When in pregnancy is the best time to make your first appointment? The answer may surprise you. It’s before you become pregnant. This is especially important if you are planning to have your first baby, have a known medical problem, had previous pregnancy complications, or a family history that might put you or your baby at risk.
A preconception visit is an opportunity to review past medical, obstetric, family and social history that could have a significant impact on the outcome of your pregnancy. You should come to the visit prepared to be open and forthright with your provider about your past and current medical problems; medications; and family, obstetric, and sexual history. Ideally, you should come with your partner; however, if there are things about the past that you may not wish your partner to know, then the first visit may be better made alone. Under those circumstances, it is most helpful if you can gather pertinent personal, genetic and family history regarding your significant other so that this information can be integrated into the counseling session.
Here are just a few ways preconception counseling contributes to a healthy outcome for your baby and why you should consider counseling:
Prenatal vitamins are well balanced and contain at least 400 mcg of folic acid. Folic acid taken before conception can significantly reduce the risk for neural tube defects (failure of complete closure of the spine) and also may reduce the risk for other abnormalities involving the face, abdominal wall and even the heart.
The spine closes between 24 and 28 days after conception, approximately six weeks from the start of the last normal menstrual period, and the heart is almost completely formed between days 35-56. These developments may be weeks before a woman sees her provider for the first obstetric visit. So, if folic acid is not begun before conception, the opportunity to derive a benefit from its use may be easily missed.
If you or any other family member has had a baby with a neural tube defect or heart abnormality, the dosage of folic acid can be safely increased to 4,000 mcg and may reduce your risk for a baby with such problems by 70 percent or more. This dose of folic acid also often is prescribed to women being treated for seizure disorders or diabetes or taking other medications known to be associated with these birth defects.
Prenatal vitamins also contain appropriate amounts of the fat-soluble vitamins A, D and E. Taken in excess before conception or during the early stages of fetal development, these vitamins can be harmful to a baby. In fact, if you have been on high doses of vitamin A for a prolonged period or have taken a medicinal vitamin A derivative such as Accutane for acne, you should not get pregnant for at least three months after discontinuing the drug.
If you work with young children or immunosuppressed individuals or have a young child in a daycare setting, you should consider being screened for previous exposure to parvovirus B19 (the cause of fifth disease) and cytomegalovirus (CMV) before conception. Both of these viruses are very common, especially in young children, and both can cause serious problems for a fetus if the mother develops a primary infection during a pregnancy. Both viruses can cause first-time infections in mothers that are unrecognized or show no symptoms and may still have severe consequences for the baby.
If you are found already to have protective antibodies to these viruses, indicating previous exposure, you are at as low risk as possible for serious fetal infection. If you do not, since no vaccine is available for either virus, your doctor can discuss how you can minimize risk of exposure during a pregnancy.
If you have a chronic medical condition, the goal is to optimize therapy before conception. This approach involves evaluating current disease status, reviewing medications and stabilizing the condition, making you as normal as possible, with treatment that has the highest likelihood of minimizing fetal risk from the disease and from the medications used to treat the condition—particularly in the first trimester.
Common medical problems include diabetes, obesity, hypertension and thyroid disease. Of these, diabetes is of great concern for the baby during the first four to eight weeks of development. Poorly controlled diabetes in the first trimester is associated with at least a two to four-fold risk for major birth defects, especially of the heart, spine and abdominal wall.
Bringing maternal blood sugars into normal range before conception and maintaining good control during early fetal development has been shown to lower birth defect rates to levels close to those of the general population. Again, unless you are seen before conception, the opportunity to achieve this level of diabetic control often is missed.
There are growing concerns that women with hypothyroidism, even when subclinical (that is, not showing symptoms), may be at risk for recurrent miscarriage, preterm birth and neuropsychological impairment of their offspring.
Thyroid disease is very common in reproductive age women. Currently, it is recommended that only women with a personal or family history of thyroid disease or an autoimmune disorder, recurrent pregnancy losses, or symptoms of thyroid disease be screened; however, targeted screening detects only about two-thirds of hypothyroid women. Because the cost of screening is low and the treatment so simple and safe, there are now many advocates for universal screening in women anticipating pregnancy.
Obesity also has been shown to be associated with adverse pregnancy outcome, including reduced fertility, miscarriage, pre-gestational and gestational diabetes, pregnancy-induced hypertensive disorders, preterm births, multiple gestations, urinary tract infections and risk for cesarean section. If you are overweight, you are encouraged to consider a weight reduction program involving diet, exercise, behavior modification and even bariatric surgery before conceiving.
If you have had problems with previous pregnancies, preconception counseling can be a big benefit. Even if physicians can’t always identify the underlying causes, they do know that obstetric history tends to repeat itself. The issues of concern range from hypertensive disorders, gestational diabetes, small babies, large babies, blood clots and bleeding problems to the most common repetitive complications of preterm labor and delivery. The earlier you can be monitored for possible recurrence of a problem pregnancy, the more likely measures can be taken to minimize or prevent a poor outcome.
Preconception counseling provides an excellent opportunity to evaluate risk factors for chromosomal abnormalities and heritable conditions. Although anyone can have a baby with a chromosomal abnormality, the risk for these increases with maternal age. Balanced chromosomal rearrangements in a parent also account for up to five percent of cases of recurrent pregnancy loss.
Other indications for genetic counseling include a known or suspected hereditary disease in a parent or family member, family history of birth defects, chromosomal abnormalities or developmental delay, and ethnic background. Common examples for which screenings are available include cystic fibrosis, hemoglobinopathies (e.g., sickle cell disease and thalassemia), fragile X syndrome, hemophilia, muscular dystrophy, Huntington’s chorea and a host of metabolic disorders that have higher prevalence in certain ethnic groups (e.g., Tay-Sachs disease in individuals of Jewish and Cajun descent). The genes for these conditions are carried in some populations at much higher frequencies than most patients realize and usually are not recognized in the individuals who are only “carriers.”
There’s nothing like having a good conversation about this most important life event with a caring physician who can answer your questions, give you medical advice and offer wise counsel. Preconception counseling offers an opportunity to provide an ounce of prevention and preparation that can minimize preventable pregnancy complications and unnecessary grief. It also helps you prepare for the joy and the responsibilities of bringing a healthy child into the world.
If you believe you would benefit from preconception counseling with a maternal-fetal medicine specialist, ask your primary care doctor for more information.
Division of Maternal-Fetal Medicine
Department of Obstetrics & Gynecology
890 W. Faris Road, Suite 470
Greenville, SC 29605
1120 Grove Road, Suite B
Greenville, SC 29605
2000 E. Greenville St., Suite 4600
Anderson, SC 29621
101 Gregor Mendel Circle
Greenwood, SC 29646
22725 Hwy. 76 East
Clinton, SC 29325
1351 Crestview Road
Easley, SC 29642
Phone: (864) 455-1600