Why Preconception Counselling Matters: A Fetal Medicine Specialist's Perspective

Martin Maher
May 11
5 min read

The most important antenatal appointment may be the one that happens before pregnancy even begins.

As a consultant obstetrician, I spend much of my time caring for women during high-risk pregnancies — managing complications, monitoring fetal development, and guiding families through some of the most anxious weeks of their lives. What I see every day reinforces a conviction I hold deeply: so much of what I deal with in the antenatal clinic could have been better anticipated, mitigated, or even prevented with thoughtful preconception care.

Preconception counselling is not yet the norm. Many women still attend their first antenatal appointment at eight or ten weeks of pregnancy, at which point several critical windows have already closed. My hope, through writing this, is to change that.

What Is Preconception Counselling?

Preconception counselling is a structured medical consultation that takes place before conception — ideally three to twelve months before a couple begins trying for a baby. It is an opportunity to review a woman's (and her partner's) medical history, lifestyle, medications, and family background, and to create a personalised plan to optimise the conditions for a healthy pregnancy.

It is not exclusively for women with known medical problems. It is for everyone.

Why the Time Before Pregnancy Is So Critical

The first eight weeks of pregnancy are a period of extraordinary biological activity. By the time most women realise they are pregnant, the fetal heart has already begun beating, the neural tube — which forms the brain and spinal cord — has closed, and the foundations of every major organ system are being laid. These events happen before most antenatal care begins.

This is why what happens before conception matters so profoundly.

Folic acid supplementation is a well-established example. We know that taking 400 micrograms of folic acid daily, starting at least one month before conception, significantly reduces the risk of neural tube defects such as spina bifida. Yet a striking proportion of pregnancies are unplanned, and even among those that are planned, many women only begin supplementation once they discover they are pregnant — too late for the neural tube, which closes by around day 28 post-conception.

Preconception counselling ensures these conversations happen in time to make a difference.

Who Benefits Most?

While every woman planning a pregnancy benefits from preconception advice, the value is amplified significantly in certain groups.

Women with pre-existing medical conditions. Conditions such as diabetes, epilepsy, hypertension, thyroid disease, lupus, inflammatory bowel disease, and mental health disorders all require careful management before and during pregnancy. Some medications commonly used to treat these conditions carry teratogenic risks — meaning they can cause harm to a developing embryo — and require switching to safer alternatives before conception, not after. In the context of epilepsy, for example, valproate carries serious risks in pregnancy and its use requires careful review and specialist input before conception.

Women with a history of previous pregnancy complications. Those who have experienced recurrent miscarriage, pre-eclampsia, a preterm birth, a baby with a chromosomal or structural abnormality, or a stillbirth deserve dedicated preconception review. Understanding what happened and why — and what can be done differently — can be genuinely transformative.

Women with a family history of genetic conditions. Where there is a family history of inherited disorders such as cystic fibrosis, sickle cell disease, thalassaemia, fragile X syndrome, or BRCA mutations, preconception counselling allows for referral to a clinical geneticist and discussion of options including carrier testing and preimplantation genetic testing.

Women with a raised BMI. Obesity in pregnancy is associated with a significantly increased risk of gestational diabetes, pre-eclampsia, thromboembolism, congenital anomalies, and caesarean section. Preconception is the most appropriate time to address weight and lifestyle, with appropriate support and without the physiological constraints of an ongoing pregnancy.

Women of advanced maternal age. Fertility declines with age, and the risk of chromosomal anomalies increases. Preconception counselling allows for a frank, evidence-based conversation about these realities, fertility options, and antenatal screening.

Women from certain ethnic backgrounds. Conditions such as sickle cell disease and thalassaemia have higher prevalence in specific populations. Carrier screening before conception allows couples to understand their risk and make informed reproductive decisions.

What Does a Preconception Consultation Cover?

A thorough preconception consultation typically includes:

Medical history review. A detailed assessment of any existing conditions, past pregnancies, surgical history, and current medications.

Medication review. Ensuring all regular medications are safe in pregnancy and, where necessary, switching to safer alternatives in advance of conception.

Lifestyle optimisation. Advice on folic acid and vitamin D supplementation, smoking cessation, alcohol, recreational drug use, exercise, diet, and weight management.

Immunisation review. Checking immunity to rubella and varicella, and ensuring relevant vaccinations are up to date before pregnancy (as live vaccines cannot be given during pregnancy).

Screening for infections. Including HIV, hepatitis B and C, syphilis, and — where clinically indicated — chlamydia or toxoplasmosis risk.

Genetic and family history. Identifying conditions that may warrant carrier testing or genetics referral.

Cervical screening. Ensuring smear tests are up to date, as treatment of cervical abnormalities is more straightforward outside of pregnancy.

Mental health. Discussing pre-existing mental health conditions, the risk of perinatal mental illness, and — where medication is involved — the balance of risks in pregnancy.

Planning for monitoring. For women with complex histories, mapping out what additional surveillance or specialist input will be needed once pregnancy is confirmed.

A Conversation Worth Having

I am sometimes asked whether preconception counselling is really necessary — whether good antenatal care covers everything that needs to be covered. My answer is always the same: antenatal care is designed to manage an ongoing pregnancy. Preconception care is designed to give that pregnancy the best possible start.

In fetal medicine, we see the downstream consequences of conditions that were unoptimised at conception — uncontrolled diabetes leading to major cardiac defects, teratogenic medication exposure causing limb abnormalities, unrecognised thrombophilia contributing to recurrent pregnancy loss. These are not rare events. And while not every adverse outcome is preventable, many can be significantly reduced with the right information at the right time.

That time is before pregnancy begins.

How to Access Preconception Counselling

If you are planning a pregnancy and have any pre-existing medical conditions, a previous complicated pregnancy, or concerns about your family history, I would encourage you to seek preconception advice proactively. You can begin with your GP, who can address many aspects of preconception care directly and refer you to the appropriate specialist — whether that is an obstetrician, a clinical geneticist, a diabetologist, or a fetal medicine unit — depending on your individual circumstances.

If you have had a previous pregnancy complication and would like to discuss what this might mean for a future pregnancy, or if you have a complex medical history and are unsure where to start, a dedicated preconception consultation with a specialist obstetrician can provide clarity, reassurance, and a concrete plan.

You can book a private consultation with Mr Maher at The Pregnancy Experts, Lancashire or virtually.

Pregnancy is one of the most significant experiences of a person's life. The preparation deserves to match the stakes.

This blog has been written for general informational purposes. It does not constitute medical advice. Please speak with your own doctor or specialist for guidance specific to your circumstances.