4 Mandish K. Dhanjal1,2 1 Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK 2 Imperial College London, London, UK A woman who enters pregnancy in a good state of health with a healthy diet and well‐controlled medical disease is more likely to have a healthy pregnancy and a good outcome than a woman who enters pregnancy with an unhealthy lifestyle and uncontrolled medical disease. Pre‐conception or pre‐pregnancy counselling involves seeing women several months prior to conception in order to discuss and modify lifestyle choices and assess and improve medical health before pregnancy. The National Institute for Health and Care Excellence (NICE) has identified pre‐conception counselling as an important area in their antenatal guidelines [1] and the importance of pre‐conception health was highlighted in the Chief Medical Officer’s Annual Report in 2014 [2]. All women considering having a baby should see their general practitioner (GP), and if they have a medical disease a specialist in the management of their particular disease, for pre‐pregnancy counselling prior to conceiving. The purpose of these consultations is to: Broadly, for any medical condition, there should be a discussion about whether becoming pregnant has risks for the mother or fetus. Pre‐pregnancy counselling will inform women of their risks, empowering them to make an informed decision whether or not to proceed with pregnancy. It will allow planning or prevention of pregnancy, and access to the appropriate multidisciplinary specialized services if necessary. Importantly, it is a conduit to influencing the health outcomes of the future generation, as improving maternal health and in particular obesity can impact on reducing the burden of some non‐communicable diseases in the offspring. All women will benefit from the general advice offered by GPs. The confidential enquiry reporting maternal deaths has specifically recommended that pre‐conception counselling be provided for women of childbearing age with pre‐existing serious medical or mental health conditions that may be aggravated by pregnancy, in particular the commoner conditions including epilepsy, diabetes, congenital or known acquired cardiac disease, autoimmune disorders, obesity with body mass index (BMI) of 30 or more, and severe pre‐existing or past mental illness [3]. The recommendation especially applies to women prior to having assisted reproduction and other fertility treatments. This should ideally take place 3–6 months prior to conceiving; however, few women are sufficiently motivated to see a doctor prior to getting pregnant, even if they have a medical illness. Dedicated pre‐pregnancy clinics or pre‐pregnancy health check clinics would be ideal, but very few health authorities offer this service. Additionally, it is estimated that 25–40% of pregnancies are unplanned. Unplanned pregnancies are associated with adverse outcomes, including low birthweight babies, preterm delivery and postnatal depression [2]. Pre‐conception advice should therefore occur opportunistically when women of childbearing age attend their GP for contraception or for baby and toddler checks, attend their specialist for review of their medical disease or if they are referred to infertility clinics. The average age of first sexual intercourse is 16 years and 0.44% of girls under the age of 16 years in England and Wales get pregnant [4]. Two‐thirds of these girls undergo a termination of pregnancy [3]. The UK has the highest teenage pregnancy rate in western Europe despite a fall of 25% in the last decade. Some medical conditions, such as complex congenital heart disease, would necessitate a discussion about pregnancy during adolescence (12–15 years old) depending on the degree of maturity of the child. This is not to encourage pregnancy in these teenagers, but to educate them of the risks that unintended pregnancy may hold for them. Implicit in any discussion is the need for adequate contraception (see Chapter 65). Long‐acting reversible contraceptive agents, including progesterone‐containing implants, intrauterine devices and injections, are 20–100 times more effective in preventing pregnancy than contraceptive pills or barrier methods such as condoms [2]. GPs are best placed to do this as they have a long‐term relationship with their patients and will usually be seeing them for contraceptive advice and for other medical conditions. Specialists also have a role, particularly diabetologists, neurologists and cardiologists, who will be seeing adolescents and women of reproductive age for regular checks of their diabetes, epilepsy or heart disease. Pre‐conception counselling is vital in these groups as it can directly influence pregnancy outcome. Unfortunately some specialists may be reluctant to discuss the implications of medical disease and the associated medications in pregnancy because they are not up to date with current evidence in pregnancy, whereas some others may give incorrect advice despite not being up to date. Misadvice is of significant concern and thus maternal medicine specialists and obstetric physicians are ideally placed to offer pre‐conception advice to women with medical disease. They are well informed as to the effects of various medical diseases in pregnancy and are aware of the implications of drug use in pregnancy. Many will have dedicated pre‐conception clinics in tertiary care. Many maternal medicine specialists will also be able to offer detailed contraceptive advice and in many instances are able to administer long‐acting contraceptives, avoiding delay in gaining effective contraception. Women intending to conceive should be encouraged to eat fruit, vegetables, starchy foods (bread, pasta, rice and potatoes), protein (lean meat, fish, beans and lentils), fibre (wholegrain breads, fruit and vegetables) and dairy foods (pasteurized milk, yoghurt and hard, cottage or processed cheese) [1]. These will assist in increasing the stores of vitamins, iron and calcium. Continuing a healthy diet in pregnancy can have beneficial effects on childhood cardiovascular function [2]. The unpredictability regarding the exact moment a woman becomes pregnant leads to the recommendation that women trying to conceive should avoid the foods listed in Table 4.1, which may contain organisms or substances that can be harmful in early gestation. Even a planned pregnancy is not detected until 5–6 weeks of gestation, at which stage vulnerable organs, particularly the central nervous system, have already started developing and the neural tube is completely formed. Table 4.1 Foods that can affect the fetus in very early pregnancy. Vegetarians and vegans are at risk of nutritional deficiencies, particularly of vitamins B12 and D, and may benefit from advice from a dietitian. Women who have a heavy intake of caffeine should be advised to cut down before pregnancy. The Food Standards Agency recommends that pregnant women should limit their consumption of caffeine in pregnancy to 300 mg daily or less (four cups of coffee, eight cups of tea, or eight cans of cola) [1]. High caffeine intake mildly increases the risk of fetal growth restriction. Folic acid 0.4 mg daily is recommended to all women trying to conceive and should be continued until 12 weeks’ gestation along with an increase in folate‐containing foods as this has been shown in randomized controlled trials to significantly reduce the incidence of fetal neural tube defects (NTDs) such as spina bifida and anencephaly [5]. A higher dose of folic acid (5 mg daily) is required in women: Some countries have fortified certain foods (e.g. flour, cereals) with folate in order to help protect those women who cannot afford medical supplementation and those who have an unplanned pregnancy [8]. There is some evidence that the risk of other congenital malformations may be reduced with folate and multivitamin supplementation [9]. Vitamin D 10 µg (400 IU) daily is recommended by the UK Department of Health for pregnant and breastfeeding women [10]. Vitamin D deficiency results in osteomalacia that can present with muscle and bony pain [1]. Vitamin D may play a role in early placental development, and subsequently the development of pre‐eclampsia. Studies show that vitamin D levels are lower in women with pre‐eclampsia compared with normotensive women, and meta‐analyses have shown that women who received vitamin D supplements plus calcium compared with no supplements halve their risk of developing pre‐eclampsia [11,12]. Maternal vitamin D deficiency can also result in fetal vitamin D deficiency, which is associated with hypocalcaemic seizures and childhood rickets [11]. The primary source of vitamin D is from exposure to sunlight, although it can be found in fatty fish, mushrooms, egg yolk and liver. Routine screening for vitamin D deficiency in pregnancy is not recommended. Women with the following risk factors will need to empirically take a higher dose of vitamin D (at least 1000 IU daily) [11]: Women with renal disease may not metabolize vitamin D effectively and will require the use of active vitamin D metabolites instead [11]. Women should be advised to stop smoking prior to pregnancy. They are usually aware of the risks to their own health, but are often less aware of the risks to the fetus, which include miscarriage, placental abruption, placenta praevia, premature rupture of membranes, preterm delivery, low birthweight, cleft lip and cleft palate, perinatal mortality, sudden infant death syndrome and impaired cognitive development [1]. Discussion of these risks often provides a strong motivation to pregnant women to stop smoking. It is estimated that if all pregnant women stopped smoking there would be a 10% reduction in fetal and infant deaths. Advice from the doctor, smoking cessation programmes and self‐help manuals have been shown to help women stop smoking. Nicotine replacement therapy including nicotine patches and e‐cigarettes, can help wean women off tobacco. The UK Department of Health advice recommends that women who are pregnant or planning pregnancy should be advised that the safest approach is not to drink alcohol at all [13]. In the first trimester there may be an increased risk of miscarriage. Thereafter, although there is no evidence of fetal harm with drinking one to two standard units of alcohol once or twice per week, there is no clear scientific evidence to support a quantified limit for drinking in pregnancy. The dangers to the fetus of drinking alcohol in pregnancy occur with greater consumption, so that women who binge drink (more than five standard drinks or 7.5 UK units on a single occasion) or drink heavily are at risk of subfertility, miscarriage, aneuploidy, structural congenital anomalies, fetal growth restriction, perinatal death and developmental delay [1,13]. Binge drinkers are more likely to have an unplanned pregnancy and hence may continue to drink erratically in the first trimester without knowing they are pregnant. Fetal alcohol syndrome occurs in 0.6 per 1000 live births (Canadian data) and is characterized by distinctive facial features, low birthweight, and behavioural and intellectual difficulties in later life. There is a further spectrum of fetal alcohol disorders [13]. Alcohol misuse can result in maternal ill health and is a significant cause of maternal death [3]. Women should be advised to enter pregnancy with a normal BMI of 18.5–24.9 kg/m2 [2]. Women who are underweight (BMI <18.5 kg/m2) may find it difficult to conceive due to anovulatory cycles. They are at risk of osteoporosis and nutritional deficiencies. They have an increased chance of fetal intrauterine growth restriction and low birthweight babies. They should be assessed for eating disorders. Overweight women (BMI 25–29.9 kg/m2) and obese women (BMI ≥30 kg/m2) should lose weight by dieting and exercise before conceiving. They may require referral to a dietitian. They should be informed of the adverse pregnancy outcomes associated with obesity (Table 4.2) [14]. Table 4.2 Risks of obesity to mother and her offspring. For women who are morbidly obese (obesity grade III) with a BMI of 40 kg/m2 or more it is very difficult to achieve a normal BMI. In addition to referral to a dietitian, they should be assisted to lose weight by a variety of methods including prescription of weight reduction medication in a carefully supervised manner and referral for bariatric surgery. They should be strongly advised to defer pregnancy until they have lost weight. Bariatric surgery results in weight loss either by reducing gastric capacity (e.g. sleeve gastrectomy, laparoscopic adjustable gastric banding) or by malabsorption (e.g. Roux‐en‐Y gastric bypass, biliopancreatic diversion) and this weight loss results in improved fertility [15]. However, women should be advised not to get pregnant whilst they are losing weight following surgery. They should use adequate contraception, preferably a non‐oral method, and wait until their BMI stabilizes to prevent nutritional deficiencies affecting the fetus. Maternal and fetal outcomes improve following bariatric surgery, with reduced rates of gestational diabetes, pre‐eclampsia, and large for gestational age babies. Studies have shown an increased incidence of small for gestational age babies and an increased chance of pretem birth following bariatric surgery [15]. Women should be recommended to remain on vitamin supplementation. The method of bariatric surgery may influence outcomes, although few studies have compared pregnancy outcomes after different types of surgery. There is less anaemia and vitamin and micronutrient deficiency with sleeve gastrectomy and gastric banding compared with Roux‐en‐Y gastric bypass or biliopancreatic diversion, which are more effective at achieving long‐term weight loss [15].
Pre‐conception Counselling
Purpose of pre‐conception counselling
Who needs pre‐conception counselling?
Timing of pre‐conception counselling
Healthcare professionals who should undertake pre‐conception counselling
General pre‐conception advice
Diet
Supplements
Folic acid
Vitamin D
Smoking
Alcohol
Body weight
Underweight
Obesity
Maternal risks of obesity
Subfertility
Miscarriage
Hypertensive disease
Gestational diabetes
Thromboembolism
Infection
Cardiac disease
Instrumental deliveries
Caesarean section
Postpartum haemorrhage
Maternal death
Risks to fetus of maternal obesity
Neural tube defects
Large for dates
Preterm delivery
Shoulder dystocia
Increase in birthweight
Stillbirth
Risks to offspring of maternal obesity
Neonatal hypoglycaemia
Obesity as children and adults
Diabetes
Hypertension
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