As the concept of preconception care has evolved in the health care community, several professional organizations have addressed its importance for their members, and some have developed specific guidelines or standards for preconception care.
In nursing, there are several professional organizations whose members care for reproductive age women. The AANP (American Academy of Nurse Practitioners) is the largest national professional organization for nurse practitioners of all specialties, with 15,000 members. While many nurse practitioners might be delivering preconception health services, AANP has not developed specific educational standards specific to this topical area, nor do their generic practice standards include preconception health. According to AANP Executive Director Dr. Judith Dempster (personal communication, April 11, 2005), members with questions about preconception health standards would be referred to specialty organizations such as AWHONN.
AWHONN (Association of Women’s Health, Obstetric and Neonatal Nurses) is the official professional organization for women’s health and obstetric nurses, and is comprised of 22,000 nurses whose goals are to promote excellence in nursing practice. While AWHONN does not have specific standards of care for women during the preconception period, they do offer many products to their members which discuss preconception health, including a practice monograph which outlines the importance and components of preconception care . They also publish a Clinical Position Statement which states that AWHONN supports legislation and policies that encourage women of childbearing age to consume 400 micrograms of synthetic folic acid every day . In addition, AWHONN is also a member of the National Council on Folic Acid (NCFA), a partnership of over 80 national organizations and associations, state folic acid councils and government agencies. While not strictly a preconceptional project, AWHONN developed a specific Clinical Position Statement on Smoking and Childbearing, urging nurses to screen women for tobacco use and help women stop smoking . Although nurses initiated this program during pregnancy, it had major interconceptional ramifications for the women involved, and has added to the literature on smoking cessation for women of reproductive age .
ACNM, the American College of Nurse Midwives is the professional organization for all nurse midwives in the United States, and represents over 7,000 nurse midwives who are providers of comprehensive women’s health. In their Core Competencies for Basic Midwifery Practice (www.acnm.org/prof/display.cfm?id=137) they have specific educational and practice standards for preconception health for women. These standards are:
“V. Components of Midwifery Care: The Primary Health Care of Women
B. Applies knowledge of midwifery practice in the preconception period that includes, but is not limited to, the following:
1. Assessment of individual and family readiness for pregnancy, including emotional, psychosocial and sexual factors
2. Impact of health, family and genetic history on pregnancy outcomes
3. Influence of environmental and occupational factors, health habits, and behavior on pregnancy planning
4. Health and laboratory screening to evaluate the potential for a healthy pregnancy” (p. 3)
NAPNAP (the National Association of Pediatric Nurse Practitioners) does not publish any guidelines or standards for preconception care. Their members provide services for adolescents, but the organization has not yet addressed preconception care in a structured manner (personal communication Dr. Karen Kelly Thomas, Executive Director NAPNAP, April 13, 2005). They have, however, published at least one article in their official journal on the topic .
In terms of general nursing education, the AACN (The American Association of Colleges of Nursing) does not offer specific guidelines for what is to be taught to student nurses about preconception health, but rather sets standards for overall educational goals.
Organizations for all professionals
The March of Dimes, while not an organization which targets just one type of professional, has been producing numerous materials for health care professionals about preconception health for many years. Materials and products that the March of Dimes produces for providers of care include: their nursing module Preconception Health Promotion: A Focus for Women’s Wellness , a Preconception Curriculum consisting of power point slides for Obstetricians, Family Medicine specialists, Pediatricians, and Internists which suggests that every visit to a health care provider should include elements of preconception care, a Preconception Screening and Counseling Tool, grants to the March of Dimes Chapters for preconception services, an educational program called Genetics and Your Practice (CD and online), and a Genetic screening pocket guide. Many of these can be found on their website www.marchofdimes.com, and their Spanish language website www.nacersano.org. They also produce an e-preconception newsletter (Spanish), an education program for Spanish women called Comenzando Bien, and pamphlets for patient education such as Are You Ready?, Think Ahead for a Healthy Baby, Folic Acid brochures, and Pre-Pregnancy Planning Fact Sheet.
The CDC, the March of Dimes, and the National Council on Folic Acid (NCFA) have organized a national folic acid promotion effort for the prevention of serious birth defects of the brain and spine (neural tube defects or NTDs). The goal of the effort is to teach all women about the importance of getting enough folic acid every day. The effort aims to reach every woman who could possibly become pregnant, as well as teach health care professionals and community advocacy groups about the importance of folic acid. The CDC, the March of Dimes, and NCFA have created messages, materials, websites, and other tools to reach providers and women with the folic acid message. In 2005, the CDC and March of Dimes collaborated to develop a national summit on preconception care in order to bring together all the stakeholders in the subject; this supplement issue of Maternal Child Health is one of the many consequences of these efforts by CDC/MOD.
The American Academy of Pediatrics represents 60,000 pediatricians, many of whom provide adolescent services to young women of reproductive age. They publish, along with the American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, the document which is generally accepted to be the outline for acceptable care during the perinatal period for women and infants. In the current edition, 5 pages are devoted to preconception care, which is described as “the identification of those conditions that could affect a future pregnancy or fetus, and that may be amenable to intervention (p. 73)” . The Guidelines note that all encounters with women of reproductive age should include counseling about health which could optimize pregnancy outcome. AAP is also a member of the National Organization on Fetal Alcohol Syndrome, which addresses medical school curriculum for fetal alcohol syndrome, and AAP supports numerous state-wide programs to enhance adolescent health before childbearing. In the American Board of Pediatrics study guide for the certifying examining for Adolescent Medicine certification, materials included are prevention of pregnancy, prevention of substance use, and general reproductive health care, all of which contribute to better preconception health (www.aap.org/sections/adol/adol.pdf).
The American Academy of Family Physicians (AAFP) represents 94,000 family physicians, residents and medical students in the United States, and sets the professional standards for care delivered by family physicians. While no specific guidelines or standards for preconception health services developed by AAFP could be located, AAFP addresses the issue of preconception care in many articles in their official journal, and in other practice venues such as suggestions to increase use of folic acid [22, 23].
CREOG is the Council on Resident Education in Obstetrics and Gynecology, and is charged with setting the educational standards for obstetricians and gynecologists in training. CREOG’s Educational Objectives are contained in its core curriculum . Regarding preconception care, CREOG’s core curriculum states: “In evaluating patients for preconceptional care, obstetrician gynecologists must assess those factors of the history, physical examination, and diagnostic studies that pregnancy would alter; assess the patient’s access to and compliance with a plan of prenatal care; and consult with or refer her to other experts on specific conditions that may arise during the pregnancy.”(p. 39). Its standards are as follows:
“ II. Antepartum Care—Preconceptional Care
1. Perform a thorough history, assessing historical and ongoing risks that my affect future pregnancy
2. Counsel a patient regarding the impact of pregnancy on maternal medical conditions.
3. Counsel a patient regarding the impact of maternal medical conditions on pregnancy
4. Counsel a patient regarding appropriate lifestyle modification conducive to favorable pregnancy outcome.
5. Counsel a patient regarding appropriate preconception testing.
6. Counsel a patient regarding pregnancy associated risks and conditions, such as advanced age, hypertension, diabetes, genetic disorder, prior aneuploid or anomalous fetus/newborn” (p. 49)
ACOG, the American College of Obstetricians and Gynecologists represents 46,000 obstetricians and gynecologists in the United States, and in 2005 celebrated its 50th anniversary. ACOG has advocated for preconception care for several decades, and offers the most detailed guidelines for the provision of preconception services. ACOG’s acknowledges that while ideal health prior to pregnancy does not guarantee a perfect or uncomplicated pregnancy, women who are considering pregnancy should undergo comprehensive preconception evaluation, examination, and counseling. However, preconception care is best when it is provided as part of primary health care, rather than as a discrete new category of health care, particularly since almost one-half of all pregnancies in the United States are unintended [25, 26].
Components of preconception care—ACOG
In examining multiple documents produced by ACOG in recent years, certain components of preconception care can be delineated.
Preconception counseling should occur at periodic assessments for all reproductively capable women. These assessments may be yearly or as appropriate . Counseling should include discussions about the likelihood of pregnancy (planned or unplanned), counseling on appropriate medical care and behavior to optimize pregnancy outcomes, specific health risks the woman has that may predispose her to an adverse pregnancy outcome if not addressed, and how to either effectively prevent an unplanned pregnancy or to maximize her physical and emotional health prior to a planned or even unplanned event. Even clinicians that do not provide prenatal care should be able to provide preconception counseling and screening to their reproductively capable patients.
The patient’s history should be reviewed and updated on an annual basis or more often if appropriate. The history should include a review of any medical conditions and medications the patient may be using. It is important to ask about prescription as well as over the counter drugs, herbs, and supplements. Inquiries about occupational and hobby exposures to chemicals, solvents, or heavy metals should be made. In this manner, potentially teratogenic agents may be identified.
The patient’s reproductive history may provide important clues about future pregnancy risks. Recurrent miscarriages should raise suspicion of a possible genetic or chromosomal problem. The neonatal outcome of previous pregnancies should be noted but it is equally as important to ask women about the current health of any children they have as some congenital disorders do not become manifest until several months or even years after birth and may not be considered by the family to represent a congenital defect.
Genetic disorders and genetic screening
The woman’s family history and ethnicity for genetic disorders and malformations should be obtained. Carrier screening for Tay-Sachs disease is recommended for individuals of Eastern European (Ashkenazi) Jewish, French Canadian and Cajun descent . ACOG recommends offering cystic fibrosis screening to individuals with a family history, reproductive partners of persons with cystic fibrosis, and to couples in whom one or both partners are Caucasian and are planning pregnancy .
Carrier screening for Tay-Sachs, Canavan disease, cystic fibrosis, and familial dysautonomia should be offered to Ashkenazi Jewish individuals during preconception screening. These same individuals may be offered or may request screening for Gaucher disease, Niemann-Pick disease type A, Fanconi anemia group C, Bloom syndrome, or mucolipidosis IV as well. Carrier screening should be offered to any individual with a positive family history of one of these disorders; the screening should be for the specific disorder. When only one partner is of Ashkenazi Jewish descent, that individual should be screened first. Except for Tay-Sachs and cystic fibrosis, the carrier frequency and detection rate for the other disorders is unknown.
If an individual is found to be a carrier for Tay-Sachs or one of the other aforementioned diseases, their relatives are at risk for carrying the same mutation; carriers are encouraged to inform their relatives of the risk and availability of carrier screening .
Other screening tests exist for genetic disorders with an increased incidence in specific ethnic groups, e.g., alpha or beta thalassemia screening in Orientals, beta thalassemia screening for those of Mediterranean descent, and sickle cell disease screening for African-Americans.
Women who have had a previous pregnancy complicated by autosomal trisomy, a sex chromosome aneuploidy, or if either partner has a chromosome translocation or inversion or aneuploidy should be given education about their increased risk of recurrence in future pregnancies and a referral for pre-pregnancy genetic counseling should be offered .
Immunizations and infectious diseases
The woman’s immunization status, history of childhood diseases, and risk for exposure to hepatitis, HIV, or other sexually transmitted infections needs to be updated at least annually. When practical, preconceptional immunization of women to prevent disease in the offspring is preferred to vaccination of pregnant women with certain vaccines .
Approximately 30% of US adults have serologic evidence of prior exposure to toxoplasma gondii, a known teratogen. Screening for Toxoplasma gondii is controversial because evidence that treatment prevents congenital disease is lacking. All reproductively capable women should be advised to avoid eating undercooked or raw meat, wear gloves when working with soil, and practice safe-handling techniques when changing cat litter .
Congenital cytomegalovirus (CMV) infection occurs in 1% of all live births in the United States and causes major neonatal illness in 5% to 10% of these cases. Women with young children or those who work with young children may be counseled about reducing the risk of CMV through universal precautions, e.g. the use of latex gloves and rigorous hand-washing after handling diapers or after exposure to respiratory secretions. There are currently no other specific recommendations as there is no evidence that screening and/or treatment programs prevent infection [32, 33].
All women should be kept current with age-appropriate vaccines. Reproductive aged women should be asked about previous infection with varicella and offered vaccination if they report no known history of chickenpox. Conception should be delayed until 1 month after the second injection is given. Women who expect to be at least 3 months pregnant during the influenza season (November to April) should be vaccinated.
A woman’s lifestyle and social behaviors should be reviewed and updated frequently. The use of alcohol, smoking, or other substances may have significant effects on pregnancy. Smoking during pregnancy is associated with low birth weight, abruptio placenta, preeclampsia, and preterm labor . A woman’s personal situation has a significant effect on her health and often changes over time. Clinicians should ask all women about intimate partner violence and women should be aware that it may escalate during pregnancy. In addition, a woman’s mental health history may provide clues about recurrence risks either during or after a pregnancy.
A woman’s dietary habits should be reviewed. Daily folic acid intake of 0.4 mg should begin at least 1 month before pregnancy and continue through the first trimester. For women who have had a child with a neural tube defect, a higher dose of folic acid (4.0 mg/d) is recommended and has been shown to decrease the recurrence rate of neural tube defects . Women who may become pregnant—planned or unplanned—should be aware of recent FDA warnings to avoid specific types of fish as they may be high in methyl mercury—a known neurotoxin to a developing fetal nervous system. Women should also be questioned about the need for any dietary restrictions they may have required in childhood. Women with PKU in childhood may not currently be adhering to a phenylalanine free diet but hyperphenylananinemia is associated with neurological impairment in a developing fetus.
Maternal prepregnancy weight is associated with several adverse outcomes. Women weighing more than >300 lbs (>136 kg) prior to pregnancy have a markedly increased risk for developing gestational diabetes, preeclampsia, and requiring a cesarean delivery compared with women weighing 100–149 lbs (45–67 kg). In one study, even among a subsample of women who did not have any diabetic or hypertensive diseases, excess weight significantly increased the likelihood of macrosomia and NICU treatment . The relationship between maternal obesity and perinatal outcomes is necessary when discussing routine care as well as specific preconception planning.
Medical history and conditions
While most reproductive aged women are healthy, there are specific medical conditions associated with adverse pregnancy outcomes if untreated or treated poorly. Some medical conditions are contraindications to pregnancy. Hypertension should be under control prior to initiation of a pregnancy and women using angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists who are considering pregnancy should be switched to other agents and adjusted on these medications prior to conception. Certain cardiac disorders, such as primary pulmonary hypertension, place women at a very high risk for morbidity or mortality during pregnancy . There is an increased risk (3–10%, depending on the parent’s condition) of congenital heart disease among children born to women who have a history of a congenital heard defect .
Women with a history of thromboembolism have an increased risk of recurrence during pregnancy. Women with a history of thrombosis should be offered testing for inherited or acquired thrombophilias, particularly if the results of the testing would affect the management of future pregnancies. Testing may be considered in women with a family history of thrombosis or a first degree relative with a specific mutation .
It is very important that women receive a thorough work-up and evaluation prior to being diagnosed with a seizure disorder and started on medication. Women diagnosed with seizures of unknown etiology should be told that even if they are on no medications at all, they have a two-fold higher risk for congenital malformations in their offspring than individuals without seizures. Anticonvulsant therapy use during pregnancy, particularly hydantoin or valproic acid, is associated with an increased risk for specific congenital defects. It is important to determine if anticonvulsant medication can be safely discontinued or to initiate therapeutic changes before pregnancy occurs. Women should be told that enzyme-inducing antiepileptic drugs may lower the efficacy of combination oral contraceptives, so an oral contraceptive containing a higher estrogenic concentration may be necessary. For women taking antiepileptic drugs who are considering a pregnancy, folic acid supplementation 5 mg/day is recommended for one month prior to conception and until the end of the first trimester .
Women with poorly controlled asthma before pregnancy tend to have increased difficulty with asthma during pregnancy . Severe, poorly controlled asthma may have an adverse effect on fetal outcome as a result of chronic or intermittent maternal hypoxaemia .
Women with quiescent autoimmune disease or a distant history of disease should be carefully evaluated and counseled about maternal and fetal risks. Patients should be counseled that the best time to attempt conception is during periods of inactive disease.
Women should be made aware of the deleterious effects of hypothyroidism in pregnancy, including an increased incidence of abortion, obstetric complications and fetal abnormalities in untreated women [43, 44]. Women being treated for hypothyroidism will require increased doses of thyroxine early and throughout pregnancy in order to maintain adequate levels; this is especially important during the first trimester . Low maternal thyroxine concentrations may lead to impaired neurodevelopmental outcome in the neonate and child. Routine assessment for the presence of subclinical hypothyroidism is not recommended. ACOG recommends testing of thyroid function only in women with a personal history of thyroid disease or symptoms of thyroid disease .
Diabetes mellitus represents a medical condition where preconception control has been proven to translate into improved maternal-fetal outcomes. Patients with poor glucose control during the first 8–10 weeks of pregnancy have a 2–3 fold higher risk of birth defects in their offspring than patients without diabetes. Good glycemic control before conception diminishes the risk of birth defects to a level comparable to that of the normal population .
Women should be asked about any ongoing dermatologic therapy she may be receiving. Isotretinoin (Accutane) is used for a variety of skin conditions and is a known teratogen. Some anti-psoriasis treatments (Acetretin X and methotrexate) are known teratogens, while some antiviral medications (podophyllum) are contraindicated in pregnancy.
Table 1 includes suggestions for the clinician during routine or periodic health assessments to optimize possible future pregnancy outcomes for all reproductively capable women.