Preconception Medication Counseling: How to Adjust Drugs to Protect Future Babies

Half of all pregnancies in the U.S. are unplanned. That means for many women, the first weeks of pregnancy - when the baby’s heart, brain, and spine are forming - happen before they even know they’re pregnant. And if they’re taking certain medications during that time, the risks to the baby can be serious. This is why preconception medication counseling isn’t just a good idea - it’s essential care for anyone who could become pregnant.

Why Timing Matters More Than You Think

Most people think pregnancy risks start once you miss your period. But the truth is, the biggest dangers happen before that. Between weeks 3 and 8 after conception, the embryo is building its major organs. That’s when exposure to certain drugs can cause birth defects - and most women don’t even know they’re pregnant yet.

That’s why waiting until you’re pregnant to talk about your meds is too late. By then, the damage might already be done. Preconception counseling means reviewing every pill, supplement, and over-the-counter drug you take - before you get pregnant. This isn’t just for women planning to conceive. It’s for anyone who’s sexually active and not using birth control, because you can’t predict when conception will happen.

Medications That Can Hurt a Developing Baby

Not all medications are safe during early pregnancy. Some are known to cause serious harm. Here are the big ones doctors watch for:

• Valproic acid (used for epilepsy and bipolar disorder): Increases neural tube defect risk from 0.1% to over 10%. Switching to lamotrigine before pregnancy cuts that risk dramatically.
• ACE inhibitors (like lisinopril or enalapril): Used for high blood pressure. Can cause kidney failure and low amniotic fluid in the fetus if taken after the first trimester.
• Warfarin (a blood thinner): Linked to fetal warfarin syndrome, which causes facial deformities and bone problems.
• Isotretinoin (Accutane for acne): One of the most dangerous. Up to 35% of babies exposed in early pregnancy have major birth defects.
• Methotrexate (for rheumatoid arthritis or cancer): Causes miscarriage or severe birth defects. Must be stopped at least 3 months before trying to conceive.
• Dolutegravir (an HIV medication): Early data showed a small increase in neural tube defects. Now, doctors weigh risks carefully and may switch to safer alternatives.

These aren’t rare cases. A 2021 JAMA study of over 12,000 women found that those who got preconception counseling had 37% fewer major birth defects. The biggest drops? 42% fewer neural tube defects and 33% fewer heart problems.

What a Good Counseling Session Looks Like

Preconception counseling isn’t a one-time lecture. It’s a process. Here’s what it should include:

1. Ask the key question: “Would you like to become pregnant in the next year?” This simple question, recommended by ACOG, opens the door for honest conversation - even if the patient says no.
2. Review every medication: Prescription, OTC, herbal, vitamins. No exceptions. Even something as simple as ibuprofen can be risky if taken daily.
3. Check the risk level: Doctors use updated FDA labels (Pregnancy and Lactation Labeling Rule) and trusted databases like MotherToBaby or TERIS to rate each drug’s danger level.
4. Plan the switch: Some meds need to be changed months in advance. Methotrexate? Stop 3 months before. ACE inhibitors? Switch to methyldopa or labetalol at least one cycle before conception.
5. Start folic acid: At least 400 mcg daily, ideally 3 months before trying. This cuts neural tube defect risk by up to 70%.
6. Document everything: Use ICD-10 code Z31.69 for preconception counseling. It’s not just paperwork - it’s how care gets tracked and paid for.

For women with chronic conditions like epilepsy, diabetes, or autoimmune disease, this isn’t optional. Stopping the wrong drug can be just as dangerous as keeping it. A woman with uncontrolled seizures is at higher risk of miscarriage and fetal injury than one whose seizures are managed with a safer medication like lamotrigine.

Why So Many Women Are Still Not Getting This Care

You’d think this would be standard. But here’s the reality:

• Only 24% of reproductive-aged women receive any kind of preconception care, according to national survey data.
• Just 41% of primary care doctors routinely check for teratogenic meds.
• On Reddit, 68% of women said they were never asked about their meds before getting pregnant - even though they were on regular prescriptions.
• Many feel caught between specialists: “My neurologist said talk to my OB. My OB said talk to my neurologist.”

Part of the problem is that healthcare is broken into silos. A woman might see her rheumatologist every 3 months, her PCP once a year, and her OB-GYN only when she’s pregnant. No one’s connecting the dots.

Another issue? Fear. Patients are scared to stop their meds. “What if my anxiety gets worse?” or “What if I have a seizure?” Providers sometimes overestimate risks and stop needed drugs - a mistake called “therapeutic nihilism.” The goal isn’t to stop all meds. It’s to swap risky ones for safer ones.

How Technology Is Helping - and Where It’s Falling Short

Some clinics are using electronic health records (EHRs) to catch risky meds before they’re prescribed. Epic’s Care Everywhere system, for example, flags high-risk drugs and prompts providers to discuss alternatives. A 2022 study found this reduced dangerous exposures by 29%.

But only 35% of U.S. healthcare systems have this tech. And even when it’s there, it’s not foolproof. If a patient takes a supplement not in the system, or buys a drug over the counter, the alert won’t trigger.

AI tools are emerging. The University of Washington’s PreConception Medication Advisor prototype correctly identified risk levels in 92% of cases. But these aren’t widely available yet.

Meanwhile, insurance coverage is uneven. Medicaid patients are less than half as likely to get counseling as those with private insurance. Rural women face even bigger gaps - only 12% receive counseling compared to 33% in cities.

What You Can Do Right Now

You don’t need to wait for your doctor to bring it up. Here’s how to take charge:

• If you’re on any chronic medication and could get pregnant, ask: “Is this safe if I conceive?”
• Bring a full list of everything you take - including vitamins, herbal teas, and CBD oil.
• Ask for a referral to a maternal-fetal medicine specialist if you have a complex condition.
• Start folic acid today. It’s cheap, safe, and proven to help.
• If you’re not ready to get pregnant, use reliable birth control. That’s part of the plan too.

There’s no shame in needing help. Most women who get preconception counseling say they wish they’d done it sooner. One woman on BabyCenter described how her MFM specialist created a 6-month plan to switch her from valproic acid to lamotrigine, with weekly check-ins and extra folate. She went on to have a healthy baby. That didn’t happen by accident. It happened because someone took the time to plan ahead.

The Future of Preconception Care

Things are changing. The FDA now requires all new drugs to include clear fetal risk data. CMS requires Medicaid to cover preconception counseling. And in 2024, Congress introduced the PRECONCEPTION Act, which could make this care mandatory for insurance plans.

But until then, the responsibility falls on you and your providers. This isn’t about being perfect. It’s about being informed. You don’t need to have it all figured out. You just need to start the conversation.

Because the best time to protect your future baby isn’t when you’re pregnant. It’s before you even try.