Clinical Review

Prepregnancy care

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3467 (Published 31 May 2012) Cite this as: BMJ 2012;344:e3467
  1. Srividya Seshadri, subspecialty training fellow in reproductive medicine1,
  2. Pippa Oakeshott, reader in general practice2,
  3. Catherine Nelson-Piercy, professor of obstetric medicine1,
  4. Lucy C Chappell, clinical senior lecturer in maternal and fetal medicine3
  1. 1Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  2. 2Population Health Sciences and Education, St George’s, University of London, London, UK
  3. 3Women’s Health Academic Centre, King’s College, London SE1 7EH, UK
  1. Correspondence to: L C Chappell lucy.chappell{at}kcl.ac.uk

Summary points

  • Consider offering opportunistic prepregnancy advice to all women of reproductive age, particularly when providing contraception

  • Behavioural changes include stopping smoking, reducing alcohol and caffeine intake, avoiding substance misuse, and optimisation of weight

  • Folic acid is recommended from before conception until 12 weeks’ gestation to prevent neural tube defects

  • Check immunity to rubella in women suspected to be non-immune

  • Review chronic medical and psychiatric conditions, in addition to therapeutic drugs, to optimise care; liaise with specialists

  • Offer genetic counselling to couples with an affected child or family history of a genetic disorder

Prepregnancy care aims to recognise and amend lifestyle, behavioural, medical, and social risks to a woman’s health or pregnancy outcome, and ultimately it aims to reduce maternal and perinatal morbidity and mortality.1 Where such risks are not modifiable, prepregnancy counselling aims to ensure that a woman is told of the potential risks and can make an informed decision about the pregnancy. Prepregnancy advice can be offered to a woman of reproductive age by any healthcare professional who has contact with her with the aim of optimising pregnancy outcomes. With around half of pregnancies in the United Kingdomw1 and the United Statesw2 unplanned, a proactive approach is needed. This review is relevant to general practitioners, nurses, and family planning doctors in the community and to specialists in secondary care who see women of reproductive age.

Sources and selection criteria

We searched PubMed (in January 2012) for articles on prepregnancy care, advice, and counselling, together with those on modification of lifestyle behaviour before pregnancy. The MeSH terms for the search included: “preconception”, “periconception”, “pre-pregnancy”, “pre-conceptional”, in addition to keyword variations. We obtained information from prospective randomised clinical trials, cohort studies, systematic reviews, and meta-analyses. We searched national guidelines for those including advice on prepregnancy care.

Why should prepregnancy advice become an integral part of healthcare services?

More than half of maternal deaths in the UK are caused by pre-existing medical conditions, particularly cardiac, neurological, and psychiatric illnesses, together with an increasing contribution from obesity.2 The triennial report on maternal deaths from the Centre for Maternal and Child Enquiries in the UK has highlighted the important role of prepregnancy care, particularly in the management of women with pre-existing medical conditions. The recommendations include routine commissioning of such services as an integral part of the maternity services network. These recommendations reflect the increasing awareness that women may not receive the necessary specialist advice or obtain optimal care, particularly around appropriate use of therapeutic drugs.

What lifestyle changes should a woman planning pregnancy consider?

Advise women considering pregnancy to start folic acid supplementation and, where appropriate, to stop smoking; limit alcohol and caffeine intake; avoid use of illicit drugs; and optimise their weight, diet, and physical health. Table 1 provides evidence for these interventions and recommendations for prepregnancy advice.

Table 1

Prepregnancy lifestyle modification: evidence and recommendations

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A Cochrane review of randomised controlled trials showed that supplementation with 400 µg of folic acid for three months before conception and during the first trimester of pregnancy decreases the risk of neural tube defects (such as spina bifida) in the fetus by 72% (relative risk 0.28, 95% confidence intervals 0.13 to 0.58).3 National guidelines recommend increasing the dose of folic acid to as much as 5 mg in patients with a personal or a family history of spina bifida, diabetes,w3 or sickle cell diseasew4 and in those receiving antiepileptic drugs.w5

The implementation of lifestyle changes may be more challenging. In the latest survey from England, 32% of mothers reported smoking in the 12 months before or during pregnancy, but nearly half of these women gave up before or during pregnancy.w6 Only 17% of mothers continued to smoke throughout pregnancy, and this group may need extra help with smoking cessation. In a similar survey, 29% of adult women had drunk more than three units and 13% of women reported drinking more than six units on at least one day in the week before interview.w7 In 2010-11, the prevalence of illicit drug use among adults was 8.8%; 6.8% of 16-59 year olds had used cannabis in the past year and 2.1% had used cocaine.w8

Offer general health advice where appropriate including optimisation of weight and blood pressure through diet and physical activity, maintenance of good oral hygiene, compliance with cervical screening, need for vitamin D supplementation if appropriate, and screening for intimate partner violence (most prevalent in women of reproductive age) (table 1). A detailed clinical review on travel in pregnancy has been published previously.4 Advise a woman to consider travelling before, rather than during, pregnancy where possible if she has a medical condition that may deteriorate during pregnancy (such as cardiac disease) or if she intends to visit high risk areas (such as malaria endemic countries and those with high rates of traveller’s diarrhoea or other infections).

Which infections can harm the fetus?

Exposure to rubella in early pregnancy can result in congenital rubella syndrome (including sensorineural deafness, ocular abnormalities, cardiovascular defects, mental retardation, microcephaly, and spastic diplegia; table 2). Many women in developed countries will have been vaccinated as children; women from other countries may not be immunised. In the absence of a vaccination history, check for rubella antibodies and arrange subsequent vaccination if the woman is not immune.5 Advise women to avoid conception for a month after vaccination.w9

Table 2

Infections with particular impact on the fetus

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If acquired during pregnancy, varicella, cytomegalovirus, and toxoplasmosis can lead to congenital malformations in the fetus (table 2). However, the UK has no national screening programmes for prepregnancy or prenatal testing for these infections.w10 This is because the National Screening Committee in the UK has concluded that either no good quality evidence is available on the efficacy of screening or research has found that screening for a particular condition causes more harm than good.6

Consider specific viral testing (for example, for HIV, hepatitis B, or hepatitis C), if appropriate, to minimise viral load before or during pregnancy and reduce vertical transmission. The British Association for Sexual Health and HIV recommends that HIV testing be offered routinely to all adults registering in general practice in the UK in areas where the prevalence of diagnosed HIV infection is greater than two in 1000.7 Prepregnancy screening for sexually transmitted infections—such as chlamydia, gonorrhoea, and syphilis—is not routinely indicated in the UK, but there is a national programme of opportunistic screening for chlamydia (which can cause pelvic infection and difficulty in conceiving) for women under 25 years old.

Which drugs should be avoided and which are safe to continue?

A cohort study in 81 975 pregnant women from the UK general practice research database showed that 65% of participants received one or more prescriptions in the three months before and 10 weeks after conception.8 In this study, 7% of prescriptions were for US Food and Drug Administration category “X” drugs (with potential teratogenic risk that outweighs maternal benefit). The safety of these therapeutic drugs needs to be considered in women of reproductive age, to ensure that potentially teratogenic drugs are avoided if possible and that women are given correct advice on when it is safer to continue with drugs during pregnancy (table 3). Advice on teratogenicity is available from the British National Formulary and the National Teratology Information Service.9 10

Table 3

Drugs that need review

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Depending on the severity of the medical condition, the safety profile of the drug, and the period of exposure that is related to teratogenicity, some drugs may need to be stopped (for example, methotrexate, isotretinoin, and mycophenolate mofetil) or timed (for example, radioactive iodine) before conception to allow for a wash out period. Other drugs can be continued until a menstrual period is first missed, with advice for an early pregnancy test and cessation of the drug on confirmation of pregnancy (for example, angiotensin converting enzyme inhibitors used for renoprotection and warfarin used for women with a high risk of a thromboembolic event). Women who are advised to stop a drug on successful conception must be given clear advice on obtaining safe alternatives to avoid prolonged times with no appropriate treatment (for example, women who switch from warfarin to low molecular weight heparin).

Give women specific advice that it is safe and important to continue certain drugs. Examples include the continued use of steroid inhalers in asthma; immunosuppression for transplant recipients, women with inflammatory bowel disease, or those with connective tissue disorders; proton pump inhibitors for women taking steroids; and antiepileptic drugs. In these instances, discontinuing the drug may cause a flare of the underlying disease that puts the pregnancy at considerably greater risk than any theoretical risk from the drug itself.

What advice should be given to a woman with a chronic medical condition?

Substandard care in women with pre-existing medical conditions has been a recurrent theme of the report on maternal deaths from the Centre for Maternal and Child Enquiries in the UK, and the report advises prepregnancy counselling for women with epilepsy, diabetes, asthma, congenital or known acquired cardiac disease, autoimmune disorders, renal or liver disease, obesity (body mass index of 30 or more), severe pre-existing or past mental illness, and HIV infection.2 The impact of pregnancy on the disease and potential impact of the condition on the pregnancy should be considered, together with appropriate changes to drugs or levels of surveillance. Vulnerable groups such as migrant women or those with poor socioeconomic status may be particularly at risk. The box provides recommendations for prepregnancy advice for specific medical conditions.

Recommendations for prepregnancy counselling in specific medical conditions

Asthma
  • Counsel regarding the importance of good asthma control during pregnancy and that β2 agonists, inhaled steroids, and oral steroids are safe in pregnancy

  • Avoid trigger factors (allergens such as pollen, environmental pollutants, dust, indoor mould, smoking)

Cardiac disease
  • Refer a woman with pre-existing disease to specialist centres to optimise her medical condition before pregnancy

Hypertension
  • Optimise blood pressure to reduce risk of superimposed pre-eclampsia

  • Consider changing drugs (stop angiotensin converting enzyme inhibitors or angiotensin receptor blockers at conception and switch to safer alternatives)

Epilepsy
  • Advise regarding teratogenic risks (particularly neural tube defects) of antiepileptic drugs

  • Give a higher dose of periconceptional folic acid supplements (5 mg rather than 400 µg daily)

  • Advise on benefits to the fetus of good seizure control through scrupulous adherence to drugs

  • Consider increasing the dose of certain antiepileptic drugs (particularly lamotrigine) to ensure optimal seizure control

  • Refer for regular specialist review

Diabetes
  • Advise on consequences of poor glycaemic control (congenital anomalies, miscarriage, pre-eclampsia, stillbirth)

  • Discuss benefits of tight glycaemic control through a balanced diet, appropriate treatment, and regular monitoring before and during pregnancy

  • Discuss the identification and management of hypoglycaemic episodes

  • Offer prepregnancy screening for nephropathy (urinalysis for proteinuria, measurement of serum creatinine) and retinopathy (by ophthalmological assessment)

Asthma is the most common chronic medical condition in pregnancy; reassure women that well controlled asthma does not adversely affect the outcome of pregnancy and that they should not discontinue their regular drugs.11

Cardiac disease is the leading cause of maternal deaths in the UK,2 and liaison with specialist care is essential for women with pre-existing heart disease. Women at increased risk of undetected cardiac disease (such as migrant women) require a clinical cardiovascular examination including blood pressure and urinalysis.

Women with epilepsy need specialist prepregnancy advice (box). Additional risk factors such as low socioeconomic status can predispose to poor seizure control; these women may need additional support and monitoring to ensure that their epilepsy is well controlled.

Women with type 1 and type 2 diabetes are at risk of complications.12 Women with type 2 diabetes may not be under specialist review, but a population based cohort reported that they have the same risk of adverse pregnancy outcomes and require the same level of prepregnancy counselling as those with type 1 diabetes (box). In a systematic review, preconception care (including improving glycaemic control to keep glycated haemoglobin (HbA1c) at 53 mmol/mol or lower; educating patients; screening for complications; using contraception until tighter control is achieved; supplementing with folic acid) was shown to reduce congenital malformations, preterm delivery, and perinatal mortality, with a parallel reduction in first trimester HbA1c.13 Treatment with metformin is now often continued throughout pregnancy.14

Normal concentrations of maternal thyroid hormone are essential for fetal brain development; a recent review summarised the evidence that untreated maternal hypothyroidism is associated with lower IQ in children.15 Check thyroid function tests in women with known hypothyroidism who are planning a pregnancy to ensure that thyroid stimulating hormone is within the normal range. A randomised controlled trial of population based thyroid screening (at 15 weeks’ gestation) and treatment of women found to have hypothyroidism found no benefit on childhood cognitive function,16 so universal screening is not recommended.

Specialists managing women with other chronic conditions (renal disease, gastroenterological disease, and liver disease; neurological and autoimmune disorders; HIV infection) need to offer prepregnancy advice proactively, including discussion of risks, management of drugs, optimisation of the condition, and surveillance that will be needed during pregnancy.

Why is prepregnancy advice important to women with mental health disorders?

In the past, the risks of deterioration of psychiatric disorders in pregnancy and the impact on maternal deaths (particularly suicide) were poorly appreciated. More recently, the need for identification and appropriate management of such women has been recognised, largely due to capture of data for the report on maternal deaths from the Centre for Maternal and Child Enquiries in the UK.2 Prepregnancy counselling includes review of drugs and symptoms and referral to psychiatric services as needed. The most recent report on maternal deaths recommends that general practitioners be aware of the risks and refer women for specialist psychiatric input. The need to recognise the increased risk of suicide (either related to a history of psychiatric disorder or substance misuse) is also emphasised.2 Assess smoking, alcohol intake, and substance misuse and provide specific advice and support to help women reduce these behaviours. Input from a multidisciplinary team (mental health nurse, general practitioner, and psychiatrist) before pregnancy may help prepare women for the additional vulnerabilities of pregnancy and the postpartum period.

When should women with a pre-existing medical condition conceive?

In women with certain medical conditions, conception during a period of disease quiescence or stability is associated with improved pregnancy outcome. This includes women with lupus nephritis,17 recipients of a liver or renal transplant,18 19 and women with inflammatory bowel disease.20

Should prepregnancy genetic screening be carried out?

Genetic screening includes testing asymptomatic carriers who might be at increased risk of a disease because of their ethnicity or familial ancestry and screening women with a known genetic disease who may pass on the mutation to the fetus. The consequences of offering genetic screening must first be discussed with the woman (for example, an offer of termination of pregnancy for an affected fetus diagnosed through invasive testing such as amniocentesis or chorionic villus sampling, or preimplantation genetic diagnosis for a small number of conditions).

The cystic fibrosis gene is most commonly carried by people of white European descent, with about one in 25 carrying one of the mutations. A prenatal screening policy for cystic fibrosis in the UK is currently under consideration. In the US, the American Congress of Obstetricians and Gynecologists’ committee on genetics recommends screening for the 23 most common mutations for cystic fibrosis (of 1700 identified) in all women of reproductive age.21

Screening for sickle cell disease and thalassaemia in the antenatal period was implemented in 2005 by the National Screening Committee in the UK.22 In areas of high prevalence of sickle cell disease (≥1.5/10 000 pregnancies), all pregnant women are offered screening, whereas in areas of low prevalence (<1.5/10 000 pregnancies), screening is undertaken after using the family origin questionnaire. Evaluation of red cell indices is used to screen for thalassaemia. Prepregnancy screening for sickle cell disease or thalassaemia is not routine in the UK, but some couples may request screening to increase the chance of conceiving a non-affected child (for example, through preimplantation genetic diagnosis or artificial insemination by a donor).

The UK National Screening Committee recommends additional screening for certain population groups, such as Ashkenazi Jews, who are at increased risk of Tay-Sachs disease, a life threatening metabolic disorder.w10 In all cases where screening is offered, appropriate genetic counselling is needed to explain and provide information for a couple about their reproductive options.

Some women may also have a known genetic mutation, either as an asymptomatic carrier (for example, haemophilia) or as an affected person (for example, achondroplasia). Offer these women access to specialist genetic counselling services before pregnancy, to enable mutation testing where appropriate and a discussion of choices for pregnancy.

What is the best way to get pregnant?

In couples who do not use contraception and have regular sexual intercourse, conception rates are 84% within one year and 92% by the end of the second year.23 Sexual intercourse every two to three days optimises the chances of getting pregnant; couples do not need to time intercourse with ovulation because this often causes undue stress and does not increase the chances of success. Conception rates may be lower in women who do not have a regular menstrual cycle.24 One in six couples will not have achieved a pregnancy after a year of unprotected intercourse; consider referral for investigation of fertility and possible assisted reproductive techniques at this stage.

What is the evidence that prepregnancy health promotion works?

Several studies have evaluated prepregnancy health promotion; a systematic review assessed four trials that looked at interventions of brief advice, health education, and lifestyle education against usual care or no specific care.25 Although health interventions seemed to have some effects on maternal behaviour (such as a lower rate of binge drinking), there was little evidence of improved pregnancy outcome (evaluated in only one trial). The authors concluded that more research was needed in this area and that, in view of the high unplanned pregnancy rate, consideration needed to be given to reaching all women of reproductive age. The Centre for Maternal and Child Enquiries’ report, however, has emphasised the importance of prepregnancy counselling for women with a medical condition.2 We now need to increase our understanding of those components of prepregnancy advice that are most likely to improve outcomes, and of the best means of implementing effective interventions.

Ongoing research and questions for future research

  • PRAMS (Pregnancy Risk Assessment Monitoring System) is a surveillance project of the Centers for Disease Control and Prevention and state health departments, which is collecting state specific population based data on maternal attitudes and experiences before, during, and shortly after pregnancy (www.cdc.gov/prams/)

  • What is the best way to offer prepregnancy care so that it reaches the greatest number of women and those with most need? Should it be part of routine contraceptive care?

  • What might motivate a higher proportion of women of reproductive age to plan a pregnancy and follow recommendations to optimise outcome? Should any such effort be part of sex and relationship education at school?

  • What is the best way of monitoring the use of therapeutic drugs in pregnancy through a national registry system?

  • What is the effect of offering routine genetic screening for mutations most common in a particular population?

  • Do prepregnancy and peripregnancy vitamin D supplements benefit pregnancy outcomes in some ethnic groups?

  • What is the best way to ensure that ethnic minority groups have adequate periconceptional intake of folic acid?

Additional educational resources

Resources for healthcare professionals
  • UK National Screening Committee (URL here)—Database for screening policy

  • Health Protection Agency (URL here)—Information on infectious diseases in relation to pregnancy

  • Confidential Enquiry into Maternal and Child Health (URL here)—Mission statement of the Centre for Maternal and Child Enquiries

  • Royal College of Obstetricians and Gynaecologists (URL here)—Guidelines on a variety of topics related to prepregnancy care (such as weight management) and pregnancy (such as vitamin supplementation and infections in pregnancy)

  • American Congress of Obstetricians and Gynecologists (URL here)—ACOG committee opinion no 313, 2005. The importance of preconception care in the continuum of women’s health care

Resources for patients
  • NHS Choices. Getting pregnant (URL here)—NHS pregnancy and baby guide

  • Centers for Disease Control and Prevention (URL here)—Getting ready for a healthy pregnancy: advice on preconception care, sexual health, and women’s health in general

  • Tommy’s (URL here)—Getting pregnant: tips for planning a pregnancy from this UK charity dedicated to pregnancy problems

  • March of Dimes (URL here)—Get ready for pregnancy: advice on preconception care from a global charitable organisation

Notes

Cite this as: BMJ 2012;344:e3467

Footnotes

  • Contributors: SS performed the literature search and wrote the initial draft. LCC revised this and further drafts. PO and CN-P provided further contributions and revised subsequent drafts. All authors approved the final version. LCC is guarantor.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; externally peer reviewed.

References