The Best Prenatal Care Begins Before Conception
A preconceptional visit is a lot more than meeting the person with whom you will be very intimate over the course of a year and during one of the most vulnerable periods of your life, although that is important too. It is an opportunity to review past medical, obstetrical, family, and social history that could have a significant impact on the outcome of a pregnancy. A woman should come to a preconceptional visit prepared to be open and forthright with her provider about her past and current problems, medications, sexual history, obstetrical history and the like. Ideally, she should come with her partner; however, if there are things about the past that she does not want her partner to know, then that first visit may be better made alone. Under those circumstances, it is most helpful if she can gather pertinent personal, genetic, and family history regarding her significant other so that this can be integrated into the counseling session. Let me provide just a few examples of where preconceptional counseling can make a big difference.
• If not offered at the time of the visit, ask your provider for a prescription prenatal vitamin. These are ‘well-balanced’ and most contain 400mcg of folic acid. Folic acid taken prior to conception can significantly reduce the risk for neural tube defects (failure of complete closure of the spine) and may also reduce the risk for other ‘midline defects’ involving the face, abdominal wall, and even the heart. If you or any other family member has had a baby with a neural tube defect, the dosage of folic acid can be safely increased to 4000mcg and may reduce your risk for a baby with such a problem by 70% or more. The spine closes between 24 and 28 days after conception, about 6 weeks from the start of the last normal menstrual period, and usually weeks before someone will get to see their provider for the first obstetrical visit. So, if folic acid is not begun prior to conception, the opportunity to derive a benefit from its use may be easily missed.
• Prenatal vitamins also contain appropriate amounts of the ‘fat soluble vitamins,’ vitamins A, D, and E. Taken in excess, these vitamins can be harmful to a baby, so if you are currently supplementing your diet with ‘megadoses’ of these or any other over-the-counter preparations (yes, even ‘natural herbal’ compounds), you should make your provider aware of what these are and, if there is any question of safety, discontinue them prior to conception. In fact, if you have been on high doses of vitamin A for a prolonged period, or taken a medicinal vitamin A derivative such as Accutane(TM) for acne, you should probably not get pregnant for at least 3 months after discontinuing the drug.
• If you work with young children, immunosuppressed individuals, or have a young child in a day care setting, you should consider serologic screening for previous exposure to parvovirus B19 (the cause of “Fifth’s disease”) and for 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. Also, both viruses can cause unrecognized or completely “asymptomatic” primary infections in the mother that may have just as severe consequences for the baby. If you have protective IgG antibody to these viruses, indicating previous exposure, you are at as low a risk as possible for serious fetal infection. If you do not, since no vaccine is available for either virus, you should minimize risk of exposure during a pregnancy to potential sources of infection, and even consider repeat serologic screening in each trimester to see if you have “seroconverted” as the result of an asymptomatic infection. Any respiratory tract illness with fever during pregnancy might also be seen as a reason to rescreen the known seronegative woman.
• If a woman has a chronic medical condition, the goal should be to optimize therapy prior to conception. This involves evaluating current disease status and stabilizing the condition, making the woman as ‘normal’ as possible, with treatment that has the highest likelihood of minimizing fetal risk (from standpoints of both the disease and the therapy) in the first trimester. The most common problems we deal with are hypertension, thyroid disease, and diabetes. Of these, diabetes is probably the greatest concern for the baby during the first 6-8 weeks of development. For reasons that are still not clear, poorly-controlled diabetes in first trimester is associated with at least a 2-4-fold risk for major anomalies, especially of the heart, spine, and abdominal wall. Bringing maternal blood sugars into normal range during ‘embryogenesis’ has been shown to lower the anomaly rate to levels close to those of the general population. Again, unless the woman is seen prior to conception, the opportunity to achieve this level of diabetic control is often missed. (By the way, diabetics are one group of patients I will routinely offer 4000mcg folic acid daily to prior to conception).
• If there have been problems with the past obstetrical history, this is a major reason for seeking preconceptional counseling since, even if we sometimes aren’t smart enough to figure out why, we do know that obstetrical history tends to repeat itself. The issues of concern here range from hypertensive disorders, gestational diabetes, small babies, large babies, blood clots, and bleeding problems to the most common repetitive complication, preterm labor and delivery. We have devoted several posts to the latter, but I wanted to revisit it again briefly here. Yesterday, I took care of a woman who presented to our service for the first time at 24 weeks’ pregnant with a cervix that had dilated to 3 cm and was almost completely ‘effaced,’ or thinned out. She was barely contracting and had come in because she was feeling “pressure like when I had delivered before.” The kicker here is that she had delivered early before at 26 weeks’ after spending 4 weeks in a hospital for premature cervical change without labor. Despite the fact that she had told her physician about this past obstetrical history, she had not been plugged into any special care during the current pregnancy to evaluate the possibility of “cervical incompetence” that was strongly suggested by the past, and now reaffirmed by the current, pregnancy. We may have salvaged a better outcome for the current pregnancy with the ‘rescue cerclage’ we placed yesterday (although we are far from ‘out of the woods’), but that would have been much better (and safer) if it had been placed at the end of first trimester or with the first real evidence of loss of integrity at the internal cervical os that could have been readily detected by serial ultrasound assessment.
• Finally, I just want to provide one more example that some women may and others may not consider being a ‘benefit’ of preconceptional counseling. I really enjoy talking with women planning to have their first babies. Within the past year, I saw a couple who had decided that “the time was right to start a family.” They just wanted to talk with a doctor before she stopped her birth control pills. She had absolutely no identifiable ‘risk factors.’ She was healthy, she had no medical problems, she had no ‘vices, such as smoking or excessive alcohol use, there was no significant family or genetic history on either side that could be elucidated, she exercised regularly, and best of all she was excited about getting pregnant. We talked about the basic care given in pregnancy, expected weight gain, recommended and ‘optional’ laboratory studies, ultrasound and a host of other more routine things. I gave her a prescription for a prenatal vitamin and instructed her to start taking them regularly. She was going to “stop my pills and can’t wait to tell my friends the minute I think I am pregnant.” She had actually anticipated my next comment and it was the perfect segue for the one caution I always give to women planning their first pregnancies. “You might want to wait on that,” I said. “Getting pregnant, or telling my friends?” she asked. I told her it was the latter and the reason for that is there is an extraordinarily high spontaneous miscarriage rate (perhaps as high as 40-70%) among women having their true first pregnancies and for that reason, she “might want to wait until she was nearing the end of the first trimester before “telling the world.” “It sometimes can make things easier if it doesn’t turn out,” I told her. To make a long story short, I saw her back in the office for an ultrasound about 8 months later when she was 20 weeks’ pregnant. Her first comment was that she wanted to thank me for the “words of caution.” When I asked her what she meant, she told me that she had gotten pregnant within the month after we had first talked but had miscarried that baby very early in the pregnancy. She told me that she had followed my advice and “would have been devastated” if she had told all her friends and then lost the baby. To her, this was clearly a benefit of preconceptional counseling, and one that she was quite grateful to have gotten…