“Considering Pregnancy? The Importance of a Pre-Conception Visit” with Dr. Sara Kostant

In this episode, Dr. Fox and Dr. Kostant discuss the preconception visit, when a patient and her OB/GYN discuss conception and early pregnancy. They explain when patients should start thinking about preconception and the topics covered during that appointment, including vitamins, vaccinations, carrier screenings, IVF, and more.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an ob-gyn and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Sara, welcome back to “Healthful Woman.” How are you doing? 


Dr. Konstant: Thanks. Well, this is my third time. I’m on a roll. 


Dr. Fox: I know. You’re all over it. This is unbelievable. You know, you’re gonna quit your job and end up just podcasting full-time. 


Dr. Konstant: I don’t know. I don’t know if I’m ready to do that yet. I’d miss delivering babies a little too much. 


Dr. Fox: That’s a fair point. I was thinking it’s ironic because the last time we had you on, we were discussing the postpartum visit or not the visit but the postpartum time period. And now we’re gonna be talking about the pre-pregnancy time period. So you’re really getting the bookends of the pregnancy here. 


Dr. Konstant: Yeah. That’s actually interesting. I didn’t even think about that when I decided to talk about this, but it’s another time that…I think, we focus so much on the pregnancy itself but this is another period of time that really can set you up for having a less complicated pregnancy. I don’t know that everyone really thinks about it so much. So I’m glad we’re talking about it today. 


Dr. Fox: Yeah, 100%. I was actually thinking the same thing. I actually jotted something down in my notes that I agree. I think most people don’t realize that it’s even a thing to see your ob-gyn before you get pregnant. I mean, people go sort of regularly, or many women go regularly, and let’s say it’s once a year or whatever it is, and so there’s gonna be some visit that’s within a year. But at those visits, it’s not always specifically discussed. I mean, I would say a lot of ob-gyns proactively talk about, you know, upcoming pregnancies, but sometimes it doesn’t happen. And, I think, it’s an important topic to discuss before pregnancy because there’s things that we do. 


Dr. Konstant: I tend to bring it up whenever I’m even just doing an annual exam. Even if the patient has not brought up that she’s considering pregnancy, I’ll just bring it up casually and just say, you know, “Is getting pregnant something that’s completely off the radar for you for now, or is it something you may consider in the next year or two?” And if it’s something that’s on their mind, I’ll definitely go through some of the things that we’re gonna go through today because there’s things that…well, sometimes I’ll mention them, and patients will say, you know, “I didn’t really think about that.” Like it’s not something that had crossed their mind that they should consider before trying to get pregnant. 


Dr. Fox: Yeah. Absolutely. And, you know, some of these things as we’re gonna discuss are obviously more crucial than others but particularly for someone who does something that might be, you know, really important even if they’re not considering a pregnancy. People get pregnant without always planning it. And so it’s something people should have on their radar. Like we’ll talk about someone with certain medical conditions or medicines or this or that, you know, if they’re on a really reliable form of contraception, okay, but, you know, what if it doesn’t work, or what if they’re not on it, or what if they’re switching, or whatever it might be? It’s just something that should be on people’s radars in general, but certainly, if someone is planning a pregnancy, it makes a lot of sense to include a visit with the ob-gyn as part of that plan. 


Dr. Konstant: Absolutely. Even if someone also is in excellent health and doesn’t have any medical issues, nothing that’s been flagged as, “Oh, this might be high risk in your pregnancy,” there’s still a lot of things, you know, that we can go over. 


Dr. Fox: Yeah. Absolutely. So, we’re gonna go through them together, no particular order. We’ll sort of just brainstorm. And the first thing for me that comes to mind, which is really, you know, the simplest, is a prenatal vitamin or some sort of multivitamin that people generally should be taking when they get pregnant. 


Dr. Konstant: I bring that up as well. And a lot of patients will also ask me, “Is there any particular vitamin that I should take?” And I’ll tell them as long as it’s a standard formulation of a prenatal vitamin which comes with folic acid, there’s no particular brand that I favor, you know, one more than the other. I do tell patients who have trouble swallowing pills or who, you know, they may wanna consider a smaller pill or patients that find that the prenatal just doesn’t agree with them, prenatal vitamins do have a little bit of iron, which is very critical during the pregnancy. When you’re not pregnant with a balanced diet it’s not necessarily as critical. The folic acid is really what’s key during the preconception period. I’ll tell patients, “Just at least get the folic acid separately because sometimes that’s just easier to take. And then once you become pregnant, then switch over to a prenatal, so you can, you know, start getting the iron and the other vitamins and minerals that are there.” 


Dr. Fox: Yeah. I mean, I tell them very similar to what you do. The folic acid is really the one that’s more important to have on board when you get pregnant because the folic acid has been shown to lower the risk of a certain type of birth defect that babies can have called spina bifida and things like spina bifida. And that’s really the most important one. Probably, it’s a good idea for women to be up, you know, with calcium, and maybe their vitamin D, not as critical. And, I think, just like you said, the way vitamins are made, the difference between the sizes of the vitamins tends to be what’s in them. So something like folic acid takes up very little room. So you can get a ton of folic acid in a tiny, little pill, and that’s very easy to swallow. But once you start putting in things like particularly calcium and iron, those two take up a lot of space. So that’s why some of these prenatals are very big because they try to put in enough calcium and iron. And sometimes for a lot of women, they should take those separately, just take a folic acid and may be split up their vitamins. It may be easier to take, you know, two small pills and a chewable than it is to try to take one big prenatal. But this is something to discuss, you know, with the doctor. Again, most of us are gonna be fine as long as someone’s taking either folic acid alone or something with folic acid in it, even multivitamins, I mean, even Flintstone vitamins, I mean you could really get almost anything with folic acid. 


Dr. Konstant: Oh, Flintstone vitamins. I haven’t thought of those in years. 


Dr. Fox: Yeah. Two of those tend to be about the same as one prenatal. So people like them. They work. 


Dr. Konstant: And I tell patients for folic acid, standard dose at least 400 micrograms, mcg. Many prenatal vitamins come with 800 or even more, but 400 micrograms is the minimum standard dose for most patients going into pregnancy. 


Dr. Fox: Right. And if someone sees on their bottle that it’s written in milligrams, so one milligram is 1,000 micrograms. So if it says 1 milligram or 0.8 milligrams, that would be 1,000 micrograms or 800. So those are the right numbers. And the only people who really need to take more folic acid than that would either be, you know, rare people with certain medical issues, which is not sort of typical or people with a history of a prior pregnancy with spina bifida or something like that where we recommend like megadoses in the next pregnancy. But these are people who are gonna know that already from the last pregnancy. For standard like you said that dose. Another thing that a lot of people don’t realize is getting their vaccines up to date. 


Dr. Konstant: Yes. And I’ve also been asking patients about that and offering to check their titers for measles, mumps, rubella, and varicella, chickenpox, because if those show that they’re immune, they’re good. They don’t need any of those vaccines. But if they’re not immune to any of those…and sometimes women don’t know. Maybe they got the vaccines as a child, especially with chickenpox. Some patients were vaccinated, but the earlier vaccines didn’t always give full immunity. So if we detect before pregnancy that, you know, someone’s chickenpox titer is low, they can get the varicella vaccine before pregnancy. Measles vaccine, the MMR, the varicella vaccine, cannot be given during pregnancy. We check those titers whenever someone comes to us for a new pregnancy visit. But if we see that they’re not immune, we make a note of it because if that patient is exposed to chickenpox during the pregnancy, she would be more at risk. But we can’t actually vaccinate. We end up doing the vaccinations, you know, even in the hospital after delivery. But checking those and getting the vaccines if a woman’s not immune is definitely really important. 


Dr. Fox: Right. I think that for vaccines, and that probably deserves its own podcast, there are types of vaccines that we do give in pregnancy, and there’s types of vaccines that we don’t give in pregnancy. And basically, the ones we don’t give in pregnancy are the ones that are made with a little bit of the live virus in it. And the fear of giving those in pregnancy is maybe the live virus will somehow get to the baby, cause a birth defect, make the mother ill, or whatever it is. It’s actually not really been reported, meaning no one’s ever seen a birth defect in a baby caused by one of these vaccines. But just to be cautious, we don’t give them in pregnancy, and so we try to give them pre-pregnancy ideally or like you said after pregnancy if we notice it. And the reason these viruses in particular it’s important to be vaccinated against is that if someone gets one of these illnesses during pregnancy, someone gets chickenpox during pregnancy, it can be very dangerous for the mother. Measles and rubella can be dangerous for the mother or for the baby. Some of these viruses if the mother catches it during pregnancy can be dangerous to her, and some of them can be dangerous to her as well as the fetus. But that’s the reason we love for people to be immune to these conditions before pregnancy. 


Dr. Konstant: Absolutely. I also tell patients as far as, you know, other vaccines, the flu vaccine we can give during pregnancy. So, if someone’s due for the flu vaccine for herself, I recommend it, but that’s something that if someone is pregnant and they just haven’t managed to get it, you know, we can give that in pregnancy. That’s less of a concern. 


Dr. Fox: Right. The flu we just give if they’re due for a flu vaccine for general health, yeah, because it’s not something that needs to be done before pregnancy like these that you mentioned need to be given before. Like things like tetanus vaccine, you know, boosters can be done during pregnancy. In fact, they’re recommended during pregnancy as it turns out, not because of the tetanus, but because of the whooping cough portion, but whatever, because that’s a vaccine that does not have a live virus, so we can give it. And then also in terms of things like exposures, I mean, obviously, if someone’s smoking or drinking either heavily or socially, how do you talk to them about that about when they should quit, how they should quit in terms of that? 


Dr. Konstant: I tell patients once they are actually, you know, trying to get pregnant like they have stopped contraception, they’re basically fine getting pregnant at any time, you know, some patients, and we’ll get into this more, they may be actively timing intercourse, but once they’re actually planning on getting pregnant, if someone is a social drinker and doesn’t have, you know, an addiction, which is again a separate issue, I usually tell patients to stop once they’re trying to get pregnant. Smoking, the same thing. Again, definitely, someone who’s a regular smoker who’s addicted to nicotine, it’s a much more difficult situation. That’s something I would even really…you know, I always tell patients pregnant or not pregnant, planning on getting pregnant, not planning on getting pregnant to try, you know, to cut down on and quit smoking. But the reason I tell patients to do that even when they’re trying to get pregnant is exposure. They have the most effect during the very early stages of development, sometimes even before a woman really realizes yet that she’s pregnant. So ideally, having as little exposure as possible during the first few weeks of pregnancy is really important. So I tell patients to stop the drinking and smoking pretty much as soon as they’re trying to get pregnant. 


I have had patients who found out they were pregnant, and they were like, “Oh, no, you know, I didn’t think I’d get pregnant this fast, or, you know, I had some drinks and went out with some friends, and then I found out I’m pregnant, and I was definitely having some alcohol when I was pregnant.” I reassure them that, you know, with an exception of, you know, again, pretty heavy binge drinking, it’s still very unlikely that that drink had any negative effect on the development. But ideally going into it just because with drinking, we don’t have an exact amount, “Oh, if you drink, you know, this many glasses of wine, you know, this will be the effect.” You know, because we just don’t know the line that, you know, you cross where there could be any concern. I just tell patients not to do that during…you know, when they’re trying to get pregnant. 


Dr. Fox: Right. It’s strategic because of what you said, not everyone knows automatically when they’re getting pregnant. Typically, you know, around the time you miss your period, you’re pregnant. But, you know, everyone’s a little bit different with whether periods are like regularly, what do they notice, what do they not. When people come and they say, “Oh, my God, you know, I was drinking, you know, the night we conceived or a week later,” as it turns out fortunately in that very, very, very early stage like from conception for the next several weeks, that sort of like pre-organs, and so it’s not typically a risk with these exposures, fortunately. And so if someone either knows exactly when they’re getting pregnant like they do an IVF, for example, or they got pregnant and then go back and say, “Oh, no, I was drinking during those first few weeks,” it really isn’t an issue. But I agree, it just removes a lot of stress and anxiety if people, you know, they know, “I got pregnant and I wasn’t drinking,” and so they don’t have to worry about it. 


Smoking is a much more difficult topic because typically, we’re seeing people who are drinking socially and so, you know, stopping to drink is not usually an issue with addiction. It’s an issue with just their lifestyle, whereas smoking, a lot of people smoke, it’s very hard to quit. And I found that the nice thing about planning a pregnancy is for many women in upcoming pregnancy is pretty much the motivation they needed to really get on it and to reduce and potentially quit smoking. And even those who have a pretty significant addiction when that motivation is there, they can start a real process of whether it’s, you know, just cutting down or, you know, nicotine patches or, you know, whatever it is to sort of work with someone to reduce it. And pregnancy seems to motivate a lot of people to do that, which is great for their overall health, you know, regardless of the pregnancy. 


Dr. Konstant: I’ve actually noticed that I’ve had a few patients who smoked for years, and they were able to quit because they knew they were planning on getting pregnant, or at least they significantly cut down to the point where, you know, they were having the occasional cigarette and then, you know, maybe got pregnant but then cut that down even further. You know, by the time they were in the first trimester, you know, they weren’t smoking anymore. For at least one patient I can think of, she never smoked again even after she delivered. She was done. She actually, you know, lost the craving for that at that point. 


Dr. Fox: Right. If someone’s able to get off of smoking and they go through a whole pregnancy, it’s essentially a year, and so that’s a long time and true… It happens to be smoking as far as we know does not cause birth defects. It’s not the same as alcohol. The exposure is not good but for different reasons. And so it’s also one of these things we’re cutting down as much as possible. Even if someone can’t quit, just reducing is gonna be beneficial to her health and to the baby. So, we try to be very positive, very motivating for women to cut back as much as possible even if it’s not quitting entirely. 


Dr. Konstant: Yes. Definitely. 


Dr. Fox: Excellent. What other things do you like to go over at a preconception visit? 


Dr. Konstant: So a couple of things. And this is one thing that, I think, a lot of people…really like it doesn’t even occur to them as much, but allergy testing. And the reason why is I see a lot of women who will come in who will report that they’re allergic to penicillin. And when I talk to them, they’ll say that when they were a child or a baby, they may have had some reaction, and pretty much ever since then, they have told every doctor that they’re allergic to penicillin, and they’ve never taken any penicillin-related antibiotics. And the reason why it’s good for women in this situation to actually get allergy tested to really confirm they have a penicillin allergy is many of the antibiotics that we use in pregnancy, you know, if anyone would need an antibiotic are penicillin related antibiotics. Those are the antibiotics that are the most studied and sometimes the safest and most effective in pregnancy. So if someone does have a true penicillin allergy, we have some alternatives. If someone gets tested and actually finds out that she’s not allergic in the end, it makes it a lot easier in case she does need to be treated. I’ll tell patients…and again, this is definitely…there’s a lot of things we’re gonna go over, and there’s definitely some things that are more critical to do before you get pregnant. If a patient has time to see an allergist and actually just have allergy testing to make sure she’s really allergic to the medications that she’s been told she’s allergic to, that can be very helpful. 


Dr. Fox: Yeah. And also those tests are not reliable in pregnancy. That’s the other thing. So, it’s not something you wanna wait till you’re pregnant because your entire allergic and immune system is altered in pregnancy, and so not everyone’s gonna rely on the testing done then. And so that’s something may as well do it if you have an opportunity because it definitely can help in pregnancy. And also, you know, people go their whole lives saying they’re allergic to things then they realize they’re not. And, you know, again, it’s not gonna be life or death typically, but sometimes you wanna give a certain antibiotic, and you can’t because they’re like, “Listen, I can’t give it to you if you’re allergic, but it’ll be good to know.” Yeah. So that’s a good one. What else do you go over? 


Dr. Konstant: Carrier screening, which, I think, patients are becoming a little more familiar with. It basically tests to see if a woman is a carrier for about 283 diseases that could be passed to their children if their partner also carries those diseases. So, if a woman carries let’s say I’ll pick a disease that many people have heard of, cystic fibrosis, which is a very serious and can be fatal. It’s a long-term chronic illness. The lung disease patients who have it, you know, have shortened life spans. So if a woman carries cystic fibrosis…she doesn’t have it, but if her partner has it, is a carrier for it, there’s about a 25% chance each time she gets pregnant that their child could actually have the disease. So many women carry diseases they have no idea. You know, they’ll never be affected by it. The benefit of knowing this before pregnancy is that if a couple knows in advance, they find out, you know, “Wow, we’re actually both carriers for the same type of cystic fibrosis,” you know, to avoid having to have to go through the 25% chance of having a child with cystic fibrosis, they may decide to do, you know, in vitro fertilization, IVF, and pre-test the embryos to make sure that, you know, when they have an embryo implanted, it’s not an embryo that’s affected by cystic fibrosis. Obviously, you know, this is a very expensive process if someone decides to go down that road. 


But, I think, it’s at least good to know that in advance because if you find out once someone’s pregnant, and the couple does carrier screening, if then they find out they’re both carriers of a disease, then the decision they’re facing is, “Do we actually go ahead and test the pregnancy with diagnostic testing,” which would include either an amniocentesis or a chorionic villi sampling, which is a procedure that our office does a lot, but there are some risks associated with it. “Do we do that procedure now, find out?” And then if we actually find out that our child is affected by this very serious disease, there’s now, you know, “Do we wanna be faced with the decision of do we continue the pregnancy? Do we not continue the pregnancy?” So, I think, just having that out of the way before pregnancy, I think, is a good idea because that way…in most cases, most couples do not carry the same disease. It’ll just be another, you know, weight off your shoulders. If that is the case, then the couple can decide, “Look, is this disease serious enough that we, you know, want to do IVF?” Maybe it’s a chronic disease that’s not as serious, and that couple would feel comfortable saying, “Look, we’ll go ahead and try to get pregnant on our own, and we’re fine, you know, if we have a child affected by this. It’s not something that we would terminate the pregnancy for.” And that’s fine too as long as, you know, patients are aware of, you know, what they’re carriers for. 


Dr. Fox: Right. We had a whole podcast on carrier screening. And what you’re saying is so important because normally carrier screening, it ends up being done during pregnancy just because that’s when, you know, people didn’t plan, they get pregnant, and we check. And again, like you said, 99% of the time it’s okay because the couple even though they’re probably each a carrier of something, it’s rarely the same thing, and so it doesn’t really matter practically. But for the couples that find out they are carrier couples, particularly if it’s a condition that’s quite serious, they really…most of them would have liked the option to do IVF before pregnancy. And again, maybe they would do it. Maybe they wouldn’t. And so it’s really something…there’s no reason not to do it before pregnancy because since it’s a genetic test of the parents, the results are gonna be same for the rest of their lives. I mean, whatever her test result is today, it’s gonna be the same 20 years from now, and it would have been the same 20 years ago. It’s a genetic test. The only reason you may wanna wait until preconception as opposed to like the second you’re dating someone or married is because the test itself gets updated with new conditions because new research. If you do it and then you’re gonna get pregnant five years later, you’re probably gonna have to repeat the additional ones anyway. So that’s, you know, a practical consideration. Would you rather do it once or do it several times? But ultimately, before pregnancy is gonna be more meaningful in terms of a plan than during pregnancy. And that’s just something that the reasons done during pregnancy is typically people don’t have that visit beforehand or, you know, they don’t ask or the doctor doesn’t ask. And so that’s important. 


And one of the other new twists, and we had another podcast about this, is about cancer genetics. There is more and more information about genes that people can carry that would put their children at increased risk for cancer. And this is not something that both partners would have to carry, just one of them. And so, for example, someone, their sister, their mother, whoever it is has breast cancer, they may wanna find out, “Do I carry the BRCA gene that puts me at risk for cancer and all of my children particularly my daughters?” And again, the same thing, it’s something that if you knew before pregnancy, you might make the decision, not necessarily, but might make the decision to do IVF and then test the embryos beforehand. And this is something to talk about because that type of testing is complex. It requires counseling, and you wanna sort it all out before you get pregnant rather than trying to, you know, figure it out when you are pregnant, and you “can’t do anything about it” at that time other than potentially terminate a pregnancy. Ob-gyns are very familiar with, you know, genetic screening. We do this all the time. It’s just something to know about doing before pregnancy. 


Another thing I like to always talk about people is just their general health, you know, and going over the value of nutrition during pregnancy but obviously entering pregnancy already with good nutrition, good eating habits, exercise. These are things that are…I tell them, “If you’re gonna walk into pregnancy healthy in terms of how fit you are, it’s gonna change the entire course of pregnancy.” People get pregnant, and they don’t eat right, and people get pregnant, and they don’t exercise, or people out of shape. And it’s okay. They usually do fine. It’s not like a disaster. But if someone is able to be more fit, they have more stamina, they have better, you know, cardiovascular health, you know, they lost those 10 pounds that they always wanted to take off, the whole pregnancy they’re gonna feel better, and probably they’re gonna have a lower risk of a lot of complications of pregnancy related to those things, you know, like diabetes and high blood pressure. And so it’s another great motivator for people if they’re planning a pregnancy to really…if they’re not already doing these things to start them. 


Dr. Konstant: I really stress exercise especially. I think some people have…you know, they’re on a certain time frame for getting pregnant, and they may feel down because they feel like, “Look, I’m not gonna be able to re-haul my entire life.” And, you know, if they are let’s say overweight or they’ve been told they’re overweight, they’re like, “Look, I really wanna get in better shape, but I don’t know if I’m gonna be able to get to that point before the time when I really would, you know, like to try to get pregnant.” Every situation is different. But I tell patients if you can at least get into like a regular exercise program, by the time you get pregnant like even if someone is actually, you know, so baseline technically, you know, like overweight, just having exercise regularly, you decrease your chance of, you know, gestational diabetes in the pregnancy. You’ll feel much better. You’ll be less out of breath during the pregnancy. It may help stabilize your weight gain during the pregnancy. So you will gain some weight but not as much as you would have. So by exercise, it doesn’t mean, you know, working out five days a week doing like a really, you know, tough weightlifting or HIIT class. It can be even just taking like a really…a good, you know, brisk power walk every day and doing some like, you know, bodyweight exercises for, you know, 15, 20 minutes like 3 times a week, like something like that. If you start that let’s say like, you know, four months before you think you’re gonna start trying to get pregnant, by the time you get pregnant, you can keep doing that. We did a whole podcast on exercise and pregnancy. I tell patients, you know, “Keep going with it.” But at least, you know, even if you can’t completely overhaul your diet, at least try to get the exercise in. 


Dr. Fox: Yeah. I mean, pregnancy is rough. It’s hard to go through pregnancy. And then when you’re finished, now what? You have to recover, and you have a baby to take care of, and so it’s hard. And in my experience, it’s night and day, the people who enter pregnancy already on some sort of exercise program or in good shape, and they’re sort of used to it, how much on average, how much better they fare during pregnancy than women who don’t. And I just think it’s such a great opportunity to think about this before pregnancy to really, you know, push yourself if possible, I mean, you know, some people, whatever. It’s just a great motivator to do that, and it does have tremendous benefits. I mean, there are some extreme examples. Again, these are the exception where I see women like, “Listen, you’re really…” She has a real lot of weight to lose. She’s thinking about bariatric surgery. I mean, we’re talking about…you know, these are exceptions. And sometimes I will tell someone, “Listen, you’re better off waiting a year losing all this weight and then getting pregnant.” But it’s a conversation. Most people that’s not gonna be the case obviously. But it’s important to talk about this to figure this out on the front end rather than, again, trying to catch up once you’re already pregnant to figure out what to do. Because that first trimester people are very weak. They’re nauseous. Like it’s hard to start these things in the first trimester. So the time people really can start them they’re already, you know, 14, 15, 16 weeks, and it’s…you know, they lost that opportunity to have it going into pregnancy. 


Dr. Konstant: Yeah. Absolutely. 


Dr. Fox: And then what about things like screening tests in general, just general health type of exams that people might be due for? 


Dr. Konstant: Yeah. I think it’s important to get as up to date on everything as you can. If a patient is seeing a gynecologist, you know, making sure she’s up to date on her Pap smear. You did a podcast recently on just pregnancy in women over 40. And we definitely see many women in our office that are over 40. And 40 is the age where we start screening for breast cancer with yearly mammograms. And I’ve seen many patients come to us pregnant in their early 40s, and they actually haven’t had their first mammogram yet. And so I tell patients that, you know, if they’re thinking of getting pregnant, they’re going to be 40, 41, you know, when they might get pregnant to make sure to that, you know, they get their mammogram done before they get pregnant just to make sure that that’s clear. You know, obviously, mammograms are indicated earlier. If someone’s, you know, 36 and planning on getting pregnant and feels any type of breast mass, you know, planning on getting pregnant or not, that should be evaluated too. But definitely, you know, getting the mammogram done if a woman is turning 40 and is due for that. 


You know, I also tell patients it’s good to have a primary care doctor such as an internist. If you’ve had any, you know, strong family history of diabetes or high blood pressure, even if you don’t have those issues now, just to do a checkup and make sure you’re up to date on things like cholesterol screening. Some women also with a really strong family history of diabetes even if they’ve never been told that they’re diabetic might benefit from some testing just to make sure that they’re not, you know, pre-diabetic. So these are all things that if you have a check-in with even an internist, and you let that doctor know that you’re planning, you know, a pregnancy let’s say in the next year, you can…even just the general test that gynecologists don’t routinely do. We order the breast screening test and Pap smear. And I’ll sometimes order blood work, you know, to check for anemia and hypothyroidism, but I always tell patients to see a primary care doctor as well. 


Dr. Fox: A lot of women won’t actually need any of these things, and that’s fine. But sometimes women don’t know, for example, that, “Oh, I didn’t realize because of my age and my family history, I really should get a baseline colonoscopy let’s say.” You can do a colonoscopy when pregnant, but it’s more complicated. It’s more difficult. You know, you have the baby, you yourself are pregnant, and the gastroenterologists are usually [inaudible 00:28:08], same with the mammograms. It’s not like the radiation is so dangerous, but, you know, the breast tissue changes in pregnancy. And so all these things that…you know, whether someone does or doesn’t need a colonoscopy, do they need anything in terms of like checking your cholesterol like you said because the cholesterol values like are totally different when you’re pregnant, and so if you need to check it, you check it when you’re pregnant, like you said, screen for diabetes. Again, not everyone needs these things but to know if you need them to do it before. 


Even something as simple as going to the dentist. You can go to the dentist when you’re pregnant. It’s perfectly fine. There’s like 99% out of 100 things they’re gonna do are safe, and they ask us, and we say they’re safe. But everyone, it becomes such an ordeal when, you know, the dentist, “I wanna do this. I’ll ask your doctor.” They ask us. And it’s like a back and forth. Everyone’s afraid that like something horrible is gonna happen. The [inaudible 00:28:50] just go before you get pregnant. Let them do your cleaning. Let them do your doing checkup. If they wanna fill like cavities, they’ll do it. You don’t have to think about it when you’re pregnant, which is a really nice thing. If you have the opportunity to plan this, it’s really good. You can always see a general doctor when you’re pregnant as well, but there’s some things they won’t be able to do reliably when you’re pregnant, and some things that they’ll just have to wait till afterwards, which is usually fine. But that delay of a year sometimes means something. 


Dr. Konstant: And actually, I’m glad you brought the dentist because I tell patients during pregnancy if they’re due for their cleaning to absolutely go. But pre-pregnancy if you’re due, it’s definitely great to get any cavities, anything out of the way that you need done before. Having good dental health is actually very beneficial for the pregnancy. You know, if someone does, unfortunately, have let’s say multiple cavities that they’re not really aware of in terms gum disease, you know, that can be treated. And sometimes the bacteria from that can lead to an increased risk of certain pregnancy complications if someone has significant dental disease. So definitely getting that checked out, making sure there’s nothing that needs to be taken care of before, not even from like exposure risk from needing anesthesia or anything like that, even just from going into the pregnancy with, you know, healthy gums, healthy teeth. 


Dr. Fox: Yeah, 100%. And also, you know, if they have to do procedures, people bleed more in pregnancy. So, if they have to have something for their gums or a teeth pulled, it’s doable in pregnancy, and it’s typically safe, but it’s just a little bit harder. And the dentist, you know, tend to prefer you not being pregnant, and the pregnant patients tend to prefer not being pregnant. And so it just makes it easier. And, I think, in terms of sort of standard things, a lot of people also it’s important for their expectations for fertility when talking with the ob-gyn. Someone says, “I’m gonna try getting pregnant,” and then they think, “All right. So I’m gonna stop my birth control, and I’ll be pregnant next month.” And, you know, that might happen, but, I think, a lot of women don’t always know what to expect, you know, based on their age and this, what’s the likelihood. And when women find out that usually on average, it takes about four cycles to get pregnant, and that’s normal, and so then they’re maybe less stressed or anxious about the fact that it didn’t happen on the first time, or, for example, we find out that she’s having very irregular periods or even if we knew this we’ll say, “All right. Listen, you know, this may make it difficult for you to get pregnant, and so maybe we should address this or at least see how you do for only a couple of months and then evaluate.” 


And when I spoke to Dr. Lobel about fertility, she was saying, you know, “If someone has irregular periods, you know, evaluate it much sooner because like she’s a setup for having a hard time to get pregnant and why cause all that time and stress?” And it doesn’t mean you have to do IVF. It just means it should be addressed. And so having this conversation beforehand is also helpful because then sometimes women come to our office and they’ve been trying for four to six months, and they’re distraught. And this could have been addressed earlier so they didn’t have to go through all that stress or at least they would have known that it’s gonna happen and that their expectations aren’t sort of unmet. 


Dr. Konstant: You know, absolutely. You know, I’ve had patients who are stopping contraception, they wanna get pregnant, but they’re fine if it happens in six months to a year, or if it happens next month. They’ll give it a year if they don’t care, you know, how long it takes, and they really don’t wanna, you know, intervene. But then I have patients that really want to get pregnant fairly quickly, and again, I’ll always go over what the typical expected, you know, time frame is. But as you said, if there’s anything else, I think, is gonna make it more difficult for a woman to get pregnant, irregular cycles tend to be probably one of the most common culprits, or if someone tells me that they have a history of endometriosis, they’ve had surgeries for endometriosis, and now they’re trying to get pregnant, I’ll tell them, “Look, we know in women with your condition that sometimes it can take longer to get pregnant. You may have some scarring, you know, internally of the Fallopian tubes. And, in fact, if that’s the case, you may need significant help getting pregnant.” So I’ll just set a time frame where I’ll say, you know, it would actually not be unreasonable to maybe have a study done to look to make sure your Fallopian tubes are open, maybe see an infertility, you know, specialist. Then you can decide how aggressive you wanna be right away. But that’s not someone I’m going to say…you know, even if, you know, a woman who’s let’s say 26 years old from age perspective, no fertility issues, I’m not gonna tell her, “Oh, yeah, you know, just give it a year,” because she may actually have an underlying issue that’s gonna make it difficult no matter what her ovarian function, no matter how old she is. 


Dr. Fox: Right. Right. I think that’s really important. Again, it’s just from a conversation. I wanna talk about a few more sort of “mundane things,” and then we’ll talk about medical conditions. But in terms of mundane things, another thing that, I think, people forget to plan is who’s gonna take care of you when you’re pregnant. Because a lot of people…a lot of women when they’re seeing an ob-gyn, there are some who do continue and take care of pregnant women sort of obstetricians who continue, you know, take care of them, deliver them. And some of them just do gynecology or first-trimester pregnancy, and they no longer do deliveries. And we all trained in doing deliveries, but some continue, some don’t. And sometimes women they’re seeing a gynecologist, and this is…they’re pregnant and like, all right, and the gynecologist is like, “Now you gotta go somewhere else,” and like, “What? Like what do you mean?” And, I think, it’s just important to plan that. And the reason it’s important to plan is number one, you don’t wanna be like stressed and racing around trying to find a doctor at the last minute. But also you may…it may change, for example, if you have a choice of insurance plans, and one of them, you know, has a certain doctor and one of them doesn’t, or you may wanna look into, you know, “Do I wanna be at a certain hospital, and who are the doctors affiliated with that hospital?” I mean, it may have implications or that you may wanna meet people before you get pregnant so you don’t have to start, you know, “interviewing doctors” when you’re already pregnant. And so that’s just something to double-check. Who do you plan to take care of you when you’re pregnant? 


And then other things like insurance, like the same thing with your health insurance to make sure that you have the right one in terms of pregnancy benefits. And like I said, the doctors who may take care of you or the hospitals is important. But also things like life insurance and disability. A lot of people when they wanna sign up for that if they’re already pregnant, it’s complicated because that’s a condition you have right now, and it’s, you know, “a condition.” I mean, it’s sort of weird that we call it that, but whatever. But also like blood work that they wanna normally do is sometimes is out of whack. I’ve had a lot of people say, “Oh, I got blood work done, and my cholesterol was sky-high. Now I can’t get life insurance or whatever.” And it was only high because they were pregnant. You know, insurance companies don’t always discern that. So it’s just something…you know, again, these are mundane things, and they’re not life and death obviously. But if you’re thinking of getting a life insurance or disability policy, you know, get that squared away before you get pregnant or double-check that if it matters or what they require in terms of blood testing or whatnot. And also, you know, with your health insurance nowadays, it’s just a really important piece to make sure it’s the right one you want for when you are pregnant. 


Dr. Konstant: And the other issue is even complications sometimes during pregnancy. We obviously hope that most pregnancies are not gonna have any complications. But, you know, even if mom and baby are fine in the end, just having had certain pregnancy complications from what I understand can sometimes also make it a little more challenging to get life insurance or disability insurance or at least the policy that you would want afterwards, even when you’re not actually pregnant anymore. So, I think, getting that squared away before you even go down the road of pregnancy is ideal. 


Dr. Fox: Yeah. And I would say just from a financial planning perspective, we’re gonna take a side road here, when people ask me, you know, “Should I get life insurance?” I would say, “Once you have kids, you need life insurance.” It’s just basically how it goes. And that’s usually what pushes people. Some people are very diligent and get it when they’re young and this because they have good rates. But for most people sort of, you know, like me, they don’t think about it until they’re getting older. Once you start having kids, you’re like, “Oh, like whoa, you know, like we need to plan.” And so if you’re thinking of getting pregnant, you should also be thinking about getting life insurance anyways. And so it’s a good time to have a conversation with someone who knows something about this and maybe getting that squared away before you get pregnant. People who deal with this will know also sort of how it’ll affect you or not. So those are like sort of the mundane. And, I think, the most critical aspect of this is for people who actually do have medical conditions, whether they think them insignificant, or whether they know that they’re significant, there are so many things that you wanna take care of before pregnancy in terms of a medical condition. 


I mean, when we think about women who get pregnant or are gonna get pregnant and have a medical condition, we always think of three things, sort of how is getting pregnant going to affect the condition? Meaning, are you at a point right now where if you get pregnant, you’re gonna get really sick, right? Is it gonna make you worse or potentially make you better or have no effect? Unfortunately, that’s not typical but okay. And the second is how is the medical condition gonna affect pregnancy? Are you at an increased risk for birth defects, for preterm birth, or whatever, something like that? And the third is treatments, whether they’re medications, whether they’re procedures, whether they’re imaging studies, do they have to be changed in pregnancy? And having that all optimized before pregnancy is so crucial. And I say optimized because you’re not gonna cure someone’s hypertension or diabetes before they get pregnant, right? They’re gonna have it. But if you have it optimized that they’re seeing the right doctors, they are taking the right medications, ideally, they’ve met either with the obstetrician or a maternal-fetal medicine specialist if necessary to have a plan in place for what happens when I get pregnant. When I see people before pregnancy for those types of visits, I’m so happy. I’m like, “This is great. Like this is amazing. We’re gonna plan. We’re gonna optimize the situation.” And almost always it’s not a problem for them to get pregnant. We tweak a few things, we don’t tweak a few things, or we just have a plan in place, and so everyone’s on the same page. Because, again, if you start doing these things later, it can have significant consequences for some conditions or just real annoying ones for others. 


Dr. Konstant: The other thing that goes along with that is I tell patients, “If you want to get pregnant and you are on let’s say on multiple medications for different issues…” The other thing I’ve seen is patients suddenly, you know, let’s say not…you know, maybe getting pregnant unexpectedly or not having let’s say a maternal-fetal medicine consult or a preconception consult. And they find out they’re pregnant, and in fear of, you know, “Oh, these medications might harm my baby,” they just stop their medications, which is also really not good because then you’re not treating, you know, your medical issues. So, what I would say is for women who let’s say do unexpectedly find themselves pregnant who have medical issues, try to make an appointment as soon as possible with an obstetrician and don’t…or if you’re trying to get pregnant, don’t just stop your medications like actually…because even if, you know…some medications need to be tapered off, so even if there’s a medication where, you know, you and your maternal-fetal medicine specialist have agreed, you know, this is something that you shouldn’t be on in pregnancy, we need to use an alternative, switching to medication sometimes needs to be done gradually. 


But also, you know, I remember having a patient as a resident who had a seizure disorder, and she found out she was pregnant. As soon as she had a pregnancy test, she just stopped her medication, and she started having seizures before, you know, she could see us. So, that’s another thing. There are definitely medications to treat multiple medical issues that can be taken in pregnancy that are thought to be very low risk. Women who are on certain medications that are higher risk in pregnancy can still get pregnant. They may just need to be transitioned to other, you know, effective medications that maybe they haven’t been on before. And if this is planned in advance, you know, she’ll know that she doesn’t have any bad side effects from these new medications, that they’re actually effective for her issues. So planning ahead but also not just abruptly stopping things if someone decides to go ahead and get pregnant. And I would also add to that for patients that are on medication for any mental health issues, depression, anxiety, bipolar disorder, that’s definitely another area where patients ask me all the time, you know, “Am I gonna be able to continue on my Lexapro during the pregnancy?” And that’s a whole, again, another area in and of itself. But we have many patients that continue those medications because they can’t function without them. And I would just have a discussion, you know, with your ob-gyn. Don’t just stop them abruptly because that can also then lead to, you know, just deterioration abruptly in your, you know, mental health, which isn’t good for mom or the baby. 


Dr. Fox: Yeah. Absolutely. I would say, you know, when I do these consultations, I don’t do general ob-gyn. So I would be the person seeing them sort of second. You know, if someone sees their ob-gyn and they’re planning a pregnancy and say, “All right. You’re on X, Y, and Z. You have this condition. Why don’t you see, you know, Fox and we’ll see what the story is.” I see patients, you know, in this situation all the time. It’s one of the things we do a lot. And I would say that the majority of the time, there’s nothing that I would recommend that would delay them getting pregnant. The majority of the time it’s like, “Okay. Here’s what you have. Things seem to be okay. Let’s discuss the safety medications around. They’re probably fine. You’re good. Here’s what we’re gonna do. When you get pregnant, here’s what we’re gonna do. During pregnancy, let’s make sure I, you know, develop a relationship with your neurologist, your psychiatrist, your cardiologist, whoever, so everyone’s sort of on the same page.” That’s how they usually go. 


I would say occasionally, you know, there’s a percentage where I do wanna make some changes or recommend some changes and talk to their doctor first, maybe get a couple more tests, or maybe like we said, switch one of their medications. But the delay we’re talking about is on the order of a couple of months, right? That’s sort of like the longest it’s gonna be. And most people aren’t thinking getting pregnant tomorrow when they’re having these visits, like oh, that’s well within their time frame. Again, that’s not even usual, but it happens a couple of months maybe to switch a medicine or do another test or, you know, get that operation that you’re waiting to get or, you know, whatever it is. It is so unusual that someone comes, and I would say, “You’re too sick to get pregnant ever, or the things we need to do are gonna take six months to a year.” It happens occasionally, and it’s very important obviously because, you know, potentially if they got pregnant without these things, it could be life-threatening. But that’s really the only situation where it’s gonna be six months to years if like when they get pregnant, it’ll like literally be, you know, high risk of death. Like that’s so unusual that it doesn’t happen. So people shouldn’t be afraid of this like it’s gonna somehow change their reproductive plans. Most of the time, it’s just getting a plan in place, everyone’s on the same page. Some of the times, there’s some I would call tinkering that has to be done, which is on the order of weeks to months, a couple of months, and then rarely we’ll find something that’s quite significant, but that’s really the exception. And so people should not be concerned that this type of visit’s gonna, you know, affect their, you know, reproductive plans. It’s just gonna optimize it. 


Dr. Konstant: If anything, women will actually end up getting good news at these visits… 


Dr. Fox: Yeah. Surprisingly. 


Dr. Konstant: …that there’s chance for a healthy pregnancy. Even with complicated medical issues, it can actually be very good if managed appropriately. 


Dr. Fox: A lot of it also depends on who’s taking care of them for those medical conditions. There are some doctors who do it who are very experienced and very comfortable with their patients getting pregnant, and they know what to do. And by the time I see them, I’m like, “Yeah. Your doctor’s like all over it.” Like, yes, I just basically sign off on the plan. I’m like, “It looks perfect. We’re good to go.” There are some doctors who are either less experienced with it, or they don’t typically take care of women let’s say or whatever it is, and they’re much more out of loop so to speak with pregnancy, and then sometimes we have to do a little bit more. So a lot of it depends on that. And it’s the same thing. If someone, not just their ob-gyn, if they have a condition and they’re seeing, whatever, you know, an endocrinologist, a neurologist, at some point say, “Hey, I’m thinking of getting pregnant. Do you have anything you want me to do before pregnancy or any changes?” And they’ll frequently appreciate the same type of question, so they can help plan. Most of the doctors who take care of women know this and are ready to plan for pregnancy, but it has to be brought up because they’re not always gonna bring it up to the patient herself. 


Dr. Konstant: Yeah. Absolutely. 


Dr. Fox: Wow. This is great. Sara, what an important podcast. I mean, all of us who do this find it so valuable when we see women before they get pregnant. And, I think, that the women themselves also get a real good sense of comfort and security and that everything is really optimal, and they’re entering pregnancy or the attempt of pregnancy with much more peace of mind than just finding out you’re pregnant and then, “Oh, my God, I have to take care of all these things.” And it’s why have more stress? Pregnancy is stressful enough, like why add to that? 


Dr. Konstant: Yeah. Absolutely. Yeah. I agree. One of the actually rewarding things is sometimes I’ve seen patients that I saw, you know, say for a checkup, and they come back let’s say like, you know, a year or two later for a new pregnancy visit. And, yeah, we got a lot of these things squared away, and it’s nice because, you know, they show up, and, you know, we go through everything. I think everything’s been done. It just adds some reassurance in, you know, the first few weeks. 


Dr. Fox: Excellent. Well, the preconception visit. So if you are thinking of getting pregnant, or you’re not sure if you’re thinking of getting pregnant, even if you’re seeing your doctor once a year or whatever it is, make an appointment, say, “Hey, let’s have an appointment specifically about this, to talk about this, to plan for this.” And, I think, that people will definitely be happy that they made that appointment, and it’ll be very helpful for them for their health and for their pregnancy. 


Dr. Konstant: Now go get that folic acid. 


Dr. Fox: All right. Sara, thank you so much. We’re gonna have to have you discuss something actually in pregnancy as well because we’re just…you know, as we say, we’re circling around pregnancy with you. 


Dr. Konstant: Right. Exactly. We’ll have to pick something right in the middle of pregnancy. 


Dr. Fox: All right. Sara, thank you so much. We’ll have you on again. 


Dr. Konstant: Great. Sounds good. Thanks so much. 


Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s www.healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. 


The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.