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Get healthy, then get pregnant

Special to The Times

In this country, the first prenatal visit is traditionally not scheduled until at least 8 weeks after conception. By that time, many irreversible problems may have already developed because most of the body’s vital organs are formed within the first few weeks of pregnancy.

“By the time women see a doctor, the horse is already out of the barn,” says Dr. Peter Bernstein, a maternal and fetal medicine specialist at Montefiore Medical Center in New York. “Pregnancy planning and care should begin months before a couple tries to conceive.”

Many experts believe that this late start might explain why poor pregnancy outcomes continue to be a problem in the U.S. despite dramatic improvements in prenatal care over the last two decades. Each year, close to 500,000 babies are delivered prematurely and 120,000 are born with major birth defects.

Last year, the Centers for Disease Control and Prevention (CDC) convened a panel of experts in maternal and fetal medicine to formulate recommendations for preconception health and care. The results, published in the CDC’s journal Morbidity and Mortality Weekly Report in April, provide some general guidelines for women and their medical care providers to follow.

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The panel’s recommendations stress the importance of individual responsibility, encouraging every woman, man and couple to have a “reproductive life plan” and noting that unintended pregnancies allow no opportunity for preconception care. Unfortunately, in the U.S., approximately half of all pregnancies are unplanned. “Every pregnancy should be a planned pregnancy,” says Bernstein, who was a member of the panel.

Bernstein adds that pregnancies should not only be planned, they should be planned with a doctor or other healthcare provider. That way, an appropriate action plan can be developed.

Many problems can be avoided by simply ensuring that women and couples are in better health before they get pregnant and have established healthier lifestyles, the panel concluded. Later this month, it will reconvene to identify specific strategies to achieve this. But some interventions are so logical -- and already so well-supported by science -- that there is no reason to wait for the panel’s go-ahead to begin implementing them.

The most obvious: Women who smoke should quit before getting pregnant. In spite of the fact that smoking slows fetal growth and nearly doubles the risk of having a low birth-weight baby, only one in five women who smoke successfully kicks the habit during pregnancy. The U.S. Public Health Service estimates that the number of stillbirths would fall by 11%, and the number of newborn deaths by 5%, if all pregnant women in this country stopped smoking.

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Another measure: Any woman who could become pregnant should take a multivitamin containing folic acid, a B vitamin that helps prevent potentially life-threatening abnormalities of the brain and spinal cord. Studies show that if all women consumed adequate amounts of folic acid before and during early pregnancy, up to 70% of these defects could be prevented.

Before becoming pregnant, every woman should also be tested for immunity to rubella. A highly contagious viral illness, rubella poses a serious threat to a fetus if a woman becomes infected during pregnancy. A vaccine administered at least one month prior to conception can eliminate all risk of infection.

Screening for immunity to varicella, the virus that causes chickenpox, should also be performed, and susceptible women should be vaccinated. Varicella infections early in pregnancy can cause serious birth defects; later in pregnancy, they can lead to life-threatening chickenpox infections in newborns.

A woman who is significantly overweight should lose weight before trying to conceive. Obesity dramatically increases a woman’s risk of delivering prematurely and experiencing complications during labor and delivery. Infants of obese women are at substantially higher risk for birth defects, such as heart and spinal cord abnormalities.

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Whenever possible, a woman taking any medication that could be damaging to a developing fetus should discontinue taking the drug. The acne medication Accutane (isotretinoin) is the most obvious example. Known to cause severe birth defects if taken during the first weeks after conception, the drug must be stopped at least one month before conceiving.

But other drugs such as statins, used to lower cholesterol, and ACE inhibitors, used to reduce blood pressure, are also potentially risky. When medications cannot be stopped completely, potentially risky drugs should be substituted with safer ones whenever possible.

Finally, a woman with any medical condition that can adversely affect pregnancy should not wait until she is pregnant to get the problem under optimal control. Women with diabetes, for instance, can reduce their risk of stillbirth, miscarriage and birth defects by starting pregnancy with their blood sugar under good control; women infected with HIV can significantly reduce the risk of transmitting the virus to their fetus if they are properly treated throughout pregnancy.

Although it sounds somewhat counterintuitive, contraception is also a key component of preconception care. The first step in trying to have a healthy baby is not getting pregnant when you least expect it.

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