Pre-conception counseling

is based on the medical theory that all women of child-bearing years should be pre-screened for health and risk potentials before attempting to become pregnant.pregnant Physicians and baby experts recommend that a woman visit her physician as soon as the woman is contemplating having a child, and optimally around 3 to 6 months before actual attempts are made to conceive.

 This time frame allows a woman to better prepare her body for successful conception (fertilization) and pregnancy, and allows her to reduce any health risks which are within her control,,.fertilization  many agencies have developed screening tools that physicians can use with their patients. In addition, obstetricians have developed comprehensive check-lists and assessments for the woman who is planning to become pregnant. 3

In one sense, Pre-Conception Counseling and Assessment can be compared to a well-baby visit in which a baby is screened for normal health, normal development, with the benefit of identifying emerging problems that may have gone unnoticed in an infant 4

the Pre-Conception Counseling Assessment and Screening is intended to assess normal health of a child-bearing woman, while at the same time identifying:  Existing or emerging illness or disease which may have gone undetected before, and  Existing risks for the woman who may become pregnant, and  -Existing risks which may affect a fetus if the woman does become pregnant. 5

recommendations were developed for improving preconception health through changes in:  * consumer knowledge  * clinical practice  *public health programs  * health-care financing  * data and research activities. 6

- Each recommendation has specific action steps to improve maternal and child health outcomes. -The recommendations are aimed at achieving four goals, based on personal health outcomes 7

1) Goal 1. Improve the knowledge attitudes and behaviors of men and women related to preconception health. 1) *Goal 2. Assure that all women of childbearing age receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health. 8

1) *Goal 3. Reduce risks indicated by a previous adverse pregnancy outcome through interventions, which can prevent or minimize health problems for a mother and her future children. 1) Goal 4. Reduce the disparities in adverse pregnancy outcomes. 9

 The recommendations, which are not prioritized, should be used by: 1) Consumers 2) public health 3) clinical providers 4) researchers 5) policy makers. 10

Finally, these recommendations are designed to reduce disparities in maternal and infant health by improving the preconception health of women and men. 11

Obstacles to pre-conception counseling The most common obstacle to pre-conception counseling and assessment is 1) that many pregnancies are still unplanned Globally, 38% of pregnancies are unintended. Many unintended pregnancies result from failure to use birth control or failure to use it correctly; if a birth control method fails, there is no opportunity for pre-screening and assessment.unintended pregnanciesbirth control 12

2) The second most common obstacle to pre- conception counseling and assessment is that most women do not know, realize, or understand the benefits of visiting their physician before trying to become pregnant Most women still take for granted the biological aspects of becoming pregnant, and do not consider the extreme value of pre-screening before becoming pregnant. 13

3) The third most common obstacle to pre-conception counseling and assessment may be the lack of health insurance.health insurance However, most insurances will cover this as a screening visit. Also, many physicians will do the pre- conception screening during a regular office visit or gynecological visit if the woman just informs the doctor of her desire to become pregnant. 14

**What is involved in pre-conception counseling? Pre-screening covers many body-system areas (not just the reproductive organs), as well as aspects of the woman's lifestyle and family history information. It begins with basic information and becomes more in- depth, especially if the woman has had previous illnesses, diseases, etc. Pre-screening assessments begin with a questionnaire which the woman fills out, generally before seeing the physician. Some offices have the woman go over parts of the questionnaire with a Nurse Practitioner, if available.Nurse Practitioner 15

Preconception checklist: Questions you'll be asked at your checkup  As soon as you start thinking about trying to get pregnant, you'll want to see your health practitioner for a checkup to help you determine what steps you may still need to take to become physically and emotionally ready.  The first thing your practitioner will do is ask you lots of questions about your health and lifestyle to figure out how current or past conditions may affect your pregnancy. If you already have a history on file, she may only ask for missing information. 16

Here's a list of the questions you'll probably be asked Age 1) How old are you? 2) How old is your partner? Gynecological history 1) When did your last menstrual period start? 2) Are your periods regular? 3) What kind of birth control are you using now,?birth control 4) what kinds have you used in the past? 5) Have you ever tested for ovulation? 17

6) Have you ever had an abnormal Pap smear? 7) Have you or your partner ever been diagnosed with a sexually transmitted infection? 8) Have you ever been diagnosed with pelvic inflammatory disease? 9) Have you ever been tested for HIV? 10) Have you ever been told you have uterine abnormalities? 11) Do you have any history of ovarian cysts? 12) Have you ever had any kind of gynecological surgery? 13)Have you ever been treated for infertility? 18

Gynecological history 1) When did your last menstrual period start? 2)Are your periods regular? 3)What kind of birth control are you using now, andbirth control 4)what kinds have you used in the past? 5)Have you ever tested for ovulation? 6)Have you ever had an abnormal Pap smear? 7)Have you or your partner ever been diagnosed with a sexually transmitted infection? 19

8) Have you ever been diagnosed with pelvic inflammatory disease? 9) Have you ever been tested for HIV? 10) Have you ever been told you have uterine abnormalities? 11)Do you have any history of ovarian cysts? 12)Have you ever had any kind of gynecological surgery? 13)Have you ever been treated for infertility 20

Obstetric history NOTE: If you've had complications during a pregnancy, labor, or delivery that your practitioner is unaware of, bring the related medical records with you to your checkup. 21

1)Have you ever been pregnant before? 2)Have you ever had a miscarriage? If so, how many weeks pregnant were you? Did you have a D&C? Were there complications? Do you know the cause of the miscarriage?miscarriage 3)Have you ever had an ectopic pregnancy? If so, how many weeks pregnant were you? Did you have surgery?ectopic pregnancy 4)Have you ever had an abortion? If so, in which trimester? Were there any complications?abortion 22

5)For each child you've given birth to: What was the birth date? Place of birth? How many weeks gestation? Gender? Birth weight? What kind of delivery? Any labor or delivery complications? 6)Have you ever had preterm labor or delivery?preterm labor or delivery 7)Have you ever had a cesarean section?cesarean section 8)Have you ever had pregnancy complications, such as preeclampsia, gestational, or placental problems?placental problems 23

Medical history 1)Have you ever had any serious medical problems? 2)In particular, do you have diabetes, hypertension, epilepsy or other seizure disorders, kidney disease, hepatitis or other liver disease, heart disease, a clotting disorder, lung disease including asthma, thyroid disease, cancer, or a connective tissue disease such as lupus or rheumatoid arthritis? 24

3) Has anyone in your family ever had diabetes, hypertension, a stroke, epilepsy or other seizure disorders, kidney disease, hepatitis or other liver disease, heart disease, a clotting disorder, lung disease including asthma, thyroid disease, cancer, or a connective tissue disease such as lupus or rheumatoid arthritis? 4)Do you have any digestive problems? 5)Have you ever been hospitalized? 6)Have you ever had any operations? When and why? Have you ever had problems with anesthesia? 25

7)Have you ever had a blood transfusion? 8)Are you being treated for any conditions right now? 9)What prescription or over-the-counter medications are you taking (including any herbs, vitamins, or supplements) and at what dose? 10)Are you taking prenatal vitamins? 11)Are you allergic to any drugs? Any other allergies? 12)Have you been exposed to any infectious diseases? 13)Is there anyone in your household who has or had hepatitis? Tuberculosis? 26

Vaccination history NOTE: If you have a record of your immunizations, bring it with you to your appointment. 1) Have you ever had chicken pox or been vaccinated against it?chicken pox 2) Did you complete your childhood vaccinations for measles, mumps, and rubella? Have you ever been tested for rubella immunity? 3)Have you ever been vaccinated against hepatitis B?hepatitis B 4) When was your last tetanus booster? 27

Emotional and social history 1)Have you ever suffered from mental or emotional problems, including depression or an eating disorder? 2)Have you ever been a victim of domestic violence? In your current relationship, do you ever feel threatened or are you physically or verbally abused? 28

Lifestyle questions 1)Do you smoke or use tobacco products, or are you exposed to secondhand smoke? 2)Do you use recreational drugs? 3)Do you drink coffee or other caffeinated beverages? 4)Do you see a dentist regularly? 5)Do you exercise regularly? 6)Do you have trouble maintaining a healthy weight? 7)Do you follow any particular kind of diet or have any dietary restrictions? 29

8)Do you eat a lot of fish? 9)Do you ever eat raw or undercooked meat, fish, or eggs? 10)Do you have pets or do any gardening? 11)Do you regularly use hot tubs or saunas? 12)What do you do for a living? Do you work with small children? Do you or your partner live or work near any possible hazards, such as paints or solvents, pesticides, radiation (X-rays), lead, or mercury 30

Genetic screening Has anyone in your family or your partner's family ever had: 1) Hemophilia or other bleeding disorders? 2) Blood diseases such as sickle cell anemia or thalassemia? Sickle cell trait? 3) Muscular dystrophy? 4)Down syndrome or mental retardation? Other developmental delays? 5)Premature menopause? 31

6)Cystic fibrosis? 7)Glycogen storage diseases? 8)Birth defects such as spina bifida or heart or kidney defects? 9)Phenylketonuria (PKU)? 10)Any genetic disorders or chromosomal abnormalities? Multiple miscarriages? 11)Does your partner have other children from a previous relationship? If so, do they have any problems? 12)Is there anything else I haven't asked you that you think might be important? 32

Blood work: Certain blood work may be ordered. This often includes a CBC (Complete Blood Count) which can show anemia.CBCanemia A CBC includes WBC (White Blood Cell Count) which can show the presence of infection.WBC Anemia and infection, indicating problems with the woman's overall health at that moment, can both affect a woman's ability to become pregnant at that time as well as affect the stability of the pregnancy and health of the fetus. Anemia may require ongoing evaluation and iron supplement. 33

Urine analysis :  Urine sample or urinalysis can reveal the presence of proteinuria, a possible indicator of infection or kidney disease, or the presence of blood which can indicate a urinary tract infection.urinalysisproteinuriaurinary tract infection  Urinalysis might also show the presence of glucose (glycosuria), but women of child bearing age are unlikely to have undiagnosed diabetes (this is separate from gestational diabetes that may occasionally develop during the course of a subsequent pregnancy).glycosuriagestational diabetes 34

Using the assessment * Physicians:  The areas a physician will assess are too numerous to include here. When women have pre-existing illnesses / conditions / diseases, these may add to pre-natal risks and will need ongoing evaluation.  Also any medications which are used to treat these conditions will need monitored and possibly reduced or increased.  The presence of Diabetes remains a huge risk for the unborn child, and a woman will be screened specifically for this condition.  Known diabetics will need monitored closely. 35

The woman's role  A woman may need to adjust certain aspects of her health and well-being which are in her control.  These usually include aspects of lifestyle  drug and alcohol use  exercise, rest and stress reduction.  she may need to discontinue certain herbs or over-the- counter medications as recommended by the physician.  Many physicians will also recommend pre-natal vitamins before a woman actually conceives in order to boost her overall health. 36

Folic acid supplements and pregnancy  If you take folic acid tablets (supplements) in early pregnancy you reduce the risk of having a baby born with a spinal cord problem such as spina bifida.  This is because the early development of the baby's spinal cord requires a regular, good supply of folic acid.  There is also evidence that folic acid also reduces the risk of having a baby born with a cleft lip and palate, a heart defect (congenital heart disease), and the risk of a premature (preterm or early) labor. 37

 Ideally, start taking folic acid tablets before becoming pregnant. The common advice is to start from the time you plan to become pregnant.  If the pregnancy is unplanned then start taking folic acid tablets as soon as you know that you are pregnant.  However, a recent study looked at the effect of taking folic acid for a year prior to becoming pregnant.  This study looked at the effect folic acid had on reducing preterm labor and delivery of the baby (that is, of having a 'prem' baby). 38

 The study found a significant decrease in the rate of preterm delivery for women who took folic acid for one year prior to becoming pregnant. So, you may wish to consider taking folic acid tablets well before you plan to become pregnant.  Continue to take folic acid tablets for the first 12 weeks of pregnancy.  What dose should I take? For most women the dose is 400 micrograms (0.4 mg) a day. 39

 If your risk of having a child with a spinal cord problem is increased then the dose is higher (5 mg a day - you need a prescription for this higher dose). That is, if: 1) you have had a previously affected pregnancy 2) you or your partner have a spinal cord defect 3) you are taking medication for epilepsy 4) you have celiac disease, diabetes, sickle cell anemia, or thalassaemia. 40

 In addition to folic acid supplements, you should eat a healthy diet when you are pregnant which should include foods rich in folic acid. 1)Spinach 2) Aspargus 6) Egg yolk 3)Baker yeast 7) Fortified grain 4)Beans 8) Peas 5)Lentils 41

Conclusion Pre-conception counseling, assessment and screening can aide the woman and her unborn child if she conceives. Attention to areas which can be controlled,, can improve a woman's chances to conceive as well as improve the in- utero environment of the fetus and improve the overall health of the fetus. Pre-conception counseling, assessment and screening also assists the physician in being aware of pre-existing conditions and areas of potential problems so that he/she can better evaluate and guide the woman-patient 42

 Women who are thinking of getting pregnant should see their physician first, before stopping their current birth control.  Investment of time, energy and attention to potential problems during a pre-conception planning stage can greatly benefit both the woman and future pregnancy 43