How to Create a Medication Plan Before Conception for Safety

Many women don’t realize that the first few weeks of pregnancy - when the baby’s heart, brain, and spine are forming - happen before they even know they’re pregnant. By the time a home pregnancy test turns positive, the most critical window for fetal development is already behind you. That’s why creating a medication plan before conception isn’t just a good idea - it’s essential for a healthy pregnancy.

Why Timing Matters More Than You Think

Major organs like the brain, heart, and limbs form between weeks 3 and 8 of pregnancy. If you’re taking a medication that can harm a developing fetus during that time, the damage is already done before you’ve had a chance to stop it. About 45% of pregnancies in the U.S. are unintended, which means most women aren’t thinking about their meds until it’s too late.

The good news? You have time to fix this. Experts from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommend starting your medication review at least 3 to 6 months before you start trying to conceive. That gives your body time to adjust, clear out unsafe drugs, and stabilize your health.

What Medications Are Risky Before Pregnancy?

Not all medications are dangerous, but some carry known risks. Here are the most common ones that need attention:

• Valproic acid (used for seizures and bipolar disorder): Increases the risk of neural tube defects by 10-12%. Avoid completely if possible.
• Lithium (for bipolar disorder): Linked to Ebstein’s anomaly, a rare heart defect. Risk is low (about 1 in 2,000), but still significant enough to warrant a switch.
• Topiramate (for seizures or migraines): Doubles the risk of cleft lip or palate compared to the general population.
• Methotrexate (for autoimmune diseases like lupus or rheumatoid arthritis): Highly teratogenic. Must be stopped at least 3 months before trying to conceive.
• Isotretinoin (Accutane for acne): Causes severe birth defects. Requires 1 month of contraception after stopping - but many doctors recommend 3 months to be safe.
• Warfarin (blood thinner): Crosses the placenta and can cause fetal warfarin syndrome. Switch to heparin before conception.
• Liraglutide (for weight loss or diabetes): No safety data in pregnancy. Stop at least 2 months before trying.

What Medications Are Safe - or Even Required?

Some medications aren’t just safe - they’re necessary. Stopping them can be more dangerous than keeping them.

• Folic acid: Everyone should take 400-800 mcg daily before conception. If you have epilepsy, diabetes, obesity, or a family history of neural tube defects, bump it up to 4-5 mg daily. This single supplement reduces neural tube defects by up to 70%.
• Levothyroxine (for hypothyroidism): Your thyroid needs to be perfectly balanced before pregnancy. Aim for a TSH level below 2.5 mIU/L. Once pregnant, you’ll likely need a 30% dose increase.
• Antiretrovirals (for HIV): Keeping your viral load under 50 copies/mL before conception reduces transmission risk to less than 1%. Don’t stop these - optimize them.
• Insulin (for diabetes): Better than oral diabetes pills during pregnancy. Work with your doctor to get your blood sugar into target range before conceiving.
• Low-molecular-weight heparin (for blood clots): Safe during pregnancy and doesn’t cross the placenta. Switch from warfarin before conception.

How to Build Your Personal Medication Plan

Creating your plan isn’t about guessing. It’s about structure. Follow these steps:

1. List everything: Prescription meds, over-the-counter drugs, supplements, herbs, and vitamins. Include dosages and how often you take them.
2. Meet with your doctor: Don’t wait for your OB/GYN. See your primary care provider or specialist first. Bring your list. Ask: “Is this safe before and during pregnancy?”
3. Check for alternatives: If a drug is risky, ask: “Is there another one that works just as well but is safer?” For example, lamotrigine is often preferred over valproic acid for seizures.
4. Plan for washout periods: Some drugs stay in your system for months. Methotrexate needs 3 months. Isotretinoin needs 1-3 months. Don’t skip this step.
5. Adjust your contraception: If you’re on seizure meds like carbamazepine, birth control pills may not work well. Use a backup method like an IUD or condoms with spermicide.
6. Document everything: Use ICD-10 code Z31.69 if your provider is billing for preconception counseling. Keep a copy of your plan.

Special Cases: Chronic Conditions and Pregnancy

If you have a chronic illness, your medication plan needs to be more detailed.

• Epilepsy: Use the lowest effective dose of one medication (monotherapy). Avoid valproic acid and topiramate. Lamotrigine and levetiracetam are safer choices.
• Autoimmune diseases (lupus, rheumatoid arthritis): Stop methotrexate, cyclophosphamide, and leflunomide. Sulfasalazine and hydroxychloroquine are often safe.
• Diabetes: Aim for HbA1c under 6.5% before conception. Switch from oral meds to insulin if needed.
• High blood pressure: Avoid ACE inhibitors and ARBs. Switch to methyldopa or labetalol.
• Depression or anxiety: SSRIs like sertraline and citalopram are generally considered low-risk. Don’t stop abruptly - talk to your psychiatrist.

What If You’re Already Pregnant and Didn’t Plan?

It’s not too late. If you just found out you’re pregnant and you’re on a risky medication, don’t panic. Call your doctor immediately. Many drugs are only dangerous in the first 8 weeks. After that, the risk drops significantly.

Some women worry about stopping meds cold turkey. That can be dangerous too. For example, stopping seizure meds suddenly can cause seizures, which are far more harmful to the baby than the medication itself. Work with your team to make the safest switch as soon as possible.

Why So Few Women Do This - And How to Change That

Only 38% of women with chronic conditions get a preconception medication review, according to CDC data. Why? Doctors don’t always bring it up. Many women don’t know to ask. Health systems aren’t set up to track it.

But change is happening. Kaiser Permanente, for example, has a 67% review rate among high-risk patients. They use electronic alerts and team-based care. You can do the same - just be your own advocate.

Ask your provider: “Have you reviewed all my medications for pregnancy safety?” If they say no, ask for a referral to a maternal-fetal medicine specialist or a pharmacist who specializes in pregnancy.

What’s Next: Technology and Personalized Care

In January 2023, the FDA approved the first digital tool - Luma Health’s Preconception Navigator - that uses AI to scan your meds against teratogenicity databases. It’s not a replacement for your doctor, but it’s a powerful helper.

The NIH is also launching the PharmaTox study to predict individual risk based on your genes and how your body processes drugs. In the future, your plan won’t just be based on general guidelines - it’ll be tailored to you.

Final Checklist: Your Preconception Medication Plan

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

• ✅ Folic acid: 400-800 mcg daily (4-5 mg if high-risk)
• ✅ Stopped all teratogenic drugs (valproic acid, isotretinoin, methotrexate, etc.)
• ✅ Switched to pregnancy-safe alternatives where needed
• ✅ Thyroid levels checked and optimized (TSH <2.5)
• ✅ Blood sugar, blood pressure, and mental health meds reviewed
• ✅ Contraception adjusted for drug interactions
• ✅ All changes documented and discussed with your care team

This isn’t about being perfect. It’s about being prepared. The goal isn’t to eliminate all risk - it’s to reduce it as much as possible. And that starts long before you get a positive pregnancy test.