Judith Long's Screening on 32 Weeks Pregnant - Case Study Example

Name : xxxxxxxxxxx Institution : xxxxxxxxxxx Course : xxxxxxxxxxx Title : Case Study: Judith Long is 32 weeks pregnant Tutor : xxxxxxxxxxx @ 2011 Case Study: Judith Long is 32 weeks pregnant An ultrasound is a diagnostic examination which makes use of high-frequency sound waves to generate an image of the internal organs. A screening ultrasound is important for Judith in order to assess the normal fetal growth as well as validate the due date. Since Judith is in her last trimester, ultrasound will help in monitoring fetal growth, checking the quantity of amniotic fluid, as part of other examination like the biophysical profile, determining the fetus position as well as to asses the placenta (Pillitteri 2007, Pg 12-15). Urinalysis will be done in order to perform different analytical tests for the urine. Judith will only be required to collect a sample of clean urine in a sterile container. Chemically prepared examining strips will be dipped in the urine sample to screen for specific indicators. More in-depth analysis will be carried out by analyzing the urine sample in the laboratory. The urinalysis is important in examining bladder or kidney infections, ketones, bacteria as well as proteins. High amounts of sugar can indicate gestational diabetes while increased levels of proteins indicates a likely urinary tract infection or kidney disease. Preeclampsia can be a possibility if higher amounts of protein and found in the urine combined with high blood pressure (British Medical Association 2010, Pg 20-22). If there is sugar in Judith’s urine, it does not necessarily mean she is diabetic because it is normal for kidneys to leak sugar from bloodstream into the urine. This is specifically expected if Judith had a large meal or a sweet drink. Meanwhile, she should be examined for gestational diabetes if steady levels of glucose are detected, she complains of lethargy and feels heavy and constantly tired, she is over and over again thirsty and if she is loosing weight. However, Judith has not complained of such symptoms and hence gestational diabetes will be ruled out (British Medical Association 2010, Pg 26). Protenuria is normally detected through urine dipstick or by using sulfosalicylic acid cold test within random urine samples. The concentration of protein in random samples is highly variable and is influenced by numerous factors, mostly vagina secretions, urinary tract infection as well as activity. Various clinical studies define abnormal protenuria as at least 1+ on dipstick on 2 occasions 6 or more hours apart. The 1+ protenuria test for Judith indicates that there could be a problem kidney functioning, for instance kidney infection. Furthermore, Judith is in the third trimester of her pregnancy and this can be a sign of preeclampsia. Again, there before Judith had a high blood pressure, had edema and swollen legs and constant sugar levels had been detected. An abnormal protenuria of 2+ on dipstick along with hypertension indicates that the diagnosis is preeclampsia. If this is discovered during Judith’s examinations, the doctor is supposed to document these findings and explain to Judith that it increases the probability of convulsion, abruptio placentae, fetal growth retardation, in addition to preterm delivery. However the risks for these complications are dependant on gestational age at the beginning and also on the severity of the abnormalities (Pillitteri 2007, Pg 34). During urinalysis, testing for ketones is important. Ketones are present if the body is breaking down fats in place of carbohydrates for energy. High levels of ketones imply that someone is not eating sufficiently or is dehydrated. Finally, presence of bacteria in the urine indicates urinary tract infection. A second urine sample should be collected using a catheter before establishing the type of antibiotics required (Louise 2008, Pg 42-45). The blood tests will help is identifying Judith’s blood type and Rhesus status, in addition to checking for anemia, hepatitis B, blood sugar test, immunity to rubella, glucose tolerance test and many more. Blood sugar test will be important in checking the way the whole body of Judith processes sugar. Before this test is carried out, there is no prior preparation required. What Judith has to do is to take glucose by having any sugary fluid. After one hour, liquid blood sample from Judith will be taken for analysis. In case the outcome of this high glucose test is positive, Judith is supposed to undergo a Glucose Tolerance Test and this is to ensure that she does not have gestational diabetes. For a glucose tolerance test, Judith will be required to take more than 150 mg carbohydrates, three days before the test. After the three days of carbohydrate intake, Judith has to fast for 14 hours before taking the glucose test. Throughout the fasting period, Judith will only take a few sips of drinking water. The ideal time for this test is in the morning since it will be easy for Judith to fast during the night (Louise 2008, Pg 45). Throughout the test, blood is taken to establish Judith’s “fasting blood glucose level”. After this, she is supposed to drink glucose liquid. A three hour glucose test; where, each hour, blood will be drawn for testing, and this goes on for three hours. Later on, the physician will examine the four readings of blood sugar levels, and in case few of these tests turn out to be, atypical a treatment plan for gestational diabetes is vastly recommended to Judith. If the glucose test is positive, Judith is supposed to take several nutritional adjustments. She will be required to take a good balanced diet which is an excellent blend engaging fats, proteins, vitamin supplements as well as calories. A few pregnancy exercise movements for around thirty minutes every day will be of help. If these types of lifestyle changes are not able to control diabetic issues, Judith will be given insulin injections as the last measure to control diabetes (Pillitteri 2007, Pg 26-27). Another blood test which will be carried out is alpha-fetoprotein screening (AFP). This is a blood test that will measure the level of alpha-fetoprotein in Judith’s blood. Normally, AFP is a protein that is produced by the fetal liver and is present within the fluid surrounding the fetus and crosses the placenta into mother’s blood. Abnormal levels of AFP can indicate the following: open neural tube defects (ONTD) like spina bifida, Down syndrome, chromosomal abnormalities, defects within the abdominal wall of the fetus and a miscalculated due date, since the levels fluctuate throughout pregnancy. Generally, abnormal test result of AFP can show the necessity of further testing. Normally, an ultrasound is carried out to confirm the pregnancy date and to look at the fetal spine as well as other body parts for defects. An amniocentesis can be carried out for examining increased amniotic fluid levels of AFP as well as other chemicals which might signify the presence of spina bifida (National Library Australia 2008, Pg 14).  Blood pressure test will be necessary in order to make sure that Judith does not have high blood pressure or pregnancy induced hypertension which can cause premature delivery, retarded growth or low blood flow to the infant (Louise 2008, Pg 51). The main purpose of cardiotocograph (CTG) is fetal monitoring and this is necessary for Judith because she a medical problem. The monitoring will involve the physician listening to the baby’s heart rate. This means having a CTG attached, this involves a toco to assess uterine contractions in addition to a transducer for picking up the fetal heart beat. However, Judith does not require CTG admission but she will have to undergo sporadic monitoring, where the midwife will listen using a Doppler or pinnard (Pillitteri 2007, Pg 38-40). The main reasons for monitoring Judith include breech presentation, antepartum bleeding, diabetes, prolonged rupture of membranes, big or small baby, polyhydramnios, oligohydramnios, multiple pregnancy, pre-eclampsia, reduced fetal movements as well as changes in labor. It is important for the midwife to take Judith’s heart rate and then compare it with the baby’s baseline to make sure that they are not the same. Still, Judith’s blood pressure should be recorded. The baby’s heart rate should be between 110-160bpm and the heart rate should not go below 110bpm. In case the baby’s heart rate is below 110bpm, this is a deceleration and requires medical attention. As the baby moves in the uterine, the baby’s heart rate goes up, because of his or her movements and it illustrates normal oxygen levels: this is considered normal and it is known as acceleration. The other importance of a CTG is the variability. Variability evaluates if the baby’s heart rate is between 5-25bpm and in this case the baby is normally well oxygenated. Nevertheless, the baby can sleep for about 20-90 minutes while being monitored and the variability will be decreased that is less than 5bpm. Basically, the normal CTG has these features: Baseline rate 110-160, Baseline variability of 5-25 bpm, Accelerations 15bpm for 15 seconds and No decelerations (Engel 2006, Pg 10-12). In summary, Judith requires fetal monitoring since it will monitor the fetal heart rate in addition to other functions. Fetal heart rate checks the rate and rhythm of fetal heartbeat. The fetal heart rate can change as the fetus reacts to conditions within the uterus. An unusual fetal heart rate or pattern can imply that the fetus is not receiving adequate oxygen or there could be other problems. An unusual pattern also can imply that an emergency or cesarean delivery is required. Kick charts is important since it will assist Judith in discovering a reduction in activity of the fetus. Mothers are responsive of the babies’ movements. During pregnancy, healthy babies are normally active except when they are asleep. As a result, the fetal kick count is a simple, non-invasive method of checking the well being of the baby (Pillitteri 2007, Pg 18). In regard to education, I would advice Judith regarding the numerous ways of counting the movement of the baby as well as several opinions on how many movements one is looking for within a given period of time. I would advise Judith to make sure that she times and schedules how long it takes for her to feel 10 kicks or movements. Preferably, there are supposed to be at least 10 movements in 10-12 hours. Normally 10 movements are recorded within much less time. Even if this exercise is recommended for high risk pregnancies, the counting of fetal movements starting at 28 weeks can be valuable for all pregnancies (Engel 2006, Pg 5-6). On the other hand, I would let Judith know that some medications, for instance those used in treatment of epilepsy can decrease fetal movement. As mentioned earlier, kick charts assist in discovering reduced baby’s activity and when this takes place, clinical reviews as well as a cardiotocograph (CTG) are necessary. After the diagnosis of IUGR has been discovered, it will be important in determining a specific etiology. Therapy can be non-specific but is supposed to handle the primary cause. Lots of infants considered to be growth retarded are, in retrospect, found to be constitutionally small. The main management matters are the gestational age of the pregnancy during the diagnosis as well as the necessity to speed up delivery. Most fetal deaths involving IUGR take place after 36 weeks of gestation and before labor starts. The clinician should balance the risk of delivering a premature infant against the probable for intrauterine demise (Engel 2006, Pg 2). Numerous factors cause IUGR, but they can be categorized into two big categories, based on etiology. These classifications consist of fetoplacental factors and maternal factors. In the classifications of maternal and fetoplacental factors are numerous specific causes. Historically, IUGR have been classified as symmetric or asymmetric. Symmetric IUGR refers to fetuses with similarly poor growth velocity of the head, the abdomen in addition to the long bones. Asymmetric IUGR is about infants who have their head and long bones spared compared with their abdomen and viscera (Louise 2008, Pg 8-10). Maternal causes of IUGR are the main causes of uteroplacental cases. In referring to Judith’s case, hypertension could be the cause of IUGR. Furthermore, babies of hypertensive mothers have a three-fold rise in perinatal mortality when compared to infant with IUGR whose mothers are normotensive. Pre-eclampsia lead to damage of placenta and this causes uteroplacental deficiency. This failure results into narrowing and medical degeneration of luminal and consequently causes reduced blood flow to the developing infant. As a result, infants do not grow normally (National Library Australia 2007, Pg 10). Infectious causes of fetal development delay are responsible for around 10% of all IUGR cases. The causes consist of TORCH" group: Toxoplasma, rubella, cytomegalovirus as well as herpes simplex virus types 1 and 2. Maternal pre-pregnancy weight as well as weight gain during pregnancy is key indicators of birth weight. The existing agreement is that a maternal weight gain of less than 10 kg by 40 weeks of gestation is evidently a risk factor for IUGR. Smoking in expectant mothers could also be a cause. According to medical studies, usage of alcohol by expectant mothers can cause fetal alcohol syndrome whereas taking of alcohol in the second or third trimester could cause IUGR. Usage of cocaine by the expectant mother can cause IUGR and also decreased head circumference. Other drugs linked to IUGR are steroids, warfarin and also phenytoin (National Library Australia 2007, Pg 12-14). The doctor also requires serial blood pressures every 15 minutes recorded over 2 hours, taken on her right arm with Judith lying on her left side, in order to clarify the inconsistencies, and to keep away from potential medicolegal claims. The main reason for treating hypertension is to avoid cerebrovascular accidents without compromising uteroplacental blood flow, which is already less in preeclampsia-eclampsia. The universal recommendation is to decrease the diastolic level to below 100 mm Hg, keeping it between 90 and 100 mm Hg (Louise 2008, Pg 25). The reason why Judith was lying on her left side is because if a pregnant woman lies flat on her back during the later months of the pregnancy she might begin feeling light-headed, dizzy as well as possible breathless. During pregnancy, the enlarged uterus also naturally leans towards your right side. This might make the vena cava blood vessel prone to getting compressed while lying on her back. The vena cava carries the blood supply back the body to the heart. In case this blood supply is decreased by lying on her back, this can slow the blood flow from the heart to other parts of the body, for instance the brain, lungs and as result cause breathlessness and dizzy sensations. Nevertheless, pregnant women are supposed to lay quite flat on their back before the vena cava gets compressed. Normally by lying on her left side avoids compression of the vena-cava. Furthermore, in case the blood flow to the heart, of the mother is decreased, the unborn baby can also get less blood flow for a short period of time. This can occasionally be adequate to cause the baby to be temporarily stressed and in probably open their bowels in the uterus before the birth (National Library Australia 2007, Pg 10). The physiological changes that might make these symptoms take place include estimated fetal weight gain. This is based on the measurements of head circumference, abdominal circumference in addition to femur length. These measurements will be plotted on a preexisting standardized chart. In this case, ultrasound examination will allow evaluation of fetal weight with a 15% to 28% variance. An estimated fetal weight of less than the 6th percentile will strongly compare with growth retardation. Maternal arterial umbilical blood flow will increase with the continuing pregnancy and the increase is secondary to a steady decrease within vessel resistance to blood flow. As the pregnancy advances, diastolic flow will increase and the systolic/diastolic ratio should steadily reduce. Still, an alteration within placental blood flow will take place. Most of the infants perceived to be growth-retarded for example in case of Judith who is not gaining weight, in retrospect, found to be constitutionally small. The main management matters are the gestational age of the pregnancy during the diagnosis as well as the urgency to expedite delivery. Judith should be informed that most fetal deaths involving IUGR take place 36 weeks of gestation and just before labor starts. Therefore, the clinician is supposed to balance the risk of delivering a premature infant against the prospective for intrauterine demise (National Library Australia 2007, Pg 15-18). Bibliography Engel, J.K. 2006, Pediatric Assessment, Mosby Elsevier, Canada. Louise, R., 2008, Understanding the Australian Health Care System, Elsevier Australia. British Medical Association, 2010, Medical journal of Australia, Volume 159, Issues 1. National Library Australia, 2008, Australian national bibliography: 2007: Volume 2. National Library Australia, Sydney. National Library Australia, 2007, APAIS, Australian Health affairs information service: a subject index to current literature, National Library Australia, New Jersey. Pillitteri, A. 2007, Maternal & Child Health Care of the Childbearing and Childrearing Family. 5th Edition, Lippincott Williams & Wilkins. Read More