Pregnancy Case Study

Background
Today you are meeting with Meghan, a 39-year-old non-Hispanic, White woman who is 20
weeks pregnant. Her obstetrician referred Meghan to you, a Registered Dietitian. This is
Meghans first pregnancy. Meghan is a regional sales manager for an upscale clothing store that
is having some economic difficulties right now; her company is in the middle of closing some
stores and downsizing. Meghan shares with you that this was an unexpected pregnancy. Meghan
had always wanted to be a mother, but she was too busy building her career and never felt it was
the right time. Now she states that she is excited about her pregnancy, and has already been
buying baby clothes and redecorating the second bedroom in her condo. Meghan attended a
preconception health education class and will start a childbirth class next month. Meghan is an
only child. Meghans mother and new husband live in New York, and as a newly retired couple,
plan to travel a lot to spend their winters in Mexico.
Meghan has been dating the father of the baby, Peter, for about six months when she discovered
she was pregnant. Peter is 50 years old, and an executive at Microsoft. He has two children ages
22 and 24. Peter was initially reluctant to have another child, but being a mother was very
important to Meghan, and Peter agreed to support her during this pregnancy. The work team that
Peter leads is currently in the middle of a big push for the roll out of a new version of their
software product.
Meghan is uncertain about breastfeeding at this point. She plans to go back to work a month after
she delivers, but is concerned that it would be too difficult to combine her work load with
breastfeeding.
Fitness is important to Meghan. She was a competitive runner in high school and college.
Meghan and Peter are part of a group of friends who socialize together during strenuous adult
bike and ski trips. Meghan continues to run about 15 miles a week-having cut back from 30
miles a week before she was pregnant, due to increased fatigue. She has a membership in a
health club and typically uses weights and the Stairmaster 2 or 3 times per week. She says that in
the last month she added a water aerobics class to her routine to compensate for the reduction in
her running.
There is a strong family history of obesity in Meghans family. Her father died at age 55 of heart
failure that was probably related to the diabetes he developed in his 40s. Meghan tells you that
she worries about having a big baby who will be at risk for these conditions as an adult. Meghan
also tell you that she has had to work to keep her weight under control, and she has found that a
low-carbohydrate diet is the most effective approach for her. She tells you that once, when she
failed to follow this diet for a few weeks, her weight ballooned to 125 pounds.

Anthropometric Data
Meghans pre-pregnancy weight was 120 pounds. She is 69 inches tall. Today her weight is 126
pounds.

Health History
Meghans health history is unremarkable. Her blood pressure today is within normal limits. She
denies use of drugs or tobacco.
With this pregnancy she continues to experience fatigue, nausea, intermittent constipation, and
heartburn.
Lab Values
Last week Meghan had a 50 gram oral glucose screen. Results at one hours were 120mg/100ml.
Meghans hematocrit today is 29%.

Supplements
Meghan tells you that she is taking fish out capsules to reduce her risk of developing
hypertension and calcium to prevent leg cramps. She tried standard prenatal vitamins but they
seemed to increase her nausea.

Dietary Intake
Before the visit, you asked Meghan to keep a three-day food log. She states that this pattern is
typical. Because she spends many days on the road visiting stores, she makes a point of taking
her lunch and snack with her in a cooler so she wont have to buy food of unknown quality on
the road. Weekends are variable depending on her social schedule, but she tries to get together
with a group of friends every Sunday morning. Meghan states that she works hard to avoid foods
with fat and sugar. She will occasionally have one glass of wine or beer at social events. In
addition to the foods and beverages listed below, Meghan tells you that she usually carries a
water bottle around with her and makes a point to drink at least 2 liters of water a day-more if it
is hot or she has been exercising.
Day One Day Two Day Three
Brunch
2 ounce Lox
1 ounce low fat cream cheese
plain bagel
12 ounce non-fat latte
3 ounces mimosa (1/2
champagne, orange juice

Breakfast
3 slices bacon
cup egg substitute
scrambled
12 ounces coffee with
4 ounces whole milk
Breakfast
3 slices bacon
cup egg substitute
scrambled
12 ounces coffee with
4 ounces whole milk
Snack
4 ounce plain whole milk
yogurt
2 cups Dieter Herbal Tea
Lunch
6 ounces vacuum packed tuna
12 oz diet sprite
2 rice cakes (brown rice,
plain)
11/2 ounce Pouligny Saint-
Pierre Cheese
Lunch
6 ounces vacuum packed tuna
12 oz diet sprite
2 rice cakes (brown rice,
plain)
11/2 ounce Pouligny Saint-
Pierre Cheese
Dinner
6 ounces salmon-grilled
cup asparagus
12 ounces whole milk
Snack
4 ounce plain whole milk
yogurt
2 cups Dieter Herbal Tea

Snack
4 ounce plain whole milk
yogurt
2 cups Dieter Herbal Tea

Dinner
6 ounces grilled chicken breast
2 cups Romaine lettuce
1 Tbsp Balsamic Vinaigrette
4 cherry tomatoes
12 ounces whole milk
Dinner
6 ounces sole baked in lemon
juice and 1 Tbsp Butter
1 cup steamed broccoli
1 Tbsp olive oil
12 ounces whole milk
Questions
1. Which pre-pregnancy social, dietary, and anthropometric data factors might play a role in
the outcome of Meghans pregnancy? How might these have an impact?

- The ages of both the father (50 y) and the mother (39 y) of this infant: qualities of
eggs and sperms decline due to damage of cells DNA.
- Meghans busy schedule & non breast feeding plan:
- Family history of obesity:
- Alcohol consumption: abnormal mental development and growth of offspring.
- Inadequate exercises: adequate exercises are good for both mother and fetus. Whereas
exercise in little weight gained pregnant women can cause reduction of fetal growth.
Also, skiing, water and weight are not recommended during pregnancy.
- Low-carb diet: would not meet fetal brains need for glucose, low maternal blood
glucose level affect fetal growth. Also low fiber diet cause maternal constipation.
- Consumption of processed meat: correct storage of processed meat is required to
prevent listerosis infection, which leads to spontaneous abortion and stillbirth.
- Frequent Tuna consumption: mercury contamination, which in significant amount
could cause fetus mental retardation, hearing loss, numbness, and seizures, is a big
concern.
- Underweight BMI status: Underweight and low weight gain of the mother may slow the
growth of fetus.
- Frequent Caffeine consumption: (clients daily consumption of coffee and tea is on the
edge) excessive caffeine consumption might lead to miscarriage.


2. Assess Meghans current nutritional status in terms of anthropometric data, health
history, lab values, and dietary intake information.

Ht=69 in.
wt before Pregnancy= 120 lb, wt after pregnancy= 126
Before Pregnancy BMI= 17.77 (Underweight)
After pregnancy BMI= 18.66
Recommended Energy Intake estimation according to activity= 2790 + 300= 3190 kcal
Hematocrit today is 29%.
BG level= 120mg/100ml


Day 1:

Day 2

Day 3:


According to her diet analysis, she is under severe malnutrition condition. Her carbohydrate and
fat intake are all below requirement, while protein is three times above requirement.


3. What are the nutritional concerns you have about Meghan? How might you prioritize
these concerns in terms of addressing them in the limited time you have with Meghan
today?
Meghan is under her daily caloric intake by a significant amount given the
amount of exercise she does along with the intensity of the exercise while also
being pregnant. She is consuming more vitamin A, sodium, and protein than the
daily recommendation. The main concern is the amount of calories she is eating
versus should be eating so it would be priority to increase the amount of food she
is eating during her snacks and the occasional small dinner. Another nutritional
concern involves the occasional alcoholic beverage. Although the intake is low, it
may still lead to mild or undetectable effects and is there for discouraged for those
that are pregnant.

4. What specific recommendations might you make regarding weight gain, diet, exercise,
dietary supplements, and discomforts of pregnancy?
Meghan should cut back on exercise to 30 minutes per day 5 days a week, moving
her down to a moderate intensity level. Her high level of intensity is affecting her
weight while she is not consuming enough calories to provide for her pregnancy
and her exercise. Meghan obtains most omega-3 and omega-6 fatty acids in her
diet with all the fish she eats, so supplements are not necessary. These
supplements along with a diet rich in fish could also be contributing to the high
intake of vitamin A that are almost twice as much as the daily recommendation.
Meghan should cut back on her caffeine and coffee intake. Fiber is very low right
now so adding 30 grams of fiber in the form of fruits and vegetables would help
with constipation.

5. You see Meghan again at her 32 week visit. She now weighs 140 pounds and her
hematocrit is 31%. What would you like to address at this visit?
Meghans weight gain is still a slight concern. She has gained only 20 pounds
throughout her pregnancy while the normal values are between 28-40 pounds for
a woman that is considered underweight (17.7%) in the preconception. Her
hematocrit values are within normal range for the third trimester.


































Source: http://courses.washington.edu/nutr526/cases/case1_2011.htm