PRE-CONCEPTION CARE

BY: Markos Makisha (BSc in Mw, MSc in

maternal &RH nursing)

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 Objective
At the end of this session, you will be able to:
 Define preconception care
 perform preconception counseling
 Determine preconception care components

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 preconception care

 Definition a set of interventions that aim to identify & enable

informed decision making to modify biomedical, behavioral, and
social risks to a woman’s health or pregnancy outcome through
prevention and management.
 comprehensive program of health care that identifies and reduces a
woman's reproductive risks before conception through:-
 risk assessment,
 health promotion, and
 interventions.
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 Cont..
• Even if preconception care aims primarily at improving
maternal and child health, it brings health benefits to the
adolescents, women and men.
• The preconception period is a time span of anything from 3
months to 1 year before conception .

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 goals of preconception care

 Identify potential risks to the mother, fetus, and pregnancy.

 Educate the individual about these risks, options for intervention
and management to reduce risk, and reproductive alternatives.
 Initiate interventions to provide optimum maternal, fetal, and
pregnancy outcomes. Interventions include motivational
counseling, disease optimization, and specialist referral.

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 Concepts of pre pregnancy care
1. Risk assessment - Identification of risk factors related to
pregnancy.
2. Health promotion - education regarding pregnancy risks,
management options and reproductive alternatives.

3. Medical & psychosocial interventions- Initiation of

interventions, when possible, to provide optimum pregnancy
outcome.

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 Components of pre pregnancy care

• Medical history
• Psychosocial issues
• Physical exam
• Laboratory tests

• Family history
• Nutrition assessment

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 Risk assessment

• The key task in risk assessment is to obtain history.

• Aims to identify potential risks to the mother and baby and to

rule out any potential complications of pregnancy.
• Patient education and medical interventions can be initiated
based on this information.

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 Components of risk assessment
1. History
Personal history
• age,
• education,
• Occupation

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 Components of risk assessment…

1. History…
Family history of
• Diabetes,
• Hypertension,

• phenylketonuria (PKU)
• Congenital anomalies/birth defects , pregnancy loss ,

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 Components of risk assessment…

1. History…
Family history of..
• Other chronic diseases including disability,
• Mental disorders

• Thalassemia

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 Components of risk assessment…
1. History…
Personal history of Medical conditions like:-
• Diabetes
• Seizure disorders/epilepsy
• Hypertension,
• Thyroid disorder
• STIs

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 Components of risk assessment…

Personal history of …
• Vaccination status (tetanus,diphtheria,rubella),
• Unprotected sex,
• Genetic conditions
• Mental disorders/Mental health status: depression
• Smoking, alcohol use
• Medical prescription, self-medication (over the counter)

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 Components of risk assessment…
Personal history of …
• Folic acid intake, Assess risk of nutritional deficiencies: Vegan,
Pica, Milk intolerance, Calcium or iron deficiency,
• Contraception
• Domestic violence/Intimate-partner violence (IPV)
• Environmental exposures to insecticides, pesticides, cleaning
products
• Physical exercise

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 Components of risk assessment…

obstetrics/gynecology
• Infertility
• Miscarriage, ectopic pregnancy, molar pregnancy, recurrent
pregnancy loss, preterm delivery , and stillbirth
• cesarean delivery,
• preeclampsia, placental abruption

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 Components of risk assessment…
2.Physical examination:
• General exam including assessment of the heart, breasts, lungs,
thyroid, abdomen, mouth, and genital tract,
• Body mass Index (BMI).
• Vital signs

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 Components of risk assessment…

3. Laboratory Investigations 
• HIV test
• Rubella
• varicella titer,
• Screening for hepatitis B,

• syphilis
• Complete blood count

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 Components of risk assessment…
Laboratory Investigations…
• ABO blood grouping and Rhesus
• Testing sickle cell disease and beta thalassemia, other genetic
conditions
• Fasting Blood sugar
• Clotting disorders, periodontal disease,

• Pap smear,
• Mammogram

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 Health promotion
Counseling and Education on
 Healthy lifestyles

 Healthy reproductive life planning

 Importance of early entry into prenatal care
 Folic acid intake

 Healthy diet

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 Health promotion…
 Avoiding tobacco, alcohol and harmful substances
 Avoiding medications contraindicated in pregnancy

 Risks of congenital anomalies

 Infertility counseling
 STI/HIV

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 Medical & psychosocial interventions

Prevention
• Iron and Folic acid supplementing
• Family planning services
• Safe sex

• Vaccination against rubella (MMR), tetanus and diphtheria ,

hepatitis B, influenza and HPV vaccine.

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 Medical & psychosocial interventions…
Management for
• Diabetes Mellitus tight glycemic control.
• Obesity
• Thyroid Disease
• Phenylketonuria
• Seizure disorder
• Hypertension
• Rheumatoid Arthritis
• Cancer
• Alcohol &Tobacco use

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 Target population
• All females of childbearing potential who present for a period
whether or not they are currently interested in conceiving.
• In addition to the periodic health evaluation, preconception care
occur during nonemergency health care encounters, including:
 Premarital office visit.
 Contraception counseling and provision.

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 Target population Cont.….
 After a negative pregnancy test.

 Evaluation for sexually transmitted disease or vaginal infection.

 Postpartum office visit.
 Office visit related to pregnancy termination.

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 Pre-conception counseling

• Changes risk behaviors to improve maternal &neonatal outcomes.

Environmental Toxins - avoid :-

• Household chemicals, paint thinners, pesticides, Radiation
exposure.
• Toxic exposures such air pollution, unsafe sources of water
infection (eg, Zika, Chagas disease).

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 Pre-conception Counseling…
Environmental exposure…
 Avoid Environmental hazards (eg, nonuse of safety belts;
exposure to firearms, infection; travel) and toxins
 Methyl mercury: Avoid shark, swordfish, king mackerel, and
tile fish. mercury skin-lightening creams,
 Ingest no more than 12 ounces or 2 servings of canned tuna and
no more than 6 ounces of albacore per week.
 Lead: lead may be detected in paint , imported cosmetics, food
additives/medicine, and clay.
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 Pre-conception Counseling …
occupational hazards-
• Occupational exposures, Material Safety
• woman who's occupation may pose a risk to pregnancy should
be advised to discuss this with her employer or before getting
pregnant.

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 Pre-conception Counseling …

Substance Use
• Alcohol damages neurons, & results in fetal alcohol syndrome
(FAS) & mental retardation.
• It causes stillbirth, spontaneous abortion, and low birth weight.

• Nicotine causes miscarriage, low birth weight and preterm

delivery.
• Counsel women with pre-existing depression and anxiety disorders
about the potential risks .Prevent relapse and discontinue treatment

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 Pre-conception Counseling …

• Recommend regular moderate exercise,

• Avoid hyperthermia (hot tubs),
• Counsel on the use of over-the-counter medications

• Nutritional supplements, and naturopathic substances.

• Avoid over use of: Vitamin A, Vitamin D, Caffeine.

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 Medications &toxic agents to be avoided
• Acitretin • methamphetamine
• Alcohol • Methotrexate
• ACE inhibitors • Mycophenolate
• Angiotensin receptor blockers • Nitrofurantoin
• Carbamazepine • NSAID
• Bexarotene • Paroxetine
• Cocaine • Phenobarbital
• Corticosteroids • Phenytoin
• Cyclophosphamide • Ribavirin
• Endotheline-receptores antagonist • Sulfonamides
• Fluconazole • Tamoxifen
• Isotretinione • Tetracycline
• Lead • Thalidomide
• Lithum • Tobacco
• Mercury • Valproic acid
• Marijuana • warfarin
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 Genetic conditions

• Family history is apart of genetic screening.

• The health and reproductive status of blood relative should be
reviewed for medical illnesses, mental retardation, birth defects,
infertility, and pregnancy loss.
• Sickle cell anemia,
• Cystic fibrosis,

• Thalassemia,
• Scrotal injury and temperature effects (for men) and
Infertility/sub-fertility.
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 Genetic conditions…
• Genetic counseling should be offered to all women with a
previous abnormal fetus,
• Personal or family history of genetic problems
• A history of three recurrent miscarriages.

• Recommend folic acid 5mg daily prior to conception and for 12

weeks after conception if positive family history of neural tube
defects or high risk ethnic group

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 Genetic counseling
• Reassure people who are concerned about their children
inheriting a particular disorder.
• Educate people about inherited disorders
• Allow people who are affected by inherited disorder to make
informed choices about future.

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 Domestic violence

• Is a major contributor to ill reproductive and sexual health.

• Raise awareness among such females, and build a system where

such women can feel safe reporting such incidences.
• Providing age appropriate sexuality education addresing gender
equality and human right
• Changing social norms

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 Infectious Diseases
• Counsel on prevention and risk of STI , cytomegalovirus, &
Toxoplasmosis
For HIV positive
• Link to Baseline investigations including CD4 and viral load

• Advise on contraception use to avoiding unintended pregnancy

• Advise on general health including good nutrition

• Treatment for opportunistic infections & STIs

• On PMTCT & Initiate ART/ Link to PMTCT unit

• Avoid pregnancy for 6months after recovery of chronic infections

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 Pre-conception Care to promote healthy
pregnancy
Nutrition (type of diet and intake, vitamins, supplements)
• Supplementing iron
• The intake of folic acid from at least four weeks before pregnancy
until 12 weeks of pregnancy .
• Iodization of salt o Promoting exercise .

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 Cont.…
• The neural tube closes during the first trimester of pregnancy b/n
24 &26 days after conception.
• All women planning pregnancy should take supplemental folic
acid it protect baby from  neural tube defects,  cleft lip and palate,
congenital anomalies and abruption.
• NTDs etiology often involve abnormalities in metabolism that are
potentially remediable by folic acid dietary supplementations.
• Before pregnancy, take a multivitamin with 400 micrograms of
folic acid in it each day.

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 cont.….
• The most convenient folic acid supplementation is daily intake
of a multivitamin containing 400 to 800 mcg of folic acid.
• Megavitamins, nonessential dietary supplements, and herbal
preparations should be discontinued.
• Taking Mega doses of vitamin A  during early pregnancy
associated with congenital anomalies.

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 Cont.…

• Multivitamin preparations containing more than 5000

international units of vitamin A should be avoided
• Risk of teratogensis increases at >10,000 IU/day.
• Fish –type and quantity consumed should be regulated.
• Certain types of fish should be avoided during pregnancy and
the preconception period due to teratogenic effects from
environmental toxins, particularly mercury.

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 Cont.…
• Advised to supplement their diet with a daily oral multivitamin
supplement that contains 150 to 250 mcg of iodine
• Using iodized salt and sea food that is naturally rich in iodine
• Avoided High caffeine intake or limit consumption to less than
200 to 300 mg per day.

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 chronic health problems
• Counseled Women with chronic health problems such as
hypertension or hyper/hypothyroidism about the risks during
pregnancy, and
• Change medication regimens while pregnant or conceiving to
prevent any harm to the fetus.
• Management and counseling of diabetic women during the
preconception period is more beneficial than during pregnancy

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 chronic health problems
Diabetes mellitus
 Contraception use until glycemic control is achieved, management of
complications or comorbidities is optimized
 Change ACE inhibitors, Diuretics, β-Blockers, statins to that has less risk.
 Counsel to maintain a healthy weight
 Monitor and maintain target blood sugar level:

1. Fasting capillary blood glucose: 80 -110 mg/dL

2. 2 hr. capillary postprandial blood glucose: < 150 mg/dL
 Measure Hemoglobin A1c monthly until satisfactory control is achieved
(below 7%) .

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 chronic health problems

• Counsel on effect of poor glycemic control on Mather and fetus.

• Give folic acid 4mg daily before conception until 12 weeks’
gestation .
• Encourage a diet with complex carbohydrates, soluble fiber, and
reduced levels of saturated fats. Avoid simple sugars.
• Patients already using insulin to continue to use when attempt to
conceive and during pregnancy.
•  higher dose of folic acid (0.8 to 5 mg per day)

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 chronic health problems
Hypertension
• Discontinued ACE inhibitors and replaced with another
antihypertensive drug eg, labetalol
• Epilepsy: when left untreated theses conditions can increase risk
for pregnancy complications still birth or low birth babies.

Cardiovascular disease:
• pregnancy can be life-threatening and should be avoided. Patients
taking statins are advised to discontinue them.
• Patients taking warfarin are switched to heparin.
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 chronic health problems
weight management
• BMI should be calculated at the beginning of pregnancy.
• Maintain pre-pregnancy BMI within 18.5–24.9 kg/m 2 via diet and exercise
modifications.
•  increasing awareness regarding the risks associated with being overweight or
underweight.
• Under weight <18.5
• Normal 18.5-24.9
• Over weight25-29.9
• Obes >30

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 Physical activity, exercise routine
• Initiation of strenuous exercise in pregnancy should be
avoided.

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 Social and mental health concerns
• women who smoke must be urgently advised to stop smoking.
• depression, social support, intimate partner violence and other
safety issues, unstable housing, food insecurity.
• Urgently and personally advise women who wish to become
pregnant and their partners against consuming alcohol.

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Reading assignment
• Major surgical procedures.

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 SUCCESSFUL PRECONCEPTION CARE
targets
• Absence of tobacco use
• Absence of uncontrolled depression
• Absence of sexually transmitted infections
• Teratogen avoidance
• Healthy weight (body mass index >18 and <30 kg/m2)
• Folic acid use beginning at least three months before
conception
• Optimal glycemic control
• Planned pregnancy
• First prenatal visit before 12 weeks of gestation

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 Preconception immunization
• Prevent infections with serious consequences for mother/fetus.
• Before administering any vaccine ask women if they are
pregnant or could become pregnant in the next four weeks.
• counsel about the potential risks of vaccination during
pregnancy or just before conception.

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 Preconception immunization…
• Ensure immunity against measles, mumps, rubella, and varicella
For susceptible childbearing women.
• MMR are contraindicated during pregnancy and for a defined
period before conception.
• Before administering a live vaccine ask if they are pregnant or
could become pregnant in the next four weeks and,
• Routine pregnancy testing before vaccination is not necessary if
absence of pregnancy is certain by history.

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 Preconception immunization…
Immunizations to avoid during pregnancy –
• Measles, mumps, rubella, varicella(chicken pox), live influenza
vaccine (nasal flu vaccine), Smallpox due to risk to fetus
• Certain travel vaccines: yellow fever, typhoid fever
and Japanese encephalitis
• BCG vaccine (Bacillus Calmette Guerin).
• Human papillomavirus (HPV)

• Zoster (shingles) since its safety during pregnancy is unknown,

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 Preconception immunization…
• Avoiding pregnancy for 28 days following varicella vaccination
the manufacturer labeling recommends waiting three months .
• Documenting immunity to rubella is a routine component of
preconception care.
• Live attenuated vaccine, should be given to patients who are not
pregnant and, not have evidence of immunity to rubella.
• HepB vaccination series for Newborn within 24 hours of birth.

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 Preconception immunization…
vaccines that are safe to receive during pregnancy.
• hepatitis B, Hepatitis A .
• COVID-19 .

• Influenza (Flu)
• Tetanus, diphtheria, and whooping cough (Tdap)
• Haemophilus influenzae type b (Hib) ,
• Pneumococcus, meningococcus and rabies vaccines

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• Infertility,, and adverse pregnancy outcome — The general
consensus among infertility experts is that infertility
evaluation should be undertaken for couples who have not
been able to conceive after 12 months of unprotected and
frequent intercourse,

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 Benefits of preconception care

 It reduce mortality and improve health outcomes for mother,

 It improve health outcome for the neonate/child, which will

lead to health benefits in later life as an adolescent and adult;
 Reduce the incidence of too-early and too-frequent pregnancies
and abortions; and
 Improve the nutritional status of mothers and women.

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 Cont.…
 social and economic benefits for families and communities;
 It allows men & women participation in improving their own
health, irrespective of immediate plans to become parent.
 it controls exposure to environmental risk factors in early life
and their long-term effect for example, eliminating smoking
before or during pregnancy.

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 Packages of preconception care
preconception care has two packages, namely
• healthy transitions for adolescents targeting older children
and adolescents and
• pre-pregnancy program consisting mainly of maternal and
reproductive health package for partners/couples.

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