Pre-conception Care: Risk Assessment, Interventions, Counselling and Preparation for Pregnancy

Focus: pre-conception care | Audience: emergency medicine, clinical medicine, nursing, midwifery and allied-health students.

Learning objectives

• Define pre-conception care and explain why it benefits women, men, adolescents, families and future children.
• Perform a structured biomedical, behavioural, nutritional, genetic, environmental and psychosocial risk assessment.
• Plan folic acid, immunisation, chronic-disease optimisation, infection prevention, medication review and healthy timing/spacing of pregnancy.
• Recognise conditions requiring specialist referral before conception and provide a practical follow-up plan.

1. Definition and purpose

Pre-conception care (PCC) is a set of interventions delivered before pregnancy to identify and modify biomedical, behavioural, social and environmental risks that could affect the health of the intending parent, pregnancy, fetus, newborn or family. It is not limited to a single “pre-pregnancy visit”: every consultation with a person who could become pregnant is an opportunity to ask about reproductive intentions, provide contraception if pregnancy is not desired, and improve health.

The supplied presentation emphasises prevention of maternal/child mortality, unintended pregnancy, complications, stillbirth, preterm birth, low birth weight, congenital disorders, neonatal infection, undernutrition, vertical HIV/STI transmission and later non-communicable disease. It also highlights adolescent education, delaying early marriage/pregnancy, environmental hazards and engaging men.

2. Goals of pre-conception care

1. Ensure pregnancy is wanted, timed and supported, or prevent it safely until the person is ready.
2. Optimise health and control chronic disease before embryonic development begins.
3. Prevent congenital disorders, infections, anaemia, malnutrition and avoidable medication toxicity.
4. Identify genetic, obstetric and social risks early enough for referral and informed choices.
5. Prepare both partners and the household for pregnancy, birth, parenting and emergencies.

3. Who should receive PCC?

• Anyone who may become pregnant, including adolescents, people with disabilities and those not actively planning pregnancy.
• Couples planning first or subsequent pregnancy, including after miscarriage, stillbirth, neonatal death, infertility or a complicated prior pregnancy.
• People with diabetes, hypertension, epilepsy, HIV, sickle-cell disease, thyroid disease, kidney disease, heart disease, asthma, mental illness or autoimmune disease.
• People taking potentially teratogenic medicines or exposed to radiation, pesticides, lead, mercury, solvents, heat or infectious hazards.
• Men and partners: sperm health, STI/HIV prevention, genetic risks, medication/toxin exposure, smoking/alcohol and support for a safe pregnancy.

4. First consultation: a respectful reproductive-life plan

1. Ask privately and non-judgementally: “Would you like to become pregnant in the next year?”
2. If no, provide voluntary contraception and discuss dual protection/STI prevention.
3. If yes or unsure, discuss timing, previous pregnancies, fertility concerns, health goals and safe spacing.
4. Assess consent, coercion, intimate-partner violence, sexual safety, child protection and ability to access care.
5. Agree individual goals, written actions, dates for review and referral—not a generic checklist.

5. Comprehensive risk assessment

6. Essential examination and baseline tests

• Measure blood pressure, weight, BMI, pulse, nutritional status and mental-health safety; assess oral health, thyroid, cardiovascular/respiratory status and relevant examination.
• Use pregnancy test when pregnancy is possible before prescribing teratogenic medicines or vaccines.
• Depending on risk and local policy: CBC/haemoglobin, blood group/Rh, HIV, syphilis, hepatitis B, STI testing, urinalysis, glucose/HbA1c, renal/liver tests, thyroid function, ferritin, sickle-cell/haemoglobinopathy testing and rubella/varicella immunity.
• Do not order every test for every person; explain consent, window periods, confidentiality and follow-up.

7. Nutrition and supplements

7.1 Folic acid

• For most people trying to conceive: folic acid 400 micrograms (0.4 mg) orally daily, beginning before conception and continuing through 12 weeks of pregnancy, alongside a balanced diet.
• High-dose folic acid 5 mg daily may be indicated by a clinician for previous neural-tube defect, certain anti-epileptic medicines, malabsorption, diabetes or other high-risk circumstances; confirm national guidance and timing.
• Do not use folic acid to mask untreated vitamin B12 deficiency; assess B12 when macrocytosis, neurological symptoms, malabsorption or dietary risk exists.

7.2 Iron, iodine and other nutrition

• Screen/treat anaemia and iron deficiency; the dose depends on haemoglobin, ferritin, tolerance and national protocol. Routine antenatal iron/folic-acid doses are not automatically the same as pre-conception treatment.
• Promote iodised salt and adequate protein, fruits, vegetables and safe water. Avoid megadose vitamin A/retinoids; excessive preformed vitamin A is teratogenic.
• Address underweight, obesity, eating disorders, food insecurity and pica with dietetics/social support.

8. Chronic-disease optimisation

Diabetes

• Review glucose/HbA1c, hypoglycaemia, nephropathy, retinopathy, blood pressure and medicines before conception.
• Use pre-conception targets agreed with the diabetes team; very high glucose around conception increases miscarriage and congenital anomaly risk.
• ACE inhibitors/ARBs, statins and some other medicines require replacement before pregnancy; never stop insulin without a plan.

Hypertension and cardiovascular disease

• Assess end-organ disease, renal function, medications and functional capacity. ACE inhibitors/ARBs and certain agents need planned substitution; refer severe disease/pulmonary hypertension.
• Discuss aspirin prophylaxis only when indicated by obstetric risk assessment, not self-medication.

Epilepsy and neurological disease

• Document seizure control, triggers, adherence and medicine doses; abrupt withdrawal can endanger parent and fetus.
• Use the lowest effective regimen and specialist review to avoid known high-risk exposure where alternatives exist; prescribe appropriate folic acid.

HIV, TB and chronic infection

• Confirm viral suppression, adherence, partner testing/prevention and PMTCT plan. Continue effective ART unless the HIV team changes it.
• Screen for active TB and treat promptly; review drug interactions and nutritional status.

Renal, thyroid, autoimmune and psychiatric illness

Assess disease activity, renal/liver function, thyroid control, medication safety, relapse risk and support. Planned continuation of effective psychiatric therapy is often safer than untreated severe illness or abrupt cessation.

9. Medication safety

10. Immunisation and infection prevention

• Check routine immunisation and catch up before pregnancy where possible.
• Live vaccines such as MMR or varicella are generally given before pregnancy; avoid conception for the interval recommended by the current vaccine guideline. Do not give live vaccines during pregnancy unless a specific national policy says otherwise.
• Inactivated influenza, COVID-19 and other indicated vaccines may be recommended before or during pregnancy depending on current Ugandan policy and season.
• Prevent malaria with insecticide-treated nets and local preventive strategy; review antimalarial choice before conception/travel.
• Use safe water/food, hand hygiene, dental care, STI condoms/testing and occupational protection from infections.

11. Genetic and family planning counselling

• Ask about sickle-cell trait/disease, thalassaemia, cystic fibrosis/other inherited disorders, congenital anomalies, intellectual disability, recurrent miscarriage, unexplained infant deaths and consanguinity.
• Offer haemoglobinopathy testing and partner testing where relevant in Uganda. Explain carrier status, inheritance, limitations, confidentiality and reproductive options.
• Discuss family-building options, prenatal diagnosis and referral to genetic services without coercion or stigma.

12. Lifestyle, environmental and social health

• Stop smoking and avoid second-hand smoke; offer behavioural and pharmacological cessation support appropriate to pregnancy planning.
• Stop alcohol when trying to conceive; there is no established safe amount in pregnancy.
• Promote moderate physical activity, sleep, healthy weight and treatment of dental disease.
• Reduce exposure to pesticides, lead, mercury, solvents, radiation, excessive heat and indoor smoke; use PPE and work modification.
• Ask about intimate-partner violence, reproductive coercion, forced marriage, unsafe sex and financial barriers. A safe pregnancy plan must include safety and referral, not only vitamins.

13. Timing, spacing and fertility

• Discuss voluntary birth spacing, contraception until disease/medication risks are controlled and emergency contraception when needed.
• Explain that fertility is influenced by age, ovulation, sperm health, tubal patency, sexual function, infections and timing; avoid blaming either partner.
• Offer infertility assessment after 12 months of regular unprotected intercourse, or earlier with amenorrhoea, known tubal/sperm disease, endometriosis, older age or prior pelvic infection.

14. Follow-up plan

1. Give a written risk list and action plan: tests, vaccines, medicine changes, folate start, referrals and target dates.
2. Review within weeks to confirm results, adherence, side effects and disease control.
3. Once pregnancy occurs, book early ANC promptly and communicate pre-conception findings; do not wait for routine timing if high risk.
4. Provide return precautions: severe headache/vision change, chest pain, breathlessness, seizures, uncontrolled glucose, suicidal thoughts or acute infection.

15. Worked scenarios

16. Quick self-test

1. Why is pre-conception care relevant even when pregnancy is not currently planned?
2. What is the routine folic-acid dose and when should it start?
3. Name five medicine/exposure groups requiring review.
4. Why should live vaccines be addressed before pregnancy?
5. List chronic diseases requiring planned optimisation.
6. What questions assess reproductive intention and coercion?
7. What should happen after a positive pregnancy test following PCC?

Further study and references

Starting source: Pre-conception care. Expanded using WHO pre-conception-care resources, WHO folate recommendations and Uganda Ministry of Health maternal/newborn guidance. Doses, vaccine intervals and medicine substitutions must be checked against current local protocols and specialist advice.