High Risk Pregnancy Maternal Health - Case Study Example

RUNNING HEAD: Maternal Health High Risk Pregnancy Maternal Health: Case Discussion Under the guidance of Case Description Ruth Ford, aged 38 years, is pregnant for the fifth time. She has one living child, a girl aged six. Ruths partner, the father of all her pregnancies, is away a lot and she has only her mother to help. Ruths mother, aged 65, works full time as a book keeper. Two of Ruths pregnancies were miscarriages before fourteen weeks, another was an ectopic pregnancy and one was a full term stillborn baby. The cause of this babys death has never been established. Ruth is now booking in for the eventual delivery of her current pregnancy. She is also having her first antenatal visit to an obstetrician. She is 12 weeks pregnant. Obstetrician, general practitioner or midwife? Time has come for Ruth to attend an antenatal check up. She needs to decide on whether she needs care by midwife or care by obstetrician. Midwives usually deliver at home and obstetricians deliver in the hospital. Though hospital settings have more infrastructure and expertise to take care of complications occurring during and after delivery, since most of the deliveries are uncomplicated, home delivery is sufficient for uncomplicated pregnancies under the supervision of midwives or any other trained health personnel like general practitioner. Review of literature indicates that most of the studies on the safety of delivery by midwife are on low-risk and uncomplicated pregnancies. Low-risk pregnancy means pregnancy which is less likely to have medical complications. This is determined by the fact that there are no obvious medical problems during pregnancy, the woman has started her prenatal care before19 weeks of gestation, has had 4 visits of antenatal care through the 28th week, every 2 weeks for the next 8 weeks and then weekly for the last 4 weeks (Macfarlane, McCandlish, & Campbell, 2000). It is obvious that high-risk pregnancies need to be delivered in the hospitals under expertise supervision and monitoring. According to Davies, Hey, Reid and Young et al (1996), general practitioners are apprehensive about inability to handle complications arising during homebirth. Also, some studies like Bastian, Keirse & Lancaster (1998) have revealed that home births carry high death rate due to "underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to fetal distress" (Bastian, Keirse & Lancaster, 1998). Certain emergencies like cord prolapse, inverted uterus, or bleeding of the mother and breathing problems with the infant, may need immediate intervention which can be instituted only when the patient is in the hospital. Since Ruths is a high risk pregnancy (because of previous history of abortions and still birth), she must be under the observation of an obstetrician and her delivery must be scheduled in a hospital. According to NICE guidelines (2003), obstetrician must be involved in antenatal care of high risk pregnancy and hence Ruth must be under the care of an obstetrician for antenal care and follow-up delivery. Physiological changes during pregnancy Pregnancy can cause many physiological changes. Certain changes in the breast like enlargement of breasts and darkening of nipple and alveolus can occur. Since the heavy uterus tends to push the bladder, pregnant women micturate frequently. Pregnancy also causes gums to swell and bleed. Various hormonal changes cause changes in skin like brownish marks over nose and cheeks and around eyes, known as chloasma (ACOG, 2007). Certain cardiorespiratory changes also occur during pregnancy. The volume of the blood starts increasing from about 6-8 weeks of gestation and touches maximum value at 32- 34 weeks of gestation. The increase is mainly due to increase in plasma volume rather than increase in red cell mass, leading to hemodilution and fall in hemoglobin concentration. There is hypercoagulability during pregnancy, but clotting time and bleeding time remain normal. The cardiac output increases by 30-40% in the first trimester and heart rate increases by 15% (Ciliberto and Marx, 1998). In the second trimester, diastolic pressure drops a little, but systemic arterial pressure remains normal. Enlargement of the heart occurs due to chamber dilation and hypertrophy. From the end of second trimester, the gravid uterus compresses on the inferior vena cava and the aorta in supine position causing fall in cardiac output and edema. During the course of pregnancy, veins gradually distend to as much as 150% causing reduced blood flow (Ciliberto and Marx, 1998). Miscarriage, ectopic pregnancy and stillbirth. Miscarriage or abortion refers to "spontaneous loss of a fetus before the 20th week of pregnancy" (Medlineplus, 2009). This can be inevitable, threatened, missed, complete or incomplete. Common causes of abortion are genetic anomalies like trisomies, infections, hormonal abnormalities, environmental factors and immunologic factors. Ectopic pregnancy refers to "implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, cornual region of the uterus, and the abdominal cavity" (Sepilian and Wood, 2009). Ectopic pregnancy occurs due to a combination of multiple factors like pelvic inflammatory disease, history of tubal surgery, use of assisted reproductive technology or fertility drugs, use of intrauterine device, advanced age, pathological condition of the tubes and smoking (Sepilian and Wood, 2009). Still birth or fetal demise may be defined as "death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy" (Lindsey, 2008). There are many causes for still birth. The causes can be maternal like diabetes, preeclampsia, eclampsia, advanced maternal age and uterine rupture; fetal like intrauterin growth restriction, congenital abnormality and genetic abnormality; or placental like abruption, premature rupture of membranes, placental insufficiency and fetomaternal haemorrhage (Lindsey, 2008). It is unclear whether abortion has long term adverse psychological impact on women. A systemic review study by Charles, Polis, Sridhara and Blum (2008) found conflicting results about adverse impact of miscarriages on mental health of women. Still birth does have negative mental health outcomes and the mother can suffer extreme distress, grief, intense depression lasting more than 6 months and post-traumatic distress syndrome (Badenhorst and Hughes, 2007). Primary health care in early pregnancy Early prenatal check up should include a detailed health history of Ruth, elaborate physical examination, laboratory tests like complete blood picture and blood grouping, calculation of due date and scheduling of the next antenatal visit. While taking history, details of previous pregnancies must be evaluated and the records reviewed. G5P2L1A2 : G5 will mean that this is the fifth time Ruth has conceived. P2 means Ruths pregnancy continued beyond 20 weeks twice. L1 means Ruth has one living child. A2 means Ruth underwent abortions twice. During physical examination, vital signs like heart rate, respiratory rate, temperature and blood pressure must be recorded along with height and weight (ACOG, 2007). Breasts must be examined and any corrective methods recommended for inverted nipples. Antenatal or prenatal care Prenatal care is very important in any pregnancy, more so in high risk pregnancy. Since Ruth has previous history of abortions, ectopic pregnancy and fetal loss, her current pregnancy is a high-risk pregnancy and she will need appropriate prenatal care. In the first trimester, Ruth will need assessment of her health and also the health of the fetus. According to NICE guidelines (2003), all pregnant women who seek prenatal care must be given evidence-based information and allowed to take informed decisions about their care. Issues like "who will take care of the pregnant woman" and "where will the delivery be conducted" should be based on the pregnant womans choice and after receiving enough information about various options available. NICE guidelines (2003) recognize this as "being integral to the decision-making process." Assessment of fetal wellbeing An initial transvaginal ultrasound as early as eight weeks of gestation (from the last menstrual period) is essential to establish the diagnosis of pregnancy and also to determine gestational age, ascertain mutiple pregnancy and rule out ectopic pregnancy. Between 11 to 14 weeks of gestation, screening for Down’s syndrome by looking at nuchal translucency on ultrasound should be performed. In case of doubt, combined results of nuchal translucency, human Chorionic Gonadotrophin or hCG and Pregnancy Associated Plasma Protein-A or PAPP-A must be used to ascertain the risk of Downs syndrome. Beyond 14 weeks of gestation, triple test (Alpha feto protein or AFP, hCG and estradiol-3 uE3) or quadruple test (AFP, hCG, inhibin A and uE3) must be performed to ascertain the risk of Downs syndrome. Ideal time to determine gestational age is between 10 to 13 weeks. Crown-rump measurement is the method for gestational age estimation. Beyond 14 weeks of gestation, gestational age must be determined by bi-parietal diameter method and head circumference method (NICE, 2003). In the second trimester, between 18-20 weeks of gestation, an ultrasound scan must be performed by an appropriately trained sonographer to screen for structural fetal anomalies (NICE, 2003). Health of the mother Ruth must be tested for hemoglobin, peripheral smear, blood group and red cell autoantibodies during early pregnancy and also at 28 weeks of gestation. Routine urine examination must be performed in early pregnancy to rule out asymptomatic bacteriuria. Other tests to be performed are HIV antibodies, HepB antigens, rubella IgM and VDRL, toxoplasma IgM. Blood pressure must be checked during all antenatal visits (NICE, 2003). Nutritional and pharmacological considerations Folic acid supplementation must be continued until 12 weeks of gestation to reduce the risk of neural tube defects. The dosage to be taken is 400 micrograms per day (NICE, 2003). Iron supplementation must be initiated only if anemia is present. Routine iron supplementation is not recommended in pregnancy. Vitamin A is teratogenic and hence Ruth must be advised not to take Vit A supplementation during pregnancy. Ruth must be advised methods to prevent food-borne infections like salmonellosis and listeriosis by drinking only pasteurised milk, eating only well-cooked food including vegetables, eggs, meat, poultry and eggs. Ruth must also be advised not to take any medicine without consulting a physician. This is because many medicines are teratogenic and can cause harm to the fetus (NICE, 2003). Other advice Complementary therapies may be unsafe in pregnancy and hence must be avoided. High intensity sports and exercise must also be avoided. Consumption of alcohol, smoking, cannabis and other intoxicants are harmful to the fetus and even these must be avoided (NICE, 2003). Psychological support Pregnancy is a period of great adjustment and women may find it difficult to manage various emotional, financial, social and physical demands leading to a state of anxiety. Ruth should be evaluated for various mental health conditions and referred to psychologist if necessary. If no abnormal mental condition is detected and if she is just anxious about the safety of the baby, she should be counseled appropriately. Appropriate emotional and psychological support is necessary for any women during pregnancy. Since Ruths husband is away and she has only her old mother to help her, the obstetrician must take up the responsibility of giving some emotional comfort to Ruth. If possible, the obstetrician must advise Ruths husband to stay with her as far as possible. According to cochrane review (Hodnett and Frederick, 2009), "pregnant women need the support of caring family members, friends, and health professionals. While programs which offer additional support during pregnancy are unlikely to prevent the pregnancy from resulting in a low birthweight or preterm baby, they may be helpful in reducing the likelihood of caesarean birth." Prospective education about the next two trimesters Patient education in pregnancy is essential to enhance self-care (Pasinlioglu, 2004). Ruth must be educated about the importance of prenatal care and the need for regular antenatal check ups. This is because, antenatal check-ups allow the doctor to closely watch the health of the pregnant woman and the fetus. Ruth must be educated about what is to be expected during subsequent trimesters and childbirth and labor. Ruth must be informed about the importance of nuchal scan at 11-14 weeks and anomaly scan in the second trimester. She must be informed about good eating habits, regular activity, adequate sleep, folate supplementation and to avoid smoking, alcohol, illicit drugs and unnecessary medications intake. Dietary advice must be provided. She must be asked to take balanced diet rich in milk products, fruits and vegetables. The recommended calorie intake is 2000 k calories (ACOG, 2007). She must also be educated what problems may arise in subsequent weeks to come like preeclampsia, eclampsia, placenta previa, abruptio placenta, intrauterine growth retardation and premature rupture of membranes. She must also be informed about the importance of weight monitoring. Weight monitoring gives an estimation of growth of fetus. Women who are underweight are expected to gain 25- 25 pounds during pregnancy. For those who are over weight, 15- 25 pounds weight gain is expected (ACOG, 2007). Since exercise strengthens muscles used in delivery, regular moderate exercise for atleast 30 minutes is recommended (ACOG, 2007). Other aspects like work and travel must also be discussed during antenatal visit. The mother must also be informed about various physiological changes she will undergo including enlargement of breasts, edema, increased heart rate and increased respiratory rate. Another important aspect which needs to be discussed during antenatal visit is breastfeeding. The importance of breast feeding must be driven into the minds of pregnant women right from the first antenatal check up. Conclusion Ruth is 12 weeks pregnant. Due to previous catastrophes, the current pregnancy is a high-risk one. Ruth will need to be cared by an obstetrician and the delivery must be scheduled in a hospital. Regular antenatal check up and ultrasound are crucial for vigilance and monitoring of complication. Adequate psychological, emotional and social support is essential for Ruth who has meager family support. Education helps in self-care and enhances the chances of good outcomes of pregnancy. References American College of Obstetricians and Gynecologists or ACOG. (2007). Patient Education Pamplet. Retrieved on August 15th, 009 from http://www.acog.org/publications/patient_education/ab005.cfm Badenhorst, W., and Hughes, P. (2007). Psychological aspects of perinatal loss. Best Pract Res Clin Obstet Gynaecol., 21(2), 249-59 Bastian, H., Keirse, M.J.N., & Lancaster, L.(1998). Perinatal death associated with planned home birth in Australia: population based study. BMJ, 317, 384-388. Ciliberto, C.F., and Marx, G.F. (1998). Physiological Changes Associated with Pregnancy. Physiology, 9(2), 1-3. Davies, J., Hey, E., Reid, W., Young, G. (1996). Prospective regional study of planned home birth. BMJ, 313, 1302-5 Haws, R.A., Yakoob, M.Y., Soomro, T., Menezes, E.V., Darmstadt, G.L., Bhutta, Z.A. (2009). Reducing stillbirths: screening and monitoring during pregnancy and labour. BMC Pregnancy Childbirth, 9, 1:S5. Hodnett, E.D., and Fredericks, S. (2009). Support during pregnancy for women at increased risk of low birth weight babies. Cochrane Database of Systematic Reviews, 1, CD000198. Lindsey, J.L. (2008). Evaluation of Fetal Death. Emedicine from WebMD. Retrieved on August 16th 2009 from http://emedicine.medscape.com/article/259165-overview. Macfarlane A, McCandlish R, Campbell R. (2000). Choosing between home and hospital delivery. There is no evidence that hospital is the safest place to give birth. BMJ, 320, 798. Retrieved on August 16th 2009 from http://www.bmj.com/cgi/ijlink?linkType=FULL&journalCode=bmj&resid=320/7237/798 Medline Plus. (2009). Miscarriage. Retrieved on August 16th 2009 from http://www.nlm.nih.gov/medlineplus/ency/article/001488.htm NICE Guidelines. (2003). Antenatal Care: Routine care for the healthy pregnant woman. Retrieved on August 16th 2009 from http://www.nice.org.uk/nicemedia/pdf/CG6_ANC_NICEguideline.pdf NICE Guidelines. (2007). Mental health problems during pregnancy and after giving Retrieved on August 16th 2009 from birth. http://www.nice.org.uk/nicemedia/pdf/CG045PublicInfo.pdf Pasinlioglu, T. (2004). Health education for pregnant women: the role of background characteristics. Patient Education and Counseling, 53 (1), p. 101-106 Sepilian, V.P. and Wood, E. (2009). Ectopic pregnancy. Emedicine from WebMD. Retrieved on August 16th 2009 from http://emedicine.medscape.com/article/258768-overview Read More