Pre-pregnancy counselling
The aim is to help prospective parents embark upon pregnancy under conditions most likely to ensure optimal wellbeing for the fetus. Babies conceived 18–23 months after a live birth have the lowest rate of perinatal problems.3 Ensure that a woman is rubella (and chickenpox, p 144) immune prior to pregnancy and all women should have their need for thromboprophylaxis in pregnancy considered (p 16). Other areas covered include:
- Optimal control of chronic disease (eg diabetes) before conception. This is also important for hypothyroidism as the fetus cannot make thyroxine until 12 weeks and under-replacement may affect neurodevelopment. Strict diet is essential peri-conceptually for women with phenylketonuria (PKU).
- Stop teratogens or seek expert advice prior to conception (p 29).
- Medication to protect the fetus from abnormality (eg folate supplements for neural tube defects, p 140 and below).
- Provide expert information for those at ↑risk of abnormality so pregnancy or its avoidance is an informed choice, and any tests needed (eg chorionic villus sampling, p 10) are planned. Regional genetic services give detailed pre-pregnancy counselling. See p 154. In relevant ethnic populations, take blood for thalassaemia and sickle-cell tests (p 22).
- If past/family history of thromboembolism, screen for thrombophilia.
Diet
To prevent neural tube defects and cleft lip, all should have folate-rich foods and folic acid 0.4mg daily (eg Preconceive®) from before conception—until 13 weeks' gestation (5mg/day PO if history of neural tube defect, some epileptic drugs p 29). These foods have >0.1mg of folic acid per serving: Brussels sprouts, asparagus, spinach, blackeye beans, fortified breakfast cereals. Avoid liver and vitamin A (vitamin A embryopathy risk).
Smoking
decreases ovulations, causes abnormal sperm production (± less penetrating capacity), ↑rates of miscarriage (×2), and is associated with preterm labour and lighter-for-dates babies (mean is 3376g in non-smoker; smoker: 3200g). Reduced reading ability in smokers' children up to 11yrs old shows that long-term effects are important. ~17% of smoking mothers stop before or in pregnancy.
Alcohol consumption
High levels of consumption are known to cause the fetal alcohol syndrome (p 138). Moderate drinking has not been shown to adversely affect the fetus but alcohol does cross the placenta and may affect the fetal brain. Miscarriage rates are higher among drinkers of alcohol. NICE recommends <1unit/24h. To cut consumption: see p 513.
Spontaneous abortion (SA)
At least 12% of first pregnancies spontaneously abort. Rates after 1 SA are increased to ~24%; after 2 SA to ~36%; after 3 to ~32% and after 4 to ~25%, so chances of a future pregnancy succeeding are ~2 in 3. Pregnancy order of SA/live pregnancies is also relevant: the more recent a live birth the more likely next time will be successful.
Recurrent spontaneous abortion/miscarriage
See p 261.
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