Sari Midwifery Case Studies

While providing care for Sari a number of clinical management issues arise. Firstly, Sari’s pregnancy was conceived through intrauterine insemination (IUI), risks associated with artificial reproductive technologies were likely reviewed with Sari and Jane prior to intervention . It is important that the midwife be aware of potential risks associated with this method of conception and able to review these with Sari and Jane if they have questions. IUI can include increased risks of preterm birth, low birth weight, small for gestational age, and placenta previa when compared to spontaneous conception. (1:1130,1115) Sari also describes a history of depression and treatment, which warrants close monitoring of mental health status in the current pregnancy and postpartum period as the risk of reoccurrence is 25-50% in the postpartum period. (2:e18-e19) Her history also reveals a sibling who had a potential congenital heart defect (CHD) which required surgery. There is a relative risk of 1.78 for an infant having a CHD if a family history revealed a second degree relative with any CHD. (3:297) Thus strong recommendation a second trimester anatomy ultrasound would be warranted. Further, Sari’s believes her mother may have had diabetes, which could increase Sari’s risks for gestational diabetes in this pregnancy. She later declines testing. If there are indications of increased fetal growth the topic of glucose screening may be revisited. (4:S172). Finally, in Sari’s history she indicates that she had a pap smear 2 years ago. The current guidelines recommend cervical screen every 3 years if previous pap results were normal and she may be due for cervical screening following her pregnancy, this could be done at her discharge visit. (5:2) Sari’s second trimester ultrasound reported poor views of the heart and some outflow tracts not being clearly visible. Follow up could include a repeat ultrasound, or the ultra sonographer might, as in this case, recommend follow up with fetal echocardiogram at a level III hospital. The indications for fetal echocardiogram can be fetus related, mother related, and family related . Fetus related indications include suspected CHD on screening ultrasonography, fetal chromosomal anomaly, fetal extracardiac anatomic anomaly, fetal cardiac arrhythmia, and nonimmune hydrops fetalis. (6:477) Mother related indications include CHD, maternal metabolic disease (i.e. diabetes or phenylketonuria), maternal rheumatic disease, environmental exposures (i.e. alcohol or medications), or viral infection (i.e. rubella). (6:477-8) Family related indications include previous child or parent with CHD, or with genetic disease associated with CHD. (6:478) In Sari’s case the indication for fetal echocardiogram would be suspected CHD on screening ultrasonography. Fetal echocardiogram is able to diagnose most severe types of CHD however some diseases may be missed, including, coarctation of the aorta, small ventricular and atrial septal defects, total anomalous pulmonary venous return, and mild aortic or pulmonary stenosis. (6:476) Postpartum follow up would be warranted if anything was discovered on fetal echocardiogram as it may not be possible to diagnose the full extent prenatally. (6:476) Jane reveals that Sari has been …show more content…
The midwifery team should be well informed to be able to answer questions in a supportive role. Incidence rates of ICP vary with geography and ethnicity, from less than 1% in North America and up to 4% in Chili . (11:141, 12:1-2). The cause is not well understood but it is believed to have some genetic and environmental factors. (9:178, 12:3) The genetic link is supported by the increased occurrence rates within families, ethnic and geographic variations and the high risk of reoccurrence, (60 to 70%), in subsequent pregnancies. (12:3, 13:280) Non-genetic or environmental factors include low vitamin D levels, low selenium levels, hepatitis C, multiple gestations, maternal age over 35, seasonal factors (as incidence rates increase in the winter months), and a potential hormonal component. (9:178, 11:149, 17:329) Maternal implications include varying severities of pruritus, increased risk of postpartum hemorrhage due to fat excretion from steatorrhea affecting (due to malabsorption of vitamin K absorption), long term risks of hepatobiliary cancer and autoimmune-mediated and cardiovascular diseases, and risk of reoccurrence. (9:183, 17:331) The fetal implications include increased rates of spontaneous and iatrogenic preterm labour, fetal asphyxia events, meconium stained amniotic fluid, and stillbirth. (11:142, 17:329) The severity of fetal implications is related to the level of maternal serum bile acid levels, with “severe” levels classified as >40 μmol/L. (9:183, 17:329,