Recommendations for Preconception Care

MICHAEL C. LU, MD, MPH, University of California, Los Angeles,

David Geffen School of Medicine and School of Public Health, Los Angeles, California

Every woman of reproductive age who is capable of becoming pregnant is a candidate for pre-
conception care, regardless of whether she is planning to conceive. Preconception care is aimed
at identifying and modifying biomedical, behavioral, and social risks through preventive and
management interventions. Key components include risk assessment, health promotion, and
medical and psychosocial interventions. Patients should formulate a reproductive life plan that
outlines personal goals about becoming pregnant based on the patients values and resources.
Preconception care can be provided in the primary care setting and through activities linked
to schools, workplaces, and the community. (Am Fam Physician 2007;76:397-400. Copyright
2007 American Academy of Family Physicians.)

F
Patient information: or more than two decades, prena- vaccinations, and counseling.6 Most com-

A handout on this topic is tal care has been a cornerstone for ponents of preconception care (Table 2 1,3-12)
available at http://family
doctor.org/076.xml. improving pregnancy outcomes in can be addressed in the primary care setting.
the United States. In recent years, Checklists, references, continuing education
however, limits to prenatal care and the resources, and patient information are avail-
importance of maternal health before preg- able through a number of Web sites (e.g.,
nancy have been increasingly recognized.1 http://www.marchofdimes.com/profession
The Centers for Disease Control and Preven- als/preconception.asp, http://www.cdc.gov/
tion (CDC) and the Agency for Toxic Sub- ncbddd/preconception/default.htm, http://
stances and Disease Registry recently released www.aafp.org/afp/20020615/2507.html).
recommendations to promote preconception
care in the United States.2 The recommenda- Interventions
tions are summarized in Table 12; the full Targeted interventions have been effective for
guideline is available at http://www.cdc.gov/ patients who wish to conceive. Interventions
mmwr/preview/mmwrhtml/rr5506a1.htm. include folic acid supplementation, testing for
rubella seronegativity and vaccination if indi-
Components of Preconception Care cated, tight control of pregestational diabetes,
Every woman of reproductive age who is careful management of hypothyroidism, and
capable of becoming pregnant is a candidate avoidance of teratogenic agents (e.g., isotreti-
for preconception care, even if she is not noin [Accutane], warfarin [Coumadin], some
planning to conceive. Men should also receive antiseizure medications, alcohol, tobacco).10
preconception care, although the components By the time pregnant women have their
are not as well defined in men as they are in first prenatal visit, it may be too late to pre-
women. The CDC defines preconception care vent some placental development problems
as a set of interventions that aim to identify or birth defects. Organogenesis begins early
and modify biomedical, behavioral, and social in pregnancy; therefore, initiating folic acid
risks to a womans health or pregnancy out- supplementation after neural tube closure at
come through prevention and management.2 six weeks (28 days after conception) has no
Several preconception care mod- demonstrated benefit for preventing a neural
els have been developed. 3-5 The Ameri- tube defect.13 Placental development begins
can Academy of Pediatrics and the even earlier, at implantation (seven days after
American College of Obstetricians and conception). Poor placental development has
Gynecologists classify the main compo- been linked to preeclampsia and preterm
nents of preconception care into four cat- birth14 and may play a role in fetal program-
egories: physical assessment, risk screening, ming of chronic diseases later in life.15


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 SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Screen for periodontal, urogenital, and sexually transmitted infections as indicated. C 2

Update immunization with hepatitis B, rubella, varicella, Tdap, human papillomavirus, and influenza C 2, 5
vaccines as needed.
Assess the patients risk of chromosomal or genetic disorders based on family history, ethnic C 2, 5
background, and age; offer cystic fibrosis and other carrier screening as indicated.
Assess the patients anthropometric (i.e., body mass index), biochemical (e.g., anemia), clinical, C 2, 5
and dietary risks.
Counsel the patient about possible toxins and exposure to teratogenic agents (e.g., heavy metals, C 2
solvents, pesticides, endocrine disruptors, allergens) at home, in the neighborhood, and at work;
review Material Safety Data Sheets and consult a local teratology information specialist as needed.
Screen for depression, anxiety, domestic violence, and major psychosocial stressors. C 2, 5
Laboratory testing should include a complete blood count; urinalysis; blood type and screen; C 2
screening for rubella, syphilis, hepatitis B, human immunodeficiency virus, gonorrhea, chlamydia,
and diabetes; and cervical cytology as indicated.

These recommendations are based on Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry recom-
NOTE:
mendations and emerging practice models and, therefore, receive C ratings.
Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 323 or
http://www.aafp.org/afpsort.xml.

Table 1. Summary of the CDC/ATSDR Guideline on Preconception Care

Consumer awareness: Increase public awareness about the importance of preconception health behaviors and care services by using
information and tools that are appropriate across various age groups, literacy levels (including health literacy), and cultures/languages
Health insurance coverage for women with low incomes: Increase public and private health insurance coverage for women with low
incomes to improve access to preventive womens health and pre- and interconception care
Individual responsibility across the life span: Encourage each woman, man, and couple to have a reproductive life plan (i.e., a plan, based
on the patients values and resources, to achieve a set of personal goals about having children)
Interconception care: Use the interconception period to provide additional intensive interventions to women who have had a previous
pregnancy that ended in an adverse outcome (e.g., infant death, fetal loss, birth defects, low birth weight, preterm birth)
Interventions for identified risks: Increase the proportion of women who receive interventions as follow-up to preconception risk
screening, focusing on high-priority interventions (i.e., those with evidence of effectiveness and the greatest potential impact)
Monitoring improvements: Maximize public health surveillance and related research mechanisms to monitor preconception health
Prepregnancy checkup: As a component of maternity care, offer one prepregnancy visit for couples and persons planning pregnancy
Preventive visits: As a part of primary care visits, provide risk assessment, education, and health promotion counseling to all women of
childbearing age
Public health programs and strategies: Integrate components of preconception health care into existing local public health and related
programs, including an emphasis on interconception interventions for women with previous adverse pregnancy outcomes
Research: Increase the evidence base and promote the use of the evidence to improve preconception health

NOTE: The items in this table are not prioritized and should be addressed simultaneously.
CDC = Centers for Disease Control and Prevention; ATSDR = Agency for Toxic Substances and Disease Registry.
Information from reference 2.

During early prenatal care, it is often too response.18 Chronic psychological or biologic
late to restore allostasis16 (i.e., the bodys abil- stress can wear out these systems. Women
ity to maintain stability through change17). who enter pregnancy with worn-out allostatic
Examples of allostasis include feedback inhi- systems (e.g., dysregulated stress or inflam-
bition in the hypothalamic-pituitary-adrenal matory response) may be more susceptible to
(HPA) axis to regulate stress response17 and pregnancy complications, including preterm
counterregulation of the immune system by birth. Therefore, restoring allostasis is an
the HPA axis to modulate inflammatory important objective of preconception care.

398 American Family Physician www.aafp.org/afp Volume 76, Number 3 August 1, 2007
 Table 2. Components of Preconception Care

Risk assessment Health promotion

Reproductive life plan: Ask your patient if she plans to have children (or Family planning: Promote family planning based on
additional children if she is already a mother) and how long she plans to wait the patients reproductive life plan; for women who
until she becomes pregnant; help her develop a plan, based on her values are not planning to become pregnant, promote
and resources, to achieve those goals effective contraceptive use and discuss emergency
contraception
Reproductive history: Review previous adverse pregnancy outcomes
(e.g., infant death, fetal loss, birth defects, low birth weight, preterm birth) Healthy weight and nutrition: Promote a healthy
and assess ongoing biobehavioral risks that could lead to recurrence in a prepregnancy weight (ideal BMI is 19.8 to 26.0
subsequent pregnancy kg per m2) through exercise and nutrition; discuss
macro- and micronutrients, including getting five-
Medical history: Ask if the patient has a history of conditions that
a-day (i.e., two servings of fruit and three servings
could affect future pregnancies (e.g., rheumatic heart disease,
of vegetables) and taking a daily multivitamin that
thromboembolism, autoimmune diseases); screen for ongoing chronic
contains folic acid
conditions such as hypertension and diabetes
Healthy behaviors: Promote healthy behaviors such as
Medication use: Review the patients current medication use; avoid FDA
nutrition, exercise, safe sex, effective contraceptive
pregnancy category X medications and most category D medications
use, dental flossing, and use of preventive
unless potential maternal benefits outweigh fetal risks; review the use of
health services; discourage risky behaviors such
over-the-counter medications, herbs, and supplements
as douching, not wearing a seatbelt, smoking
Infections and immunizations: Screen for periodontal, urogenital, and sexually (e.g., use the five As [Ask, Advise, Assess, Assist,
transmitted infections as indicated; update immunization with hepatitis B, Arrange] for smoking cessation9 ), and alcohol and
rubella, varicella, Tdap, human papillomavirus, and influenza vaccines as substance abuse
needed; counsel the patient about preventing TORCH infections
Stress resilience: Promote nutrition, exercise,
Genetic screening and family history: Assess the patients risk of sufficient sleep, and relaxation techniques; address
chromosomal or genetic disorders based on family history, ethnic ongoing stressors (e.g., domestic violence); identify
background, and age; offer cystic fibrosis and other carrier screening resources to help the patient develop problem-
as indicated; discuss management of known genetic disorders (e.g., solving and conflict-resolution skills, positive mental
phenylketonuria, thrombophilia) before and during pregnancy health, and strong relationships
Nutritional assessment: Assess the ABCDs of nutrition: anthropometric Healthy environments: Discuss household,
factors (e.g., BMI), biochemical factors (e.g., anemia), clinical factors, and neighborhood, and occupational exposures
dietary risks to heavy metals, organic solvents, pesticides,
Substance abuse: Ask the patient about tobacco, alcohol, and drug use; use endocrine disruptors, and allergens; give practical
CAGE7 or T-ACE8 questionnaires to screen for alcohol and substance abuse tips such as how to avoid exposures
Toxins and teratogenic agents: Counsel the patient about possible toxins and Interconception care: Promote breastfeeding,
exposure to teratogenic agents at home, in the neighborhood, and in the placing infants on their backs to sleep to reduce
workplace (e.g., heavy metals, solvents, pesticides, endocrine disruptors, the risk of sudden infant death syndrome, positive
allergens); review Material Safety Data Sheets and consult a local parenting behaviors, and the reduction of ongoing
teratology information specialist (http://otispregnancy.org/otis_find_a_tis. biobehavioral risks1
asp) as needed Medical and psychosocial interventions for
Psychosocial concerns: Screen for depression, anxiety, domestic violence, identified risks
and major psychosocial stressors Interventions should address identified medical and
Physical examination: Focus on periodontal, thyroid, heart, breast, and psychosocial risks; examples include folic acid
pelvic examinations supplementation, testing for rubella seronegativity
Laboratory testing: Testing should include a complete blood count; urinalysis; and vaccination if indicated, tight control of
blood type and screen; and, when indicated, screening for rubella, syphilis, pregestational diabetes, careful management of
hepatitis B, human immunodeficiency virus, gonorrhea, chlamydia, and hypothyroidism, and avoidance of teratogenic agents
diabetes and cervical cytology; consider measuring thyroid-stimulating (e.g., isotretinoin [Accutane], warfarin [Coumadin],
hormone levels some antiseizure medications, alcohol, tobacco)10

FDA = U.S. Food and Drug Administration; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; TORCH =Toxoplasmosis, Other
viruses, Rubella, Cytomegaloviruses, Herpes (simplex) viruses; BMI = body mass index; CAGE = Cut down on drinking, Annoyance with criticisms
about drinking, Guilt about drinking, and using alcohol as an Eye opener; T-ACE = Tolerance, Annoyance, Cut down, Eye-opener.
Information from references 1, and 3 through 12.

In addition to targeting optimal health Implementation

outcomes for the baby, preconception care Preconception care includes more than a sin-
should promote the mothers health, regard- gle prepregnancy office visit and less than all
less of her plans for future pregnancies.2 well-woman examinations20; however, there
Evidence suggests that pregnancy complica- is no consensus on this. For some physicians,
tions such as preeclampsia or preterm birth preconception care is a single prepregnancy
may increase the mothers risk of chronic checkup a few months before the patient
diseases later in life.19 attempts to conceive. A single visit, however,

August 1, 2007 Volume 76, Number 3 www.aafp.org/afp American Family Physician 399
Preconception Care

may not be sufficient to address every preconception REFERENCES

issue, and approximately one half of all pregnancies in
1. Lu MC, Kotelchuck M, Culhane JF, Hobel CJ, Klerman LV, Thorp JM
the United States that are unintended at conception will Jr. Preconception care between pregnancies: the content of internatal
be missed during the visit.21 For other physicians, precon- care. Matern Child Health J 2006;10(suppl 7):107-22.
ception care includes all well-woman examinations and 2. Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS,
et al. Recommendations to improve preconception health and health
primary care visits from prepubescence to menopause.22 careUnited States. MMWR Recomm Rep 2006;55(RR-6):1-23.
In practice, however, such frequent assessments may not 3. Cefalo RC, Moos MK. Preconceptional Health Care: A Practical Guide.
be feasible or reimbursable, and some components (e.g., 2nd ed. St. Louis, Mo.: Mosby, 1995.
genetic and laboratory testing) may not be indicated or 4. Jack BW, Culpepper L. Preconception care. J Fam Pract 1991;32:306-15.
5. American College of Obstetricians and Gynecologists. Preconceptional
appropriate at every visit. care. ACOG Technical Bulletin No. 205, May 1995. Int J Gynaecol
Physicians can start by asking female patients at every Obstet 1995;50:201-7.
visit about their reproductive life plan23 (i.e., a plan, 6. American Academy of Pediatrics, American College of Obstetricians
based on the patients values and resources, to achieve a and Gynecologists. Guidelines for perinatal care. 5th ed. Elk Grove Vil-
lage, Ill.: American Academy of Pediatrics, 2002.
set of personal goals about having children).2 The ques- 7. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;
tions should include whether the patient intends to have 252:1905-7.
a child (or additional children if she is already a mother) 8. Sokol RJ, Martier SS, Ager JW. T-ACE questions: practical prenatal
detection of risk-drinking. Am J Obstet Gynecol 1989;160:863-70.
and her timeline for having children.24 If the patient
9. U.S. Department of Health and Human Services. Fiore MC, Bailey WC,
plans to have a child within the next year or two, she Cohen SJ, et al. Treating tobacco use and dependence. Rockville, Md.:
and her partner should return for a full assessment. U.S. Dept of Health and Human Services, Public Health Service, 2000.
Follow-up visits should be scheduled according to the 10. Atrash HK, Johnson K, Adams MM, Cordero JF, Howse J. Preconception
care for improving perinatal outcomes: the time to act. Matern Child
patients individual risks. If the patient does not plan to Health J 2006;10(5 suppl):3-11.
become pregnant in the next one to two years or does 11. March of Dimes. Preconception health and health care. Accessed Feb-
not plan to have children, she should continue to receive ruary 8, 2007, at: http://www.marchofdimes.com/professionals/pre
conception.asp.
well-woman examinations, which include routinely
12. Brundage SC. Preconception health care. Am Fam Physician 2002;
addressing her family planning needs and updating her 65:2507-14.
reproductive life plan. 13. Milunsky A, Jick H, Jick SS, Bruell CL, MacLaughlin DS, Rothman KJ, et
A survey of family physicians and obstetricians/gyne- al. Multivitamin/folic acid supplementation in early pregnancy reduces
the prevalence of neural tube defects. JAMA 1989;262:2847-52.
cologists found that only one in six had provided pre-
14. Norwitz ER. Defective implantation and placentation: laying the blueprint
conception care to most women for whom they provided for pregnancy complications. Reprod Biomed Online 2006;13:591-9.
prenatal care.25 In addition to family physicians and 15. Godfrey KM. The role of the placenta in fetal programming. Placenta
obstetricians/gynecologists, other health care profes- 2002;23(suppl A):S20-7.
16. McEwen BS. Protective and damaging effects of stress mediators.
sionals (e.g., health educators, social workers) should be N Engl J Med 1998;338:171-9.
prepared to contribute to comprehensive preconception 17. Lu MC, Tache V, Alexander GR, Kotelchuck M, Halfon N. Preventing low
care. Preconception health can be promoted at work- birth weight: is prenatal care the answer? J Matern Fetal Neonatal Med
2003;13:362-80.
places, at schools, and in the community.
18. Chrousos GP. The stress response and immune function: clinical impli-
The author thanks Hani Atrash, MD, MPH; Brian Jack, MD; Kay Johnson, cations. Ann N Y Acad Sci 2000;917:38-67.
MPH; and Sam Posner, PhD, for their assistance in the preparation of 19. Smith GC, Pell JP, Walsh D. Pregnancy complications and maternal risk
this manuscript. of ischaemic heart disease: a retrospective cohort study of 129,290
births. Lancet 2001;357:2002-6.
20. Posner SF, Johnson K, Parker C, Atrash H, Biermann J. The national sum-
The Author mit on preconception care: a summary of concepts and recommenda-
tions. Matern Child Health J 2006;10(5 suppl):199-207.
MICHAEL C. LU, MD, MPH, is an associate professor of obstetrics and
21. Henshaw SK. Unintended pregnancy in the United States. Fam Plann
gynecology at the David Geffen School of Medicine at the University of Perspect 1998;30:24-9, 46.
California, Los Angeles, (UCLA) and is an associate professor of com-
22. Moos MK. Preconception care: every woman, every time. AWHONN
munity health sciences at the UCLA School of Public Health. He also is Lifelines 2006;10:332-4.
a member of the Centers for Disease Control and Preventions Panel on
23. American College of Obstetricians and Gynecologists. The importance
Preconception Care. Dr. Lu received his medical degree from the University of preconception care in the continuum of womens health care.
of California, San Francisco, and completed an obstetrics and gynecology ACOG Committee Opinion No. 313, September 2005. Obstet Gynecol
residency at the University of California, Irvine, Medical Center. 2005;106:665-6.
Address correspondence to Michael C. Lu, MD, MPH, UCLA School of 24. Moos MK. Preconception health: where to from here? Womens Health
Public Health, P.O. Box 951772, Los Angeles, CA 90095-1772 (e-mail: Issues 2006;16:156-8.
mclu@ucla.edu). Reprints are not available from the author. 25. Henderson JT, Weisman CS, Grason H. Are two doctors better than
one? Womens physician use and appropriate care. Womens Health
Author disclosure: Nothing to disclose. Issues 2002;12:139-49.

400 American Family Physician www.aafp.org/afp Volume 76, Number 3 August 1, 2007