Working through Common Pregnancy Case Studies and Other Issues in Advanced Nursing Practice

Social Determinants of Heath (SDoH)

Preconception Goal:

Plans to conceive after her wedding in two months; seeks pre-pregnancy guidance.

Medical History:

Seizure disorder diagnosed at 18; seizure-free for 10 years.

Medications: Levetiracetam 500 mg twice daily. No allergies.

Lifestyle:

Lives with fiancé; works full-time as a teacher. Denies alcohol, tobacco, or drug use.

OB-GYN history:

G0; regular cycles; uses condoms; LMP two weeks ago; last Pap in 2020 (normal); no STI history.

Vaccination: Uncertain of vaccine history; hasn’t received influenza, COVID-19, or HPV vaccines.

Diet:

Occasional constipation managed with diet; not on prenatal vitamins.

Additional Data Required:

·         Vaccination records: Tdap, MMR, varicella, hepatitis B status.

·         Seizure management: Past medication adjustments or side effects.

·         Fertility risks: Understanding of AED risks in pregnancy.

·         Nutrition/lifestyle: Dietary intake, activity, sleep patterns.

·         Mental health: Stress, mood, or emotional concerns.

·         Environment: Occupational or household exposures.

·         Family history: Epilepsy, chronic illness, or genetic risks.

BP 130/84 mmHg, HR 80 bpm, RR 18/min, Temp 37.1°C, Weight 118 lbs, BMI 19.0. Vitals are within normal limits.

General Appearance:

Alert, oriented, well-nourished, and in no acute distress. Appears her stated age.

Neurologic Exam:

Normal motor strength (5/5), reflexes (2+), and coordination. No gait abnormalities or sensory deficits.

Cardiovascular/Respiratory: Heart and lung exams are normal. No murmurs, wheezes, or respiratory distress.

Abdominal Exam:

Abdomen soft, non-tender, with normal bowel sounds. No organomegaly or masses detected.

Pelvic Exam:

External genitalia normal. Uterus anteflexed and non-tender. No adnexal masses. Cervix without lesions or discharge.

Skin and lymphatic:

Skin warm, dry, intact. No rash or lymphadenopathy.

Psychiatric:

Mood and affect are appropriate. No signs of anxiety or depression.

Additional Data Required:

·         CBC, CMP, TSH, serum folate

·         Rubella, varicella, Hepatitis B titers

·         HIV, RPR, STI screening

·         Levetiracetam serum level

·         Pap smear (last done in 2020)

·         Immunization status: Tdap, COVID-19, influenza, HPV

Folic acid level: Assess baseline folate status. Women on antiepileptic drugs require higher folic acid intake (4 mg/day) to prevent neural tube defects in the fetus (Merrell & McMurry, 2023).

Thyroid-stimulating hormone (TSH): Thyroid disorders can interfere with fertility and early fetal development. Preconception TSH screening is recommended for women with chronic conditions (Singh et al., 2025).

Serum levetiracetam level:

To ensure therapeutic dosing and avoid subtherapeutic levels or toxicity during preconception planning. Monitoring helps reduce seizure risk during pregnancy (Craig et al., 2021).

Complete blood count (CBC) and comprehensive metabolic panel (CMP):

Baseline labs to identify anemia, infection, renal or hepatic dysfunction, all of which may impact pregnancy management (Freeman & Zubair, 2025).

Rubella and varicella titers: Assess immunity to infections that can cause congenital anomalies. Non-immune women should be vaccinated before pregnancy (Patel & Tobin, 2025).

Hepatitis B surface antibody:

To confirm immunity. If non-immune, vaccination is recommended preconceptionally (Makan et al., 2023).

Immunization Deficiency – ICD-10: Z23

Denise reports no recent influenza or COVID-19 vaccinations and is unsure about her Tdap, HPV, and hepatitis B status. Inadequate immunity to vaccine-preventable infections such as rubella, varicella, and hepatitis B can lead to adverse fetal outcomes, including congenital anomalies and vertical transmission (Justiz Vaillant & Qurie, 2023). A thorough assessment of her immunization history and serologic testing is essential to guide appropriate vaccination before pregnancy.

Intervention: Continue levetiracetam at the lowest effective dose.

Rationale:

Levetiracetam is preferred in pregnancy due to its lower risk of birth defects compared to older AEDs. Stopping therapy increases seizure risk, which can endanger both the mother and fetus. Serum drug levels should be monitored due to altered metabolism in pregnancy (Medicines and Healthcare Products Regulatory Agency, 2021).

Nutritional Deficiency (Z13.228)

Intervention: Start high-dose folic acid (4 mg/day) and prenatal vitamins.

Rationale:

AEDs may reduce folate levels, increasing neural tube defect risk. Supplementation should begin before conception and continue during early pregnancy (Kiani, 2022).

Immunization Deficiency (Z23)

Intervention:

Update influenza, Tdap, COVID-19, and HPV vaccines; give MMR and varicella if non-immune.
Rationale:

Preconception immunization prevents congenital infections. Live vaccines (MMR, varicella) should be given ≥1 month before conception; inactivated vaccines can be given during pregnancy (CDC, 2025).

Economic Stability and Employment: Denise is employed full-time, suggesting financial stability and access to resources. However, her work may contribute to stress or time limitations when coordinating specialty care.

Social Support System: She lives with her fiancé, providing emotional support during preconception planning. A strong support network can improve prenatal adherence and reduce maternal stress.

Access to Care: Denise actively engages in medical care, including neurology follow-up. Her initiative in seeking preconception counseling reflects good access to and utilization of healthcare services.

Race and Ethnicity: As a Black woman, Denise may face systemic biases in healthcare that contribute to disparities in maternal outcomes. Culturally competent, equity-focused care is essential to address these risks.

Referral to the neurologist ensures her seizure disorder remains well-controlled. Antiepileptic drug levels may fluctuate during pregnancy, increasing the risk of breakthrough seizures (Li & Meador, 2022).

Genetic Counseling:

Due to her chronic condition and use of antiepileptic drugs, genetic counseling is recommended to assess potential teratogenic risks and guide reproductive decision-making (Fowler et al., 2023).

Nutritionist/Dietitian:

With a BMI of 19.0 and no prenatal vitamin use, dietary counseling will help support optimal weight gain, folic acid intake, and overall maternal-fetal nutrition (Dewidar et al., 2023).

OB/GYN:

Establishing preconception care with an OB/GYN ensures early prenatal planning, appropriate screenings, and coordination of care for a high-risk pregnancy.

Patient Education Needs:

·         Folic Acid Supplementation: Educate on the need for 4 mg/day of folic acid due to AED use and its role in preventing neural tube defects (ODS, 2022).

·         Medication Safety: Discuss the importance of maintaining therapeutic AED levels and not stopping medication without medical guidance.

·         Vaccinations: Explain the timing of live (MMR, varicella) and inactive (Tdap, flu) vaccines pre-pregnancy to reduce preventable maternal-fetal infections (Etti et al., 2022).

·         Preconception Health: Provide guidance on healthy weight, stress reduction, early prenatal visits, and avoidance of teratogens.

Identify data provided in your chosen case and any additional data needed.

Objective findings.

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Describe the rationale for each test or intervention with supporting references.

Describe the rationales for your choice of each diagnosis with supporting references.

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Social Determinants of Heath (SDoH) for your chosen case.

Describe rationales and supporting references for each.