1) What blood test would you order and why? (1 point)
- Quantitative hCG blood test: measures serum beta human chorionic gonadotropin levels (US FDA, 2013)
- Above normal hCG values: determines if patient is having a normal pregnancy and the number of fetuses as well as gestational age, or if amenorrhea is due to hydatidiform mole, choriocarcinoma, or ovarian cancer (Ratcliffe et al., 2008; US FDA, 2013)
- Below normal hCG values: indicates ectopic pregnancy, fetal death, incomplete abortion, or threatened spontaneous abortion (US FDA, 2013)
2). What is her estimated date of confinement (EDC) based on her LMP? (1 point)
- Based on Naegele’s rule of 280 days from the first day of the LMP (Ratcliffe et al., 2008)
3). What is her Gravidity, Parity, Abortions? (1 point)
- Gravidity - 3, Parity - 2, Abortions - 14). Identify two goals of prenatal care? (2 points)
- Ensure the health of the baby – size for gestational age, FHR, results of screening tests (ACOG, 2014)
- Identify maternal risks for complicated pregnancy – minimize risks, prevent anticipated problems (ACOG, 2014)
5). What are 8 things normally covered in the prenatal visit(s) and briefly explain why? Keep in mind this is throughout the pregnancy, not just the initial visit (8 points). It is not just labs, US etc., keep in mind if not diagnosed with a pregnancy can't move forward.
- Weight measurement – determine amount and rate of weight gain in comparison with ideal values
- Measurement of blood pressure – detect PIH and facilitate prompt management
- Measurement of uterine size – monitor fetal growth in relation to gestational age
- Physical examination – detect signs of complications such as edema
- Urine test – detect protein indicative of preeclampsia; bacteria and blood associated with urinary tract infection
- Fetal heart rate (FHR) measurement – assess the rate and rhythm indicative of the adequacy of fetal oxygenation; alerts to any compromise necessitating interventions
- Screening tests – ascertain the presence of blood-borne and other infections, blood disorders, anemia, rhesus factor status, rubella and varicella virus immunity
- Nutritional status monitoring – blood cell counts and physical examination to rule out anemia; adherence to a balanced diet in relation to nutritional needs and type 2 diabetes
(Ratcliffe et al., 2008; Orshan, 2008; Storck, 2013; Morrison et al., 2011; ACOG, 2014)
6.) Identify 10 risk factors for Jennifer and briefly provide the rationale. (20 points)
- Type 2 diabetes – increases the risk of pre-eclampsia, pregnancy-induced hypertension (PIH), pre-term delivery, caesarean section, and chronic complications in the mother such as diabetic retinopathy and nephropathy (Lapolla, Dalfra & Fedele, 2008); also increases the risk for perinatal mortality, congenital malformation, macrosomia, and large-for-gestational-age (LGA) newborns (Temple & Murphy, 2010)
- Hypothyroidism – associated with a higher risk of miscarriage, preterm birth, PIH, pre-eclampsia, abruptio placentae, postpartum bleeding, anemia, perinatal morbidity and mortality, congenital cretinism and deafness in the child, and impairment in the child’s neuropsychological development (Reid et al., 2013)
- Comorbid depression and anxiety – linked with a higher incidence of preterm delivery and low-birth-weight (LBW) infants; some evidence of lower APGAR scores, difficult temperament during infancy, and behavioral problems in childhood; antepartum depression and anxiety predicts postpartum depression and anxiety, as well as poor self-care and difficulty adapting to parenting role (Field et al., 2010; Leigh & Milgrom, 2008)
- Smoking – implicated in LBW infants, congenital anomalies, attention deficit hyperactivity disorder, asthma in childhood and adulthood, and lower cognitive ability (Agrawal et al., 2010; Bharadwaj, Johnsen & Loken, 2012)
- Obesity – increases the risk of PIH, preeclampsia, intra- and postoperative complications in the event of a C-section, stillbirth, preterm delivery, congenital abnormalities, fetal macrosomia, and obesity in childhood and adolescence (ACOG, 2013)
- Previous C-section – increases the risk for ectopic pregnancy, Cesarean scar pregnancy, placenta accreta, placenta previa, and uterine rupture (Timor-Tristsch & Monteagudo, 2012)
- History of miscarriage – linked with preterm birth, premature rupture of membranes, PIH, preeclampsia, C-section, and fetal growth restriction in a population study (Weintraub et al., 2011)
- Unemployment and lack of insurance – associated with inadequate prenatal care and poorer maternal and neonatal outcomes (Temple & Murphy, 2010)
- Ethnicity – associated with inadequate prenatal care and poorer maternal and neonatal outcomes (Temple & Murphy, 2010)
- Inside and outside cat – increases the risk for Toxoplasma gondii infection that may cause spontaneous abortion, stillbirth, and congenital malformations (Pappas, Roussos & Falagas, 2009)7). Identify the trimester of pregnancy and provide 2 psychological examples of what she can expect in this trimester. (2 points)
- Second trimester
- Psychological examples: May feel grief over the loss of pre-pregnancy body size and shape; quickening that occurs at around 20 weeks of gestation may enhance bonding with the baby; ambivalence may still remain (Orshan, 2008)
8.) Which medications will she be allowed to continue and which ones might be changed during her pregnancy and provide rationale. (3 points)
- Medications allowed:
Synthroid (levothyroxine) - systematic review shows that normalization of thyroid hormone decreases the incidence of preterm births and may also reduce the incidence of miscarriage (Reid et al., 2013); not associated with adverse effects in mother and baby (Carney, Quinlan & West, 2014)
Metformin - safe for both mother and baby; improves glucose control thus preventing fetal exposure to hyperglycemia; alternative for those who do not want insulin therapy (Simmons, 2010)
- Medications that need changing:
Paxil (paroxetine) - evidence from two systematic reviews show an increased risk of congenital heart malformations (Tuccori et al., 2009; Udechuku et al., 2010); inconsistent findings regarding the risk for preterm birth and adaptation difficulties in the newborn (Udechuku et al., 2010)
9). Why does she need a vitamin with folic acid and how much folic acid is needed? (2 points)
- Folic acid supplementation - prevents neural tube defects such as anencephaly and spina bifida (Morrison et al., 2011)
- Standard dose - 400 micrograms; patient does not have a history of giving birth to a newborn with a neural tube defect warranting a higher dose (Division of Birth Defects, 2012)10). Based on the World Health Organization recommendations for weight gain, what is her BMI and recommended total weight gain for this pregnancy? (2 point)
- BMI: 34.2 (kg/m2), obese (cut-off is 30.0) (Rasmussen, Catalano & Yaktine, 2009)
- Recommended total weight gain: 11-20 lbs. if singleton pregnancy; 25-42 lbs. if pregnant with twins (Rasmussen, Catalano & Yaktine, 2009)
11). Identify 5 common problems in pregnancy. (5 points)
- Anemia – inadequate iron and folate intake resulting in a red blood cell count that is below normal with symptoms including weakness and fatigue
- Hypertension – suboptimal control of blood pressure increasing the risk of various adverse maternal and fetal outcomes
- Obesity – also increases the risk of adverse maternal and fetal outcomes
- Urinary tract infections – higher incidence in diabetic and pregnant women with symptoms including difficulty passing urine; requires antibiotic therapy
- Depression – brought on by psychological changes during pregnancy or clinical in nature; can lead to poor self-care leading to suboptimal birth outcomes
(Division of Reproductive Health, 2014)
References
Agrawal, A., Scherrer, J.F., Grant, J.D., Sartor, C.E., Pergadia, M.L., Duncan, A.E., Xian, H. (2010). The effects of maternal smoking during pregnancy on offspring outcomes. Preventive Medicine, 50(1), 13-18. doi:10.1016/j.ypmed.2009.12.009
American College of Obstetricians and Gynecologists (2013). Committee opinion: Obesity in pregnancy. Retrieved from http://www.acog.org/- /media/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/co549.p df?dmc=1&ts=20140930T1253372883
American College of Obstetricians and Gynecologists (2014). Routine prenatal care and testing. Retrieved from http://www.acog.org/~/media/For%20Patients/faq133.pdf
Bharadwaj, P., Johnsen, J.V., & Loken, K.V. (2012). Smoking bans, maternal smoking and birth outcomes. Retrieved from http://ftp.iza.org/dp7006.pdf
Carney, L.A., Quinlan, J.D., & West, J.M. (2014). Thyroid disease in pregnancy. American Family Physician, 89(4), 273-278. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24695447
Division of Birth Defects (2012). Folic acid recommendations. Retrieved from http://www.cdc.gov/ncbddd/folicacid/recommendations.html
Division of Reproductive Health (2014). Pregnancy complications. Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregcomplications.htm
Field, T., Diego, M., Hernandez-Reif, M., Figueiredo, B., Deeds, B., Ascencio, A., Kuhn, C. (2010). Comorbid depression and anxiety effects on pregnancy and neonatal outcome. Infant Behavior and Development, 33(1), 23-29. doi:10.1016/j.infbeh.2009.10.004
Food and Drug Administration (2013). Blood human chorionic gonadotropin (hCG) assays: What laboratorians should know about false-positive results. Retrieved from http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDevi ceSafety/ucm109390.htm
Lapolla, A., Dalfra, M.G., & Fedele, D. (2008). Pregnancy complicated by type 2 diabetes: An emerging problem. Diabetes Research and Clinical Practice, 80(1), 2-7. doi:10.1016/j.diabres.2007.11.009
Leigh, B., & Milgrom, J. (2008). Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry, 8(24), 1-11. doi:10.1186/1471-244X-8-24
Morrison, J.C., Elliott, J., Knuppel, R.A., Sibai, B., & Pill, M.W. (2011). Current issues and perspectives in prenatal nutrition. Research and Reports in Neonatology, 2011(1), 25- 38. doi: 10.2147/RRN.S19797
Orshan, S.A. (2008). Maternity, newborn, and women’s health: Comprehensive care across the life span. Philadelphia, PA: Lippincott Williams & Wilkins.
Pappas, G., Roussos, N., & Falagas, M.E. (2009). Toxoplasmosis snapshots: Global status of Toxoplasma gondii seroprevalence and implications for pregnancy and congenital toxoplasmosis. International Journal for Parasitology, 39(12), 1385-1394. doi:10.1016/j.ijpara.2009.04.003
Rasmussen, K.M., Catalano, P.M., & Yaktine, A.L. (2009). New guidelines for weight gain during pregnancy: What obstetrician/gynecologists should know. Current Opinion in Obstetric Gynecology, 21(6), 521-526. doi:10.1097/GCO.0b013e328332d24e.
Ratcliffe, S.D. (2008). Family medicine obstetrics. Philadelphia, PA: Mosby Elsevier.
Reid, S.M., Middleton, P., Cossich, M.C., Crowther, C.A., & Bain, E. (2013). Interventions for clinical and subclinical hypothyroidism pre-pregnancy and during pregnancy (review). Cochrane Database of Systematic Reviews, 5(CD007752), 1-37. doi: 10.1002/14651858.CD007752.pub3.
Simmons, D. (2010). Metformin treatment for type 2 diabetes in pregnancy? Best Practice & Research Clinical Endocrinology & Metabolism, 24(4), 625-634. doi:10.1016/j.beem.2010.05.002
Storck, S. (2013). Diabetes diet – gestational. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007430.htm
Timor-Tritsch, I.E., & Monteagudo, A. (2012). Unforeseen consequences of the increasing rate of cesarean deliveries: Early placenta accreta and cesarean scar pregnancy: A review. American Journal of Obstetrics & Gynecology, 207(1), 14-19. doi: 10.1016/j.ajog.2012.03.007
Temple, R., & Murphy, H. (2010). Type 2 diabetes in pregnancy – An increasing problem. Best Practice & Research Clinical Endocrinology & Metabolism, 24(4), 591-603. doi:10.1016/j.beem.2010.05.011
Tuccori, M., Testi, A., Antonioli, L., Fornai, M., Montagnani, S., Ghisu, N., Del Tacca, M. (2009). Safety concerns associated with the use of serotonin reuptake inhibitors and other serotonergic/noradrenergic antidepressants during pregnancy: A review. Clinical Therapeutics, 31(Theme Issue), 1426-1453. doi: l0.1016/J.c1lnthera.2009.07.009
Udechuku, A., Nguyen, T., Hill, R., & Szego, K. (2010). Antidepressants in pregnancy: A systematic review. Australian and New Zealand Journal of Psychiatry, 44(11), 978- 996. doi: 10.3109/00048674.2010.507543.
Weintraub, A.Y., Sergienko, R., Harlev, A., Holcberg, G., Mazor, M., Wiznitzer, A., & Sheiner, E. (2011). An initial miscarriage is associated with adverse pregnancy outcomes in the following pregnancy. American Journal of Obstetrics & Gynecology, 205(286), e1-e5. doi: 10.1016/j.ajog.2011.06.053
