Case Two: High Risk Pregnancy

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Skye

Initial Contact

The Diabetes Maternity support services team at a tertiary care center has received a referral for a 18 year old young woman who has had insulin dependent diabetes since she was 5 years old. The team includes the following health professionals: physician, nurse, health educator, dietitian, and social worker. The team is housed in a large urban hospital that is about 20 miles from the suburb where Skye is currently living. Skye found her way to your team as a consequence of a visit to a local Planned Parenthood program for a pregnancy test. She was quickly referred to the Healthy Start Medicaid program for pregnant women. The Healthy Start intake worker assessed Skye as a very high risk pregnant woman and referred her for your specialty care.

 Skye has been in and out of foster care most of her life. This has made maintaining regular contact with consistent health care providers very difficult. For the last year Skye has had intermittent contact with the health care system because she has been more or less living on the street. She was getting access to insulin through a community clinic that serves street kids, but she frequently missed her appointments at the clinic. Today Hemoglobin A1C values are 5 standard deviations above the mean, she has trace amounts of keytones in her urine, and her hematocrit is 30%.

Skye has not been to school for the last year or so, and her attendance was spotty for several years before that. However, she appears to have good reading and writing skills, and a good understanding of the basics of diabetes self care.

Skye states that she loves her baby very much and wants to do what's best to assure a successful pregnancy. However, she has strong feelings about being told what to do. She let's you know quite clearly that she doesn't like to eat when she's not hungry, she hates vegetables and dairy products, she doesn't like to take pills, and she doesn't like people "fussing" over her.

When she was 15 Skye took birth control pills for a while, but then she heard that they might make her glucose tolerance problems worse. For the past year, she has been losing weight on purpose by using a little less insulin than she thought that she should, and her periods had become very irregular. She was not using birth control at the time of conception because she thought that she couldn't get pregnant.

Skye has been taking 22 units of intermediate insulin twice a day for a total of 44 units per day.  She usually takes the insulin at about 10:00 am when she gets up and at 4:00 pm. She has not been monitoring her blood glucose levels.

Skye states that she weighed about 110 pounds when she got pregnant. Today she weighs 54 kg. She is 5' 6" tall. Skye thinks that her last period was about 14 weeks ago.

Skye has smoked since she was about 12 years old. She states that she knows that cigarette smoking is bad for her baby, and she wants to quit as soon as her life becomes less stressful. Right now she is smoking about a pack and a half a day. She denies alcohol or drug exposure.

Skye complains of "morning sickness" and being very tired. She spends most of her time sitting around and watching TV.

Skye has just moved into her boyfriend's family home. Her boyfriend, Jake, and his mother accompany Skye her on her clinic visit today. Jake's mom has taken the afternoon off work to bring Jake and Skye to this appointment in the only car the household has, but she states that she won't be able to do this on a regular basis. Jake's mother works the swing shifts as a nurse's aide at a long term care facility. During the day she is often busy taking care of her own mother who has a "bad heart" and lives by herself about a mile away. Jake has older brothers who no longer live at home. Jake is a senior in high school, and although he has had some difficult times, he expresses interest in graduating from high school and continuing at a community college. Finances are tight in this household, and there are times toward the end of the month when there is little food in the house. Jake's mother states that she is willing to support Skye and her pregnancy in any way she can, but she expresses concerns about her limited time and money. She states that she does have some understanding of the importance of food and insulin for those with diabetes.

Skye paints the following picture of a "typical" daily food pattern:

Discussion

1. What are the perinatal risks to Skye and her baby due to poor glycemic control at the time of conception, thorough gestation, and following birth?
2. What are the potential consequences of Skye's prenatal BMI? Her smoking?
3. What initial assessment procedures and tests would be appropriate?
4. What initial changes might you suggest in Skye's insulin schedule?
5. What would you do to instigate a blood glucose monitoring system?
6. How should the team decide who will become the primary case manager for Skye?
7. What suggestions might you make for the food insecurity experienced by this household?
8. What is your plan in terms of suggested energy intake, calories from protein, fat, and carbohydrate, and fiber?
9. What specific dietary changes would you recommend? How would you go about planning a diet at this first visit? What would be your long term plan?
10. What would you say about exercise?
11. Would you recommend dietary supplements? Which supplements?

Second Visit

Skye has missed an appointment, and she returns today at 16 weeks gestation. Today she weighs 58 kg. She states that she is feeling much better. She has been keeping some records of her diet, insulin and glucose monitoring. They are as follows:

Food Records

Blood Glucose Records

Skye has been looking into a high school program for pregnant and parenting women. She's seriously considering enrolling, but she wonders if she can handle going to school and all the self care that she requires right now. She's also asking about her ability to breastfeed - both as a mother with insulin dependent diabetes and also as a full time student. Jake is here for today's appointment, and he states that he is proud of the changes that Skye has made and that he wants her to breastfeed the baby because he thinks that it is the best thing for the baby.

She has managed to cut back to 10 cigarettes each day. She states that she has been feeling less tired, and that she been taking daily walks at about 12:00 each day with a neighbor who is at home with her own breastfeeding infant.

Discussion

1. What assessment procedures and tests are appropriate?
2. What feedback do you give Skye about the changes that she has made?
3. What further changes might you suggest to the diet or insulin pattern?
4. What advice can you give Skye about breastfeeding?
5. What further diabetes education counseling might you attempt today?

Follow-up

 Thanks to the help of your team Skye delivers an apparently healthy, 3,200 gram baby at 39 weeks. Congratulations to you all!!

 She managed to make the dietary changes that you suggested and to monitor her blood glucose levels fairly consistently. Her last Hgb A1C was 2 standard deviations above normal. Her last hematocrit was 34%. Her weight gain pattern was as follows:

Discussion

1. Comment on Skye's weight gain pattern.
2. If you were to conduct an evaluation of your team approach to diabetes maternity support, what outcomes would you measure?
3. What plans would you make for consistent follow-up for Skye and her baby? What services are needed? How can adequate follow-up best be promoted?

References

Food Safety During Pregnancy: http://www.ext.colostate.edu/pubs/foodnut/09372.html

Sweet Success Guidelines for Care - 2002. California Diabetes and Pregnancy Program - on reserve at Health Sciences Library

Nutrition and the Pregnant Adolescent: A Practical Reference Guide: http://www.epi.umn.edu/let/pubs/nmpa.shtm

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

The National Center for Complementary and Alternative Medicine (NCCAM) http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html

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