Preconception Counseling: Optimizing Health for a Successful Pregnancy

• The counseling is for couples who want to get pregnant. 
• Many times, there are situations where couples could have visited a doctor before pregnancy or earlier. 
• Various factors contribute to the necessity of counseling in couples, such as the changing lifestyle, socioeconomic conditions, cultural aspects, etc.

Purpose

• To provide general advice, knowledge, and attitude about lifestyle behaviors.
  • Lifestyle and behavioral modifications should start earlier to benefit from the changes in the antenatal period.
• The counseling also helps detect medical or mental health issues that can impact pregnancy.
• Assess known medical diseases and optimize disease states. For example, diabetes or heart disease.
• Identify couples at risk of having genetic disorders in offspring.
• Interventions to prevent or minimize recurrent adverse outcomes.
  • If there is a condition where pregnancy is a high risk, the risk of mortality, contraception, and other options need to be discussed. 
• Discuss contraception if pregnancy is not advisable or being planned.

Also read: Puerperium: Understanding the Postpartum Period

Who Needs Preconception Counseling?

Ideally, all women require preconception counseling. However, there are certain conditions when counseling can be very crucial, as intervention in preconception can impact the pregnancy outcome. 

Diabetes: 

A diabetic woman can be counseled for blood sugar control. If HbA1c (<6.5%) levels are higher, then the woman is at increased risk of abortion and congenital anomalies.

• Apart from this, there has to be a treatment review to manage the complications and optimize the disease status. Evidence of retinopathy, nephropathy, or any other conditions is used to understand the impact of diabetes on her current physical state. Based on the state, draw in place measures to optimize the condition for a positive future pregnancy outcome. 

Hypertension: 

• Women with hypertension may be on certain drugs (angiotensin receptor blockers, ace inhibitors) that are not good for pregnancy. The drugs should be managed in consultation with her physician. A good outcome for the mother and the baby is directly related to the state of the heart.

Heart Disease:

• Pregnancy puts a load on the heart, and the cardiac output needs to increase. So, there has to be an assessment of what heart disease the woman has and her cardiac status. Based on the data, optimizing the heart condition should be the priority.
• There are certain diseases like rheumatic heart disease, mito stenosis, and aortic stenosis that are common. There are also patients with severe MS and severe AS who undergo interventions in the form of valves or similar replacements. 
• Such complications cannot be handled during pregnancy if the woman requires it. In such conditions, counseling can help. Valve replacement is a contraindication in pregnancy.  

Other Disease

• Epilepsy review and medical management
• Thyroid disease review and medical management
• Autoimmune disorder review and medical management
• History of previous offspring with genetic disorders
• Obesity 
• Mental illness 

Also read: Physiology Of Lactation : Prolactin Hormone

Pregnancy Is Not Recommended

• Pulmonary artery hypertension and pregnancy are not recommended. 
• Severe systemic ventricular dysfunction. Pregnancy is not recommended if the ejection fraction is less than 30%.
• History of peripartum cardiomyopathy with residual impairment of LV function.
• Severe left-sided obstructive lesions of the heart.
• Marfan syndrome with aortic root dilation > 40 mm.
• Diabetes with Hb1Ac < 10%. Here, there is a significant risk of fetal anomaly.
• Breast cancer in the last 2 years.
  • It is better to not conceive within the next two years of breast cancer. Many women here are on tamoxifen, and it should be stopped at least two before conception.
• Recurrent uterine scar rupture.

Timing

• Ideally, 3-6 months before conception.
• Usually, there is reluctance to seek counseling. 
• Issue of unplanned pregnancy. 
• Opportunistic counseling

Approach

• Personal details:
  • Information such as age, socioeconomic status, and educational status. The counseling is against personal information. 
• Preliminary examination
• Lifestyle history: food habits and exercise. 
• Addiction or substance abuse:
  • It happens in every status of the society. So, knowing this is important for the evening and must be asked carefully so as not to offend anyone. 
• Reproductive history:
  • Everything about it, beginning from the menstrual cycle information to all other information like past obstetric history, abortion, hypertension issues, etc. 
• Environmental and social stress:
  • Sometimes, this is disregarded, but it is important to be aware of this. It can be managed by psychological therapy. 
• Immunization status:
  • MMR vaccination, measles, varicella chicken pox, hepatitis B, and recent COVID vaccination. 
• Medical and family history 
• Medication history
• Screening for genetic disorder (case-to-case basis):
  • It is not routinely done and varies on a case-by-case basis.

Also read: Pruritus In Pregnancy : Clinical Presentation

Lab Investigations

• Complete blood count
• Blood grouping & Rh
• Rubella IgG
• Blood glucose
• VDRL
• Hepatitis B
• HIV (patient can opt out of it)
• TSH, HbA1c
• Screening for thalassemia & sickle cell

Ideal Population Of Conception

• It is not right to be scared with the right advice regarding delaying the pregnancy. There exist difficult choices for women given the career, personal, cultural, and social aspects. 
• Fertility in women peacocks between the ages of 20 and 24  decreases a little by the age of 30-32 years. After that age, the decline is fairly rapid. 
• Overall, 15–19% lower fertility between the ages 30 and 34.
• 26–46% lower fertility between the ages of 35 and 39. This is a significant decline. 

Pregnancy Complications In Relation To Maternal Age

• Pregnancy complications happen particularly in extreme age groups, adolescent pregnancy, and advanced maternal age.
• The risk of preterm delivery and low birth increases in both the extremes of the age group.
• Hypertension risk is more so in adolescent pregnancy and preeclampsia risk.
• The risk of preterm, low birth, chronic hypertension, and diabetes is increased in adolescents as well, age 30 and more.
• The risk of the fetus with advanced maternal age is more likely. Advanced maternal age has various health complications such as diabetes, BP, and hypertension, which may add to the risk to the fetus. 
• In such situations, indicated preterm deliveries are performed, which again correlate to the low birth rate. 
• Most fetal complications or comorbidities are because of indicated preterm deliveries. Complications such as fetal growth restriction are one of the complications.
• Increased risk of multiple pregnancies in women with   greater than 35 years.
• Women of advanced age conceived through alternative methods such as IVF. The ART techniques induce some fetal complications. 
• Women more than 35-37 requesting a delay in pregnancy need to be informed about the possible complications involved. If the woman wants to get pregnant at 40, the medical counseling must provide thorough information regarding the medical risks and comorbidities. All the efforts are directed towards helping the woman make a conscious decision and also assist in reconsidering the decision owing to future complications. 
• For healthy women, the risk of complications is not that high. 
• Maintaining a healthy lifestyle again takes precedence to have a better chance of pregnancy and its outcome. 

Also read: Effective Study Techniques for OBS-GYN Residents

Aging And Reproduction In Women

• With aging women, the risk of having a miscarriage also increases.
• Fertility declines rapidly, as shown in the graph (pink line).
• Below the age of 30 years, the miscarriage rate varies between 7 and 15%.
• Beyond the age of 30–34, the miscarriage rate increases, but not much.
• Beyond the age of 35, the rate of miscarriage has sharply increased.
• The above information must be part of the counseling process.
• However, the right age for a woman to conceive is when the woman feels physically, psychologically, socially, economically, right, and responsible.
• Counseling assists women with the right information to make just and informed decisions. 

Importance Of Optimizing Bmi

• Underweight
  • Risk of nutritional deficiencies
    • Not maintaining adequate BMI due to nutrition deficiencies. 
  • Low birth weight
  • Small for gestational age
  • Preterm birth
  • Stillbirth

Also read: Placental Development And Circulation

Obesity

• Reduced fecundity
• Miscarriage
• Hypertension and preeclampsia
• Gestational diabetes
• Labor abnormalities and complications
• Operative complications
• Increased risk of infection, systemic or wound infections. 

• Obesity has become a problem in the current scenario. 
• Young adolescents, because of lifestyle choices, are going towards obesity. 
• Women in the reproductive age group go towards obesity. 
• In India, diabetes is a major health problem. PCOS is on the rise. 
• From the figure above, there are fat cells and adipocytes. They are important and act as energy storage.
• Apart from being the energy cells, the cells also secrete substances called cytokines, also known as adipokines. 
• Cytokines are responsible for a variety of endocrine and paracrine effects.
• For instance, there is adiponectin. It increases insulin sensitivity; it blocks the release of glucose from the liver (hepatic release of glucose).
• It is also cardio-protective as far as circulating lipids are concerned.
• Obesity is linked to diabetes, preeclampsia, and hypertension. Furthermore, there is an increased linkage to pre-term pregnancy. 
• All of the inflammatory cytokines may also accumulate in the follicular fluid. Therefore, they will also affect the oocyte development and maturation. Furthermore, there is an aneuploidy rate. 
• The blastocyst, the early embryo, is also going to suffer from oxidative stress. Inflammatory cytokines are involved in creating an environment, and thus, the environment becomes the problem. 

Also read: Puerperium: Understanding the Postpartum Period

Preconditional Condition Of Embryo

• There are studies conducted in epigenetics. It means the fetal environment during the periconceptional period also plays a role in determining future conditions or lifelong conditions. For example, obese women tend to beget obese children. 
• FGR, identified in utero, is related to an increased risk of obesity in adulthood.
• Enutoro environment determines the risk of having metabolic disturbances, obesity, and dyslipidemia in adulthood as well. 
• Due to the fetal environment, some epigenetic influences are taking place.  
• Epigenetic influences: the genetic makeup of the genes inherited is decided at fertilization when the zygote is formed. However, certain genes are expressed or repressed. So, it is not about the changes in the DNA makeup but the changes in the packaging of DNA. 
• These epigenetic influences are changed or dysregulated by an unhealthy fetal environment. The unhealthy environment could be because of maternal undernutrition or obesity. Obesity co-exists with micronutrient deficiency. 

Importance Of Optimising Bmi Preconceptionally

• Referring to neonatal outcomes, the poor success of lifestyle interventions during pregnancy has been attributed to their late introduction. In this regard, it is presumed that early gene expression within the placenta has already been programmed. 
• Preconception weight normalization is supported by a population-based cohort study in which there was a 10% lower risk of stillbirth, preeclampsia, GDM, & macrosomia with a 10% decrease in pre-pregnancy BMI.
  • Above are the excerpts from the paper Preconception Health in the Good Woman: TOG, Jan 2022.
• Intervention should be put in place in the preconception period for two reasons.
  • There is enough time for the intervention to work.
  • Factors operating in the fetal environment early on in the periconceptional period could not be periconceptional lifestyle modification.

Also read: How to Prepare Gynaecology and Obstetrics for Medical PG Entrance exams?

Guidance

• Diet and exercise
  • Diet has to be balanced with a good amount of whole grains, vegetables, fruits, and cereals.
  • Nutritionists can be involved in the process. 
• Exercise
  • An active lifestyle is important
  • Supplements
  • Optimization of weight
  • General advice about caffeine, smoking, and alcohol.
  • Family planning and contraception 
• Foods to avoid
  • Uncooked, undercooked, cured meat.
  • Certain types of fish: swordfish, king mackerel
  • Raw shellfish (oyster)
  • Unpasteurized milk/ cheese.
  • Liver and liver products. 
• Advice on alcohol and caffeine consumption
  • There is no safe limit for alcohol, no matter what is written in various Google articles. 
  • Any alcohol is bad. There is no study on the safe limits of alcohol in pregnancy. 
  • Avoid it altogether. 
  • Caffeine consumption should not be excessive, as it is related to miscarriage, FGR, and preterm birth.
  • The risk of fetal growth restriction (FGR) is unsettled. 
  • High caffeine intake (more than 500 mg/day) can increase the risk of abortion.
  • Moderate intake (less than 200 mg/ day) is not linked to adverse effects in pregnancy. 
  • Limiting caffeine intake and taking it in moderation is advised. 
• Avoid smoking
  • Smoking by women is bad, but passive smoking is also bad.
    • Miscarriage
    • Low birth weight
    • Stillbirth
    • Placental abruption
    • Preterm birth
    • Impaired neurological development
    • SIDS, ADHD.
  • Interventions to reduce and quit smoking eventually must be in place in the periconceptional period only. 

Also Read: Neuroendocrinology Of Female Reproduction And Steroid Hormones

How Smoking Effects

• From the basic understanding, cigarette smoke contains CO, tar, and nicotine.
• The CO binds to hemoglobin in the form of CO-Hb, carboxyHb, at the expense of oxygen. 
• This decreased the oxygen-carrying capacity.
• The baseline carboxyHb in smokers is 4%, while for chronic smokers, it could be as high as 13%.
• In non-smokers, the baseline is 1%.
• There is impaired oxygen delivery to the fetoplacental unit. This is the reason for all the associated complications.
• Nicotine stimulates the parasympathetic system, crosses the placenta, reaches the fetus, and leads to parasympathetic stimulation of the fetus as well.
• It can have a direct effect on the fetus and the fetus’s brain development (nicotinic acetylcholine receptors, or nAChRs), and it can also have a direct effect on the placental vasculature as well. 
• Couples need to be rightly advised about smoking impact and make necessary changes to their lifestyle for a positive pregnancy and pregnancy outcome.

Iron Supplementation

• As per WHO, iron supplements must be given even in the preconception period where anemia is prevalent in the population (more than 20%).
• Over 40% of the women worldwide are anemic in the periconceptional period.
• Iron deficiency contributed to 20% of maternal deaths worldwide.

Immunization Status

• Immunization is important because the mother will not get the infection when she gets pregnant. If there is a maternal infection (rubella, varicella chicken pox, cytomegalovirus) during pregnancy, it can lead to fetal infection by vertical transmission leading to fetal abnormalities.
• Vaccination helps form antibodies, protecting the women, and crosses the placenta, providing fetal and newborn protection (till the newborn immunization starts).
• Unfortunately, there are no vaccines for everything. So, which are the vaccines given and not given during the periconceptional period?
• Strongly advisable: MMR vaccine
  • All women in the periconceptional period should be screened for rubella immunity.
  • Avoid pregnancy one month after vaccination.
• Strongly advisable: Hep B
  • Hepatitis B vaccine is for high-risk women.
  • Those with HBV-positive partners.
  • HIV-positive women
  • High-risk sexual behavior
• Desirable vaccine: Varicella
  • A lot of women are immune due to prior childhood infection or immunization. 
  • In such conditions, IgG levels can be checked. If not immune, get vaccinated and avoid pregnancy for a month.
  • MMR vaccine and Varicella vaccine are the two vaccines given in the periconceptional period. 
• Desirable vaccine: Influenza
  • It is especially for those affected by chronic medical disorders like diabetes, heart disease, asthma, or HIV infection.
  • It is the intramuscular vaccine (can be given in pregnancy) and not the live intranasal vaccine. 
• Desirable vaccine: TDAP
  • TDAP is tetanus, diphtheria, and adult pertussis. It can be offered in the periconceptional period if there is a risk of exposure.
• Desirable vaccine: HPV vaccination
  • It is increasingly being recommended, creating awareness for girls between 9 and 26 years.
  • Several girls are not vaccinated in childhood and only in the childbearing age range (21 years) who are married and want to get pregnant. This opportunity can be used to give the HPV vaccine. 
  • For young adolescent girls, under 14 years, a 2-dose schedule. Beyond 14 years, a 3-dose schedule is maintained. 

Also Read: Pruritus In Pregnancy : Clinical Presentation

Who Requires Genetic Counseling

• If there is a history of birth defects, chromosomal abnormality, intellectual disability, or developmental delay in a parent’s previous child or family member, it is important to opt for full genetic counseling.
  • 3 generation pedigree analysis is required. 
  • Many times, women themselves cannot provide the information. 
  • Also, there could be a lack of documentation in the genetics regard.
  • Involvement of the family is important if there is a possibility of genetic issues in the offspring. 
• History of recurrent pregnancy loss.
• History of consanguinity
• Personal or family history of known or suspected hereditary disease
  • Genetic counseling will begin with the possibility of assessing the fetus being affected. 
  • Interventions come later.
  • Counseling is relative to the genetic diseases prevalent in India and clinically relevant information of the patient.
• Advance parent age
• Belonging to a particular ethnic background (increased prevalence of genetic disease). 
• Identifying couples benefiting from detailed genetic counseling is the objective of the initial genetic counseling. Later comes the care and reference to the appropriate consultants. 

Hope you found this blog helpful for your  Principles And Practie Of Gynaecology OBS-GYN preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.