How to Create a Medication Plan Before Conception for Safety

Many women don’t realize that the most critical time for fetal development happens before they even know they’re pregnant. Major organs form between weeks 3 and 8 of gestation - often before a missed period. If you’re taking medications for a chronic condition, this window can be dangerous. A medication that’s perfectly safe for you might pose serious risks to a developing embryo. That’s why creating a medication plan before conception isn’t just a good idea - it’s essential.

Why Timing Matters More Than You Think

You might think, “I’ll stop taking that pill as soon as I find out I’m pregnant.” But by then, it’s often too late. The neural tube, which becomes the brain and spinal cord, closes by week 6. Heart structures form by week 8. If you’re on a drug like valproic acid for seizures, or isotretinoin for acne, or methotrexate for autoimmune disease, those first few weeks are when damage happens - and you probably didn’t even know you were carrying.

According to the American College of Obstetricians and Gynecologists (ACOG), nearly half of all pregnancies in the U.S. are unintended. That means most women aren’t thinking about their meds when conception occurs. The result? Up to 10 times higher risk of major birth defects for some medications. This isn’t theoretical. Studies show women who get preconception counseling have 28% fewer major congenital malformations than those who don’t.

Start with a Full Medication Inventory

Don’t just think about prescriptions. Include over-the-counter drugs, supplements, herbal remedies, and even vitamins. Many people assume natural equals safe - but that’s not true. St. John’s wort can interfere with fertility. High-dose vitamin A (over 10,000 IU/day) is linked to birth defects. Even some fish oil supplements contain levels of vitamin A that exceed safe limits.

Make a list of everything you take daily. Include:

• Brand and generic names
• Dosage and frequency
• Why you take it
• When you started
• Any side effects you’ve noticed

Bring this list to your doctor. Don’t assume they know what you’re taking. A 2022 ACOG survey found that only 24% of OB/GYNs consistently review preconception medications - even though 89% agree it’s important. You have to be the one to start the conversation.

High-Risk Medications to Review Immediately

Some drugs are known to cause serious birth defects. These need to be stopped - and replaced - well before you try to conceive. Here are the big ones:

• Valproic acid (Depakote): Used for epilepsy and bipolar disorder. Increases risk of neural tube defects by up to 10 times. Avoid completely if possible.
• Methotrexate: Used for rheumatoid arthritis, psoriasis, and some cancers. Causes miscarriage and severe birth defects. Must be stopped at least 3 months before conception.
• Isotretinoin (Accutane): For severe acne. Even one dose can cause heart, brain, and facial defects. Requires one full month of contraception after stopping - and a negative pregnancy test before restarting.
• Lithium: For bipolar disorder. Linked to Ebstein’s anomaly, a rare heart defect. Requires careful monitoring and possible switch to alternatives like lamotrigine.
• Warfarin (Coumadin): For blood clots. Crosses the placenta and can cause fetal warfarin syndrome. Must be switched to low-molecular-weight heparin before pregnancy.
• Topiramate: For seizures and migraines. Increases risk of cleft lip/palate. Dose reduction or replacement is strongly advised.

For each of these, your doctor should have a safe alternative ready. Don’t just stop cold turkey - that can be dangerous. Switching meds takes time. That’s why you need at least 3 to 6 months before trying to conceive.

Folic Acid: The One Supplement Everyone Needs

Folic acid isn’t optional. It’s non-negotiable. The CDC, WHO, and ACOG all agree: every woman of childbearing age should take 400 to 800 micrograms daily. Why? Because it reduces neural tube defects - like spina bifida - by up to 70%.

But here’s the catch: if you have certain conditions, you need more.

• General population: 400-800 mcg daily
• History of neural tube defect in previous pregnancy: 4,000-5,000 mcg daily
• On anticonvulsants like valproic acid or carbamazepine: 4,000-5,000 mcg daily
• Diabetes or obesity (BMI ≥30): 4,000-5,000 mcg daily

Start taking it at least 3 months before conception. Don’t wait until you miss your period. Most prenatal vitamins only contain 800 mcg - if you’re high-risk, you’ll need a separate prescription-strength dose.

Chronic Conditions: Tailoring Your Plan

If you have a chronic illness, your medication plan needs to be customized. Here’s how it works for common conditions:

Thyroid Disorders

Hypothyroidism during early pregnancy increases miscarriage risk by 60%. Your TSH (thyroid-stimulating hormone) should be under 2.5 mIU/L before conception. Once pregnant, your levothyroxine dose typically needs to increase by 30% - often by week 4. Don’t wait for symptoms. Get blood work done before you start trying.

Autoimmune Diseases (Lupus, Rheumatoid Arthritis)

Drugs like cyclophosphamide and leflunomide are teratogenic and must be stopped months ahead. But not all are dangerous. Sulfasalazine and hydroxychloroquine are considered safe during pregnancy. Work with a rheumatologist to switch safely. Ideally, your disease should be in remission for at least 3-6 months before conception.

Seizure Disorders

Polytherapy (multiple seizure meds) increases risk. Monotherapy at the lowest effective dose is preferred. Avoid valproic acid and topiramate if possible. Lamotrigine and levetiracetam are safer options. Make sure your neurologist and OB/GYN are communicating.

HIV

Antiretroviral therapy is not only safe during pregnancy - it’s life-saving. The goal: viral load under 50 copies/mL before conception. This reduces transmission risk from 25% to less than 1%. Some drugs like efavirenz are avoided in early pregnancy - your HIV specialist will adjust your regimen.

Obesity and Diabetes

Weight-loss drugs like liraglutide (Saxenda) and semaglutide (Wegovy) have no proven safety data in pregnancy. Stop them at least 2 months before trying to conceive. For diabetes, aim for HbA1c under 6.5% before pregnancy. Poorly controlled blood sugar increases risk of heart defects, stillbirth, and preterm birth.

What About Birth Control?

This is a common blind spot. If you’re on meds that need time to clear - like methotrexate or isotretinoin - you still need reliable birth control. But here’s the problem: some seizure medications (carbamazepine, phenytoin) speed up the breakdown of hormonal birth control. That means the pill, patch, or ring might not work.

Solution? Use a non-hormonal method: copper IUD, condoms with spermicide, or a progestin-only implant (which isn’t affected by enzyme-inducing drugs). Talk to your doctor about the best combo for your meds.

When to See Who

You don’t need to see 10 specialists at once. But timing matters:

• 3-6 months before conception: See your OB/GYN or primary care provider for overall review.
• 2-4 weeks after that: Schedule appointments with your specialist - neurologist, rheumatologist, endocrinologist, psychiatrist, etc.
• At least 1 month before stopping: If you’re on isotretinoin or methotrexate, begin transition.
• Within 2 weeks of starting folic acid: Get your blood work done (TSH, HbA1c, drug levels) to establish baseline.

Use ICD-10 code Z31.69 when billing for preconception counseling. It’s a real code - and it helps track how often this care is being provided.

Barriers and How to Overcome Them

The system isn’t perfect. Only 38% of women with chronic conditions get a documented preconception medication review. Why? Doctors are busy. Patients don’t know to ask. Insurance doesn’t always cover it.

Here’s what you can do:

• Bring your medication list to every appointment - even if it’s not for pregnancy.
• Ask: “If I wanted to get pregnant in the next year, what would you change in my meds?”
• If your doctor says, “We’ll deal with it when you’re pregnant,” say: “I’ve read that the first 8 weeks are critical. I want to plan ahead.”
• Use digital tools like Luma Health’s Preconception Navigator - FDA-approved and integrates with 1,200+ drug databases.

Countries like Sweden and the Netherlands have national preconception programs. Their birth defect rates are 35% lower than the U.S. We don’t need new science - we need better systems. But you don’t have to wait for them. You can start today.

Final Checklist: Your Preconception Medication Plan

Before you stop using birth control, make sure you’ve checked these boxes:

• ✅ Listed every medication, supplement, and herb you take
• ✅ Reviewed each with your doctor - no assumptions
• ✅ Stopped high-risk drugs (valproic acid, methotrexate, isotretinoin, etc.) with safe alternatives in place
• ✅ Started 400-5,000 mcg of folic acid daily (based on your risk)
• ✅ Achieved target TSH (<2.5 mIU/L), HbA1c (<6.5%), or other key biomarkers
• ✅ Switched to a reliable birth control method if you’re on enzyme-inducing meds
• ✅ Scheduled specialist visits (neurologist, rheumatologist, endocrinologist)
• ✅ Documented your plan - write it down or save it in your phone

This isn’t about being perfect. It’s about being prepared. You can’t control everything. But you can control your meds before conception. And that one step can mean the difference between a healthy baby and a preventable tragedy.