AAFP Releases Position Paper on Preconception Care
Am Fam Physician. 2016 Sep 15;94(6):508-510.
Author disclosure: No relevant financial affiliations.
Key Points for Practice
• A woman's reproductive plan should be discussed at each visit because her plans may change depending on life circumstances.
• Women of reproductive age should take a daily supplement of 400 to 800 mcg of folic acid, starting before conception, and consume a balanced diet of folate-rich foods to reduce the risk of neural tube defects.
• Health concerns in men such as diabetes mellitus, erectile dysfunction, and testicular conditions may affect fertility.
• A man's lifestyle factors, including tobacco smoking and sexually transmitted infections, can directly impact his partner's pregnancy.
From the AFP Editors
Preconception care is defined as personalized care for men and women that is focused on reducing maternal and fetal morbidity and mortality, increasing chances of conception, and preventing unintended pregnancies. Family physicians have the opportunity to discuss risk factors that negatively impact maternal and infant health such as being overweight, smoking, hypertension, and diabetes mellitus.
There are multiple barriers to providing comprehensive preconception care. Usually, preconception is focused on patients planning a pregnancy. Because one-half of U.S. pregnancies are reported as unintended, the timing of addressing preconception is a challenge. Most women recognize the need for counseling before conception to achieve optimal health outcomes, but the majority reported that they did not receive any counseling, and most physicians did not provide or recommend counseling to their patients of reproductive age. The American Academy of Family Physicians (AAFP) has released a position paper providing evidence-based recommendations that address reproductive health care.
Preconception Interventions for Women
A woman's reproductive plan should be discussed at each visit because her plans may change depending on life circumstances. These discussions should include risks due to age, maternal or paternal conditions, and obstetric and family history. Women who wish to prevent pregnancy should be offered contraceptive methods approved by the U.S. Food and Drug Administration, an assessment to identify safe methods, counseling to help choose a contraceptive method, and prompt delivery of the contraceptive method selected. Shared decision making and tailored information should focus on patient preferences. Routine counseling about emergency contraception should also be available when needed.
Overall health and management of chronic conditions are essential for proper preconception care. Women of reproductive age should take a daily supplement of 400 to 800 mcg of folic acid, starting before conception and continuing through 12 weeks of pregnancy, and consume a balanced diet of folate-rich foods to reduce the risk of neural tube defects. Obesity, chronic hypertension, diabetes, and lifestyle risks (e.g., use of alcohol, tobacco, illicit substances) can lead to pregnancy complications and should be addressed, as well as counseling on medication use. Many commonly prescribed medications are considered unsafe in pregnancy and it may be necessary to switch to safer medications before conception. A mental health assessment should be included in preconception care because mood and anxiety disorders are highly prevalent in women of reproductive age, with a high prevalence of relapse of a previously diagnosed mental health disorder or a new-onset disorder in pregnancy. Treatment for these disorders during pregnancy should be individualized. Immunization status should be evaluated annually in all women of reproductive age.
Table 1 shows general recommendations for preconception interventions for women.
General Recommendations for Preconception Interventions for Women
Chronic disease management
Hypertension: women of reproductive age should have blood pressure checks during routine care. If diagnosed with hypertension, they should be counseled on lifestyle changes and medications that are safe in pregnancy.
Diabetes mellitus: women who have diabetes should be counseled about the importance of glycemic control.
Depression and anxiety disorders: women of reproductive age should be screened for depression and anxiety disorders and counseled about potential risks of untreated illness. Medications should be prescribed or adjusted before conception, if appropriate.
Assess for use of teratogenic medications and optimize risk profile of medications.
When pregnancy is not desired, discuss safe sex and effective contraceptive methods.
Family and genetic history
Assess pregnancy risks on the basis of maternal age, maternal and paternal health, obstetric history, and family history.
All women of reproductive age should be advised to take folic acid and to consume a balanced, healthy diet including folate-rich foods. Women at high risk of neural tube defects should take higher levels
This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.
A collection of Practice Guidelines published in AFP is available at http://www.aafp.org/afp/practguide.
Copyright © 2016 by the American Academy of Family Physicians.
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