Preventive activities before pregnancy
| Age | - 2 | 2 - 3 | 4 - 9 | 10 - 14 | 15 - 19 | 20 - 24 | 25 - 29 | 30 - 34 | 35 - 39 | 40 - 44 | 45 - 49 | 50 - 54 | 55 - 59 | 60 - 64 | 65+ |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 17 | X | X | X | X | X | X |
Every woman aged 15–49 years should be considered for preconception care (C). Preconception care is a set of interventions that aim to identify and modify biomedical, behavioral and social risks to a woman’s health or pregnancy outcome through prevention and management.45 This should include smoking cessation (A)46 and advice to consider abstinence from alcohol (especially in the early stages of pregnancy),47 folic acid supplementation (A),48 review of immunisation status (C),49 medications (B),50 and chronic medical conditions, especially glucose control in patients with diabetes (B).51
There is evidence to show improved birth outcomes with preconception health care in women with diabetes, phenylketonuria and nutritional deficiency,52 as well as benefit from the use of folate supplementation and a reduction in maternal anxiety.53 The following table lists the potential interventions recommended by expert groups in preconception care (C).
What does preconception care include?
Medical issues
Reproductive life plan
Assist your patient in developing a reproductive life plan that includes whether they want
to have children and if so, discuss the number, spacing and timing of children.
Reproductive history
Have there been any problems with previous pregnancies such as infant death, fetal loss, birth
defects, low birth weight, preterm birth, or gestational diabetes? Are there any ongoing risks that could lead to a recurrence in any future pregnancy?
Medical history
Are there any medical conditions that may affect future pregnancies? Are chronic conditions
such as diabetes, thyroid disease, hypertension, epilepsy and thrombophilias well managed?
Medication use
Review all current medications, including over-the-counter medications, vitamins and supplements.
Genetic/family history
Assess risk of chromosomal/genetic disorders, based on family history/ethnic background (eg.
neural tube defects [NTD], cystic fibrosis, fragile X syndrome, Tay-Sachs disease, thalassaemia, sickle cell anaemia, and phenylketonuria).
General physical assessment
Pap test and breast examinations should be conducted before pregnancy if due or indicated
respectively. Also assess body mass index (BMI), blood pressure (BP) and ask about periodontal disease.
Substance use
Ask about tobacco, alcohol and illegal drug use.
Vaccinations
Vaccinations can prevent some infections that may be contracted during pregnancy. If previous
vaccination history or infection is uncertain, testing should be undertaken to determine immunity to varicella and rubella, so that vaccination can be provided to nonimmune women. Women
receiving live viral vaccines such as measles/mumps/rubella (MMR) and varicella should be advised against falling pregnant within 28 days of vaccination.
- If indicated, MMR and varicella (in those without a clear history of chickenpox or nonimmune on testing) should be given at least 28 days before conception
- Influenza is recommended during pregnancy to protect against infection (if in second or third trimester during influenza season)
- Diphtheria/tetanus/pertussis (to protect the newborn from tetanus or pertussis) should be considered before conception.
Lifestyle issues
Family planning
Based on the patient’s reproductive life plan, discuss fertility awareness, chance of conception
and risk of infertility and fetal abnormality. For women not planning to become pregnant, discuss effective contraception and emergency contraceptive options.
Folic acid supplementation
Women should take a 0.4–0.5 mg supplement of folic acid per day for at least 1 month before
pregnancy and for the first 3 months after conception. In women at high risk (ie. those with
a reproductive or family history of NTD, those who have had a previous pregnancy affected
by NTD, those on antiepileptics, or those who have diabetes) the dose should be increased
to 5 mg/day.
Healthy weight, nutrition and exercise
Discuss weight management and caution against being over or underweight. Recommend regular
moderate intensity exercise and assess risk of nutritional deficiencies (eg. vegan diet, lactose
intolerant, calcium or iron, vitamin D deficiency due to lack of sun exposure).
Psychosocial health
Provide support and identify coping strategies to improve your patient’s emotional health
and wellbeing.
Smoking, alcohol and illegal drug cessation (as indicated)
Smoking and illegal drug use during pregnancy can have serious consequences for an unborn
child and should be stopped before conception. There are no safe limits of alcohol consumption
during pregnancy.
Healthy environment
Repeated exposure to hazardous toxins in the household and workplace environment can
impact on fertility and increase the risk of miscarriage and birth defects. Discuss the avoidance
of TORCH infections:
- toxoplasmosis – avoid cat litter, garden soil, and raw/undercooked meat, unpasteurised milk products, wash all fruit and vegetables
- cytomegalovirus, parvovirus B19 (fifth disease) – discuss the importance of frequent hand washing (and the additional risk reduction by the use of gloves when changing nappies in child and health care workers)
- listeriosis – avoid paté, soft cheeses (eg. feta, brie, blue vein), pre-packaged salads, deli meats, and chilled/smoked seafood. Wash all fruit and vegetables before eating
- fish – limit the amount of fish containing high levels of mercury.
(See www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm for information on folate, listeria and mercury)
| Intervention | Technique | References |
|---|---|---|
| Folate supplementation |
|
48,54-56 |
| Smoking cessation | Women should be informed that tobacco affects fetal growth and all women should be advised to stop smoking. Evidence exists to suggest improved cognitive ability in children of mothers who quit smoking during gestation (III A). Pharmacotherapy should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of pharmacotherapy and potential continued smoking | 57 |
| Alcohol and illicit drug use | Women should be informed of the potential harmful effects of alcohol to the fetus and should be advised that there are no safe limits of alcohol consumption during pregnancy. Women should be informed that illicit drug use may harm the fetus and advised to avoid use | 47 |
| Inter pregnancy interval | Worse perinatal outcomes with inter pregnancy intervals <18 months or >59 months, namely pre-term birth, low birth weight and small for gestational age | 58 |
| Chronic diseases | Optimise control of existing chronic diseases (eg. diabetes, hypertension, epilepsy). Avoid teratogenic medications | 56 |
| Preconception care resources for GPs and patients | Address risk factors using Pregnancy Lifescripts. Available at www.agpn.com.au/site/index.cfm?display=24414 |
Health inequality
Less than 50% of women in Victoria and New South Wales supplement their diet with folate periconceptually. This figure is lower in:59
- women in lower socioeconomic groups
- indigenous women
- rural women
- younger women
- multiparous women.
Strategy
Refer to general principles as discussed in the introduction and as outlined in the ‘green book’.
© The Royal Australian College of General Practitioners
Printed from www.racgp.org.au/redbook