Pre-pregnancy counselling should include ways to improve a couple's chances of conception and advice on antenatal care to prevent disease and improve postnatal outcomes.
Being either underweight (BMI <19kg/m2) or obese (BMI >29kg/m2) will reduce a woman's chances of conceiving; for men, a BMI >29kg/m2 reduces fertility.1 In pregnancy, being overweight or obese has been linked to increased risk of many complications, such as diabetes, pre-eclampsia and antenatal haemorrhage, as well as problems during labour, such as failure to progress, shoulder dystocia and postnatal haemorrhage.
Weight management should be considered in advance of fertility management.
Certain foods pose a risk in pregnancy and these should be highlighted to the patient.
Toxoplasmosis can be contracted from undercooked meat, infected soil/water and cat faeces, so advise on hygiene.
Avoiding peanuts in pregnancy has yet to be proven to modulate the risk of childhood anaphylaxis to peanuts.2 However, if there is a history of peanut allergy in either partner or any previous children, peanuts may be avoided while the couple are trying to conceive.
Exercise is safe to continue while trying to conceive and improves health during pregnancy, also reducing stress and helping with relaxation.
There is evidence to suggest that women should avoid alcohol when trying to conceive as it may reduce fertility.3 Drinking alcohol during pregnancy is linked with an increased incidence of spontaneous abortion4 and fetal disease, including growth retardation and fetal alcohol syndrome. However, the critical level of consumption has not been established.
Abstinence in the first three months of pregnancy, followed by a limit of one to two units per week after that, is advisable.
Recreational drugs have been shown to affect sperm quality and the developing fetus. Caffeine intake should only be in moderation, although the evidence against heavy intake is not well established.
Women who smoke during pregnancy have a greater risk of miscarriage, stillbirth, premature birth, complications during and after pregnancy and labour, and having low birthweight babies. Patients should receive smoking cessation counselling.
2. Stopping contraception
While the return to ovulation may be slightly delayed, there is no evidence that women need to leave a gap after stopping hormonal contraception before trying to conceive. The only advantage in doing this is that the woman will be more certain of the date of conception once she has had a proper period.
3. Vitamin supplements
Supplementation with folic acid in early pregnancy has been shown to prevent neural tube disorders.5 All women planning a pregnancy are advised to take folic acid 400 microgram daily from when contraception stops until week 12 of the pregnancy.
If the patient has had a previous pregnancy affected by spina bifida, or she or her partner have a neural tube defect, or if she has epilepsy, diabetes, sickle cell, coeliac disease, or thalassaemia, or is obese, she should take a much higher dose of folic acid (5mg per day).6,7
Green leafy vegetables, and breads and cereals with added folic acid, are also advisable.
All women should be informed about adequate vitamin D stores during pregnancy, especially women with limited exposure to sunlight, such as those who stay covered if outdoors.
Vitamin A supplements can harm the growing fetus and should be avoided during pre-conception and pregnancy. Liver can contain high levels of vitamin A and should be avoided during pregnancy.
4. Additional issues
Check rubella vaccination status before conception and administer the vaccine if the woman has not been vaccinated in childhood, or if her immunity levels are low.
Current and ongoing medications, including OTC medications, may present a risk to a potential pregnancy, so specialist advice about alternatives should be sought.
Disabilities may need to be considered with regard to their effect on labour.
Screening for STIs should be discussed and undertaken if there is a perceived risk. Consider the patient's work environment and any risks posed.
- Dr Jenkins is a GP in Bristol
1. NICE. Assessment and treatment for people with fertility problems. CG011; February 2004.
2. Binkley KE, Leaver C, Ray JG. Allergy Asthma Clin Immunol 2011; 7: 17.
3. Jensen TK, Hjollund NH, Henriksen TB et al. BMJ 1998; 317: 505-10.
4. NICE. Antenatal care for the healthy pregnant woman. CG62; March 2008.
5. Lumley J, Watson L, Watson M et al. Cochrane Database Syst Rev 2001; (3): CD001056.
6. CMACE/RCOG joint guideline: management of women with obesity in pregnancy. March 2010. www.rcog.org.uk/files/rcog-corp/CMACERCOGJointGuidelineManagementWomenObesityPregnancya.pdf
7. Folic acid to prevent neural tube defects. DTB 1994; 32: 31-2.