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Case 6.1 Preconception Planning

By Sara Smoller, RN, MSN, ANP‐BC

SUBJECTIVE

Delilah is a 28‐year‐old female who presents to discuss her plans to conceive. She is in a monogamous relationship with her husband. They are excited about the possibility of starting a family and want to do so in 6 months when her husband gets out of law school. Delilah wants to know what she should be doing to ensure that she is healthy and has a healthy pregnancy. She is worried she may have difficulty getting pregnant as her older sister had to go through in‐vitro fertilization; she is wondering if she needs a referral to a fertility specialist. She has never been pregnant before. Her last Pap smear was 3 years ago and was normal. Her last menstrual period was 2 weeks ago. She reports regular menses.

Past medical history: G0P0; moderate persistent asthma, currently well controlled; appendectomy at age 21

Family history: Mother with Type 2 diabetes; father with bipolar depression (poorly managed)—she has minimal contact.

Social History: Delilah works as a flight attendant 7 days on, 7 days off. She engages in minimal physical activity other than being active/on her feet at work. She’s been married for 2.5 years and feels safe at home. Her husband is in law school. Delilah drinks 1–2 glasses of wine per night and smokes “socially” about 5 cigarettes per week. She denies any marijuana or other drug use. Her sleeping habits are poor; when she is working she is flying between time zones and often is awake overnight. She states she averages about 5 hours of sleep per night. She drinks 3–4 cups of black coffee daily.

Medications: Fluticasone inhaler 220mcg 1 puff bid; albuterol inhaler 1–2 puffs q6h prn shortness of breath; Apri OCPs; Ibuprofen 200–400 mg prn headache

Allergies: NKDA

OBJECTIVE

Vital signs: Temperature 97.6°F (orally); BP 118/72; pulse 72 and regular. She is 5 ft 5 inches tall and 183 pounds.

General: Delilah is pleasant and cooperative and is sitting comfortably in the exam room.

Eyes: PERRL. No injection or icterus.

Mouth: No lesions or exudates.

Neck: Thyroid palpable without enlargement or nodules.

Cardiac: Regular rate and rhythm, no murmurs.

Lungs: Clear bilaterally.

Breasts: No lumps, masses, nipple discharge, or skin changes.

Abdomen: Soft, nontender, nondistended. No palpable masses or hepatosplenomegaly.

CRITICAL THINKING

1 What health recommendations should be made for Delilah in order to help her prepare for pregnancy?

2 What laboratory/diagnostic testing is recommended?

3 How Delilah’s medication list be adjusted? Are any of the medications teratogenic? Are there any medications/vitamins or supplements she should start taking?

4 When should she stop her birth control pills?

5 How should she be counseled about seeing a fertility specialist? When would this be recommended?

6 Would anything be different if Delilah were 38 instead of 28?

7 Are any other referrals recommended?