Some patients may decide health risks are too great
Separating preconception and contraceptive counseling between OB/GYNs and patients burdens patients and fractures reproductive healthcare. A better solution is to look at pregnancy planning, pregnancy prevention, and risk evaluation holistically.1
“This clinical perspective is about the importance of making a comprehensive reproductive health visit to help patients optimize reproductive autonomy,” says Carly M. Dahl, MD, a fellow in the division of maternal fetal medicine in the department of obstetrics and gynecology at the University of Utah in Salt Lake City.
“We have prepared pregnancy planning and risk evaluation clinics, where we have combined preconception consultation and complex contraception visits, so patients are able to receive information about their pregnancy risks,” Dahl explains. “If pregnancy sounds undesirable at that time, then we also discuss options for contraception as a routine part of the visit.”
This strategy is a rethinking of the standard way providers handle preconception visits.
“When people have a preconception consult, we just assume they want to be pregnant, and we advise them on optimizing their health to have a safe pregnancy,” Dahl says. “Rethinking the consult is reframing how folks are going into this consult and knowing that high-risk individuals may hear about the risk and may not want to become pregnant.”
OB/GYNs may assume patients want to get pregnant as soon as possible, but that often is not the case.
“The goal is for people to go into pregnancy with their eyes wide open,” Dahl says. “Knowing if they want to be pregnant what the risks of their pregnancy could be to them, the pregnant individual, and how significant those risks are — when we can estimate that — and talk a little about the risks to their fetus.”
Clinicians advise patients about any actions they can take to modify their health prior to becoming pregnant so their pregnancy will be safer. Patients with diabetes and high blood pressure may have greater risk of preeclampsia or heart failure, for instance.
There are things they can do, such as exercising more and eating healthier, and managing their medication, in the months or years before they become pregnant to reduce those risks.
“This can decrease their chances of having a congenital anomaly, and those are the things we talk about with patients,” Dahl says.
For example, if a pregnant person has diabetes that is poorly managed, then the fetus is at a higher risk of having congenital heart disease and issues with the central nervous system, she explains.
“It can be they’re on medication, but their medication needs to be adjusted,” she adds.
The preconception consult also assesses patients’ risk according to their past pregnancy experiences.
“If they had a prior pregnancy and had heart failure after pregnancy, we evaluate what the likelihood of that happening again is,” Dahl says. “We discuss the risks of maternal morbidity events and maternal mortality events, and we frame their desire for pregnancy based on those risks.”
The provider may ask a patient if they wish to become pregnant, understanding those risks. If they decide they do not want to become pregnant, the clinician will talk about effective contraceptive methods that are safe, based on the patient’s medical history.
“Those conversations can be nuanced and require some thoughtful planning,” Dahl says.
It is possible for providers to cover all of these topics within a 60-minute patient consult.
Preconception conversations that include stark details about a particular patient’s risk factors and which include contraception counseling can be sensitive to approach.
“People expect pregnancy to be a natural process, where nothing goes wrong, and this is not the reality in a lot of cases,” Dahl says. “We find that patients are surprised to hear about these risks when they have not been discussed with them in previous medical visits.”
Some patients choose not to pursue pregnancy after hearing the risks. Others may pursue pregnancy and will do what they can to optimize their health to reduce the risk of pregnancy and fetal complications. Those people may see a high-risk pregnancy doctor throughout their pregnancy. They also may understand that they should be close to a hospital during their pregnancy, so they may want to delay their pregnancy to make it as healthy as possible, she explains.
Providers also could discuss what could happen if the pregnancy ends in miscarriage or if the fetus has serious fetal anomalies. This talk could include a discussion of the state’s abortion laws.
“Regardless of what a person’s maternal condition is prior to pregnancy, we always discuss the state restrictions for abortion care so patients can be informed,” Dahl says.
“There are a lot of misconceptions about what is legal and what is not legal,” she adds.
For example, in Utah, there is access to abortion care through 17 weeks and six days of gestation. At 18 weeks and later, abortion is prohibited, with legal exceptions for the risk of maternal life or serious impairment to a major bodily function, or if there is a fetal anomaly that is incompatible with life, or if the pregnant person is younger than age 14 years and has reported being raped to law enforcement. Doctors can provide abortions for patients having a miscarriage, Dahl explains.
“If the condition your baby has is not survivable, you don’t have to go through the rest of your pregnancy, and it doesn’t have to go through an ethics or legal board,” Dahl says. “But it must be confirmed by two fetal medicine physicians, and we have to sign lots of forms.”
The challenge in many states that restrict abortion is that state laws do not always define fetal anomalies in the same way medical providers and patients may. A pregnant patient could be told that the fetus has a genetic disorder in which a very low percentage of infants will survive for up to a few years. This condition may not be seen as incompatible with life by a state’s abortion law.
“There are certain conditions people may not think is quality of life for the child, and they cannot receive a termination of the pregnancy after 18 weeks, which is almost always when these conditions are diagnosed,” Dahl explains. “So, we refer patients out of state for abortion care.”
Explaining risks to patients is challenging because there is no way an OB/GYN can predict when an adverse pregnancy outcome will happen.
“We may know who is at higher risk, but we can’t say with certainty,” she says. “We don’t know who will have premature rupture of membranes that puts them at risk of infection, and there’s always some risk when you’re living in a state with significant abortion restrictions because we can’t predict those risks.”
REFERENCE
- Dahl CM, Fay KE, Wright S, Heuser C. Pregnancy planning, prevention, and risk evaluation clinics: Rethinking the traditional preconception consult. Am J Obstet Gynecol MFM 2024;6:101376.
