At Your Fingertips (Desires Pregnancy) - Before, Between & Beyond Pregnancy

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Components of Care	Key Questions/Assessments	Key Recommendations/Patient Education Supports

Family Planning Guidance	Would you like to become pregnant in the next year? (woman indicates “yes”)	• Based on desires regarding timing of pregnancy and issues you and patient agree should be addressed prior to conception, provide appropriate family planning guidance. • If relevant, educate about safest interpregnancy intervals (18-59 months). • Refer to Family Planning Guidance link for more detailed guidance
Nutrition	BMI Assess use of Folic Acid and other nutritional supplementation.	• Counsel about advantages of achieving weight as close as possible to ideal BMI (18.5-24.9) and specific risks of underweight and obesity to overall health and to future pregnancies. • Recommend a varied, balanced diet and a multivitamin with at least 400 mcg folic acid for daily use (even if pregnancy plans are uncertain or change). • Refer to Nutrition link for more detailed guidance
Infectious Disease Status and Immunizations	Review immunization status Assess risks for, at a minimum, influenza, Hepatitis B, rubella, varicella, tuberculosis, HIV, HPV	• Offer Hepatitis B, HPV, Rubella, Varicella and COVID-19 immunizations, as indicated (if decision made to administer live vaccines, caution against conception for appropriate interval). • Test for infectious diseases listed on left, as indicated and provide counseling on risk reduction behaviors. • Refer to Infectious Disease Status and Immunizations link for more detailed guidance
Chronic Diseases	Review patient history for evidence of chronic disease (e.g. hypertension, diabetes, seizure disorder, etc.).	• Provide education on implications of the disease for her own health, the effects of pregnancy on the disease, and the effects of the disease on pregnancy/ fetal/ neonatal outcomes. • Evaluate target organs affected by disease (e.g. kidneys in diabetes). • Strive for optimal control with fewest/safest medications. • Enlist specialists (e.g. maternal-fetal medicine, internists) for guidance. • Refer to Chronic Diseases link for more detailed guidance
Medications	Assess prescription, OTC and herbal medication profile.	• Help woman achieve safest medication profile prior to conception (may require working with other specialists to achieve—e.g. mental health, internists, dermatologists, etc.). • For essential medication, aim for the choice(s) that balance optimal effectiveness with lowest teratogenic potential at the lowest effective dose. • Stress that herbal products are not required to be tested for safety in and around pregnancy. • Educate woman NOT to stop prescription drugs prescribed for chronic diseases without medical consultation—even if she thinks she has become pregnant. • Refer to Medications link for more detailed guidance
Substance Use	Use a tool such as the NIDA Quick Screen to assess substance exposures: In the past year how often have you used the following? • 4 or more drinks of alcohol in a day (never, once or twice, monthly, weekly, daily or almost daily) • Tobacco products (never, once or twice, monthly, weekly, daily or almost daily) • Prescription drugs for nonmedical reasons (never, once or twice, monthly, weekly, daily or almost daily) • Illegal drugs (never, once or twice, monthly, weekly, daily or almost daily)	• Advise all women that no amount of alcohol has proven safe at any time in pregnancy. • Use best practice such as SBIRT to counsel women who screen positive for alcohol, prescription and illegal drug abuse. • Use best practice of 5As to counsel women who use tobacco products. • Refer women who disclose signs of symptoms of addiction for more extensive treatment. • Refer to Substance Use link for more detailed guidance
Previous Pregnancy Outcomes	If history of prior pregnancy, assess if complicated by: miscarriage, preterm birth, low birth weight, congenital anomalies, cesarean birth, preeclampsia, GDM, uterine anomalies	•If the patient has a history of serious pregnancy complications, consider referral to a maternal-fetal medicine (MFM) specialist for a preconception consultation • Refer to Previous Pregnancy Outcomes link for more detailed guidance
Genetic Risks	Undertake a quick genetic screen: • Do you, your partner, previous children or other relatives have a birth defect, genetic condition, developmental delay or learning disability? • Are you or your partner of Eastern European Jewish ancestry? Of Caucasian, non-Hispanic ancestry? Of FrenchCanadian or Cajun ancestry? Of African, Mediterranean or Asian ancestry? • Have you had two or more miscarriages? • Have you or your partner had a previous pregnancy end because of a birth defect, genetic disease, or death before or after birth? • Will you be 35 years old or older when you plan to give birth?	• In most situations, the couple should be referred to a qualified health care provider for appropriate genetic counseling and potential testing. • Refer to Genetics Risks link for more detailed guidance
Mental Health History	All women should be assessed for depression at least once a year (an assessment tool such as the PHQ-9 screen can be used) In addition, ask about: history of mental illness; mood disorders, suicidal ideation, homicidal ideation, postpartum depression, behavioral changes	• If under current treatment, assess safety of drug profile (see Medication link) • Underscore the risks of stopping any medication without medical supervision, even if she thinks she has become pregnant. • Counsel woman about potential for exacerbations or recurrences in and following pregnancy and about strategies to identify and manage such occurrences. • Refer to Mental Health History link for more detailed guidance
Interpersonal/ Intimate Partner Violence	Explain that you regularly ask all women a series of questions to assess their safety. Suggested queries include: • Are you in a relationship with a person who threatens or physically hurts you? • Within the past year have you been hit, slapped, kicked or otherwise physically hurt by someone? • Do you ever feel afraid of your partner? • Has anyone forced you to have sexual activities that made you feel uncomfortable? • Does your partner also want a pregnancy in the next year?	• If the woman answers “yes” to any of the first 4 questions: • Acknowledge the trauma; • Express concern for her welfare; • Provide referrals to local and national resources (Refer to Interpersonal/ Intimate Partner Violence link for more detailed guidance) • Educate women in violent relationships, that there is no evidence that pregnancy resolves violence and that, in fact, it often increases during pregnancy. • Encourage woman to create a safety plan. • If woman indicates partner not supportive of pregnancy plans, explore more fully.

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