Case Study For Comprehensive Prenatal Care Assignment

Case Study For Comprehensive Prenatal Care Assignment

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Discussion Response

1. Angelina M’s Post

Hello, your approach to the patient’s care seems thorough and appropriate. Based on the information provided, I agree with the decision to order Beta-HCG testing of urine and blood, an ultrasound, and a CBC for BB’s evaluation. However, I would caution against ordering some tests such as a quadruple screening, as it may be ineffective at this time. The test can be performed at 20 weeks gestation to determine the risk for certain chromosomal abnormalities such as Down Syndrome or neural tube defects such as spina bifida (Chitty, 2021).  Additionally, while BB’s age places her in the advanced maternal age category, this does not necessarily mean she will have complications. Rather, her risk factors should be assessed and addressed accordingly. I believe this approach is a good starting point for BB’s evaluation, but caution should be exercised in ordering some tests or treatments. Consider a consultation with a genetic counselor to discuss the risk of chromosomal abnormalities given the patient’s advanced maternal age and previous history of pregnancy complications (Dobrescu et al., 2019)Case Study For Comprehensive Prenatal Care Assignment. The genetic counselor can provide additional information on screening options and potential risks to the patient and fetus.

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References

Chitty, D. L. (2021). Poster abstracts of the ISPD 25th international conference on prenatal diagnosis and therapy, virtual, 6–8 June 2021. Prenatal Diagnosis, 41(S1), 10–153. https://doi.org/10.1002/pd.6016

Dobrescu, M. A., Burada, F., Cucu, M. G., Riza, A. L., Chelu, G., Plesea, R. M., Cucu, A., Cimpoeru, A. L., & Ioana, M. (2019). Prenatal genetic counseling in congenital anomalies. Congenital Anomalies – from the Embryo to the Neonate. https://doi.org/10.5772/intechopen.74394

Catrina’s Post

Hello, your discussion provides comprehensive, standard prenatal care, including ultrasound and routine blood work, based on the information provided. The patient provided in the discussion is an African American and requires comprehensive care as you have discussed above. African American women have a higher risk of pregnancy complications and maternal mortality rates. Therefore, it might be beneficial to conduct additional screening for conditions that disproportionately affect African American women, such as sickle cell disease, gestational diabetes, and hypertension (Zhou et al., 2019)Case Study For Comprehensive Prenatal Care Assignment. Additionally, culturally sensitive care that takes into account the patient’s beliefs and practices is essential.

These considerations can help improve patient outcomes and reduce disparities in maternal health. Since the patient is a vegetarian, it may be necessary to ensure that she is receiving adequate amounts of certain nutrients, such as iron and vitamin B12, and to consider supplementing her diet if necessary. Plant-based foods do not naturally contain vitamin B12 and supplementation is essential to avoid deficiency (Niklewicz et al., 2022). It is also important to discuss the patient’s social support network and identify any potential stressors or barriers to care that may need to be addressed to facilitate a healthy pregnancy and prevent complications such as miscarriage and postpartum depression.

References

Niklewicz, A., Smith, A. D., Smith, A., Holzer, A., Klein, A., McCaddon, A., Molloy, A. M., Wolffenbuttel, B. H. R., Nexo, E., McNulty, H., Refsum, H., Gueant, J.-L., Dib, M.-J., Ward, M., Murphy, M., Green, R., Ahmadi, K. R., Hannibal, L., Warren, M. J., & Owen, P. J. (2022). The importance of vitamin B12 for individuals choosing plant-based diets. European Journal of Nutrition. https://doi.org/10.1007/s00394-022-03025-4

Zhou, J., Han, J., Nutescu, E. A., Galanter, W. L., Walton, S. M., Gordeuk, V. R., Saraf, S. L., & Calip, G. S. (2019). Similar burden of type 2 diabetes among adult patients with sickle cell disease relative to African Americans in the U.S. population: A six‐year population‐based cohort analysis. British Journal of Haematology, 185(1), 116–127. https://doi.org/10.1111/bjh.15773 Case Study For Comprehensive Prenatal Care Assignment

This is a continuation of order ID#249688 . Reply to peer’s post:  1 to 2 paragraphs per pear response.

Note: Explain how you might think differently about the types of tests or treatment options your colleagues suggested and why.

Responses are directed to the peer, they are at a critical level means discussing things such as your opinion of the point mentioned, why you hold that opinion, what you see wrong with the point mentioned, how you see the point consistent/inconsistent with what you have learned so far,

Cite your reference(s) using APA 7 format.

– Responses are supported with at least 2 scholarly source per response

Angelina M’ Post

Patient Information:

Initials: B.B, Age: 39, Sex: Female, Race: Caucasian

C.C. “I am here today because I had positive home pregnancy test”

HPI:

B.B. is a 39-year-old Caucasian female G5-P3-T3-A2-L3 that presents to the clinic with a positive home pregnancy test. She reports her LMP was 1/15/2023. She reports that she has been experiencing breast tenderness, fatigue, and nausea which made her suspect that she was pregnant Case Study For Comprehensive Prenatal Care Assignment.

Current Medication: Women vitamins for the past 6 years

Allergies: Not mention

PMHx:  Negative health history

Soc & Substance Hx: Not mention

Fam Hx: Not mention

Surgical Hx: C-section in 2017

Mental Hx: Not mention

Violence Hx: Not mention

Reproductive Hx: Menarche age 12. She reports normal menstrual periods that come every 28 days and lasting for 5 days. LMP 1/15/2023. Negative STD history. Negative history for abnormal pap smears. Sexually active.

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G5-P3-T3-A2-L3.

• G1: 2015, NSVD with epidural at 41 weeks. No complications
• G2: 2016, NVSD with epidural at 37 weeks. Complication: Disappearing twin.
• G3: 2017, primary c/s with spinal at 39 weeks. Male. Complication: c/s for breech after failed version.
• G4: 2019, ectopic pregnancy at 6 weeks. Treated with methotrexate.

ROS:

General: Reports Fatigue. Denies chills, fever, or night sweats. Denies dizziness or lightheadedness.

Breast: Reports tenderness. Denies lumps and discharge.

Cardiovascular/Peripheral Vascular: Chest pain/tightness. Denies history of angina, heart murmur, or circulation problems. Denies edema. No history of blood clots.

Respiratory: Denies shortness of breath or difficulty breathing. Denies cough. No history of a pulmonary embolism.

Gastrointestinal: Reports Nausea. Denies constipation or diarrhea. Denies changes in bowel movements. Denies history of heartburn or GERD.

Genitourinary/Reproductive: Denies any burning with urination or frequency. Denies any vaginal bleeding or discharge. LMP: 1/15/23. She is sexually active. Denies pain during intercourse.

O.

Physical examination information not provided

Diagnostic test:

• Beta-human chorionic gonadotropin (Beta-HCG) testing of urine
• Beta-Human chorionic gonadotropin (Beta-HCG) testing of blood
• Ultrasound: Can be used to detect a intrauterine pregnancy, ectopic pregnancy, finding suggestive of an extrauterine pregnancy (Anderson & Ghaffarian, 2023)
• CBC

A:

1. Encounter for supervision of normal pregnancy: ICD Z34.9

Indications for obtaining a pregnancy test, urine, or serum, include females of child-bearing age with symptoms including amenorrhea, nausea, vomiting, abdominal/pelvic pain, urinary symptoms, dizziness, or hypotension (Anderson & Ghaffarian, 2023)Case Study For Comprehensive Prenatal Care Assignment. BB presents to the clinic with a missed menstrual period, nausea, vomiting, fatigue, and a positive home pregnancy test that warrants further evaluation. Pregnancy can be confirmed using ultrasound or ultrasound or beta-human chorionic gonadotropin (Beta-HCG) testing. If a patient has elevated HCG levels, it is a good indicator of pregnancy. However, this test does have the potential for false positives. In early pregnancy, transabdominal ultrasound is used to detect the presence of an intrauterine pregnancy (Anderson & Ghaffarian, 2023).

2. Supervision of elderly multigravida, first trimester: ICD 009.521

Pregnancy at advanced maternal age is classified when a mother is 35 years old or older and is considered a risk factor for adverse maternal and perinatal outcomes (Glick et al., 2021). BB is 39 years old, placing her in the advanced maternal age category. Risk factors associated with advanced maternal age include the risk of spontaneous miscarriage, preterm labor, gestational diabetes mellitus, pre-eclampsia, stillbirth, and chromosomal abnormalities (Glick et al., 2021)Case Study For Comprehensive Prenatal Care Assignment. BB is at increased risk for complications because she is 39 years old and has a prior history of ectopic pregnancy and disappearing twin with her second pregnancy. Considering her age and possible risk factors, I would consider ordering an early GTT and quadruple screening to evaluate if the baby is at risk for specific congenital disabilities.

3. Encounter for antenatal screening of mother: ICD-Z36

 Antenatal screening is defined as population screening to identify people with a genetic risk or risk of having a child with a congenital or genetic disorder through biochemical genetic or ultrasound screening (Vass et al., 2019). Since BB is advanced maternal age, it would be essential to perform testing to genetic to rule out any congenital abnormalities or Down syndrome because chromosomal and congenital anomalies have increased prevalence among fetuses of AMA mothers (Glick et al., 2021)Case Study For Comprehensive Prenatal Care Assignment. Test that can be ordered includes Chorionic villus sampling, quadruple blood screening test, and amniocentesis.

4. Nausea and vomiting of Pregnancy (NVP)

Nausea and vomiting of pregnancy (NVP) are common conditions that affect 70% of pregnant women and usually begin at 6-8 weeks of gestation and resolve around 16-20 weeks (Liu et al., 2021). BB reports that nausea was one of the symptoms she was experiencing that made her suspect she was pregnant. It is essential to educate mothers if they develop hyperemesis gravidarum (HG), which is a severe form of NVP to contact a health care provider because it can lead to dehydration, electrolyte balance changes, ketosis, neurological disorder, muscle weakness, and fatigue (Liu et al., 2021). BB will be prescribed Diclegis, which will help relieve the nausea symptoms.

P.

• If serum Beta-HCG is positive a confirmation appointment will be scheduled.
• New OB appointment will be scheduled to start prenatal care. At her initial prenatal care, I would order CBC, urine culture, gonorrhea and chlamydia screening, and blood work for syphilis, HIV, Hep B screening, Blood type and antibody screening, Rh, and rubella titers.
• Start B.B. on prenatal vitamins
• Since BB is AMA, I would discuss ordering genetic testing since chromosomal and congenital anomalies have increased prevalence among fetuses of AMA mothers (Glick et al., 2021)Case Study For Comprehensive Prenatal Care Assignment.
• AMA mothers are at increased risk of developing gestational diabetes, so I would consider ordering an early GTT screening test.

Referral: OB/GYN physician for confirmation of pregnancy

Treatment:

• Start prenatal vitamins
• Doxylamine-pyridoxine (Diclegis) 10-10mg is recommended as a first line treatment for nausea and vomiting during pregnancy (Persaud et al., 2018).

Reflection:

BB positive home pregnany test and presenting symptoms make me suspect she is pregnant. Ordering a serum Beta-HCG and transabdominal ultrasound will allow for a more definitive diagnosis. With her prior history of a miscarriage, ectopic pregnancy, and age, I think it would be beneficial to order genetic testing to rule out chromosomal and congenital anomalies Case Study For Comprehensive Prenatal Care Assignment.

Reference

Anderson, J., & Ghaffarian, K. (2023). Early pregnancy Diagnosis. https://www.ncbi.nlm.nih.gov/books/NBK556135/Links to an external site.

Glick, I., Kadish, E., & Rottenstreich, M. (2021). Management of Pregnancy in Women of Advanced Maternal Age: Improving Outcomes for Mother and Baby. International journal of women’s health, 13, 751–759. https://doi.org/10.2147/IJWH.S283216Links to an external site.

Liu, C., Zhao, G., Qiao, D., Wang, L., He, Y., Zhao, M., Fan, Y., & Jiang, E. (2022). Emerging Progress in Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum: Challenges and Opportunities. Frontiers in medicine, 8, 809270. https://doi.org/10.3389/fmed.2021.809270

Persaud, N., Meaney, C., El-Emam, K., Moineddin, R., & Thorpe, K. (2018). Doxylamine-pyridoxine for nausea and vomiting of pregnancy randomized placebo controlled trial: Prespecified analyses and reanalysis. PloS one, 13(1), e0189978. https://doi.org/10.1371/journal.pone.0189978Links to an external site.

Vass, C. M., Georgsson, S., Ulph, F., & Payne, K. (2019). Preferences for aspects of antenatal and newborn screening: a systematic review. BMC pregnancy and childbirth, 19(1), 131. https://doi.org/10.1186/s12884-019-2278-7

Catrina’s post

Patient Information: S.J.   29-year-old    African American   female.

S.

CC: “I need to confirm my pregnancy”

HPI S.J. is a 29-year-old female presenting today at your clinic with a positive home pregnancy test.  Patient stated that symptoms of occasional nausea, breast tenderness and fatigue started about 1-2 months ago, which caused her to suspect that she was pregnant.  Her medical history is negative.  Surgical history negative.  Gyn history 1^st menses age 12, with cycles coming every 28 days and lasting for 5 days.  Her pap and std history are negative.  She has been taking a woman’s gummy vitamin for the past year. Case Study For Comprehensive Prenatal Care Assignment

Location: uterus (amenorrhea), breast and abdomen

Onset: 1-2 months ago

Character:  none

Associated signs and symptoms: nausea, breast tenderness, fatigue

Timing: occasional

Exacerbating/relieving factors: none

Severity: 2/10

Current Medications:

• Women’s gummy vitamins daily

PMHx: Up to date on immunizations. Gestational DM in 2014 & 2017. No past hospitalizations. No current medical history.

Soc & Substance Hx: Shirley denies smoking, alcohol, and recreational drug use. She is a warehouse supervisor at Amazon and works 36 hrs. per week. She and her fiancé have been together for 5 years, and he works in an accounting office. They live in a 3-bedroom townhouse within easy walking distance to schools and stores. Her fiancé’s parents live in the same complex they do, and her parents and younger sister live about a mile away. Patient stated that she has become a vegetarian since her last pregnancy.

Fam Hx: Case Study For Comprehensive Prenatal Care Assignment

• Mother and Father alive/well;
• Maternal grandmother alive; with HTN;
• Paternal grandmother/grandfather unknown;
• Brother (27 y/0)- alive/ well
• One sister (32 y/o)– alive/ well.

Surgical Hx: Negative

Mental Hx: Denies depression or suicidal/homicidal ideation.

Violence Hx: Denies history of violence or intimate partner violence.

Reproductive Hx:

• –Last pap: none
• -LMP: 1/15/2023
• -Contraception: None
• -Vaginal Intercourse: Vaginal and Oral
• -Positive home pregnancy test

 ROS:

GENERAL: Reports fatigue for 1-2 months. Denies any fever, chills, weakness, dizziness or night sweats.

HEENT: Denies vision disturbances, hearing, sore throat, runny nose and headaches.

Cardiovascular: Denies chest pain or chest discomfort. Denies palpitations or edema noted.

Respiratory: Denies shortness of breath, cough, or sputum.

Gastrointestinal: Reports occasional nausea. Denies vomiting, diarrhea, anorexia, and bloody stools.

Genitourinary/Reproductive:  Denies pain with urination, burning, bleeding or irritation.  Reports LMP: 1/15/2023 with a productive home pregnancy test. Denies any reproductive issues or use of contraceptives against pregnancy. Her OB history:

• G6 T2 P1 A2 L4

  O.

ROS.

Physical exam: Height: 162.6.  Weight: 80kg.  BMI: 30.3.  BP: 112/68.  P: 86.  RR: 18.  Temp: 98.5 oral.  O2: 100%

GENERAL: Alert and oriented. In no acute distress, appears stated age.

Lungs/CV: Lung/ chest sounds are clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam.

Breasts: tender with palpitation; normal anatomy and form

Abdomen: soft, round, +BS.  Nontender.

GU/Reproductive: Urine pregnancy test resulted positive.  Patient refused pap testing at this moment.  Fundus palpable on abdomen; no cervical tenderness, masses or lumps noted.  Fetus heart tones with doppler 150bpm Case Study For Comprehensive Prenatal Care Assignment

Extremities: warm to touch; normal for ethnicity.

Diagnostic results:

• Urine pregnancy (resulting positive) and urinalysis w/culture.
• New OB Labs- CBC, HepB, HepC, Rubella IGg, RPR, G/C/Trich, Hemoglobin Electrophoresis , sickle cell, HgbA1C, T&S/ Rh factor per ACOG guidelines
• FHT with handheld doppler: 145-150 bpm
• Early 1hr glucola 50g due to BMI 30.3. per ACOG guideline. BS resulted 110, which is a normal glucose at the moment. Glucose can not exceed 140 or patient will need to take a 3 hour fasting glucola .
• NAAT test is highly sensitive for detecting trichomonas, chlamydia, gonorrhea as stated by the Gynecologic Health Care in 2022.

A .

Primary Diagnoses:

Pregnancy- Due to the patient’s positive pregnancy test, amenorrhea since 1/15/2023, symptoms of fatigue/ breast soreness and clinical urine test for hCG in urine resulting positive the patient is confirmed to be currently pregnancy.  As stated by Life Forward in 2022.  hCG is produced when the fertilized egg attaches to the uterus about 6 days after fertilization. Case Study For Comprehensive Prenatal Care Assignment

Differential Diagnoses:

Gestational Diabetes- The patient has a BMI of 30.3, which puts her at risk for having gestational diabetes.  Other risk factor will consist of her race, history of gestational diabetes, and age as stated by Johns Hopkins Medicine in 2023.

Vitamin D deficiency – Patient is at risk for this diagnosis due to her history of eating a vegetarian diet for 6 years and darker skin ethnicity as stated by ACOG in 2021. 

.P.

Further diagnostics:

• Ultrasound on next OB visit due to the need of scheduling to assess pregnancy confirmation and determination of dating per ACOG
• Anatomy ultrasound starting at 18 weeks per ACOG
• Quad Screening on next OB visit often between 15-22 weeks per ACOG- screen risk for chromosomal disorder and neural tube defects.
• I hr Glucola at 24-28 weeks per ACOG
• Fetal height will be measured at 20 weeks:
• T-dap vaccine: between 27-36 weeks to prevent whooping cough in babies younger than 3 months per ACOG
• Group B Strep (GBS) at 36 weeks per ACOG
• Repeat of CBC at 32 weeks to assess for anemia
• 3rds labs at 36 weeks Case Study For Comprehensive Prenatal Care Assignment

Therapeutic interventions:

• Prenatal vitamins
• Iron supplement
• Folic acid 0.4mg daily due to current diet of vegetarian, which may result in low B12
• Diclegis 10mg two tablets PO qhs for nausea
  

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Patient education:

• If any signs of bleeding, heavy spotting, severe abdominal pain or extreme nausea and vomiting, patient should go to the nearest emergency room for evaluation.
• Eat a balanced diet consisting of 3meals and 2 snack daily. Due to patient’s diet, vegetarian, patient should eat foods high in folic acid to prevent B12 deficiency and high vitamin D.  Examples are dark, green leafy veggies, asparagus, legumes, broccoli, strawberries, avocado, okra, grapefruit, milk, cheese, yogurt, etc.  Patient can use free online resources such as MyPlate as a visual example of portions needed, vegetarian meal plans and nutrition education. Due to patients’ history of gestational DM, this is very important to avoid gestational DM with this pregnancy.
• Patient is advised to eat 5-6 small portion of meals throughout the day to decrease the sensation of nausea. These meals should be lukewarm or cold while avoid spicy or greasy foods.
• Due to iron sometimes causing an increase in nausea, patient is advised to not take iron with PNV until symptoms improve. Patient should still take folic acid and PNV daily.
• Ginger can be consumed through other foods due to its ability to improve nausea symptoms.
• Patient is educated on the importance of resting when able due to fatigue being a common issue in the 1^stThis should improve later in pregnancy.
• Patient is educated on wear a fitted, supportive bra to help relieve symptoms of breast tenderness due to an increase in progesterone and estrogen in preparation of lactation as stated by (Schuilling, 2022)Case Study For Comprehensive Prenatal Care Assignment.

Patient Disposition:

The patient should return to the clinic in four weeks for next OB appointment and first ultrasound appointment.

References

Johns Hopkins Medicine. (2023). Gestational Diabetes Mellitus (GDM). Retrieved from Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes/gestational-diabetes

Life Forward. (2022, January 4). How to confirm pregnancy (and Why it’s so important). Retrieved from Life Forward: https://www.lifeforwardcincy.org/questions/2022/1/4/how-to-confirm-pregnancy-and-why-its-so-important

Schuilling, K. &. (2022). In K. &. Schuilling, Gynecologic Health Care (4 ed.). Burlington, Massachusetts: Jones & Bartlett Learning.

The American College of Obstetricians and Gynecologists. (2021). Routine tests during pregnancy. Retrieved from The American College of Obstetricians and Gynecologists: The American College of Obstetricians and Gynecologists. (2021).

The American College of Obstetrician’s and Gynecologists. (2022). Tdap vaccination during pregnancy: frequently asked questions. Retrieved from The American College of Obstetrician’s and Gynecologists: https://www.acog.org/store/products/patient-education/fast-facts/tdap-vaccination-during-pregnancy

The American College of Obstetrician’s and Gynecologists. (2021). Vitamin D: Screening and Supplementation during pregnancy. Retrieved from The American College of Obstetrician’s and Gynecologists: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/07/vitamin-d-screening-and-supplementation-during-pregnancy Case Study For Comprehensive Prenatal Care Assignment