Guidelines 2016 – Preconception Care
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
advanced planning aimed at reducing maternal and perinatal mortality and morbidity1
II. ETIOLOGY
a. reasons for promoting preconception care (Pcc) include
1. Maximizing healthy life for woman and baby
2. identifying any medical condition or medications in either prospective parent
3. identifying genetic disorders
4. reviewing past gestational and pregnancy history
5. identifying high-risk exposures (e.g., tobacco, drug, and alcohol use) and environmental hazards (e.g., toxins; chemicals, including pesticides, gases, certain foods)
III. HISTORY
a. Woman’s medical and surgical history, including but not limited to
1. Diabetes
2. Phenylketonuria (PKU)
3. cardiovascular issues, including elevated blood pressure
4. Lung
5. thyroid
6. Kidney
7. infectious diseases (e.g., HiV, hepatitis B and c, toxoplasmosis, rubella, varicella, tuberculosis [tB], sexually transmitted infec- tions [Stis], vaginosis, vaginitis)
8. autoimmune diseases
9. connective tissue disorders
10. eating disorders
11. Metabolic conditions
12. Psychiatric illness or mental health issues
13. epilepsy
14. thromboembolic episodes
15. any surgery
16. Diethylstilbestrol (DeS) exposure
17. allergies
B. obstetric and gynecologic history
1. contraception
2. Menstrual history
3. Gynecologic history
4. Pap smear history
5. High-risk behaviors (including Stis)
6. Pregnancy history, including spontaneous abortion and therapeutic abortion
c. immune status: need to have documentation
1. rubella
2. tuberculosis
3. Hepatitis a, B, and c
4. Varicella
5. tetanus if 10 years or more in the past
6. Polio
7. influenza
D. Drug history
1. current prescription medications: Some medications have different safety periods between cessation of menses and conception.
2. current over-the-counter medications
3. current vitamin and botanical use
4. “Street” drug–use history
e. nutritional status
1. Height and weight, body mass index (BMi)
2. eating habits; note especially fad diets, veganism
3. Food allergies
4. caffeine and artificial sweetener intake
5. History of being overweight or underweight: underweight BMi, less than 19.8 kg/m2; overweight BMi, greater than 25 to
29.9 kg/m2; and obese BMi, greater than 30.0 kg/m2 (national institutes of Health guidelines)
6. History of an eating disorder
7. current exercise habits and other physical activities
F. Genetic history
1. May use a genogram to identify couples with a personal or family history of problematic diseases, such as
a. tay–Sachs disease
b. thalassemia
c. Sickle cell disease or trait
d. Phenylketonuria
e. cystic fibrosis
f. Hemophilia
g. Mental retardation
h. Myotonic dystrophy
i. adult polycystic kidney disease
j. Birth defects
k. other anemias
2. Family background
a. related outside marriage
b. ethnic background: african american, Mediterranean, ashkenazi Jew, and asian
G. exposure to teratogenic toxins; areas of concern include
1. exposure to
a. Metals (lead)
b. organic solvents
c. Gases
d. ionizing radiation
e. Pollutants (e.g., secondhand smoke)
f. Pesticides, herbicides
g. Lead paint
h. Plastics, vinyl monomers
i. Hyperthermia
2. Use of
a. alcohol
b. tobacco products
H. Social history
1. age
2. Marital/partner status
3. Family structure; household composition
4. Support systems
5. employment/financial status
6. cultural beliefs
7. child care issues
8. Safety issues (e.g., spousal/partner abuse)
9. Work history: exposure to chemicals, radiation, standing at work, and occupational risks such as not wearing respirator, mask, and special clothing
i. Partner health history
thorough health/genetic/social history should be taken on pro- spective fathers. Little conclusive research has been done on how a partner’s exposures to chemicals/toxins/drugs may affect fetal development. recent studies have indicated that alcohol consump- tion in the month prior to conception contributes to low spermato- genesis. Findings need to be integrated with maternal health history findings.
IV. PHYSICAL EXAMINATION
a. Baseline height, weight, BMi, and vital signs
B. General physical examination, including pelvic examination
c. comprehensive exam based on medical history
V. LABORATORY EXAMINATION
a. Pap smear as indicated per american Society for colposcopy and cervical Pathology (aSccP) guidelines
B. Baseline studies may be considered, including
1. Blood rh and type
2. Hemoglobin/hematocrit
3. Urinalysis
4. rapid plasma reagin (rPr) test/Venereal Disease research Laboratory (VDrL) test
5. check status for
a. Hepatitis B, c
b. Varicella
c. rubella
d. HiV
e. tuberculosis
6. Based on history, check
a. toxoplasmosis
b. cytomegalovirus (cMV)
7. Gonorrhea, Chlamydia, wet mount, mycoplasma, and ureaplasma
VI. EDUCATION
a. Begin at least 1 month prior to planned conception
1. avoid environmental toxins
2. cease smoking and alcohol consumption and use of street drugs
3. Begin exercise program (e.g., walking, swimming, cycling): heart rate not to exceed 140 beats per second
4. Bring immunizations up to date (if live vaccine is used, postpone conception at least 1 month; centers for Disease control and Prevention [cDc] recommendation)
5. eat a balanced diet
6. Start vitamin therapy
a. 0.4 mg orally of folic acid daily (increase dosage for women who are at increased risk for neural tube defects, or are obese, to
0.8 mg daily; some sources say 5 mg/d)
b. increase calcium intake to an equivalent of 1 quart of milk daily (or 1,200–1,500 mg/d)
c. Prenatal vitamins (extra folic acid may not be necessary)
7. avoid or at least decrease caffeine intake
8. consult with primary care provider regarding prescrip- tion medications (e.g., psychotropics, antihypertensives, and anticonvulsants), botanicals, and vitamins
9. if hemoglobin is less than 12 g/dL, add iron to prenatal vitamins.
10. Women with PKU should start a low-phenylalanine diet
11. avoid hot tubs and saunas (bringing body temperature above 101°F can damage the embryo)
12. Do not empty cat litter boxes.
13. Do not consume raw meat or raw fish.
VII. REFERRAL/CONSULTATION
a. For genetic consultation if indicated
B. evaluation of prescriptive medication use with specialists
c. Substance abuse counseling if indicated
D. nutritional counseling if indicated (e.g., obesity, gestational diabetes with prior pregnancies, vegetarian)
e. community/federal programs for financial assistance if indicated
F. Domestic violence intervention
VIII. FOLLOW-UP
a. refer for obstetric care if pregnancy occurs (if setting does not provide care)
B. if conception does not occur within 1 year, return for further evaluation/possible referral
c. consider sooner if older than age 30
Appendix I may be photocopied or adapted for your patients. See Bibliographies.
Websites: www.asccp.org/portals/9/docs/ASCCP%20Guidelines%20%20-%20 3.21.13.pdf; www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm; www.cdc.gov/ preconception/careforwomen
NOTE
1. ideally, women should consider having a reproductive life plan.
Website: March of Dimes Reproductive Life Plan at www.Marchofdimes.org/ pregnancy/planning-your-pregnancy.aspx