CHONG

HUA HOSPITAL
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Don Mariano Cui Street, Cebu City




Sausa-Nacario Family

Sitio Gonzales, Barangay Kamputhaw, Cebu City, Cebu

A Clinico-Sociological Case Presentation

Submitted by:

Autentico, Dominique
Balansag, Charmia Kim
Dalanon, Mark Lester
De la Cruz, Karina Louise
Dumangas, Liv
Verallo, Sophia Vivien
Yu, Eda Erika





Community Medicine Post-Graduate Interns
January-February 2018
INTRODUCTION

“I am a child.”
Within each of us, there is the voice of a child. A child who marvels at the smallest of
wonders, but also cowers at the most harmless horrors. A child whose worry is fleeting, but
whose joy is also unending. A child whose heart is full and unbroken.
But the journey of life is a long, winding road, often paved with unforgiving
potholes, dubious detours, and many roadblocks. How do you begin at the starting line, and
find your way to the end? How do you suddenly come to the crossroads, with no idea which
way to go? How do you unexpectedly find yourself lost after one wrong turn?
Suddenly, you are tumbling through dark alleys, making mistake after mistake, turn
after hopeless turn.
You try to take a step back, reach within yourself to search for that voice. You stop
and wish to go back to a time when your greatest fears were merely washed away by simple
joys. But that voice is gone. There is no going back now.
“I have a child. I’m not a child anymore.”


GENERAL OBJECTIVE

To present a case of a 21 year old female with an OB score of G3P2(2002), currently
diagnosed with a pregnancy uterine, 25 weeks AOG.


SPECIFIC OBJECTIVES

1. To present the family profile of the Sausa-Nacario family.
2. To assess the family dynamics using appropriate family assessment tools.
3. To conduct a thorough history and physical examination of the index case.
4. To develop a plan of care that includes diagnostic and therapeutic management
appropriate for the index case’s age of gestation, while taking into consideration
the capabilities of the family and maximizing community resources.
5. To discuss the available options and possible interventions focused on proper
health monitoring of the index case and her unborn child, identification of
 modifiable risk factors for the development of complications, and the
prevention of these complications.
6. To educate the index case, as well as her family, on the importance of proper
pre-natal care and to encourage compliance to scheduled pre-natal visits.
7. To educate the family on the importance of family planning, for the overall
physical and social well-being of every family member.
8. To assess the impact of the index case’s condition and the burden of this
condition to the family.
9. To create a family wellness plan, including individualized goals for each member
of the family.


SCOPE AND LIMITATIONS

This Clinico-Sociological Case (CSC) is limited to the Sausa-Nacario family and those
family members living within the household. The study was conducted at Sitio Gonzales,
Cebu City, from January 11, 2018 to February 08, 2018. The discussion will focus on the
index case’s identified problems: history of teenage pregnancy. Interventions done were
limited within the resources of the St. Gerard Wellness Center and the financial capacity of
the family.


MEDICAL SCENARIO

Informant: Patient
Reliability: 90%

Patient is a 21 year old, Female, Filipino, Roman Catholic, currently residing in Sitio
Gonzales, Brgy. Kamputhaw, Cebu City, Cebu.
Patient is not a known diabetic, hypertensive or asthmatic. Patient had no previous
hospitalizations or surgeries. Patient has no known food or drug allergies as claimed.
Patient was able to finish until fourth year highschool at City Central School after
which she worked as a saleslady in SM Seaside Cebu in 2015. She then decided to stop
working when she found out that she was pregnant with her first child. In 2016, she went
back to work as waitress in a restaurant in Gorordo, Cebu. However, due to personal
reasons, the patient decided to resign from her job. She and her husband currently owns a
computer shop which is their main source of living. The patient currently lives in a 2 storey
house made of mixed materials which has a single bedroom and bathroom on the second
floor. The first floor serves as a kitchen and computer shop. She shares this house together
with her live in partner and their 2 children. She has three meals a day, consisting of rice and
meat and canned goods. Patient has a regular bowel movement, usually once a day, with
soft brown stool and regular bladder voiding pattern, about 4-5 times in a day. She is a non-
smoker, non alcoholic beverage drinker and denies illicit drug use. Patient has no recent
travel history.
Patient is a G3P2 (2002). Her first child is a male and was born term in 2014 via NSD
at CCMC when she was still 18 years old while her second child is a female and was born
term via NSD at Panganiban Birthing Center at 20 years old. Both pregnancies were non
high risk and the deliveries were both uneventful and had no complications. Patient is
currently pregnant with her third child. Last menstrual period is September 1, 2017 with
AOG calculated to be at 23 5/7 weeks . Menarche at 17 years old and patient has regular
monthly menstruation usually lasting 3 days, consuming 5 pads for the whole duration.
History of dysmenorrhea noted. Coitarche at 18 years old with 1 sexual partner, does not
use any contraceptive method, no history of sexually transmitted diseases as claimed.
Patient has not undergone papsmear.
Herefofamilial history inludes Hypertension on the maternal side and Diabetes
Mellitus on the paternal side.

History of Present Illness:
PROBLEM: Amenorrhea
3 months prior to consult, patient noted amenorrhea for almost 2 months and
recalled Last menstrual period is September 1, 2017. Patient was anxious to know if she was
pregnant again for the third time. Thus, she bought a pregnancy test kit which resulted to a
positive pregnancy test.

Physical Examination
Examined an alert, awake, quiet, afebrile, patient not in respiratory distress with the ff. v/s:
BP: 100/60mmHg PR: 75bpm RR: 20cpm T: 37.0 C
O2: 99% Wt: 44kg Height 154 cm BMI:18.55

Skin: brown complexion, warm, dry, good turgor and mobility, no rashes or lesions
HEENT: no scalp lesions, pink palpebral conjunctiva, anicteric sclerae, no nasal
discharges, pink and moist oral mucosa
Chest and Lungs: equal chest expansion, clear breath sounds
Cardiovascular: adynamic precordium, distinct heart sounds, no murmurs
Abdomen: gravid, normoactive bowel sounds
Fundal Height: 23cm
Fetal Heart Tone: 150 bpm
Leopold’s Manuever: L1- Cepahalic, L2-Fetal Back, L3- Breech
Genitourinary System: (-) costovertebral angle tenderness, bilaterally
Extremities: CRT <2 seconds, strong peripheral pulses
Neurological Examination:
Cerebral: alert, coherent, oriented to time place and person
Cerebellar: smooth, well-coordinated movements by finger-to-nose test and heel-to-shin
test
Cranial Nerves:
Cranial nerve I: able to identify odors
Cranial nerve II, III: (+) Pupillary light reflex, direct and consensual in each eye
Cranial nerve III, IV, VI: EOM full range by finger following test, no diplopia
Cranial nerve V: muscles of mastication strong, facial sensation intact
Cranial nerve VII: no facial asymmetry, facial expressions symmetrical
Cranial nerve VIII: can hear spoken voice at 2 feet
Cranial nerve IX, X: (+) gag reflex, uvula midline at rest, well-modulated voice
Cranial nerve XI: can shrug shoulders against resistance
Cranial nerve XII: tongue midline on rest and on protrusion
Sensory: light touch, temperature, pain sensations intact
Motor: good muscle tone, no limitation of range of motion, 5/5 mm strength on all
extremities
Reflexes:




CLINICAL FORMULATION

PROBLEM: Amenorrhea

Primary Impression: G3P2 (2002) Pregnancy Uterine, 23 5/7 weeks AOG by LMP, not in
labor
Our primary impression is pregnancy, due to the 2-month history of amenorrhea,
with index case currently sexually active with no oral contraceptive use. This is further
supported by a positive home urine pregnancy test result. Patient is a 21-year old with 2
previous pregnancies born via NSD with no complications. Current pregnancy is considered a
high-risk pregnancy, since the index case has multiple risk factors associated with high-risk
pregnancy, based on the list from Nelson’s Textbook of Pediatrics: poverty, unemployment,
low educational status, poor healthcare attitudes, absence of prenatal care, unmarried
status, short interpregnancy interval and poor weight gain during pregnancy. Pregnancies in
teenagers are at increased risk for intrauterine growth restriction, fetal distress, and
intrauterine death. Patient’s LMP: 9/1/2018, with AOG calculated to be at 23 5/7 weeks.

DIAGNOSTIC PLAN
Definitive:
Presumptive:
1. β-hCG detection in urine or preferably blood
! to detect β-hCG production by a predicted corpus luteum from a
pregnancy
Definitive:
2. Transvaginal Ultrasound (<16 weeks) or Pelvic Ultrasound (>16 weeks)
! to detect fetus as well as perform fetal aging and gender along
with visualization of relevant anatomy to exclude other possible
concomitant anatomic abnormalities
Supportive:
1. Complete Blood Count
• to determine presence of infection, inflammation or anemia
2. Urinalysis
• to determine presence of hematuria, pyuria or bacteruria seen with
urinary tract infection
 3. HIV Ab test
• serologic test to screen for HIV
4. VDRL test
• serologic test to screen for Syphilis
5. Pap Smear
• to determine presence of sexually transmitted diseases and cellular
changes at high risk for Cervical Cancer
6. FBS/OGTT
• screen for Gestational Diabetes Mellitus

THERAPEUTIC MANAGEMENT
The list of the following management processes are based on the case's needs as per
recommendations of the facets of both Pediatrics and OB-GYN:

Management of Adolescent Pregnancy (1,2)
1. Discussion of the patient’s options
a. Releasing the child to an adoptive family
b. Electively terminating the pregnancy (not applicable on our case or in the
Philippines)
c. Raising the child herself with the help of the family, and/or other social
resources
2. Conduct and schedule Prenatal Check ups


Weeks

First Visit 15-20 24-28 29-41
History
Complete ●
Updated ● ● ●
Physical Examination
Complete ●
Blood Pressure ● ● ● ●
Maternal Weight ● ● ● ●
Pelvic/Cervical
●
Examination
Fundal Height ● ● ● ●
Fetal Heart Rate/Fetal
● ● ● ●
Position
Laboratory Tests
Hematocrit or
● ●
hemoglobin
Blood Type and Rh Factor ●
Antibody Screen ● A
Pap smear screening ●
Glucose Tolerance Test ●
Fetal Aneuploidy
B and/or B
Screening
Neural-tube defect
B
screening
Cystic fibrosis screening B or B
Urine Protein
●
Assessment
Urine Culture ●
Rubella Serology ●
Syphilis Serology ● C
Gonococcal Screening D D
Chlamydial Screening ● C
Hepatitis B Serology ● D
HIV Serology B D
Group B Streptococcus
E
culture
Tuberculosis Screening
A: performed at 28 weeks, if indicated
B: test should be offered
C: High-risk women should be retested at the beginning of the third
trimester
D: High-risk women should be screened at the first prenatal visit and
again in the third trimester
E: Rectovaginal culture should be obtained between 35 and 37 weeks
Cunningham et al (2014), Williams Obstetrics 24ed,McGraw-Hill

Table 1. Schedule and Typical Components of Routine Prenatal Care


3. Start the following prenatal supplements:
• Multivitamins + Fe tablet, 1 tablet OD before breakfast
• Calcium + Vitamin D tablet, 1 tablet twice a day after meals
4. Create a medical home for Adolescent parents and their children (6)
• Emphasize anticipatory guidance, parenting, and basic child care–giving
skills,
5. Provide Comprehensive, multidisciplinary care
! Access community resources such as special Supplemental Nutrition
Program for Women, Infants, and Children
! Provide medical and developmental services to low-income parents
and children
! Facilitate coordination of services
o encourage high school completion
o assess risk of domestic violence
o adapt counseling to developmental level of adolescent
! Utilize school-, home-, and office-based interventions
! Consider use of support groups
If mother decides to raise the child:
o encourage breastfeeding
! Support breastfeeding in home, work, and school settings
o encourage adolescent parenting
! Work with other involved adults such as grandparents to encourage
developmental growth of adolescent as parent as well as optimize
infant developmental outcomes
o awareness and monitoring of developmental progression of infant and
adolescent parent
! Advocate for high-quality community resources for adolescents,
including developmental resources, child care, and parenting classes
 Adolescent
Pregnancy

High-Risk Pregnancy

Medical Management Psychosocial Care

- Prenatal labs & Supplements - Counseling

- Nutrition - Coordination with family
- Breastfeeding & basic child care giving - Encourage educational
completion
skills


Figure 1. Algorithm for Medical Treatment of Adolescent Pregnancy

CASE DISCUSSION

Definition
Adolescents, according to Nelson Textbook of Pediatrics, are those from ages 12- 20
years old. (1)

I. ADOLESCENT PREGNANCY

Adolescent pregnancy is not an uncommon circumstance. According to the World
Vision.Org, the Philippines has the highest rate of teenage pregnancies in the Association of
Southeast Asian Nations. Teenage pregnancy poses tremendous risks on both mother and
child; therefore, a careful plan of management must be initiated. Studies show that many
teenage mothers have been exposed to violence or abuse prior to pregnancy. According to
the results of the 2013 National Demographic and Health Survey (NDHS), one in ten young
Filipino women age 15-19 has begun childbearing: 8 percent are already mothers and
another 2 percent are pregnant with their first child

Etiology
Worldwide, poverty and lower educational attainment are risk factors for
adolescent pregnancy. Once pregnant, an adolescent becomes more likely than her non-
pregnant peers to have lower educational attainment, to drop out of school and to have
lower socioeconomic status and lower social capital. In industrialized countries, older
adolescents use hormonal contraceptives and condoms resulting in a lowered risk of
unplanned pregnancy while younger teenagers are less deliberate and logical and their
sexual activity is likely to be sporadic or even coercive contributing to inconsistent
contraceptive use and greater risk of unplanned pregnancy. In non-industrialized countries,
laws permitting marriage of young and mid-adolescents, poverty and limited female
education are associated with increased adolescent pregnancy rates. (1)


Figure 2. Causes of Teen Pregnancy


Physiology
Pregnancy, a product of fertilization and implantation occurs with ovulation, when
the secondary oocyte and adhered cells of the cumulus-oocyte complex are freed from the
ovary. Oocyte is then quickly engulfed by the fallopian tube infundibulum and transported
by movement of cilia and tubal peristalsis. Fertilization occurs in the oviduct and takes place
within a few hours and no more than a day after ovulation. Because of this narrow
opportunity window, spermatozoa must be present in the fallopian tube at the time of
oocyte arrival. Almost all pregnancies result when intercourse occurs during the 2 days
preceding or on the day of ovulation.
Early human development is described by days or weeks post fertilization, that is
post conceptional. However, clinical pregnancy dating is calculated from the start of last
menses. Since the follicular phase length is more variable than the luteal phase, one week
post fertilization corresponds to approximately 3 weeks from the last menstrual period in
women with regular 28-day cycles.

 Fetal Period
This period begins 8 weeks after fertilization or 10 weeks after onset of last menses.
At this time, the embryo-fetus is nearly 4 cm long. Development during the fetal period
consists of growth and maturation of structures that were formed during the embryogenic
period. Crown-to rump (CRL) measurements, which correspond to the sitting height, are the
most accurate for dating.
Uterus palpable above the symphysis pubis
Fetal CRL is 6- 7 cm
12 weeks AOG The fingers and toes have become differentiated and external genitalia are
beginning to show definitive signs of male or female gender
The fetus begins to make spontaneous movements
14 weeks Gender can be determined
Fetal CRL is 12 cm and weight is 110 g
16 weeks AOG Eye movements begin coinciding with midbrain maturation
Fetus weighs more than 300 g and weight increases in a linear manner
20 weeks AOG Fetus moves about every minute and is active 10-30 percent of the time
Fetal skin is less transparent, a downy lanugo covers its entire body and
some scalp hair has developed
Fetus now weighs approximately 630 g
24 weeks AOG The canalicular period of lung development is nearly complete
Fetal CRL is 25 cm and weighs about 1100 g
Thin skin is red and covered with vernix caseosa
28 weeks AOG Peak of isolated eye blinking
Normal neonate born at this age has a 90% chance of survival without
physical or neurological impairment
32 weeks AOG Fetal CRL of 28 cm and weighs approximately 1800 g
Skin is red and wrinkled
36 weeks AOG Fetal CRL is 32 cm and weighs approximately 2500 g
Body has become more rotund and previous wrinkled facial appearance has
been lost
40 weeks AOG Term from the onset of the last menstrual period
Fetus is now fully developed with CRL about 36 cm and weighs 3400 g

Table 2. Table of Fetal Development

Maternal Physiology
A. Reproductive Tract:
1. Uterus
For the first few weeks, the uterus maintains its original piriform or pear shape. But
as pregnancy advances, the corpus and fundus become more globular and almost spherical
by 12 weeks’ gestation. By the end of 12 weeks’ gestation, the uterus has increased in size to
be contained within the pelvis. As it enlarges, it makes contact with the anterior abdominal
wall, displaces the intestines laterally and superiorly, and can reach as far as almost touching
the liver. .
 Beginning in the early pregnancy, uterus undergoes irregular contractions that are
normally painless, called Braxton Hicks contractions which are unpredictable and
nonrhythmic. During the second trimester, these contractions may be detected by bimanual
examination. Until the last several weeks of pregnancy, these contractions are infrequent
but increases during the last week or two, contracting as often as 10-20 minutes and with
degree of rhythmicity.
2. Cervix
As early as 1 month after conception, the cervix undergoes softening and cyanosis
that result from increased vascularity and edema, and cervical gland hyperplasia and
hypertrophy. Rearrangement of collagen-rich connective tissue occurs to maintain
pregnancy to term, dilatation to aid in delivery and repair following parturition. Cervical
ripening, regulated by estrogen and progesterone metabolism, involves decreased collagen
and proteoglycan concentrations while increasing water content.
3. Ovaries
During pregnancy, ovulation ceases and maturation of new follicles is suspended.
The single corpus luteum found in pregnant women functions maximally during the first 6-7
weeks of pregnancy and thereafter contributes relatively little to progesterone production.
4. Vagina and Perineum
As with the cervix, there is an increased vascularity and hyperemia of the skin
and muscles of the perineum and vulva, prominently affecting the vagina and results in
violet color characteristic of Chadwick sign.

B. Breast:
Women often experience breast tenderness and paresthesia in the early weeks of
pregnancy. Breasts are also noted to have an increase in size, with veins visible beneath the
skin. Striations may also develop. The nipples become considerably larger, more deeply
pigmented and more erectile. Colostrum can often be expressed in the first few months.
The areolas become broader and more deeply pigmented.

C. Skin:
Beginning after midpregnancy, reddish, slightly depressed streaks commonly
develop in the abdominal skin and sometimes in the skin over the breast and thighs, called
stria gravidarum or stretch marks. Hyperpigmentation is also seen, accentuated in those
with a darker complexion. The midline of the anterior abdominal wall skin takes a dark
brown, black pigmentation to form the linea nigra. Occasionally, irregular brownish patches
of varying size appear on the face and neck giving rise to cholasma or melasma gravidarum
or the mask of pregnancy. Angiomas or vascular spiders are minute, red skin elevations with
radicles branching out from a central lesions, develop in two thirds of white women and
approximately 10 percent of black women, common on the face, neck, upper chest and
arms. This has no clinical significance and is most likely a consequence of hyperstrogenemia.

D. Metabolic changes:
In response to the increased demands of the rapidly growing fetus and placenta,
pregnant woman undergoes metabolic changes that are numerous and intense. By the third
trimester, maternal basal metabolic rate increased by 10-20 percent compared with that of
nonpregnant state. WHO estimates that additional total pregnancy energy demands
associated with normal pregnancy are approximately 85 kcal/day, 285 kcal/day and 475
kcal/day during the first, second and third trimester respectively.

E. Hematological Changes:
The well-known hypervolemia associated with normal pregnancy averages 40-45
percent above the nonpregnant blood volume after 32 to 34 weeks. Because of great plasma
augmentation, hemoglobin concentrations and hematocrit decreases slightly during
pregnancy. Hemoglobin concentration at term averages 12.5 g/dL and in approximately 5
percent of women, it is below 11.0 g/dL. Thus a hemoglobin below 11.0 g/dL especially late
in pregnancy should be considered abnormal and usually due to iron deficiency rather than
hypervolemia.

F. Cardiovascular System:
During pregnancy and puerperium, the heart and circulation undergo remarkable
physiologic adaptation. Changes in cardiac function become apparent during the first 8
weeks of pregnancy. Cardiac output is increased as early as the fifth week and reflects a
reduced systemic vascular resistance and increased heart rate. The resting pulse rate
increases approximately 10 beats/min.

G. Respiratory Tract:
Diaphragm rises about 4 cm during pregnancy. Subcostal angle widens appreciably
as the transverse diameter of thoracic cage lengthens approximately 2 cm. The thoracic
circumference increases about 6 cm but not sufficiently to prevent reduced lung volumes
created by the elevated diaphragm. Even so, diaphragmatic excursion is greater in pregnant
than in nonpregnant women.

H. Urinary System:
Kidney size increase approximately 1.5 cm. Both glomerular filtration rate (GFR) and
renal plasma flow increase early in pregnancy. GFR increases as much as 25 percent by the
second week after conception and 50 percent by the beginning of the second trimester.
Glucosuria during pregnancy may not be abnormal and this can be attributed by the increase
in GFR with impaired tubular reabsorptive capacity for filtered glucose. Hematuria is often
the result of contamination during collection and if not most often suggests urinary tract
disease. Proteinuria is typically defined as protein excretion rate of at least 300 mg/day due
to the hyperfiltration in pregnancy.

I. Gastrointestinal Tract:
Pyrosis (heartburn) is common during pregnancy and is most likely caused by reflux
of acidic secretions into the lower esophagus. Gastric emptying time appears to be
unchanged during each trimester and compared with nonpregannct women. Hemorrhoids
are common during pregnancy caused by constipation and elevated pressure in veins below
the level of the enlarged uterus. Liver size is not increased in pregnancy and some laboratory
results may be altered. The serum albumin concentration decreases and may be near 3.0
g/dL in late pregnancy.

J. Endocrine System:
During pregnancy, the pituitary gland enlarges by approximately 135 percent
primarily caused by estrogen-stimulated hypertrophy and hyperplasia of the lactotrophs.
The maternal pituitary gland however is not essential for pregnancy. During the first
trimester, growth hormone is secreted predominantly from the maternal pituitary gland. As
early as 8 weeks AOG, growth hormone secreted from the placenta becomes detectable and
by 17 weeks AOG, it is the principal source of Growth hormone. Maternal plasma prolactin
levels increases markedly during normal pregnancy and concentrations are usually tenfold
greater at term about 150 ng/mL compared with those of nonpregnant women. During
lactation, pulsatile bursts of proalctin occur in response to suckling. Oxytocin and
Antidiuretic hormone (vasopressin) are produced in the posterior pituitary gland.
 Physiologic changes in pregnancy cause the thyroid gland to increase production of
thyroid hormones by 40 to 100 percent to meet maternal and fetal needs. To accomplish
this, thyroid gland undergoes moderate enlargement.

K. Musculoskeletal System:
Progressive lordosis is a characteristic feature of normal pregnancy. Compensating
for the anterior position of the enlarging uterus, lordosis shifts the center of gravity back
over the lower extremities. The sacroiliac, sacrococcygeal and pubic joints have increased
mobility during pregnancy.

Clinical Manifestations
Adolescents may experience the traditional symptoms of pregnancy: nausea and
vomiting, swollen breasts and amenorrhea. Often, the presentation is less classic. Headache,
fatigue, abdominal pain, dizziness, and scanty or irregular menses are common presenting
complaints

CLASSIC SYMPTOMS
Missed menses, breast tenderness, nipple sensitivity, vomiting, fatigue, abdominal and
back pain, weight gain, urinary frequency
Teens may present with unrelated symptoms that enable them to visit the doctor and
maintain confidentiality

LABORATORY DIAGNOSIS
Tests for Human Chorionic Gonadotropin in urine or blood may be positive 7-10 days after
fertilization, depending on sensitivity
Irregular menses make ovulation/fertilization difficult to predict
Home pregnancy tests have a high error rate

PHYSICAL CHANGES
2-3weeks after implantation: cervical softening and cyanosis
8 week: uterus size of orange
12 week: uterus size of grapefruit and palpable suprapubically
20 week: uterus at umbilicus
If physical findings are not consistent with dates, ultrasound will confirm


Signs and Symptoms
1. Amenorrhea
This is defined as abrupt cessation of menstruation in a healthy reproductive-aged
woman who previously has experienced spontaneous, cyclical, predictable menses.
Amenorrhea, however, is not a reliable indicator of pregnancy since menstrual cycles
 vary differently among women and even in the same woman. Uterine bleeding
occasionally occurs after conception which may suggest menstruation. Pregnancy is still
the most common diagnosis when an adolescent presents with secondary amenorrhea.
2. Lower-Reproductive-Tract Changes
Chadwick sign is defined as when the vaginal mucosa appears bluish-red and
congested. Other changes noted include an increase in cervical softening, and the
external cervical os and cervical canal may become patulous.
3. Uterine Changes
At 6-8 weeks, cervix is noted to be firm, with a softer fundus and compressible
interposed softened isthmus (Hegar sign).At 12 weeks, the uterus is noted to be
globular, with an average diameter of 8 cm. In the later stages of pregnancy, uterine
souffle may be heard, which is defined as a soft, blowing sound synchronous with the
maternal pulse. A sharp, whistling sound synchronous with the fetal pulse 9funic
souffle) may also be heard inconsistently.
4. Breast and Skin Changes
These include increased pigmentation and visual changes in abdominal striae
5. Fetal Movement
A pregnant mother may first perceive fetal movements between 16-18 weeks, and
at about 20 weeks, the examiner may begin to detect fetal movements


Management of Adolescent Pregnancy

Basic Emergency Maternal, Obstetric and Newborn Care (BEMONC) guidelines
emphasized a special consideration for managing a pregnant adolescent, which is shown on
a table below:

When Interacting with the Adolescent
● Do not be judgmental. You should be aware of, and overcome, your own discomfort with
adolescent sexuality.
● Encourage the girl to ask questions and tell her that all topics can be discussed.
● Use simple and clear language.
● Repeat guarantee of confidentiality.
● Understand adolescent difficulties in communicating about topics related to sexuality.
 ● Support her when discussing her situation and ask if she has any particular concerns:
! Does she live with her parents, can she confide in them? Does she live as a
couple? Is she in a long-term relationship? Has she been subject to violence or
concern?
! Determine who knows about this pregnancy- she may not have revealed it openly.
! Support her concerns related to puberty, social acceptance, peer pressure,
forming relationships, social stigmas and violence.
Help the girl consider her options and to make decisions which best suit her needs
● Birth planning: delivery in a hospital or health center is highly recommended. She needs to
understand why this is important; she needs to decide if she will do it and how she will arrange it.
● Prevention of STI or HIV/AIDS is important for her and her baby. If she or her partner is at risk
of STI or HIV/AIDS, they should use a condom in all sexual relations. She may need advice on how
to discuss condom use with her partner.
● Spacing of the next pregnancy – for both the woman and baby’s health, it is recommended
that any next pregnancy be spaced by at least 2-3 years. The girl, with her partner if applicable,
needs to decide of and when a second pregnancy is desired, based on their plans. Health
adolescents can safely use any contraceptive method. The girl needs support in knowing her
options and in deciding which is best for her. Be active in providing family planning counseling and
advice.

Table 3. Management of Adolescent Pregnancy

A. Prenatal Care
This should be initiated as soon as there is a possibility of pregnancy so as to define
maternal and fetal health status, estimate gestational age, and initiate plan for continuing
obstetrical care.
Routine prenatal care usually entails the following: complete history, physical
examination, and laboratory examinations, to include Complete Blood Count and Blood
Typing with Rh Factor. (see Table 1 for Schedule and Components of Routine Pre-natal Care).
Advise for smoking cessation, intake of alcohol, and use of illicit drugs need to be
emphasized.
Traditionally, prenatal check up is scheduled at 4-week intervals until 28 weeks, then
every 2 weeks until 36 weeks, and weekly thereafter. Women with complicated pregnancies
often require return visits at 1-to-2-week intervals. For our patient, subsequent prenatal
visits have been scheduled at 4-week intervals. At every visit, fetal heart rate, growth,
 amniotic fluid volume, and activity are evaluated. Assessment of maternal blood pressure
and weight and their extent of change are done. Fundal height is also taken. Also, additional
laboratory examinations will be done if the initial results showed any abnormalities.
Basic Emergency Maternal, Obstetric and Newborn Care (BEMONC) guidelines cited
scheduling of routine antenatal care visits tabulated below:

Routine antenatal care visits

1st visit Before 4 months
2nd visit 6 months
3rd visit 8 months
4th visit 9 months

Daftary et al, Manual of Obstetrics, 3rd edition, 2016

Figure 3. Algorithm on the Management of Teenage Pregnancy


The guidelines suggested that all pregnant women should have 4 routine
antenatal visits, with the first visit done as soon as pregnancy is confirmed. At the
last prenatal visit, the pregnant woman should be informed that if she has not
delivered >2 weeks after expected date of delivery, she is to come back for another
check-up.

First Trimester
On the first visit, the following laboratory examinations need to be taken:
Hematocrit or hemoglobin levels, Blood type with Rh Factor, Antibody screening, Pap
smear screening, Urine protein assessment, Urine Culture, Rubella Serology,
Syphilis Serology, Chlamydial Screening, and Hepatitis B serology. In the case of our
patient, the following were requested after her first prenatal visit on February 2, 2018,
with the corresponding results: Urinalysis showed pyuria and bacteriuria, but with
moderate squamous epithelial cells, indicating poor catch of the specimen; CBC
showed normochromic, normocytic anemia; FBS and HbSAg Serology were
unremarkable; Pelvic Ultrasound showed uterine pregnancy at 25 3/7 weeks with
breech presentation. Results of the laboratory examinations are seen in Appendix E.
Urinalysis was advised to be repeated to confirm UTI. Fundal height was taken, with
a measurement of 23 cm. Fetal heart tone was within 150-155 beats per minute.
Patient was also started with Ferrous Sulfate 1 tablet once daily, and Calcium tablet
1 tab twice daily.

Second Trimester
No subsequent laboratory examinations may be taken if the initial results
were normal. At 11-14 weeks or at 15-20 weeks, fetal aneuploidy screening may be
performed. Neural tube defect screening may be performed at 15-20 weeks.
Patient’s scheduled 2nd visit is on March 2, 2017.

Third Trimester
At 28-32 weeks’ gestation, hematocrit/hemoglobin levels need to be
repeated, along with Syphilis screening. For those with high risk for HIV infection,
repeat testing is done prior to 36’ weeks gestation. Those who are Rh negative and
unsensitized should have an antibody screening test done with administration of anti-
D immunoglobulin at 28-29 weeks.
Administration of Tetanus-diphtheria-acellular pertussis is recommended,
preferably between 27-36 weeks to maximize passive antibody transfer. Two doses
are given at 0.5 mL IM at 1-2month interval with the 3rd dose given 6-12 months after
the 2nd dose. A single dose of booster IM injection is given every 10 years as a part
of wound care if ≥5 years since last dose, or once per pregnancy.

BEMONC cited a Tetanus Toxoid schedule tabulated below:

Tetanus Toxoid Schedule

At first contact with woman of childbearing age

or at first antenatal care visit, as early as TT1
possible

At least 4 weeks after TT1 (at next antenatal

TT2
care visit)
At least 6 months after TT2 TT3
At least 1 year after TT3 TT4
At least 1 year after TT4 TT5

Hepatitis A and B, Rabies, Tetanus, and Varicella Immunoglobulin are only

given as post-exposure prophylaxis, and are therefore not part of the routine prenatal
vaccinations.

B. Nutritional Counseling
Nutritional Counseling is an important aspect in prenatal care for a pregnant
adolescent because adolescence is a time of rapid physical growth with nutritional
requirements increasing significantly to support growth and development. With this in
mind, a pregnant adolescent would have to compete for the nutrients that the
growing fetus need thus the additional energy and nutrient demands of pregnancy
place adolescents at nutritional risk. The Gynecologic Age (GA) is the difference
between chronological age and the age of menarche. This is used as an indirect
measure of physiologic maturity and growth potential. A GA of two years or less,
such as the case of our index case, may still be a period of growth and would
indicate and increased nutrient requirement.
Weight gain is crucial in adolescent pregnancy because it predicts the fetal
outcome. Studies have shown that adolescents with inadequate weight gain,
particularly in combination with low pre pregnant weight had significantly increased
odds of small for gestational age (SGA), preterm delivery and fetal death. While
those with excessive gestational weight gain have increased risk for postpartum
weight retention and long term chronic disease. The Institute of Medicine (IOM) had
specific recommendations for total and rate of weight gain during a normal adult
pregnancy by pre pregnancy body mass index (BMI) as presented in the table below:

CATEGORY TOTAL WEIGHT 1ST TRIMESTER 2ND AND 3RD

(BMI) GAIN RANGE (lb) (lb/week) TRIMESTERS (lb/wk)
Underweight
28-40 5 1 (1-1.3)
(<18.5)

Normal Weight
25-35 3 1 (0.8-1)
(18.5-24.9)

Overweight (25.0-
15-25 2 0.66 (0.5-0.7)
29.9)

Obese (≥30.0) ≥ 15 1.5 0.5 (0.4-0.6)

In 1991, the IOM recommended that adolescents less than two years post
menarche should gain at the higher end of the weight gain range recommended for
adult pregnancy based on the pre pregnant BMI. In 2009, IOM changed their
recommendation stating that adolescents should gain in the same ranges as adult
pregnancy until further research is available. There are several issues regarding this
recommendation, one of which is the concern that growing adolescents, particularly
those with a GA of 2 years or less would require higher weight gain than non-growing
adolescents or adult pregnant women to deliver an infant of optimal size since there
is more maternal-fetal competition for nutrients. Most studies suggest that young
adolescents who are still growing transfer less of their gestational weight gain to their
developing fetuses than older adolescents or adults, despite adequate weight gain
and fat accumulation. Another concern is that excessive gestational weight gain in
adolescent pregnancy does not enhance fetal growth or length of gestation but
appears to increase the risk for postpartum weight retention, obesity and long term
chronic disease. With this, further studies are needed to come up with complete
guidelines regarding the nutritional requirements for pregnant adolescent.
In the case of our CSC index case, we will follow the 2009 IOM recommendation
which is to gain at the same range recommended for the adult pregnancy based on
the pre-pregnant BMI. Our patient’s pre pregnant BMI is 17.72, calculated from a pre-
pregnancy weight of 42kg and height of 154 cm. She is under the underweight
category thus she would require a total weight gain of around 28-40 lbs. It is
important to track her weight gain by plotting her weekly weight in the Prenatal
weight gain grid as shown below:


Figure 4. Prenatal Weight Gain Grid

It is important to have an increasing trend in the grid. In order to do so, the importance
of meal planning should be well understood by the patient. Food intake must be distributed
to three meals and two or three snacks in a day. The recommended caloric intake is
calculated by adding the Basal Metabolic Rate and Physical Activity plus 300 kcal during the
first trimester and 500 kcal during the 2nd and 3rd trimester of pregnancy. The recommended
daily caloric intake is divided to 50% carbohydrates, 20% protein and 30% fat. In our index
case, her calculated caloric requirement per day is 2,411 cal/day. The computations are
Hamilyn Nacario (Index Case)
shown in the box below.
AGE & SEX 21 years old/F

HEIGHT (cm) 154 cm
(kg)
WEIGHT 44 kg
BODY MASS INDEX 18.11 kg/m2
IDEAL BODY WEIGHT (kg) 45.5 kg + 2.3 kg for each inch > 5ft 45.5 kg

BASAL METABOLIC RATE (cal/day) 1 cal x 24 x IBW 1,092 cal/day


PHYSICAL ACTIVITY (cal/day) 75% (BMR) 819 cal/day
TOTAL ENERGY REQUIREMENTS (cal/day) (BMR + PA) + 500 2,411 cal/day
CARBOHYDRATES (grams) (50% (TER)) ÷ 4 301 g

PROTEIN (grams) (20% (TER)) ÷ 4 120 g

FAT (grams) (30% (TER)) ÷ 9 80 g

The dietary plan of our index case is based on the guidelines set by the Food and
Nutrition Research Institute on the amount of servings for each food component to meet
the patient’s needed calories per day as shown in the table below. The recently launched
2016 Pinggang Pinoy: Healthy Food Plate for Pregnant and Lactating Women also served as
a guide in planning the sample menu for our index case. The proposed dietary plan for our
index case is seen in Appendix A.

Calories Vegetable Fruit Milk Rice Meat Fat
1500 4 2 1 6 6 4
1600 4 3 1 ½ 6 6 4
1700 4 3 1 ½ 6 ½ 7 4
1800 4 3 2 7 7 4
1900 4 3 2 7 ½ 7 ½ 4
2000 4 3 2 8 8 4

Hamilyn Nacario

TOTAL
CARBOHYDRATE PROTEIN FAT
CALORIES

1,928 cal/day 241 g 96 g 64 g

MEAL
VEGETABLES FRUITS MILK RICE MEAT FAT
DISTRIBUTION
FOR ONE DAY
4 4 2 6 1/2 8 ½ 4
IN EXCHANGES

Table 4. Total Calories Computed for the Index Case

A healthy food choice plays a vital role during high risk pregnancies thus healthy
food choices must be incorporated in the family meals. Patient must eat real foods, maintain
regular meal schedule and minimize processed foods. To add to this, pregnant adolescents
must also fulfill the recommended dietary intake of vitamins and minerals that are vital to
the pregnancy. Published by the Institute of Medicine, presented in a table below are the
recommended dietary allowances for both pregnant and lactating mothers:


Recommended Daily Dietary Allowances for Adolescent and Adult

Pregnant and Lactating Women
Pregnant Lactating
AGE 14-18 19-50 14-18 19-50
Fat-Soluble Vitamins
Vitamin A 750 µg 770 µg 1200 µg 1300 µg
Vitamin D 15 µg 15 µg 15 µg 15 µg
Vitamin E 15 mg 15 mg 19 mg 19 mg
Vitamin K 75 µg 90 µg 75 µg 90 µg
Water-Soluble Vitamins
Vitamin C 80 mg 85 mg 115 mg 120 mg
Thiamin 1.4 mg 1.4 mg 1.4 mg 1.4 mg
Riboflavin 1.4 mg 1.4 mg 1.6 mg 1.6 mg
Niacin 18 mg 18 mg 17 mg 17 mg
Vitamin B6 1.9 mg 1.9 mg 2 mg 2 mg
Folate 600 µg 600 µg 500 µg 500 µg
Vitamin B12 2.6 µg 2.6 µg 2.8 µg 2.8 µg
Minerals
Calcium 1300 mg 1000 mg 1300 mg 1000 mg
Sodium 1.5 g 1.5 g 1.5 g 1.5 g
Potassium 4.7 g 4.7 g 5.1 g 5.1 g
Iron 27 mg 27 mg 10 mg 9 mg
Zinc 12 mg 11 mg 13 mg 12 mg
Iodine 220 µg 220 µg 290 µg 290 µg
Selenium 60 µg 60 µg 70 µg 70 µg
Other
Protein 71 g 71 g 71 g 71 g
Carbohydrate 175 g 175 g 210 g 210 g
Fiber 28 g 28 g 29 g 29 g


Table 5. Recommended Daily Dietary Allowances for Pregnant and Lactating Women


BEMONC guidelines stated that all pregnant, postpartum, and post-abortion women
need to receive one dose daily of folic acid and iron supplements in pregnancy and until 3
months after delivery or abortion. Summarized in a table below is the recommended dosage
and duration of folic acid and iron supplement intake for all pregnant women and those with
anemia:

Folic Acid and Iron Supplement All Women Women With Anemia
Dose 1 tablet 2 tablets
For 3 months or at least 6
In Pregnancy Throughout the pregnancy months during her pregnancy
period
Postpartum and Post-abortion 3 months


Table 6. Recommended Dosage and Duration of Folic Acid and Iron Supplements for Pregnant Women


C. Intrapartum Care
Like any other pregnancies, a teenage pregnant female may deliver via vaginal
delivery or through caesarean section, depending on circumstances. Both means are below.
1. Vaginal delivery
This is the preferred route of delivery for most. Spontaneous vaginal vertex delivery
poses the lowest risk among deliveries, has lowered risks for maternal infection,
hemorrhage, anesthesia complications, and peripartum hysterectomy.
2. Cesarean Section
Cesarean delivery is defined as birth of a fetus via laparotomy and then
hysterectomy and has two types: primary, which refers to a first-time hysterectomy, and
secondary, which refers to a histrory of prior hysterectomy. Cesarean delivery has higher
maternal surgical and medical risks but offers a lower risk for birth trauma and stillbirth for
the neonates.
Certain indications need to be met to undergo a C-section. Some of those are
outlined below. Mostly, cesarean delivery is performed due to a history of a prior cesarean
delivery, dystocia, fetal jeopardy, or abnormal fetal presentation.


Some Indications for Cesarean Delivery
Prior cesarean delivery
Abnormal placentation
Maternal request
Prior classical hysterectomy
Unknown uterine scar type
Uterine incision dehiscence
Prior full-thickness myomectomy
Genital tract obstructive mass
Invasive cervical cancer
Maternal
Prior trachelectomy
Permanent cerclage
Prior pelvic reconstructive surgery
Pelvic deformity
HSV or HIV infection
Cardiac or pulmonary disease
Cerebral aneurysm or arteriovenous malformation
Pathology requiring concurrent intraabdominal surgery
Perimortem cesarean delivery
Cephalopelvic disproportion
Maternal-Fetal Failed operative vaginal delivery
Placenta previa or placental abruption
Nonreassuring fetal status
Malpresentation
Macrosomia
Fetal Congenital anomaly
Abnormal umbilical cord Doppler study
Thrombocytopenia
Prior neonatal birth trauma

Table 7. Indications for Cesarean Delivery

D. Postpartum Care
Blood pressure and pulse should be taken every 15 minutes two hours after
delivery, and the temperature is assessed every 4 hours for the first 8 hours and then every
8 hours thereafter. Amount of vaginal bleeding needed to be noted. The fundus has to be
palpated to ensure that it has contracted. If no contraction has occurred, massage the
uterus through the abdominal wall.
The perineum should be cleansed from anterior to posterior, and a cool pack may be
placed to reduce edema and discomfort. Moist heat can also be used to relieve discomfort
Postpartum blues are relatively common in postpartum women. Several factors, to
include emotional letdown that follows the excitement and fears experienced during
pregnancy and delivery, contribute to its development. This is usually mild and lasts up to 2
to 3 days. Effective treatment includes anticipation, recognition, and reassurance.
Patient after delivery is usually discharged after 48 hours following an
uncomplicated vaginal delivery. Patient has to be advised on anticipated normal physiologic
changes she will encounter, and signs of fever, profuse vaginal bleeding, and leg pain,
swelling or tenderness. Following cesarean delivery, hospitalization up to 96 hours is
warranted.
The American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists recommend a postpartum visit between 4 to 6 weeks.

E. Medical Complications
Teenage pregnancy poses a higher-than-average risk for complications, with higher
incidences of low birth weight infants, preterm infants, neonatal deaths, passage of
moderate to heavy fetal meconium during parturition, and infant deaths within 1 year after
birth, with the highest rates occurring in the youngest and economically deprived mothers.
Miscarriages occurring during teenage pregnancy are estimated at about 15-20%.

Table 8. 2012 Guidelines for Care of Pregnant Adolescents

F. Psychosocial outcomes/risks for mother and child
Educational
Teenage mothers often do poorly in school and drop out prior to becoming
pregnant. After childbirth many choose to defer completion of their education for some
time. High school graduation or an equivalency degree is generally achieved eventually.
Mothers who have given birth as teens generally remain 2 yr behind their age-matched
peers in formal educational attainment at least through their 3rd decade. Maternal lack of
education limits the income of many of these young families.

Substance Use
Teenagers who abuse drugs, alcohol, and tobacco have higher pregnancy rates than
their peers. Most substance-abusing mothers appear to decrease or stop their substance use
while pregnant. Use begins to increase again about 6 mo postpartum, complicating the
parenting process and the mother’s return to school.

Repeat Pregnancy
Approximately 20% of all births to adolescent mothers (age 15-19 yr) are second
order or higher. Prenatal care is begun even later with a second pregnancy, and the second
infant is at higher risk of poor outcome than the first birth. Mothers at risk of early repeat
pregnancy include those who do not initiate long-acting contraceptives after the index birth,
those who do not return to school within 6 mo of the index birth, those who are married or
living with the infant’s father, and those who are no longer involved with the baby’s father
and who meet a new boyfriend who wants to have a child. To reduce repeat pregnancy rates
in these teens, programs must be tailored for this population, preferably offering
comprehensive healthcare for both the young mother and her child (Table 2). Healthcare
providers should remember to provide positive reinforcement for teen parenting successes
(i.e., compliment teen parents when they are doing a good job).

Behavioral, Educational, and Social Outcomes of Children Born to Teen Mothers
Many children born to teen mothers have behavioral problems that may be seen as
early as the preschool period. Many drop out of school early (33%), become adolescent
parents (25%), or, if male, are incarcerated (16%). Explanations for these poor outcomes
include poverty, parental learning difficulties, negative parenting styles of teen parents,
maternal depression, parental immaturity, poor parental modeling, social stress, exposure
to surrounding violence, and conflicts with grandparents, especially grandmothers.
Continued positive paternal involvement throughout the child’s life may be somewhat
protective against negative outcomes. Many of these poor outcomes appear to be
attributable to the socioeconomic/demographic situation in which the teen pregnancy has
occurred, not solely to maternal age. Even when socioeconomic status and demographics
are controlled, infants of teen mothers have lower achievement scores, lower high school
graduation rates, increased risk of teen births themselves, and, at least in Illinois (where
records include age of birth mother), a higher probability of abuse and neglect.
Comprehensive programs focused on supporting adolescent mothers and infants
utilizing life skills training, medical care, and psychosocial support demonstrate higher
employment rates, higher income, and less welfare dependency in adolescents exposed to
the programs.

Prevention of Teen Pregnancies
Adolescent pregnancy is a multifaceted problem that requires multi- factorial
solutions. e provision of contraception and education about fertility risk from the primary
care physician is important, but insufficient to address the problem fully. Family and
community involvement are essential elements for teen pregnancy prevention. Strategies
for primary prevention (preventing first births) are different from the strategies needed for
secondary prevention (preventing second or more births). Over the last 30 yr, many models
of teen pregnancy prevention programs have been implemented and evaluated. Table 3 lists
the common components of many successful evidence-based programs.
Abstinence-only sexual education aims to teach adolescents to wait until marriage
to initiate sexual activity but, unfortunately, does not mention contraception. Abstinence
education is sometimes coupled with “virginity pledges” in which teenagers pledge to
remain abstinent until they marry.
Other educational programs emphasize HIV and STI prevention and in the process
prevent pregnancy, whereas others include both abstinence and contraception in their
curricula. Sex education and teaching about contraception do not lead to an increase in
sexual activity. Teenagers who participate in programs that have comprehensive sex
education components generally have lower rates of pregnancy than those teenagers who
have exposure solely to abstinence- only programs or no sex education at all.
In the practice setting, the identification of the sexually active adolescent through a
confidential clinical interview is a first step in pregnancy prevention. The primary care
 physician should provide the teenager with factual information in a nonjudgmental manner
and then guide the teenager in the decision-making process of choosing a contraceptive.
The practice setting is an ideal setting to support the teenager who chooses to remain
abstinent. When a teenager does become pregnant and requires prenatal care services,
healthcare providers should remember that the pregnant teenager is an adolescent who has
become pregnant, not a pregnant woman who happens to be an adolescent.











Table 9. Common Components of Most Successful Evidence-Based Programs to prevent Teen Pregnancy


FAMILY PROFILE, STRUCTURE, AND FUNCTION

The Sausa-Nacario family is a lower class, nuclear type of family living in Sitio
Gonzales, Barangay Kamputhaw, Cebu City. It is comprised of four members: Hamilyn
Nacario, the index case; Sulpicio Jr. Sausa, her live-in partner; and their two children Meljun
Nacario and Risha Mae Nacario.
Hamilyn Nacario is an only child. Her father, Romeo, died on 2014 due to
pneumonia. Her mother, Heidi, is alive and well. No known heredofamilial diseases. Sulpicio
Sausa Jr. is the seventh of eight children. His mother Consolacion had been diagnosed with
hypertension. His parents and siblings are all currently able and well.


 Sausa-Nacario Family
Sitio Gonzales, Barangay Kamputhaw, Cebu City
February 6, 2018

Nacario Family
Sausa Family

Figure 5. The Sausa-Nacario Family Genogram showing three generations

Figure 6. Spot Map of the Sausa-Nacario family household from the St. Gerard Wellness Center
 The Sausa-Nacario residence is located at Sitio Gonzales, Barangay Kamputhaw,
Cebu City. At the right of the entrance of South Western University- Matias H. Aznar
Memorial College of Medicine, go through a paved path leading directly to the Kamputhaw
River. Turn left and follow the river, eventually passing by a group of houses along the river
at Sitio Gonzales. Keep going straight until reaching a house at the end of the way. Then turn
right to cross a bridge over the Kamputhaw River. Keep going straight, passing by a chapel
on the right. At the end of the road, turn left then proceed straight until reaching the end of
the path. Turn right and walk about 5 meters, arriving at Sitio Gonzales. On the left is a grey
cement wall about 6 feet high with a tree on the other side. On the left is the Sausa-Nacario
residence with cemented walls and a wooden door.
The Sausa-Nacario residence is located deep in Sitio Gonzales, accessible by foot or
by motorcycle. The area is a partially urban environment. The road leading to the residence
is paved with cement.
The family lives in a 5mx7m 2 storey house made of mixed materials. The walls are
made of a mixture of cement and wood while the second floor is made mostly of wood.
Windows made of glass jalousie are interspersed at the walls near the entrance. The floor is
made of rough cement. The roof is made of galvanized iron sheets. The ground floor
consists of the dining room and kitchen as one room. The house is in between two other
houses, sharing the same walls. A small door at the corner leads to the bathroom. There is
access to tap water from the bathroom faucet. A separate room with another door is
located at the entrance where the family runs their “piso net” business. The second floor is
the one bedroom where the family sleeps together and where the children usually stay.
Sulpicio Sausa Jr., 20 years old, male, Filipino, single, is the common law partner of
the index case. Educational attainment is 1st year high school. He has no stable job and
sometimes earns money by selling cellphones. He notes occasional bouts of anxiety but
otherwise is essentially well. He has no known comorbidities or previous illnesses. He is not
an alcoholic beverage drinker, smoker, or illicit drug user as claimed.
Hamilyn Nacario, 21 years old, female, Filipino, single, unemployed, is the index
case.
Meljun Nacario, 3 years old, male, Filipino, is the first child of the index case when,
born when she was 18 years old. He was delivered term via normal spontaneous delivery,
assisted by an obstetrician at Cebu Community Medical Center with no complications. He
had complete immunizations done at Kamputhaw Barangay Center. No previous illnesses or
hospitalizations.
 Risha Mae Nacario, 1 year old, female, Filipino, is the second child of the index case,
born when she was 20 years old. She was delivered term via normal spontaneous delivery,
assisted by a midwife at a birthing home at Pananiban Street, Cebu City with no
complications. She had complete immunizations done at Kamputhaw Barangay Center. No
previous illnesses or hospitalizations.


SITUATIONAL ANALYSIS

Romeo and Heidi were neighbors in Lahug, Cebu and close childhood friends, after
which they became lovers. Unexpectedly, Heidi got pregnant at the age of 18 years old with
their only child, Hamilyn. The two then decided to get married and raised their small family
in the place where they grew up in.
Hamilyn grew up to be sociable and friendly. She had a lot of friends and would
always prefer to go out with them during her free time. She also enjoyed going to school and
was an average student. Hamilyn was seen as a happy person in school but people didn’t
seem to know that she was actually lonely at home.
Despite being a small family, their life was not easy. Romeo worked as a plumber
and Heidi was a laundrywoman. Monthly Income averages to P1,000-P1,500, however was
irregular and depended on the availability of work. Often times, Hamilyn would be left alone
since her parents needed to find other sources of income. This made her lonely at home.
Thus, she would resort to going out and spending time with her friends instead. Due to their
financial struggle, Hamilyn was only able to finish until fourth year high school, after which
she decided to work as a sales lady in order to ease the financial burden and help her
parents.
In 2014, the family met 2 major crises. Romeo passed away due to Pneumona. This
left Heidi and Hamilyn devastated and lost. It was this time also that Hamilyn met Sulpicio Jr
through her bestfriend, Jenny. Sulpicio Jr was a cousin of Jenny and just came out of a
relationship at that time. In an effort to make her cousin and her bestfriend feel better, she
decided to introduce them to each other by giving him Hamilyn’s cellphone number. The
two instantly became close through text messages and phone calls. Sulpicio Jr became
Hamilyn’s major source of comfort and support during those trying times. Not long
thereafter, they became lovers. After 5 months of dating, Hamilyn unexpectedly became
pregnant with their first child, Meljun. This was a big disappointment on Heidi’s part, causing
a strain on her relationship with her daughter. Hamilyn, who was devastated with the loss of
her father and frustrated with her mother, decided to quit her job and leave home. She
went with Sulpicio Jr and lived in together with his family who treated her like their own.
Despite having their own financial difficulties, they took care of Hamilyn, provided the
couple with a separate house and tried their best to support for the couple’s needs with
what little they had until she gave birth with their son. Not long after giving birth, Hamilyn
reached out to her mother and asked for forgiveness which the latter reciprocated.
In 2016, Hamilyn got pregnant with their second child, Risha Mae. Unfortunately,
this was not a good timing for the couple who was struggling to make ends meet. Sulpicio Jr
did not have a steady job and resorted to occasional buying and selling of cellphones in
order to provide for his growing family. Hamilyn on the other hand, worked as a waitress in
a restaurant where her monthly pay of P2,000/ month was always given late. Adding to the
burden, is the frequent hospitalizations of Meljun due to Pneumonia. This drained the family
not only financially but also emotionally and physically. Fortunately, despite all the
challenges, Hamilyn gave birth to a normal baby girl.
In September 2017, the family continued to live life with problems in finances,
raising two children and having occasional misunderstandings between the couple. Adding
to the seemingly never ending struggle, is the unexpected pregnancy of Hamilyn in less than
a year from her previous delivery and her recent unemployment. In an effort to provide for
his family, Sulpicio Jr decided to borrow money from his siblings to set up a 2 unit computer
shop which offers internet for 1 peso per minute. Unfortunately, this is barely enough to
sustain him, his 2 children and his pregnant wife. Thus, Hamilyn is now forced to set aside
her attention on her current pregnancy; as well as her two children to focus on more
pressing concerns such as looking for other sources of income. The problems that they are
experiencing right now proves to be a big challenge for the family, yet their hope for a better
tomorrow never fails to cease.


 Sausa-Nacario Family
Sitio Gonzales, Barangay Kamputhaw, Cebu City
February 6, 2018

Sausa Family Nacario Family

! Hypertension

= Functional
= Enmeshed
… Diffuse boundaries
Figure 7. The Sausa-Nacario Family Map

The family map shows the embers of the Sausa-Nacario household, composed of
Sulpicio Jr., Hamilyn, and Meljun. It is noted that the index case has a functional relationship
with her live-in partner and with their first son, Meljun. Both Hamilyn and her partner both
share in decision-making and problem-solving matters in the family; however, Hamilyn
usually has responsibility over Meljun because Sulpicio is frequently out of the house. The
couple’s second child, Risha Mae, is currently living with her maternal grandparents, with
whom Hamilyn has mild conflict due to her feeling their presence in her family life as
overbearing. Hamilyn has only infrequent contact with her own parents.
The first person Hamilyn turns to when she needs help or has problems is her
partner, Sulpicio. He, in turn, approaches Hamilyn whenever something troubles him.
Both Hamilyn and Sulpicio discuss their problems with each other before making
decisions. Hamilyn and Meljun are easily able to express emotions, such as love, anger, or
sorrow; however, Sulpicio keeps more to himself and tends not to express his emotions
openly.
 Based on the Family APGAR, both the index case and her partner consider that they
belong to a moderately dysfunctional family. Table 10 and 11 show the Family APGAR I and
II of the Sausa-Nacario Family.

Sulpicio,
Hamilyn Average
Jr.
I am satisfied that I can turn to my family for help when
A 2 1 1.5
something is troubling me.

P I am satisfied with the way my family talks on things with me. 1 2 1.5

I am satisfied that my family accepts and supports my wishes to

G 2 2 2
take on new activities or directions

I am satisfied with the way my family expresses affection and

A 1 1 1
responds to my emotion such as anger, sorrow, and love.

R I am satisfied with the way my family and I share time together. 1 1 1

Total 7 7 7

Table 10. Family APGAR I

Parameters:
• A – adaptation to crisis
• P – partnership in decision making
• G – growth potential
• A – affection for family members
• R – resolve to share resources
Scoring:
• 0 – hardly ever
• 1 – some of the time
• 2 – almost always
APGAR Interpretation:
• 0-3 – severely dysfunctional
• 4-7 – moderately dysfunctional
• 8-10 – highly functional



Who lives in your home? How do you get along?

NAME AGE SEX WELL FAIRLY POOR

Sulpicio, Jr. 20 M √

[First Child] 3 M √

Table 11. Family APGAR II


The SCREEM tool (Table 4) allows us to delineate which aspects of the Sausa –
Nacario family they consider as a resource or as a pathology.

RESOURCE PATHOLOGY
• Sulpicio’s mother provides
financial and emotional • Hamilyn sometimes finds her
SOCIAL
support by taking custody mother-in-law overbearing
of Hamilyn’s second child
• Hamilyn believes that the
• Risha Mae lives in a
bond she formed with
CULTURAL separate household with
Sulpicio Jr. gives them
her maternal grandmother
strength to fight crisis
• Hamilyn and Sulpicio are
RELIGIOUS
non-practicing Catholics
• Hamilyn and Sulpicio are
• Sulpicio’s parents are there unemployed
ECONOMICS to back the family in times • The family has no extra
of crisis earning to set aside in time of
crisis
• Parents do not give much
EDUCATION importance to their children’s
education
• Family has poor health-
seeking behavior
• Hamilyn was able to benefit
• Poor compliance to
from intervention from the
medications due to financial
MEDICAL Department of Family
constraints
Medicine of Chong Hua
• Unable to obtain diagnostic
Hospital
procedures due to financial
constraints

Table 12. Sausa-Nacario Family SCREEM

 SAUSA-
NACARIO
FAMILY

Figure 8. Ecomap: (clockwise) Chong Hua Hospital Department of Family Medicine, Vicente Sotto
Memorial Center, PhilHealth, Barangay Health Center, CUPSI, Relatives and Friends.
 Monthly Income
Php 6,000

20%
Cellphone Sales
Piso Net Earnings
50%
From Relatives
30%

Monthly Expenses
Php 6,000

10%
Food
40% Business Expenses
25%
Electricity Bill
Water Bill
25%

Figure 9. Pie Charts of the Sausa-Nacario family’s average monthly income and monthly expenses

STRESSFUL LIFE FAMILY IN

EVENTS FUNCTIONAL
EQUILIBRIUM
• Hamilyn’s current
pregnancy
• Inability to care for
both children due to
financial constraint

INADEQUATE
RESOURCES
FAMILY IN

FUNCTIONAL

• Both Hamilyn and DISEQUILIBRIUM
Sulpicio Jr. have no ADEQUATE
stable work

EXTRAFAMILIAL
RESOURCES

• Chong Hua Hospital
Department of Family
Medicine
• VSMMC, CUPSI
• Kamputhaw Barangay
Health Center
• PhilHealth
FAMILY IN • Financial and
CRISIS emotional support from
parents-in-law



Figure 10. Smilkstein’s Cycle of Family Function

The Family in Functional Equilibrium experienced the following stressful life events:
Hamilyn’s third pregnancy a llittle more than a year after delivering her second child, and the inability
to financially support both her children. The family’s inadequate resources such as Both Hamilyn and
Sulpicio Jr. being unemployed and in financial distress placed the family in crisis. The following
extrafamilial resources: the Chong Hua Hospital Department of Family Medicine in partnership with
St. Gerard Wellness Clinic, Vicente Sotto Memorial Center, CUPSI, the Kamputhaw Barangay Health
Center, the patient’s active PhilHealth membership, and financial and emotional support from
Sulpicio’s parents placed the family back into a family in functional disequilibrium.
 Stage I. Onset of Symptoms/Illness
Hamilyn initially thought that her menstruated period was delayed, which did not bother her
at first. She did not choose to tell Sulpicio Jr. until she noted amenorrhea for two months and
performed a pregnancy test, which turned out to be positive.

Stage II. Impact Phase – Reaction to Diagnosis
Both Hamilyn and Sulpicio, when they found out about her pregnancy, were dismayed and
anxious, since their second child was born only a little over a year ago. However, once they were able
to find time to discuss her pregnancy with each other and with Sulpicio’s parents; they learned to see
this event as a blessing and a chance for their family to become closer. Despite this new outlook,
Sulpicio still worries about being able to support his growing family despite not having a stable source
of income.

Stage III. Major Therapeutic Efforts
The group was able to meet the family during field work within Sitio Gonzales. Only Hamilyn
and Meljun we’re home at the time. Hamilyn was at first silent and passive to the interventions
suggested, such as regular prenatal visits, initial laboratory exams, and taking vitamins and
supplements. However, after the second visit, she became more receptive and even chose to go to
the local health center for her first prenatal check-up.
She was later accompanied by members of the group to Vicente Sotto Memorial Hospital,
where initial labs were taken. She was also accompanied to CUPSI for an OB ultrasound.
Throughout her current pregnancy, she finds emotional support in Sulpicio Jr. and his
parents, who also help to alleviate their financial situation. The group continues to provide assistance
and encourage follow-up consultations.


FAMILY WELLNESS PLAN

PRIMARY SECONDARY TERTIARY

FAMILY TREATMENT
DIAGNOSIS HEALTH IMMUNIZA SCREENING COUNSELING
MEMBER & LIFESTYLE
EDUCATION TIONS TESTS NEEDS
CHANGES
Hamilyn 26 2/7 Prenatal Check- Tetanus Toxoid Pap Smear Diet and Nutritional
21/F weeks AOG ups: Vaccine screening exercise counselling
(Index by UTZ 1st-2nd trimester – every 3 years appropriate
case) Pregnancy every 4 weeks Annual Flu for AOG Counsel about
Uterine, 3rd trimester – Vaccine the natural
Not in Labor every 2 weeks Labor and method of
36-39 6/7 weeks – delivery birth control
 every week
40 weeks above – Post-partum Counsel on
every 3 days care responsible
• Perineal parenthood
care
Periodic health • Breast Counsel about
exam- every 2- 3 feeding skills
yrs. • Mild development
1. Health risk analgesia and education
behavior with with the help
2. Medical history Paraceta of TESDA
3. Complete PE mol
4. Health guidance q4hours
5. Periodic height/ as
weight needed
measurements/B for pain
MI • Continue
6. Skin care, sexual oral iron
maturity, treatmen
psychological t, 3
status months
7. Nutrition after
education, diet & delivery
exercise w/
behavioral Post-partum
strategies follow-up at
4-6 weeks
after
discharge
Sulpicio Essentially Periodic health Annual Flu Proper diet Nutritional
20/M Normal exam- every 2- 3 Vaccine and exercise counselling
(Live-in yrs.
partner) 1. Health risk Counsel about
behavior the natural
2. Medical history method of
3. Complete PE birth control
4. Health guidance
5. Periodic height/ Counsel on
weight responsible
measurements/B parenthood
MI
6. Skin care, sexual Counsel about
maturity, skills
psychological development
status and education
7. Nutrition with the help
education, diet & of TESDA
exercise w/
behavioral
strategies
Meljun Essentially Periodic health Catch-up Screening for Proper diet
3/M Normal exam- every 2- 3 immunization mental and and nutrition
yrs. and booster sexual maturity
1. Health risk shots: problems
behavior " Annual
2. Medical history Flu
Meljun Essentially Periodic health Catch-up Screening for Proper diet
3/M Normal exam- every 2- 3 immunization mental and and nutrition
yrs. and booster sexual maturity
1. Health risk shots: problems
behavior " Annual
2. Medical history Flu
3. Complete PE vaccine
4. Health guidance " Hep A
5. Periodic height/ series.
weight " Varicella
measurements/ vaccine.
BMI " MMR
6. Skin care, sexual vaccine.
maturity, " Japanese
psychological Encephali
status tis
7. Nutrition Vaccine
education, diet & " PCV
exercise w/ vaccine
behavioral
strategies Annual
Deworming
Risha Essentially Periodic health Catch-up Screening for Proper diet
Mae Normal exam- every 2- 3 immunization mental and and nutrition
1/F yrs. and booster sexual maturity
1. Health risk shots: problems
behavior " Annual
2. Medical history Flu
3. Complete PE vaccine
4. Health guidance " Hep A
5. Periodic height/ series.
weight " Varicella
measurements/ vaccine.
BMI " MMR
6. Skin care, sexual vaccine.
maturity, " Japanese
psychological Encephali
status tis
7. Nutrition Vaccine
education, diet & " PCV

exercise w/ vaccine
FINAL DIAGNOSIS behavioral
strategies Annual
Deworming
Medical Diagnosis:
G3P2(2002), Pregnancy Uterine, 26 2/7 Weeks AOG by Pelvic Ultrasound,
Not In Labor
Family Structure: Extended Family, Launching Stage
Family APGAR: Moderately Dysfunctional
Smilkstein’s Cycle of Family Function: Family in Functional Disequilibrium
Family Illness Trajectory: Stage of Major Therapeutic Efforts


CONCLUSION

The Sausa-Nacario family is a nuclear type of family currently residing in their home
in Sitio Gonzales, Barangay Kamputhaw, Cebu City. Based on the tools used for family
assessment, they are a Moderately Dysfunctional Family. Currently, they are at the Stage of
Major Therapeutic Efforts.
About a century ago, our national hero Dr. Jose Rizal has said “the youth is the hope
of our motherland”. But how can the youth become the hope of this nation as better and
responsible citizens when early in their lives they would already have children on their own?
Adolescent pregnancy is a multifaceted problem dealing with the physical,
emotional and social aspects of the individual, family and of the community. The impact of it
is life-long and can be a starting point of certain challenges that may be difficult to handle on
such age. Adolescent years are marked by a struggle of independence and identity. This
stage of growth and development may lead to a partial or complete standstill by an
unexpected pregnancy. When no actions are done, a series of unexpected pregnancies will
follow. The approach to this case involved a process requiring patience, understanding and
collaboration. It highlights on the importance of channeling available resources to provide
holistic care.
The case of Hamilyn is not an isolated case. It presents a scenario wherein a child is
prematurely plucked out from her youth and is now forcefully embarking on a journey to an
unfamiliar terrain, unprepared, to the responsibilities of adulthood. She was then a child
stripped off her young life to become a mother at such an early age.
Sagunsun – Bisan sa sagunsun na problema sa atong kinabuhi, dili gihapon mawala
ang paglaum sa maayong kaugmaon.


RECOMMENDATIONS

• For the Family:
" To be cooperative in the monthly prenatal check-ups to be facilitated by the
medical interns especially during follow-up visits
" To report to the medical intern-in-charge for any unusualties or concerns during
follow-up visits
 " To be compliant in having necessary laboratories taken during the course of the
pregnancy and with the medications given during the prenatal visits
" To avail of the free consultations offered by the St. Gerard Wellness Clinic

• For the Family Medicine Clinical-Clerk-In-Charge:
" To facilitate the regular monthly prenatal check-ups
" To plot the weekly weight gain of the index case in the Pre-natal Weight Gain
Grid and to ensure an increasing trend in the weight of the patient.
" To monitor the compliance to medications, vitamins and therapy of the index
case
" To cater to the problems of the index case regarding her condition as well as the
treatment
" To properly endorse the index case to the next intern-in-charge
APPENDIX A

Prenatal Laboratory Results of Index Case

Date taken: 2/2/18

FBS 83.92 mg/dl

HBs Ag Non-reactive


Complete Blood Count

WBC Count 8.91 Differential Count

RBC Count 3.82 Neutrophil 64.8 %

Hb 10.4 Lymphocyte 25.5 %

Hct 31 Monocyte 5.2 %

MCV 81.2 Eosinophil 4.3 %

MCH 27.2 I 0.2 %

MCHC 335

RDW 38.4 fl

Platelet 279
Count


Pelvic Ultrasound
Interpretation: Pregnancy Uterine, 25 4/7 weeks AOG, live, singleton, breech
presentation; Adequate amniotic fluid volume; Anterior placenta, grade II, high lying;
EFW within 10-90th percentile of growth curve