Nutrients

Dietary supplements

All women of reproductive age should be asked about their use of dietary supplements (vitamins, minerals, traditional/home remedies, herbal products, weight loss products, etc) as part of preconception care and should be advised about what is or is not known about their safety, impact, and efficacy.

Vitamin A

Currently the recommended dietary allowance of preformed vitamin A for women is 700 retinal activity equivalents (RAEs) per day, with a tolerable upper intake level for pregnancy of 3000 RAEs/day or 10,000 IU/day).

Folic acid

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

Multivitamins

All women of reproductive age should be encouraged to take a folic acid–containing multivitamin supplement for the purpose of supporting healthy pregnancy outcomes and preventing congenital anomalies.

Vitamin D

There is insufficient evidence to recommend for or against routine screening or vitamin D supplementation during preconception counseling. Based on the emerging data of the importance of vitamin D for women and infants, however, clinicians should be aware of the risk factors for vitamin D deficiency. Additionally, for women with vitamin D deficiency, education on vitamin D in the diet and supplementation should be a part of preconception care. Currently, we do not have data for the optimal dose before and during pregnancy. More data are needed urgently.

Calcium

Women of reproductive age should be counseled about the importance of achieving the recommended calcium intake level through diet or supplementation. Calcium supplements should be recommended if dietary sources are inadequate.

Iron

At a preconception visit, screening should be conducted for women with risk factors for iron deficiency for the purposes of identifying and treating anemia. There is evidence to recommend that all women be screened at a preconception visit for iron deficiency anemia for the purpose of improving perinatal outcome.

Essential fatty acids

During the preconception period, women should be encouraged to eat a diet rich in essential fatty acids, including omega-3 and omega-6 fatty acids. To achieve this, women should be advised to consume at least 12 ounces of fish and no more than 6 ounces of canned albacore tuna weekly. More research is needed critically to assess the risks and benefits of fish and fish oil consumption during the preconception period.

Iodine

Women of reproductive age with iodine deficiency should be counseled about the risks of this condition to pregnancy outcomes and about the importance of maintaining adequate daily dietary iodine intake of 150 µg during preconception and at least 200 µg when pregnant or lactating. Public health efforts to implement salt iodization programs should be encouraged for all women who reside in regions with endemic iodine deficiency.

Overweight

All women should have their BMI calculated at least annually. All women with a BMI of ≥ 25 kg/m² should be counseled about the risks to their own health, the additional risks associated with exceeding the overweight category, and the risks to future pregnancies, including infertility. All women with a BMI of ≥ 25 kg/m² should be offered specific strategies to improve the balance and quality of the diet, to decrease caloric intake, and to increase physical activity and should be encouraged to consider enrolling in structured weight loss programs.

Underweight

All women should have their BMI calculated at least annually. All women with a BMI of ≤ 18.5 kg/m² should be counseled about the short- and long-term risks to their 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.

Eating disorders

All women with anorexia and bulimia should be counseled about the risks to fertility and future pregnancies. Women with these disorders should be encouraged to enter into treatment programs before pregnancy.

Medication

Prescription

As part of preconception care, all women should be screened for the use of teratogenic medications and should receive counseling about the potential impact of chronic health conditions and medications on pregnancy outcomes for mother and child. Whenever possible, potentially teratogenic medications should be switched to safer medications before conception. For women with chronic conditions with serious morbidity (to mother and infant), the fewest number and lowest dosages of essential medications that control maternal disease should be used. For women who do not desire pregnancy, a plan for contraception should be addressed and initiated.

Over-the-counter medication

Health care providers should educate women of reproductive age about the need to discuss the use of over-the-counter medications with their provider when planning a pregnancy. Women should be advised specifically not to use aspirin if they are planning a pregnancy
or become pregnant.

Dietary supplements

Health care providers should educate women of reproductive age about the need to discuss the use of dietary supplements before pregnancy (which include herbs, weight loss products, and sport supplements) and should caution women about the unknown safety profile of many supplements. High-quality and prescription-quality dietary supplements should be encouraged.

Reproductive history

Prior preterm birth infant

Pregnancy history should be obtained from all women of reproductive age. Women with a history of preterm or low-birthweight infant should be evaluated for remediable causes to be addressed before the next pregnancy and should be informed of the potential benefit of treatment with progesterone in subsequent pregnancy.

Prior cesarean delivery

Preconception counseling of women with previous cesarean delivery should include counseling about waiting at least 18 months before the next pregnancy and about possible modes of delivery so the patient enters the next pregnancy informed of the risks and options. Ideally, the counseling should begin immediately after the cesarean delivery and continue at postpartum visits.

Prior miscarriage

Women with sporadic spontaneous abortion should be reassured of a low likelihood of recurrence and offered routine preconception care. Women with ≥ 3 early losses should be offered a work-up to identify a cause. Therapy that is based on the identified cause may be undertaken. For women with no identified cause, the prognosis is favorable with supportive care.

Prior stillbirth

At the time of the stillbirth, a thorough investigation to determine the cause should be performed and communicated to the patient. At the preconception visit, women with a previous stillbirth should receive counseling about the increased risk of adverse pregnancy outcomes and may require referral for support. Any appropriate work-up to define the cause of the previous stillbirth should be performed if it was not done as part of the initial workup. Risk factors that can be modified before the next pregnancy should be addressed (eg, smoking cessation).

Uterine anomalies

A uterine septum in a woman with poor previous reproductive performance should be corrected hysteroscopically before the next conception. All other anomalies call for specific delineation of the anomaly and any associated vaginal and renal malformations. Although surgical correction may be advised in some cases, heightened awareness and surveillance during a subsequent pregnancy and labor should help optimize outcomes.

Special populations

Women with disabilities

Women with disabilities should receive counseling about the risks of any medications
that they use and about options to alter dosage or switch to safer medications before conception. The medical, social, and psychologic issues that are related to pregnancy and the disability should be assessed, and the woman and her family should be counseled about them. Healthcare providers should offer women with disabilities contraceptive choices that are practical and appropriate for the individual’s me­dical and personal needs. Issues that involve informed consent and guardianship must be addressed when caring for women with developmental disabilities in relation to contraception and pregnancy. Referral for genetic counseling, if appropriate, is indicated for all women before conception; however, it may raise difficult psychosocial issues for women with disabilities; therefore, counseling referrals should be handled sensitively.

Cancer

Newly diagnosed cancer survivors should be educated about fertility preservation options as soon as feasible and should be referred to reproductive specialists if these options are desired. Cancer survivors who consider pregnancy should be counseled about the potential reproductive effects of various cancer treatments on fertility and on pregnancy. Women who have received alkylating chemotherapeutic agents and/or pelvic or abdominal radiation should be counseled that they have an increased risk for premature ovarian failure. Women who have had pelvic or abdominal irradiation should be counseled that they are at risk for having a low birthweight infant. When considering pregnancy, breast cancer survivors who are candidates for selective estrogen receptor modulators should be counseled that these agents are generally avoided during pregnancy because of case reports of animal and human birth defects. A reliable nonhormonal contraceptive method should be used during treatment with a selective estrogen receptor modulator. Genetic counseling and testing should be offered to survivors of cancers that are linked to genetic mutations to inform their decisions about future reproduction. Female cancer survivors who received anthracycline chemotherapy, radiation to the heart or surrounding tissues, or both should be evaluated by a cardiologist before conception. Annual breast screening for female childhood cancer survivors who received chest radiation is recommended beginning at age 25 years.

Men

Despite the challenges and barriers, we recommend that each man who is planning with
their partner to conceive a pregnancy should undergo a comprehensive medical evaluation for the purposes of disease prevention and detection and preconception education. Management should be optimized for any high-risk behaviors or poorly controlled disease states before conception is attempted.