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Preconception Counseling and Care

This is a corrected version of the article that appeared in print.

Elizabeth D. Close, MD
April O. Gunn, DO
Alexandria Cooke, MD

American Family Physician. 2023;108(6):605-613.

Author disclosure: No relevant financial relationships.

Primary care for women and other patients with similar reproductive potential can include a discussion about pregnancy and, depending on the patient’s intent, contraceptive care or preconception care. Folic acid supplementation of at least 400 mcg per day is recommended to reduce the risk of neural tube defects, because many pregnancies are unplanned. Having a body mass index of 18.5 to 24.9 kg per m2 before pregnancy also reduces complications. Patients with a history of bariatric surgery should delay pregnancy for at least 12 months post-procedure and ensure that their nutritional status is adequate before conception. It is essential to review the patient’s medications and chronic medical conditions to avoid teratogens and optimize treatment before conception to reduce maternal and fetal morbidity and mortality. Having a prepregnancy A1C level of less than 6.5% is strongly recommended for patients with diabetes mellitus to minimize congenital anomalies and complications. Vaccinations should be updated to prevent adverse outcomes related to infections. Infectious disease screenings should be updated before conception to allow for treatment, prophylaxis, or timing of pregnancy to avoid complications. Screening and counseling should be provided for substance use and potential environmental exposures to identify and mitigate detrimental exposures before pregnancy.

The World Health Organization recognizes preconception care as a way to improve the health of women before pregnancy and to improve pregnancy-related maternal and fetal outcomes.1 Individuals with reproductive potential should be encouraged during routine visits to develop a reproductive plan, regardless of their intent to become pregnant, because about 45% of pregnancies in the United States are unintended.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comment
Preconception counseling can be initiated during any clinical encounter by inquiring whether the patient would like to become pregnant within the next year.3 C Committee opinion based on data from systematic review and consensus recommendation
High-risk, potentially teratogenic medications should be avoided in patients with the potential for pregnancy in the absence of contraception or reduced to the lowest dosage possible if essential to control disease.2–4 C Retrospective review of high-risk prescription medications, committee opinion, and consensus recommendation
The U.S. Preventive Services Task Force and other groups recommend that all women and people who could become pregnant take a supplement of 400 to 800 mcg of folic acid per day beginning at least one month before conception.36,38,39 A Guideline recommendation based on systematic review of five randomized controlled trials that showed protective effect to prevent development of neural tube defects with daily folic acid supplementation
When counseling women on weight loss before pregnancy, physicians should explain the benefits of having a BMI of 18.5 to 24.9 kg per m2. Weight loss of 10% can reduce complications of preeclampsia, gestational diabetes mellitus, indicated preterm delivery, macrosomia, and stillbirth.40,41 Further reductions of BMI by 20% to 30% reduce the risk of cesarean delivery, shoulder dystocia, neonatal intensive care unit admission, and in-hospital newborn mortality.40 B Systematic review of cohort data from multiple studies demonstrate pregnancy complications related to increased or decreased BMI
Patients should avoid pregnancy until 12 to 24 months after bariatric surgery because this is the period of most rapid weight loss and potential nutritional deficiencies.49–52 C Practice guidelines from multiple organizations, based on high-quality systematic review, cohort studies, and expert consensus
The American Diabetes Association recommends that all women of reproductive age who have diabetes be counseled about the risks of the condition in pregnancy and offered contraception when pregnancy is not desired. If pregnancy is desired, physicians should offer contraception until the patient’s A1C level is controlled, preferably less than 6.5% to minimize complications.57,58 C Guideline recommendation from the American Diabetes Association and expert opinion

BMI = body mass index.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

ELIZABETH D. CLOSE, MD, FAAFP, is an associate professor in the Department of Family Medicine at the University of Tennessee Health Science Center College of Medicine–Chattanooga.

APRIL O. GUNN, DO, is an assistant professor in the Department of Family Medicine at the University of Tennessee Health Science Center College of Medicine–Chattanooga.

ALEXANDRIA COOKE, MD, is an assistant professor in the Department of Family Medicine at the University of Tennessee Health Science Center College of Medicine–Chattanooga.

Address correspondence to Elizabeth D. Close, MD, FAAFP, University of Tennessee College of Medicine, 1100 E. Third St., Chattanooga, TN 37403 (elizabeth.close@erlanger.org). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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