Pregnancy Case Study: Laura

Pregnancy Case Study: Laura

Background

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You work as a nutrition consultant with a group of midwives. Today you are meeting with Laura, a 34 year old woman who is 30 weeks pregnant. Laura has had one previous pregnancy that resulted in the birth of a 4400 g healthy baby, Sarah, who is now 16 months old. Laura is married, and her husband, David, is with her at this visit. David works full time as a Physician Assistant, but the practice that he works for has recently been purchased by a health plan and he is unsure about his job’s future right now. Laura works half time as a legal secretary.

Laura and David carefully planned for their first pregnancy. They were married several years ago, but waited to have their first child until they were financially secure enough that Laura could work part time after the baby came. They both made a point of making healthy food choices and avoiding alcohol when they were trying to conceive their first child. They attended both a preconception health education class and a prepared childbirth class.

Sarah proved to be a challenging baby. She is only now beginning to sleep through the night. She had “colic” symptoms until she was almost 6 months old. Laura and David felt strongly about breastfeeding, and had been to classes and read books about breastfeeding. However, they encountered some difficulties with breastfeeding for the first few weeks. These included sore nipples, a breast infection, and a perceived lack of an adequate milk supply. When Laura went back to work 3 months post partum Sarah eagerly took bottles of formula while her mother was at work. Despite Laura’s plan to maintain exclusive breastfeeding and pumping of breastmilk for several months, Sarah was soon just nursing a couple of times a day, and stopped nursing altogether 2 to 3 weeks after Laura discovered that she was pregnant again.

Laura and David had wanted another child at some point, but this current pregnancy was not intended. Although they have accepted the pregnancy, they state that they have concerns about the effect that a new baby will have on Sarah, their marriage, and their finances.

Laura and David have good health insurance coverage, but Laura has only been seen 4 times for prenatal care for this pregnancy.

Anthropometric Data

Laura’s prepregnancy weight with this pregnancy was 175 #. She is 61 ” tall. She gained 55 pounds in her first pregnancy, and lost 20 of those pounds before she became pregnant again. Today her weight is 200#.

Health History

Laura’s health history is unremarkable. Her blood pressure today is within normal limits. She denies use of drugs, tobacco.

Laura states that she does not like to exercise. She joined a health club a few years ago, but stopped going after about 6 weeks because she felt out of place and she thought that it was boring. She started a walking program after her first pregnancy with another new mother from her mom’s group, but her friend moved away and Laura doesn’t like to walk alone.

At the beginning of both of her pregnancies Laura experienced considerable nausea and occasional vomiting as well as overwhelming fatigue. Today Laura complains of the onset of several pregnancy discomforts that also bothered her toward the end of her first pregnancy. These include heartburn, intermittent diarrhea and constipation, fatigue, and edema in her ankles.

Laboratory Values

Last week Laura had a 50 gram oral glucose screen. Results at one hour were 120 mg/100 ml. Laura’s hematocrit today is 31%.

Supplements

Laura is intermittently taking a standard prenatal vitamin and mineral supplement that contains 30 mg per day of elemental iron. She feels that this supplement has contributed to some of her pregnancy related discomforts. David has recently been to a continuing education conference on nutrition and reproductive health. There were several vendors of nutritional supplements who displayed products at the conference. He is asking your advice today about fish oil, zinc, and calcium supplements in pregnancy.

Dietary Intake

Before the visit you asked Laura to keep three day food records. She brings them with her today. She states that this pattern is typical for a weekday when she works mornings. Saturdays are variable depending on what errands need to be done, but usually one or two meals are at a fast food place. On Sundays Laura goes out with David and Sarah after church for a large breakfast at Denny’s (fried eggs, bacon, toast, hash browns) and then has a pizza meal in the evening.

Questions:

1. Discuss the possible role that pregnancy intendedness may play in both of Laura’s pregnancies.
2. Assess and explain anthropometric data, health history, lab values, and dietary intake information.
3. What are the nutritional concerns you have about Laura?
4. What impacts might her weight status have on this pregnancy?
5. What recommendations might you make regarding weight gain, diet, exercise dietary supplements, and discomforts of pregnancy?
6. If you have the opportunity to see Laura at her next prenatal visits at 32 and 34 weeks, how would you prioritize and plan your counseling?

REFERENCES

Listeriosis fact sheet:  http://www.fsis.usda.gov/factsheets/Protect_Your_Baby/index.asp

Natural Medicines Comprehensive Database (must access from UW recognized computer or proxy) http://www.naturaldatabase.com/

American Dietetic Association Position Statement: Nutrition and lifestyle for a healthy pregnancy outcome:  http://courses.washington.edu/nutr526/resources/ADAPregnancy.pdf

Pregnancy Weight Gain Grids:  http://www.healthy-baby.org/pdf/WeightGainInstAndForm.pdf

American College of Obstetricians and Gynacologists:  Exercise during pregnancy and the postpartum period.Clin Obstet Gynecol. 2003 Jun;46(2):496-9.  Available through UW eJournals.