Ask everyone of reproductive age
- 'Would you like to become pregnant in the next year?' One question separates those who want contraception from those who need preconception care, and it belongs in every visit.
- Reproductive life plan: how many children, when, and what would need to change first.
What to optimise before conception
| Area | What to do | Why it matters |
|---|---|---|
| Folic acid | 0.4 mg daily from at least a month before conception through the first trimester; 4 mg daily with a prior neural tube defect (and higher-dose regimens in some guidance for diabetes, epilepsy on valproate, obesity) | Neural tube closure is complete by 4 weeks after conception, before most women know they are pregnant |
| Diabetes | HbA1c as close to normal as safely possible (under 6.5 percent where achievable) before stopping contraception; switch from oral agents to insulin if needed; retinal and renal review | Malformations track first-trimester glucose |
| Hypertension | Stop ACE inhibitors, ARBs and most diuretics; change to labetalol, nifedipine or methyldopa | Renin-angiotensin blockers are fetotoxic in the second and third trimesters and best avoided from the start |
| Epilepsy | Review with neurology: lowest effective dose, monotherapy, avoid valproate where any alternative exists; high-dose folic acid | Valproate carries the highest malformation and neurodevelopmental risk |
| Thyroid | Treat hypothyroidism to a TSH in the lower normal range; increase levothyroxine by about 25 to 30 percent once pregnant | Fetal brain development depends on maternal thyroxine in the first trimester |
| Weight | Address underweight and obesity before, not during, pregnancy; bariatric surgery patients need micronutrient planning and a delay of 12 to 18 months | Obesity raises the risk of diabetes, hypertension, stillbirth and caesarean |
| Vaccines | Check rubella and varicella immunity and vaccinate before conception (live vaccines, then avoid pregnancy for a month); hepatitis B; influenza and COVID-19 any time; pertussis is given in each pregnancy | Congenital rubella and varicella are preventable |
| Medicines and exposures | Review every prescription, over-the-counter drug and supplement; isotretinoin, methotrexate, warfarin, statins, mycophenolate need a plan; stop smoking, alcohol and other substances | The first trimester is when most structural harm happens |
Screening offered before pregnancy
- Carrier screening: cystic fibrosis, spinal muscular atrophy and haemoglobinopathies are offered to all in current ACOG guidance, with expanded panels by choice; knowing before pregnancy leaves every option open.
- Infections: HIV, syphilis, hepatitis B and C, and the immunity checks above; treat and vaccinate first.
- Family history: genetic conditions, recurrent loss, venous thrombosis, and a partner's history too.
- Mental health: depression and anxiety are common; a plan for medication in pregnancy is made before, not after, a positive test.
- Interpregnancy interval: at least 18 months from birth to the next conception lowers preterm birth and low birth weight; under 6 months carries the highest risk.
Check
A 31-year-old with type 2 diabetes on metformin and ramipril wants to conceive. What comes first?