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.
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.
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.
Review all current medications for teratogenic effects, including over-the-counter medications, vitamins and supplements.
(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.
Ask about tobacco, alcohol and illegal drug use. Offer counselling and referral for specialised assistance when use is identified.
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:
- 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).
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
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).
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.
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
Preconception: Preventive interventions