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As I was reading the case, I couldn't help but remember many women I have seen undergoing similar issues. However, as I always say, each case is individual, and should be understood that way to be able to comprehend the person's particular needs. From a biopsychosocial perspective, we could point out:
1) complete blood work needs to be done (FBC, LFTs, U&E, iron levels), condering she has a BMI of 17 and is showing signs of dehydration. Liason with her GP would be beneficial to find out previous BMIs.
2) obs team (including midwife) need to do a continuous assessment on fetal wellbeing and compliance on Imogen's part with folic acid, iron, etc. She might need to ge them intravenously with the IV fluids to ensure the baby's safety.
3) the perinatal psychiatrist should be flagged on the case to take a full history of what is mentioned as "anxiety". Did she suffer from generalised anxiety disorder, panic disorder, specific anxiety related to pregnancy, body image, etc? Was she ever treated with medication and/or psychotherapy? What was the outcome? A differential diagnosis with an eating disorder should be carried out by the psychiatrist.
4) the partner needs to be heavily involved. First of all, acknowledging how distressing this situation is for both of them is key. I would assess them separately and together to tease out what emotional and interpersonal issues they might be experiencing.
5) Most importanty, the MDT needs to be part of this case, a social worker could be involved in case there are worries regarding the home environment, vincular psychotherapy might be needed, a public health nurse might need to visit and assess their home, the obs and psych teams should give their input.

Thankyou
Cath

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 😊we do have joint clinics in Malta but it is run different from UK.  the obstetrician is only present during the antenatal psychiatric visits. 

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 😊we do have joint clinics in Malta but it is run different from UK.  the obstetrician is only present during the antenatal psychiatric visits. 

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Claire
Thanks Claire x

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Potential Issues with this Case:

1 -Attitudes to body weight, weight gain and eating behaviour in pregnancy
2 - Spectrum of eating disorders in the perinatal period

What information do you want to know to help you with managing this situation effectively?

1 -  information regarding Imogen’s current physical wellbeing. Inclusive of current weight, PUQE score, blood work up (FBC, U&E, LFTS, calcium, bone density,  magnesium, phosphate, potassium, glucose, Serum TSH levels) Urinalysis, ECG and physical presentation
PUQE score added below?

2.     From a clinical perspective, further information regarding Imogen’s current mental wellbeing. Inclusive of PHQ-9, GAD-7, SCOFF Questionnaire, EDE-Q.

3.     Historic or long standing mental health issues, if Imogen has ever received and treatment/medication/support for her anxiety. Imogen’s previous relationships surrounding diet and food. Is her relationship with body image long standing?

4.     Greater understanding of Imogen’s socioeconomic background, support network and life experiences.

5.     Greater understanding of the dynamics of Rogers and Imogen’s relationship

Who else do you want to talk to?

1.     Liaise with the GP/ Community Midwife – to establish if Imogen has demonstrated behaviours consistent with these today. Gaining a greater understanding of Imogen’s previous mental health issues. Furthermore, I would wish to speak to both of these professions in order to update them on potential diagnosis and establish a multi-disciplinary approach in the community setting to ensure there are steps in place to actively maintain/improve Imogen’s physical and mental wellbeing.

2.     Obstetric Team to establish management a management plan for the physical wellbeing of Imogen and the foetus – regular growth scans at 28/32/26 weeks. Consideration of early IOL depending on findings and Imogen’s mental wellbeing.

3.     Discussion with dieticians to enable Imogen to have an element of self-management within her care.

4.     Perinatal mental health team

Develop some questions that you need to answer

1.     How the role of family support and education may be impactful upon Imogen and her ability to improve her mental health and relationship with her body image?

2.     What opportunities do health care professionals have to engage Imogen within her care, what are the opportune times for these intervention and what are the barriers to these?

3.     How can we enable Imogen to self-manage her condition? What form of contingency planning can be put in place?

4.     What are the experiences of women with an eating disorder in the perinatal period?

5.     What are the physical and psychosocial implications of eating disorders on the developing foetus and the mother-infant dyad?

6.     In an ethical and legal stance, what responsibilities do health care professionals have to safeguard Imogen and the unborn?

7.     What factors predispose women to eating disorders?
Thanks Zoe,I've added the PUQE score, it is what it says on the tin!
Cath

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In my opinion the main issues that concern me are the BMI of 17 : this maybe indicative of an eating disorder or due to her hyperemises and the Intrauterine growth retardation.
One must take note  and evaluate her anxiety, feeling of distress and her protective fetal position all may be indicative to antenatal depression.  This may be the cause of her vomiting, leading also to IUGR and the low BMI.
The four admissions to hospital may also be a call for help. maybe she is trying to get away from home due to relationship issues.  Although Roger seems supportive he doesn't seem to me worried about Imogen since he is playing with his mobile and once she is given IVI fluid he leaves.  they might be having relationship issues that is triggering her anxiety, which in my opinion needs to be explored.
Other areas to explore:
-I would ask Imogen about her pregnancy, was it a planned and consensual pregnancy? what are her feelings about her pregnancy and whether the pregnancy is wanted?
- I would ask  Imogen about her past history of anxiety and other mental health issues, if she is currently on medication  or taking therapy for her anxiety issues.
- I would investigate about her family history of mental health disorders.
- if she has family members that can support her.
- I would ask about domestic violence.       I would talk to

the Obstetric team to better understand the obstetric management and investigations required for better care and management for Imogen and her baby.

the Perinatal Mental Health team (PMHT) for proper diagnosis of the illness/disorder and management of care.

the GP to explore p/h of anxiety, other mental health issues and further medical health history.

the community midwife to provide adequate support to Imogen, to liaise with the PMHT and plan women centered care.

Subject areas that I would like to develop are:
Body Image and Eating disorder in pregnancy
How can midwives engage Imogen in the plan of her care? In Malta care is more medically oriented and patients are submissive to what doctors say.

Thanks Claire,
Do you have joint care clinics in Malta Obst/psychiatrist?
Cath

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What I would want to explore and want more information about is:
- What triggers Imogen's anxiety, is it well controlled at present? What treatment is she on/had and is she currently on any medication or therapy to manage it? Could also check with GP
- Explore why she has a BMI of 17, has she got a condition, eating disorder, what is her diet and life style like before pregnancy and how has it changed since she has become pregnant?
- This is her 4th admission, did the anti-emetics work last time? If so for how long. What triggers her vomiting? Obstetric team input and dietitian to manage the sickness and to make a plan to carry out the appropriate investigations. Also input for management of potential fetal growth restriction
- How is Imogen feeling about the pregnancy, is there anything else upsetting her?
- Explore the relationship between Imogen and Rodger as when she had vomited in a bowl he was on his phone and showed little interest.
- Explore her job role as a carer is she able to have her breaks and manage her diet and fluid intake there?
Thanks Aimee, also was she on medication and did she stop it once she was pregnant? Lots of women do this and often its the wrong thing to do.
I would be thinking about safeguarding also and asking the Routine enquiry questions once Roger has gone.
Cath

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My issues to explore with Imogen, Roger, her community midwife and GP: past history of anxiety - need to liaise with GP for further details, any record of input from secondary MH services, any medication historically/ current, any associated eating disorder assessments/ diagnoses made in past. Low BMI, would be interested to know of her normal eating patterns, any history of being overweight, any recent (pre-pregnancy) weight loss. Would be interested in her blood profile at booking and now, as well as urinalysis.
I would be considering heightened anxiety due to concern about weight gain in pregnancy, that may be related to an underlying eating disorder and/or due to increased anxiety around changing body shape in pregnancy. This would not be unpicked quickly.
Initially i would be looking to stabilize her with fluids and anti-emetics, whilst liaising with GP. I would then take a full history from Imogen and request consent to liaise with secondary mental health services (perinatal mental health teams) to support her to manage her anxiety. If there are concerns surrounding body image/ underlying eating disorder, I would also request Imogens consent to refer to specialist ED services to joint work alongside mental health services - in my locality these are separate, i appreciate this may not be the case elsewhere.
I am concerned about the lack of support from roger when Imogen is distressed and would want to explore any relationship or safeguarding concerns Imogen might have.
I agree
Cath

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The concerns include multiple admissions, uncontrollable hyperemesis gravidarum, despite medication being prescribed, reduced SFH, low BMI and the fact that no staff have seen Imogen vomit. It would also be concerning to hear the negative comments she made about herself and how low she appeared.

The issues, which appear to be an eating disorder/body dysmorphia and depression are very complex and would require a multidisciplinary approach to provide the correct amount of support and care for Imogen to improve.

I have limited knowledge regarding eating disorders and the management of these. I’m hoping this course will enable me to gain further insight into these and gain awareness into the appropriate management available. I will also continue to read around this subject area.
Amy
Excellent
Cath

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Facts-  First time mum. Pregnancy is a new experience.
?Hyperemesis Gravidarum an unpleasant condition.
Underweight BMI of 17.
Tachycardia
Symphysis Fundal height lower than expected at this gestation. ? Issue with fetal growth.
Distressed with sickness bowls however no vomiting seen.
Undergoing IV hydration
Antiemetics prescribed.

Issues
Imogen presents as a case of Hyperemesis. This can cause women distress and due to their poor ill health it can cause mental distress. Can invoke poor bonding with parents and the baby, as baby is seen to be the cause of the illness. Rodger may feel powerless to help Imogen and paternal mental health is being compromised seeing his partner ill in hospital and distressed.

Issue of infection-  Tachycardia, ill and what could be classed as worrying behaviour. ?Sepsis Bloods, further observation needed. To confirm.

Imogen's emotional health is an issue here. She has a history of anxiety and is seen curled in a ball crying. I would wish to ask Imogen about her current emotional health including tools of PHQ9  and GAD7. This would open up discussion with Imogen about what her results show and may prompt more dialogue from her.  She is also seen with vomit bowls yet no vomiting. Is this related to Bulimia? Is anxiety heightening this condition for her. Is weight gain in pregnancy causing this to be out of control for her? Is Imogen reaching out for help by seeking help from the hospital but feeling too scared or ashamed to admit an eating disorder?  Are her physical symptoms including tachycardia and low BMI relating to Bulimia and possible malnutrition?. I would wish to ask Imogen if she has any current or history with eating disorders as part of an assessment of her current emotional wellbeing.

However this being said I can see how this could be overlooked by a hospital ward whom do not see Imogen regularly as they will focus on treatment of the physical issues.  This is where it is important to Liaise with her regular community midwife. I would also wish to liaise with Imogen's GP and would ask her consent to do so.

I would be open with Imogen and discuss Rodger's behaviour and how she feels about this? Could I offer help? Within this enquire RE domestic abuse too.

Considering the increasing evidence around the importance of paternal mental health. I would ask Rodger how he was, does he need anything? Does he have concerns about Imogen he would like us to discuss?

Imogen will require Obstetric review and an ongoing plan of care. Including a growth scan to assess the growth and wellbeing of the fetus (my trust policy is within 72 hours). Due to low BMI the Obstetric team can also refer to a dietician. Serial growth scans due her low BMI will also be required 2-3 weekly (guidance of perinatal institute).

Imogen would require closer monitoring of her weight. She may not have been weighed since her booking appointment in early pregnancy as routine is booking, 28 weeks and 36 weeks.

It would be beneficial to liaise with the mental health service/ perinatal mental health service with consent. I would encourage Imogen to access support for her own mental health to develop positive coping strategies to manage anxiety and difficult emotions,  so she is able to be emotionally responsive to her baby. Midwifery, health visiting and perinatal mental health services could work together with Imogen and Rodger to offer parenting support, encourage bonding with their baby and explain the importance of these for baby brain development.

In referring to specialist mental health services Imogen could then be referred to specialist eating disorder services whom could explore this further with her.

My view is that it would be beneficial for her named midwife to increase appointment frequency for example to 2 weekly,  to monitor well being more closely and be able to offer Rodger and Imogen more support.

Questions I would like to explore-

What interventions are effective in managing eating disorders in pregnancy?

How often are women asked if they have a history of eating disorders?

What is the impact upon the child as a result of parental eating disorders?
Thanks Chloe, great consideration of the impact of the MDT
Cath

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BMI 17 is in the underweight range for non pregnant women. Imogen is 26 weeks pregnant.
As a mental health nurse I need to be clear of my role and responsibilities and work within my professional competencies. It is unclear whether Imogen is making herself vomit, which would be indicative of a possible eating disorder. Imogen presents as having low mood and appears anxious.
I would first establish what Imogens pre pregnancy weight was in order to establish a pre pregnancy BMI for comparison.
I would liaise with the midwife and obstetrician assigned to Imogens care to establish what bloods have been done and the results. I would discuss the regularity of growth scans with the midwofery team and any cause for concern around these.
I would conduct a full mental health assessment with Imogen, taking a thorough history of social and environmental issues from birth onwards eg relationships with parents, childhood, any past traumas etc leading up to the present day. I would explore with Imogen her relationship with food from an early age and identify  when she began to have body image issues and whether we could identify a trigger for this. Has Imogen ever received treatment from mental health in childhood or adulthood and if so, what this entailed, was there any diagnosis, what treatment she received, had she learned any strategies that she can use today to help minimise her distress.
Any past premenstrual issues re mood?
Is this Imogens first pregnancy? If not were there any mental health issues in previous pregnancy? Any close female family relatives experienced perinatal mental health issues? Establish any family mental health issues past or current.
Does Imogen have any thoughts of harm to self or others? Any thoughts of harming unborn? Any suicidal ideation, plan or intent? How does she feel about unborn child? Was the pregnancy planned/wanted? Does she feel that she has bonded with her unborn child?
Has Imogen ever/currently prescribed any medication for mental health, What is this medication, side effects, efficacy.
What other medication is Imogen taking, including over the counter medication. Did Imogen cease medication recently? What was the reason for this. All of the above information would then be shared with the psychiatrist in my team. I would offer Imogen an appointment with team psychiatrist to discuss medication if necessarry.
I would explore Imogens relationship with her partner and her relationships with other family members and friends. What support does Imogen have in place?
How is her partner coping with Imogens pregnancy and the underlying issues? Offer partner a referral for therapy if necessary.
Depending on the information gathered at the full mental health assessment and the information from the midwifery team I may consider a referral for CBT to explore triggers, early warning signs and strategies and a referral to the local specialist eating disorder team
I would see Imogen weekly initially until she commences treatment with the CBT therapist.

Thanks Amanda,
Imogen is a primigravida, which means forst pregnancy. Your discussion of collaborative working is great.
Cath

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I wonder if Imogen has an underlying eating disorder. I know she has no medical history except anxiety however she has a low BMI, history of anxiety and no one has actually seen her being sick.  The pregnancy could potentially be exacerbating her anxiety and potential eating disorder.
Thankyou
Cath

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the symptoms that Imogen is experiencing are very much related to antenatal depression.
Would you like to elaborate on this please?
Cath