A 27-year-old woman, gravida 2 para 0 aborta 2, comes to the office for a preconceptual counseling visit. The patient had a spontaneous first trimester abortion 5 years ago and an ectopic pregnancy treated with methotrexate 3 years ago. Since then, the patient has been using depot medroxyprogesterone injections for contraception; her last dose was administered 13 weeks ago. She has been amenorrheic for the past 2 years. The patient has mild persistent asthma for which she takes an inhaled glucocorticoid and a short-acting beta agonist as needed. She does not use tobacco, alcohol, or illicit drugs. The patient drinks 2 cups of coffee each morning and has a glass of noncaffeinated diet soda with dinner. She follows a low-carbohydrate diet and exercises regularly. The patient has a younger brother with autism and a cousin who had a termination for a fetus with trisomy 18. Vital signs are normal. BMI is 24 kg/m². Physical examination is unremarkable. The patient asks if there is anything she can do to prepare for pregnancy. In addition to discontinuation of the medroxyprogesterone injections, which of the following is the best advice for this patient?

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Explanation: 11ec2b69_c03a_28ff_8f63_b1b9a831bde2_MD0005_00 Folate deficiency during pregnancy can lead to inadequate cell turnover in the closure and incomplete formation of the neural tube (normally occurring by 6 weeks gestation). Folate is naturally found in green vegetables and other foods. Folic acid is its synthetic form, found in supplements and added to fortified foods, with a higher bioavailability than natural folate. However, women following a low-carbohydrate diet may not ingest enough fortified foods to meet the minimum daily folate requirement without additional supplementation. All women planning pregnancy should begin supplementing 0.4 mg of folic acid daily >1 month prior to conception and continue through the first trimester of pregnancy to decrease the risk of neural tube defects. Because many pregnancies are unplanned, it is recommended that women of childbearing age consume this amount daily. A higher dose of 4 mg daily is recommended for women who have risk factors for a neural tube defect (eg, antiepileptic use, prior pregnancy with a neural tube defect). (Choice A) Consultation due to recurrent miscarriage is not indicated until >3 spontaneous abortions, not inclusive of ectopic pregnancies. In addition, aneuploidy (eg, trisomy 18) is due to errors in meiosis and is typically not genetic. (Choice B) Moderate levels of caffeine intake (<200 mg/day) are not associated with adverse effects during pregnancy. (Choice D) Obesity is associated with an increased risk of complications in pregnancy (eg, gestational diabetes mellitus, hypertension). This patient has a normal weight and would not benefit from weight loss. (Choice E) Inadequately treated asthma can lead to fetal and maternal mortality. The mildly increased risk of cleft palate associated with systemic glucocorticoid use is minimal compared to the risk of uncontrolled asthma. Inhaled glucocorticoids pose no or minimal risk to pregnancy and can prevent the need for systemic medication. Educational objective: All women planning pregnancy should take 0.4 mg of folic acid daily for >1 month prior to conception to decrease the risk of neural tube defects; women at high risk for these defects should take 4 mg of folic acid daily. References: Effects and safety of periconceptional folate supplementation for preventing birth defects. (http://www.ncbi.nlm.nih.gov/pubmed/26662928) Folic acid supplementation for the prevention of neural tube defects: US Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/28097362)

A 27-Year-Old Woman, Gravida 2 Para 0 Aborta 2, Comes