Gynecologists, internists, family practitioners, and pediatricians have the best opportunity to provide preventive counseling during periodic health maintenance examinations. The occasion of a negative pregnancy test is also an excellent time for education. Jack and colleagues (1995) administered a comprehensive preconceptional risk survey to 136 such women, and almost 95 percent reported at least one problem that could afect a uture pregnancy. These included medical or reproductive problems-52 percent; family history of genetic disease-50 percent; increased risk of human immunodeiciency virus infection-30 percent; increased risk of hepatitis B and illegal substance abuse-25 percent; alcohol use-17 percent; and nutritional risks-54 percent. Counselors should be knowledgeable regarding relevant medical diseases, prior surgery, reproductive disorders, or genetic conditions and must be able to interpret data and recommendations provided by other specialists (Simpson, 2014). If the practitioner is uncomfortable providing guidance, the woman or couple should be referred to an appropriate counselor.
Women presenting specifically for preconceptional evaluation should be advised that information collection may be time consuming, depending on the number and complexity of factors that require assessment. he intake evaluation includes a thorough review of the medical, obstetrical, social, and family histories. Useul information is more likely to be obtained by asking specific questions regarding each of these histories and each family member than by asking general, open-ended questions. Some important information can be obtained by questionnaires that address these topics. Answers are reviewed with the couple to ensure appropriate follow-up, including obtaining relevant medical records.
With specific medical conditions, general points include how pregnancy will afect maternl health and how a high-risk condition might afect the fetus. terward, advice for improving outcome is provided. Some chronic conditions that may ffect pregnancy outcomes include treated or active cancer, prior peripartum cardiomyopathy, and systemic lupus erythematosus (mant, 2015; Buyon, 2015; McNamara, 2015). Importantly, psychological health should be considered (Lassi, 2014). Detailed preconceptional information regarding a few exemplary conditions is found in the next sections and in the other topic-speciic chapters of this text.
Because maternal and fetal pathology associated with hyperglycemia is well known, diabetes is the protoype of a condition for which preconceptional counseling is beneficial. Diabetesassociated risks to both mother and fetus are discussed in detail in Chapter 57 (p. 1099). Many of these complications can be avoided if glucose control is optimized before conception. Another important aspect of counseling pertains to the frequent use of teratogenic angiotensin-converting enzyme inhibitors in this population (Podymow, 2015).
The American College of Obstetricians and Gynecologists (2016a) has concluded that preconceptional counseling for women with pregestational diabetes is both beneicial and costefective and should be encouraged. The American Diabetes Association has promulgated consensus recommendations for preconceptional care for diabetic women (Kitzmiller, 2008). hese guidelines advise obtaining a thorough inventory of disease duration and related complications and completing a clinical and laboratory examination for end-organ damage. Perhaps most essential, they encourage a preconceptional goal of the lowest hemoglobin Ale level possible without undue hypoglycemic risk to the mother. In addition to assessing diabetic control during the preceding 6 weeks, hemoglobin Ale measurement can also be used to estimate risks for major anomalies as shown in Figure lthough these data are from women with severe overt diabetes, the incidence of fetal anomalies in women who have gestational diabetes with fasting hyperglycemia is increased fourfold compared with that in normal women (Sheield, 2002).