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Plz answer the question in the case study and edit it as a word doc.
The chapter 5 PPT may help .
CASE STUDY 2
Introduction: Sarah Henley is a 31-year-old female gravida 3 para 2 who presented to the emergency room in her 23rd week gestation. She fell on the ice this morning and has now experienced some vaginal spotting and abdominal pain. She is now admitted to rule out premature labor secondary to her fall.
History: Mrs. Henley has had two previous pregnancies delivered at 38 and 37 weeks respectively. Patient states that she is much more tired with this pregnancy but has related it to having two small children. She describes being short of breath, which she states also occurred commonly with previous pregnancies, but may be earlier this pregnancy.
Current medications: none except prenatal vitamins. States she doesn’t take everyday because they make her nauseaous.
Laboratory Values: Hgb. 9.1 g/dl; Ferritin 10 (g/dL [consistent with microcytic, hypochromic iron deficiency anemia]
Lifestyle: Alcohol – denies; Smoker – yes ½ pack per day; husband smokes also.
Ht. 5’5” Wt. 145 lbs. Pre-pregnancy – 135# Gained 15-18 lbs. with previous two pregnancies (3 years and 18 months ago).
Nutrition History: Patient states appetite is good. She suffered a lot of morning sickness during the first trimester but is better now.
Usual dietary intake: AM: coffee, cold cereal, occasionally toast
Lunch: sandwich or soup
Dinner: casserole such as hamburger helper, hot dogs, soup. About twice a week she cooks a full meal with meat and vegetables. Husband works nights so she doesn’t always cook every night.
24 hour recall: 2 c. Frosted Flakes; ½ c. whole milk, black coffee
Lunch: hot dog on bun, ½ c. macaroni and cheese
Dinner: 3 oz. Salisbury steak, 1 c. green beans, 1 roll, 1 c. black coffee.
1. In reading the patient’s medical record, you note that she is in her 24th week gestation. You also learn she is “gravida 3 para 2.” What does this mean?
2. Mrs. Henley’s physician indicated the need for additional lab work when her admitting CBC revealed low hemoglobin. Why is this a concern? Are normal changes in hemoglobin associated with pregnancy? If so, what? Do any other hematological values normally change in pregnancy? Explain.
3. Check Mrs. Henley’s prepregnancy weight. How much weight has she gained? Plot her weight gain on the maternal weight gain curve. Is her gain adequate? How does her weight gain compare to current recommendations? Was the weight gained during her previous pregnancies within normal limits?
4. What factors in her pregnancy histories indicate any additional risk factors for the development of iron deficiency anemia? Were her other pregnancies normal?
5. Could anything else in her medical, nutritional, or lifestyle history affect her pregnancy outcome? Explain.
6. Assess this patient’s average daily iron intake. Actually enter food into a diet analysis program and PRINT and attach it to this case! How does this compare to the RDI for iron during pregnancy? Are there any other nutrients you should be concerned about? Use printout referenced above and address the inadequacies.
7. What are good dietary sources of iron? Is the absorption of iron affected by any other conditions? Explain.
8. 8. Mrs. Henley states she loves eating fish that her family catches. Are there any specific recommendations you would make to her regarding fish intake during pregnancy?
9. You note in Mrs. Henley’s history that she has received nutrition counseling from the WIC program. What is WIC? Would you refer her back to that program? If so, how would you make this referral?
Chapter 5
Nutrition during Pregnancy:
Conditions & Interventions
*
Overview
Nutritional interventions
improve outcomes
based on scientific evidence
safety, effectiveness, and affordability
*
Health Conditions, Pregnancy, & Nutrition
Hypertensive disorders of pregnancy
Preexisting & gestational diabetes
Multifetal pregnancies
HIV/AIDS
Eating disorders
Obesity
Fetal alcohol spectrum
Adolescent pregnancy
*
Hypertensive Disorders of Pregnancy
BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic BP
Contributes to stillbirths, fetal & newborn deaths, & other complications
*
Hypertensive Disorders of Pregnancy, Oxidative Stress, and Nutrition
R/T:
Inflammation
Oxidative stress
Damage to the
endothelium
*
Hypertensive Disorders of Pregnancy, Oxidative Stress, and Nutrition
Consequences:
Impaired blood flow
Increased tendency to clot
Plaque
*
Environmental Factors that Increase Oxidative Stress
Trans fat
Inadequate intake of antioxidants
High intake of simple sugars
Elevated BG
Excess body fat
Sedentary
Smoking
*
Hypertensive Disorders of Pregnancy
Chronic Hypertension, Preexisting
Gestational HTN
Preeclampsia, Eclampsia
Preeclampsia Superimposed on Chronic HTN
*
Chronic Hypertension
present before pregnancy or diagnosed <20W
Blood pressure ≥ 160/110 mm Hg increased risk of:
fetal death, preterm delivery, & fetal growth retardation
*
Nutritional Interventions for Women with Chronic HTN in Pregnancy
adequate & balanced diet
If salt-sensitive, Na restriction req. for BP control
*
Gestational Hypertension
HTN diagnosed for first time after 20W
If BP returns to normal by 12 weeks postpartum
transient HTN of pregnancy
*
Preeclampsia-Eclampsia
>20 weeks gestation
**Proteinuria—urinary excretion of protein
Eclampsia—occurrence of seizures not attributed to other causes
*
S/S of Preeclampsia
HTN
urinary PRO
plasma volume expansion
Low urine output
H/A
Sensitivity to light
Blurred vision
Abd pain
Nausea
platelet aggregation, vasoconstriction
*
Outcomes related to the existence of preeclampsia during pregnancy
*
Risk Factors for
Preeclampsia
*
Recommendations for Preeclampsia
Antihypertensive meds
Low dose aspirin
Calcium, 1000-2000 mg
Vitamins C, 200 mg & E, 400 IU
5-9 fruits & vegetables
3 Regular meals + snacks
Appropriate weight gain, physical activity
*
Diabetes in Pregnancy
Type 1 diabetes
Type 2 diabetes
Gestational
*
Potential Consequences of Gestational Diabetes-Fetus
BG from mother reaches fetus
insulin glucose uptake & TG in fetus
Fetal changes, risk later in life
Insulin resistance
Type 2 DM
HTN
*
Risk Factors for Gestational Diabetes
*
Adverse Outcomes Associated
with
Gestational Diabetes
*
Glucose Screening
First screen
oral glucose challenge test (GTT)
If elevated
oral GTT is given
≥2 of the following levels are exceeded:
Overnight fast 95 mg/dL
1-hour after glucose load 180 mg/dL
2-hours after glucose load 155 mg/dL
3-hours after glucose load 140 mg/dL
*
TX of Gestational Diabetes
First approach
normalize BG with diet & exercise
After 2 weeks, if BG high
Insulin
MNT adverse perinatal outcomes
Appropriate weight gain
Postpartum F/U
*
DIET for Gestational Diabetes
What would you recommend
?
*
Type 1 Diabetes during Pregnancy
Mother @ risk of:
Kidney disease
HTN
Newborn @ risk of:
Mortality
Being SGA or LGA
Hypoglycemia within 12 hours after birth
*
Nutritional Mgmt of Type 1 DM during Pregnancy
Control of BG!
Nutritional adequacy of diet
Rec. weight gain
Careful home monitoring:
BG
dietary intake
Exercise
Insulin
urinary ketone levels
*
Multifetal Pregnancies
Twin births
in 1980 = 1 in 56
in 2005 = 1 in 32
Triplet & higher order
in 1980 = 1 in 2941
in 2005= 1 in 558 WOW!
*
Background Information
About Multifetal Pregnancies
Dizygotic
2 eggs fertilized
AKA Fraternal
~70% of twins
Different genetic “fingerprints”
Incidence increased by perinatal nutrient supplements
Monozygotic
1 egg is fertilized
AKA Identical
Always same sex
~30% of twins
Rates appear not to be influenced by heredity
*
Risks Associated with Multifetal Pregnancy
*
Complications Increase as Number of Fetuses Increases
*
Median Birthweight for Gestational Age at Delivery of Twins
*
Nutrition & Outcome of Multifetal Pregnancy
Weight gain c twin
35-45 lbs
0.5 lbs/W 1st trimester
1.5 lbs/W 2-3 trimesters
Weight gain c triplets
~45-55 lbs or 1.5 lbs/W
*
Nutrition & Outcome of Multifetal Pregnancy
Dietary intake
essential fatty
acids, Fe & Ca
V & M/ PNV
*
HIV/AIDS during Pregnancy
Primary Goal-prevent transmission to baby
Meds, c-section
TX
Consequences
Nutritional factors
increase the most in advanced stages
no standards of care during pregnancy exist
*
ED in Pregnancy
Rare
Most subfertile or infertile
Bulimics more likely
*
Eating Disorders in Pregnancy
Higher risk for
Miscarriage
HTN
difficult deliveries
LBW
Refer to ED clinic or specialist
Counseling
Behavior modification
*
Obesity & Excess Weight Gain
risk :
Cesarean delivery
Hypertensive disorders of pregnancy
Gestational DM
Macrosomic Babies
*
Fetal Alcohol Spectrum
range of effects
fetal alcohol exposure
mental & physical
Effects:
Behavioral problems
Mental retardation
Aggressiveness
Nervousness & short attention span
Stunting growth & birth defects
*
Fetal Alcohol Spectrum Stats
One of the leading preventable cause of birth defects
~1 in 12 American pregnant women drink alcohol
1 in 30 consume ≥5 drinks on 1 occasion at least monthly
1 in 1000 newborns are affected by FAS
*
Effects of Alcohol on Pregnancy Outcome
easily crosses placenta
remains in fetal circulation
lacks enzymes to break down alcohol
Exposure during critical periods of growth & development
permanently impair organ & tissue
*
Effects of Alcohol on
Pregnancy Outcome
Heavy drinking (4-5 drinks/D)
Miscarriage
Stillbirth
infant death
~40% of fetuses will have FAS
No “safe” dose so no alcohol at all
*
Fetal Alcohol Syndrome
1973
Characteristics:
anomalies of eyes, nose, heart & CNS
growth retardation
small head
mental retardation
*
Nutrition & Teen Pregnancy
Growth of Mom!
Infants average 155g less than those born to older adults
*
Risks Associated with Adolescent Pregnancy
*
Dietary Recommendations for Pregnant Teens
more kcals to support own growth + fetus
Caloric need from nutrient-dense diet
Calcium DRI pregnant teens is 1300 mg
*
