How to Create a Medication Plan Before Conception for Safety

Most women don’t realize that the critical window for fetal development starts before they even know they’re pregnant. By the time a pregnancy test turns positive, the baby’s heart, brain, spine, and limbs have already begun forming-between weeks 3 and 8. If you’re taking any medications-prescription, over-the-counter, or even herbal supplements-this is the time to review them. Waiting until you’re pregnant to make changes can put your baby at risk for serious birth defects.

Why Preconception Medication Planning Matters

About 45% of pregnancies in the U.S. are unintended. That means nearly half of all women are exposed to medications during those first crucial weeks without knowing it. Some drugs, like valproic acid for seizures or isotretinoin for acne, can cause major malformations even at low doses. The risk isn’t theoretical: women taking teratogenic medications before conception have 2 to 10 times higher chances of having a baby with a congenital anomaly, according to the Teratology Society’s 2022 registry data.

The good news? Planning ahead cuts that risk dramatically. A 2021 study in the New England Journal of Medicine found that women who received preconception counseling had 28% fewer major birth defects than those who didn’t. This isn’t about avoiding all meds-it’s about switching to safer options, adjusting doses, or timing changes so your body has time to clear risky drugs before conception.

Start with Folic Acid-No Exceptions

Folic acid is the one supplement every woman planning pregnancy should take, no matter her health status. The World Health Organization recommends 400 mcg daily for all women aged 15 to 49. In the U.S., the Office on Women’s Health echoes this, adding that women with certain conditions need more.

If you have epilepsy, diabetes, obesity, or a previous baby with a neural tube defect, you’ll need 4 to 5 mg daily. That’s 10 times the standard dose. Valproic acid and other anticonvulsants increase neural tube defect risk from the baseline 0.1% to 1-2%. Taking high-dose folic acid reduces that risk significantly. Start at least three months before trying to conceive. Don’t wait until you miss your period.

Medications to Avoid Before Pregnancy

Some drugs are simply too dangerous to use while trying to get pregnant. Here’s what to watch for:

• Valproic acid (Depakote): Linked to a 10.7% rate of major congenital malformations. Avoid entirely if possible. Switch to lamotrigine or levetiracetam under neurologist supervision.
• Lithium: Increases risk of Ebstein’s anomaly (a heart defect) by about 1 in 2,000 births. If you have bipolar disorder, work with your psychiatrist to transition to safer alternatives like lamotrigine or quetiapine.
• Topiramate: Raises the risk of cleft lip or palate to 1.4% (compared to 0.36% normally). If you’re on it for migraines or seizures, ask about alternatives.
• Methotrexate: Used for rheumatoid arthritis, psoriasis, or cancer. It’s a powerful teratogen. You must stop it at least three months before conception-sometimes longer. One ovulatory cycle isn’t enough.
• Isotretinoin (Accutane): For severe acne. Must be stopped at least one month before trying to conceive, and you must use two forms of birth control during treatment and for one month after. The iPLEDGE program enforces this in the U.S.
• Warfarin (Coumadin): Crosses the placenta and can cause fetal warfarin syndrome. Switch to low-molecular-weight heparin (like Lovenox) before conception if you’re on blood thinners for clots or heart conditions.

Medications That Are Safe-or Safer-During Preconception

Many chronic conditions can be managed safely with the right drugs. Here’s what’s considered low-risk:

• Levothyroxine: For hypothyroidism. Keep your TSH below 2.5 mIU/L before pregnancy. Once pregnant, increase your dose by about 30% right away. Untreated hypothyroidism raises miscarriage risk by 60%.
• Insulin: For diabetes. Insulin doesn’t cross the placenta. Avoid oral diabetes drugs like metformin or sulfonylureas unless your doctor says it’s safe-some are used off-label, but insulin is the gold standard.
• Acetaminophen (Tylenol): Safe for pain and fever. Avoid NSAIDs like ibuprofen or naproxen, especially after 20 weeks, but even before conception, it’s better to limit them.
• SSRIs like sertraline: For depression or anxiety. While some antidepressants carry risks, sertraline and citalopram are among the safest options. Stopping medication abruptly can be more dangerous than continuing it.
• Sulfasalazine: For inflammatory bowel disease or rheumatoid arthritis. Allowed under European guidelines and often used safely in the U.S. under supervision.

Timing Is Everything

You can’t rush this. Most medications need time to clear your system. Here’s what to plan for:

• Methotrexate: Wait 3 months (at least 3 full menstrual cycles).
• Isotretinoin: Wait 1 month after stopping.
• Enzyme-inducing antiepileptics (carbamazepine, phenytoin): These reduce the effectiveness of birth control pills. Switch to an IUD or progestin-only pill before trying to conceive.
• Antiretrovirals for HIV: Aim for a viral load under 50 copies/mL before conception. Some guidelines accept under 200, but lower is better to prevent transmission.

Work With Your Care Team

This isn’t a solo project. You need input from multiple specialists:

• Your OB/GYN or midwife for general preconception screening.
• Your primary care provider to coordinate everything.
• Your neurologist if you have seizures.
• Your rheumatologist if you have lupus, RA, or another autoimmune disease.
• Your psychiatrist if you take mood stabilizers or antidepressants.
• Your endocrinologist if you have thyroid or diabetes issues.

Don’t wait for your annual checkup. Schedule a dedicated preconception visit at least 3 to 6 months before you plan to conceive. Use ICD-10 code Z31.69 when booking-it’s the official code for preconception counseling.

What About Supplements and Herbal Products?

Many women think “natural” means safe. That’s not true. St. John’s wort can interfere with birth control and antidepressants. Black cohosh and dong quai may affect hormone levels. Even high-dose vitamin A (over 10,000 IU/day) can cause birth defects.

Stick to prenatal vitamins with folic acid, iron, and DHA. Avoid any supplement not approved by your doctor. If you’re taking something for anxiety, sleep, or digestion, bring the bottle to your appointment. No judgment-just information.

Barriers and Real-World Challenges

Even though guidelines are clear, most women don’t get this care. Only 38% of women with chronic conditions receive documented preconception medication reviews, according to CDC’s PRAMS data. In fee-for-service clinics, the rate is as low as 18%. Even when providers know it’s important, they don’t have time. A typical 15-minute appointment doesn’t leave room to review 10 medications.

Kaiser Permanente, with its integrated system, achieves 67% preconception review rates. That’s because they schedule it as a standard part of care. If you’re in a fragmented system, take charge. Bring a list of all your meds-prescription, OTC, supplements-to your next appointment. Ask: “Are any of these unsafe if I get pregnant?”

What’s New in 2026

The FDA approved its first digital preconception tool, Luma Health’s Preconception Navigator, in January 2023. It uses AI to cross-check your meds against teratogenicity databases. It’s not a replacement for your doctor, but it’s a great way to prepare questions.

New research is also expanding who needs this care. Women with a BMI over 30 are now included in preconception guidelines. Medications like liraglutide (for weight loss) should be stopped two months before conception because safety data is lacking. And the NIH is launching the PharmaTox study to build personalized risk models based on your genetics and metabolism.

Next Steps: Your 6-Month Action Plan

Here’s what to do, month by month:

1. Month 1-2: List every medication, supplement, and herb you take. Include doses and why you take them. Bring this to your primary care provider.
2. Month 3: Schedule a preconception visit with your OB/GYN. Ask for a referral to specialists if needed.
3. Month 4: Start high-dose folic acid (4-5 mg if high-risk, 0.4-0.8 mg if average risk). Begin switching medications under medical supervision.
4. Month 5: Get blood work done: TSH, HbA1c, liver and kidney function, and any condition-specific labs.
5. Month 6: Confirm all meds are safe. Use backup contraception if you’re on drugs that interact with birth control. Start tracking ovulation if you’re ready to try.

There’s no perfect time to start. But the sooner you begin, the safer your pregnancy will be. You’re not just planning for a baby-you’re planning for a healthy start.