Preconception care seeks to
ensure optimal health for all women of childbearing age before a first
pregnancy or between pregnancies (also known as interconception care).
Preconception care involves identifying and managing health issues that may
pose a risk to mothers or infants and that require action before conception or
very early in pregnancy for maximal impact.1,2 As approximately
half of all pregnancies in the United States are unplanned, preconception care
(including risk screening, health promotion, and effective interventions)
should be viewed as part of routine health care rather than a single clinical
Goals and Recommendations
In 2006, the
Centers for Disease Control and Prevention (CDC) Preconception Care Work Group
and the Select Panel on Preconception Care (SPPC) developed four overarching
goals to improve preconception health and health care in the U.S. (TABLE 1)
and 10 recommendations to achieve those four goals (TABLE 2).4,5
The recommendations utilize both clinical care and public health strategies to
encourage the best possible health for a woman throughout her lifespan.4
Due to the many
publications focusing on preconception care in the past few years, several
sets of recommendations have emerged. Although each set is slightly different,
there is significant overlap between them. Utilizing clinical practice
guidelines and evidence-based data, the CDC and the SPPC compiled a list of 14
recommendations for preconception care (TABLE 3).4-6 The
American College of Obstetricians and Gynecologists and the American Academy
of Pediatrics have further defined four main categories for these 14
interventions: 1) maternal assessment, 2) screening, 3) vaccinations, and 4)
About one in 100 women of
childbearing age in the U.S. has diabetes before pregnancy, referred to as pregestational
diabetes. If the mother's pregestational diabetes is poorly controlled in
early pregnancy, her baby is three to four times more likely to have a
congenital heart defect or neural tube defect than the baby of a woman without
diabetes. Other risks to the fetus include stillbirth, miscarriage, premature
birth, and newborn complications such as jaundice. Because of the risks
associated with poorly controlled pregestational diabetes, women should
consult with their health care providers for optimal disease state management
before conception, maintaining good glycemic control before and during
pregnancy. These women should also receive nutritional counseling specific to
the management of diabetes during pregnancy.5,
Women with hypothyroidism
should make their health care providers aware of their intention to conceive.
Untreated overt hypothyroidism increases the likelihood of spontaneous
abortion, stillbirth, low birth weight, and certain pregnancy complications
such as maternal hypertension. While levothyroxine therapy is safe during
pregnancy, the mother's dose of levothyroxine must be adjusted during
pregnancy for proper fetal neurologic development. As a women's thyroid
function may change during pregnancy, more frequent monitoring of serum
thyroid-stimulating hormone (TSH) levels may be warranted. The American
Association of Clinical Endocrinologists recommends routinely screening women
for thyroid dysfunction by obtaining TSH measurements before pregnancy or
during the first trimester.5,8
With newborn screening, most patients with phenylketonuria (PKU) are
identified at a very early age and can successfully manage the disease through
dietary restrictions. Approximately 3,000 women of childbearing age in the
U.S. were diagnosed with PKU in infancy. Most of these women have relaxed
their dietary restrictions in adulthood and therefore have increased levels of
phenylalanine. It is essential that women with PKU adhere to the dietary
restrictions at least three months prior to conception and throughout
pregnancy to avoid negative consequences to the fetus, such as mental
retardation, microcephaly, and congenital heart defects.5,7
Oral Anticoagulant Use:
Warfarin is known to be teratogenic, with the potential to cause a
characteristic embryopathy if exposure occurs during the first trimester.
Exposure after the first trimester may result in fetal central nervous system
(CNS) abnormalities or bleeding, although these complications occur less
frequently. Before conception, each woman receiving warfarin should seek
advice from her health care provider regarding the appropriate anticoagulation
therapy required during her pregnancy, including the possibility of switching
to a nonteratogenic agent to avoid exposure to warfarin during early pregnancy.5,9
Antiepileptic Drug Use:
Epilepsy affects approximately 1% of the U.S. population, representing an
estimated 1 million women of childbearing potential. Certain antiepileptic
drugs (AEDs), such as valproic acid, are known teratogens. The risk of
teratogenic effects also increases with polytherapy and higher doses of these
drugs. Women with epilepsy should consult with their health care provider as
to whether the AED regimen should be altered before conception.5,10
The CDC and the SPPC indicated that "recommendations suggest that women who
are on a regimen of these drugs and who are contemplating pregnancy should be
prescribed a lower dosage of these drugs."5
Isotretinoin, approved by the FDA for the treatment of severe recalcitrant
nodular acne, is marketed under the brand names Accutane, Amnesteem, Claravis,
and Sotret. Isotretinoin is contraindicated during pregnancy, as it has been
shown to cause birth defects such as ear, eye, and heart abnormalities; cleft
lip or palate; microcephaly; hydrocephalus; and mental retardation. Use during
pregnancy also increases the risk of infant death, premature delivery, and
miscarriage. Women of childbearing age who use isotretinoin should ensure
effective pregnancy prevention by utilizing two forms of contraception. Men
and women receiving isotretinoin must register with a risk management program
known as iPLEDGE.5,7
As part of routine
medical care, the CDC recommends that all individuals aged 13 to 64 years be
screened for HIV. There are approximately 120,000 to 160,000 women with HIV in
the U.S.; about 80% are of childbearing age. Since many women do not realize
that they are infected, routine screening assists in the identification of HIV
before conception. As a result, appropriate treatment can be initiated and
women can be educated regarding the timing of conception.5,7
Infections: It is
estimated that each year 19 million individuals in the U.S. contract a
sexually transmitted infection (STI). STIs have the potential to cause fetal
death, stillbirth, miscarriage, or physical and developmental disabilities
such as mental retardation and blindness. Early screening and treatment can
help to prevent these adverse outcomes.5,7
If a pregnant woman becomes infected with the rubella virus in the first or
second trimester, her baby may be born with congenital rubella syndrome (birth
defects of the eye, ear, heart, and/or CNS). The infection may also cause
miscarriage or stillbirth. Most women of childbearing age in the U.S. are
seropositive for rubella (either through vaccination or previous infection);
about 10% are susceptible to the disease. Although the incidence of
rubella in the U.S. has sharply decreased over the last few decades, cases
continue to be introduced through international travel. Therefore, it is
important that all women be tested for immunity to rubella before conception.
Women without immunity should consider vaccination and should delay attempting
to conceive for 28 days after vaccination. The vaccine is not recommended for
pregnant women; rather, the woman should be closely monitored and instructed
to avoid individuals with the disease and should be vaccinated after delivery.5,7
Prior to the availability
of the hepatitis B virus (HBV) vaccine, an estimated 30% to 40% of chronic
infections were believed to have resulted from perinatal or early childhood
transmission. Therefore, it is advised that women (and men) who are at risk
for contracting HBV infection through mucosal or percutaneous exposure to
blood or through sexual transmission receive vaccination to avoid the
long-term consequences of HBV and prevent transmission to the fetus.5,11
Adequate folic acid intake at least four weeks before conception and during
the first trimester of pregnancy has been shown to reduce the risk of neural
tube defects by 50% to 70%. Therefore, it is recommended that all women of
childbearing potential consume 400 mcg (0.4 mg) of folic acid daily. Food
sources include orange juice, peanuts, dark green leafy vegetables, and
fortified grains and pastas. Since many times it is difficult to obtain the
recommended amount from diet alone, women of childbearing potential should be
encouraged to take a multivitamin with 400 mcg of folic acid daily. Women with
a higher risk of having a baby with a neural tube defect may be advised to
take up to 4,000 mcg of folic acid daily in the preconception period and
Smoking has been
associated with adverse perinatal outcomes such as preterm birth and low birth
weight. Smoking also has well-documented negative consequences on maternal
health. In the U.S., at least 10% of women smoke while pregnant. Only 20% of
women who smoke at the time of conception are able to successfully quit
smoking during pregnancy; therefore, women who smoke should be encouraged to
stop before conception. Education is a key component, as data presented by the
March of Dimes suggest that understanding the harmful effects of smoking is an
important determinant of whether a woman will quit smoking during pregnancy.
In addition, utilization of a counseling approach known as "The 5 As" (Ask,
Advise, Assess, Assist, and Arrange) has demonstrated improved smoking
cessation rates among pregnant women.5,7
Alcohol and Other
Recreational Drug Misuse:
Use of alcohol or other recreational drugs during pregnancy can harm the
developing fetus. For example, alcohol intake during pregnancy may result in
fetal alcohol spectrum disorder (effects such as birth defects; learning,
emotional, or behavioral problems; or mental retardation). The most severe
outcome is fetal alcohol syndrome. An estimated 13% of pregnant women consume
alcohol, and up to 40,000 babies are born each year negatively impacted by a
form of alcohol-related sequelae.5,7
It is important that women
planning pregnancy refrain from drinking any amount of alcohol. If a woman
suspects she is pregnant, she should also discontinue use of alcohol.
Likewise, other recreational drugs should not be used at any time during
pregnancy due to the potential negative consequences to the fetus.5,7
About 20% of women of childbearing age in the U.S. are obese (body mass index >=30).
Maternal obesity can lead to adverse perinatal outcomes such as fetal or
infant death, birth defects (especially neural tube defects), or labor and
delivery compilations, as well as maternal complications such as hypertension
or gestational diabetes. Before conception, women should be counseled
regarding appropriate weight loss and nutritional intake to reduce these risks.5,7
Preconception Health Issues
considerations for men as well in the preconceptional period. A man's family
health history is significant when planning pregnancy, as it, along with
maternal family health history, allows for a comprehensive review of genetic
risks. Men should be screened for STIs and treated appropriately to mitigate
transmission to their partners. Men should not smoke around their partners to
avoid the harmful effects of second-hand smoke. Occupational exposures to
chemicals or toxins may affect spermatogenesis and male fertility; men should
also be careful to avoid exposing their partners to these hazards. Men should
be educated about these risks and about ways to reduce their impact in order
to optimize pregnancy outcomes.12
care--between pregnancies--is a subset of preconception care. As indicated in
goal 3 and recommendation 5 from the CDC and the SPPC, interconception care
should be provided to women who have previously experienced an adverse fetal
outcome. During this period, targeted interventions should be performed.4
preconception care, women of childbearing age are encouraged to maintain good
health for themselves. Preconception care also helps women prepare for a
healthy pregnancy.4 As pharmacists, we have a unique opportunity to
impact the provision of preconception care through counseling and educating
women and prescribers about preconception health.
1. Biermann J, Lang
Dunlop A, Brady C, et al. Promising practices in preconception care for women
at risk for poor health and pregnancy outcomes. Matern Child Health J.
2. Preconception health
and care, 2006. Centers for Disease Control and Prevention.
April 20, 2008.
3. Henshaw SK.
Unintended pregnancy in the United States. Fam Plan Perspect.
4. Centers for Disease
Control and Prevention. Recommendations to improve preconception health and
health care--United States: a report of the CDC/ATSDR Preconception Care Work
Group and the Select Panel on Preconception Care. MMWR. 2006;55:1-22.
5. Kent H, Johnson K,
Curtis M, et al. Proceedings of the preconception health and health care
clinical, public health, and consumer workgroup meetings. Centers for Disease
Control and Prevention; June 27-28, 2006; Atlanta, GA.
Accessed April 20, 2008.
6. Preconception care
questions and answers. Professionals. CDC.
www.cdc.gov/ncbddd/preconception/QandA_providers.htm. Accessed April 20, 2008.
7. Preconception risk
reduction. March of Dimes. www.marchofdimes.com/professionals/19695.asp.
Accessed April 29, 2008.
8. AACE Thyroid Task
Force. American Association of Clinical Endocrinologists medical guidelines
for clinical practice for the evaluation and treatment of hyperthyroidism and
hypothyroidism. 2006 amended version.
www.aace.com/pub/pdf/guidelines/hypo_hyper.pdf. Accessed April 29, 2008.
9. Hirsh J,
Fuster V, Ansell J, Halperin JL. American Heart Association/American
College of Cardiology Foundation guide to warfarin therapy. Circulation.
10. Practice parameter
management issues for women with epilepsy. Summary statement, 1998. American
Academy of Neurology.
Accessed April 29, 2008.
11. Centers for Disease
Control and Prevention. A comprehensive immunization strategy to eliminate
transmission of hepatitis B virus infection in the United States:
recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR.
12. Preconception care
questions and answers. General public. CDC.
www.cdc.gov/ncbddd/preconception/QandA.htm#5. Accessed April 20, 2008.
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