Clinical challenge

Case 1

Tibor, 25 years of age, and Monika, 24 years of age, are recent immigrants from Hungary and are unfamiliar with the Australian healthcare system. They present to you seeking a referral to an obstetrician and gynaecologist because they would like to discuss pre-pregnancy concerns.

Question 1

Which of the following statements regarding antenatal care provided in Australia is correct?

1. Australia has a higher maternal morbidity rate than other comparable OECD countries.
2. In Australia, women only receive pregnancy care through an obstetrician or midwife-led clinic.
3. In Australia, general practitioners (GPs) order too many pathology and radiology tests when managing pregnant women.
4. In Australia, 87% of women who gave birth in 2013 had seven or more antenatal visits.

Question 2

As part of providing preconception advice, you discuss the importance of nutrition before, during and after pregnancy.

Which of the following poor health outcomes are reduced by healthy dietary behaviour?

1. Anaemia in pregnancy
2. Low birth weight infants
3. Gestational diabetes mellitus
4. Preterm birth and miscarriage
5. All of the above

Question 3

Monika asks for more information about weight gain during pregnancy.

Which of the following statements regarding weight gain during pregnancy is correct?

1. Women should aim to keep body mass index (BMI) constant throughout a pregnancy.
2. Women should aim to gain approximately 18 kg during a pregnancy.
3. Excessive gestational weight gain can result in risk of adverse outcomes.
4. Gestational weight gain has little effect on lifelong risk for chronic disease.
5. Women are needlessly concerned about gestational weight gain.

Question 4

Monika attends your clinic several months later delighted by a positive home pregnancy test the day before. She has been taking a pregnancy-specific multivitamin for six months and asks if she should modify her diet in any way.

Which of the following statements regarding antenatal nutrition is best supported by current evidence?

1. All pregnant women need to double their vegetable intake in the first trimester.
2. Most pregnant women are not meeting their recommended intake of vegetables.
3. Most pregnant women need to increase organic vegetable intake during the first trimester.
4. All pregnant women need to increase their servings of protein in the first trimester.

Question 5

You examine Monika and note her height is 162 cm and weight 85 kg, giving her a BMI of 31.2 kg/m2. She reports her weight has been stable since 16 years of age.

Which of the following statements regarding Monika’s weight is correct?

1. Monika is obese, and should work with a dietician to achieve a healthier BMI.
2. Monika is overweight, but the increased caloric needs of breastfeeding will help her to lose weight.
3. On the basis of Monika’s pre-pregnancy weight, she should undertake closer monitoring for gestational diabetes mellitus.
4. On the basis of Monika’s pre-pregnancy weight, she should aim for a weight gain of 5–9 kg.

Question 6

Monika informs you she has been considering a Paleo diet. She asks your opinion on how much meat she should eat daily.

Which of the following statements is best supported by current evidence?

1. There is some evidence a Paleo diet would assist Monika with healthy weight gain in pregnancy.
2. Healthier dietary protein is available in lean meats and poultry, fish, legumes and nuts.
3. Adult women need 65 g of cooked lean meat or 100 g of cooked lean poultry a day.
4. Intake of lean meat is not recommended due to links with colorectal cancer.
5. Grass-fed meat has a superior omega-3 profile, balancing out the saturated fat content.

Question 7

You offer Monika some general advice regarding eating well during pregnancy and breastfeeding. Which of the following recommendations is correct?

1. Eat adequate wholegrains.
2. Choose foods lower in iron.
3. Avoid foods such as fresh milk.
4. Drink fruit juice most days.
5. Eat five pieces of fruit most days.

Question 8

Monika’s partner Tibor makes an appointment with you soon after. Tibor wants to discuss his general health as he has not had a check-up in many years, and he wants to ‘be ready’. The most appropriate way to openly engage Tibor in discussion about his fatherhood would be to:

1. offer recommendations on local day care
2. use a ‘needs-first’ approach to uncover Monika’s priorities in this pregnancy
3. use the ‘strengths-first’ approach to uncover Tibor’s strengths in fatherhood
4. offer recommendations on examination and blood tests
5. offer recommendations on work–life balance.

Question 9

On reflection, after Tibor leaves, you consider how your practice might better engage men in the perinatal period.

Which of the following is an example of father-inclusive practice?

1. Employing married male clinic staff
2. Opening clinic during business hours
3. Highlighting gender gap to clinic staff
4. Avoiding phone contact with patients
5. Opening clinic outside business hours

Question 10

 On the basis of this information, which of the following is the most likely cause of Maria’s sore nipple?

1. Nipple vasospasm
2. Herpes simplex infection
3. Bacterial nipple infection
4. Candida nipple infection
5. Blocked milk ducts

Question 11

Maria also wants to discuss advice she has received from her pharmacist about breastfeeding. Which of the following statements regarding breastfeeding is correct?

1. Heat packs or insulated breast pads ensure a more comfortable attachment.
2. Leaning forward while feeding reduces breast sagging.
3. ‘Cluster feeding’ in the evenings is unusual for infants.
4. Infants should take a wide mouthful of breast.

Question 12

Maria has also been concerned about Catherine’s stools. Which of the following statements regarding stooling in infants is correct?

1. From eight weeks on, stooling patterns can be highly variable.
2. A fully breastfed infant should pass five or more motions per day.
3. Lactose overload may cause stools that appear loose and mustard-like.
4. Occasional green stools are usually a sign of significant pathology.
5. From eight weeks on, constipation is highly unusual.