Preconception Counseling Key Considerations

Preconception Counseling is defined by the World Health Organization (WHO) as the provision of biomedical, behavioral and social health interventions to women and couples before conception occurs, aimed at improving their health status, and reducing behaviors and individual and environmental factors that could contribute to poor maternal and child health outcomes. Its ultimate aim is improved maternal and child health outcomes, in both the short and long term.2

Defined by the Centers for Disease Control and Prevention (CDC) as a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management.3


Goals of Preconception Counseling among HIV-infected Women4

  • Prevention of unintended pregnancy
  • Prevent HIV transmission to the partner
  • Optimize maternal and paternal health
  • Improve maternal and fetal outcomes
  • Prevent perinatal HIV transmission

Who should receive preconception counseling?

The Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission recommend:5

  • Discussing childbearing intentions with all women of childbearing age on an ongoing basis throughout the course of their care.
  • Include information about effective and appropriate contraceptive methods to reduce the likelihood of unintended pregnancy.
  • During preconception counseling include information on safer sexual practices and elimination of use of alcohol and illicit drugs, and smoking, which are important for the health of all women as well as for fetal/infant health, should pregnancy occur.
  • Choosing an ART regimen for HIV infected women of childbearing age based on consideration of effectiveness for treatment of maternal disease, teratogenic potential of drugs in the regimen should pregnancy occur and possible adverse outcomes for mother and fetus.

According to the World Health Organization (WHO):2

  • Preconception care interventions do not need to be delivered as one package.
  • Interventions could be delivered both in health facilities and in community settings.
  • The logical target group for initiating work in this area is individuals and couples contemplating a pregnancy.
  • The next group to consider is individuals who are not currently contemplating a pregnancy.
  • Finally, couples with a previous adverse reproductive outcomes, and individuals with pre-existing genetic risks or genetic conditions such as thalassemia, or health conditions such as diabetes or epilepsy need to be reached with interventions tailored to their special needs.

Reproductive Rights / Sexual and Reproductive Health

  • All couples and individuals have the right to decide freely and responsibly the number, spacing, and timing of their children, and to have the information and means to do so.1
  • Decisions concerning reproduction should be made free from discrimination, coercion and violence.1

 

Figure 1. Components of Preconception Counseling for HIV–infected Women

Components of Preconception Counseling for HIV-infected Women
Planning and Timing of Pregnancy
• Optimize a woman's health prior to conception
• Diet and physical activity
• Social support
Contraception options if not planning pregnancy

Optimize Medical conditions
Diabetes
Hypertension
• Seizure disorder
• Thrombophilia
• Depression
• Anxiety

Screen for Infectious Diseases and Vaccinate if Appropriate
• Hepatitis B
Hepatitis C
• Herpes simplex
• Syphilis
• Gonorrhea/Chlamydia
• Cytomegalovirus
• Varicella
• Measles, Mumps, Rubella
Tuberculosis

Environmental Toxins
• Smoking cessation
• Screen for alcohol abuse
• Screen for illicit drug use

Family and genetic history
Review medication history
Perinatal HIV Transmission

 

Table 1. Medication used for HIV or co-morbidities that should be avoided during pregnancy

Drug Concern
Efavirenz Contraindicated during the first trimester due to teratogenicity
Stavudine/Didanosine This combination should be avoided during pregnancy as fatal lactic acidosis has been reported as well as pancreatitis
Ribavirin This drug is an asbolute contraindication during pregnancy

Links for Preconception Care

  1. WHO's Meeting to Develop a Global Consensus on Preconception Care to Reduce Maternal and Childhood Mortality and Morbidity .
  2. United Nations Population Fund, Reproductive Rights and Sexual Health Framework.
  3. WHO Guidelines on Care, Treatment and Support for Women Living with HIV/AIDS and Their Children in Resource-constrained Settings.
  4. British HIV Association, BASHH and FSRH Guidelines for the Management of the Sexual and Reproductive Health of People Living with HIV Infection 2008.
  5. AJOG, The clinical content of preconception care:an overview and preparation of this supplement.
  6. Systematic Review of Preconception Risks and Interventions.
  7. Preconception Care: A Good Beginning.
  8. WHO's Reproductive Choices and Family Planning for People Living with HIV.

 

References

  1. United Nations. Programme of Action. Adopted at the International Conference on Population and Development, Cairo, 5-13 September 1994. New York, 1994, paragraph 7.12.
  2. Meeting to Develop a Global Consensus on Preconception Care to Reduce Maternal and Childhood Mortality and Morbidity. Accessed 18 Nov 2013.
  3. Centers for Disease Control and Prevention.  Recommendations to improve preconception health and health care-United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.  MMWR 2006;55 (no. RR-6).
  4. American College of Obstetricians and Gynecologists (ACOG). Gynecological care for women with human immunodeficiency virus, Practice Bulletin, No.117; December 2010.
  5. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Accessed 12 Nov 2013;22-26.