NUR 656 Module 3 Milestone One Example

Milestone One: The First Prenatal Visit at Nine Weeks After a Pregnancy Complicated by Preeclampsia

[Student Name]

Southern New Hampshire University

NUR 656: Primary Care of Women

Module Three Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: The First Prenatal Visit at Nine Weeks After a Pregnancy Complicated by Preeclampsia

The first prenatal visit sets the course of a pregnancy. It confirms dating, identifies risks, starts preventive measures and establishes a relationship with the patient. For a woman whose previous pregnancy was complicated by preeclampsia, the visit carries particular weight, because an effective preventive measure, low-dose aspirin, works best when started early in pregnancy. Ana is a 31-year-old seen at a composite community health center at nine weeks of gestation in her second pregnancy. This milestone documents her first prenatal visit and explains the reasoning behind each element. It argues that a systematic first visit that identifies preeclampsia risk, applies current preventive recommendations and prepares the patient to recognize warning signs can reduce the chance that her first pregnancy's complication repeats.

History

Ana's last menstrual period began nine weeks and two days ago; her cycles are regular. A home pregnancy test was positive two weeks ago. She has mild nausea without vomiting and no bleeding or pain. Her first pregnancy, three years ago, was complicated by preeclampsia diagnosed at 34 weeks with blood pressures of 150/100 and protein in the urine; labor was induced at 35 weeks, and her son spent five days in the neonatal unit. Her blood pressure returned to normal within six weeks after birth, and she has had normal readings at annual visits since. She has no diabetes, kidney disease or autoimmune disease. She does not smoke, drink alcohol or use drugs. She has been taking a multivitamin with folic acid since learning she was pregnant. Her mother had high blood pressure in pregnancy. She works as a school bus driver and lives with her husband and son. Screening for depression, intimate partner violence and food insecurity was negative.

Examination and Laboratory Tests

Blood pressure 124/78 on two readings, heart rate 82, body mass index 31. The general examination is normal. On bedside ultrasound one embryo was seen inside the uterus with a visible heartbeat, and its measured length matched nine weeks and one day, so her dates stand.

The standard first-trimester panel was ordered: complete blood count, blood type, Rh factor and antibody screen, rubella immunity, syphilis, HIV, hepatitis B surface antigen and hepatitis C antibody, urinalysis and urine culture. Because of her history, baseline tests were added to allow comparison if preeclampsia develops later: serum creatinine, liver enzymes, platelet count and a urine protein-to-creatinine ratio. Because her body mass index is above 30 and she has a family history of hypertensive disorders, early screening for diabetes was also ordered. Her cervical screening was up to date. Options for aneuploidy screening, including cell-free DNA testing, were explained, and she chose cell-free DNA at ten weeks.

Assessment

1. Intrauterine pregnancy at nine weeks by dates and ultrasound, G2P0101.

2. High risk for preeclampsia. The USPSTF recommends low-dose aspirin, 81 mg daily, after 12 weeks of gestation for pregnant people at high risk of preeclampsia, and identifies a history of preeclampsia as a high-risk factor; the Task Force also lists moderate risk factors, such as obesity and a family history of preeclampsia, and recommends aspirin when more than one is present (Davidson et al., 2021). Ana has one high-risk factor and two moderate factors. The evidence for early treatment is strong. In the ASPRE trial, Rolnik et al. (2017) randomized women identified as high risk by first-trimester screening to aspirin 150 mg nightly or placebo from 11 to 14 weeks until 36 weeks, and preterm preeclampsia occurred in 1.6% of the aspirin group compared with 4.3% of the placebo group.

3. Folic acid supplementation. The USPSTF recommends that all persons who plan to or could become pregnant take a daily supplement containing 0.4 to 0.8 mg of folic acid to prevent neural tube defects (Bibbins-Domingo et al., 2017). Ana's multivitamin contains 0.8 mg.

Plan

Aspirin: begin 81 mg daily at 12 weeks, taken at bedtime, and continue until delivery, with the obstetric consultant's agreement. Ana was told that aspirin at this dose is considered safe in pregnancy and reduces, but does not eliminate, the chance of preeclampsia. Blood pressure: she will check her blood pressure at home twice a week with a validated cuff provided by the clinic and report any reading of 140/90 or higher. Continue her multivitamin with folic acid. Vaccines: influenza vaccine given today; Tdap planned between 27 and 36 weeks; other vaccines reviewed according to season and current recommendations.

Consultation: because of her prior preterm preeclampsia, a consultation with maternal-fetal medicine will be arranged to agree on a plan for growth ultrasounds and the timing of delivery. Follow-up visits every four weeks until 28 weeks, then more often, with blood pressure and urine protein checked at each visit.

Social supports matter to this plan. Ana drives a school bus and worried that frequent visits would cost her shifts; her visits were scheduled for early afternoon, between routes, and she was given a work note explaining the medical need for regular checks. Her husband will attend the maternal-fetal medicine consultation so that both understand the plan and the warning signs.

Education

Ana was taught the warning signs of preeclampsia that require an immediate call or emergency visit: severe headache that does not improve, vision changes, aching under her right ribs, a face or hands that puff up quickly, shortness of breath and a home blood pressure of 160/110 or higher. She was told that preeclampsia can develop after delivery as well, up to six weeks postpartum. She was also given guidance on nausea, safe foods and physical activity, and on bleeding or pain that should prompt a call. She repeated the warning signs back correctly and received them in writing.

Conclusion

Ana's first prenatal visit confirmed a healthy early pregnancy and identified her as high risk for preeclampsia. Applying the USPSTF recommendations on aspirin and folic acid, grounding the aspirin decision in the ASPRE trial, adding baseline tests, arranging home blood pressure monitoring and consultation and teaching warning signs gives her the best chance of a different outcome this time.

References

Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Davidson, K. W., Epling, J. W., García, F. A. R., Kemper, A. R., Krist, A. H., Kurth, A. E., Landefeld, C. S., Mangione, C. M., Phillips, W. R., Phipps, M. G., Pignone, M. P., Silverstein, M., & Tseng, C. W. (2017). Folic acid supplementation for the prevention of neural tube defects: US Preventive Services Task Force recommendation statement. JAMA, 317(2), 183-189. https://doi.org/10.1001/jama.2016.19438

Davidson, K. W., Barry, M. J., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., Donahue, K. E., Doubeni, C. A., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Silverstein, M., Simon, M. A., Stevermer, J., Tseng, C. W., & Wong, J. B. (2021). Aspirin use to prevent preeclampsia and related morbidity and mortality: US Preventive Services Task Force recommendation statement. JAMA, 326(12), 1186-1191. https://doi.org/10.1001/jama.2021.14781

Rolnik, D. L., Wright, D., Poon, L. C., O'Gorman, N., Syngelaki, A., de Paco Matallana, C., Akolekar, R., Cicero, S., Janga, D., Singh, M., Molina, F. S., Persico, N., Jani, J. C., Plasencia, W., Papaioannou, G., Tenenbaum-Gavish, K., Meiri, H., Gizurarson, S., Maclagan, K., & Nicolaides, K. H. (2017). Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. New England Journal of Medicine, 377(7), 613-622. https://doi.org/10.1056/NEJMoa1704559