Preconception Care and Pregnancy

Preconception Care

Preconception counseling: Many women seek advice from their primary care physician before trying to conceive. Preconception counseling includes the following:

• review of medications for teratogenic risks

• ensuring chronic conditions are well controlled

• recommending folic acid supplementation

• ensuring vaccines are up to date, including influenza and Covid-19

• assessment for dangerous environmental exposures, including Zika virus

• discussion of family genetic history

• screening for depression and anxiety disorders; intimate partner violence; and alcohol, tobacco, and illicit drug use

Recommendations for Preconception Counseling and Care is a comprehensive guide developed by the American Academy of Family Physicians (AAFP).

Key considerations prior to pregnancy:

• Folic acid supplementation: All women contemplating pregnancy (and all women using inadequate contraception who are at risk of pregnancy) should begin a folic acid supplement to reduce the risk of neural tube defects.

• Immunization status: Consider screening for varicella and rubella with routine labs before conception because live vaccines can’t be administered during pregnancy.

• Medication reconciliation: A thorough medication reconciliation should be performed, with discontinuation or replacement of medications that are known to be teratogenic and encouragement to continue medications that are clinically necessary.

For more guidance and information on medication safety during pregnancy, see Over-the-Counter Medications in Pregnancy and the table below of AAFP medication guidelines for common medical conditions in women considering pregnancy:

(Source: Recommendations for Preconception Counseling and Care. Am Fam Physician 2013. Reprinted with permission.)

Pregnancy

Comanagement of Medical Issues during Pregnancy

It is important to know how to manage chronic medical problems, such as diabetes, hypertension, depression, asthma, and hyperlipidemia throughout pregnancy. See the table above and the reviews and guidelines associated with this rotation guide for more information on the management of specific conditions, including diabetes, chronic hypertension, asthma, venous thromboembolism, and depression. Keep in mind the following general points:

• Contraindications: Some medications commonly used to treat these conditions are contraindicated in pregnancy.

• Dose adjustment: The dose of some medications (e.g., levothyroxine) needs to be increased during pregnancy.

• Pain management: Acetaminophen is generally considered safe, but nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in pregnancy.

Medication exposure during breastfeeding: After delivery, breastfeeding mothers often have similar questions and concerns about medication safety. The National Library of Medicine’s Drug and Lactation Database (LactMed) provides information on drug safety during breastfeeding and suggests therapeutic alternatives.

Covid-19 vaccination in pregnancy: The Centers for Disease Control and Prevention (CDC) recommends that all persons older than 6 months, including pregnant, recently pregnant, and lactating individuals, complete a primary two-vaccine Covid-19 series followed by an updated booster vaccine.

First-Trimester Bleeding

Some women with confirmed pregnancy present to the primary care office with first-trimester bleeding. The following algorithm is a helpful guide for the evaluation of patients with bleeding during the first trimester:

(Source: Reproductive Health Access Project 2017.)