Preconception Counseling

Definition

Preconception counseling is patient education that helps a woman to make lifestyle changes before conception that will assist in promoting a healthy pregnancy and a healthy baby.

Purpose

Various health and environmental factors can increase the rate of abnormalities, referred to as birth defects, seen in babies at birth. Examples of these abnormalities are conditions such as cleft palate/lip, congenital heart disease, or spina bifida (opening of the spine). Some abnormalities are hereditary.

Pregnancy can worsen some chronic maternal diseases or increase the risk of poor neonatal outcome. In addition, some medications used by the pregnant woman may cause developmental problems in the fetus.

Precautions

Not all women visit a health care provider during the critical early weeks of pregnancy. Thus, as a part of patient education, health care professionals should provide preconception counseling in all encounters with women of childbearing age.

Description

Preconception counseling should address the following areas:

Nutrition

DIET. The importance of a well-balanced, nutritious diet should be emphasized in preconception counseling. A woman who is underweight when she conceives may have a small baby (small babies are more likely to have problems during labor and immediately after delivery). A woman who is overweight is at increased risk of developing elevated blood pressure and gestational diabetes during pregnancy. Women should be informed that trying to lose weight during pregnancy is not advised, as it could rob a developing baby of essential nutrients.

Obstetric history data

Pregnancies and births (term, preterm, abortions, living)

Date of each birth (month and year)

Outcome of each birth:

    Gestational age at birth

    Type of delivery

    Length of labor

    Birth weight

    Gender

    Complications during pregnancy, at delivery, postpartum

Any depression during the year after birth

Present health

Names and location of children

Feelings about previous pregnancies, birthing experiences, parenting

Feelings about any perinatal loss or other losses in which children were involved.

source: Wheeler, L. Nurse-Midwifery Handbook: A Practical Guide to Prenatal and Postpartum Care. Philadelphia: Lippincott-Raven Pub., 1997.

FOLIC ACID SUPPLEMENTATION. Even though many grains and other products are fortified with folic acid (a B vitamin), the level may not be high enough to increase the folic acid intake of most child bearing-age women to the recommended level of 400 micrograms (mcg) per day. Therefore, most women of childbearing age should consume 400 mcg (0.4 milligrams, or mg) of folic acid per day. Women with a previous child with a neural tube defect and women on antiseizure medication need extra folic acid. Folic acid is thought to help prevent certain birth abnormalities, including spina bifida, other neural-tube defects, and possibly heart abnormalities. Folic acid may also reduce the likelihood of getting colon cancer and coronary heart disease.

MULTIVITAMIN SUPPLEMENTATION. To ensure an adequate daily intake of vitamins and minerals, women of reproductive age should take a multivitamin supplement that contains folic acid. Women planning on a pregnancy should be cautious to avoid an excess intake of vitamin A, however. It has been chemically associated with a class of retinoids recognized to cause birth abnormalities. Vitamin A doses larger than 10,000 international units (IU) have been linked to a nearly five-fold increase in the occurrence of congenital heart malformations.

Immunizations

RUBELLA (GERMAN MEASLES). All women of childbearing age should be immunized against to rubella. Contracting rubella during pregnancy can result in numerous severe birth abnormalities, including deafness, heart defects, cataracts, and mental retardation. Conception is not recommended for at least three months after receiving an immunization for rubella, and the immunization may not be given during pregnancy.

VARICELLA (CHICKEN POX). A woman who has not had varicella should be immunized for it prior to conception. Varicella infection can result in serious maternal and fetal complications. For example, 9 percent of women who contract varicella in pregnancy will develop varicella pneumonia. The varicella immunization may not be given during pregnancy.

Risk reduction

Women contemplating pregnancy should be counseled concerning the following lifestyle behaviors and their potential implications. A woman may not even be aware that she is pregnant for the first few weeks and may engage in dangerous lifestyle behaviors during a critical period of embryonic development. If conception is a possibility, women should try to maintain a healthy lifestyle so that their babies will have the best odds of a good outcome at birth and later on in life.

ALCOHOL. Consumption of alcohol during pregnancy can lead to fetal alcohol syndrome, a condition resulting in several physical and behavioral problems in affected children. Even intake of lower levels of alcohol can cause neurological and behavioral problems in children of women who drink during pregnancy. Studies have found that children of women who consumed alcohol during pregnancy had lower birth weights, were shorter, and had smaller head circumferences.

DRUGS. Infants of pregnant drug users are at risk for prematurity, low birth weight, and perinatal death. Women who abuse drugs should be offered support and referred to groups that can help with drug addiction.

TOBACCO. Women who smoke during pregnancy have an increased risk for abruptio placentae, placenta previa, and preeclampsia. Their babies may be born prematurely, be smaller, have congenital abnormalities, be at increased risk for sudden infant death syndrome (SIDS), and possibly have developmental delays.

Medical conditions and pregnancy

DIABETES MELLITUS. Women with diabetes mellitus should try to attain stability in their blood sugar levels prior to conception. Some oral medications for diabetes are contraindicated during pregnancy, so planning is necessary for conception. Complications of diabetes mellitus include large or small babies.

OTHER COMPLICATIONS. Women with medical conditions who are contemplating pregnancy should be counseled as to pregnancy risks for themselves and their babies. For example, a woman who has epilepsy should consult with her physician or nurse practitioner about the toxicity of the current medication she is taking to control seizures; a less toxic medication may be recommended for the period of preconception and pregnancy.

REDUCTION IN EXPOSURE TO TERATOGENS. Exposure to various substances can be teratogenic (capable of causing birth defects). Teratogenic hazards include anticancer drugs, and perhaps occupational substances such as organic solvents and anesthetic gases.

Some teratogens can even cause birth defects when the exposure took place prior to conception. The father's exposure to occupational toxins can also cause miscarriages, preterm deliveries, and birth defects.

Genetic counseling

Couples may wish to have genetic counseling if there is a family history of a child with a genetic abnormality, because of ethnically associated genetic diseases, or for advanced maternal/paternal age (age34 or 35 in women, unknown in men).

Other issues

Preconception counseling may include discussions of several other health-related issues:

• contraception
• domestic violence
• exercise
• gynecological screening
• use of prescription and over-the-counter medications
• general health
• safe sex
• sibling concerns

Preparation

Insertion of a form in the patient's chart addressing issues related to preconception counseling can guide the health care provider in performing a thorough assessment and providing appropriate interventions.

Results

Preconception counseling can result in healthier pregnancies, culminating in good birth outcomes.

Health care team roles

The opportunity to provide preconception counseling exists at any time a health care provider is assessing or educating a woman of childbearing age. (Such providers include nurses, nurse practitioners, obstetricians, perinatalogists, dieticians, substance-abuse counselors, social workers, geneticists, radiologists, and radiology technicians.) Health care professionals who are not trained to provide genetic counseling should be prepared to provide support related to genetic testing.

KEY TERMS

Abruptio placentae— Premature separation of the placenta from the uterine wall. Occurs late in pregnancy and results in bleeding that may or may not establish an obstetrical emergency.

Placenta previa— The placenta usually touches or implants on the posterior aspect of the uterus, away from the cervix. In a placenta previa, the location of implantation of the placenta is low in the uterus and may totally or partially occlude the cervix. A placenta previa may cause complications at delivery, such as excessive bleeding.

Preeclampsia— Also called pregnancy-induced hypertension or toxemia of pregnancy. A condition unique to pregnancy, preeclampsia symptoms include elevated blood pressure, protein in the urine (proteinuria), and edema. Exists in varying degrees of severity and can result in maternal seizure activity.

Resources

BOOKS

Pillitteri, A. Maternal & Child Health Nursing, 3rd ed. Philadelphia: Lippincott, 1999.

PERIODICALS

Morrison, E. H. "Update in Maternity Care: Periconception Care." Primary Care; Clinics in Office Practice 27, no. 1 (March 2000).

ORGANIZATIONS

Alliance of Genetic Support Groups. 4301 Connecticut Avenue NW, Suite 404, Washington, DC 20008-2304. (800) 336-4363, (202) 966-5557. Fax (202) 966-8553. 〈http://www.geneticalliance.org/〉.

National Clearinghouse for Maternal and Child Health. 2070 Chain Bridge Road, Suite 450, Vienna, VA 22182-2536. (888) 434-4624, (703) 356-1964. Fax (703) 821-2098. 〈http://www.nmchc.org/〉.

National Society of Genetic Counselors. 233 Canterbury Drive, Wallingford, PA 19086-6617. (610) 872-7608. 〈http://www.nsgc.org/faq_consumers.asp/〉.

OTHER

Issue: Role of the Registered Nurse in Support of Patients as Related to Genetic Testing. 〈http://209.236.2.215/new/positionstatements/genetictestingrole/genetictestingrole.html〉.