- MS NO: ONG-18-1929

ACOG COMMITTEE OPINION

Number 762

Committee on Gynecologic Practice

American Society for Reproductive Medicine
This Committee Opinion was developed jointly by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice and the
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American Society for Reproductive Medicine in collaboration with committee member Daniel M. Breitkopf, MD and ASRM member Micah Hill, DO.

Prepregnancy Counseling
ABSTRACT: The goal of prepregnancy care is to reduce the risk of adverse health effects for the woman,
fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, and provide
education about healthy pregnancy. All those planning to initiate a pregnancy should be counseled, including
heterosexual, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals.
Counseling can begin with the following question: “Would you like to become pregnant in the next year?”
Prepregnancy counseling is appropriate whether the reproductive-aged patient is currently using contraception
or planning pregnancy. Because health status and risk factors can change over time, prepregnancy counseling
should occur several times during a woman’s reproductive lifespan, increasing her opportunity for education and
potentially maximizing her reproductive and pregnancy outcomes. Many chronic medical conditions such as
diabetes, hypertension, psychiatric illness, and thyroid disease have implications for pregnancy outcomes and
should be optimally managed before pregnancy. Counseling patients about optimal intervals between pregnancies
may be helpful to reduce future complications. Assessment of the need for sexually transmitted infection screen-
ing should be performed at the time of prepregnancy counseling. Women who present for prepregnancy coun-
seling should be offered screening for the same genetic conditions as recommended for pregnant women. All
patients should be routinely asked about their use of alcohol, nicotine products, and drugs, including prescription
opioids and other medications used for nonmedical reasons. Screening for intimate partner violence should occur
during prepregnancy counseling. Female prepregnancy folic acid supplementation should be encouraged to reduce
the risk of neural tube defects.

Recommendations and Conclusions c The goal of prepregnancy care is to reduce the risk
of adverse health effects for the woman, fetus, and
The American College of Obstetricians and Gynecologists
(ACOG) and the American Society for Reproductive neonate by working with the woman to optimize
Medicine (ASRM) make the following recommendations health, address modifiable risk factors, and provide
and conclusions: education about healthy pregnancy.
c Any patient encounter with nonpregnant women or c Women should be counseled to seek medical care
men with reproductive potential (eg, not post- before attempting to become pregnant or as soon as
hysterectomy or poststerilization) is an opportunity they believe they are pregnant to aid in correct
to counsel about wellness and healthy habits, which dating and to be monitored for any medical con-
may improve reproductive and obstetric outcomes ditions in which treatment should be modified
should they choose to reproduce. during pregnancy.
c Counseling can begin with the following question: c Many chronic medical conditions such as diabetes,
“Would you like to become pregnant in the next year?” hypertension, psychiatric illness, and thyroid disease

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 have implications for pregnancy outcomes and nancy visit (when the patient presents to discuss
should be optimally managed before pregnancy. a potential future pregnancy) provides an excellent
c All prescription and nonprescription medications opportunity to counsel patients about maintaining
a healthy lifestyle and minimizing health risks (1). The
should be reviewed during prepregnancy counseling.
goal of prepregnancy care is to reduce the risk of adverse
This review also should include nutritional supple- health effects for the woman, fetus, and neonate by work-
ments and herbal products that patients may not ing with the woman to optimize health, address modifi-
consider to be medication use but could affect able risk factors, and provide education about healthy
reproduction and pregnancy. pregnancy. Prepregnancy counseling should include
c Women who present for prepregnancy counseling a review of a patient’s immunizations, an assessment
should be offered screening for the same genetic for immunity, and other screenings and tests, as appro-
conditions as recommended for pregnant women. priate. All those planning to initiate a pregnancy should
be counseled, including heterosexual, lesbian, gay, bisex-
c Women of reproductive age should have their ual, transgender, queer, intersex, asexual, and gender
immunization status assessed annually for tetanus nonconforming individuals. Pregnancy complications
toxoid, reduced diphtheria toxoid, and acellular may be reduced by appropriate identification and mitiga-
pertussis (Tdap); measles–mumps–rubella; hepatitis tion of risk factors, while genetic screening may allow
B; and varicella. a couple to make informed decisions regarding family
c All patients should receive an annual influenza planning. Management of preexisting medical conditions
vaccination; those women who are or will be preg- may be optimized during the prepregnancy period,
reducing the chances of pregnancy-related complications.
nant during influenza season will have additional
Additionally, understanding aspects of patients’ social
benefits. context during prepregnancy counseling may identify
c Assessment of the need for sexually transmitted ways to help improve prenatal care usage, including
infection (STI) screening should be performed at the understanding barriers that patients may face when ac-
time of prepregnancy counseling. cessing health care.
c Patients with potential exposure to certain infectious
diseases, such as the Zika virus, should be counseled Timing of Prepregnancy Counseling
regarding travel restrictions and appropriate waiting Direct screening for a patient’s pregnancy intentions, as
time before attempting pregnancy. stated in the “One Key Question Initiative,” is a core
component of high-quality, primary preventive care serv-
c All patients should be routinely asked about their ices (2). Any patient encounter with nonpregnant women
use of alcohol, nicotine products, and drugs, or men with reproductive potential (eg, not posthyster-
including prescription opioids and other medi- ectomy or poststerilization) is an opportunity to counsel
cations used for nonmedical reasons. about wellness and healthy habits, which may improve
c Screening for intimate partner violence should occur reproductive and obstetric outcomes should they choose
during prepregnancy counseling. to reproduce. Counseling can begin with the following
question: “Would you like to become pregnant in the next
c Female prepregnancy folic acid supplementation year?” Prepregnancy counseling is appropriate whether
should be encouraged to reduce the risk of neural the reproductive-aged patient is currently using contra-
tube defects (NTDs). ception or planning pregnancy. Because health status and
c Patients should be screened regarding their diet and risk factors can change over time, prepregnancy counsel-
vitamin supplements to confirm they are meeting ing should occur several times during a woman’s repro-
recommended daily allowances for calcium, iron, ductive lifespan, increasing her opportunity for education
and potentially maximizing her reproductive and preg-
vitamin A, vitamin B12, vitamin B, vitamin D, and
nancy outcomes. Additionally, prepregnancy counseling
other nutrients.
can be performed by the obstetrician–gynecologist of an
c Patients should be encouraged to try to attain a body infertile patient before referral to a reproductive endo-
mass index (BMI) in the normal range before at- crinologist, further streamlining patient education. The
tempting pregnancy, because abnormal high or low American College of Obstetricians and Gynecologists and
BMI is associated with infertility and maternal and ASRM support coverage for and access to recommended
fetal pregnancy complications. prepregnancy counseling and services as a core compo-
nent of women’s health care.
Introduction
Obstetrician–gynecologists have a prime opportunity to Family Planning and Pregnancy Spacing
improve maternal and fetal outcomes through prepreg- Family planning is a foundational aspect of prepreg-
nancy counseling. Like a well-woman visit, the prepreg- nancy counseling. Approximately 45% of the pregnancies

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in the United States are unintended, and unintended be optimally managed before pregnancy (Table 1). Con-
pregnancy increases the risk of pregnancy complications sideration may be given to referral to a maternal–fetal
(3). Education and enhanced awareness of the effect of medicine specialist. Data are insufficient to recommend
age on fertility (4) and planning for family size are essen- for or against universal screening for subclinical thyroid
tial in counseling the patient who desires pregnancy. disease; however, screening may be appropriate for pa-
Counseling patients about optimal intervals between tients with risk factors (eg, age greater than 30 years,
pregnancies may be helpful to reduce future complica- morbid obesity, history of pregnancy loss, preterm
tions. Women should be advised to avoid interpregnancy delivery, or infertility) (13).
intervals shorter than 6 months and should be counseled
about the risks and benefits of repeat pregnancy sooner Review of Current Medications
than 18 months (5, 6). Short interpregnancy intervals All prescription and nonprescription medications should
also are associated with reduced vaginal birth after cesar- be reviewed during prepregnancy counseling. This
ean success for women undergoing labor after cesarean review also should include nutritional supplements and
(also referred to as trial of labor after cesarean) (7). The herbal products that patients may not consider to be
Centers for Disease Control and Prevention’s (CDC) U.S. medication use but could affect reproduction and
Medical Eligibility Criteria for Contraceptive Use and U.S. pregnancy. The pregnancy safety of each medication
Selected Practice Recommendations for Contraceptive Use and supplement should be discussed. Medications with
(8, 9) can be used to facilitate evidence-based contracep- potential teratogenicity should be reviewed and the
tion counseling to meet an individual patient’s family specific risks of each individual medication discussed in
planning and pregnancy spacing needs. For infertile detail. The importance of reliable contraception should
women planning to use assisted reproductive technology be emphasized when a patient is taking potentially
to become pregnant, a pregnancy interval less than 18 teratogenic medications. For a patient who desires
months but greater than 6 months may be advisable (10). pregnancy, potentially teratogenic medication should be
An ovulatory woman who is younger than 35 years adjusted in collaboration with the prescribing health care
who desires pregnancy and who does not have a clearly provider before the patient discontinues contraception.
identifiable risk factor for infertility should be expedi- The lowest effective doses of the safest medications
tiously evaluated if she has not become pregnant after 12 should be used whenever it is medically reasonable to
months of unprotected intercourse. A woman who is 36 do so. For information on the effects of medications used
years and older should be evaluated after 6 months. A to manage depression during pregnancy, see The Man-
comprehensive evaluation should be conducted and agement of Depression During Pregnancy, a report jointly
treatment initiated by a heath care provider with developed by ACOG and the American Psychiatric Asso-
adequate training and expertise. For anovulatory women ciation (14). Male partners should be screened for the use
and those with a clearly identifiable risk factor for of androgens, such as testosterone. Androgen use is asso-
infertility, strong consideration should be given to ciated with azoospermia and infertility in males, which
evaluation and treatment upon presentation. may be reversible in some cases with cessation (15, 16).
Referral to a fertility specialist for males and females
may be considered at any point if the infertility etiology, Review of Family and Genetic History
indicated treatment, or attempted treatment failures
exceeds the expertise of the obstetrician–gynecologist. A genetic and family history of the patient and her
Monthly ovulation is likely in women with regular and partner should be obtained (17–20). This may include
predictable menses with no greater than 2–3-day vari- family history of genetic disorders, birth defects, mental
ance within a range of 25–35 days. For example, a woman disorders, and breast, ovarian, uterine, and colon cancer.
with cycles every 26–28 days is likely ovulatory, while When any genetic disease carrier status is diagnosed in
a woman with cycles of 25, 34, 26, then 35 days is likely one or both partners, full medical records review and
not ovulatory. Patients desiring pregnancy should be genetic counseling are recommended to educate the
counseled that the fertile window is having sexual inter- patient on the effects of the disease and the potential
course in the 3–4 days before ovulation and that inter- options for prepregnancy and early pregnancy screening
course every 1–2 days yields the highest pregnancy rates of offspring. Women who present for prepregnancy
(11). Patients may inquire about ovulation predictor kits counseling should be offered screening for the same
or electronic apps for fertility. These tools vary in quality, genetic conditions as recommended for pregnant
and data on their usefulness are limited (12). women, though insurance coverage for screening may
be lacking and may be a barrier for some patients.
Screening in the prepregnancy period offers the addi-
Review of Medical, Surgical, and tional advantages of identifying, before pregnancy, cou-
Psychiatric Histories ples at risk of having children with genetic diseases and
Many chronic medical conditions such as diabetes, offering appropriate testing to optimize patient educa-
hypertension, psychiatric illness, and thyroid disease tion, counseling, and options for achieving pregnancy.
have implications for pregnancy outcomes and should Couples at risk of having children with specific genetic

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 Table 1. Major Medical Conditions That Affect Pregnancy

Condition Associated Risks Treatment Goals

Pregestational Congenital anomalies The importance of euglycemic control HbA1C ,6.5%

diabetes mellitus and pregnancy-related before and during pregnancy should be (48 mmol/mol), to reduce
complications emphasized. Optimal weight management the risk of congenital
also should be discussed in the context of anomalies*
managing blood sugars. Consideration
should be given to testing for underlying
vasculopathy with retinal examination, 24-
hour urine protein testing, and
electrocardiography. Thyroid dysfunction is
common in women with pregestational
diabetes; therefore, screening for thyroid
function should be performed.
Chronic hypertension Preeclampsia and Assessment of the teratogenic risk of —
intrauterine growth hypertensive medications should be
restriction performed. Angiotensin converting enzyme
inhibitors and angiotensin receptor blockers
are contraindicated in pregnancy.
Consideration should be given to testing for
ventricular hypertrophy, retinopathy, and
renal disease for women with longstanding
or uncontrolled hypertension.y
Hypothyroidism Spontaneous abortion, Screening based on risk factors, rather than Treat if thyrotropin
(untreated) preeclampsia, preterm universal screening, should be considered (previously thyroid-
birth, placental for patients who are planning pregnancy.yz stimulating hormone) is
abruption, and fetal above the upper level of
death normal.
Bariatric surgery A period of rapid weight Contraceptive counseling during the —
loss typically occurs in postoperative period is important because
the first 12–24 months the risk of oral contraceptive failure in
postoperatively. During patients who have bariatric surgery with
this period, pregnancy is a malabsorptive component is increased.
less desirable because of Counseling regarding the benefits of
potential effects on fetal nonoral contraceptive or LARC methods is
growth. recommended.§
Mood disorders Impaired maternal infant Women with established depression or —
bonding, risk of maternal anxiety should be counseled regarding the
self-harm, or neglect. risks of these conditions in pregnancy and
Antidepressants and the risks and benefits of treatment. The risk
antipsychotic of relapse for bipolar disorder is higher in
medications increase pregnancy, thus women with this condition
anovulation and should establish a strategy for managing
decrease fecundability.k¶ relapse while planning for a pregnancy.
Women with schizophrenia should receive
counseling regarding the risks of the
condition on pregnancy and the importance
of establishing a plan for managing the
condition during pregnancy.
(Continued )

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 Table 1. Major Medical Conditions That Affect Pregnancy (continued )
Condition Associated Risks Treatment Goals

Human Vertical transmission Women with HIV should receive Viral load should be
immunodeficiency prepregnancy counseling, including undetectable and
virus (HIV) a discussion of interventions to reduce patients should be co-
vertical transmission, methods for managed with an HIV
optimizing long-term health, and the few health care provider.
potential effects of antiretroviral
medications on the fetus.# Antiretroviral
therapy should be instituted before
pregnancy and continued during pregnancy.
Medications should not be discontinued
during the first trimester. Women should
continue seeing their HIV health care
providers.

Serodiscordant couples should receive

information about the risk of sexual and
perinatal transmission and about safer
methods for achieving pregnancy.**

Women at the highest risk of acquiring HIV

infection (eg, a woman not infected with
HIV with a male sexual partner who is
known to be infected with HIV) should be
considered candidates for preexposure
prophylaxis. The use of daily oral
preexposure prophylaxis during pregnancy
and lactation for women without HIV with
HIV-infected partners has had limited study;
however, the drug combination of tenofovir
and emtricitabine is commonly used during
pregnancy and has a reassuring safety
profile.yy
Thrombophilia DVT or PE during Consider and plan for thromboprophylaxis —
pregnancy or in the during pregnancy.zz
postpartum period
Previous pregnancy Recurrence in future Assess and counsel on risk of recurrence. —
complications pregnancies
Abbreviations: DVT, deep vein thrombosis; HbA1C, hemoglobin A1 ; HIV, human immunodeficiency virus; LARC, long-acting reversible contraception; PE, pulmonary embolism.
C

*Management of diabetes in pregnancy: standards of medical care in diabetes—2018. American Diabetes Association. Diabetes Care 2018;41:S137–43.
y
Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association
of Clinical Endocrinologists and the American Thyroid Association. American Association of Clinical Endocrinologists and American Thyroid Association Taskforce on
Hypothyroidism in Adults. [published errata appear in Thyroid 2013;23:251; Thyroid 2013;23:129]. Thyroid 2012;22:1200–35.
z
Subclinical hypothyroidism in the infertile female population: a guideline. Practice Committee of the American Society for Reproductive Medicine. Fertil Steril 2015;104:545–53.
§
Bariatric surgery and pregnancy. ACOG Practice Bulletin No. 105. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:1405–13.
k
Casilla-Lennon MM, Meltzer-Brody S, Steiner AZ. The effect of antidepressants on fertility. Am J Obstet Gynecol 2016;215:314.e1–5.
¶
Besnard I, Auclair V, Callery G, Gabriel-Bordenave C, Roberge C. Antipsychotic-drug-induced hyperprolactinemia: physiopathology, clinical features and guidance. Encephale
2014;40:86–94.
#
Gynecologic care for women and adolescents with human immunodeficiency virus. Practice Bulletin No. 167. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2016;128:e89–110.
**
Recommendations for reducing the risk of viral transmission during fertility treatment with the use of autologous gametes: a committee opinion. Practice Committee of
American Society for Reproductive Medicine. Fertil Steril 2013;99:340–6.
yy
Preexposure prophylaxis for the prevention of human immunodeficiency virus. Committee Opinion No. 595. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2014;123:1133–6.
zz
Inherited thrombophilias in pregnancy. Practice Bulletin No. 138. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:706–17.

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diseases can be counseled about the disease inheritance cancer screening should be performed in accordance
and course and offered referral for potential interven- with current guidelines. The HPV vaccination currently
tions, such as preimplantation genetic testing. See Table 2 is not recommended during pregnancy but should not be
for counseling and screening recommendations. avoided or delayed because a woman may want to
become pregnant or may be actively trying to become
Immunizations pregnant. If the HPV vaccine series is started and
Women of reproductive age should have their immuni- a patient then becomes pregnant, completion of the
zation status assessed annually for Tdap, measles– vaccine series should be delayed until that pregnancy is
mumps–rubella, hepatitis B, and varicella. All patients completed (22, 23). Vaccinations for rubella and varicella
should receive an annual influenza vaccination; those should be given at least 28 days before pregnancy, or in
women who are or will be pregnant during influenza the postpartum period if not previously given. Because
season will have additional benefits (21). Adult women two doses of the varicella vaccine are recommended, and
who have never received a dose of Tdap or whose Tdap the CDC recommends that women not become pregnant
vaccination status is unknown should receive a single for 1 month after being vaccinated, a woman who desires
dose, as recommended for nonpregnant adults by the pregnancy should begin vaccination 2 months before
CDC. Additionally, Tdap vaccine should be given to all attempting pregnancy (24). Some advanced-
women during each pregnancy between 27–36 weeks reproductive-age patients may wish to reproduce, and
regardless of prepregnancy immunization history. those age 50 years and older should also be vaccinated
Human papillomavirus vaccination (HPV) and cervical against herpes zoster (25). The need for other immuni-

Table 2. Family and Genetic History Counseling and Screening Recommendations

Condition Who to Counsel Considerations

Canavan disease Carrier screening for those of Ashkenazi Jewish —

descent.

When only one partner is of Ashkenazi Jewish

descent, that individual should be offered screening
first. If it is determined that this individual is a carrier,
the other partner should be offered screening.*
Cystic fibrosis All women who are considering pregnancy* —
Familial Carrier screening for those of Ashkenazi Jewish —
dysautonomia descent.

When only one partner is of Ashkenazi Jewish

descent, that individual should be offered screening
first. If it is determined that this individual is a carrier,
the other partner should be offered screening.*
Fragile X Any woman with a family history of fragile X-related Women without risk factors who request fragile X
disorders or intellectual disability suggestive of fragile screening may be tested after informed consent.
X syndrome and any woman younger than the age of
40 with unexplained ovarian insufficiency.*
Hemoglobinopathies Couples at risk of having a child with thalassemia or —
sickle cell disease should be offered genetic
counseling to review prenatal testing and reproduction
options.y
Spinal muscular All women who are considering pregnancy —
atrophy
Tay–Sachs disease If either member of the couple is of Ashkenazi Jewish, Biochemical testing can be altered in women who are
French-Canadian, or Cajun descent; those with pregnant or using oral contraceptive pills, so leukocyte
a family history consistent with Tay-Sachs disease testing must be used in these patients.*
also should be offered screening.*
*Carrier screening for genetic conditions. Committee Opinion No. 691. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e41–55.
y
Hemoglobinopathies in pregnancy. Practice Bulletin No. 78. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:229–37.

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zations should be assessed during a prepregnancy visit by additional tool to reduce the risk of sexual transmission
reviewing health, lifestyle, and occupational risks of other (38). A non-HIV-infected woman with an HIV-infected
infections and administering required doses as indicated male partner with whom she wants to achieve pregnancy
(26). The CDC’s Advisory Committee on Immunization should be offered a referral to a subspecialist with the
Practice immunization schedules provide the most cur- requisite training and experience in infectious disease or
rent information on immunization recommendations reproductive endocrinology and infertility for counsel-
(27). ing. Like prepregnancy counseling for non-HIV-
infected women, the goals for HIV-infected women are
Infectious Disease Screening to improve the health of the women before pregnancy
Assessment of the need for STI screening should be and to identify risk factors for adverse maternal and fetal
performed at the time of prepregnancy counseling. outcomes. Safe sex practices and avoidance of STIs
Guidance on recommended STI screening is available should be discussed, and both partners should be
from the CDC (28) and ASRM (29). Gonorrhea, chla- screened for STIs, which should be treated if present.
mydial infection, syphilis, and human immunodeficiency The choice of antiretroviral therapy in women of child-
virus (HIV) should be screened for based on age and risk bearing capacity should take into consideration the regi-
factors. Counseling to reduce STI risk should be pro- men’s effectiveness, the women’s hepatitis B status, the
vided (26). For current guidance on hepatitis C screening teratogenic potential of the medications, potential drug
for nonpregnant women, see the CDC’s recommenda- interactions, and possible maternal and fetal adverse out-
tions (30). Those at high risk of tuberculosis should be comes (37). See ACOG’s Practice Bulletin No. 167, Gyne-
screened and treated appropriately before pregnancy cologic Care for Women and Adolescents With Human
(26). Exposure to toxoplasmosis should be assessed and Immunodeficiency Virus, for more information.
avoidance counseled. Much attention has been given to
educational programs to reduce maternal Toxoplasma
gondii infection and, thus, congenital toxoplasmosis. Substance Use Assessment
However, despite the successes demonstrated in some All patients should be routinely asked about their use of
observational studies, several reviews (including a Co- alcohol, nicotine products, and drugs, including pre-
chrane review) suggest that weaknesses in study design scription opioids and other medications used for non-
prevent the conclusion that such strategies effectively medical reasons (39, 40). Adverse effects associated with
reduce congenital toxoplasmosis (31). Patients with smoking during pregnancy include intrauterine growth
potential exposure to certain infectious diseases, such restriction, placenta previa, abruptio placentae, decreased
as the Zika virus, should be counseled regarding travel maternal thyroid function (41, 42), preterm prelabor
restrictions and appropriate waiting time before attempt- rupture of membranes (also referred to as premature
ing pregnancy. Obstetrician–gynecologists may ask the rupture of membranes) (43, 44), low birth weight, peri-
patient about recent or upcoming travel history for natal mortality (41), and ectopic pregnancy (41). Chil-
herself and her partner. The CDC offers up-to-date guid- dren born to women who smoke during pregnancy are at
ance on Zika precautions (32) and other infectious dis- an increased risk of asthma, infantile colic, and child-
eases (33). Information and guidance on the Zika virus hood obesity (45–47). Pregnancy appears to motivate
also is available from ACOG (34) and ASRM (35). women to stop smoking; 46% of prepregnancy smokers
quit smoking directly before or during pregnancy (48);
Individuals with Human however, women who are unable to quit during preg-
Immunodeficiency Virus nancy likely have a tobacco use disorder (49). Effective
All reproductive-aged patients living with HIV should strategies for tobacco cessation should be employed, such
receive prepregnancy counseling if considering preg- as the 5A’s intervention model (40).
nancy (36). Prepregnancy counseling should include Alcohol use patterns should be determined and
a detailed discussion of interventions to reduce the risk patients counseled that there is no safe level or type of
of perinatal transmission, ways to optimize long-term alcohol use during pregnancy. Fetal alcohol spectrum
health, and the possible effects of antiretroviral medica- disorders are the most severe result of prenatal drinking
tions on the fetus. Any HIV-infected patients who are and are associated with central nervous system abnor-
contemplating pregnancy should be counseled that they malities, growth defects, and facial dysmorphia. Alcohol-
should be receiving treatment with antiretroviral therapy, related birth defects include growth deformities, facial
with the goal of a plasma viral load suppressed to an abnormalities, central nervous system impairment,
undetectable level before achieving pregnancy. Artificial behavioral disorders, and impaired intellectual develop-
insemination is the safest way for an HIV-infected cou- ment (50). Alcohol can affect a fetus at any stage of
ple to become pregnant while minimizing the risk of pregnancy, and the cognitive defects and behavioral
HIV transmission to an HIV-negative partner (37). Pre- problems that result from prenatal alcohol exposure are
pregnancy administration of antiretroviral preexposure lifelong. Brief behavioral counseling interventions can
prophylaxis for HIV-uninfected partners may offer an reduce the risk of alcohol-exposed pregnancies (50–52).

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 Marijuana is used by an estimated 2–5% of pregnant pregnancy with an NTD or women with seizure disor-
women. Several states have recently legalized marijuana ders, should be counseled to take 4 mg of folic acid daily
for recreational use or medicinal purposes. Marijuana (57). Because of the risk of vitamin A toxicity, women
may have harmful effects on reproduction and the effect who need additional folic acid should not take additional
of smoking marijuana during pregnancy may be as prenatal vitamins; instead, women at higher risk of
harmful as tobacco (53). Patients who are contemplating NTDs should be prescribed additional folic acid supple-
pregnancy should be encouraged to discontinue mari- ments. Most prenatal multivitamins contain adequate
juana use. Patients contemplating pregnancy should be amounts of folic acid for average-risk-women (58). Pre-
screened for opioid use and opioid use disorder. See natal vitamins use also is associated with a lower risk of
ACOG Committee Opinion No. 711, Opioid Use and miscarriage (59). Moderate caffeine consumption (less
Opioid Use Disorder in Pregnancy, for validated screen- than 200 mg per day) does not appear to be a major
ing tools, such as questionnaires, including 4Ps, NIDA contributing factor in miscarriage or preterm birth (60).
Quick Screen, and CRAFFT (for women 26 years or Patients should be screened regarding their diet and
younger) (39). vitamin supplements to confirm they are meeting
recommended daily allowances for calcium, iron, vita-
Exposure to Violence, Intimate Partner min A, vitamin B12, vitamin B, vitamin D, and other
Violence, and Reproductive and nutrients. The U.S. Department of Agriculture offers
Sexual Coercion tools for self-dietary assessment (61), and the Office of
More than one in three women in the United States have Disease Prevention and Health Promotion offers clinical
experienced rape, physical violence, or stalking by an guidance (62). Recommended daily allowances are avail-
intimate partner in their lifetime (54). Screening for inti- able in Guidelines for Perinatal Care, Eighth Edition,
mate partner violence should occur during prepregnancy from ACOG and the American Academy of Pediatrics
counseling. The discussion regarding intimate partner (63). Consumption of fish with high mercury levels
violence should be framed by indicating that all patients should be discouraged (64, 65) and the U.S. Food and
in the practice are screened. Assurances of privacy and Drug Administration provides a patient resource for fish
confidentiality are important components of intimate to avoid (66). Maternal listeria infection has been asso-
partner violence screening; however, some state laws ciated with preterm delivery and other obstetric and neo-
place mandatory reporting requirements on health care natal complications, and pregnant women should be
providers for certain types of injuries or disclosures and advised to avoid eating foods with a high risk of listeria
for certain groups of patients. Therefore, it also is impor- contamination. See the CDC guidance for foods to avoid
tant to inform patients about what it is necessary, under (67). Patients who are at risk of eating disorders should
state laws, for physicians to disclose to authorities. Sam- be screened and counseled (63). Patients with malab-
ple questions to begin the conversation are provided in sorptive gastrointestinal disease, bariatric surgery, or
ACOG Committee Opinion No. 518, Intimate Partner those on a vegan diet may require vitamin and mineral
Violence (54). Self-administered questionnaires are as supplementation.
effective as a physician interview in screening for inti-
mate partner violence and reproductive coercion. Sexual
coercion includes a range of behavior that a partner may Achieving and Maintaining a Healthy
use related to sexual decision making to pressure or Body Weight
coerce a person to have sex without using physical force Patients should be encouraged to try to attain a BMI in
(55). The most common forms of reproductive coercion the normal range before attempting pregnancy because
include sabotage of contraceptive methods, pregnancy abnormal high or low BMI is associated with infertility
coercion, and pregnancy pressure (56). If ongoing abuse and maternal and fetal pregnancy complications (68).
is identified, assessment of the immediate safety of the The reproductive risks of obesity include, but are not
patient and her family should be ascertained and com- limited to, infertility, miscarriage, birth defects, preterm
munity resources for victims should be provided. delivery, gestational diabetes, gestational hypertension,
cesarean delivery, and thromboembolic events (69, 70).
Assess Nutritional Status Obesity also increases the risk of nonreproductive dis-
Fruits, vegetables, and daily multivitamins are good eases, including stroke, heart disease, certain types of
sources of antioxidants and vitamins that may assist in cancer, arthritis, high cholesterol, hypertension, and dia-
reproductive health for males and females. Female betes (71). Pregnant women with low BMI are at risk of
prepregnancy folic acid supplementation should be having small-for-gestational-age fetuses and low-birth-
encouraged to reduce the risk of NTDs. All women of weight infants (72). Ideally, weight should be optimized
reproductive age (15–45 years) should take folic acid before a woman attempts to becoming pregnant (70),
supplementation. For average-risk women, supplementa- although the health benefits of postponing pregnancy
tion with 400 micrograms per day is adequate. Women need to be balanced against reduced fecundity with
at increased risk of NTDs, including women with a prior female aging (4, 69).

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Assess Exercise and Physical Activity care providers, and patients. You may view these resources
Regular physical exercise improves cardiovascular health, at www.acog.org/More-Info/PrepregnancyCounseling.
reduces obesity and associated medical comorbidities, These resources are for information only and are not
and improves longevity. Patients should exercise mod- meant to be comprehensive. Referral to these resources
erately at least 30 minutes a day, 5 days a week, for does not imply the American College of Obstetricians
a minimum of 150 minutes of moderate exercise per and Gynecologists’ endorsement of the organization, the
week (73). These levels of exercise are recommended organization’s website, or the content of the resource.
prepregnancy, during pregnancy, and in postpartum The resources may change without notice.
women. Dietary modifications in concert with exercise
produce greater weight loss than exercise alone (73). References
Compared with their nonathlete peers, competitive ath- 1. Well-woman visit. ACOG Committee Opinion No. 755.
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and Gynecologists. Published by Wolters Kluwer Health, Inc.
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71. Challenges for overweight and obese women. Committee be reproduced, stored in a retrieval system, posted on the Internet,
or transmitted, in any form or by any means, electronic, mechanical,
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voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It
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reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or
advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
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