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 39 40. Adverse effects associated with smoking during pregnancy include intrauterine growth restriction, placenta previa, abruptio placentae, decreased maternal thyroid function 41 42, preterm prelabor rupture of membranes (also referred to as premature rupture of membranes) 43 44, low birth weight, perinatal mortality 41, and ectopic pregnancy 41. Children born to women who smoke during pregnancy are at an increased risk of asthma, infantile colic, and childhood obesity 45 46 47. Pregnancy appears to motivate women to stop smoking; 46% of prepregnancy smokers quit smoking directly before or during pregnancy 48; however, women who are unable to quit during pregnancy likely have a tobacco use disorder 49. Effective strategies for tobacco cessation should be employed, such as the 5A's intervention model 40.
Alcohol use patterns should be determined and patients counseled that there is no safe level or type of alcohol use during pregnancy. Fetal alcohol spectrum disorders are the most severe result of prenatal drinking and are associated with central nervous system abnormalities, growth defects, and facial dysmorphia. Alcohol-related birth defects include growth deformities, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development 50. Alcohol can affect a fetus at any stage of pregnancy, and the cognitive defects and behavioral problems that result from prenatal alcohol exposure are lifelong. Brief behavioral counseling interventions can reduce the risk of alcohol-exposed pregnancies 50 51 52.
Marijuana is used by an estimated 2–5% of pregnant women. Several states have recently legalized marijuana for recreational use or medicinal purposes. Marijuana may have harmful effects on reproduction and the effect of smoking marijuana during pregnancy may be as harmful as tobacco 53. Patients who are contemplating pregnancy should be encouraged to discontinue marijuana use. Patients contemplating pregnancy should be screened for opioid use and opioid use disorder. See ACOG Committee Opinion No. 711, Opioid Use and Opioid Use Disorder in Pregnancy , for validated screening tools, such as questionnaires, including 4Ps, NIDA Quick Screen, and CRAFFT (for women 26 years or younger) 39.
More than one in three women in the United States have experienced rape, physical violence, or stalking by an intimate partner in their lifetime 54. Screening for intimate partner violence should occur during prepregnancy counseling. The discussion regarding intimate partner violence should be framed by indicating that all patients in the practice are screened. Assurances of privacy and confidentiality are important components of intimate partner violence screening; however, some state laws place mandatory reporting requirements on health care providers for certain types of injuries or disclosures and for certain groups of patients. Therefore, it also is important to inform patients about what it is necessary, under state laws, for physicians to disclose to authorities. Sample questions to begin the conversation are provided in ACOG Committee Opinion No. 518, Intimate Partner Violence 54. Self-administered questionnaires are as effective as a physician interview in screening for intimate partner violence and reproductive coercion. Sexual coercion includes a range of behavior that a partner may use related to sexual decision making to pressure or coerce a person to have sex without using physical force 55. The most common forms of reproductive coercion include sabotage of contraceptive methods, pregnancy coercion, and pregnancy pressure 56. If ongoing abuse is identified, assessment of the immediate safety of the patient and her family should be ascertained and community resources for victims should be provided.
Fruits, vegetables, and daily multivitamins are good sources of antioxidants and vitamins that may assist in reproductive health for males and females. Female prepregnancy folic acid supplementation should be encouraged to reduce the risk of NTDs. All women of reproductive age (15–45 years) should take folic acid supplementation. For average-risk women, supplementation with 400 micrograms per day is adequate. Women at increased risk of NTDs, including women with a prior pregnancy with an NTD or women with seizure disorders, should be counseled to take 4 mg of folic acid daily 57. Because of the risk of vitamin A toxicity, women who need additional folic acid should not take additional prenatal vitamins; instead, women at higher risk of NTDs should be prescribed additional folic acid supplements. Most prenatal multivitamins contain adequate amounts of folic acid for average-risk-women 58. Prenatal vitamins use also is associated with a lower risk of miscarriage 59. Moderate caffeine consumption (less than 200 mg per day) does not appear to be a major contributing factor in miscarriage or preterm birth 60.
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.
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