Case Two: High Risk Pregnancy - Kayla

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Kayla

Background

Your Maternity Support Services (MSS)/ Maternity Case management team at a community clinic has received a referral for Kayla from the family planning clinic at your facility.  Kayla is 16 years old.   In addition to her first MSS visit, Kayla will have her first prenatal care visit at your clinic with a midwife today. Kayla comes to clinic alone.

Kayla has a fairly flat affect and spends most of her time looking at the floor and speaking softly.  In response to your questions Kayla tells you that she doesn't really know when her last period was, but thinks that it may have been 3 or 4 months ago.  She states that her periods have never been very regular.

Kayla lives with her mother and 3 younger siblings in a low income apartment near your clinic. Her mother works as a home health aide for a local agency, and has been going to community college at night to become a Licensed Practical Nurse. .  Kayla has had an "on and off " boyfriend, Brandon, for about two years.  She knows that Brandon is the father of this baby.  Brandon has not been told about the pregnancy yet.   Kayla's mother relies on her to take care of her brothers and sisters after school and on weekends.  Kayla is a sophomore in high school.  She tells you that she has been missing a lot of school lately because she has been very tired in the mornings.  She also complains of "morning sickness,"  and says that she has been throwing up most mornings.  She and  her brothers and sisters spend most of their time at home watching TV.  She denies alcohol, tobacco, or drug use. Kayla has not had routine health monitoring visits since she was "a baby" because the family has not had health insurance.  Some of her teeth appear to be decayed and her gums appear to be red and inflamed.  Kayla's father lives in Arizona and is a member of the Navajo Nation.

Kayla's mother shops for the family once a week on the weekends, and Kayla is responsible for making most of the meals.  She tells you that the family relies on "starchy" foods like hamburger helper and top ramen.  Kayla's mother just found out that Kayla is pregnant.  Kayla reports that her mother is very angry right now, but she expects her to "come around."  Kayla's mother has diabetes.  Kayla is unsure about the details, but does tell you that her mother "probably weighs about 200 pounds" and that she does not take insulin. 

Kayla thinks that she weighed about 155 pounds when she got pregnant. Today she weighs 165 pounds.  She is 5' 3" tall.  Her blood pressure today is  125/80.    Her hematocrit is  30% .

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

Discussion

1. What are the potential consequences of Kayla's prenatal BMI?
2. What further assessment procedures and tests would be appropriate?
3. Even if you don't plan to address all the issues today, what would be the best plan for Kayla for total daily energy intake, calories from protein, fat, and carbohydrate, and fiber?
4. 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?
5. What would you say about physical activity?
6. Would you recommend dietary supplements? Which supplements?
7. Would you suggest that your MSS team make other referrals?
8. What special considerations would you give to this situation in terms of Kayla's age and development?

Second Visit

Kayla returns today one week after her initial visit.  Her pregnancy has been dated by ultrasound and she is thought to be at 22 weeks gestation today. Her weight is 170 pounds.

She is accompanied by her mother.  Her mother tells you that she is still angry about this pregnancy because she doesn't want Kayla to have the hardships that she did in life.  However, Kayla's mother states that she is committed to helping Kayla and her baby.  She also tells you that it is very difficult for her to buy the foods that she knows she needs for her own health and the health of her children. 

The venous plasma glucose concentrations from Kayla's 100 g glucose tolerance test that she completed three days after her last visit with you are as follows:

Food Records

Discussion

1. What do the results of the glucose tolerance test indicate?
2. What dietary recommendations will you make?
3. What suggestions might you make for the food insecurity experienced by this household?

Third Visit

Kayla is now at 26 weeks gestation.  She has had several visits with the social worker and an obstetrician since you last saw her.  She is more communicative today, and she is again accompanied by her mother.  She reports that she has been going to school most days now, and is feeling less tired.  She has been taking a prenatal vitamin with iron.  Kayla now weighs 172 pounds. 

Her blood pressure is 145/90.  She denies headaches or blurred vision.  Her urine tests 1+dipstick in a random urine determination with no evidence of urinary tract infection. The pregnancy is being followed closely in a high risk clinic, but since you have established a relationship with Kayla the team has decided that you should continue to provide her nutritional care.

Kayla is now enrolled in a high school program for pregnant and parenting student. Some of the young women in her class are breastfeeding.  Although the school offers on-site child care and support for breastfeeding, Kayla is not sure if she'll be able to breastfeed.  She's concerned about the effect of diabetes and about the fact that her mother was never able to successfully breastfeed because she couldn't "make enough milk." 

One of the girls in Kayla's class had severe preeclampsia that resulted in a very uncomfortable pregnancy, prolonged hospitalization, and an early delivery of a high risk infant.  Kayla is worried about this possibility and wants to know what she can do with her diet to prevent "toxemia." 

Food Records

Whole Blood Glucose Records

Discussion

1. What additional assessment procedures and tests are appropriate?
2. What feedback do you give Kayla about the changes that she has made?
3. What further changes might you suggest to the diet plan?
4. What advice can you give Kayla about breastfeeding as an adolescent? As a mother who had GDM?
5. What can you tell her about her diet and her concerns about her blood pressure?
6. What further counseling might you attempt today?
7. What plans might the MSS team make for supporting Kayla for the rest of her pregnancy and post partum?

References

Food Safety for Moms to Be: http://www.cfsan.fda.gov/~pregnant/while.html

Diagnosis and Management of Preeclampsia:  http://www.aafp.org/afp/20041215/2317.html

Maternity Support Services:  http://www.doh.wa.gov/cfh/mch/maternity_support_services.htm

Nutrition and Food Resources: http://foodhelp.wa.gov/index.htm

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

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

Gestational Diabetes Mellitus. Diabetes Care, January 2004 vol. 27 no. suppl 1 s88-s90

Gestational Diabetes:  Nutrition Guidelines: http://www.cdphe.state.co.us/pp/womens/GDM/GDM_Nutrition_Guidelines.pdf

Oral Health and Pregnancy:  a review  Gajendra and Kumar. 

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