Preconception Advice

Because at least 50% of pregnancies are unplanned in the USA, we have several recommendations for women of childbearing age.

1. Folic Acid Supplementation - We recommend that all women in the USA follow the U.S. Public Health Service guidelines:
   • "All women of childbearing age in the United States who are capable of becoming pregnant should consume 0.4 mg of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spina bifida or other Neural Tube Defects (NTDs). Because the effects of high intakes (of folic acid) are not well known but include complicating the diagnosis of vitamin B12 deficiency, care should be taken to keep the total folate consumption at less than 1 mg per day, except under the supervision of a physician."
2. Patients at increased risk for a first occurrence of having a child with a NTD include:
   
   1. Couples with a close relative (eg sibling, niece, nephew) with an NTD (risk is approximately 0.3-1.0%)
   2. Women with insulin dependent diabetes mellitus (risk is approximately 1%)
      
   3. Women with seizure disorders who are being treated with Valproic acid or carbamazepine (risk is approximately 1%)
      
      These patients should be refered to an Obstetrician Gynecologist for preconception counseling and specific risk assessment. The efficacy of folic acid supplementation has not been evaluated in these patients.
3. Patients at risk for recurrance of fetus with a NTD are patients who have had a previous fetus or child affected by a NTD (Anencephaly, Spina Bifida, Encephalocele). The committee of Obsetetrics: Maternal and Fetal Medicine of the American College of Obstetricians and Gynecologists recommends in the ACO6 Technical Bulletin - Number 120 - March 1993:
   • "Unless contraindicated, these patients should be offered treatement with 4.0mg folic acid daily, preferably starting 1 month prior to the time they plan to become pregnant and continuing through the first 3 months of pregnancy."

Patients should be advised not to attempt to achieve these dosages of folate by taking over-the-counter or prescription multivitamins with folate because of the possibility of ingesting harmful levels of other vitamins (eg Vitamin A). Furthermore, these patients should be counseled that preconception folic acid supplementation did not prevent all NTDs in the studies to date. High-risk patients should be counseled regarding the methods available for the detection of NTDs (Ultrasound and Amniocentesis) and these modalities should be offered to those high risk patients. They should be cautioned that folic acid supplementation does not preclude the need for consideration of prenatal testing for NTDs.