Case Two: High Risk Pregnancy - Orchard

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Orchard

Background

Your WIC team at a community clinic has received a referral for Orchard from the family planning clinic at your facility.  Orchard is 16 years old.   In addition to her WIC visit, Orchard is having her first prenatal care visit at your clinic with a midwife today. Orchard comes to clinic alone.

Orchard has a fairly flat affect, spends most of her time looking at the floor, and speaks in monotones.  In response to your questions Orchard tells you that she doesn't really know when her last period was, but thinks that it may have been 4 or 5 months ago.  She has never had regular periods.

Orchard lives with her mother and 3 younger siblings in a low income apartment near your clinic. She has not seen her father for several years, and most of her mother's family lives in Arizona. 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.  Orchard's mother relies on her to take care of her brothers and sisters after school and on weekends.  Orchard 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. When you ask about physical activity Orchard states that she likes to work out along with fitness shows on television for an hour or two each day when she is feeling OK.  She denies alcohol, tobacco or drug use. Orchard 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. 

Orchard's mother shops for the family's food once a week on the weekends, and Orchard is responsible for making most of the meals.  She tells you that the family relies on "starchy" foods like hamburger helper and top ramen, but that she doesn't like to eat those foods.  Orchard's mother just found out that Orchard is pregnant.  Orchard reports that her mother is very angry right now, but she expects her to "come around."  Orchard's mother has diabetes and hypertension.   Orchard is unsure about the details, but does tell you that her mother "probably weighs about 200 pounds".  Orchard states that her mother gained a lot of weight in pregnancy, and she is very clear that she doesn't want to gain "a lot of weight and get fat too" - the most animated thing she says during her whole visit with you.

Orchard thinks that she weighed about 108 pounds when she got pregnant. Today she weighs 115 pounds.  She is 5' 6" tall.  Her blood pressure today is  130/85.    Her hematocrit is  29% .  50g 1 hour glucose screen results are:  120 mg/100 ml.

Orchard says that she doesn't eat at regular times and that she and often skips meals. She paints the following picture of a "typical" daily food pattern:

Discussion

1. What are the potential consequences of Orchard's prenatal BMI?
2. Plot her weight gain.  What are the potential consequences of her weight gain pattern so far?
3. 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 nutrient and food recommendations for pregnant teens of her body size. Compile a list of concerns about her nutritional situation.
4. In combination with her diet, what might her hematocrit value tell you?
5. If you could address all these concerns today, what actions would you suggest that Orchard take for each concern?
6. What special considerations would you give to this situation in terms of Orchard's age, developmental stage and personal situation? What approaches would you take to your nutritional counseling based on these factors?
7. What nutrition-related issues would you actually prioritize for today's visit?
8. What referrals might be indicated? 

Second Visit

Orchard returns today three weeks after her initial visit.  She been using the WIC checks that you gave her at her first visit, but is almost out of WIC food for the month.  Her pregnancy has been dated by ultrasound, and she is thought to be at 24 weeks gestation today. Her weight is 118 pounds. Her hematocrit is 29%. Her blood pressure is 145/95.  Her urinary protein screening test is normal.

She is accompanied by her mother. Her mother tells you that she is still angry about this pregnancy because she doesn't want Orchard to have the hardships that she did in life. However, Orchard's mother states that she is committed to helping Orchard 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. Orchard's mother has been learning about breastfeeding in her courses. She really wants Orchard to breastfeed, but she has questions about Orchard's ability to breastfeed as a teenager. Orchard's mother herself had  preeclampsia and a preterm delivery in her last pregnancy and is asking you today what Orchard should do to avoid both of these in her own pregnancy.

Food Records

Discussion

1. What do the blood pressure measures and urinary protein screen indicate might be happening? What advice can you give about any dietary changes related to changes in blood pressure status during pregnancy?
2. What will you say to Orchard about her diet?
3. What suggestions might you make for the food insecurity experienced by this household?
4. What can you say to Orchard and her mother about Orchard's ability to breastfeed?  Resources and referrals to support breastfeeding?

References

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

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

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

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

Oral Health and Pregnancy:  a review  Gajendra and Kumar. 

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