PRECONCEPTION AND interconception care ^292

Every encounter with the health care system should be viewed as an oppor­tunity to improve reproductive health in women capable of becoming pregnant. A woman’s awareness of reproductive risks, health-enhancing behaviors, and family planning options is essential to improving her own health and the outcomes of pregnancy.

Reproductive health hazards—including the use of alcohol, tobacco, and other drugs—exist across all socioeconomic and age groups; therefore, all women capable of becoming pregnant should develop a reproductive health plan and should discuss it in a nondirective way at each subsequent visit. The discussion should include assessment of the desirability of a future pregnancy; determination of steps that need to be taken either to prevent, or to plan for and optimize, a pregnancy; and evaluation of cur­rent health status (see also the “Family Planning” section earlier in Part 3). Adolescents and women in their 40s require a special approach and focus because reproductive health risks and the rates of unintended pregnancy are highest in these groups. Reproductive messages and strategies to deliver them should be developed for men as well.

Women of advanced reproductive age are more likely to have infertility issues caused by oocyte abnormalities and decreased ovarian reserve as well as an increased risk of pregnancy loss.

Reproductive health screening, contraceptive counseling, and precon­ception considerations should not be limited to obstetrician-gynecologists and other providers of women’s health care. Because reproductive health can significantly affect the development of chronic health conditions and the management of those conditions can affect pregnancy outcomes, it is crucial that reproductive health be considered by all health care providers serving women in their reproductive years.

Preconception Care ^394

As it is with well-woman care, contraceptive planning is a key part of pre­conception care. Women who do not wish to become pregnant should be encouraged to use effective methods of contraception (see also the “Family Planning” section earlier in Part 3). Women who are contemplating preg­nancy should be encouraged to undergo a comprehensive preconception evaluation and counseling and to formulate a reproductive health plan that addresses the optimal number, spacing, and timing of children in the family; real and perceived barriers to achieving these goals; and age-related changes in fertility. Because unintended pregnancy is so common, ele­ments of this visit also should be incorporated into the well-woman visit for women capable of becoming pregnant (see also the “Family Planning” section earlier in Part 3).

Although most pregnancies result in good maternal and fetal outcomes, some pregnancies result in adverse health effects for the woman, fetus, or newborn. Even though some adverse outcomes cannot be prevented, opti­mizing a woman’s health and knowledge before she plans and conceives a pregnancy may eliminate or reduce the risk. For example, initiation of folic acid supplementation at least 1 month before pregnancy reduces the incidence of neural tube defects.

At the preconception visit, information that may have a bearing on a future pregnancy should be obtained through patient history, physical assessment, and screening and testing, as appropriate. After this informa­tion has been obtained, the clinician may provide patient counseling and make recommendations for interventions to help the patient achieve opti­mal physical and psychologic health before pregnancy, as well as provide information about what to expect during pregnancy. This visit also is an opportunity to identify fertility issues, with referral to a fertility specialist as appropriate.

History

A comprehensive history should be taken. Attention should be focused on how a future pregnancy might affect the woman’s own health and be affected by her medical, reproductive, immunization, and family histories; use of medications or substances; nutritional status; and environmental exposures.

Medical History

Conditions that may have an effect on pregnancy should be covered in the medical history. Information should be obtained about chronic conditions, such as diabetes mellitus; phenylketonuria; thyroid disease; hypertension; epilepsy; anemia and disorders of coagulation; autoimmune disorders; herpes and other sexually transmitted infections, including human immu­nodeficiency virus (HIV); heart disease; kidney disease; endocrine disease; and reactive airway disease. Because some women are not aware they were ever diagnosed with phenylketonuria, they should be asked whether they were placed on a special diet during childhood.

Box 3-19. Conditions Associated With Increased Risk of Adverse Health Events as a Result of Unintended Pregnancy ^

• Breast cancer

• Complicated valvular heart disease

• Diabetes: type 1 diabetes mellitus; with nephropathy, retinopathy, neu­ropathy, or other vascular disease; or of more than 20 years' duration

• Endometrial or ovarian cancer

• Epilepsy

• Hypertension (systolic greater than 160 mm Hg or diastolic greater than 100 mm Hg)

• History of bariatric surgery within the past 2 years

• Human immunodeficiency virus or acquired immune deficiency syndrome

• Ischemic heart disease

• Malignant gestational trophoblastic disease

• Malignant liver tumors (hepatoma) and hepatocellular carcinoma of the liver

• Peripartum cardiomyopathy

• Schistosomiasis with fibrosis of the liver

• Severe (decompensated) cirrhosis

• Sickle cell disease

• Solid organ transplantation within the past 2 years

• Stroke

• Systemic lupus erythematosus

• Thrombogenic mutations

• Tuberculosis

Reprinted from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention. MMWR Recomm Rep 2010;59 (RR-4):1-86.

disease history. A psychiatric history also should be obtained to identify women who have a history of, or are currently being treated for, depression or other psychiatric disorders.

Reproductive History

Patients should be asked about conditions that may affect future preg­nancy. These conditions include a history of therapy or surgery on the cervix, ovaries, uterus, or fallopian tubes; in utero exposure to diethylstil­bestrol; and prior adverse pregnancy outcomes.

Immunization History

An immunization history should be obtained, and vaccination(s) should be offered to women found to be at risk (see also “'Counseling” later in this section).

Family History

The patient should be questioned about specific conditions related to ethnic background and family history suggestive of genetic disorders, such as muscular dystrophy, hemophilia, Tay-Sachs disease, sickle cell disease, cystic fibrosis, thalassemia, consanguinity, mental retardation, anatomic birth defects, Down syndrome, and other chromosomal abnormalities. It is reasonable to offer cystic fibrosis carrier screening to all patients. Further genetic screening and testing may be recommended based on family his­tory or ethnic background (see also “Counseling” later in this section).

Medication and Substance Use and Abuse

Prescription medication used to treat various medical conditions may pose an increased risk for the fetus. Patients should be asked about prescription and over-the-counter medications that they take regularly or as needed. They should be asked specifically about medications that they may be reluctant to mention (or may not consider to be medications), such as sedatives or tranquilizers, herbal supplements, or appetite suppressants. Use of tobacco, alcohol, and illegal drugs should be determined. Patients should be reassured of the confidentiality of this information in an attempt to ensure a candid response (see also “Counseling” later in this section and the “Substance Use and Abuse” section earlier in Part 3).

Nutritional Status

The patient’s height and weight and a general assessment of her dietary habits should be recorded. Information about her use of dietary supple­ments (including folic acid and other vitamins), efforts to control weight, any history of eating disorders, such as bulimia or anorexia, and prior obe­sity should be obtained in the inquiry.

Environmental Factors

Patient exposure to toxic environmental chemicals and other stressors is ubiquitous, and preconception exposure to toxic environmental agents can have a profound and lasting effect on reproductive health across the life course.

Physical Assessment

After a history is obtained, a complete physical assessment of the patient should be performed, with emphasis on conditions that might affect pregnancy adversely (see Box 3-19). Body mass index (BMI) should be calculated. A pelvic examination should be conducted to detect possible reproductive anomalies that may influence conception and pregnancy.

Screening and Testing

Cervical cytologic testing and screening for sexually transmitted infections should be performed when appropriate (see also the “Cancer Screening and Prevention” section and the “Sexually Transmitted Infections” section in Part 3). Testing for HIV is recommended for women seeking precon­ception care. Where legal, opt-out HIV screening should be performed, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care, unless the patient declines testing. Physicians should be aware of state laws related to HIV testing. If a patient declines HIV testing, this should be noted in the medical record.

Box 3-20. Sources of Current Teratogen Information ^

Several sources of useful current information regarding potential teratogens are available, including numerous teratogen information services available through­out the United States that serve specific geographic areas. For information on the teratogen service in a particular area, contact the following:

Organization of Teratology Information Specialists 5034A Thoroughbred Lane

Brentwood, TN 37027

(615) 649-3082 www.mothertobaby.org

The following web site provides a variety of resources and links:

Teratology Society

1821 Michael Faraday Drive, Suite 300

Reston, VA 20190

(703) 438-3104 www.teratology.org

The following computerized teratology and reproductive risk database offers up-to-date summaries of electronic resources that provide teratology informa­tion at no cost:

TOXNET - Toxicology Data Network National Library of Medicine

Two Democracy Plaza, Suite 440 and Suite 510

6707 Democracy Blvd., MSC 5467 Bethesda, MD 20892

(301) 496-1131

1-888-FINDNLM

www.toxnet.nlm.nih.gov

Counseling ^385

After the history and physical assessment are completed, the patient should be counseled regarding risk factors and lifestyle changes that may increase her chance of having a successful pregnancy and a healthy infant. Measures should be taken to modify behavior that may be detrimental, such as smoking, alcohol consumption, or poor nutrition. It should be stressed to the patient that a healthy lifestyle not only will improve her chances of having a healthy pregnancy but also will have long-term benefits for herself and her family; however, patients should be informed that ideal physical health before pregnancy does not prevent all complications of pregnancy. Pregnancy complications or discomforts may necessitate changes in life­style, such as interruption of work, that are not predictable before preg­nancy or even in early pregnancy.

Immunizations

Vaccination(s) should be offered to women found to be at risk of, or susceptible to the following: measles, mumps, rubella, varicella, hepa­titis A, hepatitis B, meningococcus, and pneumococcus. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends vaccination with the inactivated influenza vaccine for all women who will be pregnant through the influenza season (October through May in the United States). In addition, women who have not been immunized with the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine or women whose vaccine status is unknown should be offered immunization with the Tdap vaccine. The human papillomavirus (HPV) vaccination can be offered to appropriate nonpregnant women. However, because the vaccine is not recommended during pregnancy, completion of the vaccine series may need to be delayed until the postpartum period.

Nutrition and Weight

Patients should be counseled on appropriate weight for height, recommen­dation for folic acid supplementation, and avoidance of excessive vitamin supplementation or food fads, with referral for in-depth counseling, if appropriate. Counseling should include the provision of specific informa­tion concerning the maternal and fetal risks of obesity in pregnancy and encouragement to undertake a weight-reduction program, if appropriate (see also the “Fitness” section earlier in Part 3).

Women should be advised to achieve a near-normal BMI before attempting conception because infertility as well as maternal and fetal complications are associated with abnormal BMI. All women should be encouraged to exercise at least 30 minutes on most days of the week (see also the “Fitness” section earlier in Part 3). Obese women should be advised regarding their increased risk of adverse perinatal outcomes, including difficulty becoming pregnant, conception of a fetus with a variety of birth defects, preterm delivery, diabetes, cesarean delivery, and hypertensive dis­ease (see also the “Fitness” section earlier in Part 3).

The preconception ingestion of folic acid has been shown to reduce the risk of neural tube defects. The U.S. Public Health Service has advocated that all women who are capable of becoming pregnant take 0.4 mg of folic acid daily to prevent neural tube defects. For this reason, the recom­mended dietary allowance for folic acid has been increased to 0.4 mg as well. Although many grains now are fortified with folic acid, it is unlikely that a daily intake of 0.4 mg can be achieved through diet alone. Therefore, daily supplementation with a multivitamin is recommended for all women who are capable of becoming pregnant. Patients at high risk of neural tube defects (eg, those who have a history of neural tube defects, have had an affected infant, or are taking anticonvulsant medication) should begin ingesting 4 mg of folic acid daily at least 1 month before the time they plan to become pregnant and continue through the first 3 months of pregnancy. This higher dosage of folic acid should be prescribed by a health care pro­vider. Although folic acid is relatively nontoxic, increasing the doses of multivitamin preparations to reach the higher level is not advised because of the potential for ingesting excessive amounts of other vitamins that may be harmful.

Chronic Medical Conditions

Patients should be counseled about the possible effects of pregnancy on existing medical conditions for the woman and the possible effects of the woman’s existing medical conditions on the fetus, and interventions should be introduced. Women with metabolic diseases, such as phenylke­tonuria and diabetes mellitus, should be counseled regarding the impor­tance of appropriate diet and metabolic control before, during, and after pregnancy. Dietary restrictions that result in lower maternal phenylalanine levels appear to reduce the risk of fetal abnormalities. Good glycemic control reduces the risk of miscarriage, fetal anomalies, and other adverse pregnancy outcomes in women with diabetes mellitus. To be most effec­tive, appropriate dietary modifications should begin before pregnancy.

Medication Use

In general, using the lowest effective dose of only necessary medications is recommended. The use of known or potential teratogenic medications should be addressed. Some common teratogenic medications include the oral anticoagulant warfarin, the antiseizure drugs valproic acid and carba­mazepine, isotretinoin, and angiotensin-converting enzyme inhibitors (see also “Depression and Psychiatric Illness” later in this section).

Environmental Factors

Once an environmental toxin exposure inventory has been completed, information should be given regarding the avoidance of exposure to toxic agents at home, in the community, and at work with possible referrals to occupational medicine programs or United States Pediatric Environmental Health Specialty Units if a serious exposure is found. Intervention as early as possible during the preconception period is advised to alert patients regarding avoidance of toxic exposure and to ensure beneficial environ­mental exposure, eg, fresh fruit and vegetables, unprocessed food, outdoor activities, and a safe and nurturing physical and social environment. Also, women in the preconception period should be advised to avoid eating some large fish, such as shark, swordfish, king mackerel, and tilefish, which are known to contain high levels of methylmercury, a known teratogen.

Physicians in the United States are required to report illnesses or inju­ries that may be work related, and reporting requirements vary by state. Illnesses include acute and chronic conditions, such as a skin disease (eg, contact dermatitis), respiratory disorder (eg, occupational asthma), or poisoning (eg, lead poisoning or pesticide intoxication). Resources for information about how to report occupational and environmental illnesses include local and state health agencies and the Association of Occupational and Environmental Clinics (www.aoec.org/about.htm).

Maternal Age

Women should be educated regarding pregnancy risks with advancing maternal age. Complications of pregnancy that are more common in preg­nant women older than 35 years include gestational diabetes, hypertensive disorders, cesarean delivery, maternal mortality, and possibly perinatal mortality and neural tube defects. Although any woman may give birth to a child with Down syndrome or other trisomy, the risk of autosomal trisomy increases with advancing maternal age.

Genetic Counseling

Couples with identifiable risks of having a child with heritable abnormali­ties and couples with genetic concerns should be counseled appropriately or referred to genetic counseling services. Genetic counseling includes in­depth assessment of risks and discussion of availability and limitations of prenatal diagnosis and options. Recognizing positive carrier status before pregnancy allows couples to understand the risks outside the emotional context of pregnancy; allows time for thorough family evaluation, when indicated; and prepares the couple for prenatal diagnostic testing during pregnancy, if desired (see also the “Genetic Risk Assessment” section earlier in Part 3).

Substance Use and Abuse

The preconception interview allows for timely education about medica­tion and substance use and abuse in pregnancy, informed decision mak­ing about the risks to the fetus, and the introduction of interventions for patients who abuse substances. Behavioral counseling for substance use and abuse issues can be particularly effective during the preconception period. Women who smoke cigarettes or use any other form of tobacco product should be encouraged and supported in an effort to quit. This is a good opportunity to offer referral to smoking cessation programs. Other important behavioral issues to address include alcohol use and misuse and the abuse of prescription and nonprescription recreational drugs. Women who are trying to become pregnant should be counseled to completely refrain from all alcohol use and from misuse and abuse of prescription and nonprescription recreational drugs. Referral relationships with appropriate resources should be established and used as needed to assist women with these issues. Women who are counseled about substance use and abuse should be monitored to assess adherence to recommendations. (For infor­mation on interventions, see also the “Substance Use and Abuse” section earlier in Part 3.)

Depression and Psychiatric Illness ^390

Patients should be counseled regarding the possibility of postpartum depression. This condition is more common in women with a history of depression before pregnancy, previous postpartum depression, or other psychiatric disorders. Women who have been receiving treatment for depression should receive counseling concerning the management options during pregnancy. Consultation with the prescribing psychiatrist is recom­mended regarding antidepressant medication dosing and safety (see also the “Depression” section later in Part 3).

Intimate Partner and Domestic Violence

Aspects of an individual’s home environment may be of concern. Fear and abuse are problems for many women. It is important to determine if the woman feels safe and what options she may have if she does not feel safe. In reproductive coercion, a woman’s partner interferes with her reproduc­tive choices, such as whether to become pregnant or continue a pregnancy (see also the “Abuse” section later in Part 3).

Interconception Care

Interconception care refers to care that is delivered between a woman’s pregnancies. Because certain adverse outcomes in pregnancy have implica­tions for well-woman care and the health of future pregnancies, intercon­ception care offers a valuable opportunity to improve a woman’s health and the health of any children she may have in the future. Women with preeclampsia are almost four times more likely to develop diabetes and almost 12 times more likely to develop hypertension that requires drug treatment. Up to 70% of women with gestational diabetes mellitus develop type 2 diabetes mellitus within 5 years of the pregnancy. Excessive preg­nancy weight gain and failure to lose weight after delivery can adversely affect a woman’s immediate and future health.

The key element in interconception care is the postpartum visit. This is a critical opportunity to gather information related to the pregnancy; per­form a physical evaluation and any needed screening and testing; counsel the patient on recommended lifestyle changes and health care interven­tions; and transition the patient back to well-woman care for surveillance and management of any identified medical conditions.

History

At the postpartum visit, an interval history should be obtained to supple­ment the obstetric history. Obstetric complications should be noted, espe­cially hypertensive disorders (such as pregnancy-induced hypertension, preeclampsia, and eclampsia), gestational diabetes, and preterm delivery. Specific inquiries should be made regarding breastfeeding and contracep­tive use.

Physical Assessment

The examination should include an evaluation of weight, blood pressure, breasts, and abdomen as well as a pelvic examination. Although many con­traceptive methods can be initiated immediately after delivery (see also the “Family Planning” section earlier in part 3), the postpartum visit is also an opportunity to insert long-acting reversible contraceptive methods if this was not done after delivery.

Screening and Testing

All women with gestational diabetes mellitus should be screened at 6-12 weeks postpartum. Either a fasting plasma glucose test or the 75-g, 2-hour oral glucose tolerance test is appropriate for diagnosing diabetes. According to the American Diabetes Association, the hemoglobin A_1c test is also appropriate for diabetes screening and diagnosis in adults. Although the fasting plasma glucose test is easier to perform, it lacks sensitivity for detecting other forms of abnormal glucose metabolism; results of the oral glucose tolerance test can confirm an impaired fasting glucose level and impaired glucose tolerance. If the results of the postpartum screen are nor­mal, the American Diabetes Association recommends repeat testing at least every 3 years. Women should be encouraged to discuss their gestational diabetes mellitus history and need for screening with all of their health care providers (see also the “Diabetes Mellitus” section earlier in Part 3).

The postpartum visit is an opportune time to review adult immuniza­tions, such as rubella and varicella vaccination for women who are sus­ceptible and did not receive the vaccine immediately postpartum. Women who did not receive the Tdap vaccine during the current pregnancy or immediately after delivery should receive a dose to ensure pertussis immunity and reduce the risk of transmission to the newborn. Other test­ing and laboratory data should be obtained as indicated.

Depression is very common during the postpartum period, but at this time there is insufficient evidence to support a firm recommendation for postpartum screening. There are also insufficient data to recommend how often screening should be done. However, screening for depression has the potential to benefit a woman and her family and should be strongly con­sidered. Women with a positive assessment require follow-up evaluation and treatment if indicated (see also the “Depression” section later in Part 3).

Counseling

The postpartum visit is an excellent time to begin preconception counsel­ing for the woman who may wish to have children in the future (see also “Preconception Care” earlier in this section). This counseling includes review of the patient’s reproductive health plan for the planning, spac­ing, and timing of the next pregnancy; discussion of health-promotion measures; and timely intervention to reduce medical and psychosocial risks. A woman who plans to have another child can be counseled that in its Healthy People 2020 initiative, the U.S. Department of Health and Human Services recommends that women avoid conceiving within 18 months of a previous birth to help optimize maternal and fetal outcomes. Discussion about health promotion may include counseling regarding haz­ardous behaviors, such as those related to sexually transmitted infections, tobacco, alcohol, and other substance use, as well as positive recommenda­tions regarding folic acid use, breastfeeding, and contraceptive use. Other interventions may include treatment of infections; nutrition counseling, supplementation, and guidance on postpartum weight loss; and appropri­ate referrals for follow-up care. Depending on the outcome of the patient’s pregnancy, it may be advantageous to discuss the implications of diabetes mellitus, fetal growth restriction, preterm birth, hypertension, fetal anoma­lies, and other conditions that may recur in a future pregnancy.

Women with a history of substance abuse should receive supportive guidance during the postpartum visit to prevent relapse to prepregnancy behaviors. If the mother used opioid drugs before or during pregnancy, she is at high risk of an overdose during the postpartum period and should be immediately referred to an addiction medicine specialist.

Many women experience some degree of emotional lability in the post­partum period. If this persists or develops into clinically significant depres­sion, intervention may be necessary. The emotional status of a woman whose pregnancy had an abnormal outcome also should be assessed, with referrals for counseling and treatment as appropriate.

Transition to Well-Woman Care

At the postpartum visit, the obstetrician or other obstetric care provider should identify interval care recommendations for general health promo­tion and for reproductive health promotion. Regardless of whether the woman’s subsequent well-woman care will be provided by the obstetric care provider who attended the delivery, an internist, a family physician, or another health care provider, it is important to clearly identify needed follow-up care, such as repeat glucose screening. Patient handoffs are a necessary component of current medical care. Accurate communication of information about a patient from one member of the health care team to another is a critical element of patient care and safety. In order to be effec­tive, communication should be complete, clear, concise, and timely.

Bibliography

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 7th ed. Elk Grove Village (IL): AAP; Washington, DC: American College of Obstetricians and Gynecologists; 2012.

American Heart Association. 2011 AHA guidelines for cardiovascular disease prevention in women: for obstetrician-gynecologists and other reproductive health professionals. Dallas (TX): AHA; 2011. Available at: http://www.womens health.gov/heart-truth/heart-truth-docs/OBGYN/508%20OBGYN%20100311.pdf. Retrieved July 29, 2013.

Carrier screening for fragile X syndrome. Committee Opinion No. 469. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:1008-10. [PubMed] [Obstetrics & Gynecology]

Communication strategies for patient handoffs. Committee Opinion No. 517. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119: 408-11. [PubMed] [Obstetrics & Gynecology]

Department of Health and Human Services. Healthy People 2020 topics and objec­tives: family planning. Available at: http://www.healthypeople.gov/2020/topics objectives2020/overview.aspx?topicId=13. Retrieved September 27, 2013.

Exposure to toxic environmental agents. Committee Opinion No. 575. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:931-5. [PubMed] [Obstetrics & Gynecology]

Female age-related fertility decline. Committee Opinion No. 589. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:719-21. [PubMed] [Obstetrics & Gynecology]

Gestational Diabetes Mellitus. Practice Bulletin No. 137. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:406-16. [PubMed] [Obstetrics & Gynecology]

Maternal decision making, ethics, and the law. ACOG Committee Opinion No. 321. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106: 1127-37. [PubMed] [Obstetrics & Gynecology]

Maternal phenylketonuria. ACOG Committee Opinion No. 449. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1432-3. [PubMed] [Obstetrics & Gynecology]

Neural tube defects. ACOG Practice Bulletin No. 44. American College of Obste­tricians and Gynecologists. Obstet Gynecol 2003;102:203-13. [PubMed] [Obstetrics & Gynecology]

Nonmedical use of prescription drugs. Committee Opinion No. 538. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:977-82. [PubMed] [Obstetrics & Gynecology]

Preconception and prenatal carrier screening for genetic diseases in individuals of Eastern European Jewish descent. ACOG Committee Opinion No. 442. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:950-3. [PubMed] [Obstetrics & Gynecology]

Pregestational diabetes mellitus. ACOG Practice Bulletin No. 60. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;105:675-85. [PubMed] [Obstetrics & Gynecology]

Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin No. 77. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109: 217-27. [PubMed] [Obstetrics & Gynecology]

Screening for Tay-Sachs disease. ACOG Committee Opinion No. 318. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:893-4. [PubMed] [Obstetrics & Gynecology]

The importance of preconception care in the continuum of women's health care. ACOG Committee Opinion No. 313. American College of Obstetricians and Gyne­cologists. Obstet Gynecol 2005;106:665-6. [PubMed] [Obstetrics & Gynecology]

Tobacco use and women's health. Committee Opinion No. 503. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:746-50. [PubMed] [Obstetrics & Gynecology]

U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention. MMWR Recomm Rep 2010;59 (RR-4):1-86. [PubMed] [Full Text]

Update on carrier screening for cystic fibrosis. Committee Opinion No. 486. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1028-31. [PubMed] [Obstetrics & Gynecology]

Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vac­cination. Committee Opinion No. 566. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1411-4. [PubMed] [Obstetrics & Gynecology]

Resources

American College of Obstetricians and Gynecologists. Good health before preg­nancy: preconception care. Patient Education Pamphlet AP056. Washington, DC: American College of Obstetricians and Gynecologists; 2012.

American College of Obstetricians and Gynecologists. Immunization for women. Washington, DC: American College of Obstetricians and Gynecologists; 2012. Available at: http://www.immunizationforwomen.org/. Retrieved September 4, 2013. American College of Obstetricians and Gynecologists. Immunization resources for obstetrician-gynecologists: a comprehensive tool kit. Washington, DC: American College of Obstetricians and Gynecologists; 2013. Available at: http://www.acog. org/~/media/Departments/Immunization/ImmunizationToolkit.pdf?dmc=1&ts- 20130709T1011229407. Retrieved September 27, 2013.

American College of Obstetricians and Gynecologists. Later childbearing. Patient Education Pamphlet AP060. Washington, DC: American College of Obstetricians and Gynecologists; 2012.

American College of Obstetricians and Gynecologists. Your pregnancy and child­birth: month to month. 5th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2010.

American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine. Exposure to toxic environmental agents. Washington, DC; Birmingham (AL): American College of Obstetricians and Gynecologists; ASRM; 2013. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/ Health_Care_for_Underserved_Women/~/media/Committee%20Opinions/ Committee%20on%20Health%20Care%20for%20Underserved%20Women/ ExposuretoToxic.pdf. Retrieved September 27, 2013.

Association of Occupational and Environmental Clinics. Available at: http://www. aoec.org. Retrieved September 27, 2013.

Association of Reproductive Health Professionals. Fish consumption to promote good health and minimize contaminants. A quick reference guide for clinicians. Washington, DC: ARHP; 2008. Available at: http://www.arhp.org/uploadDocs/ QRGfishandhealth.pdf. Retrieved July 29, 2013.

Bombard JM, Robbins CL, Dietz PM, Valderrama AL. Preconception care: the perfect opportunity for health care providers to advise lifestyle changes for hypertensive women. Am J Health Promot 2013;27:S43-9. [PubMed] [Full Text]

Jack BW, Atrash H, Coonrod DV, Moos MK, O'Donnell J, Johnson K. The clinical content of preconception care: an overview and preparation of this supplement. Am J Obstet Gynecol 2008;199:S266-79. [PubMed] [Full Text]

Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, et al. 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. CDC/ATSDR Preconception Care Work Group, Select Panel on Preconception Care. MMWR Recomm Rep 2006;55:1-23. [PubMed] [Full Text] Kaye K, Suellentrop K, Sloup C. The fog zone: how misperceptions, magical thinking, and ambivalence put young adults at risk for unplanned pregnancy. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2009. Available at: http://thenationalcampaign.org/sites/default/files/ resource-primary-download/FogZone.pdf. Retrieved March 28, 2014.

Lead screening during pregnancy and lactation. Committee Opinion No. 533. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120: 416-20. [PubMed] [Obstetrics & Gynecology]

Mitchell EW, Verbiest S. Effective strategies for promoting preconception health— from research to practice. Am J Health Promot 2013;27:S1-3. [PubMed] [Full Text] Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circula­tion 2011;123:1243-62. [PubMed] [Full Text]

Organization of Teratology Information Specialists. Available at: http://www.moth ertobaby.org. Retrieved July 30, 2013.

Preconception Health Council of California. Interconception care project of California. Available at: http://www.everywomancalifornia.org/content_display. cfm?categoriesID=121&contentID=359. Retrieved July 30, 2013.

Teratology Society. Available at: http://www.teratology.org. Retrieved July 30, 2013. Toriello HV. Policy statement on folic acid and neural tube defects. Policy and Practice Guideline Committee of the American College of Medical Genetics. Genet Med 2011;13:593-6. [PubMed] [Full Text]

TOXNET—Toxicology Data Network. Available at: http://toxnet.nlm.nih.gov. Retrieved July 30, 2013.

University of California, San Francisco. Clinical practice: resources for health care professionals to promote environmental health. Program on Reproductive Health and the Environment. Available at: http://prhe.ucsf.edu/prhe/clinical_resources. html. Retrieved September 27, 2013.