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
Breakfast
Breakfast
2 ounce Lox
3 slices bacon
3 slices bacon
1 ounce low fat cream cheese
cup egg substitute
cup egg substitute
plain bagel
scrambled
scrambled
12 ounce non-fat latte
12 ounces coffee with
12 ounces coffee with
3 ounces mimosa (1/2
4 ounces whole milk
4 ounces whole milk
champagne, orange juice
Snack
4 ounce plain whole milk
yogurt
2 cups Dieter Herbal Tea

Dinner
6 ounces salmon-grilled
cup asparagus
12 ounces whole milk

Lunch
6 ounces vacuum packed tuna
12 oz diet sprite
2 rice cakes (brown rice,
plain)
11/2 ounce Pouligny SaintPierre Cheese
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 SaintPierre Cheese
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? Socially Meghan
consumes alcohol at brunch with her friends and admits to the occasional beer or other
alcoholic drink which risks fetal alcohol syndrome. She is under a lot of social and
environmental stress at work which could lead to hypertension. Meghan was underweight
with a bmi 120*703/69=17.7 and at 20 weeks it has only risen to 18.6 which is barely
above normal. she needs to gain 28 to 40 pounds during her pregnancy because she was
underweight to begin with so she hasnt even gained enough for the first few weeks.
Also she is 39 which puts her child at risk for birth defects and puts Meghan at risk for
complications during delivery. Her Dietary habit of consuming large fish regularly like
tuna makes it more likely that her mercury levels are too high. She also eats soft cheese
pretty often which has bacteria in it that can cause spontaneous miscarriage
2. Assess Meghans current nutritional status in terms of anthropometric data, health history, lab
values, and dietary intake information. In her health history Meghan did not eat enough to
compensate for her exorcise level and especially during this pregnancy is not consuming enough
calories or carbs. Her sugar levels from the glucose panel were in a healthy range but her weight
is way too low for this stage in pregnancy. It is good that she is denying the use of tobacco and
drugs. Her blood pressure is normal but she does continue to experience fatigue nausea
constipation and heartburn.
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? I would
tell her to up her folic acid intake. You can have just folic acid supplements instead of the
pregnancy vitamins and she is not consuming enough vegetables and fruit which naturally have
folic acid. She is not Eating iron dense food like dark green veggies or red meat and she is not
taking a supplement which is bad because a pregnant woman needs 1000 additional milligrams
of iron over all. She is also consuming too much dairy and as we mentioned earlier her large fish
intake is too high and she shouldnt eat soft cheese and shouldnt drink alcohol.
4. What specific recommendations might you make regarding weight gain, diet, exercise, dietary
supplements, and discomforts of pregnancy? She should gradually increase her body weight
because her weight is too low now. Meghan should not be lifting weights or cutting back. She
should also be cutting back or ceasing her use of the stairmaster. If the pre natal vitamin is
hurting her stomach she could try eating it with larger more carbohydrate and fiber dense meals.
If that doesnt work than she should take a folate supplement fiber and iron. She should also
remove thecalcium supplement because her dairy intake is high. All the symptoms she is
experiencing are normal but to combat the heartburn she could try eating smaller meals more
often throughout the day.
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? She has gained 14 pounds in 12 weeks but
that is normal at this stage of pregnancy. However her weight gain should be around 38 to 40
pounds overall so she should work on gaining more. Her hematocrit level has gone up which is
an indicator that her iron level has gone up and it is within the range it is supposed to be. That is

a very good sign because as we mentioned earlier pregnant women need around 1000 extra
milligrams of iron during pregnancy.

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