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Women’s Health - Preconception Care and Pregnancy - Fast Facts | NEJM Resident 360

Preconception counseling: Many women seek advice from their primary care physician before trying to conceive. Preconception counseling includes the following:

• Review medications for teratogenic risks.

• Ensure chronic conditions are well controlled.

• Recommend folic acid supplementation.

• Assess for dangerous environmental exposures, including Zika virus.

• Discuss family genetic history.

• Screen for depression and anxiety disorders; intimate partner violence; and alcohol, tobacco, and illicit drug use.

Recommendations for Preconception Counseling and Care is a comprehensive guide developed by the American Academy of Family Physicians (AAFP).

Key considerations prior to pregnancy:

• Folic acid supplementation: All women contemplating pregnancy (and all women using inadequate contraception who are at risk of pregnancy) should begin a folic acid supplement to reduce the risk of neural tube defects.

• Immunization status: Consider screening for varicella and rubella with routine labs before conception because live vaccines can’t be administered during pregnancy.

• Medication reconciliation: A thorough medication reconciliation should be performed, with discontinuation or replacement of medications that are known to be teratogenic and encouragement to continue medications that are clinically necessary.

For more guidance and information on medication safety during pregnancy, see Over-the-Counter Medications in Pregnancy and the table below of AAFP medication guidelines for common medical conditions:

Pregnancy

Co-Management of Medical Issues during Pregnancy

It is important to know how to manage chronic medical problems, such as diabetes, hypertension, depression, asthma, and hyperlipidemia throughout the pregnancy. See table above and the reviews and guidelines associated with this rotation guide for more information on management of specific conditions, including diabetes, chronic hypertension, asthma, venous thromboembolism, and depression. Keep in mind the following general points:

• Contraindications: Some medications commonly used to treat these conditions are contraindicated in pregnancy.

• Dose adjustment: The dose of some medications (e.g., levothyroxine) needs to be increased during pregnancy.

• Pain management: Acetaminophen is generally considered safe, but nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in pregnancy.

Medication exposure during breastfeeding: After delivery, breastfeeding mothers often have similar questions and concerns about medication safety. The U.S. National Library of Medicine’s Drug and Lactation Database (LactMed) provides information on drug safety during breastfeeding and suggests therapeutic alternatives.

**Covid-19 vaccination in pregnancy:**American College of Obstetricians and Gynecologists (ACOG) recommends the following:

• all eligible persons older than 12 years, including pregnant and lactating individuals, receive a COVID-19 vaccine or vaccine series

• pregnant and recently pregnant people up to 6 weeks postpartum, including pregnant and recently pregnant health care workers, receive a booster dose of COVID-19 vaccine following the completion of their initial COVID-19 vaccine or vaccine series

First-Trimester Bleeding

Some women with confirmed pregnancy present to the primary care office with first-trimester bleeding. The following algorithm is a helpful guide for the evaluation of these women:

Evaluation of First-Trimester Bleeding

For more on complications of pregnancy (including ectopic pregnancy and preeclampsia/eclampsia/HELLP Syndrome, see abdomino-pelvic emergencies in the IM Emergency Medicine rotation guide.

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