For patients with complex medical histories, prior pregnancy complications, or known risk factors, preconception counseling covers far more ground than a standard well-woman visit. This worksheet covers medication safety and switching before conception, expanded carrier screening, maternal health optimization for conditions including diabetes, hypertension, autoimmune disease, and epilepsy, STI and intimate partner violence screening, genetic counseling, and mental health planning; particularly for patients with prior loss.
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Pregnancy and Obstetric History
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Prior pregnancy outcomes shape almost every preconception decision. Document what happened and flag anything that was never fully explained or followed up.
Prior losses
I have had one or more pregnancy losses (miscarriage, ectopic, or molar pregnancy)
Note total number and gestational ages if known.
I have had two or more losses (recurrent pregnancy loss)
Standard RPL workup includes APS panel, karyotype, uterine anatomy, thyroid, and more. Ask whether your workup was complete.
I have had a stillbirth (loss after 20 weeks)
Stillbirth workup, placental pathology, and cause of death documentation are important before the next pregnancy. Risk recurrence varies significantly by cause.
I have had a pregnancy termination (for any reason)
Relevant for surgical history, uterine anatomy, and in some cases Rh sensitization status.
Prior complications
Prior preterm birth (before 37 weeks)
Gestational age at delivery, cause if known, and whether progesterone or cerclage was used are all relevant for next pregnancy planning.
Prior preeclampsia or severe hypertensive disorder of pregnancy
Recurrence risk varies by severity and gestational age. Low-dose aspirin, timing of initiation, and blood pressure optimization before conception matter.
Prior gestational diabetes
Screen for type 2 diabetes before the next pregnancy. Preconception glucose optimization significantly affects early fetal development.
Prior cesarean delivery or uterine surgery
Number of cesareans, type of incision (classical vs low transverse), and any uterine anomaly repairs affect future delivery planning and risk.
Prior fetal anomaly, genetic diagnosis, or chromosomal finding
Whether caused by de novo mutation, inherited condition, or unknown etiology affects recurrence risk and preconception genetic counseling needs.
Prior placental complication (abruption, placenta previa, accreta)
Placental complications can have significant recurrence risk and alter delivery planning.
Pregnancy spacing
I am planning this pregnancy less than 18 months after a prior delivery
Short interpregnancy intervals (under 18 months) are associated with increased risk of preterm birth, fetal growth restriction, and maternal anemia. ACOG recommends discussing optimal spacing, particularly after cesarean delivery.
I have had a prior cesarean and am planning the next pregnancy timing
After cesarean, ACOG recommends waiting at least 18 months before the next delivery to reduce risk of uterine rupture, placenta previa, and placenta accreta. Discuss timing with your care team.
Medication Review
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Many medications require review, dose adjustment, or switching before conception. This is one of the most important and most often overlooked parts of preconception care. Flag anything that applies and bring the list to your prescriber and your OB.
Psychiatric and neurological medications
Antidepressants (SSRIs, SNRIs, TCAs, MAOIs)
Most SSRIs are considered relatively safe in pregnancy, but neonatal adaptation syndrome and timing of use in late pregnancy are important to discuss. Do not stop without guidance.
Mood stabilizers (lithium, valproate, lamotrigine, carbamazepine)
Valproate carries significant teratogenic risk and is generally not recommended in pregnancy. Lithium and lamotrigine require close monitoring. Do not stop without guidance.
Antipsychotics (quetiapine, risperidone, olanzapine, aripiprazole)
Gestational diabetes risk is elevated with some antipsychotics. Discuss risk-benefit with your psychiatrist and OB together before conception.
Anti-epileptic drugs (levetiracetam, topiramate, phenytoin, zonisamide)
Folic acid supplementation at higher doses (4mg) is often recommended for patients on AEDs. Some AEDs significantly increase neural tube defect risk. Neurology should be involved.
Cardiovascular and blood pressure medications
ACE inhibitors or ARBs (lisinopril, losartan, valsartan)
Contraindicated in pregnancy. Must be switched to a pregnancy-safe antihypertensive before conception. This is a priority switch.
Statins (atorvastatin, rosuvastatin, simvastatin)
Generally discontinued before conception. Discuss timing with your cardiologist or internist.
Anticoagulants (warfarin, apixaban, rivaroxaban)
Warfarin is teratogenic in the first trimester. DOACs (apixaban, rivaroxaban) are not approved in pregnancy. Transition to low molecular weight heparin planning is essential before conception.
Autoimmune and rheumatologic medications
Methotrexate
Must be discontinued at least 3 months before conception. Teratogenic. Requires folic acid supplementation and confirmed washout.
Mycophenolate (CellCept)
Contraindicated in pregnancy. Must be switched well before conception. Requires careful transition planning with your rheumatologist or transplant team.
Biologics (adalimumab, infliximab, rituximab, belimumab)
Safety profiles vary significantly. Some are considered compatible with pregnancy; others require washout. This is a nuanced discussion requiring your rheumatologist and MFM together.
Hydroxychloroquine (Plaquenil)
Generally considered safe and often continued in pregnancy for lupus and autoimmune conditions. Discuss with your rheumatologist.
Other medications requiring review
Isotretinoin (Accutane)
Highly teratogenic. Must be discontinued and pregnancy avoided for at least one month after stopping. Enrolled in iPLEDGE program.
NSAIDs (ibuprofen, naproxen) used regularly
Associated with ovulation suppression and, in later pregnancy, premature ductus arteriosus closure. Discuss alternatives before conception.
Thyroid medications (levothyroxine, methimazole, PTU)
Thyroid function should be optimized before conception. TSH target in early pregnancy is typically under 2.5. Methimazole requires special consideration in first trimester.
Diabetes medications (metformin, GLP-1 agonists, insulin)
GLP-1 agonists (Ozempic, Wegovy, Mounjaro) should be stopped before conception; limited pregnancy safety data. Metformin is often continued. Insulin management should be reviewed. HbA1c target before conception is typically under 6.5%.
Any other prescription medications taken daily
Bring a complete medication list including dose and indication to your preconception appointment.
Genetic and Carrier Screening
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Expanded carrier screening is now recommended for all patients considering pregnancy regardless of ethnicity or family history. Knowing your carrier status before conception gives you the most options. A positive result in one partner requires partner testing before conception.
Carrier screening
I have had expanded carrier screening (300+ conditions panel)
Current ACOG guidance supports expanded carrier screening for all patients. This goes well beyond the older ethnicity-based panels and includes cystic fibrosis, spinal muscular atrophy, fragile X, and hundreds of other conditions.
My partner or co-parent has had carrier screening
If you are a carrier for a recessive condition, your partner's carrier status determines whether your pregnancy is at risk. Partner testing before conception is strongly preferred.
I have been identified as a carrier for a specific condition
If you already know you are a carrier, genetic counseling before conception is important to understand your specific recurrence risk and options including IVF with preimplantation genetic testing (PGT-M).
Both my partner or co-parent and I are carriers for the same condition
Each pregnancy carries a 25% chance of an affected child for most autosomal recessive conditions. Genetic counseling and discussion of prenatal diagnosis or PGT-M options should happen before conception.
Family history and known genetic conditions
There is a known genetic condition in my family or my partner's family
Whether autosomal dominant, recessive, X-linked, or chromosomal, a detailed family history review with a genetic counselor before conception can clarify recurrence risk.
A previous child or pregnancy was diagnosed with a chromosomal condition
Recurrence risk depends on whether the condition was de novo or inherited. Parental karyotyping may be indicated if not already done.
I or my partner have a personal diagnosis of a genetic or hereditary condition
Conditions like BRCA mutations, Marfan syndrome, hereditary thrombophilia, myotonic dystrophy, and others have implications for pregnancy planning and prenatal testing.
I am of Ashkenazi Jewish, African, Mediterranean, or Southeast Asian ancestry
Certain populations have higher carrier frequencies for specific conditions (Tay-Sachs, sickle cell, thalassemia, Gaucher). Expanded carrier screening covers these but knowing your ancestry context helps interpret results.
Genetic counseling
I have met with a genetic counselor before this pregnancy
Genetic counseling before conception is recommended for anyone with a personal or family history of a genetic condition, prior affected pregnancy, or positive carrier screen result.
Maternal Health Conditions
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Chronic medical conditions affect pregnancy risk and require optimization before conception. Each condition below has specific preconception targets. Flag what applies and bring to your specialist and your OB together.
Cardiovascular and metabolic
Chronic hypertension
Blood pressure should be well-controlled before conception. ACE inhibitors and ARBs must be switched. Target BP before conception is typically under 130/80. Cardiology or nephrology input may be needed.
Type 1 or Type 2 diabetes
HbA1c should ideally be under 6.5% before conception. Poorly controlled diabetes in early pregnancy significantly increases risk of congenital anomalies. Endocrinology involvement is important.
Obesity (BMI over 30)
Associated with increased risk of gestational diabetes, preeclampsia, preterm birth, cesarean, and fetal anomalies. Weight loss before conception, when achievable, significantly reduces these risks. GLP-1 agonists should be stopped before conception.
Cardiac disease (congenital, valvular, arrhythmia, cardiomyopathy)
Pregnancy significantly increases cardiac demand. Some cardiac conditions carry high maternal mortality risk in pregnancy. Cardiology clearance and risk stratification (mWHO classification) should happen before conception.
Kidney disease or renal impairment
Baseline creatinine, GFR, and proteinuria levels before conception help stratify risk. Significant renal impairment increases risk of preeclampsia, preterm birth, and fetal growth restriction.
Autoimmune and hematologic
Lupus (SLE) or mixed connective tissue disease
Disease should be in remission for at least 6 months before conception. Anti-Ro/SSA and anti-La/SSB antibody status is important for neonatal lupus risk assessment. Hydroxychloroquine is typically continued.
Antiphospholipid syndrome (APS)
One of the most important treatable causes of recurrent pregnancy loss and preterm birth. Requires confirmation on two occasions 12 weeks apart. Treatment typically involves low-dose aspirin and heparin.
Thrombophilia (Factor V Leiden, prothrombin mutation, protein C/S deficiency, ATIII deficiency)
Inherited thrombophilias have variable risk in pregnancy. Testing may be indicated based on personal or family history of clots or prior pregnancy complications. Not all thrombophilias require treatment in pregnancy.
Rheumatoid arthritis or other inflammatory arthritis
Many DMARDs require switching before conception. Disease activity should be assessed. Some medications need significant washout periods.
Sickle cell disease or thalassemia
Maternal risk in pregnancy is significant with sickle cell disease. Partner carrier testing is essential. Hematology involvement before conception is important.
Neurological and psychiatric
Epilepsy or seizure disorder
Antiepileptic drug review with neurology is essential before conception. Higher-dose folic acid (4mg) is typically recommended. Seizure control in pregnancy is a priority; sudden changes to AEDs can be dangerous.
Depression, anxiety, PTSD, or other mental health condition
Mental health history significantly affects the preconception and pregnancy experience, especially after prior loss or complicated pregnancy. Medication review and psychological support planning should happen before conception.
Eating disorder history
Active or prior eating disorders affect nutritional status, fetal growth, and mental health in pregnancy. Nutritional assessment, weight restoration if needed, and psychological support should be addressed before conception.
Thyroid and endocrine
Hypothyroidism or Hashimoto's thyroiditis
TSH should be under 2.5 before conception and in early pregnancy. Dose adjustment is often needed once pregnant. Check TSH 4 to 6 weeks before attempting conception.
Hyperthyroidism or Graves' disease
Thyroid hormone levels should be well-controlled before conception. Methimazole and PTU have different risk profiles in early vs later pregnancy. TSH receptor antibody levels matter for fetal risk assessment.
Supplements, Nutrition, and Lifestyle
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Nutritional status and lifestyle factors have meaningful effects on conception, early fetal development, and pregnancy outcomes. Several of these should be addressed weeks to months before conception, not after a positive test.
Supplements
Taking folic acid or prenatal vitamin with folate (at least 400mcg daily)
Should be started at least one month before conception. Patients on antiepileptic drugs, with prior neural tube defect pregnancy, or with certain metabolic conditions may need 4mg daily. Discuss your dose.
Vitamin D status checked and optimized
Vitamin D deficiency is common and associated with adverse pregnancy outcomes. A level check before conception is reasonable, particularly in patients with limited sun exposure or darker skin tone.
Iron status checked (particularly if prior anemia or vegetarian/vegan diet)
Iron deficiency before conception is common and harder to correct once pregnant. A CBC and ferritin before conception is reasonable for high-risk patients.
Lifestyle
Alcohol use discussed
No safe level of alcohol in pregnancy has been established. Stopping before conception is recommended. If alcohol use is significant, discuss cessation support before conception.
Tobacco or nicotine use discussed
Smoking significantly increases risk of ectopic pregnancy, preterm birth, fetal growth restriction, and placental complications. Cessation before conception is strongly recommended.
Cannabis use discussed
Cannabis use in pregnancy is associated with fetal growth restriction and neurodevelopmental effects. No safe level has been established. Cessation before conception is recommended.
Vaccinations
Rubella and varicella immunity confirmed
Live vaccines (MMR, varicella) cannot be given in pregnancy. If immunity is not confirmed, vaccination should happen at least one month before conception.
Hepatitis B immune or vaccinated
Hepatitis B vaccination is safe before conception. Hepatitis B status should be confirmed.
Mental Health and Pregnancy Planning
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For patients with prior pregnancy complications or loss, the psychological work of the next pregnancy often begins before conception. This section is not a clinical checklist; it is a space to identify what support you want in place before you start.
I have processed or am actively working through a prior pregnancy loss or traumatic birth experience
Unresolved grief or trauma does not have to be fully resolved before the next pregnancy, but awareness and support structures help. Therapists who specialize in perinatal loss and pregnancy after loss exist and are valuable.
I have a therapist, counselor, or mental health provider I can engage during the next pregnancy
Anxiety in subsequent pregnancy after a prior loss is well-documented and distinct from general pregnancy anxiety. Having support identified before conception means you don't have to find it in a moment of crisis.
I have discussed with my partner, co-parent, or support person what the next pregnancy may feel like emotionally
Partners and support people often experience the anxiety of a subsequent pregnancy differently than the pregnant person. Early conversation about expectations and needs helps.
I have identified what monitoring or care plan I want in the next pregnancy
Some patients want more frequent visits, earlier ultrasound, or specific monitoring that may not be standard. Knowing what you want before conception lets you have that conversation with your provider in advance.
I know who my care team will be and have established care before conception
For high-risk patients, establishing care with an MFM or maternal medicine provider before conception; not after the first positive test; gives more time to optimize everything on this list.
Screening and Safety
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ACOG recommends several screening topics at preconception that are often not raised in standard appointments. These are included here because they matter for pregnancy planning and because they are frequently missed.
Infectious disease and STI screening
HIV status known and current
HIV testing is recommended at preconception. People living with HIV can have healthy pregnancies with appropriate antiretroviral therapy. Preconception counseling with an HIV specialist and MFM is important.
Hepatitis C status known
Hepatitis C screening is recommended before pregnancy. Highly effective treatments exist and should ideally be completed before conception.
STI screening (chlamydia, gonorrhea, syphilis) up to date
Untreated STIs can affect fertility and pregnancy outcomes. Screening before conception is appropriate, particularly for patients under 25 or with new or multiple partners.
Substance use
Opioid use or opioid use disorder discussed
ACOG recommends screening all patients contemplating pregnancy for opioid use and opioid use disorder. Validated tools include 4Ps and NIDA Quick Screen. Patients on medication-assisted treatment (buprenorphine, methadone) should not stop before conception without specialist guidance; abrupt cessation carries significant risk.
Other substance use discussed (stimulants, benzodiazepines, other)
Benzodiazepine use requires careful tapering before and during pregnancy; abrupt discontinuation is dangerous. Stimulant use is associated with fetal growth restriction and preterm birth. Discuss all substances with your care team without fear of judgment.
Safety and environment
Intimate partner violence or relationship safety discussed
ACOG recommends screening for intimate partner violence at preconception. Pregnancy can intensify existing violence. Confidential screening and safety planning resources are available. This conversation is best had privately, without a partner present.
Occupational or environmental exposures identified
Workplace exposures to lead, mercury, organic solvents, pesticides, radiation, or anesthetic gases carry reproductive risk. Home exposures (old paint, well water, chemical products) are also relevant. Discuss any known exposures with your care team.
Oral health
Dental care up to date before conception
Periodontal disease has been associated with preterm birth and preeclampsia, though the causal relationship is debated. Dental cleanings and necessary procedures are safe before and during pregnancy. Addressing dental issues before conception avoids the need for treatment during pregnancy.
When you are done
Print this worksheet and bring it to your preconception appointment.
Use the Print / Save PDF button in the top right. The printed version shows all sections, your checked items, and your notes. It is designed to be a working document for your appointment, not a summary.
This worksheet is for health education purposes only and does not constitute medical advice. It does not replace a preconception visit with a qualified clinician. © 2026 Elizabeth Morgan MD · lizmorganmd.com
Dr. Elizabeth Morgan, MD, MS, FACOG · Board-Certified MFM Subspecialist
Content last reviewed: April 2026. Primary evidence: ACOG Committee Opinion No. 762: Prepregnancy Counseling (2019); ACOG Expanded Carrier Screening (2023 update).
Content informed by ACOG Committee Opinion No. 762: Prepregnancy Counseling (2019)