Best Prenatal Care Begins Before Conception: A Doctor’s Perspective

I was talking with a reporter the other day about routine pregnancy care and the first question she asked me was, “When in pregnancy is it best to make your first doctor’s appointment?” She was caught off guard when I told her, “That’s easy. Before you ever get pregnant!” We have preached for a long time that the best prenatal care begins prior to conception. This is especially true for women planning to have their first babies, women with known medical problems, and women who had complications during a previous pregnancy.

A preconceptional visit is a lot more than meeting the person with whom you will be very intimate over the course of a year and during one of the most vulnerable periods of your life, although that is important too. It is an opportunity to review past medical, obstetrical, family, and social history that could have a significant impact on the outcome of a pregnancy. A woman should come to a preconceptional visit prepared to be open and forthright with her provider about her past and current problems, medications, sexual history, obstetrical history and the like. Ideally, she should come with her partner; however, if there are things about the past that she does not want her partner to know, then that first visit may be better made alone. Under those circumstances, it is most helpful if she can gather pertinent personal, genetic, and family history regarding her significant other so that this can be integrated into the counseling session.

Let me provide just a few examples of where preconceptional counseling can make a big difference.

  • If not offered at the time of the visit, ask your provider for a prescription prenatal vitamin. These are ‘well-balanced’ and most contain 400mcg of folic acid. Folic acid taken prior to conception can significantly reduce the risk for neural tube defects (failure of complete closure of the spine) and may also reduce the risk for other ‘midline defects’ involving the face, abdominal wall, and even the heart. If you or any other family member has had a baby with a neural tube defect, the dosage of folic acid can be safely increased to 4000mcg and may reduce your risk for a baby with such a problem by 70% or more. The spine closes between 24 and 28 days after conception, about 6 weeks from the start of the last normal menstrual period, and usually weeks before someone will get to see their provider for the first obstetrical visit. So, if folic acid is not begun prior to conception, the opportunity to derive a benefit from its use may be easily missed.
  • Prenatal vitamins also contain appropriate amounts of the ‘fat soluble vitamins,’ vitamins A, D, and E. Taken in excess, these vitamins can be harmful to a baby, so if you are currently supplementing your diet with ‘megadoses’ of these or any other over-the-counter preparations (yes, even ‘natural herbal’ compounds), you should make your provider aware of what these are and, if there is any question of safety, discontinue them prior to conception. In fact, if you have been on high doses of vitamin A for a prolonged period, or taken a medicinal vitamin A derivative such as Accutane(TM) for acne, you should probably not get pregnant for at least 3 months after discontinuing the drug.
  • If you work with young children, immunosuppressed individuals, or have a young child in a day care setting, you should consider serologic screening for previous exposure to parvovirus B19 (the cause of “Fifth’s disease”) and for cytomegalovirus (CMV) before conception. Both of these viruses are very common, especially in young children, and both can cause serious problems for a fetus if the mother develops a “primary infection’ during a pregnancy. Also, both viruses can cause unrecognized or completely “asymptomatic” primary infections in the mother that may have just as severe consequences for the baby. If you have protective IgG antibody to these viruses, indicating previous exposure, you are at as low a risk as possible for serious fetal infection. If you do not, since no vaccine is available for either virus, you should minimize risk of exposure during a pregnancy to potential sources of infection, and even consider repeat serologic screening in each trimester to see if you have “seroconverted” as the result of an asymptomatic infection. Any respiratory tract illness with fever during pregnancy might also be seen as a reason to rescreen the known seronegative woman.
  • If a woman has a chronic medical condition, the goal should be to optimize therapy prior to conception. This involves evaluating current disease status and stabilizing the condition, making the woman as ‘normal’ as possible, with treatment that has the highest likelihood of minimizing fetal risk (from standpoints of both the disease and the therapy) in the first trimester. The most common problems we deal with are hypertension, thyroid disease, and diabetes. Of these, diabetes is probably the greatest concern for the baby during the first 6-8 weeks of development. For reasons that are still not clear, poorly-controlled diabetes in first trimester is associated with at least a 2-4-fold risk for major anomalies, especially of the heart, spine, and abdominal wall. Bringing maternal blood sugars into normal range during ‘embryogenesis’ has been shown to lower the anomaly rate to levels close to those of the general population. Again, unless the woman is seen prior to conception, the opportunity to achieve this level of diabetic control is often missed. (By the way, diabetics are one group of patients I will routinely offer 4000mcg folic acid daily to prior to conception).
  • If there have been problems with the past obstetrical history, this is a major reason for seeking preconceptional counseling since, even if we sometimes aren’t smart enough to figure out why, we do know that obstetrical history tends to repeat itself. The issues of concern here range from hypertensive disorders, gestational diabetes, small babies, large babies, blood clots, and bleeding problems to the most common repetitive complication, such as preterm labor and delivery.

Source: Kenneth F. Trofatter, Jr., MD, Phd; Healthline.com

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