Enabling Healthy Pregnancy

Pregnancy is one way that people build families. Enabling healthy pregnancy by providing pre-pregnancy care is an essential component of quality SRH services. 

Providers should collect a thorough history and offer basic services and education about how to achieve a healthy pregnancy for all people who wish to become pregnant and those who would find pregnancy acceptable, including people who may become pregnant through penis-in-vagina sex and people who may use medically assisted reproduction. Information about healthy pregnancy can also be offered to those who are not immediately interested in pregnancy or would find pregnancy unacceptable at the present time. For those with partners, evaluation of all partners occurs concurrently, if appropriate.

The history collected should focus on the patient’s expressed reproductive goals and include only what is relevant to their circumstances. Elements of a comprehensive sexual and reproductive history in support of achieving pregnancy include:

• Medical history, including current health issues; review of systems, past illnesses, and surgeries, with special attention to endocrine (thyroid, hirsutism) and autoimmune disorders; and any illness, injuries, or medical conditions that may affect reproductive function.
• Fertility history as appropriate, including length of time patient has engaged in unprotected penis-in-vagina sex, level of fertility awareness, and previous infertility evaluation or treatment.
• Genitourinary and reproductive history, including history of STI or exposure, and sexual history. (See guidance on the 6 Ps in Section 4, "Taking a Sexual History.”) For persons assigned female at birth (AFAB): sexual dysfunction, vaginismus, dyspareunia; menstrual history, including oligomenorrhea, dysmenorrhea, amenorrhea, obstetric/pregnancy history; gynecologic history, including endometriosis, fibroids, pelvic inflammatory disease (PID), abnormal cervical cytology, and procedures. For persons assigned male at birth (AMAB): erectile or ejaculatory dysfunction, trauma, infection, varicocele, and procedures. 
• Past surgeries or hospitalizations specifically affecting reproductive organs or systems.
• Family history and genetic carrier screening.
• Current medications and ingested substances, including over-the-counter medications, vitamins or herbs, exogenous steroid hormones, and prescription medications, all to assess for compatibility with pregnancy or risk of infertility.
• Social and lifestyle history: relationship status, family structure, sexual partners, employment and recreational activities (with special attention to impact on reproductive function), nutrition, exercise, sleep, stress, and use of substances such as caffeine, alcohol, tobacco, and recreational drugs.
• Immunization status and titers infections associated with pregnancy complications but that are vaccine preventable (varicella, measles, rubella).
• Mental health history, including current and past depression, anxiety, bipolar disorder, eating disorders, PTSD, substance use disorder, other psychiatric disorders, or physical, sexual or emotional abuse; screening for current domestic abuse and safety in the patient’s home.

Professional organizations such as ACOG and the CDC136 recommend that counseling to support achieving a healthy pregnancy include:

• Adequate nutritional intake and maintaining regular moderate physical exercise. 
• Daily folic acid supplementation to decrease the risk of neural tube defects.
• Persons with chronic medical conditions (such as heart disease or autoimmune disorders) should discuss their desires for pregnancy with their providers to maximize control of the medical condition and avoid potentially teratogenic medications or those associated with pregnancy or fertility complications.
• Persons with diabetes aim for glucose levels as close to normal as is safely possible—ideally A1C <6.5 percent.
• Recommend that any individual contributing to pregnancy through gestation of pregnancy, egg, or sperm provision avoid alcohol, nicotine and other recreational drugs, and high caffeine intake, which may all negatively impact fertility and pregnancy outcomes.
• Recommending limiting exposures to toxins that may be harmful to a developing fetus, including lead, radiation, and chemical solvents.
• Fertility awareness education, including information about the fertile phase and tools such as ovulation predictor kits and cervical mucus monitoring that can be used to help identify ovulation.