Health promotion

Health promotion, family planning and reproduction life plan⁽¹⁶⁾

Routine health promotion activities for all women of reproductive age should begin with screening women for their intentions to become or not become pregnant in the shortand long-term and their risk of conceiving (whether intended or not). Providers should encourage patients (women, men, and couples) to consider a reproductive life plan and educate patients about how their reproductive life plan impacts contraceptive and medical decision-making. Every woman of reproductive age should receive information and counseling about all forms of contraception and the use of emergency contraception that is consistent with their reproductive life plan and risk of pregnancy.

Physical aktivity

All women should be assessed regarding weightbearing and cardiovascular exercise and be offered recommendations appropriate to their physical abilities.

Weight status

All women should have their body mass index (BMI) calculated at least annually. All women with BMIs ≥ 26 kg/m² should be counseled about the risks to their own health, the risks for exceeding the overweight category, and the risks to future pregnancies, including infertility. These women should be offered specific behavioral strategies to decrease caloric intake and increase physical activity and be encouraged to consider enrolling in structured weight loss programs. All women with a BMI ≤ 19.8 kg/m² should be counseled about
the short- and long-term risks to the own health and the risks to future pregnancies, including infertility.
All women with a low BMI should be assessed for eating disorders and distortions of body image. Women unwilling to consider and achieve weight gain may require referral for further evaluation of eating disorders.

Nutrient intake

All women of reproductive age should be assessed for nutritional adequacy and receive a recommendation to take a multivitamin supplement if any question of ability to meet
the recommended daily allowance through food sources is uncovered. Care must be taken to counsel against ingesting supplements in excess of the recommended daily allowance.

Folate

All women of reproductive age should be advised to ingest 0.4 mg (400 µg) of synthetic folic acid daily from fortified foods and/or supplements and to consume a balanced, healthy diet of folate-rich food.

Immunizations

All women of reproductive age should have their immunization status for tetanusdiphtheria toxoid/diphtheria-tetanus-pertussis; measles, mumps, and rubella; and varicella reviewed annually and updated as indicated. All women should be assessed annually for health, lifestyle, and occupational risks for other infections and be offered indicated immunizations.

Substance use

All women should be assessed for use of tobacco at each encounter with the healthcare system; women who smoke should be counseled to limit exposure. All women should be assessed at least annually for alcohol use patterns and risky drinking behaviors and be provided with appropriate counseling; all women should be advised of the risks to the embryo/fetus of alcohol exposure in pregnancy and that no safe level of consumption has been established.

Sexually transmitted infections (STIs)

Healthcare providers regularly and routinely should assess STI risks, provide counseling and other strategies (including immunizations) to prevent acquisition of STIs, and to provide indicated STI testing and treatment for all women of childbearing age.

Immunization

Human papillomavirus (HPV)

Women should be screened routinely for HPV-associated abnormalities of the cervix with cytologic (Papanicolaou) screening. Recommended subgroups should receive the HPV vaccine for the purpose of decreasing the incidence of cervical abnormalities and cancer.
By avoiding procedures of the cervix because of abnormalities caused by HPV, the vaccine could help maintain cervical competency during pregnancy.

Hepatitis B

All high-risk women who have not been vaccinated previously should receive hepatitis
B vaccine before pregnancy; women who are chronic carriers should be instructed on ways to prevent transmission to close contacts and how to prevent vertical transmission to their babies.

Varicella

Because the varicella vaccine is contraindicated during pregnancy, screening for varicella immunity (by either a history of previous vaccination, previous varicella infection verified
by a healthcare provider, or laboratory evidence of immunity) should be done as part of a preconception visit. All nonpregnant women of childbearing age who do not have evidence of varicella immunity should be vaccinated against varicella.

Measles, mumps, and rubella

All women of reproductive age should be screened for rubella immunity. Immunization should be offered to women who have not been vaccinated or who are not immune and who are not pregnant. Women should be counseled not to become pregnant for 3 months after receiving vaccination. This vaccination will provide protection against measles, mumps, and rubella.

Influenza

Influenza vaccination is recommended for women who will be pregnant during influenza season and for any woman with increased risk for influenza-related complications, such as cardiopulmonary disease or metabolic disorders, before influenza season begins.

Diphtheria-tetanuspertussis vaccination

Women of reproductive age should be up-to-date for tetanus toxoid, because passive immunity is probably protective against neonatal tetanus. The diphtheria-tetanuspertussis vaccine is recommended for women who might become pregnant or immediately after delivery to avoid complications of pertussis in the newborn infant.

Infectious disease

Human immunodeficiency virus

All men and women should be encouraged to know their human immunodeficiency virus status before pregnancy and should be counseled about safe sexual practices. Women who test positive must be informed of the risks of vertical transmission to the infant and the associated morbidity and mortality probabilities. These women should be offered contraception. Women who choose pregnancy should be counseled about the availability of treatment to prevent vertical transmission and that treatment should begin before pregnancy.

Hepatitis C

There are no data that preconception screening for hepatitis C in low-risk women will improve perinatal outcomes. Screening for high-risk women is recommended. Women who are positive for hepatitis C and desire pregnancy should be counseled regarding the uncertain infectivity, the link between viral load and neonatal transmission, the importance of avoiding hepatotoxic drugs, and the risk of chronic liver disease. Women who are being treated for hepatitis C should have their reproductive plans reviewed and use adequate contraception while on therapy.

Tuberculosis

All high-risk women should be screened for tuberculosis and treated appropriately before pregnancy.

Toxoplasmosis

There is no clear evidence that preconception counseling and testing will reduce
Toxoplasma gondii infection or improve treatment of women who are infected. However, if preconception testing is done, women who test positive can be reassured that they are not at risk of contracting toxoplasmosis during pregnancy; women who are negative can be counseled about ways to prevent infection during pregnancy. For women who convert during pregnancy, treatment should be offered.

Cytomegalovirus

Women who have young children or who work with infants and young children should be counseled about reducing the risk of cytomegalovirus through universal precautions (eg, the use of latex gloves and rigorous hand-washing after handling diapers or after exposure to respiratory secretions).

Listerosis

Because it is not clear at what point in pregnancy women who are exposed to Listeria will become ill, preconception care should include teaching women to avoid pâté and fresh soft cheeses made from unpasteurized milk and to cook ready-to-eat foods such as hotdogs, deli meats, and left-over foods.

Parvovirus

There is not yet evidence that screening for antibody status against parvovirus or counseling about ways to avoid infection in pregnancy will improve perinatal outcomes. Good hygiene practices should be encouraged for all pregnant women.

Malaria

Women who are planning a pregnancy should be advised to avoid travel to malariaendemic areas. If travel cannot be deferred, the traveler should be advised to defer pregnancy and use effective contraception until travel is completed and to follow preventive approaches. Antimalarial chemoprophylaxis should be provided to women who plan a pregnancy who travel to malaria-endemic areas.

Gonorrhea

High-risk women should be screened for gonorrhea during a preconception visit, and women who are infected should be treated. Screening should also occur early during pregnancy and be repeated in high-risk women.

Syphilis

High-risk women should be screened for syphilis during a preconception visit, and women who are infected should be treated. Because the United States Preventive Services Task Force and Centers for Disease Control and Prevention recommend screening all women during pregnancy for syphilis, screening for syphilis immediately before conception is recommended.

Asymptomatic bacteruria

There have been no studies to show that women with asymptomatic bacteriuria who are identified and treated in the preconception period have lower rates of low birthweight births. Further, women often have persistent or recurrent bacteriuria, despite repeated courses of antibiotics; such re-infection frequently occurs within a few months of treatment. Thus, a woman who is identified and treated for asymptomatic bacteriuria before conception must be screened again during pregnancy. For these reasons, screening for this condition as part of routine preconception care currently is not recommended.

Periodontal disease

There are no studies that evaluate the role of preconception or interconception screening and treatment of periodontal disease and its effect on reproductive outcomes. Routine screening and treatment of periodontal disease during preconception care, although of considerable benefit to the mother, is not recommended at this time as part of preconception care, because there is no clearly shown benefit to the fetus.

Bacterial vaginosis (BV)

There are no studies that evaluate the role of preconception or interconception screening and treatment for BV and its effect on reproductive outcomes; such studies are a high priority. Routine screening and treatment of BV among asymptomatic pregnant women of average risk should not be performed because of the lack of demonstrated benefit and the possibility of adverse effects of treatment for women without BV. For pregnant women with previous preterm delivery, the inconsistent results of well-done studies prevent a clear recommendation for or against screening; however, some studies support early screening and treatment with a regimen that contains oral metronidazole. For women with symptomatic BV infection, treatment is appropriate for pregnant women and for women planning pregnancy.

Group B Streptococcus

Screening for group B Streptococcus colonization at a preconception visit is not indicated and should not be performed.

Medical conditions

Diabetes mellitus

All women with diabetes mellitus should be counseled about the importance of diabetes mellitus control before considering pregnancy. Important counseling topics include maintaining optimal weight control, maximizing diabetes mellitus control, selfglucose monitoring, a regular exercise program, and tobacco, alcohol, and drug cessation, along with social support to assist during the pregnancy. In the months before pregnancy, these women should demonstrate as near-normal glycosylated hemoglobin level as possible for the purpose of decreasing the rate of congenital anomalies. Women with poor control of their diabetes mellitus should be encouraged to use effective birth control. Testing to detect prediabetes and type 2 diabetes in asymptomatic women should be considered in adults who are overweight or obese (BMI ≥ 25 kg/m²) and who have 1 or more additional risk factors for diabetes, including a history of gestational diabetes mellitus.

Thyroid disease

Women with hypothyroidism should be counseled about the risks of this condition to pregnancy outcomes and the importance of achieving optimal replacement therapy before conception. All women with symptoms of hypothyroidism should be screened for thyroid disease; if there is hypothyroidism, adequate therapy should be initiated.

Phenylketonuria

Women of reproductive age with phenylketonuria should be counseled about the importance of maintaining a low phenylalanine level during their childbearing years and should be encouraged to resume a low phenylalanine diet, particularly when they are planning to become pregnant, to avoid adverse outcomes for the offspring. Women who do not desire a pregnancy should be encouraged to use contraception.

Seizure disorders

Women of reproductive age with seizure disorders should be counseled about the risks of increased seizure frequency in pregnancy, the potential effects of seizures and anticonvulsant medications on pregnancy outcomes, and the need to plan their pregnancies with a healthcare provider well in advance of a planned conception. Women who take liver enzyme-inducing anticonvulsants should be counseled about the increased risk of hormonal contraceptive failure. Whenever possible, women of reproductive age should be placed on anticonvulsant monotherapy with the lowest effective dose to control seizures. Women who are planning a pregnancy should be fully evaluated for consideration of alteration or withdrawal of the anticonvulsant regimen before conception, and folic acid supplementation of 4 mg per day should be initiated for at least 1 month before conception and until the end of the first trimester to prevent neural tube defects.

Hypertension

Women of reproductive age with chronic hypertension should be counseled about the risks associated with hypertension during pregnancy for both the woman and her offspring and the possible need to change the antihypertensive regimen when she is planning a pregnancy. Women with hypertension for several years should be assessed for ventricular hypertrophy, retinopathy, and renal disease before pregnancy. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are contraindicated during pregnancy; women who could become pregnant while taking these medications should be counseled about their adverse fetal effects and should be offered contraception if they are not planning a pregnancy. Women who are planning a pregnancy should discontinue these medications before pregnancy.

Rheumatoid arthritis

Women with known history of rheumatoid arthritis should be advised of the natural history of the disease during pregnancy and the probability of a flare after pregnancy. The most important task is to review the patient’s medi­cation use. Nonsteroidal antiinflammatory drugs should be discontinued by 27 weeks of gestation. Methotrexate and leflunomide are extremely teratogenic and should be stopped in men and women planning a pregnancy.

Lupus

Women of reproductive age with lupus should be counseled about the risks associated with lupus during pregnancy for both the woman and her offspring, the importance of optimizing disease control before pregnancy, the possible need to change the medication regimen close to conception or early in pregnancy, and the importance of specialized prenatal care once pregnant. Women whose treatment regimen involves cyclophosphamide should be advised of its teratogenic nature; whenever possible, the treatment should be changed to a safer regimen before conception, and the women should be offered contraception if they are not planning a pregnancy.

Renal disease

Women of reproductive age with renal disease should be counseled about the likelihood of progression of renal disease during pregnancy and irrespective of pregnancy, the increased risk of adverse pregnancy outcomes for the woman and offspring, and the importance of achievement or maintenance of normal blood pressure before conception. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are contraindicated during pregnancy; women who could become pregnant while taking these medications should be counseled about their adverse fetal effects and should be offered contraception if they are not planning a pregnancy. Women who are planning a pregnancy should discontinue these medications before pregnancy in favor of a safer regimen, whenever possible. Women who do not desire pregnancy should be offered an appropriate method of contraception.

Cardiovascular disease

Women of reproductive age with cardiac disease should be counseled about the risks that pregnancy presents to their health and the risks of the cardiac condition and any medications needed to treat the condition (eg, warfarin) on pregnancy-related outcomes. Women who are considering or planning a pregnancy should be counseled to achieve optimum control of the condition before conception and should be offered a suitable contraceptive method to achieve optimum timing of the pregnancy. Women whose treatment regimen involves warfarin should be counseled about its teratogenic nature; whenever possible, the treatment should be changed to a less teratogenic anticoagulant before conception. Women with a congenital cardiac condition should be offered preconception genetic counseling. Women who do not desire a pregnancy should be offered a suitable form of contraception.

Thrombophilia

Providers may consider screening women of childbearing age for a personal or family history of venous thrombotic events or recurrent or severe adverse pregnancy outcomes. Women with a personal or family history suggestive of thrombophilia may then be offered counseling and testing for thrombophilias if they are contemplating pregnancy. Screening for thrombophilias with laboratory testing in routine care is not recommended. Women of reproductive age with a known genetic thrombophilia should be offered preconception genetic counseling to address the risk of the condition to the offspring. Women of reproductive age with a thrombophilia whose treatment regimen involves warfarin should be counseled about its teratogenic nature; whenever possible, the treatment should be changed to a less teratogenic anticoagulant before conception.

Asthma

All women with asthma should be counseled about the potential for their asthma control to worsen with pregnancy and the importance of achieving asthma control before a pregnancy through appropriate medical management and avoidance of triggers. Women with asthma who are planning to become pregnant or who could become pregnant should be treated with pharmacologic step therapy for their chronic asthma based on the American College of Allergy, Asthma, and Immunology–American College of Obstetricians and Gynecologists recommendations for the Pharmacologic Step Therapy of Chronic Asthma During Pregnancy. Women with poor control of their asthma should be encouraged to use effective birth control until symptom control is achieved.

Psychiatric condition

Depression/anxiety

Providers should screen and be vigilant for depression and anxiety disorders among women of reproductive age because treating or controlling these conditions before pregnancy may help prevent negative pregnancy and family outcomes. Women of reproductive age with depressive and anxiety disorders who are planning a pregnancy or who could become pregnant should be informed about the potential risks of an untreated illness during pregnancy and about the risks and benefits of various treatments during pregnancy.

Bipolar disease

Women of reproductive age with bipolar disorder should be counseled that pregnancy is a time of substantial risk of relapse, particularly after discontinuation of ongoing mood-stabilizing maintenance treatment. A relapse prevention and management strategy for bipolar disorder should be outlined before the patient attempts conception. Women of reproductive age with bipolar disorder should be counseled regarding contraceptive options, which should include options that will prevent conception during bipolar episodes.

Schizophrenia

Women of reproductive age with schizophrenia should be counseled, together with a partner or family member whenever possible, about the risks of pregnancy on their condition and the risk of their condition on pregnancy-related outcomes. They should be counseled about the importance of prenatal care, and a relapse prevention and management strategy of the illness should be outlined before the patient attempts conception. Appropriate contraception should be offered to women who do not desire a pregnancy.

Parental exposure

Alcohol

All women of childbearing age should be screened for alcohol use, and brief interventions should be provided in primary care settings, which should include advice regarding the potential for adverse health outcomes. Brief interventions should include accurate information about the consequences of alcohol consumption, which should include the effects of drinking during pregnancy, information about effects beginning early during the first trimester, and warnings that no safe level of consumption has been established. Women who show signs of alcohol dependence should be educated about the risks of alcohol consumption; for women who are interested in modifying their alcohol use patterns, efforts should be made to identify programs that would assist them in achieving cessation and long-term abstinence. Contraception consultation and services should be offered and pregnancy should be delayed until it can be an alcohol-free pregnancy.

Tobacco

All women of childbearing age should be screened for tobacco use. Brief interventions should be provided to all tobacco users and should include brief counseling that describes the benefits of not smoking before, during, and after pregnancy; discussion of medication; and referral for more intensive services (individual, group, or telephone counseling) if the woman is willing to use these services. For pregnant women, augmented counseling interventions should be used.

Illicit substances

A careful history should be obtained to identify use of illegal substances as part of the preconception risk assessment. Men and women should be counseled about the risks of using illicit drugs before and during pregnancy and offered information on programs that support abstinence and rehabilitation. Contraception services should be offered, and pregnancy should be delayed until individuals are drug free.

Family and genetic history

All individuals

All women who are considering pregnancy should have a screening history in the preconception visit. Providers should ask about risks to pregnancy on the basis of maternal age, maternal and paternal medical conditions, obstetric history, and family history.
Ideally, a 3-generation family medical history should be obtained for both members of the couple, with the goal of identifying known genetic disorders, congenital malformations, developmental delay/mental retardation, and ethnicity. If this screening history indicates the possibility of a genetic disease, specific counseling should be given, which may include referral to a genetic counselor or clinical geneticist.

Ethnicity-based

Couples who are at risk for any ethnicity-based conditions should be offered preconception counseling about the risks of that condition to future pregnancies. Screening and/or testing should be offered on the basis of the couples’ preferences. This may require referral to a genetic counselor or clinical geneticist, especially in the instance of a positive finding.

Family history

Individuals identified as having a family history of developmental delay, congenital anomalies, or other genetic disorders should be offered a referral to an appropriate specialist to better quantify the risk to a potential pregnancy.

Previous pregnancies

If at least 1 member of a couple has a known chromosomal anomaly, in vitro fertilization with preimplantation genetic diagnosis should be discussed.

Known genetic conditions

Suspected genetic disorders may require further work-up prior to conception. Known or discovered genetic conditions should be optimally managed before and after conception.