Letters to the Editor

Am Fam Physician. 2003 Feb 15;67(4):701-702.

Importance of Preconception Counseling

to the editor: We enjoyed reading Dr. Brundage's thorough presentation of preconception health care in the June 15, 2002 issue of American Family Physician.1 The article1 provided an excellent review of the potential areas in which patients may benefit from preconception counseling. However, we believe that family physicians need additional tools to address the challenges they face in transmitting this information to their patients. A “preconception visit” for all women would be ideal, but they rarely occur in the real world. There are many situations in which preconception counseling strategies would be appropriate, such as at the time of a negative pregnancy test, during a well-woman examination, or during a follow-up visit after a miscarriage; unfortunately, these situations have not been thoroughly studied.

One study2 showed that simply providing information to women and their physicians about preconception risks did not increase effective interventions. Although preconception health care has been shown to be valuable for women with certain medical conditions, such as diabetes and epilepsy,3,4 the provision of preconception care has not been well studied in low-risk patients.

Medical knowledge is constantly expanding, and there are ever-increasing demands on our time as family physicians. Therefore, we need practical, proven suggestions for providing preconception counseling in the real world, so the information that was so well presented in Dr. Brundage's article1 can be effectively passed on to patients.

REFERENCES

1. Brundage SC. Preconception health care. Am Fam Physician. 2002;65:2507–14.

2. Jack BW, Culpepper L, Babcock J, Kogan MD, Weismiller D. Addressing preconception risks identified at the time of a negative pregnancy test. A randomized trial. J Fam Pract. 1998;47:33–8.

3. McElvy SS, Miodovnik M, Rosenn B, Khoury JC, Siddiqi T, Dignan PS, et al. A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels. J Matern Fetal Med. 2000;9:14–20.

4. Betts T, Fox C. Proactive pre-conception counseling for women with epilepsy—is it effective? Seizure. 1999;8:322–7.

IN REPLY: The letter from Dr. Uhl and colleagues from the U.S. Food and Drug Administration provides some valuable Web sites for current electronic databases and an update on the pregnancy risk categorization of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor antagonists. I applaud their efforts to inform practicing physicians of updated and timely information. User-friendly Web sites are a valuable tool. The most important fact for the practicing physician to remember about antihypertensives is that ACE inhibitors, angiotensin-II receptor antagonists, beta blockers, and thiazide diuretics are in pregnancy risk Category D for a significant portion of pregnancy. This is not an indication for termination of pregnancy, but a warning that if the drug is used in a woman of childbearing age, the woman should be counseled to see her doctor for a medication change as soon as she suspects she could be pregnant.

The letter from Drs. Muchowski and Paladine highlights the need for additional practical tools to help family physicians provide real-time counseling to most patients (who do not come in for preconception counseling appointments). As a practicing physician, the most useful tools for me are a concise checklist of preconception topics to discuss as needed and a patient information handout, both of which were included in my article.1 A user-friendly Web site is also very useful. Other useful tools include patient history and encounter forms that prompt the physician to discuss particular areas of concern. Electronic mail messages to patients and electronic patient-tracking databases also can be used to enhance the tailoring of the message to meet the specific needs of the individual patient.

REFERENCE

1. Brundage SC. Preconception health care. Am Fam Physician. 2002;65:2507–14.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.


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