Running head: FELICITY'S PREGNANCY CASE STUDY Felicity's Pregnancy Case Study Korey Houska Purdue Global 1 FELICITY'S PREGNANCY CASE STUDY Felicity's Pregnancy Case Study Felicity is a 29 year old diabetic female who presented to visit for an initial encounter related to pregnancy. She works a professional career and has a busy life preventing her from getting into the office for a visit until she is three weeks along in pregnancy. High risk pregnancies may be defined by a few different criteria. Felicity being diabetic is one such criteria. Until relatively recently diabetic women were encouraged to avoid pregnancy. The concerns may have been valid as there are increased risks to the mother as well as the developing fetus. Problems that may be a part of the pregnancy for the mother include pre-eclampsia, anxiety, depression, worsening control of blood glucose levels, and development of diabetes complications like retinopathy, neuropathy, and hypertension (McGrath & Chrisler, 2017). Issues that may affect the fetus include stillbirth, miscarriage, abnormally large growth, and congenital malformations affecting cardiac, renal, gastrointestinal, and central nervous organs including neural tube defects (McGrath & Chrisler, 2017). It is important to monitor blood glucose levels as well as hemoglobin A1C and maintain stricter controls during pregnancy to best manage the disease process of diabetes mellitus including preventing diabetic complications. Teratogenic effects of folic acid deficiency Teratogenic effects resulting from a deficiency of folic acid are neural tube defects, which affect the development of the brain, spinal cord, and associated structures. These defects are of two types: open and closed. The open types are more common and include anencephaly, encephaloceles, hydranencephaly, iniencephaly, schizencephaly, and spina bifida. The closed types are exceedingly rare and include lipomyelomeningocele, lipomeningocele, and tethered cord. 2 FELICITY'S PREGNANCY CASE STUDY 3 Anencephaly, which happens during the fourth week of development, is a condition in which the fetus doesn’t develop a complete brain due to a failure to close of the head end of the neural tube. The fetus is either stillborn or dies within hours to days after birth; this defect is incompatible with life. Encephaloceles are membrane-covered, sac-like protrusions of brain through the skull. Hydranencephaly is when the hemispheres of the cerebrum are missing and instead the space is filled with cerebrospinal fluid. Iniencephaly causes the head to be bent back toward the spine; this defect is generally incompatible with life so the fetus may be born live but usually dies within hours (Alvis-Miranda, Bula-Anichiarico, Calderón-Miranda, & MoscoteSalazar, 2015). Schizencephaly causes the development of clefs in the cerebral hemispheres that may fill with cerebrospinal fluid. Spina bifida, which presents as two different types, either spina bifida cystica and spina bifida occulata. Spina bifida cystica includes meningoceles and myelomeningioceles. Meningiocele being less severe than myelomeningiocele as it only affects the meninges and not the spinal cord itself. Spina bifida occulata affects the bones of the spine but not the spinal cord or spinal nerves. Lipomyelomeningocele is a fatty growth that is attached to both the spinal cord and meninges; lipomeningocele is a fatty growth attached to just the meninges and is sometimes erroneously included as a type of spina bifida; and tethered cord is when the spinal cord is stuck to a hardened structure of the spine. All of these neural tube defects develop during weeks three through nine of fetal growth as this is when the majority of central nervous system development happens as well as much organogenesis in the fetus making it important for the mother to participate in preventative measures during the first trimester of the pregnancy thus reducing the likelihood of these defects presenting. FELICITY'S PREGNANCY CASE STUDY 4 Folic acid supplementation Neural tube defects can be significantly reduced if folic acid supplementation is done daily by women of childbearing age (Clarke & Bennett, 2014). Folic acid supplementation of 400 µg -800 µg is an A level recommendation from the US Preventive Task Force, meaning the certainty of benefit is high for this intervention to aid in the prevention of neural tube defects (Tennant, 2014). Folate, or vitamin B9, is a water soluble vitamin that is necessary for cell division and the synthesis of deoxyribonucleic acid (DNA). It is present in some foods. Folic acid, however, is scarce in foods which is why some foods have been fortified with it. Even with a diet including fortified foods, it is still important for supplementation during pregnancy to ensure high enough levels to aid in fetal development. This deficiency may be overcome with the folic acid supplementation and assists in reducing the likelihood of neural tube defects some 70% (Cawley et al., 2016). The deficiency of folate itself doesn’t cause the neural tube defect, rather it is due to a gene-environment interaction caused by the C677T methylenetetrahydrofolate reductase (MTHFR) variant but supplementation of folic acid has been shown to reduce the risk of fetal development of neural tube defects. Additional testing to complete It has been noted that vitamin B-12 may provide additional reduction in incidences of neural tube defects so checking her level and recommending supplementation if low may be appropriate. Another correlation that has been made regarding the development of neural tube defects is an increase homocysteine level in the mother suggesting a deficiency in tissue micronutrients FELICITY'S PREGNANCY CASE STUDY 5 and this increased homocysteine level may be present irrespective of folic acid and vitamin B-12 supplementation. Alpha-fetoprotein (AFP) a fetal liver produced protein which is also present in the amniotic fluid surrounding the fetus may be present in maternal blood which, at high levels, would be diagnostic for neural tube defects. Maternal serum testing is a combined blood serum test, generally completed between week 15 and 21 testing for a few markers including AFP. This test may indicate the possibility that fetal abnormalities including neural tube defects, trisomy 18 known as Edward syndrome, and trisomy 21 known as Down syndrome are present. Being that the test is a screening and not a diagnostic test the results aren’t necessarily creating a diagnosis for the fetus rather it is indicating the likelihood of the presence of an abnormality. Additional testing including ultrasound and other imaging may be appropriate depending on the results of the maternal serum testing. Also, imaging will be important for monitoring development as diabetic pregnancies can result in abnormally large fetuses which may lead to issues during childbirth and that data will likely show up on imaging and a plan would be able to be created to manage the birth to reduce risks to the mother and the baby. Conclusion While Felicity may be past the suggested start time for starting folic acid supplementation it is important for her to begin this as soon as possible to limit the potential effects to the fetus of a deficiency. She should also be educated regarding the risks for herself and the fetus related to her diabetes including the importance of maintaining strict blood glucose standards and monitoring her hemoglobin A1C to verify adequate control of the diabetes and limit its potential adverse effects to her and to the fetus. Monitoring folate levels as well as vitamin B12 and homocysteine may provide additional data in changes needed to any supplementation. Creating a FELICITY'S PREGNANCY CASE STUDY 6 detailed plan of care, discussing objective measures to monitor, and encouraging Felicity to have a thorough support system in place may aid in stress reduction which can help in alleviating any fears that may be present with Felicity. FELICITY'S PREGNANCY CASE STUDY 7 References Alvis-Miranda, H. R., Bula-Anichiarico, D. A., Calderón-Miranda, W. G., & Moscote-Salazar, L. R. (2015). Iniencephaly: Case Report. Journal of pediatric neurosciences, 10(2), 181– 184. doi:10.4103/1817-1745.159211 Cawley, S., Mullaney, L., McKeating, A., Farren, M., McCartney, D., & Turner, M. J. (2016). An analysis of folic acid supplementation in women presenting for antenatal care. Journal of Public Health, 38(1), 122. Retrieved from https://search-ebscohostcom.libauth.purdueglobal.edu/login.aspx?direct=true&db=edb&AN=113009737&site=ed s-live Clarke, R., & Bennett, D. (2014). Folate and prevention of neural tube defects. BMJ: British Medical Journal, 349(7969). Retrieved from https://search-ebscohostcom.libauth.purdueglobal.edu/login.aspx?direct=true&db=edb&AN=108501453&site=ed s-live McGrath, M., & Chrisler, J. C. (2017). A lot of hard work, but doable: Pregnancy experiences of women with type-1 diabetes. Health Care for Women International, 38(6), 571–592. https://doi.org/10.1080/07399332.2016.1267183 Tennant, G. A. (2014). Nutrition and Pregnancy: Folate and Folic Acid. International Journal of Childbirth Education, 29(3), 25–28. Retrieved from https://search-ebscohostcom.libauth.purdueglobal.edu/login.aspx?direct=true&db=hch&AN=99881857&site=eds -live
