Second Pregnancy Aggravated by Multiple Risk Factors Case Study

Introduction

Pregnancy is a challenging time for the female body: the entire organism mobilizes to allocate resources and ensure that the baby’s development is healthy and passes the most important milestones. Today, the prenatal and neonatal processes are studied well enough to identify key predictors of a mother’s and baby’s health before and after birth. Thus, it is important that an expecting couple take their doctor’s guidance seriously. The end goal is to avoid unnecessary risk or moderate them, in case eliminating them completely is not possible. This paper concerns the case of Shanvi – a 30-year-old woman going through a second pregnancy.

Her situation is far from ideal and aggravated by multiple risk factors, including both physiological and social. The outcome is the premature birth of a baby boy that scored relatively low on the Apgar scale and displayed health issues. Four factors might have shaped this patient’s outcome: type II diabetes, depression, high BMI, and high blood pressure. In this paper, discuss two risk factors – type II diabetes and depression – at length and give recommendations on how the case could have been handled better.

The factor I: Type II Diabetes

Type II diabetes mellitus is the most common type of diabetes. Based on self-reported data, around 6% of Australians (1.2 million) suffer from this condition (American Diabetes Association, 2015). Diabetes is a chronic disease which means that there are no shortcuts or easy solutions. It needs to be handled carefully and thoughtfully on a daily basis. This is especially true for women who want to have children. It is recommended that they manage their blood sugar levels even before starting to try for a baby (American Diabetes Association, 2015). It is not uncommon for women not to be aware of their pregnancy during the first few weeks.

This unawareness alongside unbalanced sugar levels is very dangerous: recent studies have shown that high blood sugar during the first term is associated with birth defects. These include diabetic embryopathy, especially anencephaly, microcephaly, and congenital heart disease. Aside from that, babies of mothers with diabetes are likely to be large, therefore, complicating delivery. They are also likely to have low blood sugar soon after birth.

The definite list of birth complications is below. Some of them seem to be the case for Shanvi, as explained further:

1. Stillbirth (fetal death). Pregnant women with diabetes are more likely to have stillbirths. While it is not entirely Shanvi’s case, it should be noted that diabetes might have contributed to her first baby’s early death (at three days post-birth). It is possible that the baby was growing slowly in the uterus because of poor circulation. Other likely reasons include high blood pressure and damaged small blood vessels. The exact reason stillbirths are prevalent in women with diabetes has yet to be known;
2. Respiratory distress. Respiratory distress was observed in Shanvi’s baby right after birth and persisted for the days to come. This unfortunate phenomenon can also be attributed to type II diabetes: excessive glucose in a baby’s system may prevent the lungs from growing fully. As a result, newborns have breathing problems, especially those who were born prematurely, which is the case for Shanvi (birth at 32 weeks) (Hod, Jovanovic, Di Renzo, De Leiva, & Langer, 2016).

Fortunately, Shanvi’s baby son did not suffer from the following common diabetes-related conditions:

1. Major birth defects in the heart and blood vessels, brain and spine, urinary system and kidneys, and digestive system;
2. Macrosomia. This term describes newborns that are much larger than normal. When the mother’s blood has too much sugar, the baby’s pancreas releases more insulin to process the glucose. As a result, the baby grows more fat than usual and ends up being quite large;
3. Birth injury. This negative outcome is tied to the previous phenomenon: the baby’s large size is tied to birth complications. In case the delivery process is not handled right, the mother or the baby, or even both, might get injured (Hod et al., 2016).

Now, it is difficult to say whether Shanvi managed her blood sugar properly prior to becoming pregnant for the second time. However, it is safe to say that even if she consulted a doctor regarding her issues, she did not follow through with the recommendations.

Type II diabetes is often associated with obesity, which is the case for Shanvi as her BMI exceeds the norm of 24-25 for her age. At a BMI of 33.4, she is far from healthy and, therefore, exposing herself and her baby to health risks. In preparation for pregnancy, her family doctor would have advised her to try to lose some weight to get it closer to the norm – alas, it never happened. It is a sheer assumption at this point, but perhaps, Shanvi being overweight is somehow related to her anxiety and depression, which will be analyzed in more detail in the next section.

Factor II: Depression and Anxiety

Depression is a serious mental disorder characterized by overwhelming feelings of sadness and dejection about one’s life (Gentile, 2017). It affects the way a person thinks, feels, and acts and can interfere with his or her daily activities. Depression is often (but not always) accompanied by anxiety – another mental disorder. Anxiety keeps a person agitated at all times, even in the absence of an actual threat (Gentile, 2017). It is readily imaginable how having these two conditions at the same time could significantly decrease a person’s quality of life. Living with the reality of mental disorders must be especially challenging for pregnant women since expecting a child is both physically straining and emotionally intense.

Given Shanvi’s current situation, she seems to be at a high risk of having depression and anxiety. From her medical story, it is hard to say whether these two conditions might have stemmed from her family’s genetic portrait. Hence, Shanvi’s doctor can only rely on analyzing environmental factors that might have contributed to her actual state. First, not so long ago, Shanvi lost a child – her first baby only survived the first three days after premature birth. The death of a child is always a tragedy, and in her case, it was aggravated by the total lack of support from her husband, Sanjeep. He seems to be blaming her for the first child’s death – an unnecessary, cruel punishment for a struggling wife.

Second, Shanvi and Sanjeep have recently immigrated to Australia from India. One can assume that the period of adaptation may also present certain challenges for both spouses. Sanjeep is emotionally abusive toward Shanvi: ever since the woman quit her job, he is controlling the family’s finances single-handedly, refusing his wife any self-autonomy. At the same time, Sanjeep shows disdain for Shanvi’s choice to be a stay-at-home parent for some time.

Apart from that, he puts pressure on his pregnant wife, stating that he wants her to have a baby boy – something that she clearly cannot control. The last but not the least factor for depression and anxiety is the recent death of Shanvi’s father. It seems that the patient is going through a lot and may need psychotherapy.

Depression during pregnancy, otherwise known as prepartum depression, should not go untreated. The risks of being depressed while expecting a baby are well studied and gauged. According to Chan, Natekar, Einarson, and Koren (2014), maternal depression has been found to be associated with multiple detrimental health concerns that affect both the baby and the mother. The following seems to apply to Shanvi’s case: babies of depressed mothers are likely to be born prematurely and have low birth weight. In the long perspective, these children can display high impulsivity, struggle with social interactions, and have cognitive, behavioural, and emotional difficulties. These possible outcomes should be considered when observing the baby’s development in the years to come.

The adverse outcomes of unaddressed maternal depression are also detrimental to the mother’s well-being. Pregnant women with depression are at risk of anxiety and suicidal ideation (Chan et al., 2014). Apart from that, depressed mothers-to-be often face complications and are readmitted to antenatal care at higher rates than non-depressed women. In particular, there is an association between maternal depression and preeclampsia -a condition that caused Shanvi’s hospitalization. Lastly, depression discourages women from taking care of themselves during pregnancy (Chan et al., 2014).

Maintaining healthy nutrition and avoiding risky behaviours may seem nonsensical to a person who struggles with a mental disorder. This is an assumption, but maybe depression and anxiety prevented Shanvi from managing her diabetes and overweight.

Neonatal Risk Factors

Aside from prenatal risk factors, Shanvi’s baby is likely to have been exposed to certain risks during delivery. First, Shanvi displayed a reduced amniotic fluid index (AFI), meaning that the volume of amniotic fluid did not match the baby’s respective stage of development. This condition presents certain risks, such as the embryo’s underdevelopment and post-date birth, with the latter obviously not being the case for Shanvi. The former, however, should be taken into consideration when observing the baby’s growth. Respiratory distress detected in the baby right after birth can be explained by premature delivery, the use of anaesthesia, and fluoxetine, an antidepressant. Fluoxetine has also been found to cause pulmonary hypertension and withdrawal syndrome in neonates.

Postnatal Care

Diabetes

The common guidelines for managing type II diabetes in postpartum women include the following:

1. regularly checking blood glucose levels since insulin requirements may change postpartum;
2. ensure that treatment for low blood glucose levels is readily available at all times;
3. keep in mind that breastfeeding can reduce the mother’s need for insulin, so it is recommended to have a snack and a drink before or during nursing;
4. take type II diabetes into consideration when discussing contraception with the family doctor;
5. attend follow-up appointments to keep blood glucose levels in check;
6. optimize blood glucose levels when planning subsequent pregnancies (McCance, 2015).

It is important that Shanvi is aware of her condition and can effectively adopt self-management strategies. Her husband should be advised to cooperate and help her maintain a lifestyle that would alleviate diabetes-related risks.

Obesity

Shanvi should receive proper counselling regarding her weight issues. It is normal for both obese women and women of normal weight to gain weight during pregnancy. However, studies show that if the weight gain remains at six months postpartum, the likelihood of losing it drops dramatically. Therefore, it is imperative that Shanvi meets a consultant such as a nutrition specialist to develop a meal plan that would help her meet her weight goals.

Apart from that, a health worker can advise Shanvi on physical activities appropriate for postpartum women. Regular exercise is good not only for losing weight but also for fighting off depression and anxiety symptoms (Knapen, Vancampfort, Moriën, & Marchal, 2015). Maintaining a healthy weight will allow the patient to be more active and able of taking care of the baby. Moreover, reducing the BMI is likely to help her have healthier subsequent pregnancies if she is planning to have more children.

A domain in which weight-related problems may occur is breastfeeding. Several studies have found that obese women tend to have problems nursing their infants, with a significant share of them cancelling breastfeeding prematurely (Turcksin, Bel, Galjaard, & Devlieger, 2014).

If this turns out to be the case for Shanvi, one way to go about it is to assign her to a breastfeeding counsellor who would provide guidance in person or over the phone. Lastly, Shanvi might need professional advice on contraception if she does not plan any more pregnancies in the nearest future. It has been found that intrauterine devices and contraceptive implants were the most effective birth control methods for obese women.

Depression

Prenatal depression puts Shanvi at a high risk of postpartum depression that might prevent her from taking care of herself and the newborn (Gaillard, Le Strat, Mandelbrot, Keita, & Dubertret, 2014). A health worker may play a key role in tackling depression in new mothers. To do this, it is important to build a rapport with Shanvi and make sure that she can trust her doctor. Psychological problems are often dismissed because patients are too afraid of speaking up for fear of stigma or misunderstanding. In this case, continuity of care is of great importance: health workers should collaborate and communicate to take up an interdisciplinary approach.

Medical records regarding Shanvi’s prenatal depression should be considered by her postpartum health providers. If her depression and anxiety persist, a combination of psychological and physiological care may be the best strategy (Vasa et al., 2014). It is important to prescribe antidepressants that would not interfere with breastfeeding. Apart from that, attending group and individual therapy where Shanvi could share her experience and feel validated may also be highly beneficial.

It should be noted that while Shanvi is a self-governing, independent woman who is capable of handling distress on her own, it would still be better to include her husband. Now that they both have become parents, they should be aware of potential shifts in couple dynamics.

Shanvi may be in an extremely vulnerable state for months after birth, which needs to be acknowledged by her husband. Sofar, Sanjeep displayed some abusive behaviours such as taking control of finances and blaming Shanvi for events that she could not prevent. It is not up to health workers to advise the woman on separating herself from her spouse. However, on par with group therapy for depression, couple therapy may also be a solid recommendation.

According to Asen (2108), emotionally focused therapy was found to be effective in 75% of all cases. This type of couple and family therapy focuses on eliminating negative communication patterns and emphasizing love and attachment as the primary bonds between two or more people. It is evident that the couple is failing to be compassionate toward each other. Thus, attending therapy sessions might as well help Shanvi and Sanjeep rediscover each other and reach mutual understanding.

Conclusion

The case of Shanvi is quite complex and requires careful analysis. From the patient’s anamnesis, it has become clear that multiple factors have contributed to pregnancy complications, premature birth, and the infant’s health issues. It appears that Shanvi failed to manage her type II diabetes properly, and unbalanced blood sugar levels might have jeopardized the wellbeing of the baby. It is also possible that type II diabetes was one of the reasons behind Shanvi’s first baby’s death at three days postpartum. Another significant health risk was depression triggered by an array of stressful events: relocation, the death of Shanvi’s father, the loss of the first child, and marital issues.

Depressed women are likely to have premature births and neglect health routines. Among other risk factors are high body mass index and elevated blood pressure. Postnatal care for Shanvi should include strategies aiming at moderating her weight, introducing an active lifestyle, managing diabetes, and alleviating depression symptoms. A combination of medication and therapy, as well as spousal involvement, may be highly beneficial for the wellbeing of the mother and the baby.

References

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Asen, E., & Jones, E. (2018). Systemic couple therapy and depression. Abingdon-on-Thames, UK: Routledge.

Chan, J., Natekar, A., Einarson, A., & Koren, G. (2014). Risks of untreated depression in pregnancy. Canadian Family Physician Medecin de Famille Canadien, 60(3), 242–243.

Gaillard, A., Le Strat, Y., Mandelbrot, L., Keita, H., & Dubertret, C. (2014). Predictors of postpartum depression: Prospective study of 264 women followed during pregnancy and postpartum. Psychiatry Research, 215(2), 341-346.

Gentile, S. (2017). Untreated depression during pregnancy: Short-and long-term effects in offspring. A systematic review. Neuroscience, 342, 154-166.

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Turcksin, R., Bel, S., Galjaard, S., & Devlieger, R. (2014). Maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review. Maternal & Child Nutrition, 10(2), 166-183.

Vasa, R., Eldeirawi, K., Kuriakose, V. G., Nair, J., Newsom, C., & Bates, J. (2014). Postpartum depression in mothers of infants in neonatal intensive care unit: risk factors and management strategies. American Journal of Perinatology, 31(05), 425-434.