Based on the Department's pre-conception care lectures. Many serious problems in pregnancy are decided before the woman knows she is pregnant, so this is the cheapest and earliest intervention in obstetrics.
The reasoning chain: which women are at risk before they conceive → what in their history, examination and tests tells you → what can be fixed now (disease control, drugs, vaccines, folic acid, weight, habits) → plan the timing and spacing of the pregnancy.
1. What it is, and who it is for
Pre-conception care is a set of interventions that identify and modify biomedical, behavioural and social risks to a woman's health and to future pregnancies. The target group is women of reproductive age (15 to 49 years), but men are included in several parts.
Objectives
- Health promotion and education to improve knowledge, attitudes and behaviour of men and women about pregnancy.
- Evidence-based screening for pregnancy risks.
- Interventions to deal with the risks and conditions found.
- Contribute to universal coverage of essential obstetric care.
2. Why it matters
- Early fetal development is the most vulnerable. The fetus is most susceptible to structural problems in weeks 4 to 10, when many women do not yet know they are pregnant. By the first antenatal visit (recommended before 16 weeks) most of the damage that could have been prevented is done.
- In many African settings poor birth outcomes are driven by things that can be addressed beforehand: prematurity, birth asphyxia and infection in newborns; postpartum haemorrhage as the leading single cause of maternal death; HIV (young women are several times more likely to be infected than young men of the same age); malaria and anaemia in pregnancy; smoking, alcohol and drug misuse; and childhood malnutrition, stunting and obesity that later affect pregnancy.
3. Who is at risk? (the reproductive health risk list)
| Risk | Examples |
|---|---|
| Age and parity | Under 18 or over 35; grand multiparity (gravida 5 and above); short birth interval |
| Social | Low socio-economic status, gender-based violence, FGM, early marriage, harmful food taboos and delays in seeking care |
| Previous adverse outcomes | Recurrent miscarriages, stillbirth, early neonatal death, a baby with a congenital abnormality |
| Medical conditions | Anaemia, malaria, HIV/AIDS, TB, STIs, heart disease, diabetes, sickle cell disease, asthma, hypertension, kidney disease, ABO and rhesus incompatibility, breast and cervical cancer |
| Obstetric complications | Previous postpartum haemorrhage, caesarean section scars, previous preterm labour, previous pre-eclampsia or eclampsia |
| Substances | Smoking, alcohol, drugs, teratogenic prescription or over-the-counter medicines, herbs |
4. History: take it in eight parts
- Family history: congenital anomalies, genetic disease, diabetes, hypertension, twins.
- Medical history: diabetes, hypertension, HIV, TB, STIs and RTIs, epilepsy, cancers, breast problems.
- Obstetric and gynaecological history: pregnancy loss, preterm births, STI/PID, menstrual problems, prolonged subfertility.
- Environmental history: radiation, chemicals.
- Occupational history: type of work and long working hours (long-distance drivers, athletes, cyclists; for men, heat around the testes).
- Nutritional history: diet quality, anaemia, vegetarian diets (B12), food restrictions.
- Social history: smoking, alcohol, drugs, partner violence, support.
- Male partner history: mumps, STIs/HIV, substance misuse, tight clothing, and a semen history if there is infertility.
5. Examination and tests
Examine general health, blood pressure, weight and BMI, thyroid, heart and lungs, breasts, abdomen and pelvis, with a cervical screen if due.
Minimum investigations:
| Test | The question it answers |
|---|---|
| Full blood count | Anaemia, sickle cell trait signs, haemoglobinopathy |
| Random blood sugar | Diabetes (a major cause of malformations when poorly controlled) |
| Syphilis test | Congenital syphilis can be prevented |
| HIV test | Start treatment before pregnancy to prevent mother-to-child transmission |
| Blood group and rhesus | Plan for rhesus incompatibility |
| Urinalysis | Infection, protein, sugar |
Add rubella immunity, hepatitis B, haemoglobin electrophoresis, thyroid function and genetic tests as the history suggests.
6. Interventions
Health education and counselling: a reproductive life plan (healthy timing and spacing: wait at least 24 months after a live birth before the next conception), family planning, prenatal diagnosis and genetic counselling (Down syndrome, sickle cell disease, thalassaemia), virological screening (TORCH), and avoiding unnecessary medicines.
Lifestyle: healthy diet, a BMI between 18.5 and 25, stop alcohol, tobacco and drugs, regular exercise and adequate rest. Timing of intercourse: explain the fertile days of the ovulatory cycle; regular intercourse two to three times a week through the cycle is the best advice.
Prophylaxis:
- Folic acid for every woman trying to conceive, started at least one month (ideally three) before conception and continued to 12 weeks, to prevent neural tube defects. A higher dose is used for women with a previous neural tube defect, epilepsy on anticonvulsants, diabetes or obesity.
- Iron, zinc, iodine, calcium and vitamin A (in moderation, as vitamin A in excess is teratogenic) according to health status.
- Vaccines: rubella, hepatitis B, tetanus toxoid, and others as indicated.
Pre-existing medical problems: stabilise and optimise them before conception (diabetes control, blood pressure, epilepsy, HIV treatment, TB treatment), review every drug for safety in pregnancy (for example, switch ACE inhibitors, warfarin, valproate, methotrexate to safer options) and for effects on sperm (cytotoxics, radiation, smoking, alcohol), and refer for specialist care when needed.
7. Delivery: put it where women already go
Pre-conception services must not stand alone. Integrate them into comprehensive care clinics, family planning clinics, school health programmes, VCT centres and services that reach men.
Examiner questions
- Define pre-conception care and state its objectives.
- Why is pre-conception care more effective than care starting at the first antenatal visit?
- What is the minimum set of investigations, and why is each one done?
- Who should take high-dose folic acid?
Practice questions
1. The fetus is most vulnerable to structural malformations during: A. Weeks 1–3 · B. Weeks 4–10 · C. Weeks 12–16 · D. Weeks 20–24 · E. The third trimester Answer: B. Many women do not know they are pregnant yet.
2. Which supplement reduces the risk of neural tube defects? A. Vitamin C · B. Iron · C. Folic acid · D. Vitamin A in high dose · E. Calcium Answer: C.
3. Which statement about pre-conception care is TRUE? A. It only concerns women · B. It starts at the first antenatal visit · C. It includes the male partner and can be integrated into existing clinics · D. It only needs blood group testing · E. It is not needed if the woman is healthy Answer: C.
4. A woman with epilepsy on valproate wants to conceive. The best advice is: A. Stop all drugs · B. Review the drug with a specialist before conception and take high-dose folic acid · C. Continue valproate unchanged · D. Wait until the second trimester to review · E. Start vitamin A Answer: B.