PRECONCEPTION HEALTH CARE

• Why is a preconception check up important ?
• What does agenetic councelor do ?
• Why should women of childbearung age take a folic acid ?
• What vaccines might a woman need before pregnancy ?
• What maternal illness should be treated before pregnancy ?
• How long should a woman wait between pregnancies ?
• How can preconception care help prevent problem that occurred in past pregnancies ?
• What can a woman do to help stay healthy before pregnacy ?
• Why should a woman try to achieve a healthy weight before pregnancy ?
• References

Preconception health care is care a woman of childbearing age receives before pregnancy or between pregnancies. This type of care looks at biomedical, behavioral and social risk factors that may affect a woman’s health. The goal is to provide information and treatment before pregnancy that can improve a woman’s health and help reduce risks to her future baby.

All women of childbearing age can take steps before they get pregnant to improve their chances of having a healthy, full-term baby. By getting preconception health care, a woman can learn what steps she can take before pregnancy to protect her health and give her baby the best chance to be healthy.

Why is a preconception checkup important?
A preconception checkup can help assure that a woman is as healthy as possible before she conceives. Her provider can identify and often treat health conditions that can pose a risk in pregnancy, such as high blood pressure, diabetes or certain infections. The provider can give her information on things like nutrition, weight, smoking , drinking alcohol and occupational exposures that can pose pregnancy risks. The provider also can make sure a woman’s vaccinations are up to date and that any medications she takes are safe during pregnancy.

The provider can ask a woman about her health history, as well as that of her partner and her family. If the woman or her partner has a history of birth defects or prematurity, or if either has a high risk for a genetic disorder based on family hystory, ethnic background or age, the provider may suggest seeing a genetic concelor.

What does a genetic counselor do?
A genetic counselor discusses the risks for a genetic disease in a couple’s future children. The counselor can arrange blood tests (called carrier tests) that can identify carriers of many genetic diseases. If both parents are carriers of a disease, each child has a 25 percent chance of inheriting the disease. Carrier tests are given for a variety of conditions, including:

• Cystic fibrosis CF), a disease of the lungs and digestive system that is most common in Caucasians, but can affect children from many backgrounds
• Tay – Sachs disease, which causes fatal brain damage and is more common in people of Eastern European Jewish ancestry and in some non-Jewish individuals of French-Canadian and Cajun ancestry
• Sickle cell disease, a blood disorder that mainly affects African-Americans
• Thalassemia, a blood disorder that mainly affects those of Mediterranean, African and South Asian descent

Genetic screening and counseling before pregnancy may reassure a couple that their children are not at increased risk for a specific inherited disease. Genetic counseling also allows carriers the opportunity to understand their risk and discuss options. Women who can benefit from genetic counseling include:

• Women over age 35
• Women who have certain genetic disorders, such as phenylketonuria (PKU)
• Women who have had a child with a neural tube defect (NTDs), a birth defect of the brain and spinal cord

Why should women of childbearing age take folic acid?
Folic acid is a B vitamin that can help prevent birth defects, particularly NTDs. Studies show that if all women consumed the recommended amount of folic acid before and during early pregnancy, up to 70 percent of all NTDs could be prevented ^{(1, 2)}. Studies also suggest that folic acid may help prevent some other birth defects, including cleft lip and palate and some birth defects involving the heart ⁽¹⁾. A recent study also suggests that women who take folic acid for a least 1 year before becoming pregnant may reduce their risk of having a premature baby ⁽⁴⁾.

To prevent NTDs, most clinicians recommends that all women who could become pregnant take a multivitamin containing 400 micrograms of folic acid every day starting before pregnancy, along with eating healthy foods. This advice, based on recommendations from the Institute of Medicine (IOM) ⁽³⁾, assures that a woman gets all the folic acid and other vitamins she needs.

A woman also can get folic acid by eating a serving of folic acid-enriched cereal every day that contains 100 percent of the daily value (DV) of folic acid (400 micrograms). Healthy food choices include foods that are fortified with folic acid and foods that contain folate, the natural form of folic acid found in foods. Many grain products, including flour, rice, pasta, bread and cereals, are fortified with folic acid. Folate-rich foods include green leafy vegetables, dried beans, legumes, oranges and orange juice.

A woman who has had a pregnancy affected by an NTD should take a higher dose of folic acid. Taking a higher dose of folic acid daily (4,000 micrograms or 4 milligrams), beginning at least 1 month before pregnancy and in the first trimester of pregnancy, reduces by about 70 percent the risk of having another affected pregnancy ⁽⁵⁾. Women with diabetes or epilepsy and women who are obese are at increased risk of having a baby with an NTD ⁽¹⁾. Women with these conditions should consult their providers before pregnancy about taking a larger dose of folic acid.

What vaccines might a woman need before pregnancy?
At a preconception visit, the health care provider may do a blood test to see if a woman is immune to rubella (German measles) and chickenpox. Both of these diseases can cause birth defects and other complications if a woman gets them during pregnancy.

If a woman is not immune, she should be vaccinated before pregnancy. She should then wait 1 month after vaccination before attempting to get pregnant.

Women who are at high risk for hepatitis B (such as health care workers) and have not been vaccinated for it should consider getting the hepatitis B vaccine before or during pregnancy. This disease can be passed on to the baby during delivery. A provider also may recommend other vaccines, such as the flu shot.

What maternal illnesses should be treated before pregnancy?

• Diabetes: Women with poorly controlled diabetes that started before pregnancy are about 3 times more likely than women without diabetes to have a baby with a serious birth defect (6). They also are at increased risk for miscarriage and stillbirth and for having a baby that is very large. Controlling blood sugar before pregnancy and during the first few months of pregnancy can help prevent birth defects.
• High blood pressure: Chronic high blood pressure can increase the risk of pregnancy complications, including placental problems (solusio placenta), poor fetal growth and preeclampsia (a pregnancy-related disorder characterized by high blood pressure and protein in the urine).
• Systemic lupus erythematosus (SLE): This autoimmune disorder can cause arthritis-like symptoms, kidney disease, skin rashes and other problems. Affected pregnant women are at increased risk for miscarriage, poor fetal growth, preterm labor and stillbirth ⁽⁷⁾ . However, if symptoms are well controlled before pregnancy, the risk of these complications is reduced.
• Seizures: Some seizure control medications increase the risk of birth defects. During a preconception visit, a provider may adjust a woman’s dose or switch her to a drug that is safer for the fetus. A woman should not stop taking seizure medication without asking her provider, as seizures themselves might harm a fetus.
• PKU: Women with this inherited condition cannot process certain proteins. They must eat a special diet and be carefully monitored before and during pregnancy to prevent mental retardation and birth defects in their offspring ⁽⁶⁾ .
• Kidney disease: Some women with severe kidney disease may suffer additional kidney damage during pregnancy, and their babies may be at increased risk for death, premature delivery or poor growth ⁽⁷⁾ .

How long should a woman wait between pregnancies?
For most women, it’s best to wait at least 18 months before getting pregnant again. This gives a woman’s body enough time to get ready physically for another pregnancy. It also gives her time to adjust to life as a mom. Shorter time intervals between pregnancies may increase the risk of premature birth ⁽⁸⁾ . However, not all women can wait 18 months because of their age or other reasons. A woman should talk to her health care provider to determine the right amount of time for her.

How can preconception care help prevent problems that occurred in past pregnancies?
Even if a woman has not had problems in a previous pregnancy, preconception care can help prevent birth defects or pregnancy complications in a future pregnancy. For example, taking folic acid can help prevent NTDs, and treatment of certain health conditions, such as high blood pressure, can help prevent premature delivery. A 2006 report from the Centers for Disease Control and Prevention (CDC) recommends that all women who have had a previous pregnancy that ended in an adverse outcome receive evaluation and treatment between pregnancies to reduce the risk in future pregnancies ⁽⁶⁾.

Preconception care is important for women who have had a miscarriage, stillbirth or premature delivery. The health care provider can review a woman’s medical record and may recommend tests to help determine the cause of an adverse outcome. The tests may include blood tests and imaging tests, such as ultrasound. If tests show that a health problem in the woman may have contributed to the outcome, treatment between pregnancies often can reduce the risk of the problem recurring in another pregnancy. If a woman had a previous premature delivery, the provider may recommend lifestyle changes, such as quitting smoking, and discuss the possibility of treatment with the hormon progesterone during her next pregnancy to help reduce the risk of another premature delivery.

What can a woman do to help stay healthy before pregnancy?
A woman should:

• Avoid alcohol. Drinking alcohol during pregnancy can cause physical and mental birth defects called fetal alcohol syndrome (FAS). Because no amount of alcohol has been proven safe in pregnancy, pregnant women and women considering becoming pregnant should avoid it entirely.
• Quit smoking. Smoking during pregnancy nearly doubles the risk for having a low-birthweight baby. It also increases the risk for premature delivery, other pregnancy complications and sudden infant death syndrome (SIDS) (9). Smoking also may make it more difficult to conceive ⁽⁹⁾ .
• Stay away from cocaine and other illicit drugs and prescription drugs not prescribed for her. These drugs pose many risks, including premature delivery, low birthweight , birth defects, learning or behavioral problems, and withdrawal symptoms.
• Fully cook all meat and don’t change a cat’s litter box. Undercooked meat and cat feces can contain a parasite that causes an infection called toxoplasmosis, which can cause birth defects. Another way to avoid cat feces is to wear gloves when working in the yard or garden.
• Avoid contact with all rodents, including pet hamsters, mice and guinea pigs. These animals can carry a virus that can harm your baby ⁽¹⁰⁾ .
• Avoid sitting in hot tubs and saunas. These may elevate body temperature and, possibly, increase the risk for NTDs ⁽¹⁾ .
• Avoid hazardous chemicals, such as solvents (substances that dissolve other substances, like paint thinner). Working with solvents may increase a woman’s risk for miscarriage or having a baby with birth defects ⁽¹¹⁾ .
• Avoid eating fish that can be high in mercury. Mercury is a metal that can harm an unborn baby; it often is found in fish. Pregnant women and women considering pregnancy should not eat fish that are high in mercury, like shark, swordfish, king mackerel and tilefish ⁽¹²⁾ . These women can eat up to 12 ounces per week of fish that are low in mercury, including shrimp, salmon, pollock, catfish and canned light tuna. They should eat no more than 6 ounces of albacore (white) tuna per week. Women should always check with their local health department before eating any fish they catch themselves ⁽¹²⁾ .

Why should a woman try to achieve a healthy weight before pregnancy?
Women who begin pregnancy overweight or obese may be at increased risk of having high blood pressure and diabetes, having a baby with certain birth defects, having labor and delivery complications, and having a stillborn baby ^{(6, 7)} . They also may have more difficulties becoming pregnant ⁽¹³⁾ . Women who are underweight may be at increased risk of having a premature or low-birthweight baby ⁽⁷⁾ . A woman can help reduce her risk for these complications by attaining a healthy weight before pregnancy.

References

1. Centers for Disease Control and Prevention (CDC). Folic Acid: Frequently Asked Questions. Updated 1/30/08.
2. Berry, R.J., et al. Prevention of Neural Tube Defects with Folic Acid in China. New England Journal of Medicine, volume 341, number 20, November 11, 1999, pages 1485-1490.
3. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes: Folate, Other B Vitamins, and Choline. Washington, D.C., National Academy Press, April 7, 1998.
4. Bukowski, R., et al. Preconception Folate Prevents Preterm Delivery (abstract). American Journal of Obstetrics and Gynecology, Special Supplement, Society for Maternal and Fetal Medicine 28th Annual Meeting, volume 197, number 6, December 2007.
5. Centers for Disease Control and Prevention (CDC). Folic Acid: PHS Recommendations. Updated 7/26/05.
6. Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR). Preconception Care Work Group and the Select Panel on Preconception Care. Recommendations to Improve Preconception Health and Health Care – United States. Morbidity and Mortality Weekly Reports, volume 55, no. RR-6, April 21, 2006.
7. American College of Obstetricians and Gynecologists (ACOG). Your Pregnancy and Birth, 4th edition. ACOG, Washington, DC, 2005.
8. Conde-Agudelo, A., et al. Birth Spacing and Risk of Adverse Perinatal Outcomes. Journal of the American Medical Association, volume 295, number 15, April 19, 2006, pages 1809-1823.
9. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General – 2004. Office on Smoking and Health, Atlanta, GA..
10. Centers for Disease Control and Prevention (CDC). Lymphocytic Choriomeningitis Virus (LCMV) and Pregnancy: Facts and Prevention. Updated 9/20/06. .
11. Khattak, S., et al. Pregnancy Outcome Following Gestational Exposure to Organic Solvents. Journal of the American Medical Association, March 24/31 1999, volume 281, number 12, pages 1106-1109.
12. U.S. Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA). What You Need to Know About Mercury in Fish and Shellfish. Accessed 5/4/06.
13. American Society for Reproductive Medicine. Patient’s Fact Sheet: Weight and Fertility. Revised 8/01, accessed 5/8/06.

Reviewed by Bambang Widjanarko, 0bstetrician&gynecologist

Juni 2009