommended for those who have had a previous child with an inherited disease such as Down's syndrome or cystic fibrosis, or have a family history of a genetic disorder. Couples need to know what the risk of having an affected child is and whether screening, genetic testing, pre-natal or pre-implantation is available.
Routine screening may also be available for populations with a high incidence of certain inherited conditions for example:

• Tay Sachs disease in Ashkenazi Jews
• Sickle cell disease in patients of African origin
• Thalassaemia in patients of Mediterranean, Middle Eastern and other origins.