PREGNANCY COUNSELLING

General practi are sometimes consulted by women who state their intentions to "start a family" and ask for advice and a check-up. This provides a window of opportunity for health promotion, as it is thought that women are very motivated to alter unhealthy lifestyles at this time.

Preconceptual care is distinct from antenatal care It should include:

• 1 Informed choice, which helps women and men to understand health issues that may affect conception and pregnancy.
• 2 Women and their partners being encouraged to prepare actively for pregnancy, and be as healthy as possible.
• 3 Optimising management of chronic health problems.
• 4 Identifying couples who are at increased risk of having babies with a genetic malformation. Provide them with sufficient knowledge to make informed decisions.

A large number of pregnancies are unplanned - approximately a quarter in one study in Southampton. This and the haphazard seeking of pre-pregnancy advice by many patients means that many opportunities for pre-pregnancy counseling are missed. By the first antenatal visit, organogenesis is well underway and interventions to avoid malformations may be too late. For example, folic acid supplementation before conception and during the first trimester prevents the majority of cases of neural tube defect (NTD). Similarly, control of glucose in women with diabetes both before pregnancy and in early pregnancy helps to reduce the incidence of miscarriage, congenital malformation, stillbirth and neonatal death, so targeted care needs to occur before and in early pregnancy. Toxins such as alcohol can cause damage from the very early stages.

Efforts need to be made to offer preconception care opportunistically as part of other consultations - eg, contraception, diabetes or epilepsy reviews. Any couple being referred for infertility assessment should have had a full pre-conception assessment prior to further investigation or treatment. School-based programmes, in the context of children's reproductive and sex education, might offer better public health coverage.

Pre-conception counseling is also relevant to men. Their lifestyle and health may also affect pregnancy outcome.

Advice for all women

Timing of pregnancy

• 1 In couples having regular sexual intercourse every two or three days, and not using contraception, 84% will become pregnant within a year, and 92% within two years. The rest may take longer to conceive and some may need help or intervention.
• 2 Following use of the contraceptive injection, normal fertility may take up to a year to re-establish.

Folic acid

Supplementation with folic acid is one of the most significant preventative interventions available in the preconception / antenatal period:

• 1 All women should take at least 400 micrograms/day whilst trying to become pregnant and for at least the first three months of pregnancy to reduce the risk of NTDs.
• 2 Women at high risk of NTD should take a higher dose of 5 mg/day until 12 weeks of pregnancy. High risk is defined as:
  • - Where either partner has an NTD or has already had a pregnancy affected by NTD.
  • - Family history of NTD.
  • - Anti-epileptic medication.
  • - Coeliac disease.
  • - Diabetes (type 1 or 2).
  • - Thalassaemia trait (5 mg daily until birth of the baby).
  • - Haemolytic anaemia, particularly thalassaemia or sickle cell anaemia (5-10 mg until birth of the baby).
  • - Women with a BMI >30 kg/m2.
• 3 Diet alone (eg, green vegetables, fortified cereals) does not reliably supply adequate folic acid.

Cervical screening

• 1 Identify women who are at risk for cervical cancer.
• 2 Smears are not routinely taken during pregnancy, as pregnancy-related inflammatory changes make them difficult to interpret.
• 3 Many treatments cannot be carried out during pregnancy should an abnormality be detected.

Smoking

• 1 Smoking in pregnancy is associated with a large number of adverse effects including:
  • - Intrauterine growth restriction
  • - Miscarriage and stillbirth
  • - Premature delivery
  • - Placental problems
• 2 Also, ask regarding other smokers in the household, since smoking around a baby increases risk of sudden infant death and other respiratory diseases.
• 3 Give appropriate health education regarding the effect of smoking on pregnancy and more broadly. Offer referral to a smoking cessation service.
• 4 There is little information on the use of nicotine replacement therapy (NRT) in pregnancy but smoking gives a greater dose of nicotine and also exposes mother and fetus to other toxins. It is likely to be safer than smoking in mothers for whom non-pharmacological interventions have failed but risks and benefits should be fully discussed. NRT patches should be removed at night in pregnancy.
• 5 Advise that bupropion and varenicline should NOT be used in pregnancy.
• 6 Advise of the benefits of stopping smoking before pregnancy, so these concerns are not an issue.

Alcohol use

• 1 High levels of alcohol consumption during pregnancy may result in fetal alcohol syndrome (FAS). There are various components including growth restriction, intellectual impairment, facial anomalies and behavioral problems.
• 2 Advise women planning a pregnancy to avoid alcohol completely during the first trimester, as there appears to be a small increased risk of miscarriage associated with drinking alcohol.
• 3 National Institute for Health and Care Excellence (NICE) guidelines state there is no clear safe level of consumption but if women choose to drink alcohol during pregnancy, particularly after the first trimester, they should be advised to drink no more than 1-2 units, no more than twice a week. At this low level, there is no evidence of harm to the unborn baby. Guidelines further advise that women should avoid becoming drunk and binge drinking.
• 4 However, proposed guidelines from the Department of Health in January 2016 advised the safest advice to give women is that they should avoid drinking alcohol altogether throughout pregnancy.
• 5 Where a woman is unable to reduce her alcohol consumption with support in primary care, offer the specialist referral.

Body weight

• 1 Advise women who are overweight (BMI 25-29.9) or obese (BMI ≥30) to lose weight before becoming pregnant. A healthy weight reduces the risk of NTD, preterm delivery, gestational diabetes, cesarean delivery, hypertension and thromboembolic disease and is also more likely to promote conception. Similarly, women who are underweight may find getting pregnant difficult and be at risk of more pregnancy-related complications.
• 2 Whilst it is often impractical to achieve ideal body weight, women should be advised as to their increased risk of adverse pregnancy outcomes associated with their weight, particularly at BMIs >40. Consultation with a dietician may be helpful.