Clinical Sections
Micronutrient Optimization
Adequate micronutrient intake before pregnancy supports early fetal
development and maternal health (for more information refer to SOGC Guideline No. 427: Folic Acid and Multivitamin Supplementation for Prevention ofFolic Acid–Sensitive Congenital Anomalies).
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Preconception Domain
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Key Preconception Considerations
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Why Timing Matters
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Priority Action
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Referral
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Folic acid
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Neural tube closure occurs early
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Supplementation may begin too late if started after pregnancy
recognition
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Recommend folic acid prior to conception
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Primary care
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Iron
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Iron deficiency common in reproductive-aged individuals
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Pregnancy increases iron requirements
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Screen for anemia and provide supplementation
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Primary care
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Vitamin D
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Deficiency common in northern climates
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Supports maternal bone and immune health
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Assess risk and supplement if needed
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Primary care
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Diet quality
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Balanced diet supports reproductive health
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Nutrient availability influences fetal development
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Provide dietary counselling
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Dietitian
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Folic Acid Supplementation
Folic acid supplementation is one of the most effective preconception
interventions for preventing neural tube defects (NTDs) and supporting early
fetal development. Neural tube closure occurs very early in
embryogenesis—typically within the first four weeks of
pregnancy—often before an individual knows they are pregnant. As a
result, initiating folic acid supplementation only after pregnancy recognition
may be too late to provide optimal protection.
For this reason, folic acid supplementation should be recommended for all
individuals of reproductive age who could become pregnant, regardless of
current pregnancy intention. Ensuring adequate folate status prior to
conception supports early neural development and contributes to healthier
pregnancy outcomes.
Preconception visits provide an important opportunity to review folic acid
intake, recommend supplementation when needed, and ensure that patients
understand the importance of starting supplementation before pregnancy occurs.
Why Folic Acid Matters Before Pregnancy
Folate plays a critical role in DNA synthesis, cellular division, and early
embryonic development. Adequate folate levels during the periconception period
reduce the risk of neural tube defects such as:
- Spina bifida
- Anencephaly
- Encephalocele
Because neural tube development occurs very early in pregnancy, folate status
must be sufficient before conception and during the earliest weeks of
gestation.
Additional benefits of adequate folate intake may include:
- Support for healthy placental development
- Reduced risk of certain congenital anomalies
- Improved maternal nutritional status entering pregnancy
Clinical Recommendations
Health care providers should counsel patients of reproductive age about folic
acid supplementation as part of routine preventive care.
General recommendations include:
- Recommend daily folic acid supplementation prior to conception
- Encourage use of a prenatal or multivitamin containing folic acid
- Review supplement use during routine visits
- Reinforce that supplementation should continue during early pregnancy
For most individuals at average risk, a minimum daily dose of 0.4 mg (400
micrograms) is recommended prior to conception and during early pregnancy.
Higher doses may be indicated for individuals with increased risk of neural
tube defects and should be guided by clinical assessment.
Patients Who May Require Higher Folic Acid Doses
Higher-dose folic acid supplementation may be recommended for individuals with
specific risk factors, including:
- Previous pregnancy affected by a neural tube defect
- Pre-existing diabetes
- Obesity
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Certain medications that interfere with folate metabolism (e.g.,
antiepileptic medications)
- Malabsorption conditions
- Family history of neural tube defects
These patients may benefit from specialist consultation or individualized
supplementation guidance.
Practical Counselling for Patients
Patients should be encouraged to:
- Begin taking folic acid before trying to conceive
- Continue supplementation during early pregnancy
- Take folic acid as part of a daily multivitamin or prenatal vitamin
- Maintain a diet that includes natural folate sources, such as:
- Leafy green vegetables
- Legumes
- Citrus fruits
- Fortified grain products
While dietary folate contributes to overall nutrition, supplementation is
still recommended to ensure adequate intake.
Clinical Pearl: Because neural tube development occurs within
the first month of pregnancy, folic acid supplementation must begin before
conception to be most effective.
Quick Clinical Actions
During routine visits with patients of reproductive age:
- Ask about vitamin or supplement use
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Recommend daily folic acid supplementation
- Provide clear guidance about starting before pregnancy
- Reinforce supplementation during ongoing reproductive health visits
Even brief counselling about folic acid can significantly reduce the risk of
neural tube defects and improve pregnancy outcomes.
Weight and Metabolic Health
Body weight and metabolic health prior to pregnancy influence fertility and
pregnancy outcomes. For more information, refer to SOGC Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care
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Preconception Domain
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Key Preconception Considerations
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Why Timing Matters
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Priority Action
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Referral
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BMI
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Both high and low BMI increase pregnancy risk
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Weight influences fertility and metabolic health
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Assess BMI and discuss health goals
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Primary care
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Metabolic risk
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Obesity increases risk of gestational diabetes
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Metabolic conditions begin early in pregnancy
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Screen for metabolic risk factors
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Primary care
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Lifestyle behaviours
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Diet and activity influence metabolic health
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Behaviour changes require time
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Encourage lifestyle interventions
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Primary care
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Eating disorders
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Disordered eating affects fertility and nutrition
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May worsen during pregnancy
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Screen and refer for specialized care
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Mental health
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Physical Activity and Lifestyle
Healthy lifestyle behaviours improve metabolic health and reproductive
outcomes.
Providers should discuss:
- Regular physical activity
- Balanced diet
- Adequate sleep
- Stress management
- Reduced sedentary behaviour
Physical activity improves cardiovascular and metabolic health and may support
fertility. For additional information, refer to SOGC Guideline No. 367-2019 Canadian Guideline for Physical Activitythroughout Pregnancy.
Age and Reproductive Health
Age influences fertility, pregnancy risk, and genetic outcomes (see SOGCGuideline No. 346-Advanced Reproductive Age and Fertility).
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Domain
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Key Preconception Considerations
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Why Timing Matters
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Priority Action
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Referral
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Maternal age
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Fertility declines with age
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Delayed pregnancy may increase infertility risk
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Provide anticipatory counselling
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Primary care
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Genetic risk
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Chromosomal abnormalities increase with age
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Early counselling supports informed decisions
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Discuss genetic screening
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Genetics
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Pregnancy complications
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Advanced maternal age increases risk of complications
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Risk assessment supports planning
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Review pregnancy risks
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Obstetrics
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Paternal age
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May influence fertility and genetic risk
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Partner health influences reproductive outcomes
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Include partners in counselling
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Primary care
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Clinical Pearl: Age-Related Counselling Supports Planning
Discussing reproductive timelines helps individuals and couples make informed decisions about pregnancy timing and fertility planning.
Equity Alert: Avoid Weight Stigma
Weight stigma can reduce patient engagement and discourage individuals from seeking care. Preconception counselling should emphasize supportive health promotion rather than judgment.