Reference no: EM133309546

Case Study: Jennifer and Jonah are starting a family

Jennifer is a very busy woman. She has been building her career in business for the last few years and it's going well but takes a lot of her time. Now 35 years old, she manages a dozen new people in her group. Some of her newer staff however are not that competent so she has to continually check their work for errors before it goes out to upper management. Despite her busy and stressful schedule, Jennifer believes that she eats a healthy diet, has a healthy weight and is physically active - she walks to and from work and is enrolled in yoga and spin classes at her local gym. Her medical history involves a few conditions including occasional bouts of diarrhea and constipation which is likely caused by her mild inflammatory bowel syndrome that is aggravated by stress. As a teenager Jennifer was prescribed a 6-month course of Accutane for her acne after at which point her acne cleared. As an adult, she does suffer from asthma and has to take Salbutamol occasionally whenever she gets some bronchoconstrictions and takes Zenhale as a controller medication. Both her parents have type II diabetes and are on medications for hypertension. Her dad has some cardiovascular disease based on the mild heart attack he had a couple of years ago. Jennifer has always wanted to start a family, but her career always came first up to now. She feels that if she waits any longer, it will be too challenging to be an older mom.

Her husband Jonah is a little older than her at 45 years of age. He has a sedentary office job in government and has been working from home for the last couple of years. Unlike his wife, Jonah does not typically eat a healthy diet, is physically inactive and is overweight causing him to be a slightly hypertensive. In his spare time, he has a hobby gaming on his computer. His dad died of colon cancer metastases 5 years ago and his mother has been clinically depressed since his passing. Jennifer is concerned about his lifestyle and keeps telling Jonah that it will catch up to him someday, but he just smiles and says, "I'm OK.". He takes a proton pump inhibitor for reflux and has a bit of arthritis in his knee but does not take anything for it yet.

Jennifer and Jonah have been trying to start a family for a while now but have not had any success so under her doctor's recommendation Jennifer enrolled for testing and approval for in vitro fertilization. A few weeks later she had the procedure, using her husband's sperm as the donor and everything went pretty well with no complications. Jennifer told her husband that they should go on a big holiday now as it would be difficult to travel internationally after they had the baby, especially with all the COVID restrictions. She also wanted to travel early before she started to experience any pregnancy-related signs and symptoms like morning sickness and before she gets too big and uncomfortable and has to pee frequently. Together, Jennifer and Jonah, quickly planned a 4-week holiday as soon as it was confirmed that she was pregnant which was about 2 weeks into the pregnancy, and left after a few days later so she would not likely have any pregnancy issues or concerns. Jennifer was advised to take prenatal vitamins but did not have time to buy some so she thought it would be fine to wait and start taking them after they got back for their vacation because she feels that she has a good diet. After all it was only going to be about 4 weeks of a 40 week pregnancy.

The rush planning and packing for such a long trip was a bit stressful but they got it done and went for a 6-week vacation to the costal regions of Mexico with a few trips in the interior of the country to visit different cities as well as a couple of other beach resorts.

Of course, the airline lost their luggage, and it did not arrive for a couple of days after they got to their resort. They had a wonderful time relaxing on the beautiful sandy beaches but found the mosquitos to be a nuisance in the early evening. One night they attended a bonfire on the beach. It was quite windy and the smoke from the fire triggered an asthma attack in Jennifer. She took her Salbutamol but that was not enough, so they went to emergency where she was given more bronchodilators and a 5-day prescription of prednisone to reduce the inflammation in her lungs. Having to seek emergency care in a foreign country caused Jennifer considerable stress. A few days later she started with a bit of a fever. She thought it was either the travel stress or the pregnancy, but not wanting to take chances, they went to a doctor who told her she must have gotten some type of viral infection and just to take Tylenol for the fever and rest for a few days. Jennifer did not lose her appetite, but the food was very different than their normal diet. They tried to sample and enjoy the local cuisine as much as possible but one evening Jennifer did not feel well and started vomiting. She went to the emergency room again where they diagnosed her with food poisoning but for some reason they gave her a 10-day prescription of antibiotics. She was not sure why, but she took them as prescribed.

It was an interesting trip to say the least, but they finally arrived home again when Jennifer was close to 8 weeks pregnant. She went to her doctor for a check-up and started taking her prenatal vitamins.

Everything felt fine with the pregnancy but during a prenatal ultrasound at 20 weeks, the doctor noticed that Jennifer's placenta was small and lying low in the uterus. Further examination using doppler led to the discovery that there was increased resistance in the umbilical blood flow.

At 26 weeks' gestation Jennifer underwent the standard prenatal glucose tolerance test and the results indicated she was hyperglycemic. She was advised that she would need to change her diet to control her blood glucose levels. She did her best to adhere to this medical advice, however her glucose levels remained elevated throughout the pregnancy.

Unfortunately, Jennifer started having contractions in her 34th week of pregnancy. She was given prophylactic antibiotics and steroids and delivered the baby vaginally within 48 hours. Upon examination, Jennifer's placenta demonstrated poorly developed tertiary villous structures, including decreased numbers and size of capillaries. Interestingly, her placenta also showed evidence of a past, acute pro-inflammatory event. Despite this, Jennifer had few complications and was able to go home 48 hours postpartum. She was successfully able to breastfeed her little boy Caleb from birth. Jonah is excited too, but is not sure how to care for a newborn. They will have to adjust to a different schedule and spend quality time with Caleb. Jennifer will have to reduce her work hours after but felt that she could only afford a 6 month maternity leave from work.

Question Jennifer's pregnancy seems to have a lot of exposures, both positive and negative which could affect her fetus. Jonah is not the healthiest person either. Let's have a look at some of these.
A) List 6 environmental exposures to which Jennifer is exposed which you feel might have a negative impact on the development of her fetus and a very brief statement as to why/how it might negatively affect the fetus.

B) List 2 negative exposures or factors for Jonah which might affect the quality of his sperm, which in turn, could affect the development of the fetus.

C) What are 5 unknowns from the scenario which might impact the development of the fetus but there is insufficient information provided in the scenario to know for sure that it will have an impact on the development of the fetus? (There could be duplication with exposures mentioned in A or B).