Preconception Health Care Tool

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Preconception health care involves identifying potential physical, genetic, psychosocial, environmental and behavioural risk factors for adverse pregnancy outcomes, and reducing those risks prior to conception through counselling, education and intervention. Preconception Health Care focuses on health promotion and illness prevention for everyone of reproductive age. It is an important opportunity for primary care providers to improve maternal and infant outcomes, as the critical period for fetal development often occurs before prenatal care begins.

Reproductive life plan

Ask all individuals of reproductive age, “Would you like to have a child in the next year?”
Yes
  • Discuss family planning and conception.
  • Continue discussing preconception topics below.
  • Each of the preconception topics below should be addressed with every individual of reproductive age on an ongoing basis.
No
  • Discuss contraception options.
Not sure
Stack of papers. Ask all individuals of reproductive age, “Would you like to have a child in the next year?”
Yes
  • Discuss family planning and conception.
  • Continue discussing preconception topics below.
  • Each of the preconception topics below should be addressed with every individual of reproductive age on an ongoing basis.

Expand All

Reproductive life plan

Ask all individuals of reproductive age, “Would you like to have a child in the next year?” Encourage all individuals to make a Reproductive Life Plan.1

Prevent and promote
Screen
Manage
  • If positive pregnancy test, discuss options for prenatal care and refer accordingly.

Reproductive history

Prevent and promote

  • Gravida (G)
  • Full-term (T)
  • Premature (P)
  • Abortions (A)
  • Living children (L)

Screen

Inquire about previous pregnancies

  • Preterm Birth
  • Preeclampsia
  • Congenital anomalies
  • Stillbirth
  • Miscarriage
  • Assisted reproductive technologies
  • Gestational DM

Manage

  • Provide appropriate referrals.
  • Inform women who have had prior caesarean sections that vaginal birth is an option for their next pregnancy.40
  • Recommend folic acid 5mg daily prior to conception and for 12 weeks after conception if positive history of neural tube defect.
  • Recommend >18 and <59 month interpregnancy interval (IPI).

Sexual health

Prevent and promote

Inform all individuals of sexual health risks associated with travel to countries with reported Zika infection. Recommend patients wait 6 months following travel to attempt conception due to potential for transmission through sperm.41

Screen

Screen if high risk:

  • Chlamydia
  • Syphilis
  • Trichomoniasis
  • Gonorrhea
  • Genital herpes (if lesions)

Manage

Chronic medical conditions

Optimize management for the following diseases, as suboptimal control or treatments can increase risk for adverse maternal and/or infant outcomes.

Motherisk6 should be consulted for the safety of any medications taken by patients with chronic conditions. Motherisk Helpline: 1-877-439-2744

  • Asthma: Delay conception until good control is achieved.
  • Cancer: All individuals with cancer should be counselled regarding the potential effects of treatment on fertility and informed of options to preserve fertility, if desired, and referred appropriately.
  • Diabetes: Increased risk of birth defects can be mitigated with goodpreconception glycemic control. Encourage contraception for those without good control. Folic acid 5mg daily prior to conception and for 12 weeks after conception. ACE-Is and statins are contraindicated. Estrogen-containing contraception options should be avoided for those with DM >20 years or target end-organ damage.
  • HIV: Transmission risk to fetus is ~2% with antiretroviral therapy. Efavirenz is contraindicated. Antiretroviral drugs may interfere with hormonal contraceptive methods. Refer to specialist.
  • Hypertension: Increased risk for adverse fetal and maternal outcomes. Assess for target-end organ damage in those with long-standing hypertension. Alternatives to ACE-Is are recommended in women of reproductive age. Avoid estrogen-containing contraception options for women with severe hypertension. Inflammatory bowel disease: Counsel women to delay conception until disease is in remission. Conception during active episode increases risk of miscarriage, premature delivery, still birth or low birth weight.
  • Phenylketonuria: Encourage maintenance of low phenylalanine level during reproductive years and especially prior to conception.
  • Renal disease: Encourage optimal control prior to conception, including normal BP. Use alternative to ACE-Is. Consult with specialist.
  • Seizure disorder: Discuss potential pregnancy outcomes related to seizures and seizure medications. Take folic acid 4-5mg daily prior to conception and for 12 weeks after conception. Lowest dose of one medication recommended, when possible. Valproic acid, lithium and topiramate are contraindicated. Many antiepileptic medications may interfere with hormonal contraceptive methods.
  • Systemic lupus erythematosus, rheumatoid arthritis, and other autoimmune diseases: Delay conception until good control is achieved. Discuss natural history of disease during/after pregnancy. Cyclophosphamide, Methotrexate and Leflunomide are contraindicated. Avoid estrogen-containing contraception options in women with SLE and positive/unknown antiphospholipid antibody. Discuss use of aspirin and heparin with rheumatologist for women with SLE and antiphospholipid antibody syndrome.
  • Thromboembolic disease: Counsel women that risk for VTE during pregnancy and postpartum is increased, and many will require anticoagulation treatment. Coumadin is contraindicated. Avoid estrogen-containing contraceptive options.
  • Thyroid disease: Achieve euthyroid state prior to conception. Women with hypothyroidism should increase their dose of levothyroxine by 30% as soon as pregnancy occurs. Radioactive iodine is contraindicated. Screen all women for CBC and TSH, prior to conception.

Medication

Prevent and promote

Human teratogenicity risk is unknown for the majority of medications. Use caution when prescribing for women of reproductive age. Consult Motherisk.6

Screen

Screen for teratogenic medication use:

  • Prescribed medications
  • Over-the-counter medications
  • Complementary and alternative therapy (herbal, natural, weight loss, athletic products or supplements, etc.)

Manage

Potentially teratogenic medications should be changed to safer options. Women should be counselled not to stop prescribed medications without consulting with their provider.

  • Recommend folic acid 5mg daily prior to conception and for12 weeks after conception for women taking folate antagonists (ex. methotrexate, sulfonamides and antiepileptics).

Mental health

Prevent and promote

Promote mental health wellness through adequate sleep, work-life balance, stress reduction and social connectedness.

Screen

Manage

  • Bipolar disorder
  • Mood disorder
  • Schizophrenia
  • Counsel women with mental health diagnoses of risks of pregnancy and relapse. Strategize management.
  • Stabilize/optimize mood and anxiety level; discuss risks and benefits of medications.

Tobacco use

Prevent and promote

Encourage all individuals to be tobacco free prior to conception.

Screen

  • Tobacco (all forms)
  • Tobacco exposure (second-hand smoke)

Manage

Alcohol and other substance use

Prevent and promote

Encourage all individuals to be substance free prior to conception.

Screen

  • Alcohol
  • Other substances

Manage

Vaccinations and immunity

Prevent and promote

Vaccinate:

  • Varicella
  • Rubella
  • HPV
  • Influenza
  • Hepatitis B
  • Tetanus, Diphtheria, B Pertussis
  • Measles, Mumps

Screen

Screen for immunity:

  • Rubella
  • Hepatitis B
  • Varicella

Manage

  • Provide all immunizations required prior to conception with the exception of the flu vaccine, which can be administered before and/or during pregnancy.

Infectious disease

Prevent and promote

Vaccinate:

  • HIV
  • Parvovirus
  • Hepatitis B
  • Hepatitis C
  • Tuberculosis
  • Cytomegalovirus
  • Toxoplasmosis

Screen

Screen:

  • HIV

Screen if high risk

  • Hepatitis C
  • Tuberculosis

Manage

Family and genetic history

Prevent and promote

  • Congenital malformations, birth defects.
  • Developmental delays, learning disabilities.
  • Ethnicity.
  • Genetic disorders.22
  • Family history of a genetic condition.
  • Consanguinity (first cousins or closer).
  • Children who died at a young age (may reveal a metabolic condition).
  • History of sudden unexplained death (may indicate cardiomyopathy or metabolic condition).
  • History of infertility, multiple miscarriages (>3 or all male fetuses).

Screen

  • CBC and/or Hgb Electrophoresis for hemoglobinopathies in African, Mediterranean, Middle Eastern, Asian, Southeast Asian, and Hispanic/South/Central American individuals.
  • Cystic Fibrosis mutation in Caucasian individuals if family history present.
  • Tay-Sachs in French Canadian individuals if family history present.
  • Hematopoietic stem cells screening (Ashkenazi Jewish Screening Panel) for those with Ashkenazi Jewish ancestry.

Manage

  • Provide referral to specialist for those with family and genetic history risk factors.
  • Recommend folic acid 5mg daily prior to conception and for 12 weeks after conception if positive family history of neural tube defects or high risk ethnic group (ex. Sikh, Celtic, Northern Chinese).

Nutrition

Prevent and promote

Screen

  • Screen for issues regarding access to food, nutrition, storage, cooking facilities and folic acid.
  • Screen for iron deficiency anemia if at risk.

Manage

  • Provide referral to Dietitian or appropriate community agencies.

Weight status

Weight can increase risk of adverse pregnancy outcomes and developing chronic disease.

Prevent and promote

  • Target Body Mass Index (BMI) = 18.5-24.9 (for ages ≥19)
  • Waist Circumference (WC)29:
    • European, African, Eastern Mediterranean, Middle Eastern
      • Male target: <102cm
      • Female target: <88cm
    • South Asian, Asian, South <80cm and Central American
      • Male target: <90cm
      • Female target: <80cm
  • Target BMI for ages <1930

Screen

  • Screen BMI31 annually.
  • BMI = weight(kg)/height(m)2

Manage

  • Underweight (BMI <18.5)
  • Overweight (BMI = 25-29.9) q Obese (BMI >30)
  • Provide appropriate referrals for management.
  • Recommend folic acid 5mg daily prior to conception and for
  • 12 weeks after conception for obese individuals.
  • Discuss recommended healthy weight gain32 during pregnancy and recommend contacting EatRight Ontario 1-877-510-5102.

Physical activity

Being physically active prepares the body for the physical demands of pregnancy and can assist with stress management.

Recommend at least 150 minutes of moderate to vigorous aerobic physical activity per week, in episodes of 10 minutes or more. Add muscle and bone strengthening activities at least 2 days per week. See the Canadian Physical Activity Guidelines33

Psycosocial stressors

Prevent and promote

  • Identify stressors and discuss strategies to reduce impact

Screen

Manage

  • Inform women that violence often worsens during pregnancy and discuss safety plan.
  • Provide appropriate referrals.36

Environmental exposure

Prevent and promote

Screen

Inquire about exposures to:

  • Solvents (ask about use)
  • Plastics
  • Metals (lead, mercury)
  • Pollutants
  • Pesticides
  • Teratogenic and/or gonadotoxic treatments (chemotherapy, radiation therapy)
  • Gases
  • Radiation

Manage

Health Canada’s blood methylmercury guidance level in pregnancy or reproductive age: <8mcg/L (40nmol/L).

  • Refer to local health department if potential water/soil exposure.
  • Refer to occupational health specialist as needed.

References

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    Toronto Public Health [Internet]. Toronto (ON): Toronto Public Health; c1998-2018 [cited 2018 Oct 10]. Your Reproductive Life Plan.

  • [2]

    Society of Obstetricians and Gynaecologists of Canada [Internet]. Ottawa (ON): Society of Obstetricians and Gynaecologists of Canada; c2018 [cited 2018 Oct 10]. Choosing Wisely; Helping You Make Decisions About Contraception.

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    Liu K, Case A; Society of Obstetricians and Gynaecologists of Canada. Advanced reproductive age and fertility. Journal of Obstetrics and Gynaecology Canada [Internat]. Nov 2011 [cited 2014 Nov 4];269:1165-1175.

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    BestStart.org [Internet]. Toronto (ON): Health Nexus; c2014 [cited 2014 Oct 15].

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    Public Health Agency of Canada [Internet]. Ottawa (ON): Public Health Agency of Canada [updated 2018 June 29; cited 2018 Oct 10]. Canadian Guidelines on Sexually Transmitted Infections.

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    Motherisk [Internet]. Toronto (ON): The Hospital for Sick Children (SickKids); c1999-2018 [cited 2018 Oct 10]. Drugs in Pregnancy.

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    Before, Between, & Beyond Pregnancy [Internet]. Atlanta (GA): Preconception health and Health Care initiative [cited 2014 Oct 15]. Preconception Care Clinical Toolkit: Chronic Disease.

  • [8]

    Maurer DM, Carl R. Screening for depression. Am Fam Physician. 2012 Jan 15;85(2):139-144.

  • [9]

    Moses S [Internet]. Minneapolis (MN): Family Practice Notebook; c2014 [updated 2013 Nov 12; cited 2014 Oct 15]. Generalized Anxiety Disorder Scale

  • [10]

    Centre for Addiction and Mental Health [Internet]. Toronto (ON): Centre for Addiction and Mental Health; c2018 [cited 2018 Oct 10]. Mental Health & Addiction Information A-Z.

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    Smokers’ Helpline [Internet]. Toronto (ON): Canadian Cancer Society; c2017 [cited 2018 Oct 10]. Making a Referral.

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    Pregnets [Internet]. Toronto (ON): Centre for Addiction and Mental Health; c2014 [cited 2014 Oct 15]. Smoking During Pregnancy.

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    CAN-ADAPTT [Internet]. Toronto (ON): Centre for Addiction and Mental Health: Nicotine Dependence Clinic; c2011 [cited 2014 Oct 15]. Pregnant and Breastfeeding Women.

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    Ordean A, Midmer D, Graves L, Payne S, Hunt G; PRIMA (Pregnancy-Related Issues in the Management of Addictions) Group [Internet]. Department of Family & Community Medicine, University of Toronto; c2004-2012 [updated 2012 Apr; cited 2014 Nov 4].

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    Society of Obstetricians and Gynaecologists of Canada [Internet]. Ottawa (ON): Society of Obstetricians and Gynaecologists of Canada [cited 2018 Nov 13]. Folic Acid: For Preconception and Pregnancy.

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    Drug and Alcohol Helpline [Internet]. London (ON): ConnexOntario Health Services Information; c2018 [cited 2018 Oct 10]. Drug and Alcohol Resources in Canada.

  • [17]

    Canadian Centre on Substance Abuse [Internet]. Ottawa (ON): Canadian Centre on Substance Abuse; c2014 [cited 2014 Oct 17]. Canada’s Low-Risk Alcohol Drinking Guidelines.

  • [18]

    Centre for Disease Control and Prevention [Internet]. Atlanta (GA): Centre for Disease Control and Prevention [updated 2016 Nov 14; cited 2018 Oct 10]. Immunization.

  • [19]

    Before, Between, & Beyond Pregnancy [Internet]. Atlanta (GA): Preconception Health and Health Care initiative [cited 2014 Oct 15]. Preconception Care Clinical Toolkit: Infectious Disease and Immunizations.

  • [20]

    Centre for Disease Control and Prevention [Internet]. Atlanta (GA): Centre for Disease Control and Prevention [cited 2018 Nov 13]. Pregnancy and HIV, Viral Hepatitis, STD and TB Prevention.

  • [21]

    GECKO.ca [Internet]. Genetics Education Canada – Knowledge Organization; c2014 [cited 2014 Oct 15].

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    Wilson DR. Genetic considerations for a women’s pre-conception evaluation. J Obstet Gynaecol Can. 2011 Jan;33(1):57-64.

  • [23]

    Genetics Education Canada [Internet]. Genetics Education Canada; c2014 [cited 2014 Oct 28]. Ethnicity-based screening in Canada.

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    Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2011 Sept 1; cited 2014 Oct 15]. Eating Well with Canada’s Food Guide.

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    Dietitians of Canada [Internet]. Toronto (ON): Dietitians of Canada; c2013 [cited 2014 Oct 15]. Calcium.

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    Government of Canada [Internet]. Ottawa (ON): Government of Canada; c2010 [updated 2018 Aug 08; cited 2018 Oct 10]. Food Safety for Pregnant Women.

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    Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2012 Feb 16; cited 2014 Oct 15]. Caffeine in Food.

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    Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2012 Mar 22; cited 2014 Nov 4]. Vitamin D and Calcium: Updated Dietary Reference Intakes.

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    Heart and Stroke Foundation [Internet]. Toronto (ON): Heart and Stroke Foundation; c2014 [Cited 2018 Nov 13]. Healthy Waists.

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    Dietitians of Canada [Internet]. Toronto (ON): Dietitians of Canada; c2013 [cited 2014 Oct 15]. BMI Calculator for Children and Teens.

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    Dietitians of Canada [Internet]. Toronto (ON): Dietitians of Canada; c2013 [cited 2014 Oct 15]. Assess your BMI.

  • [32]

    Eat Right Ontario [Internet]. Toronto (ON): Dietitians of Canada; c2014 [cited 2014 Oct 15]. Planning to Be Pregnant? Healthy Tips for Healthy Weight Gain.

  • [33]

    Canadian Society for Exercise Physiology [Internet]. Ottawa (ON): Canadian Society for Exercise Physiology; c2014 [cited 2014 Oct 15]. Canadian Physical Activity Guidelines and Canadian Sedentary Behaviour Guidelines.

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    Best Start [Internet]. Toronto (ON): Health Nexus [updated 2014; cited 2014 Oct 15]. Information for Parents New to Canada

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    Before, Between, & Beyond Pregnancy [Internet]. Atlanta (GA): Preconception health and Health Care initiative [cited 2014 Oct 15]. Preconception Care Clinical Toolkit: Intimate Partner Violence.

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    Public Health Agency of Canada [Internet]. Ottawa (ON): Public Health Agency of Canada [updated 2010 Jan 28; cited 2014 Oct 15]. CPNP Projects Directory Online.

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    Exposure to toxic environmental agents. Committee Opinion No. 575. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:931–5.Exposure to toxic environmental agents. Committee Opinion No. 575. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:931–5. [cited 2018 Nov 13].

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