Pregnancy Case Study: Heather

Background

You work as a nutrition consultant in a midwifery practice. Today you are meeting with Heather, a 38 year old woman who is 29 weeks pregnant. Heather has had one previous pregnancy that resulted in the birth of a 4200 g full term baby, Mason, who is now 13 months old. Heather is married, and her husband, Michael, is with her at this visit. Michael works full time as a hospital nurse, but his hospital has been reducing nursing hours. Michael is unsure about his job's future right now. Heather works half time in the mornings as a legal secretary.  Michael works the evening shift, so that the family does not have to put Mason in child care.

Heather and Michael 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 Heather 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.

Mason proved to be a challenging baby. He is only now beginning to sleep through the night. He had "colic" symptoms in the first few months of here life and continues to be "fussy" and to require a great deal of attention during the late afternoon. Heather and Michael felt strongly about breastfeeding, and had been to classes and read books about breastfeeding. However, they encountered some difficulties with breastfeeding in the first few weeks. These included sore nipples, a breast infection, and a perceived lack of an adequate milk supply. When Heather went back to work 3 months post partum Mason eagerly took bottles of formula while his mother was at work. Despite Heather's plan to maintain exclusive breastfeeding and pumping of breastmilk for several months, Mason was soon just nursing a couple of times a day, and stopped nursing altogether when he was 4 months old.

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

Heather and Michael have good health insurance coverage, but Heather has only been seen 3 times for prenatal care for this pregnancy.

Anthropometric Data

Heather states that her prepregnancy weight with this pregnancy was about 190#. She is 62" tall. She gained 48 pounds in her first pregnancy.  Today her weight is 199#.  Records show that she weighed 195 at 20 weeks of pregnancy and 197 at 27 weeks.

Health History

Heather's blood pressure today is within normal limits. She denies use of drugs or tobacco.

Heather states that she enjoys being physically active.  She was on the swim team in high school.  Heather and Michael used to hike and kayak before Mason was born.  Now they feel that they don't have time for physical activity. Heather joined a health club that provides child care a few months ago but stopped going after about 6 weeks because she felt out of place and the child care providers kept paging her because Mason was crying and fussy.  Heather and Michael used to take Mason for walks around the neighborhood in a stroller, but now that she is older Mason struggles to climb out of the stroller.

At the beginning of both of her pregnancies Heather experienced considerable nausea and occasional vomiting as well as overwhelming fatigue. Today Heather 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

Heather's hematocrit today is 27%. Results from a 100 g oral glucose tollerance test are as follows:

Supplements

Heather 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. Michael 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 the risks and benefits associated with fish oil supplements during pregnancy.  He is also wondering about the efficacy of calcium supplements to ward off preeclampsia.

Dietary Intake

Before the visit you asked Heather 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 the family usually has a mid day meal after church at Heather's mother's house and then snacks in the evening. The family includes fish in their diet, but avoids beef, pork and poultry.  They purchase most of their milk directly through a farmer from their church.  Heather and Michael state that they have fallen out of the habit of planning and preparing dinners that require much cooking because they are seldom together for meals, and Heather is fatigued at the end of the day.

Questions:

1. What impacts might Heather's preconceptional weight status have on the outcomes of this pregnancy?
2. Discuss the possible roles that pregnancy intendedness and the spacing of pregnancies may play in the health behaviors and nutrition concerns in this pregnancy.
3. Assess anthropometric data and lab values and compare to recommendations.
4. Using both a nutrient-based approach (using your favorite dietary analysis software or NAT 2.0) and a food-based approach MyPlate Daily Food Plan for Moms  analyze Heather's diet and compare to recommendations.
5. Based on your assessment, list all the nutritional concerns you have for this pregnancy?  How would you prioritize these concerns?
6. If you are asked, what specific recommendations would you make regarding weight gain, diet, physical activity, dietary supplements, and discomforts of pregnancy?
7. If you have the opportunity to see Heather at her next prenatal visits at 30 and 32 weeks, how would you prioritize and plan your counseling?
8. What advice, recommendations or referrals might you provide this family about breastfeeding?

References & Resources

ACOG: Screening and Diagosis of Gestational Diabetes Mellitus

Recommendations to Prevent and Control Iron Deficiency in the United States (includes cut off values for screening for iron status)

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/

Position of the American Dietetic Association: Nutrition and lifestyle for a healthy pregnancy outcome.

Position of the American Dietetic Association: Obesity, Reproduction and Pregnancy Outcomes. 

Position of the American Dietetic Association: Promoting and Supporting Breastfeeding:  

Pregnancy Weight Gain Grids:  http://www.nal.usda.gov/wicworks/Sharing_Center/NY/prenatalwt_charts.pdf

American College of Obstetricians and Gynacologists: Exercise during pregnancy and the postpartum period. http://www.ncbi.nlm.nih.gov/pubmed?term=11777528

King, JC. The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies: J. Nutr. 133:1732S-1736S, May 2003

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