|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 contraceptive guidance.
• If relevant, educate about safest interconceptional lengths (18-59 months).
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, obesity to future pregnancies.
• Recommend a varied and balanced diet and a multivitamin with at least 400 mcg folic acid for daily use (even if pregnancy plans change).
• Refer to detailed guidance for specific nutrients and nutrition related disorders under Nutrition tab in full Clinical Toolkit.
|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 and Varicella immunizations, as indicated (if 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 detailed guidance for specific diseases under Infectious Disease tab in full Clinical Toolkit.
|Chronic Diseases||Review patient history for evidence of chronic disease (e.g. hypertension, diabetes, seizure disorder, etc.).||• Educate woman on implications of the disease on her own health should she conceive and on her pregnancy 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 detailed guidance for specific diseases under Chronic Disease tab in full Clinical Toolkit.
|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.
|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.
• More detailed intervention strategies are provided under Substance Use tab in full Clinical Toolkit.
|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 yes to any of these refer to guidance for specific outcome under Reproductive History tab in full Clinical Toolkit.|
|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?
|• If yes to any to any of the queries in the screen, refer to guidance under Genetic History tab in full Clinical Toolkit.
• In most situations, the couple should be referred to a qualified health care provider for appropriate counseling and potential testing.
|Mental Health History||All women should be assessed for depression at least once a year (an assessment tool such as the PDQ-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 tab in full Clinical Toolkit).
• 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 specific guidance for depression, bipolar disorders and schizophrenia under Mental Health tab in full Clinical Toolkit.
|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 Violence tab in full Clinical Toolkit for specific 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.