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MRCOG PART 2 SBAs and EMQs

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Essay 349

Posted by Ram M.

a. This lady is at high risk during her pregnancy as she has an obesity of category III acording to NICE guidance.  Together with  increased maternal age, there is increased maternal and fetal risk. The serum markers for screening for DOwn Syndrome are difficult to interprete and if possible combined test can increase the detection rate in this situation.

There is increased risk of aneuploidy and miscarriage due to poor quality of eggs at increased maternal age. There is increased risk of neural tube defect and having high dose of folic acid (5 mg daily) would reduce this risk.

There is increased risk of having big babies and hence birth dystocia. Increased BMI has also been associated with cardiac disease.

I would advise her that there is higher risk of gestational diabetes, hypertension, venous thromboembolism . She would need regular screening for blood pressure with the appropriate large cuff and a GTT would be done roultinely at 28 weeks to screen for GDM. She will be also at risk to have deficit of vitamin D and there a supplement of 10 mcg daily will be given during the pregnancy. As she is at higher risk of developing HBP, a low dose of aspirin (75 mg daily) can be considered to reduce this risk.

She will also need to be seen by an anaesthetist as there may be dificulty with venous access, regional and general anaesthesia.

b. I will recheck the blood pressure manually with a large cuff. I will also recheck the urine for proteinuria by a urinary PCR.

If the blood pressure is still high and and proteinuria present then this patient should be treated as pre eclampsia. Stabilising the patient will be the priority. Antihypertensive medication will be started accoring to the local hospital policy. 

A course of corticosteroid injection should be offered as delivery of baby will be anticipated. Blood test will be sent for FBC, U&E, LFT, serum uric acid

Other factors to assess the severity of pre eclampsia should be explored. I will ask for sign of severe head, visual disturbances, right upper quadranrt or epigastric pains. I will also check for clonus and if there is sign of severe preeclampsia, she will be started of magnesium sulphate as per hospital protocol.

Theatre staff will be informed, as well as the anaesthetist and SCBU

Prohylaxis for DVT will include TED stocking and LMWH at appropriate doses to patient's weight

Posted by A K.

A.

Consultant led care since she is high risk pregnancy. Previous obstetric history is noted along with any previous  caesarean sections if any.

Dietitian referral to advice on adequate weight gain and diet in current pregnancy.

Referral for assessment by consultant anesthetist to ascertain her risk factors for pain relief & anaesthesia.

Nuchal translucency and combined screening done to identify her risk of Down’s syndrome. That should be offered to her before 12+6 weeks of pregnancy. Referral to tertiary fetal medicine centre if results of the screening test are abnormal or increased NT.

Her increased BMI may result in suboptimal views at anomaly scan needing further scans to rule out neural tube defects or any other congenital anomaly

Calcium supplementation throughout pregnancy and lactation because of risk of hypocalcemia.

She is high risk for increased Blood pressure and pre-eclampsia so at every antenatal visit BP check and urine for proteinuria testing is must. Uterine artery notching studies at 24 weeks can be done to assess her possibility of pre-eclampsia. Low dose aspirin to be started.

She is also high risk for intrauterine growth restriction so regular growth scans after 28 weeks along with Doppler studies of umbilical artery is needed. Symphysio-fundal height measurement may be inaccurate considering her high BMI.

High risk to have gestational diabetes so blood sugar screening along with 75 grams glucose tolerance test at 16 weeks if previous gestational or diabetes and if normal repeat it at 28 weeks.

Thromboprophylaxis in the form of TED’s stocking plus Tinzaparin depending on previous history of DVT, family history of DVT or any other high risk factors as per RCOG guideline.

Presentation scan at 36 weeks may be needed because of difficulty in identifying presenting part.

Weight handling in pregnancy along with adequate high weight bearing couches and examination tables and operative tables must be considered before labour.

B.

Admission to antenatal ward.

Detailed history of any nausea, vomiting, headache, visual disturbances, visual symptoms and epigastric pain is noted.

Antenatal events and follow up till now are noted to identify any high risk factors like IUGR.

Assessment of reflexes and clonus along with fundoscopy is needed.

Uterine tenderness if any to rule out abruption and contractions should be checked on abdominal palpation. Fetal lie should be assessed if possible.

Cardiotocography for fetal assessment and ultrasound for amniotic fluid volume and Doppler studies of umbilical vessels to be done.

Full blood count,urea & electrolytes and liver function tests and coagulation screen to be done.

24 hour urine protein estimation or spot protein creatinine ratio estimation to be done.

Antihypertensive treatment to be started. Labetalol /methyldopa to be considered.

Magnesium sulphate if signs of imminent eclampsia suspected on clinical examination findings.

Steriods to be given if delivery is considered depending upon clinical assessment.

Consultant obstetrician to be informed at all stages.

Women and her partner kept informed about events and further plans.

ans to essay Posted by S M.

1) Risks to this woman in pregnancy are not only due to her age but also due to her being morbidly obese. In first trimester she is at risk of miscarriage and aneuploidy. Her risk of having a down syndrome baby, based on her age only is around 1:100. She will need screening tests such as nuchal scan and biochemistry; however, definitive diagnosis can be made only either by CVS after 11 completed weeks or amniocentesis after 16 completed weeks. Maternal risks such as pre-eclampsia and gestational diabetes are significantly high in this age group. Uterine artery Doppler at 20 weeks and OGTT at 28 weeks can predict these problems. Due to her being obese, it should be ensured that large cuff manometer is used to check her BP to avoid any misleading readings. Her obesity also puts her at risk of vitamen D deficiency so 10 mg Vit D should be prescribed from early pregnany. Fetus is at risk of Still birth, IUD and growth restriction.  Growth scans at 28 and 34 weeks will be beneficial to identify growth restriction. Risk of prolonged pregnancy, need for IOL and caesarean section will be increased. She should be seen in consultant led hospital clinic so that risks can be identified and appropriate action taken. Morbid obesity will also increase risk of thrombosis, so prophylactic LMWH should be started and continued throughout pregnany.

 

2) Detailed history of symptoms such as frontal headache, visual disturbances (pointing towards neurological irritability), nausea, vomiting, epigastric and right hypochondriac pain (due to stretching of liver capsule secondary to high BP) be enquired. Enquire about fetal movements. BP should be repeated using appropriate sized cuff. Urine sample be checked again, preferably using automated machine for proteinuria. Fundoscopy be done to rule out papilloeadema. Abdominal examination should include fundal height, look for tenderness in epigastric and hypochondriac areas. Reflexes (biceps, patellar) be checked as hyperreflexia will point towards neuronal irritability. Blood tests be done including FBC (to look for anaemia and thrombocytopaenia), LFT’s (to check for raised ALT ), Uric acid and Urea and Electrolytes. Clotting screen be done if there is evidence of thrombocytopaenia. Blood tests should be repeated daily or every other day if normal. Patient should be admitted. Antihypertensives be started first line being methyl dopa 500 mg TDS. BP be monitored 4 times daily. CTG be done to check fetal well being and repeated daily. USS be arranged to rule out IUGR and oligohydramnios. Clexane should be continued and additional TED stockings be provided. 24 hour urine be collected for estimation of proteinuria. Neonatal unit be informed of admission.  Further management will depend on BP control, blood tests and estimation of proteinuria. Follow up should be arranged if patient is discharged from the ward.  

Posted by Ana B.

The risks of obesity are associated with miscarriage, fetal anomalies, pregnancy induced hypertension, pre-eclampsia gestational diabetes and venous thromboembolism. Fetal macrosomia, fetal distress, birth injury, fetal anomalies are complications more prevalent among obese women. Obese women have higher rates of induction of labour, caesarean sections. The 2003-2005 report on confidential Enquires into Maternal Death in the UK highlighted obesity as  a significant risk factor for maternal death. More than half women who died from direct and indirect causes were either overweight or obese. One study shows that an increase of BMI of around to 2 units (from 23 to 25 BMI) increases the risk of gestational diabetes by 20-40%. The NICE guidelines advise to screen for gestational diabetes if BMI more than 30 as it is considered to be a risk factor for diabetes. If gestational diabetes is diagnosed, diabetes control should be achieved through a strict diet; insulin therapy may be required to reduce maternal and fetal morbidity. Therefore lifestyle in terms of a healthy diet and exercise are important and referral to dietician already could be offered at 10 weeks, GTT is usually performed at 28 weeks as screening for diabetes. Folic acid is advisable in high doses of 5 mg and can be increased at 10 weeks if she is on routine dose. Anaesthetic opinion should be sought; and referral could be done at 10 weeks as obese women at risk of failed epidurals, increased aspiration during general anaesthesia and difficulty with intubations, they are the most common complications. The risk of hypertension is approximately doubled. Aspirin 75 mg od from 12 weeks could be considered if other risk factors for preeclampsia are present as it showed the reduction the risk. Also ultrasound sensitivity is reduced in obese women; and consequently dating scans, detecting anomalies on ultrasound are less accurate. Prophylactic LWH is considered if additional risk factors are present.

b)

Woman should be admitted to the hospital for the course of corticosteroids and monitoring. Moderate hypertension is confirmed by BP profile; and if BP remains between 150-159 systolic and 100-109 diastolic, Labetalol (nifedipine, methyldopa as alternatives) should be started as a first line treatment, then kidney function, electrolytes, FBC, LFTs should be checked 3 times a week with BP checked 4 times a day . Birth is offered  after discussion with Consultant Obstetrician between 34 and 36 weeks (if  BP remains mild to moderate) depending on maternal and fetal condition, additional risk factors.

Consultant obstetrician and Consultant anaesthetist should be present on delivery suite  during intrapartum events, especially if delivery is by caesarean section, the senior obstetrician should be involved.

Woman should be counselled and explained the condition, risks and plan for her care.

It is important to inform The Neonatal unit; also availability of intensive antenatal care taken into account.

Chandu S Posted by Sailaja C.

 

A) 41 yrs of age, morbid obesity ( BMI 42 kg/m2) put her pregnancy under high risk.

 

 

She is at risk of developing gestational diabetes mellitus. If GDM is not identified or untreated there is risk of macrosomia which inturn associated with shoulder dystocia and birth trauma. Due to her morbid obesity she is at risk of developing macrosomia even in the absence of gestational diabetes. Screening for gestational diabetes by 2 hour 75 gm oral GTT at 24 – 28 weeks is recommended. She should be made aware of healthy eating and appropriate exercise to prevent excessive weight gain and gestational diabetes. Dietetic advice by an appropriately trained professional should be provided.

 

Nulliparity, age more than 35 years and her present BMI put her to risk of developing hypertension during pregnancy.. She should be made aware of the symptoms of preeclampsia ( head ache, visual difficulties, pain below the ribs and vomiting) to seek immediate medical advice. She should be advised to take 75 mg of asprin daily from 12 weeks until birth of the baby.

 

She is at risk of developing VTE due to the presence of two risk factors ( age > 35 yrs and obesity) which put her to intermediate risk group. Further details are obtained from history such as family or personal history of VTE, presence of medical comorbidities( eg : heart or lung disease, SLE, nephrotic sydrome) for risk assessment to categorise her risk status.

 

Expert advice is taken from trust nominated thrombosis and VTE risk is reduced by appropriate thromboprophylaxis. She is advised to avoid immobilisation, dehydration during pregnacy to reduce the risk of VTE.

 

 

She is at risk of vitamin D deficiency so advised to take 10 mcg of vitaming D daily during pregnancy.

 

Raised BMI increases the risk of spontaneous miscarrigae, and congenital anomalies. It is ideal to take 5 mg folic acid supplementation daily starting at least one month before conception continue during the first trimester of pregnancy.

 

Other fetal risks expected in this woman are prematurity and still birth.

 

 

B) She should be admitted in a consultant-led obstetric unit and managed under care of multidisciplinary team involving health care professional trained in the management of hypertensive disorders of pregnancy and anaesthetist.

 

 

She should be asked about symptoms of preeclampsia such as severe head ache, problems with vision ( blurring or flashing) , severe pain just below the ribs , vomitings and swelling of face, hands or feet. BMI is assessed. BP is recorded with an appropriate size cuff to avoid false reading.

She should be examined to assess edema, uterine height, tenderness in right hypochondriac region, and tendon reflexes. Cardiotocography is done for the assessment of fetal wellbeing

 

Spot urinary protien : creatinine ratio or 24-hr urine collection to quantify proteinuria to identify significant proteinuria if urinary protein ratio greater than 30 mg/ mmol or validated 24 hr urine collection shows greater than 300 mg protein.

Blood pressure should be measured at least four times a day. Monitioring should be carried by performing kidney function test, electrolytes, full blood count , transaminases,and bilirubin three times a week. Ultrasound fetal growth and amniotic fluid volume assessment umbilical artery doppler should carried out for monitoring of the fetus. CTG repeated weekly in the absence of complications such as vaginal bleeding, abdominal pain or maternal deteriotation.

 

Hypertension is treated with oral labetalol to keep diastolic BP between 80-100 mm Hg and systolic BP less than 150 mm Hg.

 

As she presented at 34 weeks with moderate hypertension, birth is offered at 34 to 36 weeks depending upon maternal and fetal condition. Consultant obstetrician plan regarding antenatal fetal monitoring and maternal ( biochemical, haematological and clinical) and fetal thresholds for elective birth shoudl be documented.

 

She should be assessed by obstetric anaesthetist to identify potential difficulties with venous access, regional and general anaesthesia and anaesthetic management plan for labour should be discussed and docmented.

 

At the time of admission risk assessment for VTE is done to design appropriate thromboprophylaxis with weight specific doses of low molecular weight heparin, mobilisation and avoiding dehydration.

 

Corticosteroids should be given to encourage fetal lung maturity. SCBU should be informed .

 

She should be have an assessment by a qualified professional to determine manual handling requirements.

 

Counseling for the woman should be arranged with the multidisciplinary team consisting of consultant obstetrician, neonatologist and anaesthetist to address increased risk of slow progress of labour, shoulder dystocia and emergency caesarean. High risk of anaesthetic complication and technical difficulties of caesarean section should be considered to make the decision for mode of delivery and documented.

 

Posted by ani S.

a) Being a primigravida, with a BMI of more than 42 and age of more than 40 years, she is at risk for developing hypertensive disorder and pre eclampsia. Tablet aspirin 75mg daily should be commenced from 12 weeks gestation till delivery to reduce the risk of pre eclampsia, preterm delivery and fetal or neonatal mortality. Due to her obesity, she is at increased risk for neural tube defects, folic acid 5 mg should be commenced preferably preconception and continued till 12 weeks gestation. She is also at risk of vitamin D deficiency, and should be started on vitamin D 10ugm daily preconception, throughout pregnancy and lactation. Due to advanced age, the risk for aneuploidy is increased and she should have an early scan for accurate dating of pregnancy, confrim viability and rule out anomalies. She should be offered screening for Down's syndrome using the integrated test. Diabetes mellitus is another risk for her and she should have an OGTT done between 24 to 28 weeks. If diagnosed to have gestational diabetes, she should be adviced on lifestyle modifications such as maintenance or lose weight, exercise and diet. If these are not successful, then insulin therapy would be required. The fetus is at risk of macrosomia, growth restriction, preterm birth and stillbirth. Frequent growth scans are required to monitor fetal growth as palpation and symphysiofundal height may be inaccurate. She would require an anesthetic review as she is prone for operative delivery, and might have difficulty in venous access, general and regional anaesthasia. The risk for venous thromboembolism is increased and risk assessment should be carried out at each visit and commencement of prophylaxis low molecular weight heparin when risk is significant.

b) She should be admitted and blood pressure taken using appropriate cuff. Antihypypertensive should be commenced and first line would be oral labetalol. Methyldopa or Nifedipine can be considered, taking into account their side effects. Blood pressure needs to be monitored every 6 hours with the aim of keeping the blood pressure less than 150/80-100mmHg. Investigations such as full blood count, urea and electrolytes, creatinine, uric acid and liver function test including 24 hour urine protein is taken. The fetal monitoring using cardiotocograph on admission, and ultrasound for fetal growth, liquor volume, umbilical artery doppler. If the blood results and fetal monitoring are normal, then the blood investigation would need to be repeated 3 times a week. If not, the blood investigations should be repeated more frequently. If the platelet is less than 100,000/dL, clotting profile should be sent. The fetal monitoring should not be repeated if it is normal unless there is abnormal fetal movement, vaginal bleeding, abdominal pain or deterioration in maternal condition, wherein a CTG is repeated. As she is admitted, her risk factor for venous thromboembolism is increased and she should be commenced on prophylaxis low molecular weight heparin. If delivery is anticipated, then a course of steroids should be given to reduce the risk of neonatal respiratory distress. A multidisciplinary team consisting of a consultant obstetrician, anaesthetist, neonatologist and specialist midwife should be involved in her care. If there is deterioration in maternal condition, worsening of blood investigations or fetal indications requiring delivery, it should be done at an appropriate time and place where there are adequate staff and expertise, with suitable operating table, maximal neonatal support and mode of Caesarean section.   

Posted by Sweta P.

a)

Presence of Obesity and advanced maternal age makes this pregnancy very high risk and hence antenatal care should be consultant led.She should have a early dating scan to ascertain accurate expected date of delivery. She is at high risk of trisomy hence combined or integrated screening should be offered which have greater sensitivity and specificity depending on the local availability. Obesity  per se is high risk for congenital malformations, especially neural tube and cardiac defects, hence detailed anomaly scan at 18-20 weeks should be undertaken including cardiac echocardiography. She is at high risk of developing pregnancy related hypertension including pre-eclampsia/ eclampsia hence close monitoring on blood pressure and urinalysis especially in third trimester is warranted. Low dose aspirin may be started to decrease the risk of developing the above complication. She is at high risk for gestational diabetes  hence GTT should be done around 28 weeks. She is also at a high risk of venous thromboembolism because of obesity hence there should be a low threshold to start thromboprophylaxis in the presence of other risk factors. Fetal growth restriction should be excluded by serial growth scans depending on the unit protocol. She should be seen by the anaesthetist in view of her obesity as there may be difficulties in getting intravenous access, siting epidural and intubation for general anaesthesia in labour in case the need arise. The on call obstetrician and anaesthetist should be informed once she arrives on labour ward in labour. She should have a continuous electronic fetal monitoring, with an FSE if needed, to detect any fetal distress early. The staff should be aware and ready to deal with shoulder dystocia and 3rd/4th degree tear that might occur during delivery. Postpartum thromboprophylaxis should be commenced to prevent venous throboembolism. Consider antibiotic prophylaxis for 5-7 days if she had a caesarean section to decrease the likelihood of wound site infection.

 

b)

This patient has presented with severe pre-eclampsia at 34 weeks hence inpatient admission is warranted. Symptoms of  severe pre-eclampsia like headache, visual disturbance, epigastric. right upper quadrant pain and vomiting should be enquired into. fetal wellbeing in the form of fetal movements should be enquired into. Her case notes should be reviewed to ascertain the booking blood pressure and assess her antenatal period. Growth scans, if any done, should be reviewed. Serial monitoring of her blood pressure should be done using the appropriate size cuff and spot protein-creatinine ratio should be done or 24 hours protein assessment should be commenced to quantify the proteinuria. Deep tendon reflexes and clonus should be looked for. Abdominal examination to elicit epigastric/ right upper quadrant tenderness and to assess fetal size should be done. Fetal assessment in the form of  cardiotocographic monitoring should be commenced. Fundoscopy should be considered if severe headache present to rule out raised intracranial pressure. Blood should be tested for hemoglobin levels, platelet count to rule out thrombocytopenia. If platelets less than 100X 10 9. coagulation tests should be done. Liver function tests and renal function tests should be done to exclude involvement of these organs with the pathology. If her blood pressure remains high, antihypertensives should be commenced int he form of either labetalol, nifedepine or methlydopa. SHe should have her blood pressure monitored every 1/2 hr till her BP settles after which 4 hourly monitoring must be commenced. Corticosteroid therapy should be considered if delivery is anticipated. Ultrasound should be done to assess fetal biometry (AC, EFW), fetal well being (AFI,uterine artery  Dopplers) and presentation. Her risk of venous throboembolism should be assessed and thromboprophylaxis should be commenced if deemed to be high risk. Her care should be undertaken in a multidisciplinary team involoving the midwife, obstetrician, anaesthetist and neonatalogist. In case  of worsening maternal symptoms, blood parameters and suspicion of fetal distress, delivery should be anticipated. Mode of delivery should be discussed with the patient. Induction of labour is an option if the fetal presentation is cephalic. Magnesium sulphate should be started if worsening pre-eclampsia to prevent eclampsia. Complications of pre-eclampsia, such as eclampsia, HELLP, liver capsule rupture, placental abruption should be watched out for.

Essay Posted by Dhivya C.

 

A. This woman with high BMI is at increased risk of maternal morbidity and mortality. This is a high risk prgnancy and she should have consultant led care. 

The antenatal risks associated with this pregnancy include folic acid deficiency and vitamin deficiency. I would make sure that she is on folic acid 5 mg daily during first trimester and vitamin D supplementation during pregnancy and breast feeding. Dietician involvement would help her to take a balanced diet and manage her weight during pregnancy.

Getting good quality images with Ultrasound scan for dating and to assess growth would be difficult. Women with high BMI are at increased risk of having baby with congenital abnormality. Arranging anomaly scan would help to rule out major structural anomalies. I would also offer her screening for Downs syndrome. But I would explain to her that if the results of screening comes back as high risk then doing the diagnostic tests like chorionic villus sampling or amniocentesis might be difficult.

She is also at increased risk of having hypertension, diabetes and venous thromboembolism. Checking BP and urine with every visit would help to identify high blood pressure early and manage accordingly. Glucose tolerance test should be arrange for her. Advice about mobilisation and avoiding dehydration helps to avoid venous thromboembolism. I would consider antenatal clexane if she develops any other risk factors for venousthromboembolism during pregnancy.She should receive clexane for 7 days even though she has a normal vaginal delivery.

Due to high BMI monitoring fetal growth would be difficult. I will arrrange for her to have scan at 28 and 34 weeks for fetal growth and liquor.

This lady is at high risk of having anaesthetic problems like difficulty in inserting epidural or spinal, difficult intubation and cannulation. Referring her to aneasthetist would help them to assess her and plan things before she comes in labour.

She is also at increased risk of having instrumental delivery, caesarean section, big baby, shoulder dystocia and post partum haemorrhage. When she presents in labour I would inform midwife, anaesthetist and the consultant obstetrics.  

Making sure that facilities are in place to lift the patient would help to avoid manual handling issues.

B. She is having moderate pre eclampsia. I would get history from the patient about headache, blurring of vision, epigastric pain and pedal or hand edema. I would also check about fetal movements.

Examination of abdomen should include ant abdominal tenderness, liver tenderness and checking reflexes to rule out clonus. CTG should be done to check fetal well being. Request blood s for full blood count to rule out thrombocytopenia, Liver function tests and renal function tests, Clotting screen and urates. I will also send 24 hour urine collection for estimation of proteinuria.

I would admit the women, start her on oral labetalol to control her blood pressure. As she has got 4 risk factors for venousthromboembolism ( increased maternal age, high BMI, pre eclampsia and immobilty) I would start her on prophylactic clexane dose adjusted according to her weight.

I would arrange for her to have a growth scan if she didnt had any scans over the last 2 weeks to check her fetal growth. While she is in the hospital I would check her BP atleast 4 times daily and repeat bloods for FBC, U&E, LFT and urates 3 times a week.

If the blood presurre is well controlled with anti hypertensives and if there are no fetal concerns, then induction of labour should be planned after 37 weeks.

But if the blood pressure is severe ( >160/110 mm Hg) not controlled with anti hypertensives and if she is <37 weeks gestation, I would discuss with the women for immediate delivery after a course of steroids once BP is controlled.

 

obesity Posted by aliya N.

She is at increase risk of antenatal, intrapartam and postpartam cmplications because of her increase BMI, in addition having a first baby at 41 is also of concers.

She is at risk of maternal complications like hypertension ,pre eclampsia, gestational diabetes, venous thromboembolism.for all of them proper screening with identification of problem early with appropiate management is required.BP monitoring should be sterted by CMW from 24 weeks twice weekly and after 28 weeks weekly and she should be send to day assessment if BP at any time is more than 150/100 mm hg for further assessment,

sceening of diabetes should be done at 28 weeks bt GTT

Her risk  for VTE must be assessed if she is admitted at any time anrenatally ,reassessed after 24 hours of admisson and when she comes in labour the dose must be calculated according to her BMI.

There is increase risk of fetal anomalies which can be detetced at 20 weeks scan , however further mx will depend upon the anomaly and there is no intervention in pre which can prevent i she is at.increase risk of aneuplody because of her age however the results of serum screening  should take in account her BMI. The fetal risks include increase risk of having NTD which can be prevented by giving folic acid 5mg day,deficiency od vitamin D is also common so 10 microgm of vit D is recommended.

Regarding the risk of having IUGR she needs serial growth scan

monitoring by SFH or by us is difficult and it must be considered

problems with anasthesia and iv access must be assessed by anas consultation,

maual handling issues also need to be adressed and to prevent them all of the dept taking care of her includind d suit ,tissue viabilit theatre staff, y must be informed and proper communication and documentation abd plan of care must be there.

In fact, all of her risks can be reduced by proper preconcep counselling, however there is no indication of wt reduction steps in pregnancy.

B,She should be assessed by taking a history of PE like hypertension, v dist., epigastric pain, PET bloods must be sent like FBC,U&E, LFT urate and UPCR. she should be exam for clonus and reflexes also.

A plan of mx than should be made if she is at low risk with only hypertension she can be stared with with antihypertensive and after 24 hours of molnitoring can be fup with CMW with assessment regularly at DAU. If she is diag as having PET because of symtoms , abn bloods, or inc UPCR, she needs admisson withantihypertensive and repeat monitoring of bloods,

Furthe mx will depend upon BP ,bloods SYmptoms Fetal wellbeing, steriods be given if delivery is anticipated, IOl can be condered if develops PET, monitoring in labour can be difficult may need FSE early ,C/s only for obs reasons ,consultant obs and anas must be there , drain in abd and rectus sheath and clips or interrupted in skin

postnatally assess for VTE and problems with breast feedingand refer to dietician

.

answer to essay 349 Posted by rimpi D.

a)the woman should be counselled regarding delivery in consultant led unit with multidisciplinary facilities due to her risk factors of age and category 3 obesity.she isinformed that she is high risk for aneuploidy and miscarriages as well. the risk of downs syndrome at her age is approx 1 in 100. she should be offered NT measurement by scan and combine test using NT and bhcg and PAPP-A as NT alone may give difficulty in measurement due to obesity.s should be emphasised regarding he should be reffered to tertiary clinic for CVS (11-13) wks and amnioscentesis at 16-19 wks if screen test show high risk.she also has 3 moderate risk factors for preeclampsia, age>35y, nullipara and obesity,so low dose aspirin prophylaxis of 75 mg from 12 wks till delivery should be given which reduces risk of preeclampsia of10% and preterm of 10%.she should be emphasised regarding regular scheduled antenatal check up with BP and proteinuria check up.also early referral to specialist dietician to be made as she is at high risk of developing glucose intolerance,GTT should be done as per local protocol.she is also high risk for developing VTE , so thromboptophylaxis assesment to be done at antenatal ,in case of any admissions , in labor and puerperium and LMWH should be given as per protocol, she be advised regarding good hydration , TED stockings and mobilisation.she is high risk for developing IUGR , so serial growth scan from 24 wks 4 weekly apart from the 20 wks anomaly scan to be done.

b)the history of the patient including headache, epigastric and right hypochondriac pain,pedal edema,oliguria  and their duration tobe elicited, any family history of preeclampsia should be asked.any history of antihypertensives and the duration of start to be enquired. examination will include BP measurement by using appropriate cuff size and correct positioning . present BMI to be measured.abdominal examination including SFH (may be inaccurate due to obesity), lie and presentation to be done,look for any epigastric or right hypochondriac tenderness.fetal assesment with CTG and ultrasound for liquor volume, fetal growth with umbilical artery doppler to diagnose IUGR to be done. investigations including 24 hrs urine protein,FBC,RFT, LFT, uric acid, coagulation prolfile to be sent. antihypertensives as labetalol/methyldopa to be started as per hospital protocol. if there are signs of imminent eclamosia like exaggerated knee jerk, epigastric pain or severe headache, magsulf to be started.corticosteroid dose to be given as early delivery is expected.ultimate atreatment is by delivery by vaginal or cesarean mode depending on maternal conition, cervical status and fetal condition.

Posted by H H.

XXXXXXX

 

 

This patient is at increased risk of miscarriage due to her age and her type III obesity(morbid obesity). There is no way to reduce this risk at this time.

She is at increased risk of chromosomal anomalies, with Down syndrome risk of >1 in 100 women at term. She will need to have screening tests for down ,taking in consideration that her obesity might affect serum screening tests,and the difficulties encountered on doing ultrasound scans.Trans vaginal scan will be more accurate.

She is at increased risk of congenital malformation.such as limb aplasia,neural tube deffects and cardiac anomalies. These should be screened for by the 20wk anomaly scan at a fetal medicine unit. Gastroschesis is however reduced. Theas risks can not be reduced at this pregnancy , but prenatal counseling to reduce weight before her next pregnancy might help.

She is at increase risk of gestational diabetes (GD) in this pregnancy. She should be screened for GD at 24-28wk gestation. If found to have GD, control will be by diet first and if this is not effective within 2weeks or there is fetal macrosomia, insulin control will be needed. These measures are done in a conjoint diabetic clinic.

She is at increased risk of pregnancy induced hypertension and can develop pre eclampsia. She needs her blood pressure to be monitored . BP measured at booking ,and monitored at each clinic visit with an appropriately fit BP cuff.

As this patient at risk of pre eclampsia(41y old, first pregn, BMI 42) . Low dose aspirin 75mg daily from 12wk till delivery will reduce her risk developing pre eclampsia.

She is at increased risk of venous thrombosis. This should be reduced by following local guidelines and protocols for reduction of VTE. Avoid dehydration and immobility, allow her to mobilise and be well hydrated. TEDS stockings will help if performing any procedure that involve immobility. Watch for other risk factors for VTE ,and accordingly give low molecular weght heparin in conjunction with the hematologist.

She is at increased risk of fetal macrosomia, and this can be reduced by early detection by fetal growth scan and control of GD .

 

 

2)

She has moderate pre eclampsia. She will need admission till delivery. Will ask her if she has associated ,nausea,vomiting,headache,visual disturbances or epigastria pain,all these point to impending eclampsia . I will examine her for BP with appropriate cuff,and repeat this in 4hr. Her BP will be monitored every 6hr if conservative management decided.I will test reflexes. I will do abdominal exam for tenderness,rigidity, fundal level and measure symphyseal fundal level. Will do an admission CTG , will take urine for spot protein /creatinine ratio and urine tests are not repeated if proteinuria is confirmed.Will take blood for FBC, urea and electrolytes,liver function tests and clotting screen,and these are repeated 3 times per week if conservative management is decided.

I will start controlling her BP using oral La betalol and if this is not effective will give intravenous according to local protocolls.

Will order a scan for fetal growth,liquor volume and umbilical Doppler blood flow and this will be repeated every 2wk if conservative management.

Will inform the consultant and put a plan for fetal monitoring,time of giving steroids, pediatrician to see and anesthetist to see.

Will aim to induce labour and aim for vaginal delivery unless there is obstetric indication for cesarean section,at 37 wk. Earlier induction done if ,her BP is not controlled, fetal compromise, patient has symptoms and signs,HELP syndrome, eclampsia or abnormal laboratory biochemical results.

Patient is given written and verbal information about her condition and the possibility of pr term delivery with associated risks to her and her baby. These information should be given in a multidisciplinary maner including talking to the neonatologist, anethetist ,senior midwife and obstetric consultant.

 

essay 349 answer Posted by Nabila A.

Advanced maternal age at conception is associated with several adverse outcomes....there is increased risk of spontaneous pregnancy loss(50 percent in females more than 40 years of age,risk of aneuploidy sharply rises after 35 years of age.Also ther is increased risk of ectopic pregnancy.the stillbirth rate  increases after 30 years ,moreover it is slightly higher in nulliparous .women older than 40 years of have double the risk of pre-eclampsia as well as primiparity is associated with 2 to 3 fold increased risk of pre-eclamsia.Older women are also at risk of having medical co-morbidities such as pre-existing hypertension,diabetes mellitus which complicates the situation further.

This particular patient with   

rest of the answer 349 Posted by Nabila A.

This particular patient with BMI more than 42kg/m 2 is categorized as morbidly obese .There is evidence of association between maternal obesity and increased risk of fetal structural anomalies e.g neural tube defects,spina bifidacardiovascular anomalies ,cleft lip,cleft palate,hydrocephalus,limb reduction anomalies.Mother is at risk of developing gestational diabetes,hypertensive disease,fetal macrosomia and its attendant intrapartum as well as postpartum comlications,venous thromoembolism,vitamin deficiencies.

this high risk mother should be referred to the consultant obstetrician for specialist management in liasion with the nutritionist who could advise about the necssary dietary changes so as to limit  weight gain to the minimum level.Further risk factors to be explored from the family histor of pregnancy induced hypertensive disease.Regular monitoring of the blood pressure with appropriately sized cuff ssphygmomanometer and proteinuria ,weight ,offering aneuploidy screening with appropriate counselling ,anomaly scan  20 weeks,growth scans after 28 weeks would assist in early detection of hypertensive disease or fetal growth restriction  which allow early intervention .Folic acid 5mg supplementation to be ideally started prepregnancy should be continued throughout first trimester.Vitamin D supplements may be required.Low dose aspirin shows 15 percent reduction inincidence of preeclampsia..it shold be commenced before 12 weeks gestation and continued throughout delivery.metaanalysis also shows 1 gm of calcium showed 50 percent reduction in preeclampsia.Oral GTT at 24 -28 weeks will help detect gestational diabetes and early intervention.

She will be admitted for assesment and further managementi.e screening for pre eclampsia,treatment of hypertension,fetal surveillance,decision about prophylaxis of preeclampsia as wellas decision for timing of delivery.Her b.p  measurement repeated as well as the proteinuria will be confirmed by collecting 24 hr urinary protein or protein creatinine ratio is measured.Enquiry should be made about symtoms of preeclampsiai.e headache,epigastric pain ,visual disturbances.Regular check ups serum urea and creatinine,uric acidhemoglobin,platelet count and thromocytopenia then coagulation screen,LFTs .Most clinicians will tear at levels more than 140-160 systolic and diastolic .>90-110.Treatment is mandatory  if b.p is .>or =160/100.Good control of blood pressure is necssary but it shoul not preclude the definitive  management i.e delivery if this is indicated for maternal resons (HELLP syndrome or another crises aseclampsia ,pulmonary edema,abruption ,cerebral hemorrhage,DIC,renal failure,,rapidly worsening biochemistry or fetal reasons ..fetal distress,severe FGR,reversed umblical artery flow)which will be indicated by regular ultrsound examination of the fetus  to assess growth ,liquor volume umblical artery fow on doppler ultrasound.Antenatal steroids would be considered if delivery is necessitated preterm.Magnesium sulphate prophylaxis fro the prevention of seizuers should be employed after assessment of the signs and symptoms of severe pre-eclampsia as well as taking into account the biochemistry results.intensive fetal monitoring is required as fetus is at increased risk of distress secondary to placental insufficiency.Discussion with the anaesthetist is esstial to plan the course of action during delivery with carefull assesment by the consultant anaesthetist .For the opertive delivery either vaginal or caesarean section ,consultant obstetrician should be present.

Obesity,Pre eclampsia----349 Posted by lamia T.

a)This patient is elderly primigravida and morbidly obese,so we should decide first where she should be followed up.Management in specialist obesity clinic is not feasible always,so we have to arrange multidisciplinary team management by consultant obstetrician,obstetric anaesthetist,midwifery service,specialist nurse,special trained person in manual handling device and tissue viability issue.

In antenatal assessment she is in increased risk of developing gestational DM,hypertension,pre eclampsia,venous thromboembolism,vitamine deficiency specially folic acid and vit D. Her foetus is having more chance of congenital anomaly-downs syndrome(1:100 chance),neural tube defect,macrosomia,miscarriage,prematurity,birth trauma,stillbirth,neonatal death,poor ultrasound visualization,admission in SCBU,obesity in childhood.

She should be counseled not to gain too much weight during pregnancy.She should take tablet folic acid 5 mg in first 12 weeks,vit D 10 mcg daily throughout pregnancy.

Now she is at 10 weeks,so all the booking blood test should be done.At booking visit her blood pressure should be checked with adequate size cuff and recorded accordingly. In her all antenatal follow up BP should be measured and after 20 weeks gestation urinary protein should be checked at every visit.For the risk of pre eclampsia she should take 75mg aspirin daily.

For gestational DM 2 hr 75 gm OGTT at 24-28 weeks should be done.Her family history,ethnicity will help to detect her risk.

She is 41 years old,so for screening of downs syndrome serum integrated test can be done.By usg we can detect neural tube defect,congental anomalies.

Age 41yrs ,BMI 42kg/m2,pregnancy these are her risk factors for venous thromboembolism.So plan should be taken to start LMWH .Duration will be decided after taking her history and  relevant investigations.

During intrapartum care there is risk of slow progress of labour,instrumental delivery,need for caesarean section,shoulder dystocia,anaesthetic complication,intrapartum monitoring difficulties,PPH,wound infection.There should be continuous midwifery care.Special equipment –manual handling device,operation theatre arrangement,OT bed,side elongation device,trolly everything should be arranged before.Consultant obstetrician,ST6 level anaesthetist,neonatologist should be present during labour.Third stage should be managed actively,prophylactic antibiotic,proper venous access should be maintained.

 

b)  The patient is having BP 155/105 mm of hg,2+ proteinuria at 34 weeks,so she is diagnosed as pre eclampsia with moderate hypertension.She should be admitted in hospital under level 1 care.

First we have to control her BP with oral labetolol to keep diastolic BP 80-100mmof hg and systolic BP<150mmof Hg.Nifedipine,methyldopa also can be used.In inpatient care BP should be measured 4 times a day.Blood test-RFT,LFT,FBC,Electrolytes should be done 3 times a week,no need to repeat quantification of proteinuria.

Multidisiplinary management plan should be taken with consultant obstetrician,obstetric anaesthetist,neonatologist,specialist midwife.

She should be informed about the warning signs like blurring of vision,vomiting,severe headache,epigastric pain,sudden swelling of face,hands and feet.She should inform if she is having any of these symptoms.She should be managed with iv magnesium sulphate if there is signs of impending eclampsia.Uterus should be palpated to exclude tenderness due to abruption.

Adequate thromboprophylaxis with LMWH both antenatal and postpartum 6 weeks,TEDstockings should be prescribed for her.

Plan for birth should be taken between 34+0-36+6weeks depending on her and foetal condition,risk factors,availability of neonatal services.If planned for delivery then corticosteroid should be given.For foetal monitoring  CTG should be done at diagnosis and no need repeat more than weekly if no indication.In case of vaginal bleeding,deterioration of maternal condition,reduced foetal movement,abdominal pain CTG can be repeated. Ultrasound fetal growth , amniotic fluid volume assessment , umbilical artery doppler velocimetry should be done at diagnosis and no need to repeat more than 2 weekly.Foetus is having more chance of IUGR.Consultant obstetrician should be informed in any abnormal reports.Patient sould also take part in decision making and written information should be given.If blood pressure is well controlled,foetal condion normal then plan for can be taken after 37 weeks.

Obesity Posted by HAnaa B.

A

Being 41 years old as Primigravida would increase her risk of getting child with congenital anomalies, and increase her risk of getting child with chromosomal abnormalities such as aueplodies in relation to the general population to 1 in 100.

Patient should be offered serum screening for anueploidy in her gestational age to assess her risk, include maternal alpha feto protein, estradiol and BHCG result is much reduced in MOM in relation to the general population but increased in cases of open lesion of the neural tube.

Early dating of her pregnancy through transvaginal us to asses date, major anomalies that can be detected as early as possible at that age like anencephaly and cystic hygroma.

In case of abnormal results the invasive test for detection can be offered like CVS. Through vaginal route of abdominal route to get sample from the placental tissues, sent for culture of cells, risk of miscarriage is 1-2 %, infection is one of the complications of the procedure, should be done in tertiary care.

NT scan can be done from 11-13+6 days to  normal values less than 4 mm, difficult due to body habit.

Amniocentesis can be offered later in pregnancy 14 weeks, introducing needle and getting fluid sample from around the baby, risk of miscarriage less than 1%, result would take 2 days risk of infection should be discussed.

Being morbidly obese is classifies as category 3 obesity would also increase her risk of diabetes, hypertension and preeclampsia, difficult delivery with shoulder dystocia, preterm delivery , operative delivery, miscarriage , difficult diagnosis of fetal anomalies in scan, risk of infection specially wound infection  post operative , difficult interpretation of lab results in serum screening, psychological impact ,VTE from being immobilized long time  and cardiac diseases, macrocosmic baby.

Although the problem of obesity should be dealt with in the preconception clinics before imparking on pregnancy but such patient should be helped to reduce her risk of problems by sensitive approach to her situation by experience physician, referral to the obesity clinic shared with antenatal clinics , clinical nutritionist should design her food and life style activity and caloric need during pregnancy.

It should be a continuous process of encouraging her to lose weight and get a healthy baby, her diabetic status should be assisted by 2hrs GTT, her blood pressure should be monitored carefully by using the appropriate culf size to her arm, anesthesia consultant should be are of her situation,

Her thyroid status should also be assisted.

B

Once diagnosed as hypertensive with 2+ protinuria, she should be admitted to the hospital , health care professional trained in hypertension disorders of pregnancy should assess her , no need to repeat protinuria, blood pressure should be measured 4 times a day, labetallol is the oral hypertensive medication , informed consent should be taken upon introduction of the medicine with information about its side effect, blood pressure should be kept less than 150/80-100, test for kidney function, electrolytes FBC, transamineses, and bilrubin 3 times a week should be done . Fetal monitoring should be carried out by ultrasound fetal growth, amniotic fluid volume and umbilical artery Doppler. If any result came be abnormal consultant should be informed. Repeat of the fetal wellbeing tests should be repeated in case of conservative management as when blood pressure settle down  and no need to deliver the patient ,

CTG should also be done once diagnosed and to be repeated weekly or if deterioration, vaginal bleeding, change of fetal movement or abdominal pain occur.

Timing of delivery depends on the situation and the availability of neonatal intensive care. Course of steroids should be completed.

Route of delivery is depending upon bishop score and stability of the patient general conditions, induction of labor or CS During the timing of design of delivery.

Encourage ambulation and diet in take to help decrease her risk of VTE during bed rest.

 

Plan of care should be written clear in patient notes including timing and nature of fetal monitoring, fetal indication of birth when to give steroids, discussion with neonatogist and anesthesia. HDU stuff and Operative room stuff should also be aware of her presence  

adil Posted by Adil H.

A 41 year old woman has been referred to the antenatal clinic at 10 weeks gestation in her first pregnancy. Her BMI is 42 kg/m2. (a) Discuss the antenatal risks associated with pregnancy in this woman and how these risks can be reduced [10 marks]. (b) She is referred to the assessment unit at 34 weeks gestation because her BP is 155/105 mmHg with 2+ proteinuria on automated testing. Discuss your antenatal management [10 marks].

a) There is increased risk of miscarriage, congenital anamolies, gestational diabetes , preeclampsia, and eclampsia owing to increasing maternal age, nulliparity and BMI 0f 42 Kg/m2 . She has a increased risk of iatrogenic prematurity, and thromboemblism, increased risk of intrauterine death and unexplained birth. There is risks of aneuploidy and Downs syndrome which more than 1 in 100. The complications of prophylactic thromboembolic therapy like increased risk of heamorrhage, abruption should be kept in mind.

A careful planning of pregnancy labelling her as High risk, involving multidisciplinary team like the consultant obstetrician, medical specialist , diabetic specialist, aneaesthesiologist , atleast SPR 4 and above, to review the patient , in addition genetic counsellor , and a trained midwife to present information and counsel regarding the combined test or integerated test which is recommended for screening of Downs Syndrome. Her refferal to be arranged to fetomaternal unit early incase of screen positve and arrangement of early refferal for CVS or Amniocentesis whichever appropriate, keeping in view of parental wishes. She should be screened for PIH and placed on low dose asprin 75 mg daily from 12 weeks onwards in view of her risks and at every visit should be checked for raised blood pressure and proteinuria .  She should be offered a diabetic screen by OGTT at booking and if negative then at 28 weeks. A refferral to the dietician is important and anamoly scan at 20 weeks and early ultrasound booking scan at 12 weeks would be most appropriate to detect aneuploidy. During the pregnancy third trimester she should be seen by the aneasthetist and and hdu and operation theatre staff for making appropriate arrangements ie plrovision of special OT tables making arrangemets for equipmet handling to accomodate the lady. 

b) The lady should be admitted to the high dependency unit, started on prophylactic magnesium sulphate i/v prophylactic doseage ( Magpie trial) , with strict BP monitoring every 4 hours, restriction of i/V fluids sending of bloods for Urea and electrolytes, liver function tests, FBC to check the platelet levels, 24 hour urinary proteins, PT/ APTT, she should be seen by the medical specialist , consultant obstetrician and consultant anaesthetist, and neonatologist. A joint plan should be chalked out , Blood pressure to be controlle dby addind Labetalol  , and if cannot take oral then I/V. Steroids should be administered and if she is stabilized then may continue for 48 hours or more if in dicated other wise urgent C. Section after 48 hours . One must stop LMWH 24 hours or may be at the time of addmission in the preview of early delivery.A high risk consent to be taken from the lady in view of complications of caesarean section and premature delivery.  A bed in SCBU to be arranged and if not possible then then transfer in utero to the specail care unit.

Postanatly keep admitted in the HDU , early mobilization give therapeutic dose adjusted to weight of LMWH 4 hours after surgery. Donot remove epidural catheter with in 12 hours of the last dose and cannula with in 24 hours of the last dose. Check blood pressure every 4 hours during HDU admission and maintain MEOW charts. Tlransfer to ward care when stable and check bP and proteinurea , stop Methyl Dopa if give. dischrge when stable . There in increased risk of wound infection due to obesity continue to provide extra care by involving community nurses check , BP daily for one week to 10 days if does not return to normal then arrange medical review after 6 weeks. Arrange dietician review and encourage to excercize and breast feed though it may be difficult. 

Give contraceptive advice and arrange debriefing. Send incident report with in 24 hours of the delivery . 

 

 

 

 

 

Posted by BHAWANA  P.

She is at high risk of miscarriage, structural and chromosomal abnormalities, pre-eclampsia/pregnancy induced hypertension, diabetes, difficulty in screening especially measuring nuchal translucency because of raised BMI and invasive testing can be difiicult as well, difficulty in doing anomaly scan and more chances of missing anomalies,anaesthetic problems of getting IV access,more regional and general anaesthetic complications. She is also at more risk of having intrauterine growth retardation of fetus, intrauterine death, still birth, increased pre-term birth ( both natural and iatrogenic),dysfunctional labour and increased chances of caeserean section.

To minimise risks she should be booked under consultant led care. She should be given folic acid 5mg uptil 12 weeks to minimize risks of neural tube defects. She should be given vitD 10mcg throughout pregnancy and lactation as she is at risk group of Vit D deficiency.She should be given aspirin 75mg from 12 weeks until delivery to minimise risks of PET.She should be given advise to optimize weight but weight loss is not recommended in pregnancy. Referral to dietcian should be made and adequate advice for diet and exercise should be given.GTT will be arranged between 26-28 weeks for gestational diabetes.Referral to anaesthesist should be done for discussing anaesthetic difficulties.growth scan will be arranged at 28 and 34 weeks  as IUGR can be missed in big BMI but she should be made aware that scan accuracy  also declines in big BMI. Regular B.P and urine check should be done at every ANC check and 3 weekly with community midwife from 28 weeks onwards to detect PET/PIH.I nduction of labour can be offered at term with discussion with patient and cervical and abdominal assessment and fetal factors.

As she is having mderate to severe hypertension, I will admit her and give her oral labetalol as first line treatment.If this is not effective, oral nifedipine, Iv hydralazine, Iv labetalol can be given after Iv access.I will do clinical assessment for severity of signs and symptoms like frontal headache,visual disturbances, pain under ribs, reduced fetal movements and examine her for symphsio-fundal height,epigastic tenderness,brisk reflexes and clonus.I will  do strict monitoring of her input/output and insert urinary catheter and restrict fluid to 80 ml/hr.I will send bloods for full blood count, transaminases,bilirubin and renal function tests to assess severity and diagnose complications.I will do quantification of proteinuria by doing PCR.I will do B.P monitoring 4 times/day and inform consultant.CTG monitoring to rule out acute fetal distress, USG for growth and doppler will be done on admission. Same day delivery should not be planned and fetal and maternal threshols for delivery should be documented by consultant in the notes.Steroids will be give for fetal lung maturity and neonatologist will be informed in case early delivery is needed. I will inform anaesthesist in case intense monitoring like CVP, arterial line and HDU care is needed.

If blood pressure settles,inpatient management with B.P measurement 4 times a day, thrice weekly bloods will be repeated, proteinuria need not be quantified unless clinical indications, doppler and growth scan in 2 weeks. CTG only if reduced fetal movements, PV bleeding/abdominal pain will be indicated.  I will deliver after 37 weeks but will consider delivery between 34- 36 weeks if indicated.

Essay 349 - Ans Posted by Chetna K.

Answer a) Antenatal  risks :

This is obviously a high risk case due to her first pregnancy at advanced age with class 3 (morbid ) obesity. Both mother and fetus will be at high risk. Maternal risks involve risk of spontaneous miscarriage, neural tube defects , chromosomal abnormalities and other congenital anomalies, difficulties in screening anomalies, and monitoring fetal growth clinically and radiologically both . Risk of hypertensive disorders and gestational diabetes will be high as well as placental abnormalities like placenta previa. Risk of spontaneous and iatrogenic preterm labour, , fetal loss is there. Fetal risks involve chromosomal and congenital abnormalities, prematurity, low birth weight, growth retardation or macrosomia depending on the pathology predominating.

All these risks can be reduced by modifying her antenatal care to optimize both maternal and fetal outcome. This will be by early booking in consultant’s unit, advising folic acid 5mg/day and Vitamin D 10 mcg/day, screening for  diabetes at booking visit, screening for hypertensive disorders at each visit (routine antenatal care), frequent and intensive fetal monitoring by ultrasound scans, assessing risk factors for thromboembolism at first visit, referring her to the dietician or nutritionist for dietary and exercise advice, referring to obstetric anesthetist  who will counsel and inform her regarding difficulties of venous access, epidural siting , general anesthesia and its risks .She should be counseled by a qualified health professional regarding the risks involved to her and her fetus. Her BMI should be recorded again during 3rd trimester, and her risk of thromboembolism assessed at each visit  and prophylaxis started accordingly. She should be assessed by a qualified heath professional regarding the equipments( including lateral) that will be required for manual handling. Finally a detail obstetric and anesthetic  management plan must be outlined and clearly mentioned in the information system or her hand held notes which she should be carrying at all times.

Answer b)  She is diagnosed to have moderate pre- eclampsia, her proteinuria should be quantified by either spot urine protein: creatinine ratio or 24 hour protein excretion.Her BMI should be recorded again and risk revised for thrombosis.She should be admitted and started on oral labetalol, and her BP monitored atleast four times daily. Aim should be to keep her SBP< 150 mmHg and DBP at 80 – 100 mm Hg, blood tests f or FBC, Renal function tests, transaminases, bilirubin , U & E done and repeated  on alternate days .Fetal monitoring by CTG should be done on admission and if normal should not be repeated before one week, scan done for fetal growth, amniotic fluid volume and umbilical artery Doppler velocimetry and if normal should not be repeated before 2 weeks. Any abnormal finding should be informed to the consultant obstetrician, her care plan should be outlined along with anesthetist and neonatologist regarding the thresholds for induction of labour or operative delivery . Accordingly steroid administration should be planned and depending on the control of BP, laboratory parameters, availability  of neonatal care unit, delivery should be planned.

nee my answer Posted by nee P.

             This is morbid obesity. Obesity in pregnancy is associated with increased maternal mortality & morbidity. She is at risk of developing complications like gestational diabetes. She is also at risk of developing hypertensive disorders as BMI above 35 kg/m2 . As far as her obstetric outcome is concerned, she is at risk of developing miscarriage. It is seen that obesity is associated with increased miscarriage rates. She is at risk of nutritional deficiencies 7 low folate levels & as consequence of this congenital anomalies like neural tube defects & cardiac anomalies will be more.She is also at risk of preterm labour either iatrogenic or spontaneous because of obesity/comorbidities.

               The risk can be reduced by integrated approach as there are no obesity & pregnancy clinics.Follow up to be arranged in consultant led unit. If she is on antihypertensive agents like ACE inhibitors Or on statin , stopping these agents prepregnancy/in early pregnancy to help reduce congenital anomalies. Having policies in the unit to treat obesity & associated complications. Multidisciplinary approach involving ditecian, for stressing importance of healthy eating & involvement of physian if comorbidities are there. Supplementing foloic ace 5 mg prepregnancy/early pregnancy to reduce risk of neural tube defects.Availability of large size cuff for B.P measurement or having fascilities like chair without arms & the hospital & Operation theatre well equipped to handle obese patient load. If she has additional risk factors to have low threshold to start low molecular weight heparin.As 20week scan visibility may be poor in obese patients, the risk to be explained to the patient & having repeat/further opinion scan.Having anesthetic review is very impoetant in this patient to help reduce intraop complications.

 

            This is moderate pre eclampsia. She should be admitted for assessment. Her investigations like 24 hour urine protein/protein creatinne ratio. Taking BP measurement four times a day. Sending liver function tests, renal function tests, Full blood count on admission & repeating blood tests two times a week. Advising CTG on admission & then once a week. Taking ultrasound Doppler for fetal elbeing & repeating every two weeks . Monitor for signs & symptoms of severe preeclampsia like intense headache, pain below ribs , flashes of light in front of eyes, sudden swelling all over body.  Decision to deliver if fetus under compromise or if maternal conditions worsen or if bleeding pervaginum noticed . Role of steroids antanatally for fetal lung maturity.Involvement of consultant anesthetist & consultant obstetrician for for operative delivery

essay 349 ans Posted by sujata B.

this patient is an elderly primigravida with grade 3 obesity.The antenatal risks are both to the mother and fetus.. risks to the mother include risks of miscarriage in early pregnancy, congenital abnormalities like Neural Tube Defects and Cardiac anomalies. She has a much higher risk for preeclampsia and VTE in view of her age, primiparity, and morbid obesity. She is also at a risk for gestational diabetes and macrosomia/IUGR in case of severe preeclampsia or diabetes.Her antepartum surveillance will be difficult even for the doctor and hence will be subjected to more ultrsounds which will also pose difficilty due to poor visibility due to obesity.she may have to undergo preterm delivery iatrogenically in case of added medical risk factors.There are more chances of a caesarean section.   The risks can be reduced by proper counselling in her first visit. The need for a proper diet counselling. The need to start her on 5mg of Folic Acid and 10mcg of vitamin D. The woman needs to be made aware of regular antenatal checks so that any risk factor could be detected at the earliest. Her management will require a multidisciplinary approach-the dietician, endocrinologist,and the obstetric anaesthetist and neonatologist as she enters the third trimester or earlier if the need arises. The BP should be checked with the appropriate size cuff with the arm at the level of the heart. As the serum tests for screening may not be reliable ,she should be made aware of the importance of the NT scan and the anomaly scan at 18 to 20 weeks. A fetal  ECHO will be appropriate in view of morbid obesity. She should be put on 75mgs Aspirin from 12 weeks till delivery A blood sugar screening(OGTT) will be done at booking and again at28 wks and in case of macrosomia once more at 34 weeks.. the importance of exersise, avoidance of weight gain, proper hydration should be stressed to her. She will be told that she will be seen during her pregnancy at the hospital in view of her high risk factors and a proper management plan will be made for her place of delivery.Her BMI will be reassessed at term and in case of added risk factors ,thromboprophylaxis will be discussed in liason with the haematolgist

The woman has developed moderate preeclampsia. I will admit herand start her on oral labetalol. I will advice her to alert us in case of  new complaints like headache,epigastric pain , vomiting, blurring of vision and right upper quadrant pain. I will do her 24 hr urine proteins, check her BP 6th hrly,and send her blood samples for FBC,KFT,LFT and coagulation tests.I will get her   funduscopy done and also an ULtrasound for fetal growth, AFI and doppler study. I will give her the 2 doses of antenatal steroids,and at the samee time keep a sugar chart in case insulin is required. If her BP is under control and  If the tests are normal, I will repeat them twice weekly and repeat an USG with doppler study after 2 weeks. 24hr urine protein will be done weekly. A consultation will be done with the obstetric anaesthetist, and neonatologist before plan of induction and delivery at 37 weeks. IN view of some amount of immobilisation after admission I will advice her to use the TED stockings.Thromboprophylaxis will again be considered in case of morethan 3 moderate risk factors. The woman will be counselled regarding her risk factors and the need for delivery at 37 weeks or earlier in case of uncontrolled BP, or decreasing pletelets or abnormal renal or liver functions or onset of headache or vomiting. Whille in the ward I will maintain an early warning score chart so that the ward staff are also alerted in case of risk.

Essay 349 answer Posted by Dr Dyslexia V.

Obesity in pregnancy and pre eclampsia (Essay 349)

A 41 year old woman has been referred to the antenatal clinic at 10 weeks gestation in her first pregnancy. Her BMI is 42 kg/m2. (a) Discuss the antenatal risks associated with pregnancy in this woman and how these risks can be reduced [10 marks]. (b) She is referred to the assessment unit at 34 weeks gestation because her BP is 155/105 mmHg with 2+ proteinuria on automated testing. Discuss your antenatal management [10 marks].

a)      Her antenatal risk include her age which is above 40 years old, first pregnancy and with obesity. She should be identified as a high risk pregnancy and under a consultant led care. A multidisciplinary team including a the obstetrician, feto-maternal specialist, anaesthetist, nutritionist, dietician and midwife should be involved in her care. Her weight gain should be managed with proper caloric intake, correct nutrition , exercise and other risk factor reduction such smoking and alcohol intake if present. A counselor should also be involved for motivational, emotional support during this period. She should be given folic acid of 4 mg for the increased risk of neural tube defect in obesity and 10mcg of vitamin D if she is not already on it. Transvaginal scan to assess viability, chorionicity, NT thickness at 11 to 13 weeks so any miscarriage, fetal anomaly and the dating could be done as the technical difficulty of a abdominal scan. Serum screening done for aneuiploidy done with proper weight adjustment. Fetal anomaly scan and fetal heart scan must be done by a fetomaternal specialist due to technical difficulties. Obesity is also associated with fetal growth restriction and macrosomia thus a regular growth scan would be of benefit to detect this. Apart from that ultrasound should also be done prior induction or delivery to assess presentation as it would be difficult for palpation. Screening for gestational diabetes is important as the risk is 3 fold in this group. Oral glucose tolerance test should be done at 16-18 week and repeated at 28 week. This patient is also in high risk of venous thromboembolism (VTE) and history of VTE in her or family and presence of thrombophilia must be taken. She should be given VTE prophylaxis such as TED socks and LMWH low molecular weight heparin at any of her admission, and postpartum. She is also at risk of hypertensive disease in pregnany with 3 moderate risk factors of age, BMI and primiparity and she should be given aspirin 75mg from 12 weeks onward till delivery. Blood pressure  with the appropriate sized cuff is used to check the blood pressure and urine for proteinuria checked for preeclampsia. She should be referred to the aneasthetist at 34 to 36 weeks for assessment for difficult intubation or vascular access. She would be requiring hospital delivery where all the manual handling requirements and the mutidisiplinary team are available.

b)      She is having moderate hypertension with preeclampsia with underlying obesity. She will require admission and assessment by a consultant. She will require admission and assessment by a counsultant .Symptoms of severe pre eclampsia must be ascertained such as headache, vomiting, blurring of vision, epigastric pain and sudden onset of facial and leg swelling. Examination in regards to repeating blood pressure with appropriate cuff and spot protein creatinine ratio for assessing significant proteinuria.  Presence of significant pittable edema in the sacral and lower limb region could indicate severe proteinuria. Blood should be taken for bood count, renal function , bilirubin and transaminases to assess severity of disease. CTG is done to assess fetal well being and ultrasound of growth, liquor volume and umbilical Doppler done. If BP is persistently high than anti hypertensive such as labetolol should be started to achieve BP of less than systolic of 150 and diastolic of 80 to 100 mm Hg. Steroids such as betamethasone should be given for lung maturation and the neonatologist informed in regards to possible early delivery. VTE prophylaxis such as TED socks and low molecular weight heparin given to this patient as she is at high risk. The anaestetist should be asked to review for assessment as well. The need for early delivery should be informed to the mother and the decision is a joint decision with the consultant. During the admission 4 times daily blood pressure monitoring and blood about 2 times a week to assess disease progression and need for delivery.

answer Posted by maiada  B.

a)This woman has two main problems which are advanced maternal age and morbid obesity.Regarding advanced maternal age is associated with increased risk of aneuploidy (risk of Down syndrome at this age is almost 1/65 ).Also there is an increased risk of  fetal congenital malformation such as:cardiac defects and diaphragmatic hernia.She is at risk for developing pre-eclampsia,pregnancy induced hypertension and diabetes mellites.Placenta praevia is associated with advanced maternal age.There is increased risk of perinatal morbidity and mortality including low birth-weight baby,preterm birth and unexplained fetal death.there is also an increased risk of labour dysfuction and increased need for instrumental deliveries and increased caesarean section rate.Advanced maternal age is also associated with icreased risk of maternal mortality from non-obstetric causes such as;thromboembolism.

Obesity is associated with an increased risk of maternal mortality ,diabetes mellites and pre-eclampsia.Obesity is an independent risk factor for fetal macrosomia which increase the risk of shoulder dystocia and trauma of the birth canal during labour and also increase caesarean section rate.there is also increased risk of neural tube defects in the fetuses of obese mothers.Obesity is associated with increase risk of thromboembolism.

These risks can be reduced by careful monitoring of her pregnancy which include; Chorionic villous sampling at 11-14 weeks gestation to allow early detection of aneuploidy and early termination of pregnancy (if present) after discussion with the woman.The risk of misscarriage is .,5-1% above that in general population should be explained.Anomaly scan shoud be considered at 20 weeks gestation to exclude fetal congenital anomalies.Fetal echocardiography may be required at 22-24 weeks if fetal cardiac defects is suspected and this can allow referal to specialised center  for management if required.To reduce risk of neural tube defects,Folic acid 5 mg daily should be prescribed.To reduce risk of pre-eclampsia,Low dose aspirin 75 mg daily from 12 weeks till birth should be prescribed (as per NICE guidelines as she has two moderate risk factors for pre-eclampsia).Serial fetal growth scan may be reqquired to assess fetal growth and fetal viabilitywhich may be inaccurate by abdominal palpation and the use of Sonicaide.Umbilical artery doppler may be required if small for gestational age fetus has been diagnosed by fetal growth scan.Regular monitoring of her blood presssure using an appropriate large cuff should be considered to avoid undignosed hypertension if small cuff has been used.Monitoring of serum glucose level is essential at 26-28 weeks to detect gestational diabetes by performing oral glucose tolerance test.It can be performed earlier at 16 weeks if she has history of gestational diabetes.She should be assessed for an additional risks for thromboembolism and thromboprophylaxis with low molecular weight heparin may be considered according to her risk score.

b)As she developed moderate per-eclampsia,so according to NICE guidelines,she shoud be admitted to hospital.She should be assessed by healthcare profesional who is trained in management of hypertensive diseases.First line treatment with oral Labtalol shoul be initiated aiming to keep blood pressure <150/80-100.blood pressure shoud be monitore at least 4 time a day.Tests for kidney function,electrolytes,full blood count,transaminases and bilirubin shoud be performed 3 times a week.Fetal monitorring by ultrsound scan for fetal growth and amniotic fluid volume.Umbilical artey doppler velocimetry is also required.If any abnormal fetal activity,consultant obstetrician shoul informed.Timing of birth should be discussed with the woman.If before 37 weeks BP is controlled,birth can be offered depending upon the fetal and maternal conditions and availability of neonatal intensive cae unit.After 37 weeks labour shoud be considered.

Posted by Ana B.

Hi Paul,

 

I understand all your comments, thank you.

Could you explain why you were not happy with 3 times a week blood tests in MODERATE Hypertension (NICE guidlines pre-eclapmsia section); obviously my answer was not in the order clearly..

adil Posted by Adil H.

Dear Paul , 

Could you please send in the model answer key so that things are clearer in this answer.

Posted by Muthu M.

She is High risk , she should be booked under Consultant led unit and should have care under multidisciplinary team, including Consultant Obstetrician, Consultant anesthetist and dietician.  We should give open, honest and sensitive approach to her care.  She should be explained clearly there is increased risk of miscarriage, risk of choromosomal abnormalities, developing gestational diabetes, and pre-eclampsia risk.

She should have aspirin 75mg/day starting from 12 weeks of pregnancy.  At 16 weeks, she needs GTT and should be repeated at 28weeks.  Booking blood pressure (the base line reading) and subsequent blood pressure should be recorded using large cuff and should have urine dipstick for protein during all her clinic visit.  She should receive advice regarding health diet and exercise and avoid gaining excessive weight in pregnancy.

She should be told that scanning could be difficult including nuchal scanning and risk of possibility of missing fetal anomalies.  Because of her age, and weight, she should be offered invasive screening for down’s syndrome.  It would be difficult measuring symphysis fundal height during the antenatal period and also fetal heart rate pick –up or cardio-tocography monitoring could difficult and patient should be informed.  She would need a growth scan at 34weeks.  She would definitely need thromboprophylaxis during the postnatal period for a week and antenatal period – she should be assessed if she needs admission.  Now at clinic, I would assess her any other additional risk factors for venous thromboemolism other than her age and weight in view of giving her thromboprophylaxis during the antenatal period. 

She should be assessed by anesthetist during the antenatal period, in view of epidural, spinal, if required in labour.

 

I would recheck the blood pressure with large cuff and if still high as 155/105mmg, I would admit her in view of stabilizing the blood pressure.  I would check with her any symptoms such as headache, double vision and epigastric pain.  I would examine her to check for brisk reflexes and clonus.  I would do bloods to rule out signs of HELLP syndrome or abnormalities in platelet count, rising uric acid level and abnormal liver enzymes – so, I arrange for her to have FBC, U&E, LFT, Uric acid and Protein Creatitine ratio for protein level in urine.  I would aim to bring her blood pressure less than 140/90mmHg using labetalol as the first choice.  I would also give her steroid injections X 2 to improve fetal lung maturity.  I will keep her in labourward with regular monitoring of every 15minutes and then when stabilized, every 4hours of BP check, strict input/out put chart to avoid pulmonary edema and use the modified early obstetric warning chart for monitoring.  I will inform the Consultant on-call about her admission and review and plan about delivery.  I would also inform the special care unity and also the Consultant anesthetist.  I will do continuous fetal heart rate monitoring, if situation allows arrange for scan to check growth liquor volume and Doppler of fetus.  She would need thromboprophylaxis during this admission and TED stockings.  If her blood pressure is stable with medication and she is clinically well and asymptamatic of PET and blood results are good – aim for delivery around or after 37weeks.  Then, she can be discharged home with the aim of monitoring at day unit, 3times a week.  However, if situation detoriates, she may need early delivery. 

123 Posted by vanosch M.

a) This patient is morbidly obese and she has increased risk of gestational diabetes compared to general population, this may be associted of a lot of complication it self such as marosomic fetus or polyhydroamnious and other associated complications.

Obesity is associated with increased risk of hypertensive disorders and it is effect on pregnancy such as increased incidence of pre-eclampsia and prematurity either spontaneous or iatrogenic.

obesity in pregnancy also associated with increased risk of VTE and a proper education and awareness should be given to this patient. Obese women are more prone to have vitamine defeciencies such as vit D and folic acid and suitable supplementations should be given.

from other hand this patient is 41 year old and at this age there is increased risk of congenital and chromosomal abnormalities compared to general population,and suitable antenatal screening , such as nuchal translucency thickness and anomaly scan are recomended. Advanced maternal age is also associated with high incidence of medical diseases such as hypertension and DM and detailed history should be taken with appropriate physicall examination and investigation is essential.

b)

This patient has pre-eclampsia until proven otherwise, and should be manage accordingly.

A detailed history including any history of chronic HTN and what treatment given if any , other medical history should reviewed such as DM or renal diseases that may be associated with protienurea. Obstetric history and surgicalhistory also should be inquired about as this may affect the mode of delivery later on . LMP and where shehas her antenatalcare and any ultrasound reprt may help in determining the gestational age.

Symptoms sugesting severe pre-eclampsia , such as headache, blured vision, epigastric pain or sub-costal pain, should be asked.

physical examination including vital signs ,BMI should be undertaken and abdominal examination is performed to assess the fundal hight, lie and presentaion of the fetus and any subcostal tenderness. Vaginal exam may be indicated if patient in labour.

investigations should include; contineous CTG a this is a high risk pregnancy, urinanalysis, 24 hour urine collection for protien uria. liver function tests , full blood count and renal function tests to chic for any detergment and as base line to assess the process of the disease . ultrasound scan with doppler shuold be considered as pre-eclampsia is associated with FGR and to chick for fetal well being.

Neonatologist should be informed as may be delivey is indicated and the baby still premature. After having the diagnosis of PET the managment will depend on the severity of the disease and wethere this patient on active phase of labour.

The defenitive treatment is delivery. If patient is stable and doesnot detriorate, corticosteroids may be indicated. However if patient is in labour, giving tocolysis is not indicated, and the aim is vaginal delivery unless there is obestetric indication for caesarean section, and induction of labour is indicated if she is not in labour.

the managment of HTN is not needed unless the ABP more than 170/110 mmHg and IV route is prffered , medications may include Hydralazin or Labetalol.

Magnesium sulfate should considered as prophilactic and treatment of the eclamtic sissures, and should continued for at least 24 hours after delivery.

patient should be admited into HDU and senior obstetician and anaesthetist should be involved.

regular monitoring of vital signs and input out put charts should be undertaken, with ascultation of the chest as there is risk of pulmonary oedema with fluid overload.

after delivery patient should be kept in hospital for observation for 5-7 days and blood pressure should be monitored . with repeating liver and renal functions tests .

Patient should incourged for breast feeding and apprpriate councilling with regard to contraception and recurrence rate in subsequent pregnancies.

Follow up appointment and advise for ABP check as some patient may still having high blood pressure which need appropriate follow up and treatment later on.

zainab essay 349 Posted by Zainab I.

(A)First pregnancy at advanced age with morbid obesit  put this woman at risk hypertensive disorders(gestational hypertension/pre eclampsia),leading tomaternal and perinatal mortality and morbidity.Risk may be reduced by early reognition  of high blood pressure and urinary protein  at each visit and providing appropriate management.

She is at risk of  gestational diabetes ,therefore should be screen  at 24-28 week .incase of preexisting diabetes  and if develops gestational diabetes shold be reffer to diabetes care team to manage and to avoid  maternal (preeclamsia)  and fetal(macrosomia,still birth)complications.

Due to her advanced age ,there is risk of having a baby  with chromosomal anamalies.it could be minimised by offering screenig (uss markers and bloodtest) and diagnostic test in the formof chorionic villous sampling and amniocentesis ater counsellin.This may lead to early termination  of pregnancy with less  emotional and physical trauma.

Risk of other congenital anomalies  particularly neural tube defect is higher in obese women .it can be reduced by offering high dose folic acid 5 mg /day.screening can be done by  using serum alpha fetoprotein level(high)in second trimester  and anomaly scan at 18-20 weeks.

As the risk of thromboembolic complications is higher,risk assessment should be undertaken and thromboprphylaxis should be provide

with the involvement of haematologist.it sould be in the form of thromboembolic stalkings and low molicular weight heparin,together with the advice for life style modifications to reduce weight by diet and exercise.

Obesity may render her to suffer from vitamin deficiencies ,particularly vitamin D, so she should be advised to take vit D  10 microgram daily during pregnancy. 

(B) This woman has moderate degree preeclampsia,so should be assessed by a trained health professional,expert in dealing hypertensive disorders in pregnancy.she should be admitted in hospital  to provide appropriate management. Blood pressure  should  be measured by usin appropriate cuff,in sitting position as a base line and  repeated  4 times daily  .Proteinuria  should be quantified  by using 24 urinary protein(ideally)  with appropriat sampling advice(300mg -significant )  or protein :creatinine (>30 mg/mmol/l)

She should be assessed for severity of symptoms such as sever headach,epigastric pain,and visual disturbance,looked for signs of conus papilledema, and liver tenderness .These features may indicate the  imminent eclampsia  and determin the use of prophylactic

magnesium sulphate.necessary investigation would include full blood count(  decrease  haemoglobin,increased haematocrit,decreased 

platelet ),kiney function(urea,electrolytes,creatinine)to assess renal function,liver function test (transaminases,billirubin) would be performed at diagnosis andrepeated 3 times  a week.

Intravenous access would be maintained ,fluid  would be given cautiously to avoid (not > 80ml/hr)pulmonary edema.First line treatment should be commenced  in the form of oral labetolol  ,aiming to keep the blood pressure  in the range of 150/80-100mmhg.Fetus should be monitored by ultrasound measurement of growth and liqour amount and umblical artery doppler velocimetry at diagnosis and repeated  every 2 weeks ,if managed conservatively.Cardiotocography should be performed at diagnosis and should be repeated  if ther is change in fetal movement,bleedin,pain  or detrioration in maternal  condition.

Care plane should be documented in her notes by consultant obstetrian,which should inlue maternal and fetal indicatios for elective delivery,timing with consultation of paediatrician and anaesthetist and what decisions would be made.

zainab essay 349 Posted by Zainab I.

(A)First pregnancy at advanced age with morbid obesit  put this woman at risk hypertensive disorders(gestational hypertension/pre eclampsia),leading tomaternal and perinatal mortality and morbidity.Risk may be reduced by early reognition  of high blood pressure and urinary protein  at each visit and providing appropriate management.

She is at risk of  gestational diabetes ,therefore should be screen  at 24-28 week .incase of preexisting diabetes  and if develops gestational diabetes shold be reffer to diabetes care team to manage and to avoid  maternal (preeclamsia)  and fetal(macrosomia,still birth)complications.

Due to her advanced age ,there is risk of having a baby  with chromosomal anamalies.it could be minimised by offering screenig (uss markers and bloodtest) and diagnostic test in the formof chorionic villous sampling and amniocentesis ater counsellin.This may lead to early termination  of pregnancy with less  emotional and physical trauma.

Risk of other congenital anomalies  particularly neural tube defect is higher in obese women .it can be reduced by offering high dose folic acid 5 mg /day.screening can be done by  using serum alpha fetoprotein level(high)in second trimester  and anomaly scan at 18-20 weeks.

As the risk of thromboembolic complications is higher,risk assessment should be undertaken and thromboprphylaxis should be provide

with the involvement of haematologist.it sould be in the form of thromboembolic stalkings and low molicular weight heparin,together with the advice for life style modifications to reduce weight by diet and exercise.

Obesity may render her to suffer from vitamin deficiencies ,particularly vitamin D, so she should be advised to take vit D  10 microgram daily during pregnancy. 

(B) This woman has moderate degree preeclampsia,so should be assessed by a trained health professional,expert in dealing hypertensive disorders in pregnancy.she should be admitted in hospital  to provide appropriate management. Blood pressure  should  be measured by usin appropriate cuff,in sitting position as a base line and  repeated  4 times daily  .Proteinuria  should be quantified  by using 24 urinary protein(ideally)  with appropriat sampling advice(300mg -significant )  or protein :creatinine (>30 mg/mmol/l)

She should be assessed for severity of symptoms such as sever headach,epigastric pain,and visual disturbance,looked for signs of conus papilledema, and liver tenderness .These features may indicate the  imminent eclampsia  and determin the use of prophylactic

magnesium sulphate.necessary investigation would include full blood count(  decrease  haemoglobin,increased haematocrit,decreased 

platelet ),kiney function(urea,electrolytes,creatinine)to assess renal function,liver function test (transaminases,billirubin) would be performed at diagnosis andrepeated 3 times  a week.

Intravenous access would be maintained ,fluid  would be given cautiously to avoid (not > 80ml/hr)pulmonary edema.First line treatment should be commenced  in the form of oral labetolol  ,aiming to keep the blood pressure  in the range of 150/80-100mmhg.Fetus should be monitored by ultrasound measurement of growth and liqour amount and umblical artery doppler velocimetry at diagnosis and repeated  every 2 weeks ,if managed conservatively.Cardiotocography should be performed at diagnosis and should be repeated  if ther is change in fetal movement,bleedin,pain  or detrioration in maternal  condition.

Care plane should be documented in her notes by consultant obstetrian,which should inlue maternal and fetal indicatios for elective delivery,timing with consultation of paediatrician and anaesthetist and what decisions would be made.

marking scheme? Posted by UwaChuks U.

Dear Dr. Paul

where is the marking scheme for essay 349?

sorry Posted by UwaChuks U.

I am sorry Dr. Paul I didnt notice  the 2nd page

N A Posted by naila A.
(A)The risks associated with this pregnancy are due to her age, nulliparity and high BMI. Age related risk is of Down’s syndrome, which is one in hundred at this age. I‘ll advise her for integrated testing which include ultrasound for NT and serum screening for PAPP-A in first trimester at 10 competed weeks and alfa fetoprotein,free beta hcg, serum estradiol and inhibin in second trimester at 14 to 16 weeks. The test has 85% detection rate with 1.2% false positive rate. The other test which can be offered if she want the screening to be completed in first trimester only, is combined test which include USG for NT ,and serum screening for free beta hcg and PAPP-A, all in first trimester at 10 completed weeks of gestation. The risks related to her obesity and nulliparity is increased risk of pre eclempsia which can be reduced by starting 75 mg aspirin at 12 weeks and checking her blood pressure and protein urea at every visit. If her blood pressure increases more than 85 diastolic or more than 135 systolic she’ll need twice a week testing for her BP and proteinurea.At 20 weeks I’ll advise her anomaly scan to exclude neural tube defects and cardiac anomalies as these are more common in obese patients. She is at increased risk of developing gestational diabetes due to her age and obesity for which I’ll advise OGTT at 28 weeks of gestation. She is at increased risk of nutritional deficiencies due to obesity for which I’ll advise her vitamin D 10 ug till the end of pregnancy and lactation. There is increased risk of VTE due to her age and obesity which can be reduced by advising her TED stockings and moderate exercise and at any stage if she develop any other risk factor such as pre eclempsia or varicose veins she’ll need thromboprophylaxis with LMWH.Due to obesity it may be difficult to assess fetal growth by fundal height alone therefore she may need growth scans at 28 and 32 to 34 weeks. She may need USG for presentation at term. (b) I’ll take a detailed history to assess the risk and severity of her medical condition. I’ll inquire her about past history of any cardiac or renal disease. I’ll ask her about the symptoms of severe pre eclepsia, which are severe headache, blurring of vision or flashing in front of eyes, and epigastric pain or tenderness. I’ll check her BMI and BP and palpate the abdomen for fundal height and fetal lie and presentation. I’ll check the reflexes as brisk reflexes indicate more severe disease. I’ll advise admission as moderate pre eclempsia is an indication for inpatient treatment according to nice guide lines. I’ll start oral labetalol as it is first line medication according to nice guidelines.I’ll aim to maintain her BP within the range of less than 150 systolic and diastolic between 80 to 100 because lowering of blood pressure more than this can affect her placental perfusion and lead to decrease in fetal growth. I’ll start LMWH in prophylactic dose because now she has developed three moderate risk factors for VTE. I’ll request complete blood count to check her hemoglobin and platelets, as they are affected in severe disease, and biochemistry including her liver and kidney function tests and electrolytes to assess the involvement of liver and kidneys and repeat these tests 3 times a week. I’ll request CTG and will not repeat it more than once a week until there is an indication like change in fetal movement, vaginal bleeding or leaking or abdominal pain. I’ll request ultrasound for fetal biometry, liquor and umbilical artery Doppler’s.USG need not to be repeated earlier than two weeks. If her blood pressure is well controlled with normal bloods I’ll plan to deliver her after 37 completed weeks. Uncontrolled disease is an indication for earlier delivery after giving her betamethasone for fetal lung maturity and if possible the delivery should be in a facility with appropriate neonatal care for preterm babies.
Posted by naila A.

(A)The risks associated with this pregnancy are due to her age, nulliparity and high BMI. Her age related risk is of Down’s syndrome, which is one in hundred at this age. I‘ll advise her for integrated testing which include ultrasound for NT and serum screening for PAPP-A in first trimester at 10 competed weeks and alfa fetoprotein,free beta hcg, serum estradiol and inhibin in second trimester at 14 to 16 weeks. The test has 85% detection rate with 1.2% false positive rate. The other test which can be offered if she want the screening to be completed in first trimester only, is combined test which include USG for NT ,and serum screening for free beta hcg  and PAPP-A, all in first trimester at 10 completed weeks of gestation.The test has 85 %detection rate with6.1% false positive rate. The risk related to her obesity ,age and nulliparity is increased risk of pre eclempsia which can be reduced by starting 75 mg aspirin  at 12 weeks and checking her blood pressure and protein urea at every visit. If her blood pressure increases more than 85 diastolic or more than 135 systolic she’ll need twice a week testing for her BP and proteinurea.At 20 weeks I’ll advise her anomaly scan to exclude neural tube defects and cardiac anomalies as these are more common in obese patients. She is at increased risk of developing gestational diabetes due to her age and obesity for which I’ll advise OGTT at 28 weeks of gestation. She is at increased risk of nutritional deficiencies due to obesity for which I’ll advise her vitamin D 10 ug till the end of pregnancy and lactation. There is an increased risk of VTE due to her age and obesity which can be reduced by advising her TED stockings and moderate exercise and at any stage if she develop any other risk factor such as pre eclempsia or varicose veins she’ll need thromboprophylaxis with LMWH.Due to  obesity it may be difficult to assess fetal growth by fundal height alone therefore she may need growth scans at 28 and 32 to 34 weeks. She may need USG for presentation at term.

(b) I’ll take a detailed history to assess the risk and severity of her medical condition. I’ll inquire her about past history of any cardiac or renal disease. I’ll ask her about the symptoms of severe pre eclepsia, which are severe headache, blurring of vision or flashing in front of eyes, and epigastric pain or tenderness. I’ll check her BMI and BP and palpate the abdomen for fundal height and fetal lie and presentation. I’ll check the reflexes as brisk reflexes indicate more severe disease. I’ll advise admission as moderate pre eclempsia is an indication for inpatient treatment according to nice guide lines. I’ll start oral labetalol as it is first line medication according to nice guidelines.I’ll aim to maintain her BP within the range of less than 150 systolic and diastolic between 80 to 100 because lowering of blood pressure more than this can affect her placental perfusion and lead to decrease in fetal growth. I’ll start LMWH in prophylactic dose because now she has developed three moderate risk factors for VTE. I’ll request complete blood count to check her hemoglobin and platelets, as they are affected in severe disease, and biochemistry including her liver and kidney function tests and electrolytes to assess the involvement of liver and kidneys and repeat these tests 3 times a week. I’ll request CTG and will not repeat it more than once a week until there is an indication like change in fetal movement, vaginal bleeding or leaking or abdominal pain. I’ll request ultrasound for fetal biometry, liquor and umbilical artery Doppler’s.USG need not to be repeated earlier than two weeks. If her blood pressure is well controlled with normal bloods I’ll plan to deliver her after 37 completed weeks. Uncontrolled disease is an indication for earlier delivery after giving her betamethasone for fetal lung maturity and if possible the delivery should be in a facility with appropriate neonatal care for preterm babies.      

 

Posted by naila A.

(A)The risks associated with this pregnancy are due to her age, nulliparity and high BMI.Her age related risk is of Down’s syndrome, which is one in hundred at this age. I‘ll advise her for integrated testing which include ultrasound for NT and serum screening for PAPP-A in first trimester at 10 competed weeks and alfa fetoprotein,free beta hcg, serum estradiol and inhibin in second trimester at 14 to 16 weeks. The test has 85% detection rate with 1.2% false positive rate. The other test which can be offered if she want the screening to be completed in first trimester only, is combined test which include USG for NT ,and serum screening for free beta hcg  and PAPP-A, all in first trimester at 10 completed weeks of gestation.This test has 85% detection rate with 6.1% false positive rate. The risk related to her obesity,age and nulliparity is increased risk of pre eclempsia which can be reduced by starting 75 mg aspirin  at 12 weeks and checking her blood pressure and protein urea at every visit. If her blood pressure increases more than 85 diastolic or more than 135 systolic she’ll need twice a week testing for her BP and proteinurea.At 20 weeks I’ll advise her anomaly scan to exclude neural tube defects and cardiac anomalies as these are more common in obese patients. She is at increased risk of developing gestational diabetes due to her age and obesity for which I’ll advise OGTT at 28 weeks of gestation. She is at increased risk of nutritional deficiencies due to obesity for which I’ll advise her vitamin D 10 ug till the end of pregnancy and lactation. There is increased risk of VTE due to her age and obesity which can be reduced by advising her TED stockings and moderate exercise and at any stage if she develop any other risk factor such as pre eclempsia or varicose veins she’ll need thromboprophylaxis with LMWH.Due to  obesity it may be difficult to assess fetal growth by fundal height alone therefore she may need growth scans at 28 and 32 to 34 weeks. She may need USG for presentation at term.

(b) I’ll take a detailed history to assess the risk and severity of her medical condition. I’ll inquire her about past history of any cardiac or renal disease. I’ll ask her about the symptoms of severe pre eclepsia, which are severe headache, blurring of vision or flashing in front of eyes, and epigastric pain or tenderness. I’ll check her BMI and BP and palpate the abdomen for fundal height and fetal lie and presentation. I’ll check the reflexes as brisk reflexes indicate more severe disease. I’ll advise admission as moderate pre eclempsia is an indication for inpatient treatment according to nice guide lines. I’ll start oral labetalol as it is first line medication according to nice guidelines.I’ll aim to maintain her BP within the range of less than 150 systolic and diastolic between 80 to 100 because lowering of blood pressure more than this can affect her placental perfusion and lead to decrease in fetal growth. I’ll start LMWH in prophylactic dose because now she has developed three moderate risk factors for VTE. I’ll request complete blood count to check her hemoglobin and platelets, as they are affected in severe disease, and biochemistry including her liver and kidney function tests and electrolytes to assess the involvement of liver and kidneys and repeat these tests 3 times a week. I’ll request CTG and will not repeat it more than once a week until there is an indication like change in fetal movement, vaginal bleeding or leaking or abdominal pain. I’ll request ultrasound for fetal biometry, liquor and umbilical artery Doppler’s.USG need not to be repeated earlier than two weeks. If her blood pressure is well controlled with normal bloods I’ll plan to deliver her after 37 completed weeks. Uncontrolled disease is an indication for earlier delivery after giving her betamethasone for fetal lung maturity and if possible the delivery should be in a facility with appropriate neonatal care for preterm babies.      

 

(A)The risks associated with this pregnancy are due to her age, nulliparity and high BMI.Her age related risk is of Down’s syndrome, which is one in hundred at this age. I‘ll advise her for integrated testing which include ultrasound for NT and serum screening for PAPP-A in first trimester at 10 competed weeks and alfa fetoprotein,free beta hcg, serum estradiol and inhibin in second trimester at 14 to 16 weeks. The test has 85% detection rate with 1.2% false positive rate. The other test which can be offered if she want the screening to be completed in first trimester only, is combined test which include USG for NT ,and serum screening for free beta hcg  and PAPP-A, all in first trimester at 10 completed weeks of gestation.This test has 85% detection rate with 6.1% false positive rate. The risk related to her obesity,age and nulliparity is increased risk of pre eclempsia which can be reduced by starting 75 mg aspirin  at 12 weeks and checking her blood pressure and protein urea at every visit. If her blood pressure increases more than 85 diastolic or more than 135 systolic she’ll need twice a week testing for her BP and proteinurea.At 20 weeks I’ll advise her anomaly scan to exclude neural tube defects and cardiac anomalies as these are more common in obese patients. She is at increased risk of developing gestational diabetes due to her age and obesity for which I’ll advise OGTT at 28 weeks of gestation. She is at increased risk of nutritional deficiencies due to obesity for which I’ll advise her vitamin D 10 ug till the end of pregnancy and lactation. There is increased risk of VTE due to her age and obesity which can be reduced by advising her TED stockings and moderate exercise and at any stage if she develop any other risk factor such as pre eclempsia or varicose veins she’ll need thromboprophylaxis with LMWH.Due to  obesity it may be difficult to assess fetal growth by fundal height alone therefore she may need growth scans at 28 and 32 to 34 weeks. She may need USG for presentation at term.

(b) I’ll take a detailed history to assess the risk and severity of her medical condition. I’ll inquire her about past history of any cardiac or renal disease. I’ll ask her about the symptoms of severe pre eclepsia, which are severe headache, blurring of vision or flashing in front of eyes, and epigastric pain or tenderness. I’ll check her BMI and BP and palpate the abdomen for fundal height and fetal lie and presentation. I’ll check the reflexes as brisk reflexes indicate more severe disease. I’ll advise admission as moderate pre eclempsia is an indication for inpatient treatment according to nice guide lines. I’ll start oral labetalol as it is first line medication according to nice guidelines.I’ll aim to maintain her BP within the range of less than 150 systolic and diastolic between 80 to 100 because lowering of blood pressure more than this can affect her placental perfusion and lead to decrease in fetal growth. I’ll start LMWH in prophylactic dose because now she has developed three moderate risk factors for VTE. I’ll request complete blood count to check her hemoglobin and platelets, as they are affected in severe disease, and biochemistry including her liver and kidney function tests and electrolytes to assess the involvement of liver and kidneys and repeat these tests 3 times a week. I’ll request CTG and will not repeat it more than once a week until there is an indication like change in fetal movement, vaginal bleeding or leaking or abdominal pain. I’ll request ultrasound for fetal biometry, liquor and umbilical artery Doppler’s.USG need not to be repeated earlier than two weeks. If her blood pressure is well controlled with normal bloods I’ll plan to deliver her after 37 completed weeks. Uncontrolled disease is an indication for earlier delivery after giving her betamethasone for fetal lung maturity and if possible the delivery should be in a facility with appropriate neonatal care for preterm babies.      

 

(A)The risks associated with this pregnancy are due to her age, nulliparity and high BMI.Her age related risk is of Down’s syndrome, which is one in hundred at this age. I‘ll advise her for integrated testing which include ultrasound for NT and serum screening for PAPP-A in first trimester at 10 competed weeks and alfa fetoprotein,free beta hcg, serum estradiol and inhibin in second trimester at 14 to 16 weeks. The test has 85% detection rate with 1.2% false positive rate. The other test which can be offered if she want the screening to be completed in first trimester only, is combined test which include USG for NT ,and serum screening for free beta hcg  and PAPP-A, all in first trimester at 10 completed weeks of gestation.This test has 85% detection rate with 6.1% false positive rate. The risk related to her obesity,age and nulliparity is increased risk of pre eclempsia which can be reduced by starting 75 mg aspirin  at 12 weeks and checking her blood pressure and protein urea at every visit. If her blood pressure increases more than 85 diastolic or more than 135 systolic she’ll need twice a week testing for her BP and proteinurea.At 20 weeks I’ll advise her anomaly scan to exclude neural tube defects and cardiac anomalies as these are more common in obese patients. She is at increased risk of developing gestational diabetes due to her age and obesity for which I’ll advise OGTT at 28 weeks of gestation. She is at increased risk of nutritional deficiencies due to obesity for which I’ll advise her vitamin D 10 ug till the end of pregnancy and lactation. There is increased risk of VTE due to her age and obesity which can be reduced by advising her TED stockings and moderate exercise and at any stage if she develop any other risk factor such as pre eclempsia or varicose veins she’ll need thromboprophylaxis with LMWH.Due to  obesity it may be difficult to assess fetal growth by fundal height alone therefore she may need growth scans at 28 and 32 to 34 weeks. She may need USG for presentation at term.

(b) I’ll take a detailed history to assess the risk and severity of her medical condition. I’ll inquire her about past history of any cardiac or renal disease. I’ll ask her about the symptoms of severe pre eclepsia, which are severe headache, blurring of vision or flashing in front of eyes, and epigastric pain or tenderness. I’ll check her BMI and BP and palpate the abdomen for fundal height and fetal lie and presentation. I’ll check the reflexes as brisk reflexes indicate more severe disease. I’ll advise admission as moderate pre eclempsia is an indication for inpatient treatment according to nice guide lines. I’ll start oral labetalol as it is first line medication according to nice guidelines.I’ll aim to maintain her BP within the range of less than 150 systolic and diastolic between 80 to 100 because lowering of blood pressure more than this can affect her placental perfusion and lead to decrease in fetal growth. I’ll start LMWH in prophylactic dose because now she has developed three moderate risk factors for VTE. I’ll request complete blood count to check her hemoglobin and platelets, as they are affected in severe disease, and biochemistry including her liver and kidney function tests and electrolytes to assess the involvement of liver and kidneys and repeat these tests 3 times a week. I’ll request CTG and will not repeat it more than once a week until there is an indication like change in fetal movement, vaginal bleeding or leaking or abdominal pain. I’ll request ultrasound for fetal biometry, liquor and umbilical artery Doppler’s.USG need not to be repeated earlier than two weeks. If her blood pressure is well controlled with normal bloods I’ll plan to deliver her after 37 completed weeks. Uncontrolled disease is an indication for earlier delivery after giving her betamethasone for fetal lung maturity and if possible the delivery should be in a facility with appropriate neonatal care for preterm babies.      

 

 

 


 

 


 

 

Posted by Joan B.

A 41 year old woman has been referred to the antenatal clinic at 10 weeks gestation in her first pregnancy. Her BMI is 42 kg/m2. (a) Discuss the antenatal risks associated with pregnancy in this woman and how these risks can be reduced [10 marks]. (b) She is referred to the assessment unit at 34 weeks gestation because her BP is 155/105 mmHg with 2+ proteinuria on automated testing. Discuss your antenatal management [10 marks].

a- Hight body mass index associated with increase maternal and fetus morbidity and mortality needs to look after by consultant led care, she is at increase risk of thrombo embolism, she needs referal to trust nominated midwife or specialist to start her on prophylactic dose of heparin during antenatal period and purperium.

Patient needs booking scan at 12 weeks to determine gestational age, chorionicity viability to reduce risk of unnecessory intervention either by doing induction of labour or elective caesarean section, also dating scan help us to find growth of baby which could be difficult do predict in her case by palpation, she may need growth, liquor and doppler scan at 28,32,36 weeks to assess growth.  during antenatal period.

Detail anomaly scan at 20 weeks because they at high risk of congenital anomaly, she may need echo cardiography because patient with high BMI at risk of cardiomyopathy and left ventricular dysfunction. The scan may need to be done by expert because of difficulty in doing it in her situation. Each visit needs blood pressure check by large cuff because of increase risk of hypertension and pre eclampsi, and she need asprin 75mg daily from 12 weeks of pregnancy as shows benefit to reduce pre eclampsi risk. Every clinic urin needs to be tested for protein which help diagnosis of pre eclampsia, and utrerine artery doppler between 22-24 weeks.

Normal vaginal delivery encouraged, there is no evidence induction of labour for macrosomia reduce shoulder dystorcia risk, normal vaginal delivery reduce risk of infection, complications of caesarean which is very common in obese women. Glucose tolerence test arranged at 16-18 weeks if negative arrange it again at 26-28 weeks because of gestational diabetes melitus risk.

Anaestetist review during antenatal period because of difficulty which they have in venouse section, tracheal intubation and regional anaesthesia.

manual handling process to arrange bed and theatre table and transport fascililties for her, most hospitals should have protocol help dealing with patient with high BMI.

b- Patient know have pre eclampsia, I admit her for control of her blood pressure by labetalol to control her blood pressure, ask her about symptoms of head ache, buring vision, nausia, vomitting, epigastric or right upper quadrant pain.

I send urin for protein creatinine ratio or 24hours urine collection for protein. I send bleed to check full blood count check haemoglobulin, platelets counts, liver function test checking transaminase as it increase in pre eclampsia, renal function assessment by checking urea and electrolytes and urate level.

I check fluid in put and out put and implement modified early worning chart to moniter blood pressure, pulse, oxygen saturations, temperation every 15minuts until blood pressure is controlled then half hourly then 4hourly.

I start CTG to assess baby's condition, growth, liquor and doppler scan if have time. I give her steroid helps enhance baby's lung maturity and inform neonatologist to see patient to discuss baby's condition and prognosis as may need early delivery. Then I plane delivery according to maternal and fetal condition.

essay 349 Posted by Dr.P.Vijaya P.

Obesity is an increasing problem since three decades, according to CMACE 2003-2005 report 28% of maternal deaths women were obese.Body mass index calculated by weight in kilos divided by square metre of height.BMI 25-30 is over weight, >30 is obese.If BMI is 30-34.9 ( class 1), 35-39.9 ( classs 2), 40 or above ( class 3 morbid obesity). Obesity associated with 1 trimester maiscarriages, anomalies, pregnancy induced hypertention, pre eclampsia, GDM, macrosomia, shoulder dystocia, birth injuries, operative deliveries, thromboembolism, anaesthetic complications, post partum haemorrhage, endometritis.

Care must be started at pre conception counselling and family planning appointment advice to reduce weight,diet, exercise, life style modifications.Senior obstetrician, anaesthetist ,experienced midwife and dietician like multidiscilplinary team approach should be given.To prevent miscarriages and anomalies high dose folic acid 5mg daily one month before conception and the 1 trimester must be given.If risk factors for PE better to give 75mg of aspirin daily from 12 weeks to delivery.Early booking at 12 wks by senior obstetrician to discuss her risks of thromboembolism,maternal morbidity and mortality and documented in her hand held notes and electronic patient information.75 g 2 hr test of OGTT done at 24-28 wks to detect GDM.Due to morbid obesity thromboembolism prophylaxis of LMWH considered it must be given in postpartum for 1 wk to 6 wks depending on the risk factors.

Anaesthetist must assess at booking and 3 trimester and at delivery to discuss potentiall difficulties of venous access, regional anesthesia failures, aspiration with general anaesthesia, prior epidural catheter, post partum atelectasis. Handling , proper conditioned beds ,lateral transfer equipment, personnel discussed with her and documented.

ANC visits every 3 wks from 24-32 wks , every 2 wks from 32 wks to delivery.Planned for delivery in consultant led unit.During delivery experienced midwife continuous monitoring mother and fetus with care for to avoid pressure sores.VBAC can be allowed but risk of rupture discussed.Unless obstetric indication no need of induction, high rate of IOL and failures due to obesity.For LSCS experienced obstetrician , if subcutaneous fat 2cm it should be sutured to prevent wound infection and dehiscence.Encourage post partum early mobilization, diet control, life style modification, guide for breast feeding.Follow up later for type 2 diabetes and cardio-metabolic disease.

b)At 34 wks with BP of 155/105 mm of Hg, other signs and symptoms elicited like severe headache, visual disturbances,epigastric pain/vomiting, clonus, papilloedema,liver tenderness,falling platelet count , liver enzymes(AST&ALT >70iu/l)., HELLP syndrome.Proteinuria checked again.Daily FBC,LFT,RFT must be done.Antihypertensives given when systolic BP >170 and diastole >110mm of Hg.If BP associated with s/s better to start antihypertensives like lebetalol oral or iv,nifidipine oral, iv hydralazine.If bp is under control, corticosteroids given  for lung maturity.If BP is high every 15 mts checked still stabilised, then every 30mts.If conservative management planned then 4th hrly.

Fetus monitored with daily CTG, USG for growth, AFI, Umbelical artery Doppler.

If BP under control no other problems can be delivered at term.If still high BP and associated with s/s after corticosteroids ,<32 wks better deliver by LSCS, due to failure of induction high.If >34 wks fetal position and cervical status induced with prostaglandins on a best day in best place with best team.Postpartum 5 units syntocinon im given , syntometrine and ergometrine avoided it inceases BP.

If patient develops convulsions Magnesium sulphate IV loading dose 4gms slowly in 5-10mts, maintained with 1gm/hr till 24hrs from the last seizure or delivery whichever is later.During treatment urine output, respiratory rate,knee jerks monitored.If recurrence of seizures another loading dose of 2gms can be given or maintenance dose increased to 1.5-2gms/hr.

During labour fluids restricted to 80ml/hr to prevent pulmonary embolism with input output chartsAirway, breathing ,circulation monitored.Before discharge postpartum seizures must be kept in mind and assessed..

essay 349 Posted by Dr.P.Vijaya P.

Obesity is an increasing problem since three decades, according to CMACE 2003-2005 report 28% of maternal deaths women were obese.Body mass index calculated by weight in kilos divided by square metre of height.BMI 25-30 is over weight, >30 is obese.If BMI is 30-34.9 ( class 1), 35-39.9 ( classs 2), 40 or above ( class 3 morbid obesity). Obesity associated with 1 trimester maiscarriages, anomalies, pregnancy induced hypertention, pre eclampsia, GDM, macrosomia, shoulder dystocia, birth injuries, operative deliveries, thromboembolism, anaesthetic complications, post partum haemorrhage, endometritis.

Care must be started at pre conception counselling and family planning appointment advice to reduce weight,diet, exercise, life style modifications.Senior obstetrician, anaesthetist ,experienced midwife and dietician like multidiscilplinary team approach should be given.To prevent miscarriages and anomalies high dose folic acid 5mg daily one month before conception and the 1 trimester must be given.If risk factors for PE better to give 75mg of aspirin daily from 12 weeks to delivery.Early booking at 12 wks by senior obstetrician to discuss her risks of thromboembolism,maternal morbidity and mortality and documented in her hand held notes and electronic patient information.75 g 2 hr test of OGTT done at 24-28 wks to detect GDM.Due to morbid obesity thromboembolism prophylaxis of LMWH considered it must be given in postpartum for 1 wk to 6 wks depending on the risk factors.

Anaesthetist must assess at booking and 3 trimester and at delivery to discuss potentiall difficulties of venous access, regional anesthesia failures, aspiration with general anaesthesia, prior epidural catheter, post partum atelectasis. Handling , proper conditioned beds ,lateral transfer equipment, personnel discussed with her and documented.

ANC visits every 3 wks from 24-32 wks , every 2 wks from 32 wks to delivery.Planned for delivery in consultant led unit.During delivery experienced midwife continuous monitoring mother and fetus with care for to avoid pressure sores.VBAC can be allowed but risk of rupture discussed.Unless obstetric indication no need of induction, high rate of IOL and failures due to obesity.For LSCS experienced obstetrician , if subcutaneous fat 2cm it should be sutured to prevent wound infection and dehiscence.Encourage post partum early mobilization, diet control, life style modification, guide for breast feeding.Follow up later for type 2 diabetes and cardio-metabolic disease.

b)At 34 wks with BP of 155/105 mm of Hg, other signs and symptoms elicited like severe headache, visual disturbances,epigastric pain/vomiting, clonus, papilloedema,liver tenderness,falling platelet count , liver enzymes(AST&ALT >70iu/l)., HELLP syndrome.Proteinuria checked again.Daily FBC,LFT,RFT must be done.Antihypertensives given when systolic BP >170 and diastole >110mm of Hg.If BP associated with s/s better to start antihypertensives like lebetalol oral or iv,nifidipine oral, iv hydralazine.If bp is under control, corticosteroids given  for lung maturity.If BP is high every 15 mts checked still stabilised, then every 30mts.If conservative management planned then 4th hrly.

Fetus monitored with daily CTG, USG for growth, AFI, Umbelical artery Doppler.

If BP under control no other problems can be delivered at term.If still high BP and associated with s/s after corticosteroids ,<32 wks better deliver by LSCS, due to failure of induction high.If >34 wks fetal position and cervical status induced with prostaglandins on a best day in best place with best team.Postpartum 5 units syntocinon im given , syntometrine and ergometrine avoided it inceases BP.

If patient develops convulsions Magnesium sulphate IV loading dose 4gms slowly in 5-10mts, maintained with 1gm/hr till 24hrs from the last seizure or delivery whichever is later.During treatment urine output, respiratory rate,knee jerks monitored.If recurrence of seizures another loading dose of 2gms can be given or maintenance dose increased to 1.5-2gms/hr.

During labour fluids restricted to 80ml/hr to prevent pulmonary embolism with input output chartsAirway, breathing ,circulation monitored.Before discharge postpartum seizures must be kept in mind and assessed..

essay 349 Posted by Dr.P.Vijaya P.

Obesity is an increasing problem since three decades, according to CMACE 2003-2005 report 28% of maternal deaths women were obese.Body mass index calculated by weight in kilos divided by square metre of height.BMI 25-30 is over weight, >30 is obese.If BMI is 30-34.9 ( class 1), 35-39.9 ( classs 2), 40 or above ( class 3 morbid obesity). Obesity associated with 1 trimester maiscarriages, anomalies, pregnancy induced hypertention, pre eclampsia, GDM, macrosomia, shoulder dystocia, birth injuries, operative deliveries, thromboembolism, anaesthetic complications, post partum haemorrhage, endometritis.

Care must be started at pre conception counselling and family planning appointment advice to reduce weight,diet, exercise, life style modifications.Senior obstetrician, anaesthetist ,experienced midwife and dietician like multidiscilplinary team approach should be given.To prevent miscarriages and anomalies high dose folic acid 5mg daily one month before conception and the 1 trimester must be given.If risk factors for PE better to give 75mg of aspirin daily from 12 weeks to delivery.Early booking at 12 wks by senior obstetrician to discuss her risks of thromboembolism,maternal morbidity and mortality and documented in her hand held notes and electronic patient information.75 g 2 hr test of OGTT done at 24-28 wks to detect GDM.Due to morbid obesity thromboembolism prophylaxis of LMWH considered it must be given in postpartum for 1 wk to 6 wks depending on the risk factors.

Anaesthetist must assess at booking and 3 trimester and at delivery to discuss potentiall difficulties of venous access, regional anesthesia failures, aspiration with general anaesthesia, prior epidural catheter, post partum atelectasis. Handling , proper conditioned beds ,lateral transfer equipment, personnel discussed with her and documented.

ANC visits every 3 wks from 24-32 wks , every 2 wks from 32 wks to delivery.Planned for delivery in consultant led unit.During delivery experienced midwife continuous monitoring mother and fetus with care for to avoid pressure sores.VBAC can be allowed but risk of rupture discussed.Unless obstetric indication no need of induction, high rate of IOL and failures due to obesity.For LSCS experienced obstetrician , if subcutaneous fat 2cm it should be sutured to prevent wound infection and dehiscence.Encourage post partum early mobilization, diet control, life style modification, guide for breast feeding.Follow up later for type 2 diabetes and cardio-metabolic disease.

b)At 34 wks with BP of 155/105 mm of Hg, other signs and symptoms elicited like severe headache, visual disturbances,epigastric pain/vomiting, clonus, papilloedema,liver tenderness,falling platelet count , liver enzymes(AST&ALT >70iu/l)., HELLP syndrome.Proteinuria checked again.Daily FBC,LFT,RFT must be done.Antihypertensives given when systolic BP >170 and diastole >110mm of Hg.If BP associated with s/s better to start antihypertensives like lebetalol oral or iv,nifidipine oral, iv hydralazine.If bp is under control, corticosteroids given  for lung maturity.If BP is high every 15 mts checked still stabilised, then every 30mts.If conservative management planned then 4th hrly.

Fetus monitored with daily CTG, USG for growth, AFI, Umbelical artery Doppler.

If BP under control no other problems can be delivered at term.If still high BP and associated with s/s after corticosteroids ,<32 wks better deliver by LSCS, due to failure of induction high.If >34 wks fetal position and cervical status induced with prostaglandins on a best day in best place with best team.Postpartum 5 units syntocinon im given , syntometrine and ergometrine avoided it inceases BP.

If patient develops convulsions Magnesium sulphate IV loading dose 4gms slowly in 5-10mts, maintained with 1gm/hr till 24hrs from the last seizure or delivery whichever is later.During treatment urine output, respiratory rate,knee jerks monitored.If recurrence of seizures another loading dose of 2gms can be given or maintenance dose increased to 1.5-2gms/hr.

During labour fluids restricted to 80ml/hr to prevent pulmonary embolism with input output chartsAirway, breathing ,circulation monitored.Before discharge postpartum seizures must be kept in mind and assessed..