Genetic factors

A three-generation family history of birth defects and inheritable disorders, including race and ethnicity of both parents, can provide significant information about the potential heritability of a disorder. Further testing should be recommended when there is a positive family history in the patient or her partner. Common disorders include Tay–Sachs disease (more common in Eastern European Jewish background but also recommended for a French-Canadian or Cajun background); thalassemia (more common in persons of Mediterranean or Asian background); sickle cell anemia (more common among Africans and African Americans); cystic fibrosis (more common in persons of European descent); muscular dystrophy, and Huntington’s chorea. With a family history of mental retardation, testing for fragile X syndrome should be considered. Aneuploidy in offspring of women less than 35 years old warrants further testing for paternal or maternal balanced translocations. Women over age 35 should be informed of the increased risk of aneuploidy.

Reproductive history

A review of a woman’s reproductive history will help identify factors related to a prior pregnancy that may be modifiable and the risk reduced for future pregnancies. With an unexpected pregnancy outcome such as preterm birth, severe pre-eclampsia, stillbirth or cesarean delivery, the patient may not have consulted with her obstetrician after delivery to discuss risks of recurrence in a subsequent pregnancy. Women with a prior preterm birth have a 16% risk of a second preterm birth. The risk increases significantly with two preterm (41%) and three preterm deliveries (67%). Modifiable risk factors associated with recurrent preterm birth include inflammatory changes in the placenta, low maternal pre-pregnancy weight, smoking, short interpregnancy interval (< 12 months), history of cervical insufficiency and periodontal disease, and uterine anomalies.

Women with a history of recurrent spontaneous abortion, three or more consecutive spontaneous abortions, should be offered a work-up to identify a cause. This includes measurement of antiphospholipid antibodies (lupus anticoagulant, anticardiolipin and β2-glycoprotein antibodies), parental karyotyping, and imaging of the uterus. Women with antiphospholipid antibody syndrome can initiate treatment with mini heparin prior to a planned pregnancy. Uterine anomalies and cervical incompetence have the potential to be surgically corrected prior to pregnancy.

Patients with a prior stillbirth have a risk of recurrence increased 2–10-fold over women with no prior stillbirth. A complete medical and obstetric history and a review of the available reports, including fetal autopsy, placental pathology and appropriate testing of the prior stillbirth, can identify potential risk factors and guide the consultation. Previous stillbirth can be associated with genetic disease, chromosomal disorders, and undiagnosed maternal conditions, such as diabetes or antiphospholipid antibody syndrome. A preconception visit should be individualized based on careful questioning and identification of the possible etiology to establish appropriate consultation and a care plan for the next pregnancy. Couples may require additional psychosocial support.

Women planning a subsequent delivery after a previous cesarean can be counseled about the maternal and newborn risks and benefits associated with a trial of labor versus elective cesarean. Family spacing greater than 18 months is recommended since uterine rupture with a trial of labor is reduced with this spacing. A review of potential operative morbidity with multiple cesareans and a risk assessment developing a placenta previa or accreta is warranted.

Chronic medical conditions and any complications associated with a prior pregnancy are important factors to review in preparing a care plan for future pregnancies. There is no substitute for a comprehensive assessment, including review of prior medical records.

Immunization and infectious disease history