Is preconceptional care feasible and practical?

Key organizations have published extensive guidelines and recommendations for preconceptional care, including the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), and the Centers for Disease Control and Prevention (CDC) . It is estimated that 30–90% of women have at least one indication that may benefit by an appropriate preconceptional intervention . However, only 30–50% of pregnancies are planned with a proper preconceptional care plan . Therefore, it is not merely a matter of the content of the preconceptional care plan, but mainly making it affordable, accessible, and routine for all women in their reproductive age. For diabetic women, preconceptional care is proved to save cost , and still only half of diabetic women are estimated to undergo appropriate preconceptional glycemic control .

What is the aim of preconceptional care?

The goal of preconceptional care is to improve maternal health and perinatal outcome. It can also serve to improve the general health of women at their reproductive years and beyond. These goals are achieved by means of maternal and paternal health promotion education, risk assessment, and appropriate interventions if such are indicated and of proven efficacy . For non-primiparas, other than general health promotion and improving prepregnancy chronic illness, risk reduction can also be indicated by previous pregnancy complications, if such have occurred, by inter-conceptional interventions or early measures during future pregnancies .

When should preconceptional care be provided?

It is clear and evident from multiple studies that the optimal time in which pregnancy follow-up should be initiated is prior to conception . Therefore, the timing of preconceptional health care is crucial, as the greatest impact of many of the preventable hazards occur during early pregnancy, usually when women are unaware of pregnancy or, if aware, have not yet initiated prenatal care . Not just timing but also time is of importance, as preconceptional care is more than a single appointment; rather, it is a plan of continuing measures that need time for implementation and to achieve an effect on the health status of the women.

Who should provide preconceptional counseling?

Preconceptional care is an integral part of primary care and is not merely an isolated visit prior to conception . Hence, physicians providing routine and primary health care have the best chance of providing preventive medicine, including preconceptional care – that is, gynecologists, pediatricians, family physicians, and general practitioners. Although it is usually performed by the obstetrician, as this is the natural point of care that women planning a pregnancy will reach to, its role is mainly focused at the prepregnancy meeting and not on continuing preventive medicine. Importantly, there is no single specialist for this; rather, a team approach is needed according to the identified risk factors. The concept of preconceptional counseling should be recognized by multiple professionals as they are the ones who will initiate it and refer the women to needed interventions.

What NCDs can benefit from pregnancy planning?

Diagnosing and treating some of the common NCDs may have an impact on pregnancy outcome. Ample time should be allowed to properly intervene in some of the following situations: hypertension, diabetes, obesity, systemic lupus erythematosus, thyroid disease, anemia, epilepsy, asthma, and cardiac disease.

Are there other situations that can benefit from pregnancy planning?

Yes; however, it is beyond the scope of this article, which focuses on the medical aspects of some of the major NCDs – diabetes and obesity. Other aspects such as reproductive awareness; genetic counseling; environmental exposures (e.g., medications, toxins, smoking, drugs, and alcohol); infectious diseases and vaccinations; and nutritional, social, and occupational hazards are not discussed in this article.

What is the impact of preconceptional care on diabetes-related adverse pregnancy outcome?

Preconceptional care has been shown to decrease diabetes-related complications at all stages of pregnancy . For the early complications – mainly, abortions and congenital malformations – it is well established that the critical time to achieve glycemic control is prior to 7 weeks of gestation, at which time organogenesis occurs, and ideally prior to pregnancy. However, it is also evident that for later gestational complications – preterm delivery, macrosomia, SGA, and preeclampsia – preconceptional care is also associated with improved outcome.

Dunne et al. demonstrated that diabetic women who underwent preconceptional counseling had an improved glycemic control prior and throughout pregnancy, manifested by lower mean HbA1C. Other than the well-established improvement in congenital malformation, preconceptional care was also associated with a lower rate of adverse pregnancy outcome, including preterm delivery prior to 30 weeks of gestation (17% vs. 0%), macrosomia (40% vs. 15%), SGA (8.5% vs. 0%), neonatal death (5.7% vs. 0%), and neonatal intensive care unit admissions (34% vs. 17%). Temple et al. studied 290 pregnancies complicated with type 1 diabetes mellitus (T1DM). Composite adverse pregnancy outcomes (including congenital malformation, neonatal death, and stillbirth) and delivery prior to 34 weeks of gestation were significantly lower in women who received prepregnancy care (2.9% vs. 10.2% and 5.0% vs. 14.2%, respectively). However, they did not report a reduction in rates of macrosomia (44.0% vs. 43.4%) and preeclampsia. Garcia et al. assessed the impact of preconceptional care among 185 women with type 1 and 2 diabetes. They demonstrated a higher rate of SGA babies, in those not attending preconceptional care (8.7% vs. 1.8%). Gold et al. studied the impact of prepregnancy glycemic control on the birth weight of 57 infants of type 1 diabetic mothers and concluded that glycemic control in the immediate preconception period and early first trimester appears to have a greater influence on birth weight than does the glycemic control during the later weeks of pregnancy. Recently, Wahabi et al. meta-analyzed 24 studies, with 2502 pregestational diabetic women, and concluded that preconceptional care for diabetic women is effective in reducing preterm delivery prior to 37 weeks, but did not reduce the rates of preeclampsia, macrosomia, or SGA. Similarly, Murphy et al. did not find that preconceptional care is effective in reducing the rates of preterm delivery, SGA, or macrosomia

What is the impact of preconceptional care on diabetes-related adverse pregnancy outcome?

Preconceptional care has been shown to decrease diabetes-related complications at all stages of pregnancy . For the early complications – mainly, abortions and congenital malformations – it is well established that the critical time to achieve glycemic control is prior to 7 weeks of gestation, at which time organogenesis occurs, and ideally prior to pregnancy. However, it is also evident that for later gestational complications – preterm delivery, macrosomia, SGA, and preeclampsia – preconceptional care is also associated with improved outcome.

Dunne et al. demonstrated that diabetic women who underwent preconceptional counseling had an improved glycemic control prior and throughout pregnancy, manifested by lower mean HbA1C. Other than the well-established improvement in congenital malformation, preconceptional care was also associated with a lower rate of adverse pregnancy outcome, including preterm delivery prior to 30 weeks of gestation (17% vs. 0%), macrosomia (40% vs. 15%), SGA (8.5% vs. 0%), neonatal death (5.7% vs. 0%), and neonatal intensive care unit admissions (34% vs. 17%). Temple et al. studied 290 pregnancies complicated with type 1 diabetes mellitus (T1DM). Composite adverse pregnancy outcomes (including congenital malformation, neonatal death, and stillbirth) and delivery prior to 34 weeks of gestation were significantly lower in women who received prepregnancy care (2.9% vs. 10.2% and 5.0% vs. 14.2%, respectively). However, they did not report a reduction in rates of macrosomia (44.0% vs. 43.4%) and preeclampsia. Garcia et al. assessed the impact of preconceptional care among 185 women with type 1 and 2 diabetes. They demonstrated a higher rate of SGA babies, in those not attending preconceptional care (8.7% vs. 1.8%). Gold et al. studied the impact of prepregnancy glycemic control on the birth weight of 57 infants of type 1 diabetic mothers and concluded that glycemic control in the immediate preconception period and early first trimester appears to have a greater influence on birth weight than does the glycemic control during the later weeks of pregnancy. Recently, Wahabi et al. meta-analyzed 24 studies, with 2502 pregestational diabetic women, and concluded that preconceptional care for diabetic women is effective in reducing preterm delivery prior to 37 weeks, but did not reduce the rates of preeclampsia, macrosomia, or SGA. Similarly, Murphy et al. did not find that preconceptional care is effective in reducing the rates of preterm delivery, SGA, or macrosomia