Trimester Zero

08 Dec Trimester Zero

We’re all familiar with trimesters 1, 2, and 3, but what about trimester 0? Trimester 0 is the time before becoming pregnant in which proper preconception care and counseling should be obtained. Your overall health is important long before conception, as a preventative measure to help prepare for a healthy pregnancy. Learning about the different precautions you should be taking, ensuring you are getting the proper nutrients and leading a healthy lifestyle are all important factors in preconception care. However, this doesn’t apply just for women who are avidly planning to expand their families. Almost half of all pregnancies in the U.S. are unintended, meaning all women should be educated on reproductive health and preconception care as well as continually taking care of themselves in trimester 0.¹ So, what exactly does preconception care entail? The Centers for Disease Control and Prevention (CDC) has defined preconception care as “a set of interventions that aim to identify and modify medical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management.”²

The following are 9 specific preconception wellness measures from a consensus statement from the National Preconception Health and Health Care Initiative confirming high-quality preconception care:

• Pregnancy intention³
• Access to care³
• Preconception multivitamin with folic acid³
• Tobacco avoidance³
• Absence of uncontrolled depression³
• Healthy weight³
• Absence of sexually transmitted infections (STIs)³
• Optimal glycemic control in women with pre-gestational diabetes³
• Teratogenic medication avoidance³

In addition, several national and international medical organizations and advocacy groups have developed clinical recommendations and educational materials regarding preconception care. Core preconception care considerations addressed by all include the following factors:

• Undiagnosed, untreated, or poorly controlled medical conditions⁴
• Immunization history⁴
• Medication and radiation exposure in early pregnancy⁴
• Nutritional issues⁴
• Family history and genetic risk⁴
• Tobacco and substance use and other high-risk behaviors⁴
• Occupational and environmental exposures⁴
• Social issues⁴
• Mental health issues⁴

It is important to be aware of and understand any pre-existing conditions you may have along with your family history of diseases/disorders before becoming pregnant. Every woman’s pregnancy journey looks a little different, and you want to be aware of any complications that may arise so you and your healthcare provider can better address them. For example, closely monitoring glucose in a diabetic woman before conception and throughout pregnancy can decrease maternal morbidity, spontaneous abortion, fetal malformation, fetal macrosomia, intrauterine fetal death, and neonatal morbidity.⁵

It is also critical to ensure you are obtaining the proper nutrients during trimester 0 to build up stores of essential nutrients that will be depleted once you are pregnant. Perhaps the most important vitamin that you should be implementing into your regimen is folate. Folate supplementation should begin at least 1 month before pregnancy (hence the term “trimester 0”) to reduce the incidence of neural tube defects such as spina bifida and anencephaly.^6-8 The neural tube closes at between days 14-28 of pregnancy, so building up folate stores before conception is especially important.⁹ Healthy levels of folate have been shown to correlate to healthier, fuller term pregnancies, and healthier babies.¹⁰

The type of folate is also important. It is important to take bioavailable folate, as a large percentage of women may have decreased enzymatic activity of a crucial enzyme involved in the metabolism of folic acid to the active form of folate. PrimaCare^™ contains Quatrefolic^® ((6s)-5-methyltetrahydrofolate acid glucosamine salt), which is a bioactive form of folate.

Blood volume drastically increases during pregnancy, so it is important to make sure you’re building up iron stores during trimester 0. Iron, along with folate and vitamin B12, is essential for the proper development of red blood cells.^11,12 The demand for iron increases steadily throughout pregnancy, especially in the second and third trimester.¹³ In order to meet the increased iron intake requirement during pregnancy, maternal iron stores are drawn upon, consequently increasing the risk of iron deficiency.¹⁴ Therefore, it is important to be taking iron during trimester 0 to make sure your hemoglobin levels and ferritin stores are built up before pregnancy. PrimaCare^™ contains a chelated iron, Sumalate^®, which has a 40% absorption rate that allows for decreased GI upset, when compared to other iron salts.¹⁵

Other lifestyle factors are also important for a healthy trimester 0. You should abstain from tobacco, excessive drinking, and over-eating. You should ensure you are eating a balanced diet and getting adequate exercise and sleep. You should make sure you are up to date on immunizations, and avoid highly polluted areas, which may contain harmful chemicals.

Not only does preconception care take into account physical health, but also mental health. Mental health is how we think, feel, and act as we cope with life.¹⁶ Mental health screenings and treatments are an important aspect of preconception care. Preconception mental health has been shown to be an important risk factor for pregnancy complications, such as non-live births and low birth weights.¹⁷ Women who reported poor mental health before pregnancy were 40% more likely to have a pregnancy complication, almost 50% more likely to have a non-live birth, and nearly twice as likely to give birth to a low birth weight baby.¹⁷ This illustrates that proper preconception care involving mental care is important for the outcomes and health of women and their babies.¹⁷ Not only is it important for women who have had a history with mental illness to take the necessary precautions to stay healthy and be aware of possible implications, but all women should know and understand the role mental health plays in preconception and pregnancy.

Trimester 0 is an important period of time you may not have been thinking about. It is a time to prepare mentally and physically for pregnancy. Making sure you receive proper preconception care and counseling during this time can be seen as a preventative measure to try to circumvent any complications that may arise during pregnancy. But, trimester 0 is even bigger than that. It is drawing awareness to reproductive health, before and between pregnancies. Trimester 0 is a time that all women should be aware of and talking about.

REFERENCES: 1. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24–9, 46. 2. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care—United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Morb Mortal Wkly Rep. 2006;55(RR-6):1-23. 3. Frayne DJ, Verbiest S, Chelmow D, et al. Health Care System Measures to Advance Preconception Wellness: Consensus Recommendations of the Clinical Workgroup of the National Preconception Health and Health Care Initiative. Obstet Gynecol. 2016;127(5):863-72. 4. The importance of preconception care in the continuum of women’s health care. ACOG Committee Opinion No. 313. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:665–6. 5. Pregestational diabetes mellitus. ACOG Practice Bulletin No. 60. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;105:675–85. 6. Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J Med 1992;327:1832–5. 7. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet 1991;338:131–7. 8. Botto LD, Moore CA, Khoury MJ, Erickson JD. Neural-tube defects. N Engl J Med 1999;341:1509–19. 9. Cavalli P. Prevention of Neural Tube Defects and proper folate periconceptional supplementation. J Prenat Med. 2008 Oct-Dec; 2(4): 40–41. 10. Scholl TO, Johnson WG. Folic acid: influence on the outcome of pregnancy. Am J Clin Nutr. 2000; 71(suppl):1295S–303S. 11. NIH. Dietary Supplement Fact Sheet: Folate. Office of Dietary Supplements, NIH Web site. http://ods.od.nih.gov/pdf/factsheets/ Folate-HealthProfessional.pdf. Reviewed December 14, 2012. Accessed February 26, 2014. 12. NIH. Dietary Supplement Fact Sheet: B12. Website. https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/. Updated: February 11, 2016. Accessed November 14, 2017. 13. Millman, N. Review Article: Oral Iron Prophylaxis in Pregnancy: Not Too Little and Not Too Much! Journal of Pregnancy. Volume 2012. Article ID 514345 doi:10.1155/2012/514345. 14. Scholl TO. Maternal Iron Status: Relation to fetal growth, length of gestation and the neonate’s endowment. Nutrition Reviews. 2011;69(Suppl 1):S23-S29. doi:10.1111/j.1753- 4887.2011.00429.x. 15. Kamdi SP, Palkar PJ. Efficacy and safety of ferrous asparto glycinate in the management of iron deficiency anaemia in pregnant women. J Obstet Gynaecol. 2014; Early Online: 1–5. doi:10.3109/01443615.2014.930098.16. Preconception Health and Health Care. Centers for Disease Control and Prevention. Website. https://www.cdc.gov/preconception/planning.html. Reviewed December 7, 2017. Page last updated: February 13, 2017. 17. Witt WP, Wisk LE, Cheng ER, Hampton JM, Hagen EW. Preconception Mental Health Predicts Pregnancy Complications and Adverse Birth Outcomes: A National Population-Based Study. Maternal and child health journal. 2012;16(7):1525-1541. doi:10.1007/s10995-011-0916-4.