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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

1. Preventive activities prior to 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

Every woman of reproductive age should be considered for preconception care (C). This consists of interventions that aim to identify and modify biomedical, behavioural and social risks to a woman’s health or pregnancy outcome through prevention and management.1 Preconception care should include reproductive planning and the effective use of contraception to prevent unplanned pregnancy (A), smoking cessation (A)2 and advice to consider abstinence from alcohol (especially if planning a pregnancy, or if the woman could become pregnant or is in the early stages of pregnancy),3 folic acid and iodine supplementation (A),4,5 nutrition and weight assessment,6 review of immunisation status (C),7 medications (B),8 oral health,9 and chronic medical conditions, especially glucose control in patients with diabetes (B).10

There is evidence to demonstrate improved birth outcomes with preconception healthcare in women with diabetes, phenylketonuria and nutritional deficiency,11 as well as benefit from the use of folate supplementation12 and a reduction in maternal anxiety.13 Below is information about all the potential interventions in preconception care that expert groups have recommended (C).

What does preconception care include?

Medical issues

Reproductive life plan

Assist your patients to develop a reproductive life plan that includes whether they want to have children. If they do, discuss the number, spacing and timing of intended children, and provide effective contraception to enable the implementation of this plan and reduce the risk of an unplanned pregnancy. If relevant, discuss reduction in fertility with advancing maternal age.

Reproductive history

Ask if there have been any problems with previous pregnancies such as infant death, fetal loss, birth defects (particularly neural tube defects [NTD]), low birth weight, preterm birth, or gestational diabetes. Also, if there are any ongoing risks that could lead to a recurrence in a future pregnancy.

Medical history

Ask if there are any medical conditions that may affect future pregnancies. Are chronic conditions such as diabetes, thyroid disease, hypertension, epilepsy and thrombophilia well managed? Consider if current management is optimal for early pregnancy given that early embryogenesis will occur prior to any consultation in pregnancy.

Medication use

Review all current medications for teratogenic effects, including over-the-counter medications, vitamins and supplements.

Genetic/family history (also refer to Chapter 2. Genetic counselling and testing)

Increased frequency of intellectual disability, multiple pregnancy losses, stillbirth or early death, and children with congenital abnormalities may suggest the presence of genetically determined disease. Patients of particular ethnic backgrounds may be at increased risk and can benefit from genetic testing for specific conditions. Possible consanguinity (eg cousins married to each other) should be explored, for example, by asking, ‘Is there any chance that a relative of yours might be related to someone in your partner’s family?’ General practitioners (GPs) should consider referral to, or consultation with, a genetic service for testing because test results, which rely on sensitivity, specificity and positive predictive value, are not straightforward. Testing often involves complex ethical, social and legal issues. The time on waiting lists for genetic services is usually longer than one month, so direct consultation and liaison by telephone are necessary when the genetic advice could affect a current pregnancy. Provide opportunity for carrier screening for genetic conditions (eg cystic fibrosis, haemoglobinopathies) and referral for genetic counselling based upon risk factors.

General physical assessment

Conduct a breast examination and, if it is due, perform a cervical screening test (eg Papanicolaou [Pap] test) before pregnancy. Also assess body mass index (BMI) and blood pressure (BP), and check the oral cavity.

Substance use

Ask about tobacco, alcohol and illegal drug use. Offer counselling and referral for specialised assistance when use is identified.

Vaccinations

The need for vaccination, particularly for hepatitis B, rubella and varicella, should be assessed as part of any pre‐conception health check. Vaccinations can prevent some infections that may be contracted during pregnancy, and relevant serological testing can be undertaken to ascertain immunity to hepatitis B and rubella. Routine serological testing for varicella does not provide a reliable measure of vaccine-induced immunity; however, it can indicate whether natural immunity has occurred due to prior infection. Women receiving live viral vaccines such as measles, mumps and rubella (MMR) and varicella should be advised against becoming pregnant within 28 days of vaccination. It is also important that women of child‐bearing age who present for immunisation should be questioned regarding the possibility of pregnancy as part of the routine pre-vaccination screening, to avoid inadvertent administration of a vaccine(s) not recommended in pregnancy (refer to Section 2.1.4 Pre‐vaccination screening in the Australian immunisation handbook, 10th edn). Recommended preconception vaccinations are:

  • MMR
  • varicella (in those without a clear history of chickenpox or who are non-immune on testing)
  • influenza (recommended during pregnancy)
  • diphtheria, tetanus, acellular pertussis (dTpa; to protect newborn from pertussis).

Lifestyle issues

Family planning

Based on the patient’s reproductive life plan (refer to above), discuss fertility awareness and how fertility reduces with age, chance of conception, the risk of infertility, and fetal abnormality. For patients not planning to become pregnant, discuss effective contraception and emergency contraceptive options.

Folic acid supplementation

Women should take a 0.4–0.5 mg per day supplement of folic acid for at least one month prior to pregnancy, and for the first three months after conception. Where there is a known increased risk of NTD (ie patients taking anticonvulsant medication, or with pre-pregnancy diabetes mellitus, previous child or family history of NTD, 5-methyltetrahydrofolate deficiency or BMI >30 kg/m2) or a risk of malabsorption, a 5 mg daily dose is recommended.14

Iodine supplementation

Women who are pregnant, breastfeeding or considering pregnancy should take an iodine supplement of 150 μg each day.5

Healthy weight, nutrition and exercise

Discuss weight management and caution against being overweight or underweight. Recommend regular, moderate-intensity exercise and assess risk of nutritional deficiencies (eg vegan diet, lactose intolerance, and calcium, iron or vitamin D deficiency due to lack of sun exposure).

Psychosocial health

Discuss perinatal mental health, including anxiety and depression, pre‐existing mental health conditions, psychological or psychiatric assessment and treatment, use of medication, and the risk of exacerbation of mood disorders in pregnancy and postpartum. Mental health screening should include a psychosocial assessment.

Smoking, alcohol and illegal drug cessation (as indicated)

Smoking,15 illegal drug16 and excessive alcohol use17 during pregnancy can have serious consequences for an unborn child and should be stopped prior to conception.

Healthy environments

Repeated exposure to hazardous toxins in the household and workplace environment can affect fertility and increase the risk of miscarriage and birth defects. Discuss the avoidance of TORCH infections: Toxoplasmosis, Other (eg syphilis, varicella, mumps, parvovirus and human immunodeficiency virus [HIV], listeriosis), Rubella, Cytomegalovirus and Herpes simplex.

  • Toxoplasmosis: Avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk products; wash all fruit and vegetables.
  • Cytomegalovirus, parvovirus B19 (fifth disease): Discuss the importance of frequent hand-washing. Those who work with children or in the healthcare sector can further reduce risk by using gloves when changing nappies.
  • Listeriosis: Avoid paté, soft cheeses (eg feta, brie, blue vein), prepackaged salads, deli meats and chilled/smoked seafood. Wash all fruit and vegetables before eating. Refer to Food Standards Australia New Zealand regarding folate, listeria and mercury.
  • Fish: Limit fish containing high levels of mercury
Table 1.1. Preconception: Preventive interventions
InterventionTechniqueReferences
Folate supplementation Most women: 0.5 mg/day supplementation, beginning ideally at least one month prior to conception and continuing for the first trimester
High-risk women: 5 mg/day supplementation, ideally beginning at least one month prior to conception and continuing for the first trimester
4, 18-20
Iodine supplementation All women who are pregnant, breastfeeding or considering pregnancy should take an iodine supplement of 150 μg each day 5, 14
Nutrition and weight assessment All women, especially those who become pregnant in adolescence or have closely-spaced pregnancies (interpregnancy interval less than six months), require nutritional assessment and appropriate intervention in the preconception period with an emphasis on optimising maternal body mass index (BMI) and micronutrient reserves 6, 21
Check oral cavity and referral Ask the woman if she has bleeding gums, swellings, sensitive teeth, loose teeth, holes in teeth, broken teeth, toothache, or any other problems in the mouth.
Check oral cavity to confirm. Reassure the patient that it is safe to have a range of dental treatments during pregnancy
Smoking cessation Inform women who smoke that tobacco affects fetal growth and advise them to stop smoking. Evidence exists to suggest improved cognitive ability in children of mothers who quit smoking during gestation (III, A). Consider pharmacotherapy 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 22
Alcohol and illicit drug use For women who are pregnant or planning a pregnancy, not drinking is the safest option. The risk of harm to the fetus is highest when there is high, frequent maternal alcohol intake. The risk of harm to the fetus is likely to be low if a woman has consumed only small amounts of alcohol before she knew she was pregnant. Inform pregnant women that illicit drugs may harm the fetus and advise them to avoid use 1
Interpregnancy interval Perinatal outcomes are worse with interpregnancy intervals less than 18 months or more than 59 months; the outcomes affected are preterm birth, low birth weight and small size for gestational age 23
Chronic diseases Optimise control of existing chronic diseases (eg diabetes, hypertension, epilepsy). Avoid teratogenic medications 18
BMI, body mass index

Health inequity

What are the key equity issues and who is at risk?

Preconception care is especially important to adolescents and young women in vulnerable populations.24 Adolescent parenthood is more common in low socioeconomic groups and Aboriginal and Torres Strait Islander communities, and is associated with poor birth outcomes and adverse health effects, including mental health issues and substance misuse.25–29

Decreased folate supplementation is associated with being a woman from a lower socioeconomic group, being an Aboriginal and Torres Strait Islander person, or being younger or from a rural area.30 Awareness of folic acid is related to income, educational level and younger age.31,32 Other dietary supplements may follow similar gradients.

Smoking and alcohol use in pregnancy show socioeconomic gradients. Women who are young, on a low income and of low socioeconomic status, Aboriginal and Torres Strait Islander women, single mothers, and women experiencing addiction, violence and mental health issues are all more likely to smoke during pregnancy.33,34

Women from culturally and linguistically diverse (CALD) backgrounds are more likely to experience poorer perinatal outcomes.36–38

What can GPs do?

  • Provide youth-friendly care to adolescent parents through non-judgemental, competent, considerate and respectful advice and services.39
  • Offer women culturally appropriate resources, including in the mother’s own language, about health issues and the health system, and consider the use of interpreters.
  • Link women into English language and perinatal education courses, and offer cultural brokerage through maternity liaison officers or bilingual health workers wherever possible.39
  • Refer to ‘Antenatal care for Aboriginal and Torres Strait Islander women’ in the Australian Health Ministers’ Advisory Council’s Clinical practice guidelines: Antenatal care - Module 1.39
  • Refer to the general principles of providing patient education and supporting health literacy in disadvantaged groups.

References

  1. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care – United States. MMWR Recomm Rep 2006;55(RR-6):1–23.
  2. Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2009;3:CD001055.
  3. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC, 2009.
  4. Lumley J, Watson L, Watson M, Bower C. Periconceptual supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database Syst Rev 2001;3:CD001056.
  5. National Health and Medical Research Council. Iodine supplementation for pregnant and breastfeeding women. Canberra: NHMRC, 2010 [Accessed 8 December 2015].
  6. Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception care: Nutritional risks and interventions. Reprod Health 2014;11 Suppl 3:S3.
  7. Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook. 10th edn (2015 update). Canberra: Department of Health, 2015.
  8. Australian Department of Health and Aged Care. Prescribing medicines in pregnancy. 4th edn. Canberra: Therapeutic Goods Administration, 1999.
  9. Rogers JG. Evidence-based oral health promotion resource. Melbourne: Prevention and Population Health Branch, Department of Health, 2011.
  10. Korenbrot CC, Steinberg A, Bender C, Newberry S. Preconception care: A systematic review. Matern Child Health Journal 2002;6(2):75–88.
  11. Gjerdingen DK, Fontaine P. Preconception health care: A critical task for family physicians. J Am Board Fam Pract 1991;4(4):237–50.
  12. Hodgetts VA, Morris RK, Francis A, Gardosi J, Ismail KM. Effectiveness of folic acid supplementation in pregnancy on reducing the risk of small-for-gestational age neonates: A population study, systematic review and meta-analysis. BJOG 2015;122(4):478–90.
  13. de Jong-Potjer LC, Elsinga J, le Cessie S, et al. GP-initiated preconception counselling in a randomised controlled trial does not induce anxiety. BMC Fam Pract 2006;7:66.
  14. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Vitamin and mineral supplementation and pregnancy (C-Obs 25), November 2014, amended May 2015. East Melbourne, Vic: RANZCOG, 2015 [Accessed 5 September 2015].
  15. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Women and smoking (C-Obs 53). East Melbourne, Vic: RANZCOG, 2011 [Accessed 27 May 2016].
  16. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Substance use in pregnancy (C-Obs 55). East Melbourne, Vic: RANZCOG, 2013. Available at www.ranzcog.edu.au/college-statements-guidelines.html [Accessed 27 May 2016].
  17. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Alcohol in pregnancy (C-Obs 54). East Melbourne, Vic: RANZCOG, 2014. Available at www.ranzcog.edu.au/college-statements-guidelines.html [Accessed 27 May 2016].
  18. National Institute for Health and Care Excellence. Diabetes in pregnancy: Management of diabetes and its complications from preconception to the postnatal period. London: NICE, 2015.
  19. Wilson RD, Johnson JA, Wyatt P, et al. Pre-conceptional vitamin/folic acid supplementation 2007: The use of folic acid in combination with a multivitamin supplement for the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can 2007;29(12):1003–26.
  20. US Preventive Services Task Force. Guide to clinical preventive services: Report of the US Preventive Services Task Force. 2nd edn. Alexandria, VA: Williams & Wilkins, 2002.
  21. Opray N, Grivell RM, Deussen AR, Dodd JM. Directed preconception health programs and interventions for improving pregnancy outcomes for women who are overweight or obese. Cochrane Database Syst Rev 2015;7:CD010932.
  22. The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. Melbourne: RACGP, 2011.
  23. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: A meta-analysis. JAMA 2006;295:1809–23.
  24. Hanson MA, Gluckman PD, Ma RCW, Matzen P, Biesma RG. Early life opportunities for prevention of diabetes in low and middle income countries. BMC Public Health 2012;12.
  25. Hodgkinson S, Beers L, Southammakosane C, Lewin A. Addressing the mental health needs of pregnant and parenting adolescents. Pediatrics 2014;133(1):114–22.
  26. Payne NA, Anastas JW. The mental health needs of low-income pregnant teens: A nursing-social work partnership in care. Research on Social Work Practice 2015 Sep;25(5):595–606.
  27. Penman-Aguilar A, Carter M, Snead MC, Kourtis AP. Socioeconomic disadvantage as a social determinant of teen childbearing in the US Public Health Reports 2013; 128:5–22.
  28. Hilder L, Zhichao Z, Parker M, Jahan S, Chambers G. Australia’s mothers and babies 2012. Canberra: Australian Institute of Health and Welfare, 2014.
  29. Middleton P. Preventing infant deaths among Aboriginal and teenage women in South Australia. Adelaide: The Strategic Health Research Program Team, The University of Adelaide, 2009.
  30. Australian Institute of Health and Welfare. Mandatory folic acid and iodine fortification in Australia and New Zealand: Baseline report for monitoring. Canberra: AIHW, 2011.
  31. Hage CN, Jalloul M, Sabbah M, Adib SM. Awareness and intake of folic acid for the prevention of neural tube defects among Lebanese women of childbearing age. Matern Child Health 2012;16(1):258–65.
  32. Rasmussen MM, Clemmensen D. Folic acid supplementation in pregnant women. Dan Med Bull 2010;57(1):A4134
  33. Borland T, Babayan A, Irfan S, Schwartz R. Exploring the adequacy of smoking cessation support for pregnant and postpartum women. BMC Public Health 2013;13:472
  34. Cui Y, Shooshtari S, Forget EL, Clara I, Cheung KF. Smoking during pregnancy: Findings from the 2009–2010 Canadian Community Health Survey. PLOS ONE 2014;9(1):e84640
  35. Burns L, Breen C, Bower C, O’ Leary C, Elliott EJ. Counting fetal alcohol spectrum disorder in Australia: The evidence and the challenges. Drug Alcohol Rev 2013;32(5):461–67.
  36. Laws P, Li Z, Sullivan E. Australia’s mothers and babies 2008. Canberra: Australian Institute of Health and Welfare, 2010.
  37. O’Mahony JM, Donnelly TT. How does gender influence immigrant and refugee women’s postpartum depression help-seeking experiences? J Psychiatr Ment Health Nurs 2013;20(8):714–25.
  38. O’Mahony JM, Donnelly TT, Bouchal SR, Este D. Cultural background and socioeconomic influence of immigrant and refugee women coping with postpartum depression. J Immigr Minor Health 2013;15(2):300–14.
  39. Australian Health Ministers’ Advisory Council. Clinical practice guidelines: Antenatal care – Module 1. Canberra: Department of Health and Ageing, 2012.
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