Pre-conception Counselling

Written 29th April 2020 - Last Update 12th October 2026

Pre-conception Counselling

Ideally three months before trying to conceive, though the useful window can be much longer. The prepregnancy period can range from a minimum of three months to years to improve behaviours and health. Preconception care is not limited to a first pregnancy, and addressing health and wellbeing is equally important in the interconception period.

Almost everyone has something to work on. Ninety per cent of women and over half of all men have at least one preconception health issue to address to improve reproductive outcomes.

Opening the conversation

Most women do not book a dedicated preconception appointment, so the opening has to come from the GP during an ordinary consultation. Asking about pregnancy intention is the entry point.

One Key Question — “Would you like to become pregnant in the next year?” — with four answers: yes, I don’t mind, I’m not sure, no.
A pilot study in Australian GPs found that using the One Key Question to ask about pregnancy intention was acceptable to women attending for non-preconception consultations.
GPs found the tool easy to use, with a median consultation extension time of two minutes.
A “no” answer opens contraception; anything else opens preconception care.

Barriers to delivering preconception care include low levels of community awareness, a lack of presentations for a dedicated appointment and high rates of unintended pregnancies. On the clinician side the barriers are time, competing preventive priorities and a shortage of usable resources.

Supplements

Folate. A daily folate supplement of at least 400 mcg has been demonstrated to lower neural tube defects by 72% compared with no supplementation. In Australia the practical dose is a 0.5 mg tablet daily, started at least one month before conception and continued through the first 12 weeks.
High-dose folate (5 mg) for family history or a previously affected pregnancy, BMI ≥30 kg/m², diabetes, anticonvulsant medication, or a malabsorptive condition.
Best practice is to ensure those without risk factors do not exceed the maximum daily intake of 1000 mcg, because this can result in elevated levels of unmetabolised folic acid.
Iodine 150 mcg daily for everyone planning pregnancy.
Ensure adequate iron, calcium and vitamin D intake.
Restrict vitamin A (retinol) to 800 mcg/day, caffeine to 200 mg/day from all sources, and high-mercury fish (shark or flake, orange roughy, marlin, swordfish, catfish, broadbill).

Australian uptake is poor, particularly among younger women and women having their third or later baby, so this is worth checking rather than assuming.

Weight, diabetes and other chronic disease

In 2021, almost 50% of women in Australia were above a healthy weight as they entered pregnancy. Increased weight leads to a greater risk of gestational diabetes, hypertensive disorders and pre-eclampsia, and interpregnancy weight gain raises those risks further in a dose-dependent way — women whose BMI increased by 3 kg/m² or more carry the highest risk. Low BMI matters too, with risks of nutrient deficiency, low birthweight and preterm labour.

For pre-existing diabetes, aim for an HbA1c below 6.5% before conception, since tailored education about glycaemic control reduces the risk of congenital malformations. Offer contraception until control is stable, and review micro- and macrovascular complications. After gestational diabetes, retest at 6–12 weeks postpartum to confirm normalisation.

Optimise every other chronic condition before conception rather than after, and offer contraception in the meantime while conditions are being stabilised.

Medication review

Review all medications, prescription and complementary, considering the drug indication, dosing, route of administration and alternatives, so that a developing fetus faces no or the least possible risk.

ACE inhibitors and ARBs are contraindicated — switch to a pregnancy-safe antihypertensive before conception.
Except in cases of mechanical heart valves, warfarin is contraindicated in pregnancy.
Sodium valproate, isotretinoin, methotrexate and lithium all need a specific plan rather than a generic “review”.
Teratology information resources help: MotherSafe (NSW), Reprotox and the UK Teratogen Information Service.

Smoking, alcohol and other drugs

Smoking remains an important preventable risk factor for preterm birth, low birthweight and perinatal death, and up to 22% of women smoke in the preconception and early pregnancy period, with higher rates among First Nations people, younger people and people in rural and remote areas. Vaping is not a safe substitute: the effects in pregnancy are unknown, many e-cigarettes contain harmful substances, and their use preconception and in pregnancy is not recommended.

There is no safe level of alcohol consumption in the preconception period or during pregnancy, and it is recommended that any person planning a pregnancy abstains from alcohol. Use AUDIT-C to quantify intake. Almost all women expect their healthcare provider to raise alcohol when they are planning a pregnancy, so raising it is welcome rather than intrusive. Ask about recreational drugs too, since many cross the placenta and affect fetal brain development.

Genetic carrier screening

Inherited conditions affect up to one in 400 people in Australia, so take a detailed family history in every case.

Discuss carrier screening with everyone considering pregnancy, not just those with a family history.
Medicare rebates for cystic fibrosis, spinal muscular atrophy and fragile X screening are available since November 2023, and extended panels are available privately.
Partner testing can be done at the same time, or after a positive result — get informed consent first.
The Medicare three-gene screen covers the egg contributor first, then the sperm contributor only if she carries CF or SMA. Fragile X is X-linked, so partner testing doesn’t change that result.
Reading the result:
- both partners carry the same recessive condition — 1 in 4 chance of an affected child; refer to genetics
- female carrier of an X-linked condition — refer to genetics
- one partner a carrier, the other negative — low chance, no referral
- one partner a carrier, the other untested — test the partner first. Do not refer before partner has been tested.
Point-of-care guides and CPD for GPs are on the PRECISE genomics hub (Medcast).

Refer to a genetic counsellor for a positive family history, a known genetic condition, a previously affected pregnancy, or Ashkenazi Jewish background.

Infection, immunisation and preventive screening

Review vaccination history for measles, mumps, rubella, varicella zoster, diphtheria, tetanus, pertussis and hepatitis B, and confirm immunity to varicella, rubella and hepatitis B serologically. Advise waiting 28 days after rubella and varicella vaccinations before conceiving. Offer influenza and COVID-19 vaccination, and check HPV status.

Routine screening for all potential parents: syphilis, HIV and hepatitis C, plus hepatitis B. Add chlamydia and gonorrhoea where there is a new partner, a previous STI or exposure in the last 12 months, a partner from a high-risk population, or living in or travelling to a high-prevalence area.

Cytomegalovirus is worth raising specifically. CMV can cross the placenta and is the most common congenital infection, affecting up to 2000 babies annually, yet fewer than one in five women of reproductive age know about it. Screen those with a genuine exposure risk (childcare workers, a young child in childcare) and give everyone hygiene advice.

Also cover cervical screening if due (self-collection is now available to everyone through the National Cervical Screening Program), breast awareness, and a dental check.

Interpregnancy interval

For a woman with a recent delivery, discuss timing. ACOG and the Society for Maternal-Fetal Medicine recommend patients wait at least 6 months after delivery before attempting conception again, with an ideal interval of 18 months. Interdelivery intervals under 18 months carry higher rates of uterine rupture in women attempting VBAC.

Previous pregnancy outcomes also drive the plan: placental insufficiency, intrauterine growth restriction, pre-eclampsia or gestational diabetes each point to specific interpregnancy diet, exercise and early-antenatal-intervention goals.

Assessment and management checklist

Recommend a pre-conception consultation about three months before trying to conceive, and use pregnancy-intention questions opportunistically at other visits.
Identify conditions in the psychosocial situation, family history, medical history, gynaecological history and past pregnancies that may impair conception or make the pregnancy high or moderate risk (see the risk-tier reference below).
Discuss previous pregnancy experience, and identify ongoing distress related to a previous pregnancy or birth.
Assess the couple’s genetic risk and decide whether pre-conception genetic counselling is needed.
Review all current medication, including non-prescription and recreational drugs.
Examine: heart sounds, baseline blood pressure, weight and BMI.
Check immunisation status of the patient and the partner.
Arrange investigations as indicated:
- Fasting glucose tolerance test for anyone with previous GDM.
- Cervical screening test if due.
- Vitamin D if dark skin or limited sun exposure.
- FBC, haemoglobin electrophoresis, blood group and antibodies.
- Syphilis, hepatitis B surface antigen, hepatitis C.
- Recommend HIV screening; consider chlamydia screening.
- TSH only if high risk for thyroid disease — asymptomatic patients without risk factors do not need routine thyroid screening.
Stabilise pre-existing conditions at least 8 weeks before conception, referring for a preconception obstetric consultation if the pregnancy is likely to be high or moderate risk, and to the relevant condition specialist otherwise.
Discuss genetic carrier screening with everyone, and refer for genetic counselling where indicated.
Ensure the patient knows the antenatal screening options; route this through the Maternal Fetal Medicine Unit if a high-risk pregnancy is likely.
Where distress persists after a traumatic birth, offer birthing courses, psychology referral, or pregnancy and birth planning with an obstetrician.
Address psychosocial concerns, including intimate partner violence and financial security.
Discuss fertile timing in the cycle, and start supplements one month before conception.
Arrange immunisations, brief intervention for smoking, alcohol and drugs, weight optimisation, exercise and a dental check as above.

Exercise advice: already active — 30 minutes of moderate exercise most days, or 150 minutes per week; not currently active — moderate-intensity exercise such as brisk walking that raises heart rate and breathing without breathlessness; overweight — start with 15–20 minutes and build to 30. Add pelvic floor training.

Risk-tier reference: indications for hospital antenatal care

From https://hne.communityhealthpathways.org/43477.htm

High risk pregnancy (hospital antenatal care by 14 weeks)

Past maternal history:

Cardiovascular — consider concurrent cardiology referral:
- Chronic hypertension — secondary hypertension or requiring multiple medications.
- Cardiac conditions: congenital heart disease (other than repaired VSD/ASD), ischaemic heart disease, left or right ventricular dysfunction, cardiomyopathy, valvular heart disease or valve replacement, arrhythmia requiring ongoing treatment, pulmonary hypertension, Marfan’s syndrome or other cause of aortic dilatation.
Complex psychosocial situations — may be eligible for the safe start program: violence in a relationship where the patient is unsafe to return, substance use, unmanaged psychiatric disorder, unstable housing or homelessness, immediate risk to the unborn child, lack of antenatal care, FACS involvement or children in care, relationship issues impacting the patient’s health, developmental disability with minimal capacity for a caring role, unsupported adolescent pregnancy, previous abuse or neglect of children, poor self-care.
Respiratory — consider concurrent respiratory referral: cystic fibrosis, severe asthma with poor or partial control, severe lung function disorder, active tuberculosis, lung transplant.
Gastrointestinal or infectious diseases — consider concurrent gastroenterology referral or HIV specialised referral: active inflammatory bowel disease (particularly if requiring multiple medications), liver transplant, HIV.
Genitourinary — consider concurrent nephrology referral: renal transplant, current or previous nephritis/nephrotic syndrome, polycystic kidney disease, chronic renal failure, previous trachelectomy or cone biopsy. See also Renal Disease in Pregnancy.
Neurology — consider concurrent neurology referral: epilepsy (if unstable, multiple medications, or high-risk medications e.g. sodium valproate, lithium, phenytoin), myasthenia gravis, multiple sclerosis, muscular/myotonic dystrophy, previous cerebrovascular accident, spinal cord lesion, known intracranial lesions (e.g. aneurysm, AVM).
Endocrine — consider concurrent endocrinology referral (public patients: request the combined endocrine obstetrics service): type 1 or type 2 diabetes, Graves’ disease (TRAb positive or on anti-thyroid medications), symptomatic hyperthyroid, poorly controlled hypothyroid, panhypopituitarism, Addison’s disease or Cushing’s syndrome.
- Gestational diabetes mellitus (GDM): see all patients close to point of diagnosis; those with good control and no other complications can continue shared care after initial review; if control deteriorates (fasting BGL >5.1 mmol or HbA1c >6.5%), re-refer and manage as high-risk. See also Thyroid Disease in Pregnancy.
Haematological — consider concurrent haematology referral: thrombocytopenia with platelets <80 or requiring ongoing medication, haemophilia carrier, current VTE/history of multiple VTE/VTE risk score >4 (see Thromboprophylaxis in Pregnancy — once prophylaxis is commenced, some patients are suitable for ongoing shared care with a GP management plan), significant haemoglobinopathy (e.g. HbH disease, beta thalassaemia major, sickle cell homozygous), high-risk red cell antibodies (e.g. anti-D, anti-K, anti-c at any titre, or other antibody titre >1:32) or previous offspring affected by haemolytic disease of the fetus/newborn, abnormal blood film (see Anaemia in Pregnancy), known significant bleeding disorder.
Autoimmune — consider concurrent rheumatology or immunology referral: autoimmune disease requiring ongoing medications, active or quiescent (SLE, Sjögren’s with anti-Ro/anti-La positive, systemic scleroderma, rheumatoid arthritis, ankylosing spondylitis, sarcoidosis), antiphospholipid syndrome.
Mental health — consider concurrent referral to drug and alcohol services: treatment with lithium, sodium valproate, or phenytoin. See also Perinatal Mental Wellbeing.
Other: age >50 years, active or recently treated malignancy.

Previous pregnancy factors:

Maternal: previous pre-eclampsia <34 weeks or eclampsia at any gestation; previous obstetric cholestasis onset <32 weeks and/or bile acids >100.
Fetal: more than 1 previous 2nd/3rd trimester fetal loss; previous offspring with genetic or structural anomaly; previous preterm birth <34 weeks (spontaneous or iatrogenic); previous early-onset IUGR <34 weeks; previous child affected by blood incompatibility (HFDN, neonatal alloimmune thrombocytopaenia).
Placental: previous confirmed or suspected abnormally invasive placenta (accreta).

Factors identified during current pregnancy:

Maternal: new medical condition as per past maternal history above; new diagnosis of infectious disease in pregnancy (HIV, CMV, toxoplasmosis, VZV, rubella, syphilis, parvovirus); new diagnosis of short cervix (<25mm at 16–24 weeks’ gestation).
Fetal: monochorionic twins (MCDA/MCMA) or dichorionic twins with complications; higher-order multiples; complex high-risk combined first-trimester screen (risk >1:100, NT ≥3.5mm, abnormal NIPS result); suspected fetal genetic or structural anomaly; concerning teratogenic exposures; severe fetal growth restriction (EFW or AC <5th centile at any gestation).
Placental: abnormally invasive placenta; placenta praevia with >2 prior caesarean births; vasa praevia.

Moderate risk pregnancy (hospital antenatal care by 22 weeks)