Preconception Counseling

Medical and Pregnancy History

• Comprehensive Review: Assess previous pregnancy outcomes, chronic medical conditions, surgical history, and family history of genetic disorders.

Supplements

• Folate:
  • Recommended dose: 400-500 mcg/day at least 1 month before conception and through the first 12 weeks of pregnancy.
  • Reduces the risk of neural tube defects.
  • higher dose of folic acid (5 mg daily) is recommended before conception and during pregnancy to reduce the risk of neural tube defects and other complications. The indications for 5 mg folic acid include:
    • Previous Pregnancy Affected by Neural Tube Defects/Downs Syndrome
    • Family History of Neural Tube Defects:
    • Diabetes
    • Obesity
    • Epilepsy: Women taking antiepileptic medications.
    • Malabsorption Syndromes: Conditions like coeliac disease, inflammatory bowel disease, or those who have had gastric surgery.
    • Certain Medications: Women taking medications known to interfere with folate metabolism, such as methotrexate or sulfasalazine.
    • Multiple Pregnancies: Women carrying twins or higher-order multiples.
    • Thalassemia Trait: Women with certain hemoglobinopathies like thalassemia trait.
    • High-Risk Ethnic Groups: Women from ethnic groups with a higher prevalence of neural tube defects, such as certain Aboriginal and Torres Strait Islander communities.
• Iodine:
  • Recommended dose: 150 mcg/day during pregnancy and breastfeeding.
  • Supports fetal brain development and maternal thyroid function.

Nutrition and BMI Optimization

• Optimize BMI:
  • Aim for a BMI within the normal range (18.5-24.9).
  • Set a realistic goal to lose 5-10% of body weight prior to conception if overweight or obese.
  • Referral: Refer to a dietitian for personalized nutritional guidance.

Immunizations and Screenings

• Rubella Immunity:
  • Check immunity status.
  • Administer booster if necessary, advising against pregnancy within 28 days post-vaccination.
• STI Screening:
  • Screen for common STIs (chlamydia, gonorrhoea, syphilis, HIV).
• Thyroid Function:
  • Check TSH levels, especially if there is a history of thyroid disease or symptoms.
• Vitamin D:
  • Assess levels and supplement if deficient.
• Thalassemia Screening:
  • Perform if there is an abnormal FBC or the patient belongs to a high-risk group (e.g., Mediterranean, Asian, Middle Eastern descent).

Physical Examinations

• Oral Health: Conduct a dental check-up to identify and treat any potential issues.
• Breast Examination: Perform a clinical breast exam.
• Thyroid Examination: Check for thyroid enlargement or nodules.
• Cardiovascular Examination: assess for murmurs and other cardiovascular anomalies.
• Cervical Screening: Ensure cervical screening is up to date according to Australian guidelines.

Lifestyle Modifications

• Smoking Cessation: Offer resources and support for quitting smoking.
• Alcohol and Illicit Drug Use: Counsel on the risks and encourage cessation.

Pre-conception Testing

• Oral Glucose Tolerance Test (OGTT): Recommended for high-risk groups, including women with PCOS.
• Genetic Testing: Offer pre-conception genetic testing for conditions such as cystic fibrosis, spinal muscular atrophy, and fragile X syndrome.
  • Cystic Fibrosis (CF) Screening – Mutations in the CFTR gene causing cystic fibrosis.
  • Spinal Muscular Atrophy (SMA) Screening – Mutations in the SMN1 gene causing spinal muscular atrophy.
  • Fragile X Syndrome Screening – Expansions in the FMR1 gene causing fragile X syndrome.
  • Expanded Carrier Screening Panels
  • Thalassemia and Hemoglobinopathies Screening =ethnic backgrounds (e.g., Mediterranean, Middle Eastern, Asian) or those with a family history of hemoglobin disorders.
  • sickle cell disease in individuals of African descent

Optimizing Health Before Conception

• Chronic Disease Management: Ensure optimal control of chronic conditions such as diabetes, hypertension, and epilepsy.
• TORCH Infections: Assess risk for Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes simplex virus.
• Psychosocial Assessment: Screen for anxiety and depression, provide appropriate referrals and support.

Medication Review

• Contraindicated Medications: Review and discontinue any medications that are contraindicated in pregnancy.
• Advise against the use of NSAIDs like ibuprofen.

Counseling and Education

• Exercise: Recommend at least 150 minutes of moderate-intensity exercise per week.
• Healthy BMI – recommended weight gain 11-16kg
• Antenatal Care: Discuss the importance of early and regular antenatal care to monitor the health of the mother and baby.

Interpregnancy Intervals

• Optimal Timing:
  • Educate about the risks associated with interpregnancy intervals of less than 18 months or more than 59 months.
  • Emphasize that 2-5 years is the optimal interval to reduce the risk of pre-term birth, low birth weight, and small size for gestational age.