OG5.1-2 | Preconception Counselling — Summary & Reflection

KEY TAKEAWAYS

Preconception Counselling — Key Points:

• Goal: optimise maternal health and eliminate modifiable teratogenic risk before organogenesis (weeks 3–8 of embryonic life), which occurs before most women know they are pregnant.
• Who needs detailed counselling: women with pre-existing medical conditions, teratogenic medications, adverse obstetric history, hereditary risk, or extremes of BMI.
• Medical conditions and key actions:
• Diabetes: HbA1c ≤48 mmol/mol before conception; high-dose folic acid 5 mg
• Hypertension: stop ACE inhibitors/ARBs → methyldopa/labetalol/nifedipine
• Epilepsy: switch valproate → lamotrigine/levetiracetam (neurologist review); 5 mg folic acid
• SLE: remission (SLEDAI ≤4) ≥6 months before conception; stop mycophenolate/MTX → azathioprine
• Cardiac: WHO class III = specialist co-management; class IV (Eisenmenger's, severe PAH, EF <30%) = advise against pregnancy
• Teratogenic drugs to switch: valproate, ACE inhibitors, ARBs, warfarin (→ LMWH), methotrexate, mycophenolate, isotretinoin
• Folic acid: standard 400 mcg/day for all women; 5 mg/day for previous NTD, diabetes, epilepsy, BMI >30, malabsorption
• Vaccines: MMR and varicella (live — pre-conception only, ≥1 month before conception); influenza, hepatitis B, COVID-19 (safe in pregnancy)
• High-risk factor assessment: structured history (obstetric, medical, drug, family, social), BMI + BP examination, targeted investigations (HbA1c, rubella/varicella IgG, hepatitis B, HIV, haemoglobin electrophoresis)

REFLECT

Return to the opening case of Priya — now 8 weeks pregnant, on valproate, having never received preconception counselling. Kolb's reflective cycle asks: what was the gap in the system that allowed this to happen? Could her neurologist have initiated the conversation? Her GP? A pharmacist dispensing a repeat prescription? Reflect on the 'teachable moments' in your own clinical exposure — have you ever been present when a woman with epilepsy, diabetes, or a cardiac condition was prescribed a new medication or renewed an existing one, without a preconception counselling conversation? As a future clinician, your role is not only to conduct the dedicated preconception consultation when it is requested, but to seize the opportunistic moments — every interaction with a woman of reproductive age who might become pregnant is an opportunity to check, advise, and potentially prevent harm.