Patients should be screened regarding their diet and vitamin supplements to confirm they are meeting recommended daily allowances for calcium, iron, vitamin A, vitamin B12, vitamin B, vitamin D, and other nutrients. The U.S. Department of Agriculture offers tools for self-dietary assessment 61, and the Office of Disease Prevention and Health Promotion offers clinical guidance 62. Recommended daily allowances are available in Guidelines for Perinatal Care, Eighth Edition , from ACOG and the American Academy of Pediatrics 63. Consumption of fish with high mercury levels should be discouraged 64 65 and the U.S. Food and Drug Administration provides a patient resource for fish to avoid 66. Maternal listeria infection has been associated with preterm delivery and other obstetric and neonatal complications, and pregnant women should be advised to avoid eating foods with a high risk of listeria contamination. See the CDC guidance for foods to avoid 67. Patients who are at risk of eating disorders should be screened and counseled 63. Patients with malabsorptive gastrointestinal disease, bariatric surgery, or those on a vegan diet may require vitamin and mineral supplementation.
Patients should be encouraged to try to attain a BMI in the normal range before attempting pregnancy because abnormal high or low BMI is associated with infertility and maternal and fetal pregnancy complications 68. The reproductive risks of obesity include, but are not limited to, infertility, miscarriage, birth defects, preterm delivery, gestational diabetes, gestational hypertension, cesarean delivery, and thromboembolic events 69 70. Obesity also increases the risk of nonreproductive diseases, including stroke, heart disease, certain types of cancer, arthritis, high cholesterol, hypertension, and diabetes 71. Pregnant women with low BMI are at risk of having small-for-gestational-age fetuses and low-birth-weight infants 72. Ideally, weight should be optimized before a woman attempts to becoming pregnant 70, although the health benefits of postponing pregnancy need to be balanced against reduced fecundity with female aging 4 69.
Regular physical exercise improves cardiovascular health, reduces obesity and associated medical comorbidities, and improves longevity. Patients should exercise moderately at least 30 minutes a day, 5 days a week, for a minimum of 150 minutes of moderate exercise per week 73. These levels of exercise are recommended prepregnancy, during pregnancy, and in postpartum women. Dietary modifications in concert with exercise produce greater weight loss than exercise alone 73. Compared with their nonathlete peers, competitive athletes require frequent and closer supervision because they tend to maintain a more strenuous training schedule throughout pregnancy and resume high-intensity postpartum training sooner. Competitive athletes should pay particular attention to avoiding hyperthermia, maintaining proper hydration, and sustaining adequate caloric intake to prevent weight loss that may adversely affect fetal growth 73.
Mounting and robust evidence suggests there are reproductive and pregnancy risks associated with environmental pollutants, workplace teratogens, and endocrine disruptors. By the time a woman presents with pregnancy, disruptions of organogenesis may have already occurred. For these reasons, prepregnancy patient history and identification of exposures are encouraged 74. If exposures are identified, patients can be educated regarding the avoidance of exposure to toxic agents and, when necessary, referred to occupational medicine programs. Exposures can occur both at home (eg, plastics with bisphenol-A, pesticides, lead paint, asbestos) and at work. Employment sectors at particular risk of potentially hazardous exposures during pregnancy include agriculture (pesticides), manufacturing (organic solvents and heavy metals), dry cleaning (solvents), and health care (biologics and radiation) 75. See the For More Information section for additional resources.
Women should be counseled to seek medical care before attempting to become pregnant or as soon as they believe they are pregnant to aid in correct dating and to be monitored for any medical conditions in which treatment should be modified during pregnancy. Correct first-trimester pregnancy dating provides value in managing potential subsequent pregnancy complications and indications for delivery.
The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/PrepregnancyCounseling .
These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the organization, the organization's website, or the content of the resource. The resources may change without notice.
Curtis KM , Tepper NK , Jatlaoui TC , Berry-Bibee E , Horton LG , Zapata LB , et al . U.S. medical eligibility criteria for contraceptive use, 2016 . MMWR Recomm Rep 2016 ; 65 : 1 – 104 .
Curtis KM , Jatlaoui TC , Tepper NK , Zapata LB , Horton LG , Jamieson DJ , et al . U.S. selected practice recommendations for contraceptive use, 2016 . MMWR Recomm Rep 2016 ; 65 : 1 – 66 .
Quinn MM , Rosen MP , Allen IE , Huddleston HG , Cedars MI , Fujimoto VY . Decreased clinical pregnancy and live birth rates after short interval from delivery to subsequent assisted reproductive treatment cycle . Hum Reprod 2018 ; 33 : 1316 – 21 .
Alexander EK , Pearce EN , Brent GA , Brown RS , Chen H , Dosiou C , et al . 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum . Thyroid 2017 ; 27 : 315 – 89 .
Yonkers KA , Wisner KL , Stewart DE , Oberlander TF , Dell DL , Stotland N , et al . The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists . Obstet Gynecol 2009 ; 114 : 703 – 13 .
Samplaski MK , Loai Y , Wong K , Lo KC , Grober ED , Jarvi KA . Testosterone use in the male infertility population: prescribing patterns and effects on semen and hormonal parameters . Fertil Steril 2014 ; 101 : 64 – 9 .
American Society for Reproductive Medicine . Choosing wisely: don’t prescribe testosterone or testosterone products to men contemplating/attempting to initiate pregnancy . Philadelphia (PA) : ABIM Foundation ; 2015 . Available at: http://www.choosingwisely.org/clinician-lists/asrm-testosterone-to-initiate-pregnancy . Retrieved August 21, 2018.
Markowitz LE , Dunne EF , Saraiya M , Chesson HW , Curtis CR , Gee J , et al . Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention (CDC) [published erratum appears in MMWR Recomm Rep 2014;63:1182] . MMWR Recomm Rep 2014 ; 63 ( RR-05 ): 1 – 30 .
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 .
Workowski KA , Bolan GA . Sexually transmitted diseases treatment guidelines, 2015. Centers for Disease Control and Prevention [published erratum appears in MMWR Recomm Rep 2015;64:924] . MMWR Recomm Rep 2015 ; 64 ( RR-03 ): 1 – 137 .
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 .
Cytomegalovirus, parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. Practice Bulletin No. 151. American College of Obstetricians and Gynecologists [published erratum appears in Obstet Gynecol 2016;127:405] . Obstet Gynecol 2015 ; 125 : 1510 – 25 .
Dr Eliran MorAmerican College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine . Practice advisory interim guidance for care of obstetric patients during a Zika virus outbreak . Washington, DC : ACOG; SMFM , 2018 . Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak . Retrieved September 13, 2018.
American Society of Reproductive Medicine . Guidance for providers caring for women and men of reproductive age with possible Zika virus exposure . Birmingham (AL) : ASRM ; 2017 . Available at: http://www.asrm.org/globalassets/asrm/asrm-content/news-and-publications/practice-guidelines/for-non-members/guidance_for_providers_zika_virus_exposure.pdf . Retrieved June 20, 2018.
Panel on treatment of pregnant women with HIV infection and prevention of perinatal transmission. Recommendations for use of antiretroviral drugs in transmission in the United States . Rockville (MD) : Department of Health and Human Services ; 2015 . Available at: https://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf . Retrieved June 20, 2018.
Centers for Disease Control and Prevention . U.S. Public Health Service: preexposure prophylaxis for the prevention of HIV infection in the United States – 2017 update. A clinical practice guideline . Atlanta (GA) : CDC ; 2017 . Available at: https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf . Retrieved June 20, 2018.
U.S. Surgeon General . The health consequences of smoking—50 years of progress: a report of the Surgeon General, 2014 . Washington, DC : U.S. Department of Health and Human Services ; 2014 . Available at: https://www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html . Retrieved June 20, 2018.
McDonald SD , Walker MC , Ohlsson A , Murphy KE , Beyene J , Perkins SL . The effect of tobacco exposure on maternal and fetal thyroid function . Eur J Obstet Gynecol Reprod Biol 2008 ; 140 : 38 – 42 .
Spinillo A , Nicola S , Piazzi G , Ghazal K , Colonna L , Baltaro F . Epidemiological correlates of preterm premature rupture of membranes . Int J Gynaecol Obstet 1994 ; 47 : 7 – 15 .
Carson G , Cox LV , Crane J , Croteau P , Graves L , Kluka S , et al . Alcohol use and pregnancy consensus clinical guidelines. Society of Obstetricians and Gynaecologists of Canada . J Obstet Gynaecol Can 2010 ; 32 : S1 – 31 .
Chamberlain L , Levenson R . Addressing intimate partner violence, reproductive and sexual coercion: a guide for obstetric, gynecologic and reproductive health care settings . 2nd ed . Washington, DC : American College of Obstetricians and Gynecologists ; San Francisco (CA) : Futures Without Violence ; 2012 . Available at: https://www.futureswithoutviolence.org/userfiles/file/HealthCare/reproguidelines_low_res_FINAL.pdf . Retrieved June 20, 2018.
Frayne DJ , Verbiest S , Chelmow D , Clarke H , Dunlop A , Hosmer J , et al . Health care system measures to advance preconception wellness: consensus recommendations of the clinical workgroup of the National Preconception Health and Health Care Initiative . Obstet Gynecol 2016 ; 127 : 863 – 72 .
Buck Louis GM , Sapra KJ , Schisterman EF , Lynch CD , Maisog JM , Grantz KL , et al . Lifestyle and pregnancy loss in a contemporary cohort of women recruited before conception: The LIFE Study . Fertil Steril 2016 ; 106 : 180 – 8 .
American Academy of Pediatrics, American College of Obstetricians and Gynecologists . Guidelines for perinatal care . 8th ed . Elk Grove Village (IL) : AAP ; Washington, DC : American College of Obstetricians and Gynecologists ; 2017 .
American College of Obstetricians and Gynecologists . Update on seafood consumption during pregnancy. ACOG Practice Advisory . Washington, DC : American College of Obstetricians and Gynecologists ; 2017 . Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/ACOG-Practice-Advisory-Seafood-Consumption-During-Pregnancy . Retrieved June 20, 2018.
Yu Z , Han S , Zhu J , Sun X , Ji C , Guo X . Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta-analysis . PLoS One 2013 ; 8 : e61627 .
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This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is 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 is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the 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 publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.