Pre-Pregnancy Counselling

GPs are regularly consulted by women who state their intentions to "start a family" and ask for advice and a check-up. This provides an excellent opportunity to assess the overall health of the woman and provide important information that can have a significantly beneficial effect on the pregnancy.
Preconceptual care is distinct from antenatal care and should include:

• 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.

Several conditions that have previously remained hidden, such as congenital heart defects and glucose intolerance, become clinically apparent with the extra physiological burden exerted by pregnancy.

Consider potential hazards at home (e.g. pets or farm animals) or at work. Advise to see Occupational health if there may be specific work-related hazards.

In healthy women on a normal diet, advice on eating 5 portions of fruit and vegetables per day and drinking plenty of milk 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
• Milk that has not been pasteurised
• Soft cheeses
• All fruit and vegetables should be washed.

Vegetarians, and especially vegans, are at risk of various nutritional deficiencies and may need to be referred to a dietitian.
Asian women are at special risk of vitamin D deficiency and may benefit from a supplement.
Women who are either overweight or underweight, can find getting pregnant difficult and also suffer more complications. They may also need a consultation with a dietitian.
Women should be cautioned to avoid many herbal preparations and teas; their use and safety in pregnancy has not been studied.

Folic acid

Supplementation with folic acid is one of the most significant interventions available.
400mcg/day for all women has been shown to reduce the incidence of neural tube defects (NTD), such as spina bifida, by 72%. ¹
Women who have already given birth to a child with a NTD, or who are at a higher risk should be prescribed 5mg/day. Higher risk of NTD is associated with coeliac disease, family history of NTD or anti-eplileptic medication. This dose is also recommended for women with diabetes ( type 1 or 2)² and sickle cell anaemia.³
This is given for at least one month prior to conception and three months afterwards.
Diet alone does not reliably supply an adequate folic acid for this effect.
It can be prescribed or bought over the counter cheaply.

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.

Smoking in pregnancy is associated with a large number of adverse effects in pregnancy⁴ including:

• Intrauterine growth retardation
• Miscarriage and stillbirth
• Premature delivery
• Placental problems

Counselling on smoking cessation is essential for women who intend to become pregnant and various forms of help are available.⁵
There is little information on the use of nicotine replacement therapy 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.
Bupropion should NOT be prescribed in pregnancy.⁶

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.
There is no clear safe level of consumption. One or two drinks, once or twice a week is unlikely to harm the fetus.⁷

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.

A multidisciplinary approach is essential.⁸ Most localities will have a clearly defined drug dependency service with a readily accessible entry point.

• Cocaine use in pregnancy is particularly serious and there is no substitute. It has been associated with spontaneous abortion, placental abruption, premature birth, low birthweight and sudden infant death syndrome. There is conflicting evidence regarding fetal abnormalities.⁹
• 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.
• HIV and Hep B screening is carried out in all pregnant women in the UK, but is especially important in known iv drug users. Hep C screening is also recommended in this group.

Identify women who need a cervical smear. They 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.

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

• Patients need to ensure very tight control of their blood glucose during pregnancy.
• Type 2 diabetics may need to be changed to insulin.

Chronic Hypertension

• ACE inhbitors are absolutely contraindicated; women already taking ACEI that fall pregnant should be referred promptly to a specialist for medication switching. They should be advised not to stop their ACEI before a controlled switch because of the risk to mother and fetus of of uncontrolled hypertension.¹⁰ ACEI taken in first trimester present only a small risk of fetal abnormalities.
• Methyldopa is the drug of choice.

Epilepsy

• Most anti-epileptic drugs 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.¹¹

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.
Test for immunity or vaccinate anyway. 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) 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 seronegative¹²:

• Seronegative healthcare workers who come into direct contact with patients.
• Healthy susceptible close household contacts of immunocompromised patients.
• Healthcare workers who are planning a pregnancy and are non-immune may wish to take the opportunity to be vaccinated as they will derive benefit from being protected if they are in contact with infectious 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.
There is also an increased risk of miscarriage, twins, fibroids, hypertension, gestational diabetes, labour problems, and perinatal mortality.¹³

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.
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.