Question

Background

Ami is a 34 year old woman who is 30 weeks pregnant. Laura has had one previous pregnancy that resulted in the birth of a 4200 g healthy baby who is now 16 months old. Her partner has accompanied her to the visit. Both parents work full time.

Both pregnancies were planned. They both made a point of making healthy food choices and avoiding alcohol when they were trying to conceive.

There first born has been a "fussy" baby and is just now beginning to sleep through the night. Ami encountered some difficulties with breastfeeding for the first few weeks. These included sore nipples, a breast infection, and a perceived lack of an adequate milk supply. Despite her plan to maintain exclusive breastfeeding and pumping of breastmilk for several months, after Ami returned to work, the baby was soon just nursing a couple of times a day, and stopped nursing altogether 2 to 3 weeks. They stopped breastfeeding when the baby was 9 months old.

They state that they have concerns about the effect that a new baby will have on their first child, their marriage, and their finances.

Anthropometric Data

Ami's pre-pregnancy weight with this pregnancy was 168 #. She is 61 " tall. She gained 55 pounds in her first pregnancy, and lost 20 of those pounds before she became pregnant again. Today her weight is 190#.

Health History

Health history is unremarkable. Her blood pressure today is within normal limits. She denies use of drugs, tobacco.

Ami does not have a regular exercise routine. She joined a health club a few years ago, but stopped going after about 6 weeks because she felt out of place and she thought that it was boring. She started a walking program after her first pregnancy with another new mother from her mom’s group, but her friend moved away and she doesn’t like to walk alone.

At the beginning of both of her pregnancies Ami experienced considerable nausea and occasional vomiting as well as overwhelming fatigue. Today she complains of the onset of several pregnancy discomforts that also bothered her toward the end of her first pregnancy. These include heartburn, intermittent diarrhea and constipation, fatigue, and edema in her ankles.

Laboratory Values

Last week Ami had a 50 gram oral glucose screen. Results at one hour were 120 mg/100 ml. Hematocrit today is 32%.

Supplements

Ami is intermittently taking a standard prenatal vitamin and mineral supplement that contains 30 mg per day of elemental iron. She feels that this supplement has contributed to some of her pregnancy related discomforts. She is asking your advice today about fish oil, zinc, and calcium supplements in pregnancy.

Dietary Intake

Before the visit you asked Laura to keep three day food records. She brings them with her today. She states that this pattern is typical for a weekday when she works mornings. Saturdays are variable depending on what errands need to be done, but usually one or two meals are at a fast food place. On Sundays Laura goes out with David and Sarah after church for a large breakfast at Denny's (fried eggs, bacon, toast, hash browns) and then has a pizza meal in the evening.

Day One	Day Two	Day Three
Breakfast 2 c. Coffee with cream	Breakfast 2 c. Coffee with cream	Breakfast 2 c. Coffee with cream
Break at Work Donut Decaf Coffee with cream	Break at Work Donut Decaf Coffee with cream	Break at Work Donut Decaf Coffee with cream
Lunch Tuna sandwich (water packed albacore tuna, mayo, pickle relish, white bread) 12 oz unpasturized Whole milk Potato chips Leftover bean salad	Lunch Peanut butter and jelly sandwich unpasturized Whole Milk ½ c pretzels 2 mandarin oranges	Lunch Ham and cheese sandwich (swiss cheese, mayonnaise, sliced ham, white bread) 1 c Apple slices 12 oz water
Snack 10 Triscuit Crackers 2 oz Cheddar Cheese slices	Snack 2 chocolate chip cookies	Snack 1 snack size Cheetos bag Unpasturized Apple Juice - 12 oz
Dinner 1/3 a large pepperoni Pizza small spinach salad 12 oz root beer	Dinner 1 ½ c. Spaghetti ¾ c tomato sauce with ground beef 1 ½ c Salad with iceberg lettuce, carrots, and tomatoes 2 Tbsp. Ranch Dressing 2 thick slices buttered garlic bread 12 oz whole unpasturized milk	Dinner Chicken teriyaki 1 c rice ½ c Green Peas 12 oz whole milk 1c. Hagen Das Ice Cream with Dove Chocolate Sauce

Questions:

Assess the anthropometric data, health history, lab values, and dietary intake information above.

1. What are three nutritional concerns you have for this family?
2. What impacts might Ami's weight status have on this pregnancy?
3. What recommendations might you make regarding weight gain, diet, exercise, dietary supplements, and her discomforts of pregnancy? (List at least 5)

Answer 1

Assess the anthropometric data, health history, lab values, and dietary intake information above.

1. What are three nutritional concerns you have for this family?

a)High fat diet

b) high carbohydrate diet

c)high salted

low fiber

1. What impacts might Ami's weight status have on this pregnancy?

-difficulty labour, prolonged labour,

-diabetes mellitus as its complication leads to macrosomia, which can lead to increased chance of C-section

-high blood pressure which may lead to preeclampsia  

1. What recommendations might you make regarding weight gain, diet, exercise, dietary supplements, and her discomforts of pregnancy?

-advice her to take small (quantity) meals

- include vegetables and fruits more

- reduce cream , take pizza once a week.

-avoid or stop hydrated drinks

- biscuits to two or three once daily (mostly at tea time)

-after each meal walk minimum five minutes this helps reducing your abdominal discomfort

- don't lie down immediately after food

- regular excercise of 15 to 20minutes daily is essential, can do walking or yoga , this helps in muscle strengthening.

-while lying down preferably lie on left lateral position

-while sitting keep the legs raised, don't hang it.

- take nap in the afternoon