CASE STUDYCCASE OF ANTENATAL CARE # 1 - DOC by HC120807022411

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									      CASE STUDY 13.2: FEVER DURING PREGNANCY AND LABOR

DIRECTIONS

Read and analyze this case study individually. When the others in your group have finished
reading it, answer the case study questions. Consider the steps in clinical decision-making as you
answer the questions. The other groups in the room are working on the same or a similar case
study. When all groups have finished, we will discuss the case studies and the answers each
group has developed.

CASE STUDY

Mrs. B. is a 26-year-old primigravida. She is 16 weeks pregnant and had planned to attend the
antenatal clinic next week for the first time. However, she has come to the health center today
because she has fever and chills. She has not taken any of the usual prophylactic measures
recommended during pregnancy.

ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests)

1. What will you include in your initial assessment of Mrs. B., and why?

2. What particular aspects of Mrs. B.’s physical examination will help you identify her
   problem(s)/make a diagnosis, and why?

3. What screening procedures/laboratory tests will you include (if available) in your assessment
   of Mrs. B., and why?

DIAGNOSIS (Identification of Problems/Needs)

You have completed your assessment of Mrs. B. and your main findings include the following:

Mrs. B. says that she feels very unwell. Her temperature is 39.8º C and she has a headache.
According to her menstrual history she is 16 weeks pregnant. Uterine size is consistent with
dates. She has no urinary tract symptoms, no respiratory infection symptoms and no signs of
anemia. It has not been possible to do a blood slide for malaria parasites because of a shortage of
the necessary supplies. Mrs. B. reports that she has had malaria before but cannot remember how
many times. She also reports that she is allergic to sulfonamides. You determine that
chloroquine-resistant P. falciparum malaria is endemic in the area in which Mrs. B. lives.

4. Based on these findings, what is Mrs. B.’s diagnosis, and why?

CARE PROVISION (Planning and Intervention)

5. Based on your diagnosis, what is your plan of care for Mrs. B., and why?




Module 13, Fever during Pregnancy and Labor – Page 8                MCPC Learning Resource Package
EVALUATION

Mrs. B. returns to the health center in 2 days. She says that she has been taking her treatment, as
prescribed. Her temperature is 38º C. She still has a headache and continues to feel unwell.

6. Based on these findings, what is your continuing plan of care for Mrs. B., and why?




MCPC Learning Resource Package                    Module 13, Fever during Pregnancy and Labor – Page 9
       CASE STUDY 13.2: FEVER DURING PREGNANCY AND LABOR
                            ANSWER KEY

CASE STUDY

Mrs. B. is a 26-year-old primigravida. She is 16 weeks pregnant and had planned to attend the
antenatal clinic next week for the first time. However, she has come to the health center today
because she has fever and chills. She has not taken any of the usual prophylactic measures
recommended during pregnancy.

ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests)

1. What will you include in your initial assessment of Mrs. B., and why?

      Mrs. B. should be greeted respectfully and with kindness.

      She should be told what is going to be done and listened to carefully. In addition, her
       questions should be answered in a calm and reassuring manner.

      A rapid assessment should be done to determine Mrs. B.’s degree of illness; her
       temperature, pulse, respiration rate and blood pressure should be checked, she should be
       asked how long her symptoms have been present and if she has other symptoms or signs
       that may accompany fever and chills during pregnancy (abdominal pain, dysuria or
       frequency [urinary tract infection], headache, muscle/joint pains [uncomplicated malaria],
       or difficulty breathing and/or a productive cough [pneumonia]).

      Determine whether Mrs. B. lives in a malaria-endemic region. Recent exposure to malaria
       should be noted and a history of past episodes of malaria should be obtained (women who
       acquire partial immunity to malaria are at high risk for developing severe anemia and
       having babies with low birth weights).

      Mrs. B.’s menstrual history should also be taken to establish her estimated delivery date,
       and problems associated with her present pregnancy should be noted.

2. What particular aspects of Mrs. B.’s physical examination will help you make a diagnosis or
   identify her problems/needs, and why?

      An abdominal examination should be done to check fetal size and growth. If Mrs. B. has
       symptoms of dysuria or frequency, she should be checked for flank pain and tenderness.
       If she has a cough, chest pain or difficulty breathing, her chest should be checked for
       rhonchi/rales. In addition, it would be important to establish whether her spleen is
       enlarged, as this can be present in malaria. She should also be checked for anemia by
       looking for conjunctival and palmar pallor.




Module 13, Fever during Pregnancy and Labor – Page 10              MCPC Learning Resource Package
3. What screening procedures/laboratory tests will you include (if available) in your assessment
   of Mrs. B., and why?

      Malaria should be considered the most likely diagnosis in a pregnant woman with fever
       who has been exposed to malaria (Mrs. B. lives in a malaria-endemic region); therefore, a
       microscopy of a thick and thin blood film should be done to detect and identify malaria
       parasites if feasible. If Mrs. B. has clinical signs of anemia, a hemoglobin test should also
       be done.

DIAGNOSIS (Identification of Problems/Needs)

You have completed your assessment of Mrs. B. and your main findings include the following:

Mrs. B. says that she feels very unwell. Her temperature is 39.8º C and she has a headache.
According to her menstrual history she is 16 weeks pregnant. Uterine size is consistent with
dates. She has no urinary tract symptoms, no respiratory infection symptoms and no signs of
anemia. It has not been possible to do a blood slide for malaria parasites because of a shortage of
the necessary supplies. Mrs. B. reports that she has had malaria before but cannot remember how
many times. She also reports that she is allergic to sulfonamides. You determine that
chloroquine-resistant P. falciparum malaria is endemic in the area in which Mrs. B. lives.

4. Based on these findings, what is Mrs. B.’s diagnosis, and why?

      Malaria should be considered the most likely cause of Mrs. B.’s symptoms and signs.
       Malaria is endemic in her area. Signs and symptoms are consistent with malaria.

CARE PROVISION (Planning and Intervention)

5. Based on your diagnosis, what is your plan of care for Mrs. B., and why?

      Treatment for malaria should be started based on Mrs. B.’s clinical findings.

      Because she lives in an area where chloroquine-resistant P. falciparum malaria is
       widespread, she should be treated with oral quinine salt 10 mg/kg body weight three
       times/day for 7 days. Sulfadoxine/pyrimethamine should not be used as Mrs. B. has
       reported an allergy to sulfonamides.

      Mrs. B. should be counseled about the importance of drug compliance and about the use
       of protective measures such as bednets. She should also be counseled about danger signs
       in pregnancy and the need to seek help immediately if any of these occur. She should be
       encouraged to express her concerns, listened to carefully, and provided reassurance.

      Mrs. B. should be asked to return to the health center in 2 days to monitor symptoms and
       compliance with drug therapy.




MCPC Learning Resource Package                  Module 13, Fever during Pregnancy and Labor – Page 11
EVALUATION

Mrs. B. returns to the health center in 2 days. She says that she has been taking her treatment, as
prescribed. Her temperature is 38º C. She still has a headache and continues to feel unwell.

6. Based on these findings, what is your continuing plan of care for Mrs. B., and why?

      Mrs. B. should continue with the course of quinine salt.

      She should be asked to return every 2–3 days for followup until completion of treatment.

      If treatment failure or drug toxicity is experienced, another drug such as mefloquine
       should be used.

      Basic antenatal care (early detection and treatment of problems, prophylactic
       interventions, birth plan development/revision, and plan for newborn feeding) should be
       provided, as needed.

      The use of protective measures such as bednets should again be discussed.

REFERENCES

Managing Complications in Pregnancy and Childbirth: pages S-100; S-103 to S-106




Module 13, Fever during Pregnancy and Labor – Page 12                MCPC Learning Resource Package

								
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