Chapter 20 Preconception care
Introduction
The aim of preconception care is to maximize the health of prospective parents prior to conception. This ensures they are at the peak of their health potential at the point of conception and organogenesis (17–56 days following conception) when the potential for fetal abnormality is highest, thus attempting to achieve maximum health potential of the developing baby. In an ideal world, prospective parents would present themselves to an appropriately trained healthcare professional for health screening at least 6 months prior to a planned conception. In reality, this is not usually perceived as essential by prospective parents and health professionals and it is only in retrospect when pregnancy outcome is compromised that parents seek to identify what could have prevented or reduced this outcome. Preconception care, therefore, needs to be aimed at any individual, male or female, with the potential for conception.
With the developing public health role of the midwife in providing total care for the family, every health promotion activity undertaken must include elements of preconception advice. Preconception care must be included in routine health screening activities offered by a variety of healthcare professionals, in health promotion literature and classes, in schools, during family planning or cervical screening sessions (Kierman 2006), in pregnancy testing kits, at post-abortion counselling and in any potential health education experience. Reproductive sexual health is already discussed in schools, with the aim of reducing teenage pregnancy, and this example could be applied to components of preconception care, to inform adolescents of the importance of planning and preparing for pregnancy. Women who have negative pregnancy tests should be targeted for preconception information in readiness for subsequent pregnancy. Preconception advice should be offered to women during the antenatal and postnatal periods.
Preconception care varies considerably internationally, nationally and locally, reaching a small segment of the community, usually clients who are motivated, articulate and aware of their needs, or clients who have had a compromised pregnancy and are preparing for future pregnancy. The type of screening available to women and their partners varies; thus, advising women on preconception care is often confusing. The difficulty with preconception care is that it is not perceived as a priority by healthcare professionals and is not readily available to women. Only in retrospect when pregnancy outcome is compromised do women and their partners seek information or advice on care for subsequent pregnancy. With appropriate preconception care, the care and treatment required during pregnancy is significantly reduced. For example, providing preconception care to women with diabetes reduces hospital admissions, length of stay in hospital, intensity of care of newborn infants and subsequently shortens the infant’s period of hospitalization (Kendrick 2004).
This chapter outlines some of the areas of interest to women and their partners attempting to conceive. Each area of interest is subdivided into advice a midwife could offer to women and partners and further reading or Internet addresses for additional information. It is important to remember that patterns of treatment are continually changing as new ideas and research results emerge and, therefore, midwives need to monitor changes and implement them into their care provision.
Aim of preconception care
The aim of preconception care is to increase the health of prospective parents, ensuring they are at the peak of their health potential at the point where conception occurs and throughout the period of organogenesis, enhancing the health of the developing baby.
Organogenesis
This is the period of early fetal development (17–56 days following conception) where the early cell mass of conception becomes organized into three layers: ectoderm, mesoderm and endoderm; each responsible for development of different organs or body parts in the developing baby (see Ch. 29).
Objectives of preconception care
The objectives of preconception care are to:
Taking a preconception history
When a woman and her partner present for preconception care, the supporting practitioner records a personal history. The most important aspect of preconception care is the need for a full and detailed health history from both partners and others identified as being significant, such as where genetic screening is required. The aim of the session is to assess, educate and counsel prospective parents on optimum health in preparation for pregnancy. The information obtained at this interview guides the care process, providing a baseline for subsequent comparative tests.
The interview must be undertaken in an environment where clients feel at ease, with confidentiality and privacy ensured. Appropriate allocation of time for appointments should be available, enabling time to listen and advise and undertake necessary screening tests. All tests are explained in detail, information sheets are provided and informed consent obtained. At some point it is recommended that each partner be interviewed privately so that they may disclose personal information which they do not wish their partner to know.
The preconception care assessment
The process of risk assessment in preconception care presumes the potential for adverse outcome in pregnancy (see website). The assessment focuses on identification of conditions relating to risk, assessing prospective parents’ risk of complications in pregnancy and interventions required to reduce severity of those complications. It should contain a detailed medical, psychological and social history, physical examination and health screening of both prospective parents. The need to link risk assessment to health promotion activities ensures preconception care focuses not only on diagnosis and treatment but also on creating a healthy environment for the proposed conception through advice and guidance.
Both the woman and her partner should be involved in the discussion to provide the following information:
Once a detailed history has been taken, areas of health promotion or risk are identified and screening tests performed. Not all of the following tests may be offered or deemed necessary, as they will depend on individual needs and services available. However, specialist support services are available through organizations such as Foresight.
Providing information to prospective parents
Results of screening tests are given to clients as the information becomes available, taking care not to overload the couple with details. Verbal information is supported by documents, information via the Internet, and referral to other multi-professional teams. It is important not to assume a prior level of knowledge, particularly in relation to issues such as basic anatomy, sexual health or knowledge of support services.
Nutrition
The importance of an adequate diet at conception and during pregnancy is identified as a key factor in adult health, with associated links to illness such as coronary heart disease (DH 2000). There is a direct relationship between nutritional intake, malnutrition and suboptimal nutrition in pregnancy and maternal and child health (Reifsnider & Gill 2000). Women with conditions requiring specific diets or nutritional requirements are referred or advised to seek specialist advice from a dietician. The aim is to ensure that women have a healthy body weight, sensible eating habits and suitable nutritional stores at the point of conception (Cuco et al 2006). Diet in pregnancy is influenced by morning sickness, hyperemesis, pica (food cravings) and dislike of certain foods. Nutritional assessment is important because of the increase in malnutrition and the recognition that someone who is obese can also be malnourished.
The body mass index (BMI) is still the recognized method of estimating nutritional status. A BMI of 20 or less indicates that the individual is underweight, whereas a BMI of 30 or over is indicative of obesity. Energy intake should be increased by approximately 200 calories per day during pregnancy, but no change is required while preparing to conceive.
Table 20.1 outlines the information, advice and further reading on nutrition that a midwife may find helpful when offering preconception advice on nutritional intake.
Table 20.1 Nutrition: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Obesity | Lack of essential nutrients in the first trimester influences organogenesis and fetal formation Advise women to achieve a BMI of 21–29 prior to conception Unsupervised dieting is not advised during pregnancy although a healthy low-fat diet may help regulate weight gain Refer to dietician |
Galtier-Dereure et al 2000 |
| Discussion of eating habits, although women may be reluctant to disclose information Advise women to achieve a BMI of 21–29 prior to conception Refer to general practitioner for referral to dietician, psychologist or psychiatrist Bulimia often improves during pregnancy, with 34% no longer suffering after pregnancy |
Siega-Riz et al 2008 | |
| Vitamin deficiency and supplements | If following a healthy diet, vitamin supplements are unnecessary unless medically indicated Advise women that some medications contain vitamin A, which can be teratogenic, for example, treatment for acne Avoid foods high in retinoids, such as liver and fish liver oil, as they contain high levels of vitamin A |
http://www.nutrition.org.uk/ |
| Folic acid deficiency | Advise to take folic acid, remembering to take higher dose if epileptic Alcoholics, smokers and lactating women are at increased risk of folic acid deficiency. 4 mg of folic acid is taken daily 2–3 months prior to conception to the end of the first trimester following a previous neural tube defect or if epileptic. 0.4 mg of folic acid is taken daily 2–3 months prior to conception to the end of the first trimester in a first or subsequent pregnancy where there is no history of neural tube defects Increase consumption of leafy vegetables and wholemeal products |
Lumley et al 2000 |
| Many women do not meet the recommended daily intake of 700 mg of calcium even when not pregnant Advise on daily intake of calcium, milk, cheese, fish and yogurt Refer to dietician |
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| Caffeine | Reduces implantation; two cups per day reduces the rate of conception by 27% Advise to lower caffeine intake or cease |
http://www.eatwell.gov.uk/agesandstages/pregnancy/trybaby/ |
| Anaemia | Anaemia should be diagnosed before pregnancy and the cause found and treated Advise on diet, such as bread, pulses, red meat and spinach |
Infection
Infection in the mother, and in some cases the father, may affect the developmental phases of the fetus. Infections should be diagnosed and treated prior to conception and advice given on prevention of reinfection (Table 20.2). Routine serum screening can assess immunity to infections such as rubella, and where immunity is not detected, vaccination must be offered prior to conception. Infection that causes a significant rise in body temperature may result in spontaneous abortion in early pregnancy. The impact of mumps should be considered when exploring a medical history from prospective fathers, because of associated infertility in men.
Table 20.2 Infections: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Rubella virus (German measles) | Avoid contact with infected persons for 7 days before and 5 days after rash appears Ask the GP to check immunity status and vaccinate prior to conception Avoid pregnancy for 3 months following vaccination Higher fetal risk in the first trimester Advise mothers on vaccinating children |
http://www.nhs.uk/Conditions/Rubella/Pages/Prevention.aspx |
| Erythema infectiosum (slapped cheek disease) | Avoid children with the disease. It is thought to be communicable 1 week before symptoms appear to 1 week after onset of symptoms | Morgan-Capner & Crowcroft 2000 |
| Listeriosis (Listeria monocytogenes) | A food-borne pathogen found in soil, water and some vegetation Wash hands when dealing with food May be present in ready-to-eat food, meat pies, pâtés, unpasteurized milk or goat’s milk, soft cheeses, such as Feta, Camembert, Brie and Stilton, and can survive and multiply in refrigerators at temperatures of 6°C or above Re-heat all food to steaming point, as this kills the pathogen Avoid contact with sheep during lambing and avoid handling silage Treated with antibiotics Takes up to 8 weeks for illness to emerge, so advise against pregnancy during that time |
http://www.nhs.uk/Conditions/Listeriosis/ |
| Toxoplasmosis | Caused by the parasite Toxoplasma gondii If tested prior to pregnancy and shown to carry the infection, then women are not at risk during pregnancy No risk to healthy women unless they have a compromised immune system Wear gloves when dealing with cat litter boxes Wash hands thoroughly following gardening or contact with soil Thoroughly cook meat Avoid raw or cured meat Wash hands after handling meat, fruit and vegetables (because of soil contamination) |
Turner 2000 |
| Tuberculosis | Treat prior to conception Vaccinate prior to travelling to areas where TB is prevalent Seek advice from GP if in contact with infected persons |
Bothamley 2006 |
| HIV/AIDS | Steady maintenance of low viral load and high CD4 count prior to conception reduces risks to the baby Continued unprotected sex results in an increased viral load Sperm washing and artificial insemination is available but not on the NHS Treatment with AZT Referral to sexual health team |
http://www.bhiva.org/files/file1030325.pdf |
| Chickenpox virus (varicella zoster [VZ]) | The majority of mothers who have had chickenpox develop lifelong immunity which protects their baby during pregnancy Test for VZ antibody; if not present, can receive varicella zoster immune globulin 1 in 3 women suffer spontaneous abortion following infection Avoid pregnancy for 3 months following vaccination At-risk groups include schoolteachers, childcare workers and nursery nurses Avoid infected individuals. If in contact and not immune, advise to use contraception until end of incubation period |
http://www.nhs.uk/conditions/Chickenpox/ |
| Hepatitis B | Assess hepatitis status Vaccinate before conception if in at-risk category – for example, body piercing, tattoos May recommend liver function tests to assess severity of disease |
http://www.nhs.uk/Conditions/Hepatitis-B/ |
| Group B streptococcus (GBS) | May have no effect. 25% of women of childbearing age have GBS in their vaginas with no apparent symptoms Advise women they require intravenous antibiotic therapy in labour or following rupture of membranes, to reduce the incidence of transmission to their baby |
www.gbss.org.uk |
| Cytomegalovirus | May be asymptomatic as the virus lives within the salivary glands in ‘healthy’ adults Wash hands before preparing meals |
Azam et al 2001 http://www.nhs.uk/Conditions/Cytomegalovirus/ |
| Tetanus | Clostridium tetani spores are found in soil, dust and gut of animals Wash hands following gardening or dusting |
http://www.nhs.uk/Conditions/Tetanus/Pages/Introduction.aspx |
Sexually transmitted disease
A full and detailed sexual history must be obtained before conception to assess potential risk. This area of health is often the most difficult to discuss but must be explored during the interview to determine associated risk factors. Sexually transmitted diseases, infections and infestations are on the increase and individuals need to be routinely screened. Where infections are indicated, barrier methods of contraception should be used until treatment is completed. Suspected cases are referred to genitourinary medicine clinics. Further information on sexual health is included in Chapter 57.
Reflective activity 20.2
Access the Health Protection Agency website at http://www.hpa.org.uk/. Review the various types of sexually transmitted diseases, evaluating them in relation to preconception care and the information required during discussion on a sexual history.
Medical conditions
Women and their partners who have a medical condition must attend for preconception care within a multi-professional team, consisting of specialist practitioners, obstetricians, physician and midwives. Most medical conditions, if managed effectively throughout organogenesis and the first trimester, result in sucessful outcome for mother and baby at birth (Table 20.3). In each case, early referral to the medical team is paramount.
Table 20.3 Medical conditions: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Diabetes | Involve specialist practitioners, such as diabetic liaison midwife, dieticians, physician Aim to control preconception glycaemia, reducing the incidence of fetal malformations at conception and organogenesis Measure glycosylated haemoglobin (HbA1) as this gives information of blood glucose levels over previous 4–6 weeks |
Kendrick 2004 McElvy et al 2000 |
| Epilepsy | Seek advice on anticonvulsant therapy prior to conception as this may help reduce the incidence of fetal malformations Medication levels may be reduced Anticonvulsant drugs are teratogenic Take folic acid daily. The dose should be discussed with and prescribed by a GP or physician |
British Epilepsy Association http://www.epilepsy.org.uk Helpline: 0808 800 5050 |
| Phenylketonuria | Is monogenic, autosomal recessive and affects phenylalanine metabolism Phenylalanine is present in milk, meat, fish, cheese and eggs Refer to dietician Advise woman to maintain blood phenylalanine levels between 120 and 360 mmol/L through a low-phenylalanine diet before conception occurs and during first trimester |
http://www.nhs.uk/conditions/Phenylketonuria/ |
| Hypertension | Review hypertensive medication as it may influence fetal development Refer to medical team |
Robson & Waugh 2008 |
| Systemic lupus erythematosus (SLE) | Pregnancy is not advised in women with active nervous system involvement Control associated kidney disease for 6 months prior to conception Use barrier contraceptive methods during these 6 months Refer to physician and specialist clinics |
http://www.nhs.uk/conditions/Lupus/Pages/Introduction.aspx |
| Thyroid conditions | Surveillance of thyroid function required Refer to medical team |
Robson & Waugh 2008 |
| Multiple sclerosis | Does not appear to increase obstetric complications Refer to support organizations for specialist needs and advice |
http://www.nhs.uk/conditions/Multiple-sclerosis/Pages/Introduction.aspx
http://www.mssociety.org.uk/ |
| Cancer | Clients or partners receiving chemotherapy or treatments affecting spermatogenesis or oogenesis should seek advice on storing sperm and ova Should have a cervical smear prior to conception Cancer has different outcomes in pregnancy, so it is important to seek early advice prior to conception In some instances, delay of conception may be advised to enable treatment of cancer to commence |
Grady 2006 Sood et al 2000 |
Genetics
One of the most important activities in preconception screening is assessment of risk of genetic anomalies in prospective children (Table 20.4). The level of risk is linked to the chance of a baby inheriting an abnormality from its family. A family pedigree is constructed as part of the preconception interview or with a geneticist. Pregnancy is not the time for genetic screening, as this should be completed before conception. Historically, genetic anomalies were linked to a given population, but now with a migratory world population it is difficult to label specific groups as being more at risk than others. At present, genetic counselling is only provided to a small sample of the community and in most cases does not reach those who are most at risk. The emphasis is currently on diagnosis and treatment during pregnancy rather than prevention before pregnancy (Harper 2004).
Table 20.4 Genetics: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Cystic fibrosis | Lung function determines severity of maternal outcome during pregnancy Refer to dedicated cystic fibrosis team including obstetricians |
Edenborough et al 2000 http://www.cysticfibrosis.co.uk |
| Sickle cell anaemia | Refer to specialist team |
http://www.sicklecellsociety.org
Villers et al 2008 |
| Thalassaemia | Detection of carrier status Genetic counselling Referral into the healthcare system early in pregnancy |
Sickle cell and thalassaemia support project |
| Tay–Sachs disease | A fatal genetic disorder that destroys the central nervous system Autosomal recessive disorder Send woman and partner for genetic screening prior to conception Referral to genetic counsellor |
http://www.ntsad.org/ |
Environment and lifestyle
The environment and individual lifestyles influence development of our children, not only during childhood but also during the period of organogenesis (Table 20.5). Stereotypical ideas of social class are now merging, making it difficult to determine the lifestyle of specific groups, as drinking, smoking and drug addiction cross all social barriers. The effect of some drugs on conception and organogenesis was first identified following the administration of thalidomide in the 1960s as a treatment for morning sickness, and as new drugs appear on the market the impact on the next generation of children has yet to be recognized.
Table 20.5 Environment and lifestyle: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Employment | Advice varies with type of employment Risk assessment to protect from occupational hazards Access health and safety policies at work for information on preconception and pregnancy-related issues Should avoid jobs which involve: Advise to discuss any concerns with employer Remember to enquire about partner’s employment |
|
| Stress | Avoidance of severe stress during the period of organogenesis Refer to psychologist, GP, employer’s occupational health department or other relevant organizations |
|
| Exercise | Do not take up new exercise when pregnant; take it up before pregnancy and maintain Avoid contact sports, such as kickboxing, and sports that increase core body temperature, as these are associated with spontaneous abortion Avoid hot saunas, steam rooms and spas that increase core body temperature |
Heffernan 2000 |
| Smoking | Reduces sperm count in men Both partners should stop smoking 4 months prior to conception as cigarettes produce carbon monoxide and nicotine, reducing oxygen supply to the fetus, causing vasoconstriction of spiral arterioles in the placenta Refer to support groups Advise to keep away from smoky environments |
NHS Smoking Helpline: 0800 169 0169 http://smokefree.nhs.uk/smoking-and-pregnancy/ |
| Alcohol | Alcohol crosses the placenta, being metabolized by the fetus once liver enzymes mature in the second half of pregnancy; is toxic in early pregnancy Decreases sperm count, motility of sperm and causes sperm malformations Is a testicular toxin resulting in poor sperm production, abnormal sperm cells, sterility and impotence Abstain from consumption of alcohol for at least 4 months prior to conception Discourage ‘binge’ drinking particularly during organogenesis |
Krulewitch 2005 |
| Drugs (social and prescribed) | Increased risk of structural anomalies during organogenesis, such as in the heart and great vessels, digestive system and musculoskeletal system Parents may not wish to disclose information May need to cease administration, reduce intake or supplement with less hazardous substitutes Refer to specialist practitioners |
Floyd et al 2008 |
| Alternative therapies | Therapies that include administration of herbal remedies require careful monitoring of type and quantity. Treatment should be prescribed by a registered therapist, and therefore care should be taken when self-prescribing (see Ch. 18) | http://www.grcct.org/ |
| Violence against women | Advise women on support services Refer parents to support organizations such as Relate |
Saunders 2000 |
| Pets | Special precautions should be taken when handling pets, their feeding bowls or excrement. Direct contact is not necessary as cross-infection can occur from the handler to another person or through pet equipment Toxoplasmosis is transmitted through cat faeces Advise to avoid contact with reptiles as 9 out of 10 carry Salmonella Salmonella from birds, insects, mammals and reptiles can result in meningitis or septicaemia Escherichia coli may result in food poisoning and fetal death |
|
| Hazardous substances | Recommend organically grown foods All foods should be thoroughly washed Farmers should reduce contact with pesticides or insecticides Avoid using garden insecticides, touching pet flea collars, and anti-lice shampoos |
(for all entries in this section) http://www.foresight-preconception.org.uk/books_literaturesummaries.htm |
| Solvents | Found in a variety of occupations, such as printing, dry cleaning, painting, leather industries, anaesthetics, gardening, pharmaceutics and housework Limit work with solvents |
|
| Lead | Comes from exhaust fumes, soil, food, drinking water, lead cooking utensils Wearing of protective clothing at work if in contact Mineral analysis prior to conception Filter water and avoid lead cooking equipment High levels of lead in men linked to infertility Lead moves from maternal bones to the fetus during pregnancy |
|
| Cadmium | Reduce contact with cigarette smoke, plumbing alloys, paint, batteries, fertilizers Filter water High levels of cadmium in men are linked to infertility Reduce smoking and alcohol intake as both activities increase cadmium levels Mineral analysis prior to conception |
|
| Zinc | Found in red meat, cereals, cheese and nuts Levels reduced in alcohol drinkers Low levels related to infertility in men Mineral analysis prior to conception |
|
| Aluminium | Derives from kitchen utensils, some foods cooked in aluminium pans, particularly apple and rhubarb, antacids and kitchen foil Filter water Replace kitchenware with stainless steel, enamel or glass Advise mineral analysis prior to conception |
|
| Mercury | Derives from tinned tuna, weed killers and dental amalgam; therefore dental treatment should be undertaken prior to conception or involve non-mercury-based amalgam Filter water Advise mineral analysis prior to conception |
The preconception history must include an assessment of risks associated with employment, exercise, drug consumption and smoking, plus questions on physical abuse, use of alternative therapies and exposure to toxic substances. It is important not to make assumptions about individuals but to ask detailed questions to secure a full and detailed history.
Reproductive sexual health
Barrier methods of contraception are recommended during the preparation phase for pregnancy. These are non-invasive methods with no direct influence on the body or conception. The morning-after pill is not discussed here as its function is to terminate pregnancy rather than promote it (see Ch. 27). However, preconception care advice should be included in the packaging for distribution to women (Table 20.6).
Table 20.6 Reproductive sexual health: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Oral contraception | (see Ch. 27) Cease administration 3 months before conception. Use alternative barrier methods, enabling the body to regulate hormones prior to conception and increase mineral stores such as copper and zinc Reduces zinc, manganese and vitamins A and B |
Disability
The term disability covers an extensive range of physical and mental conditions and abilities. Because the variety and scope of clients’ ability is so varied, it is necessary to refer women to appropriate specialists as early as possible prior to pregnancy, so that effective screening and care management can occur (see Table 20.7).
Table 20.7 Disability: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Disability | Refer to specialist organizations Refer to members of the multi-professional team Vary depending on the type of disability |
http://www.disabledparentsnetwork.org.uk/ |
| Mental health | Some drugs lead to birth defects; for example, diazepam causes congenital malformations if taken during first trimester Refer to psychiatrist/GP |
Frieder et al 2008 |
Midwifery and obstetric aspects
A poor obstetric or midwifery history alerts the midwife to potential problems in a subsequent pregnancy; therefore, it is essential to obtain a full obstetric and midwifery history when discussing preconception care (Table 20.8).
Table 20.8 Midwifery and obstetric aspects: preconception care, advice and further reading
| Information and advice | Further information | |
|---|---|---|
| Poor obstetric history | Need to know what occurred previously to manage preconception care appropriately This depends on the type of obstetric incident Refer to midwife or specialist obstetrician to review previous case(s) or advise on care in pregnancy |
See relevant chapters within this book |
Conclusion
The relevance of preconception care to the health of future generations still remains a minor component of health promotion, even though the impact could increase the health potential of children, both in the short and long term. Improving the health of prospective parents in turn, influences the health of their children and grandchildren. What appears insignificant information in one generation may have a compounding impact in the next. By informing prospective parents of their health status, information such as sickle cell status can be documented and used to inform other family members or partners. Any healthcare activity should involve aspects of preconception care and include both partners, taking account of the diverse nature of society, human actions and the environment. Preconception care involves a team approach including any health professional offering specialist advice. As preconception care involves such diverse issues it is impossible to include detailed information within this chapter. You are, therefore, reminded to access other relevant sources, review new evidence as it is published, and access your local preconception facilities, so that you can actively inform women of the local services available.