NRNP 6552 Week 8 Case studies – A 32-year-old African American woman presents to the clinic for her 24-week check-up.   Case # 4   A 32-year-old African American woman at 24 weeks gestation presents with persistent daily sadness, fatigue, decreased energy, and difficulty completing daily tasks and maintaining work attendance. Although she expresses happiness about her pregnancy, she reports an inability to explain her ongoing sadness. Symptoms began one week prior to presentation. Her family history is significant for paternal chronic depression and diet-controlled diabetes, while her mother has no known medical conditions. The patient currently takes a daily prenatal vitamin and denies allergies.  

Outline Subjective data.    The patient reports daily depressed mood, persistent fatigue, anhedonia, inability to perform usual daily chores, and difficulty attending work. She tried going to bed earlier without improvement. She denies understanding why she feels sad. Additional subjective data required includes a formal validated depression screening score using the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire-9 (PHQ-9), full psychiatric and prior depressive episode history, suicidal ideation assessment, relationship quality and social support evaluation, history of adverse childhood experiences, sleep pattern changes, appetite changes, and current financial or occupational stressors.	Outline   Objective findings.   Vital signs include height 5’4”, weight 147 lbs, BMI 25.2, blood pressure 132/78 mmHg, and heart rate 88 bpm. The patient appears well-nourished but demonstrates a flat affect and mildly disheveled appearance, suggesting decreased self-care. HEENT examination is normal. The neck is supple without thyromegaly. Lung auscultation is clear bilaterally. Cardiovascular exam reveals a regular rate and rhythm with a soft grade II/VI systolic murmur, likely physiologic in pregnancy. Peripheral pulses are normal without edema. Breast and genitourinary exams are consistent with normal pregnancy at 24 weeks, and fetal heart tones are present. Additional objective data should include a documented PHQ-9 or EPDS score. Laboratory evaluation should include thyroid-stimulating hormone (TSH), complete blood count (CBC), and a one-hour glucose challenge test, as this aligns with routine gestational diabetes screening at 24–28 weeks. A validated suicide risk assessment tool should also be completed.	Identify diagnostic tests, procedures, laboratory work indicated.     The American College of Obstetricians and Gynecologists recommends systematic screening and diagnosis of mental health conditions during pregnancy, including depression, anxiety, and bipolar disorder, with formal validated instruments at a minimum of twice during gestation (American College of Obstetricians and Gynecologists [ACOG], 2023a). The PHQ-9 or EPDS must be administered immediately, as these are validated, brief, and widely available instruments appropriate for perinatal populations (Kendall-Tackett, 2024). A TSH level is indicated because hypothyroidism shares overlapping symptoms of fatigue and depressed mood with antenatal depression; levothyroxine is the recommended treatment when TSH exceeds 2.5 mIU/L in pregnancy (Nguyen, 2022). A complete blood count is indicated to evaluate for iron-deficiency anemia, a common pregnancy complication contributing to fatigue and low energy. A one-hour glucose challenge test is necessary given the patient’s strong bilateral family history of diabetes. A structured suicide risk assessment using the Patient Safety Screener is mandated whenever depressive symptoms are identified, as untreated perinatal depression carries risk of maternal mortality (MS & Kay Roussos-Ross, 2023).	Distinguish at least three differential diagnoses.    Antenatal Depression: This is the most likely diagnosis given persistent sadness, anhedonia, fatigue, and impaired functioning. Family history increases susceptibility. ACOG identifies perinatal depression as a leading contributor to maternal morbidity and emphasizes early screening and treatment (ACOG, 2023a). Adjustment Disorder with Depressed Mood: The recent onset of symptoms suggests a possible stress-related response to pregnancy-related life changes. However, symptom severity and functional impairment raise concern for progression to major depression if persistent (MS & Kay Roussos-Ross, 2023). Hypothyroidism in Pregnancy: Overlapping symptoms such as fatigue and low mood necessitate exclusion of thyroid dysfunction. Pregnancy increases thyroid hormone demand, and untreated disease carries significant maternal-fetal risks (Nguyen, 2022) NRNP 6552 Week 8 Case studies – A 32-year-old African American woman presents to the clinic for her 24-week check-up..	Identify appropriate medications, treatments or other interventions associated with each differential diagnosis.    For antenatal depression, cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are evidence-based, first-line interventions for mild-to-moderate symptoms during pregnancy, avoiding fetal pharmacological exposure. When symptoms are moderate-to-severe or unresponsive to psychotherapy, sertraline is the preferred pharmacological agent given the broadest perinatal safety data among SSRIs (MS & Kay Roussos-Ross, 2023). Suicide as a leading preventable contributor to maternal mortality exceeding hemorrhage underscores the ethical imperative of timely pharmacological intervention when clinically indicated (MS & Kay Roussos-Ross, 2023). For adjustment disorder, supportive psychotherapy, social work referral, and stress reduction strategies are appropriate initial interventions. For confirmed hypothyroidism, levothyroxine is the sole recommended thyroid hormone replacement therapy during pregnancy, with monthly TSH monitoring until the target of below 2.5 mIU/L is achieved (Nguyen, 2022). Prenatal vitamins and iron supplementation should be maintained throughout regardless of confirmed diagnosis.	Explain key   Social Determinants of Heath (SDoH) for your chosen case.   This patient faces several intersecting social determinants that elevate her risk. As an African American woman, she is subject to structural racism in healthcare systems, contributing to underdiagnosis and undertreatment of perinatal mental health conditions (Blebu et al., 2024). Employment demands and the challenge of attending work while experiencing depression and fatigue signal financial vulnerability and occupational stress, creating an ethical obligation to discuss workplace accommodations. Poor social support and partner relationship quality are among the most consistently identified determinants of antenatal depression and must be explicitly assessed (Insan et al., 2022). The physical burden of untreated depression on fetal outcomes, including low birth weight and preterm birth, reinforces the urgency of intervention. Psychologically, the patient’s flat affect and disorganized appearance suggest moderate functional decline requiring immediate attention.	Describe collaborative care referrals and patient education needs for your chosen case.    Referral to a perinatal psychiatrist or licensed clinical social worker specializing in maternal mental health is strongly indicated. Integrated collaborative care models combining obstetric and psychiatric expertise demonstrate significantly improved screening utilization and treatment rates for perinatal depression (Blebu et al., 2024). The patient must be educated on the clinical distinction between normal pregnancy fatigue and clinical depression, the safety of both psychotherapy and carefully selected pharmacological agents during pregnancy, and the importance of consistent prenatal attendance and validated screening at every visit. She should be counseled on available community mental health resources, crisis hotlines, and employer accommodation rights to address financial and occupational stressors. Ethically, she must be informed of her right to participate in treatment decisions using shared decision-making. A documented safety plan addressing suicidal ideation warning signs must be established and placed in her medical record at this visit (ACOG, 2023a).

  References American College of Obstetricians and Gynecologists. (2023a). Screening and diagnosis of mental health conditions during pregnancy and postpartum: ACOG Clinical Practice Guideline No. 4. Obstetrics & Gynecology, 141(6), 1232–1261. https://doi.org/10.1097/aog.0000000000005200 Blebu, B., Jackson, A., Reina, A., Dossett, E. C., & Saleeby, E. (2024). Social determinants among pregnant clients with perinatal depression, anxiety, or serious mental illness. Health Affairs, 43(4), 532-539. https://doi.org/10.1377/hlthaff.2023.01456 Insan, N., Weke, A., Forrest, S., & Rankin, J. (2022). Social determinants of antenatal depression and anxiety among women in South Asia: A systematic review & meta-analysis. PLOS ONE, 17(2), e0263760. https://doi.org/10.1371/journal.pone.0263760 Kendall-Tackett, K. A. (2024). Screening for perinatal depression: Barriers, guidelines, and measurement scales. Journal of Clinical Medicine, 13(21), 6511. https://doi.org/10.3390/jcm13216511 MS, M., & Kay Roussos–Ross, M. D. (2023). Treatment and management of mental health conditions during pregnancy and postpartum. American College of Obstetricians and Gynecologists, 141(6), 1262–1288. https://doi.org/10.1097/aog.0000000000005202 Nguyen, C. T. (2022). Postpartum thyroiditis: Diagnosis and management. Thyroid Diseases in Pregnancy, 211-222. https://doi.org/10.1007/978-3-030-98777-0_14