INTRODUCTION

Pregnancy is usually confirmed after the missed menstrual period, a few

weeks after the conception. In early
pregnancy, the embryo is susceptible
to teratogens. Furthermore, the health
of the pregnant woman may not be optimally
suited to pregnancy. Therefore,
it seems logical that care should begin
before conception. Most women do not
visit the obstetricians before pregnancy
has been confirmed. Family doctors or
other primary health care providers are
in a better position to provide preconception
care. Some of the preconception
care can even be introduced in the
community and in schools, in the form
of health education and public health
measures. Although the impact of preconception
care for women with significant
pre-existing health problem, such
as diabetes, may be more obvious than
for women without, preconception care
should not be confined to the former
group of women. Offering preconception
care, such as folic acid supplementation
to prevent neural tube defect, to all
women may have a significant impact on
the whole population. The evidence for
the effectiveness of commonly practised
preconception care will be examined
in this article. A practical checklist for
preconception care in the primary health
care setting will also be provided.

OBJECTIVES OF
PRECONCEPTION CARE
The objectives of preconception care are
to improve the physical and psychological
health of the mother (decrease maternal
mortality and morbidity) and the
father, and to improve the health of the
offspring (decrease perinatal morbidity
and mortality). The major causes of
perinatal morbidity and mortality are low
birth weight and congenital abnormalities.
Therefore, preconception intervention
strategies are targeted at reducing
these.

PLANNED PARENTHOOD
Family planning is an important part of
preconception care. In developing countries,
maternal deaths are associated
with high multiparity and closely spaced
pregnancies.1 In developed countries, especially
in metropolitan cities, delayed

parenthood, single parenthood and lack

of support from the extended family may
pose special problems. For example, postpartum
depression occurs more often in
unplanned pregnancies, while subfertility
and miscarriages occur more often with
older maternal age.2 Women and their
partners should be given information on
contraception, and they should also be
encouraged to discuss when it is best for
them to have children.

DIETARY AND VITAMIN

SUPPLEMENTATION
Folic acid supplement use before concep3 SKP
JPOG NOV/DEC 2012 258

tion and continued to 12 weeks gestation

has been found to be effective in reducing
neural tube defects in offspring of women
in the general population (low-risk) and
also offspring of women with previous affected
babies, and women on antiepileptic
drugs (high-risk).3 For low-risk women, 400
g of folic acid daily is adequate, but for
high-risk women, 5 mg of folic acid daily is
usually prescribed.
In Southeast Asia where thalassaemia
trait is common, an increased incidence
of neural tube defect has been found
in thalassaemia trait carriers.4 It is logical
to use the higher dose of folic acid for thalassaemia
trait carriers for this purpose,
even though the 400 g and 5 mg daily doses
have not been compared in randomized
controlled trials in this group of women.
Since up to 50% of pregnancies are
unplanned, mandatory fortification of food
(mainly flour) has been used in many countries
and has been found to be effective in
reducing the prevalence of neural tube defects.
5 However, there are some concerns
that mandatory fortification exposing the
whole population to increased intake of
folic acid may lead to some adverse effects
in susceptible individuals. For example,
degenerative neurological diseases in
the elderly may potentially be worsened.6
The effectiveness of folic acid supplementation
in preventing congenital abnormalities
other than neural tube defect
has not been well established.3
Other dietary supplementations have
not been well studied or have not been
found to significantly reduce congenital
abnormalities. It must also be remembered

that high-dose vitamin A is teratogenic.7

Women with iron deficiency anaemia
should be given iron supplement to correct
the anaemia.

GOOD PRACTICE IN DRUG

PRESCRIBING
Women in the reproductive age group
should avoid teratogens unless they are
practising effective contraceptive methods.
Most drugs are of low teratogenicity,
but a good prescription practice is
not to prescribe unless necessary and
only to prescribe drugs that are proven
to be effective.8 Many commonly used
drugs are assigned to US Food and Drug
Administration (FDA) pregnancy risk category
C, which means that these drugs have
been found to be teratogenic or embryocidal
in animal studies but there are no
controlled studies in women or animals.
These drugs can be used if the potential
benefits outweigh the potential risks and
if no alternatives are found. However,
some drugs used commonly for treatment
of symptoms (eg, codeine, promethazine,
NSAIDs) are category C drugs. For symptomatic
treatment only, their use is hardly
justifiable in women who are pregnant
or who are potentially pregnant. Doctors
should be particularly cautious when prescribing
treatment for women presenting
with upper gastrointestinal tract symptoms
or urinary symptoms, as these can be
symptoms of early pregnancy.
Special caution must be taken when
prescribing categories D and X drugs.
Category D means that there is positive
evidence of human fetal risk but the benefits
from use in pregnant women may be
acceptable despite the risk. A common
example are antiepileptic drugs, most of
which are category D. Stopping antiepileptic
drugs in some women may result
in recurrence of epileptic attacks, which
is even more detrimental than antiepileptic
drugs to the mother and the baby.
Therefore, their use may be unavoidable in
some women. Folic acid supplement 5 mg
daily should be given together with antiepileptic
drugs for women who may become
pregnant.
Category X drugs are those that have
been demonstrated to be teratogenic
in humans and their associated risks in
pregnancy clearly outweigh any possible

benefits. An example is isotretinoin, a

highly teratogenic drug, which is used for
skin conditions. When category X drugs
are prescribed, women should be advised
against pregnancy and appropriate contraception
should be provided. In some countries,
medical practitioners are required
by law to ask female patients to sign a
consent agreeing to take category X drugs
and to use effective contraception while
on these drugs. Irrespective of the local
legal requirement, it is a good practice to
document in the medical record that this
has been explained to the patient.
Women in the reproductive age group
should also be educated to be cautious
when they use over-the-counter drugs,
which may include some category C drugs.
Precautions regarding their use in pregnancy
are usually stated on the package.
They should also be educated to inform
doctors if they are not practising contraception
and to ask if the prescribed drugs
are safe for pregnancy, even if they do not

Continuing Medical Education

JPOG NOV/DEC 2012 259

suspect that they are pregnant.

AVOIDANCE OF IRRADIATION
Diagnostic X-ray should be avoided during
the luteal phase of the menstrual cycle
and deferred to the follicular phase if possible.
However, most diagnostic X-rays,
except those done under fluoroscopy, have
irradiation doses below the estimated teratogenic
threshold (0.1 Gy).9 Therefore, urgent
diagnostic X-ray should not be withheld
if there is a strong indication or if alternative
non-irradiation tests are not available.
Abdominal shield should be used.
Therapeutic irradiation, including radioactive
iodine, is absolutely contraindicated
during pregnancy.

ADVICE AGAINST LIFESTYLE

SUBSTANCE USE
Alcohol consumption is associated with
increased risk of miscarriages and fetal
malformation. However, whether a low intake
(less than 5 units per week) is safe is
uncertain.10 Therefore, women planning to
get pregnant should be advised to abstain
from alcohol.
Cigarette smoking is not teratogenic
but doubles the risk of intrauterine growth
restriction and increases the risk of miscarriages

and perinatal mortality by one-third.11

Women should be encouraged and be
helped to stop smoking before pregnancy.
There is an association between use
of recreational drugs and fetal congenital
abnormalities, in particular, gastroschisis.
12 Cocaine use is associated with increased
incidence of placental abruption.

PREVENTION OF INFECTIONS
Some maternal infections can be transmitted
to the baby during pregnancy and/or delivery,
causing grave consequences to the baby.
Rubella infection in pregnancy can
cause major congenital abnormalities.
Vaccination against rubella is part of the
vaccination programme for children and
adolescents in many countries. However,
even in countries with such vaccination
programmes, doctors must be aware that
immigrants may not have been vaccinated
in their original country. Therefore, checking
the immune status and providing the
vaccination to women is an important part
of preconception care. Chickenpox infection
during pregnancy can also cause scarring
and deformity in the baby in a small
proportion of cases. Vaccination against
chickenpox in susceptible women before
pregnancy can be an option.13
Hepatitis B vaccination should be
provided to susceptible health care workers
and non-immune women whose partners
are carriers. However, women who
are hepatitis B carriers should not be unduly
worried, because effective prevention
of perinatal transmission is available.14
Screening for HIV and syphilis are
part of routine antenatal care. However,
it can be done before pregnancy. Syphilis
can be effectively treated before pregnancy.
This also allows time for contact
tracing and for more effective prevention
of re-infection during pregnancy. There is
no curative treatment for HIV, but carriers
can remain healthy with monitoring and
early antiretroviral treatment. Prevention
of perinatal transmission with antepartum
HAART (highly active antiretroviral therapy
with multiple agents) together with
intrapartum and postnatal zidovudine for
the baby is highly effective.15 Therefore,
it may not be necessary to advise against
pregnancy in carriers. With compliance,
perinatal transmission rate can be reduced
to less than 1%, but in rare instances the

baby can still be infected. Knowing the HIV

status before pregnancy may change the
reproduction plan for some women or may
help HIV-positive individuals to be better
prepared to start a family. However, negative
screening before pregnancy does not
mean that the individual is not susceptible
to infection after the screening or during
the pregnancy.

TREATMENT FOR OBESITY

It has increasingly been shown that obesity
has adverse effects on pregnancy.
The association of obesity with maternal
mortality and morbidity is well proven.
There is also evidence suggesting that
fetal congenital abnormalities and perinatal
morbidities are also increased in
obese mothers.16 Weight reduction may
potentially be harmful during pregnancy.
Therefore, weight reduction should ideally
be achieved before pregnancy.17

ATTENTION TO DENTAL
HYGIENE
Periodontal disease in pregnant women
has been found to be associated with increased
risk of preterm delivery.18 However,
treatment of the disease during pregnancy
has been shown to be ineffective in reducJPOG
NOV/DEC 2012 260

ing premature deliveries. Effectiveness of

treatment before pregnancy in improving
pregnancy outcome has not been studied.
19 Provision of dental care as part of
general health care is a good practice, but
its role in preconception care has yet to
be determined. However, for women with
medical diseases such as valvular heart
disease, good dental hygiene is a very important
part of preconception care.

CERVICAL SCREENING
Cervical smears should be taken before
pregnancy in women planning to get pregnant,
if they are not already in a regular
screening programme. Hormonal changes
in pregnancy may lead to problems in interpretation
of cervical cytology. Cervical
biopsy and treatment of cervical intraepithelial
neoplasia during pregnancy are
also associated with a higher incidence
of heavy bleeding and are generally not
advisable unless there is a suspicion of
invasive disease. With experience, colposcopic
examination during pregnancy to
detect invasive lesions is effective.20 If invasive
disease is detected, full treatment

cannot be given without terminating the

pregnancy. Therefore, screening before
pregnancy is more ideal than screening
during pregnancy.

WOMEN WITH MEDICAL

DISEASES
Women with significant medical diseases,
such as diabetes, active thyroid
diseases, epilepsy, autoimmune diseases,
renal diseases, cardiac diseases and
post transplantation, should be referred
to a maternal medicine specialist for preconception
care. Preconception care for
women with diabetes is the best known
model for preconception care in women
with significant chronic medical illness.
It is well known that the incidence of
congenital abnormalities in fetuses of
diabetic women is directly proportional
to periconception glycosylated haemoglobin
A1C, which reflects the glycaemic
control.21 Therefore, achieving good glycaemic
control before pregnancy is important.
Women with diabetes should
also be screened for diabetic retinopathy,
nephropathy and ischaemic heart
disease before pregnancy, as these complications
greatly increase the maternal
risks and perinatal mortality and morbidity.
However, good glycaemic control is
difficult to achieve and intervention programmes
have, so far, fallen short of the
expectation.22
Hypertension is often asymptomatic,
and blood pressure should be checked
even in women without a history of hypertension.

WOMEN WITH MAJOR

PSYCHIATRIC DISEASES
Women with major depression, bipolar
disorders and schizophrenia should be
under the care of a psychiatrist to ensure
that the disease is well controlled before
pregnancy. Many psychotropic drugs are
FDA category C or D. However, their use
may be unavoidable, as relapse during
pregnancy may be more detrimental to the
mother and the baby.

WOMEN AND MEN WITH

MALIGNANT DISEASES
Many malignant diseases can be successfully
treated with modern medicine.
Women and men may want to start a family
after treatment of malignant diseases.
Some treatment may affect the future fertility

of men and women. Storage of semen

or even cryopreservation of ovarian
tissues before these treatments may be
an option.23 After treatment, some women
may be concerned about the risk of recurrence
of the malignancy during pregnancy
because of altered hormonal and immune
status. Pregnancy does not affect the recurrence
risk of most malignant diseases
if the woman is disease-free before embarking
on a pregnancy. It is best to consult
an oncologist on this.

SCREENING FOR GENETIC

DISEASES
For families with no history of genetic
diseases, screening for carrier status of
any genetic disease before pregnancy is
only advisable if (1) the particular genetic
disease is common in the population, (2)
reliable screening methods are available,
and (3) the affected individual has
poor quality of life or a major handicap.
An example is - and -thalassaemia in
Southeast Asia. In Hong Kong, the prevalence
of -thalassaemia carriers and
-thalassaemia is 5.0% and 3.4%, respectively.
24 A simple complete blood picture
with mean corpuscular volume above 80 fL
effectively exclude - and -thalassaemia
trait.24 (However, it does not exclude car

Continuing

Medical Education
JPOG NOV/DEC 2012 261

riers of haemoglobin E, which is prevalent

in Thailand, and haemoglobin E thalassaemia heterozygous may have
transfusion-dependent anaemia.) Further
investigations, such as haemoglobin pattern
analysis and DNA studies may be
needed after excluding iron deficiency.
Iron deficiency can be excluded by iron
profile studies, but a simple and practical
way to exclude iron deficiency is a
therapeutic trial of iron supplement for 4
weeks. If red cell microcytosis is due to
iron deficiency alone, it should be corrected
by supplement. Which genetic diseases
to screen for and how they should
be screened for should be determined to
suit the local population. In general, it
is important that a screening test should
have a high sensitivity with a low falsepositive
rate. There is some controversy
as to whether screening should be done

before or during pregnancy. If prenatal

diagnosis is readily available and acceptable
to the couple and early antenatal care
is accessible, antenatal screening may be
more cost-effective than preconception
screening. Preconception screening has
the advantage of allowing more time for
couples to understand and consider the
options of prenatal diagnosis before the
pregnancy. Screening for genetic diseases,
whether before pregnancy or during
pregnancy, should only be done with informed
consent. Individuals should not be
coerced into undergoing genetic testing or
screening.
It is also a good practice to obtain a
genetic history from couples planning to
get pregnant. If there are any genetic diseases
in the family (eg, the womans brother
has haemophilia, if the couple already
have a child with genetic disease, or one
potential parent has a genetic disease),
referral to a geneticist for preconception
counselling and testing is recommended.
Many tests to confirm the diagnosis and