A Systems-level View of a Pregnancy with Medical Complications 2

Part II—Yvonne Chooses





Yvonne decides to have a child before opting for the cervical
conization surgery. At Dr. Trent’s suggestion, she has already begun
taking prenatal vitamins, and with the assistance of an over-the-counter
ovulation predictor kit, she is able to closely approximate the days of
the month when she is most fertile and likely to conceive.

After the second month of trying to conceive, Yvonne’s home pregnancy
test shows a positive result. With deep feelings of anxiety and elation
at the thought of carrying a baby, Yvonne calls Dr. Trent’s office to
schedule an appointment. The urine test conducted in his office confirms
the results of the home pregnancy test.

Dr. Trent, with calendar in hand, tells Yvonne, “Your estimated due
date is March 7^th. I want you to continue to take the
prenatal vitamins once daily for the extra iron and folic acid you need,
and add four glasses of milk or milk equivalents daily. Second,” he
continues, “moderate caffeine is okay, but no smoking or drinking
alcohol. Continue your normal exercise routines, but listen to your body
in terms of fatigue or nausea. Third, at about 14 weeks gestation,
we’ll schedule routine blood work to screen for spina bifida and Down
syndrome. Then, between weeks 24 and 28, we’ll do the routine screen for
gestational diabetes using an oral glucose tolerance test. Now, I know
that neither you nor anyone in your family has a history of genetic
conditions or diabetes, but such screening is routine.

“Finally, Yvonne, I would like you to schedule prenatal appointments
with me once every four weeks. Also, as with all my expectant mothers,
schedule an appointment with Dr. Costa at 20 weeks for a fetal medicine
survey. Dr. Jean Costa is a top fetal medicine specialist. She will
analyze the condition of the baby’s major body organs and alert me of
any abnormalities at the midpoint of prenatal development.”

Yvonne leaves the doctor’s office that day with her next appointment
scheduled in four weeks. That time passes by uneventfully, except for
the morning sickness during the whole first trimester that actually
occurs anytime, day or night. She tries to make good food choices, and
understands that gaining some weight during her pregnancy is natural. In
fact, as she learns from Dr. Trent, the Institute of Medicine
recommends that for women like Yvonne, who was of normal weight before
her pregnancy, total pregnancy weight gain should be 25–35 pounds.

It is a Tuesday morning when Yvonne, now 20 weeks pregnant, has her
planned ultrasound performed at the office of the fetal medicine
specialist. Gloria, the ultrasound technician, asks Yvonne if she wishes
to have the sex of the unborn child determined. “Absolutely,” Yvonne
replies emphatically.

Gloria begins the imaging procedure, and Yvonne sees a clear picture
showing the body image, four heart chambers, blood in circulation, and
individual body organs of the fetus.

“It’s a girl!” Gloria exclaims. Yvonne is delighted. Gloria then
captures several sonogram images of the unborn child for Yvonne and for
Dr. Costa’s examination.

Dr. Costa begins her consultation with Yvonne on a somber note.
“Yvonne, unfortunately, I have some bad news; there is a problem with
the baby’s kidney. There is an abnormal accumulation of urine in one
kidney, a condition called hydronephrosis. This situation could be an
indication of a more severe and widespread genetic disorder, or it could
be limited to a birth defect of a single organ.”

“How can we be sure if it is limited to the kidney?” Yvonne manages
to ask.

Dr. Costa responds, “I want to do amniocentesis in order to determine
the extent of the abnormality. Although the procedure poses some
risk—about one percent of miscarriages are related to the procedure—I
would recommend it so that we can better understand the fetal anomaly.”

Yvonne agrees to the amniocentesis, but is in utter shock. The words
“genetic disorder,” “hydronephrosis,” and “fetal anomaly” echo in her
head as she waits for Dr. Costa to finish the day’s patients and perform
the procedure.

Within an hour or so, it is underway. Yvonne sees the needle
penetrate her abdomen, and watches on the sonogram screen as the needle
enters the amniotic sac. In a matter of minutes, it is over and she is
again seated in the doctor’s consultation chair. Dr. Costa explains that
Yvonne needs to go home and rest for the remainder of the day. When
Yvonne returns for her appointment next week, Dr. Costa will have the
results of the genetic testing.

Over the next several days, Yvonne thinks about the results of the
genetic tests and her options. The joy of knowing she is having a little
girl is shadowed by the range of
possibilities in her case: from all being well with her baby, to the
child needing some sort of corrective surgery, to severe developmental
problems.

Questions

1. What is the range of normal gestation for humans? What are the
   current guidelines for good prenatal care beyond those mentioned here?
   For example, why do pregnant women need extra calcium, iron, and folic
   acid?
   
2. In cases of severe morning sickness, are prescription medicines
   advised? If so, what is the mechanism of action of these drug(s)?
   
3. What hormone(s) in the urine do over-the-counter ovulation predictor
   kits, fertility monitors, and early pregnancy tests (EPTs) measure? How
   soon after conception can EPTs be performed?
   
4. How does ultrasound technology allow image capture of the fetus in
   utero? When is an ultrasound performed during pregnancy? When is an
   amniocentesis warranted and how is it analyzed?
   
5. Up to 5% of all pregnant women are diagnosed with gestational
   diabetes, and women who have had gestational diabetes have an increased
   risk of developing Type 2 diabetes later on in life. Distinguish between
   gestational diabetes and Type 2 diabetes in terms of cause, management,
   and consequences/outcomes.