"Recommendations for Preconception Counseling and Care" (My Synopsis)

Recommendations for Preconception Counseling and Care
NARGES FARAHI, MD, and ADAM ZOLOTOR, MD, DrPH, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Am Fam Physician. 2013 Oct 15;88(8):499-506.

     Although half of all pregnancies are unintentional, preconception care can greatly benefit the fetus. All patients of reproductive age should be counseled on contraception, as well as health risks that may affect pregnancy. Patients considering becoming pregnant should consider environmental exposures, genetic history, medications, psychiatric illness, psychosocial factors, and substance abuse. Workplaces which may exposure expecting mothers to toxins include clinical and laboratory health care, dry cleaning, manufacturing, printing, and agriculture. Mercury exposure from certain fish should also be considered. Patients with a personal or family history of genetic or congential disorders should be referred for genetic counseling and carrier testing. Teratogenic medications should be stopped. Patients should be screened for depression, anxiety, substance abuse and intimate partner violence. All women should be screened for HIV, measles immunity, and rubella immunity. All high risk women should be screened for chlamydia, gonorrhea, syphilis and TB.
     All women considering having children should start taking 400 mcg of folic acid and continue until 12 weeks gestation. Patients with epilepsy, diabetes, obesity, or at high risk of neural tube defects,  can take 4-5 mg daily. 
     Patients who are overweight or obese are at increased risk of macrosomia, shoulder dystocia, IUGR, spontaneous abortion, stillbirth, and preeclampsia. Overweight patients who have oligomenorrhea or amenorrhea may regain fertility with weight loss. Patients who opt for bariatric surgery should wait 12-18 months after the procedure before getting pregnant. Post bariatric patients will also need a pre-pregnancy CBC and multivitamins to combat nutritional deficiencies. Patients who are underweight should be counseled about the risks of preterm or low birth weight births. Low birth weight is associated with osteoporosis, amenorrhea, infertility, arrhythmias and nutritional deficiencies. 
     Medications for common medical conditions may need to be altered. Patients with acne cannot take isotretinoin because it is severely teratogenic. Patients with asthma should not use oral corticosteroids because it lowers birth weight and increases the risk of preeclampsia. ACEIs and ARBs are associated with fetal anomalies and death. Diabetic patients should discontinue oral antidiabetic medications and switch to insulin. Elevated glucose can lead to congenital malformations. Patients with hyperthyroidism should use propylthiouracil instead of methimazole in the first trimester. For patients with seizure disorder, monotherapy at the lowest possible dose should be used do to the teratogenic effects of most of the antiepileptic medications. Patients who need blood thinners should not use warfarin because of its harmful side effects. Statins and atenolol should be avoided.