Essay 362

I should take detailed history about the level of the spinal cord lesion,if she is paraplegic or quadreplegic,i should ask about complications from that injury such as repeated urinary tract infections,pulmonary infection , any symptoms of autonomic dyskinasia if the lesion above T6 such as repeated episodes of throbbing headach,tachycardia,sweating,flushing, hypertension.also,if she takes any medications .Ishould also ask about any risk factors related to increase risk of thromboembolic disease such as smoking,or previous attack of DVT for her or first degree relatives.ishould make examination to see if there is skin complications of her spinal injury as compression ulcers, measuring blood pressure as this patient obese ,examination of pelvis should be done to see if there is pelvic contracture due to previous injury pelvimetry can be used .investigations as urine analysis, urea,electrolite,creatinine level to assess kidney function ,pulmonary function test if the injury above T10 as at this level cough will be impaired,Full Blood Count should be made as risk of anaemia in such injury increase,RH status also should be assessed and if negative asking about previous transfusion should be done and RH antibodies should assesed,Ultasound to confirm date and viabilty .

B-

Antenatal care should be started by councilling her about effect of her injury on her pregnancy as this will increase risk of preterm labour and IUGR  so i should teach her how to palpate her uterus to know the contarctions to avoid accidental delivery at home,if the level of injury above T12,if the lesion below T12 she will expirence normally labour pain,vaginal delivery is the aim except if there is contracture of the pelvis due to  previous accident or other obstetric indications.this pregnant lady should be seen by multidisciplinary team consist of obstetrcian.neurologist,orthopedic,anasthesitist (if there is pelvic injury,contracture).regular antenatal care every 4 weeks untill 28 weeks and assesment of cervical length every weekly to avoid preterm labour,corticosteriods should be given if preterm labour diagnosed early

blood pressure and urine analysis should be done at every visit,glucose level should be checked at booking then at 28 weeks to diagnose DM as she is obese .

Fetal follow up through detailed anomely scan at 20 weeks then growth scan at 24 weeks as the risk of IUGR increased.

as she has no more risk factors for VTE she is low risk and advice of well hydartion will be given to her and to seek medical advice early if she comlained of repeated vomiting.

At the labour if vaginal delivery is possible and if the level of the injury below T12,spinal or epidural analgesia should be offered at the start of the labour to inhibit autonomic dysreflexia,if occur during insertion of the epidural antihypertensive medications ,and vasodilators should be given,second stage of labour can be shortened by operative vaginal delivery such as ventose or forcips.

after delivery Low molcular weight heparin should be started 4 hours after to 6 weeks postnatal to decrease risk of VTE as she has moderate risk,contraceptive advice should be given.

A) In the history I would enquire about the effect of her accident on her mental health. Specifically I would ask a few brief questions to establish her risk of depression and postnatal depression. I will enquire about her support at home and ask if she needs additional help if she is feeling low in mood. I will ask about how much she can do physically and if there have been any other health consequences from the accident. I will ask about urinary and bowel symptoms as she may have incontinence or a long term catheter in situ. I will enquire about the impact on her quality of life. I will ask if this was a planned pregnancy and if it was whether she took 5mg of folic acid 1 month prior to conception until 12 weeks as this would have reduced the risk of neural tube defects to the fetus. I will ask her about a personal history of venous thromboembolism (VTE) and if she has had a positive thrombophilia screen in the past as this will determine if she will require antenatal prophylactic low molecular weight heparin (LMWH) and a higher dose if she has antithrombin III deficiency. I will ask her is she has any medical problems such as diabetes or hypertension and if she is on any regular medications that will need to be reviewed if teratogenic e.g ACEi for hypertension.  I will ask about her family history of pre-eclampsia (PET) and diabetes as these will increase her risk of PET and gestational diabetes (GDM) respectively. I will ask whether she smokes as this will increase maternal and neonatal morbidity and mortality and she can be offered cessation support.

I will check her blood pressure using the large cuff to identify hypertension and check her urine for protein, glucose and identify urinary tract infection. A midstream urine culture should be sent to screen for asymptomatic bacteriuria. I will check her legs for varicose veins as this will increase her risk of VTE. The rest of my examination will be guided by the findings in the history.

B) She will be under consutant led care through out her pregnancy and referred to an obesity antenatal clinic if one is available. She will need input from the dietician to advise her about nutrition and appropraite weight gain in pregnancy (no more than 6-7kg) . She will need referral to the anaesthetist due to her BMI and immobility. She needs to commence 75mg of Asprin once a day until delivery to reduce her risk of PET (two moderate risk factors BMI and primiparous) and also 10mcg Vit D until delivery and while breastfeeding as she is at an increased risk of Vit D deficiency. She is at an intermediate risk of VTE as she has two risk factors (BMI and immobility) so she needs to be given advice regarding being well hydrated and needs to be observed for additional risk factors requiring her to start LMWH. If she is admitted antenatally to hospital she will need LMWH as an inpatient.

If she has not had a dating scan this needs to be done urgently and serum down's screening discussed. The results of her booking bloods need to be reviewed and commence ferrous sulphate if her Hb is less than 10.5. She will need a detailed anomaly scan at 20 weeks. It should be explained to her that the sensitivity and specificity of the ultrasound scan decreases because of maternal habitus. She will need growth scans at 28-30 weeks and 32-34 weeks to assess fetal size and liquor volume and presentation as it is difficult to detect small for gestational age fetus antenatally and palpate for presentation due to maternal habitus.  Between 24-28 weeks she will require a glucose tolerance test as she is at a high risk of developing GDM. She will need repeat full blood count, blood group and autoantibodies checked at 28 weeks to dectect anaemia and confirm blood group. Her blood pressure and urinanalysis needs to be checked every 4 weeks from 16 weeks until 32 weeks and then every two weeks. Her weight needs to be rechecked in the 3rd trimester and her BMI re-calculated. 

Qn: A 24 year old woman has been referred to the antenatal clinic at 14 weeks gestation in her first pregnancy. She is wheelchair bound following an accident in childhood. Her BMI at booking is 41 kg/m2. (a) Discuss your clinical assessment of this woman [8 marks]. (b) Discuss your subsequent antenatal care given that she has no additional risk factors [12 marks].

a) I will enquire about her medical history - if she has any pre-existing diabetes, hypertension, medical problems associated with obesity. If present, I will ask her if these conditions are well controlled. Poorly controlled medical conditions require optimisation with the help of the physician. I will also ask if she has any previous abdominal surgeries. I will ask her regarding any medications that she is taking, including recreational drugs. Teratogenic drugs may need to be substituted or stopped during her pregnancy. I will ask if she has any previous thromboembolic event, any thrombophilia, family history of thromboembolism to assess her thromboembolic risk and determine need for antenatal thromboprophylaxis. I will also ask if this was a planned pregnancy and enquire about social support and her psychological/mental wellbeing. I will enquire if she smokes or drinks alcohol. I will ask her if she has been taking any folic acid/ Vitamin D supplements. I will also check her immunisation history e.g. rubella.

I will check her blood pressure using an appropriately sized cuff and examine her abdomen for any surgical scars.

b) A multidisciplinary team, including a consultant obstetrician, dietician, consultant anaesthetist and senior experienced midwife should be involved in her care.

I will arrange a transvaginal dating scan for her - to check viability, number of fetuses and date the pregnancy. Nuchal translucency and combined test for Down syndrome screening should also be offered since she is at 14 weeks' gestation.

I will advise her to take Vitamin D supplements 100mcg daily throughout the period of pregnancy up to breastfeeding. A dietician referral is important to advise her on how to limit weight gain, although weight loss is not advisable during pregnancy.

Blood pressure should be checked at every visit using an appropriately sized cuff. Urinalysis to check for proteinuria should also be done at every antenatal visit as she is at increased risk of developing pre-eclampsia and hypertensive complications. She should be started on aspirin 75mg daily till delivery to reduce her risks as she is obese and a primigravida.

Fetal anomaly scan should be arranged at 18-20 weeks as per normal. However, she should be informed that it may be technically difficult to visualise anomalies due to her habitus. Appropriate referral to a senior sonographer or a tertiary fetal medicine centre should be made if there are difficulties as she is at increased risk of congenital anomalies associated with obesity.

Oral glucose tolerance test should be offered at 24-28 weeks of gestation to screen for gestational diabetes. She is also at risk of fetal macrosomia and as it may be difficult to measure symphysial fundal height, consider fetal growth scans to monitor fetal growth, although she should be aware that such scans have their limitations in estimating fetal weight.

She is also at increased risk of thromboembolism due to high BMI and immobility. Advise her to avoid dehydration and prescribe thromboembolic deterrent stockings. If she is admitted to hospital during the antenatal period, repeat risk assessment for thromboembolism should be performed and prophylactic LMWH prescribed.

Review by consultant anaesthetist should also be arranged in the 3rd trimester to discuss options for analgesia in labour. BMI should be measured and re-recorded in the 3rd trimester as well.

She should be advised to deliver in a consultant led maternity unit and plan of delivery discussed and documented. Psychosocial support should be provided throughout antenatal visits.  Discuss and encourage breastfeeding and contraception options that she can consider post-delivery.Provide written information and contact numbers of relevant healthcare team.

Sorry, in my answer there was a typo error. I meant 10mcg Vit D.

1. she   should be asked about her general pregnancy symptom like nausea ,vomiting and how she is coping with it? She should be assessed for help and support in carry out her daily activity as she is wheel chair bound. she should be dealt with sensitive and empathetic manner ,and enquired about her weight whether it is since early age or recent development. She should be asked whether she is under weight reduction programme or medication to reduce weight.

She should be asked whether she has undergone any bariatric surgery before planning pregnancy ,and the type of surgery, as gastric banding may be troublesome during pregnancy.

 She should be asked whether this pregnancy planned or planned ,if planned then whether she took any preconceptional counseling and advice like folic acid 5 mg daily  to reduce the neural tube defect and vit D supplement 10 ug daily to reduce the deficiency.

Her menstrual history should be asked about LMP, regularity , amount and duration of flow, acne ,hirsutism as it may suggest pcos. She should be asked about any previous miscarriage and termination of pregnancy and contraceptive use and its side effect.

She should be asked about personel history of diabetes ,hypertension ,endocrinopathy for high BMI and VTE.  She should be asked for the family history of hypertension, diabetes and VTE.

Her life style should be noted about smoking , alchohal and drug abuse.

She should be enquired about her mental health issue and any history of such with her in the past or any of the family member.

She should be asked about any prescribed or over the counter she is taking for her health related issue, like hypertension, diabetes, and weight reduction.

She should be assessed for the limitation of the physical activity and any other risk factoe for the VTE.

Her blood pressure should be examined by appropriate cuff size  and BMI should be confirmed .she should be examined for the limitation of the movement ,any pressure sore or infection ,how she is managing her bladder and bowel function and general hygiene.

Ultrasound should be done for the confirmation of fetal viability and anomaly ,and she should be explained about difficulty on transabdominal ultrasound due to abdominal fat ,need of TVS and expert to confirm it.

She should be asked whether down syndrome screening done or not. If she has not done then she should be counseled and difficulty encounter in measuring nuchal translucency, and difficulty in interpretation of the serum marker due to her high BMI. It may need referral to fetal medicine centre.

2. she should be managed with the multidisciplinary team involving Obstetrician, midwifwfe ,anaesthesist  ,physyitherapist and dietician.

There should be local protocol for the management of such patient and clear referral pathway for the referral.

She should be advised that weight reduction is not advisable during pregnancy ,but calori restriction can be done with appropriate dietary counseling.

She should be explained that if there is difficulty in interpreting first trimester down syndrome screening then she has to under go second trimester triple or quadruple test ,still there may be difficulty in interpreting the serum marker then she has to go foe invasive prenatal diagnostic test.

She should be advise for the anomaly scan at 18- 20 week6 day ,and there may be difficulty in visulisation due to abdominal fat.

She should be assess for the risk of preeclampsia and since it is her first pregnancy and BMI 40 ,so she should be put on aspirin if not started at 12 weeks of gestation till delivery ,she should be refered immediately for the specialist care.

She should be assesses for the risk of developing VTE  during her antenatal care, should be advise to maintain hydration .when ever heparin prophylaxis needed it should be given according to her weight .

She should be screened for the GDM around 26-28 weeks of gestation  by OGTT, as they are high risk of developing GDM.

At each visit ,her blood pressure should be checked with appropriate cuff size along with urine albumin. she should be provided her detail and management plan in hand held notes.

She should be monitored for the fetal growth  from 28 weeks of gestation ,although difficulty may encounter during ultrasound . she is at risk of having macrosomic baby due to her high BMI.

Anaesthetic assessment in third trimester for the mode of anaesthesia, analgesia and IV line access should be done and explain about the difficulty which may encounter.

She should be assessed and documented for the appropriate manual handling assessment for the safe transfer and delivery and equipments.

Deliver should be planned at 36 weeks she should be explained that high BMI is not an indication for the induction and caesarian section.  She should be assesses for the type of morbidity she has due to accident whether it will affect he vaginal mode of delivery like positioning ,or associated pelvic fracture may need for the elective LSCS. She should be delivered in consultant led unit.

She should be given advise about breast feeding .

She should be given updated evidence base information supported  by written information leaflets.

1. The neurological status should be assessed hx and physical examination are performed to ascertain the type of disability and whether patient is quadripelgic or paraplegic.  Questions about the level of injury as higher level can be associated with autonomic hyperreflexia. Which can be associated anaesthesia, parastesia or neuropathic pain., high blood pressure and arrhythmias. Patient is asked if she can perform manual tasks and have reasonable dexterity. Patient is asked if she can pass urine without help or she needs self catheterization as this adds on risk of UTI. She is asked about faecal incontinence or impaction as well as the later can trigger symptoms of  hyperreflexia. Patient is asked about any drugs she is taking such as antihypertensive, anticoagulants and opioids  use in order to switch the medication to safer ones in regards to pregnancy. Her attitude towards pregnancy should be sensitively asked for.

b)   Patient needs to be followed up in consultant led clinic in MDT context with input form neurological team, consultant with special interest in maternal medicine midwife, social services  and community nursing staff. The benefit of each Clinic should be enhanced, as there is an obvious issue with transportation. VTE assessment should be done and, as this patient is immobile and has got a high BMI I would prescribe a prophylactic dose of LMWH throughout pregnancy and at least 6 weeks postpartum as well as TEDS stockings. I would offer USS at this stage for dating and NT if has not been already done taking into consideration her high BMI I would explain the limitation of the USS.  Screening for Down’s syndrome offered as in other patients. Patient is at higher risk of having a fetus with cardiac malformation and I would offer a n anomaly scan at 20-22/40. Also it is difficult to assess fetal growth by symphisal fundal height alone and I would offer her serial fetal growth scans. She is at higher risk of preeclampsia and if any other risk factors identified I would offer Aspirin 75 mg OD until delivery. BP and proteinuria are  checked every visit. Urine dipstick to screen for UTI and MSU are done each visit especially if  routine self catheterization. OGTT is offered at 28/40 as at higher risk of GDM.  If chronic use of opiods then Paediatric team should be informed and a discussion about risk of neonatal withdrawal syndrome. Patient is provided with contact no. and ideally the contact no. of community midwife if unable to attend due to transportation issues.

A 24 year old woman has been referred to the antenatal clinic at 14 weeks gestation in her first pregnancy. She is wheelchair bound following an accident in childhood. Her BMI at booking is 41 kg/m2. (a) Discuss your clinical assessment of this woman [8 marks]. (b) Discuss your subsequent antenatal care given that she has no additional risk factors [12 marks].
 

a. Patient is a high risk antenatal patient due to her previous history of RTA, immobile and raised BMI.  Obtain previous history of RTA, type of injury, surgical and medical treatment recieved and current ongoing follow up.  Enquire regarding the extend of immobility, urinary and facael continance secondary to the previous history.  Enquire about motor and sensory impairment in her body secondary to the accident and quality of life.  Enquire about the extend of independance or help required to attend to her daily activities such as washing herself, dressing, preparing a meal, eathing and drinking.  Exclude other medical conditions such as Diabetes, Hypertension which will precipitate her risks of complications during antenatal care such as fetal congenital anomaly, poor glycaemic control during pregnacy and associated complications and pregnancy induced hypertension.  Review medication patient is currently taking which might be contraindicated in pregnancy hence consider alternatives.  Enquire about how patient is coping with the pregnancy, family support and mental health because high risk for menta health disorders.  Measure her blood pressure, Urine for leucocytes, nitrites, protien and glucose.  If urine dip is positive sent for MC&S and treat asymptomatic UTI.  Assess her risk of thromboembolism in this pregnancy with previous history of VTE, FH of VTE, thrombophillic disorders in the family or patient and other co-morbidities. 

(b) Discuss your subsequent antenatal care given that she has no additional risk factors [12 marks].

complete her general booking of antenatal care with screening patient for infections HIV, HepB, syphillis & Rubella.  Check her Haemoglobulin to exclude iron deficiency anaemia, assess her renal function, Liver function and clotting which might be deranged secondary to her previous history and ongoing medication. Blood group and rhesus status needs identifying and Anti D offered if rhesus negative to reduce the risk of seroconversion in an invent of exposure to rhd antigens through blood transfusion or fetomaternal haemorrhage. Exclude asymptomatic bacteruria by sending an MSU.  consider a random blood sugar to exclude gestational diabetes or undiagnosed diabetes due to her raised BMI. 

Assess her booking scan and combine test results.  If she has missed the first trimester aneuploidy screen offer patient quadruple test.  book patient fo anomaly scan between 18 to 20 weeks to exclude any underlying congenital anomalies.  Her raised BMI is an indication for GTT to exclude gestation diabetes.  Haemoglobulin status and blood group rechecked at 28 weeks to exclude anaemia and development of antibodies.

Patient is immobile and raised BMI.  Therefore currently she has 2 risk factors for VTE prophylaxis.  In the absence of any other risk factors she is should be offered thromboprophylaxis postnataly for 7 days and review regulary antenatally if any changes to consider antenatal thromboproplylaxis.  the recommended thromboprophylaxis is LMWH which does not cross placenta and has a reduced risk of bleeding, thrombocytopenia, regular monitoring not required and low risk of osteophorosis in comparison to UFH. 

Patient should be reffered to the diatician and nutritionist to advise regarding healthy lifestyle and how to prevent excessive weith gain during pregnancy. 

Patient will need to be managed in a multidisciplinary team involving the obestetrician, midwife, anaesthetic, neurologist and neurosurgeons. Request review from the anaesthetic in view of suitability for regional anaesthesia and options of analgesia during labour or operative delivery.  A neurology review to assess patients current fitness and risk of deterioration of condition during pregnancy, how to avoid progression of the condition during pregnancy and any contraindications for vaginal delivery.

Social services needs involved to assess the welfare of the unborn child, family support, financial requirements, housing and extend of patients trauma restricting looking after a newborn.   

Patient should be advised to delivery at a high risk labour ward unit with continous one to one midwifery care and ctg.  mode of delivery as per the specialist input and combined agreement with the patient.

a)  History :

I would like to assess the nature of the woman’s disability and her exact reason for being in a wheelchair i.e.is it a result of a limb trauma, pelvic trauma, spinal trauma or a combination of some or all of these.  If her accident resulted in a spinal injury, I would like to know the exact level of the injury.  I would also like to know whether any surgical intervention took place as a result of the accident (specifically orthopaedic/abdominal surgery).  I would like to know about any sequelae  of her accident (in addition to her wheelchair status).  For example, bladder/bowel dysfunction and the need for catheterisation, limited hip abduction (inability to assume lithotomy position) or lymphoedema.   I would also like to ascertain whether  there are any contra-indications to regional anaesthesia or vaginal delivery. 

I would enquire about her past medical history.  Has she had any operations,  including those related and unrelated to her accident. Has she had any problems with anaesthetics.  I would also ask about any medical conditions, specifically cardio-respiratory problems and history of VTE.  I would also enquire about any mental health history/history of PTSD.

I would identify whether this lady took folic acid, specifically the  high dose (5mg)regime and also when it  was commenced (pre/post conception).   I would identify whether this lady requires analgesics or neuropathic pain medications (i.e. gabapentin) or whether she is on any other medication, such as anti-hypertensives  .  I would enquire about any allergies (drugs, latex, egg, fish etc)

I would enquire about any family history of medical problems: BP problems, diabetes, VTE and any history of genetic or congenital anomalies.

I would obtain her social history.  This would include her living arrangements and level of support/assistance she requires.  I would identify whether she smokes as this is an additional risk factor for VTE (in addition to her class III obesity and immobility).  A formal VTE risk assessment would be performed and documented in the notes.

Current pregnancy assessment & examination:

I would obtain current weight and BP.   The BP would be taken with an appropriately sized cuff and this documented in the notes.  I would ascultatate the precordium and lung fields.  Urinalysis would be obtained.  I would make an assessment of gestation: singleton/multiple with exact GA.  I would identify whether Down’s syndrome screening has taken place (NT+serum) and whether booking blood tests have been obtained and reported, specifically FBC, Blood group and antibody screen, infection screening and thalassaemia/sickle screening if appropriate.

I would examine her abdomen, pelvis, back and lower limbs, specifically looking for scars and limitation in movement.  I would perform a baseline neurological assessment specifically looking for hyper-reflexia/hypo-reflexia and spacticity.  I would also document any lower limb oedema.

b)

This lady would necessitate consultant led obstetric care.  A multidisciplinary team approach would need to be employed which would include dietetics, anaesthetics, physiotherapy plus any additional requirements that may be identified i.e. mental health input.

In view of obesity 10mcgs of vitamin D should be offered and commenced if not already done so.  A dietician would be involved to ensure a healthy diet and prevention of excessive weight gain during the pregnancy.  Education abut healthy eating patterns would be given. 

An anaesthetic review would need to be arranged and a plan for delivery made and documented in the notes.  This would specifically focus on issues of difficulty gaining IV access, difficulty with regional anaesthesia (if possible at all) and risk/difficulties with GA.  Contra-indications for vaginal delivery secondary to her post-accident status need to be identified with orthopaedic consultation if appropriate.

The lady would need to be informed about the risks associated  with the pregnancy.  These would include  difficulty in assessing the fetus (morphology & growth via USS due to poor views),the risks of GDM, macrosomia, pre-eclampsia and intrapartum problems  including difficulty with fetal monitoring, shoulder dystocia, caesarean section, PPH and perinatal morbidity.

A full thromboprophyalxis risk assessment would be performed and LMWH prescribed if required.  With x2 risk factors (obesity and Immobility) LMWH would only be required antenatally if admitted to hospital.  This should be documented in the notes and the patient made aware of this need.

Screening for GDM should be arranged.  This would include an early glucose challenge test and a 28/40 glucose tolerance test.  If +ve referral to appropriate diabetic team.

Arrangements for serial USS scanning for fetal growth/LV (as impossible to assess via SFH in this lady).

Weight should be re-documented during the third trimester.  At this stage, an assessment for manual handling requirements along with tissue viability issues should also be undertaken.  Appropriate plans should be put in place with regard to body positions in labour, repositioning schedules, skin care and support surfaces. 

Finally, a delivery plan should be formulated specifically requesting the senior anaesthetist plus obstetrician (consultant)to be informed when admitted for confinement, with early IV access obtained.

a) A history about the accident is important to identify the level of the injury and the need of any operations/repairs following that. Moreover, an enquiry about her normal function is essential in terms of mobility, sensation and continence. Any co-morbidities should also be elicited form the history as well as any additional risk factors for venous thromboembolism like past history of VTE, smoking, varicose veins, family history of VTE. Her social circumstances and the psychological wellbeing are also important to be enquired at the initial clinical assessment. It is important to ask the patient if she was taking folic acid preconceptually and up until 12 weeks and if this was at the normal or high dose. In terms of examination, her blood pressure should be checked and a urinalysis performed. Her back should be assessed for any deformities. A neurological examination for a baseline assessment of her neurological status is also important. Skin inspection should be part of the examination to exclude any pressure sores. The fetal heart should also be auscultated.

b) The patient should be booked under consultant care. She should be explained that she is at risk of VTE in pregnancy and in view of her two risk factors; the high BMI and immobility, the advice of a specialist haematologist regarding antenatal low molecular weight heparin thromboprophylaxis is essential. Moreover, in view of her BMI and the fact that it is her first pregnancy it will be recommended to commence her on Aspirin 75mg once a day until delivery in order to reduce her risk of developing pre-eclampsia. SHe should also be advised to continue or start Vitamin D 10mcg a day throughout the pregnancy and breastfeeding. At this gestation she should be offered serum screenng for chromosomal abnormalities. A detailed ultrasound scan should be arranged for about 20 weeks gestation. A close observation of the blood pressure and urinalysis is essential for early recognition of pre-eclampsia. Growth scans should be organised at 28,32 and 36 weeks. A glucose tolerance test should be organised at 28 weeks as she is at risk of developing gestational diabetes.  An anaesthetic review in the antenatal period is essential to plan for the possibility of regional analgesia in labour. If there are no contraindication, she should be allowed to have a normal vaginal delivery. It is important to ensure that all the necessary equipment are avalable for the care of this patient including hoists, appropriate size chairs, wheelchair accessible rooms and appropriate size thromboembolic stockings. When the patient presents in labour, the senior anaesthetist should be informed as well as a senior obstetrician. The theatre staff should also be aware if an operative delivery is planned to make the necessary arrangments. Postnatally she will need atleast 7 days of prophylactic LMWH and may be for longer if other risk factors are identified for example post-partum haemorrhage, prolonged labour and caesarean section.

A 24 year old woman has been referred to the antenatal clinic at 14 weeks gestation in her first pregnancy. She is wheelchair bound following an accident in childhood. Her BMI at booking is 41 kg/m2.

(a) Discuss your clinical assessment of this woman [8 marks].

Patient has 2 high risk factor for VTE immobility and morbid obesity

Present or past history of symptoms leg pain, redness, edema, buttock pain, varicose veins upto thigh suggesttive of deep vein thrombosis.

Present or past history of chest pain, sudden onset dyspnoea, cough, hemoptysis suggesting pulmonary embolism

Past history of medical disorders like diabetes, hypertension on treatment hemoglobinopathies like sickle cell diseases.

notes reviewed for nature and type childhood injury, cardiac diseases, lung disease, nephrotic syndrome, any systemic illness, autoiimune disorder like SLE which increases risk for VTE.

Known  history of blood clots in family suggesting any thrombogenic mutation and thrombophilia.

Personel history whether any problems with bowel or bladder function due to injury, smoking, alcohol, substance abuse.

Other risk factors like pregnancy concieved after ART, Hyperemesis.

Examination includes 

BMI only at booking , Pulse, blood pressure with appropriate size cuff and at every visit.

(b) Discuss your subsequent antenatal care given that she has no additional risk factors [12 marks]

To follow unit protocols for management of Morbid obesity in pregnancy. Patient requires consultant led care and joint multidiciplinary care involving dietician, obstetrican, midwife, physiotherapist and anesthesist,physician.

Blood investigations  FBC dipstic at every visit.

Routine  screenig for syphilis, hepatities B, HIV, rubella, Blood group, RH status, atypical red cell antibodies.

Ultrasound scan for gestational age confirmation, viability as they have increase risk of miscarriage.

NT scanning for anueploidy whic should be done till 13+6 weeks, can be done in this case though anueploidies not increased due to high BMI. 

Anatomy scan at 18 to 20+6 weeks of gestation may have cardiac abnormalities due to undetected diabetes.

Ultrasound growth scan from 24 weeks 28 weeks 32 weeks and 36 weeks to detect macrosomia. SFD IUGR.

Glucose tolerance test at 24- 28 weeks of gestation.

Patient plan care for pregnancy noted in paper follow up at 20 25,28 31, 34, 36weeks than weekly till 41 week.

Patient to report urgently for medical opinion assessment in case of excessive nausea vomiting, leg pain, redness, edema, SOB, chest pain. To have 24 hr access to hospital and should be accompanied by some one at all the times.

Incase of dehydration, hospital admission, smoking, preclampsia VTE risk assessment done and prophylaxis with LMWH considered.

To take tab VIT D 10 mcg every day since at high risk of osteoporosis, tab aspirin 75 mg once a day to prevent PET, wear TEDS stocking upto thigh during night to decrese risk OF VTE.

Life style modifications like moderate exercise , dietary modification but not restriction of diet.

Risk to mother like increase miscarriage, gestational diabetes, preclampsia, preterm, APH, Prolong labour, surgical difficulties in case of cesarean section, PPH, VTE , Pulmonary embolism and in very rare case mortality explained and provide written information.

Risk to fetus include preterm, birth injuries, macrosomia, IUGR, SFD perinatal morbidity and mortality

Planning place of birth at 34 weeks which will be hospital maternity unit delivery, consultant led care.

Route of delivery vaginal delivery mostly and cesarean section for obstetric indiaction only.

Anesthetic review at 36 weeks since patient at high risk for  regional and general anesthesia, like failed epidural, puncture, difficult intubation, pain coping strategies discussed. 

Incase of no spontaneous onset of labour to sweep membranes as adjunct to IOL at 40 and 41 weeks after prior information, induce at 41+6 weeks with prostglandins PGE 1.

Consultation to be documented in notes.

(a)

I will ask for her medical history. If she has history of recurrent VTE, antenatal LMWH will need to be started. If she has history of thrombophilia or medical problems such as cardiac disease, respiratory disease, SLE or nephrotic syndrome, antenatal LMWH should be started as she is morbidly obese and wheelchair bound.

I will check for any previous surgery history or if any surgery has been planned in the antenatal period as this will increase her risk of VTE.

I will ask for any family history of VTE or thrombophilia as these will increase her risk of VTE.

Additional risk factors for VTE will be asked, such as smoking, use of ART to conceive, any ongoing infection, or ongoing  hyperemesis which can cause dehydration.

I will check if she had been started on folic acid by her GP preconception and up to 12 weeks gestation. I will check if vitamin D has been started for her, which is essential for obese patients.

I will check her notes for her rubella status, and if any dating ultrasound or Down syndrome screening had been done prior to this antenatal visit.

On examination, I will check her BP with appropriate size cuff. Urine dipstick will be done to check for proteinuria.

I would also check for gross varicose veins, which is another risk factor for VTE.

(b)

I would explain that she is at risk of miscarriage, fetal structural abnormalities, intrauterine fetal death, macrosomia, pre elampsia(PE), GDM, VTE, IOL, operative deliveries, PPH.

She would need to be seen by a multidisciplinary team. She should be seen by a consultant obstetrician in the clinic to discuss delivery plans, a consultant anaesthetist to assess and discuss about early venous access and analgesia in labour. She should be seen by the dietrician to discuss on minimising weight gain during pregnancy, but weight loss should be discouraged. Other team members will include midwives and physiotherapist.

I will start aspirin 75mg daily for her as she is at risk of PR with risk factors of raised BMI and 1^st pregnancy.

I will start vitamin D 10mcg daily for her as she is obese.

I will advise her to have regular lower limb physiotherapy and to avoid dehydration to minimise VTE.

She needs regular follow up with BP check with appropriate size cuff and urine analysis for protein at every visit. VTE risk assessment should be done regularly in clinic or when she is admitted to hospital, and LMWH started if she has additional risk factor during the antenatal period.

OGTT will be performed at 28weeks as she is at risk of GDM.

I will remeasure her weight and BMI again at 3^rd trimester.

Transvaginal ultrasound scan would be needed for dating and viability ultrasound if it was not done earlier.

I would offer Down’s syndrome screening with maternal serum screening as she is already 14 weeks. However, it may not be accurate due to her raised BMI as AFP levels are lower.

She needs a detailed fetal anomaly ultrasound at 18-20 weeks as the fetus is at risk of structural abnormalities such as sacral agenesis and neural tube defects.

Symphysal fundal height is difficult to assess due to her habitus thus serial growth ultrasound will be needed to monitor for fetal growth and to detact fetal macrosomia.

Ultrasound for fetal presentation may be needed at 36 weeks as abdominal palpation may be difficult due to her habitus.

Risk assessment for manual handling requirements should be done in the 3^rd trimester to ensure that there are appropriate equipments to support her weight and transfer equipments to minimise injury to staff when transferring her.

She needs to be delivered at a consultant led unit with anaesthetist of at least ST6 level with continuous CTG monitoring with fetal scalp electrode.

(a) I would ask about her accident, if it was a spinal cord injury affecting her bladder and bowel function. I would ask if she requires clean intermittent self catheterisation as it neurogenic bladder increases her risk of urinary tract infection. I would ask if she has any sensation and motor function in her lower limbs and pelvis as it can affect the mode of delivery. I would ask her for other medical conditions and treatment that might affect obesity like pre-existing diabetes, hypertension and ischaemic heart disease. I would ask for any personal or family history of venous thromboembolism as it will increase her risk of thromboembolism. I would ask if she smokes as it is a risk factor for thromboembolism. I would ask if she has been taking folate supplement of 5mg as her fetus is at increased risk of neural tube defects. I would measure her blood pressure with an appropriate sized cuff, and do a urine dipstick for proteinuria. I would look for signs of diabetes like acanthosis nigricans.

(b) This is a high risk pregnancy and morbid obesity is associated with increased maternal morbidity and mortality. She needs to be seen in a consultant-led unit with a multidisciplinary team including a consultant obstetrician, consultant anaesthetist with an interest in obesity, specialist midwives and dietician. She needs vitamin D 10micrograms per day throughout pregnancy. She needs to be counselled about the risks of obesity and the effect on the pregnancy and baby and be referred to a dietician for advice on healthy eating habits. At every antenatal visit, her blood pressure and urine proteins should be checked as she is at increased risk of hypertensive disorders and pre-eclampsia. Aspirin 75mg should be considered for prevention of pre-eclampsia. She needs a midstream urine culture every month as she is at increased risk of asymptomatic bacteruria and she should be treated with antibiotics if the cultures are positive. As she is 14 weeks, she should be offered a quadruple serum test between 15 and 20 weeks. Even though her risk of Down Syndrome is low, she should still be offered screening. A fetal anomaly scan showed be done from 18+0 to 20+6 weeks but she must be counselled that ultrasound might be difficult in view of her weight and that obesity alone is associated with increased fetal malformations like neural tube defects. At 24-28 weeks, she needs a 75g oral glucose tolerance test to screen for gestational diabetes because she is at increased risk. She is at intermediate risk of venous thromboembolism as she is obese and immobile and would need thromboprophylaxis 7 days post delivery. At every antenatal contact, screening for additional risk factors for thromboembolism should be done. If she develops additional risk factors like pre-eclampsia or hospitalization, antenatal thromboprophylaxis should be started. Low molecular weight heparin should be used and the dose adjusted for her weight. She needs to be seen by the anaesthetist in the 3^rd trimester to discuss the options and risks of anaesthesia during labour. A professional qualified for maternal handling should be involved to discuss about the issues of transferring, safe working loads for equipments and staffing during hospitalization. Written information about obesity in pregnancy should be given and contacts for local support group should be available for her.  

If women with  term membrane rupture  for 6 hrs with HV and viral load  > 50 copies/ml presents than should we do ceasrean section still or expedite vaginal delivery with ZDV infusion.

Is the situation same whith similar clinical condition when it is pretrm rupture.

This patient is at increased risk of venous thromboembolism due to her immobility . this risk is further increased due to her morbid obesity.

The exact nature of woman’s disability would be enquired into. The extent to which she can perform her daily chores would be asked.  If  bladder and bowel continence is present would be asked.

To what extent she is dependant on her carers to carry out her daily activities will be enquired.

The degree of mobility permitted at the hip joint would be enquired along with the degree of pain she feels during her daily activities.

Any particular position relieves or exacerbates her pain. To what extent her quality of life is affected would be assessed.

I would also ask if she is having any sensory or motor impairment . this if present would suggest a higher level of lesion.

Would ask about nausea and vomiting in this pregnancy and how she is coping with the problem. As dehydration may further increase the risk of VTE.

Personal h/o thrombiphilia screening and the type of defect if she has any,as this would determine her need for antenatal thromboprophylaxis.

Family history of thrombophilias and VTE will be asked for.

Past h/o any thromboembolic event would be elicited. If she received any thromboprophylaxis and the duration of it.

Would ask about any co-existing medical conditions like diabetes mellitus, SLE ,cardiac and respirtory problems. Presence of these conditions would modify the pregnancy care.

Past h/o any surgical interventions she had, both pelvic and abdominal surgeries, bariatric surgery and renal transplantation This would help in planning the mode of delivery.

Personal history of her life style. If she smokes, consumes alcohol or uses any recreational drugs . if  she is using any psychiatric medicines for depression and anxiety,

she may need a clinical psychologist or a psychiatrist counselling.

Drug history regarding antihypertensives, oral hypoglycemics would be taken. Details of any other drugs taken and drug  allergies is important . this will help in modifying the drug regimens to those that have a known safety profile in pregnancy such as Oral hypoglycemics to insulin and ace inhibitors to labetolol.

Examination will include blood pressure measurement with an appropriately sized cuff.

Abdominal palpation for symphysio-fundal height and presentation of the fetus will be difficult .

Fetal heart would be auscultated .

Examination of skin for pressure sores, back for any orthopedic deformities is carried out.

Examination of lower limbs for swelling, redness, any varicose veins and signs of inflammation .

 calf tenderness to be looked into.  Any spasticity and difficulty in joint movements will be checked for.

Investigations  will include FBC to check for anaemia.

ABO grouping and RH typing ,antibodies screen.

screen for HIV, HBV , and rubella status.

Baseline kidney function tests and liver function tests would be done.

b) This patient needs management by a multidisciplinary team consisting of a consultant obstetrician,consultant anaesthetist, dietician and a senior midwife with experience in handling such cases , a physiotherapist and other specialists according to the complications.

I would provide relevant information about the maternal and fetal risks involved.

Weight and BP are checked and noted down.

Haemoglobin levels are checked and if  less than 10.5 gms/dl Iron supplements are given.

Obese women are at increased risk of neural tube defects hence I would ensure that the woman is taking  pre-pregnancy folic acid ,starting at least one month before conception and continuing during the first trimester of pregnancy. the dose must be 5mgms/day.

Obese pregnant women are more prone to vitamin D deficiency hence I would give her10 micrograms of Vitamin D supplementation daily.she must continue this throughout pregnancy and breast feeding.

I would refer the patient to dietician as she needs dietician’s input for a modest weight gain in pregnancy( 6-7 kgs) at the same time weight loss is not recommended.

Moderate exercises like walking for 30 mins. daily would be recommended.

I would do a dating scan to date  the pregnancy and for viability.

I will offer serum screening  for aneuploidy .

The results may not be accurate. AFP levels will be low due to obesity. and may need a fetal medicine specialist to interpret the results.

I will  assess the patient at first antenatal visit and throughout pregnancy for the risk of thromboembolism.

Will provide thromboprophylaxis according to maternal weight.

She will be encouraged to maintain good hydration and advise for lower limb exercises will be provided by  physiotherapist.

This patient is at increased risk of hypertensive disorders

At each visit her BP would be checked with appropriate sized cuff  and urine checked for proteinuria.

I would start low dose aspirin 75mgms daily until delivery as this patient is at increased risk of pre ecclampsia due to her obesity and being a primigravida.

She is at risk of gestational diabetes mellitus and would have a screening test for the same using  2 hour 75g oral glucose tolerance test at 24-28 weeks.

The fetus is at increased risk of neural tube defects.

Patient will need a  detailed fetal anomaly scan at 18-20 weeks preferably in a tertiary centre due to limitations  in the presence of marked obesity .The anatomic structures will be seen less clearly with raised BMI.

Symphysio-fundal height measurement will be unreliable and this patient will need serial growth scans every 2-4 weeks to monitor fetal growth and detect macrosomia.

Ultrasound assessment of  estimated fetal weight will be carried out in the third trimester.

This will help to formulate a plan of delivery.

CS would be recommended for babies with estimated fetal weight of more than 4.5 kgs.

fetal presentation would be assessed by ultrasound in the late third trimester.

Weight will be rechecked in the third trimester .

She needs to be referred for anaesthetic assessment so that potential difficulties with venous access, regional or general anaesthesia can be identified.

Anaethetist of ST6 level is recommended to assess the case.

An anaesthetic management plan for labour and delivery will be  discussed and documented in the medical records.

Assessment of potential risks to the staff in lifting or moving the woman is carried out in the third trimester and appropriate precautions are taken regarding the sizes of beds and tables.

Delivery would be recommended in hospital in the presence of senior obstetric and midwifery staff because  of increased risk of shoulder dystocia.

A 24 year old woman has been referred to the antenatal clinic at 14 weeks gestation in her first pregnancy. She is wheelchair bound following an accident in childhood. Her BMI at booking is 41 kg/m2. (a) Discuss your clinical assessment of this woman [8 marks]. (b) Discuss your subsequent antenatal care given that she has no additional risk factors [12 marks].

A medical history should be taken looking for any underlying medical conditions such as diabetes,or renal disease as these will further affect the pregnancy. More information is required with regards to this ladies injuries and what range of mobility she has, for example is it going to be possible to perform an vaginal examinations in labour or an instrumental delivery. It will also allow planning for admission such as special matresses or aids the patient might need. She may need additional support with the baby at home and therefore may need additional authorities input.  She is high risk for VTE therefore the risks (potential bleeding) and benefits of LMWH should be addressed and discussed with the patient. If LMWH is to be started a renal profile should be checked as the dose may need to be adjusted.  A BP should be measured with the appropriate size cuff and the urine checked. This lady may have spinal injuries and therefore she will need an anaesthetic assessment. One should establish if she has been taking 5mg folic acid. Mobility could hinder scanning and this will be compounded by the raised BMI. 

This lady should be seen in a consultant led clinic by an obstetrician ideally with a specialist interest in obesity. She should be counselled about the risks of obesity on the pregnancy such as increased risk of PET, GDM, fetal macrosomia, dysfunctional labour, congenital anomalies, PPH and increased operative delivery. She should commence Vit D if she is not already taking it. She should commence Aspirin 75mg OD. She is too late for combined screening but should be offered serum screening.. She should be made aware of the limitations and that the resuls will be affected by BMI. She should have a detailed anomaly scan as routine AN care, this should detect a NTD if present (80%).

She should have a GTT performed between 24-28 weeks. She should have her BP monitored every 3 weeks until 32 weeks and every 2 weeks afterwards to monitor for the development of PET. As abdominal palpation will be inaccurate she should have a scan for growth and presentation in the third trimester. Re weighing in the third trimester will help staff plan if any additional equipment is needed ie special theatre bed. She should be seen antenatally be the anaethetist to discuss analgesia and anaesthetic. She should be advised to stop LMWH if she goes into labour. On admission the senior registrar and anaethetist (ST6 and above) should be involved in this womans care. She should have one to one care. 

This patient is with high risk pregnancy due to her morbid obesity and immobilization.  Detailed history taken to determine the type of her disability, impact on her daily activities, any sensory or motor loss and to which extent she is dependable , any surgical operation she underwent and current medication in use As this will help in subsequent management plan of her pregnancy. Medications contraindicated in pregnancy need to be changed to alternative safe options. i will ask if she conceived spontaneously  and if  booked for antenatal care or not . Usual pregnancy symptoms like nausea, vomiting are asked for and how she is koping with them as dehydation would further put her on risk of VTE. Other risk factors for VTE are explored i-e  previous VTE , thrombophilia, VTE in first degree relative, use of OCPs. If she is receiving any thromboprophylaxis that need to be continued in pregnancy and postpartum. History of medical disorders like diabetes, hypertension  is taken as obese pt is at high  risk of developing  gestational diabetes and pregnancy induced hypertension and if these disorders already present would futher increas her risk. Her BP is checked with appropiate size cuff each time. Varicose veins, swollen legs are enquired and looked for in view of her VTE risk. i will ask her about smoking, excess use of alcohol or use of recreational drugs as they need to be modified . Thorough clinicial examination is done including systemic examination and examination of legs done. This pt should receive consultant led obstetric care.

B.

This pt should be manage by Multidiscipilinary team involving consultant obstetrician, consultant  anaesthetist, physiotherapist and experienced midwife. A detailed information is given  regarding potential risk and copmplications she may have due to her high BMI and imbolization. First of all there is difficulty in establishing her pregnancy viability and dating if not previously done without the transvaginal ultrasound. As she is at 14 weeks screening test for aneulopoidy by tripplet or quadruplet test offered . In case invasive testing by amniocentesis is required it would difficult to perform due to bulky abdomen. as pregnancy advances it would be difficult to determine fetal size, the presentation of fetus, difficult to hear Fetal heart sounds and need serial scans for fetal growth assessment as there is risk of macrosomia. In view of her high risk for developing pregnancy induced HTN, Her BP is checked with apropiate size cuff at each antenatal visit to avoid falsely high and low readings. urine analysis done to check for proteinuria and urinary tract infection at each antenatal visit. DEtailed anomaly scan is done at 18- 20 weeks. I will explain to her that it would be difficult to look for congenital anomalies especially of skeletal due to her bulky abdomen. screening for gestational diabetes offered at 24- 28 weeks. Her need for thromboprophylaxis is reviewed and if needed clear plans for antenatal and postnatal administration  are mentioned in her notes. Her hb is checked and and repeated at 28 weeks, any iron deficency is correceted with hematanics after excluding hemoglobinopathies. She is advised to adhere to her care plan as early identification and treatment of potential problems would  reduce maternal and perinatal morbidity. She is encouraged to have physiotherapy sessions . at 36 weeks her plan for delivery is made after detailed discussion with pt. If she had disability that limit her mobility at pelvis or resulted in pelvic deformity she may require delivery by elective Caesarean section. Her rewiew by anaesthetic is arranged to determine potential problems related to General / local anaesthetic. all these things clearly mentioned in her notes.        

This  is type 3 obesity ie  morbid obesity  and in the same time  she is an immobile patient ,so this increases the patient risk for thrombo embolism.

A

The direct cause of her immobility  should be adressed(whether amputaded or paralysed as  this may affect  the delivery  plan  and the proper  delivery position)

This obesity  increase the risk of developing gestational diabetes,pregnancy induced hypertention and pre-eclampsia.

Previous history of deep vein thrombosis(DVT), first degree relative with history of  DVT,history of type2 diabetes,and pe-existing hypertention , hisory of thrombophilia and antiphospholipid  syndrom is important to categorize the pt  risk for DVT.

  I would measure her blood pressure using appropriate larg cuff ,and would measure her waist

I would screen the patient  for diabetes,proteinurea, as well as for thrombophilia.

B

The antenatal care for this high risk patient  should be carried out by consultant,with advice from dietitian  regrdingr the nutrition through out the pregnancy

There would be  dificulty in assessing fetal growth and wellbeing as ultrasound image will not be clear in such morbid obesity

Growth scan shoud carried out since the 24 weeks gestation as the fetus at risk of macrosomia

The patient should be supplemented with 5mg folic acid and 10 microgram of vitamin D as both will be low in obese patient

The patient has two risk factors for DVT(immobility and obesity) so no need for antenatal thromboprophylaxis, but should be given if patient  admitted for any reason

I would advice the patient to be well rehydrated,and to use TEDS

I would screen the patient regulary for proteinurea and RFT

Glucose tolerance test should done at 24 and 28 weeks of gestation

In the third trimester the patient should be assessed  by  the anathetist, and  a plan for analgesia should be documented clearly in her antenatal book

the mode of delivery and the suitable delivery position should be written clearly in her note,as well as whom will supervise the  delivery(THE SENIOR OBSTETRITIAN. 

The patient’s clinical status of wheelchair bound to be assessed fully which regard to either motor or sensory impairment, or impairment of both or none of them.   Make sure, we liaise with the neurosurgical team and orthopaedic team in continuing care: need to know about bladder and bowel control and in relation to wheelchair situation.  Position at the time of labour and whether pushing in labour is possible to be ascertained.  During all her visits to hospital in future for scan or for examiniation – per abdominal, speculum or vaginal examination, whether we need extra help to move patient to position her in bed, to be ascertained.  Whether she had any spinal surgery and possibility of regional anesthesia in labour and delivery should be explored.  Need to make sure, moving from wheelchair to bed for examination or scan or for delivery: in view of manual handling.  Enquire in detail whether she ever had any thrombosis history or family history of thrombosis to ascertain whether she needs antenatal thromboprophylaxis as she already has moderate risk: wheelchair bound and high BMI.  We need to know whether she has any other longterm medical disorder such blood pressure, diabetes or any other condition which need modified antenatal care.

She should be cared under Consultant led clinic.  She should be advised to have Vitamin 10mcg in view of increased BMI and osteoporosis risk.  She should be given aspirin 75mg/day, in view of her BMI-first pregnancy, she is high risk of having pre-eclampsia, starting from as soon as possible (ideally from 12weeks) until delivery.  We need to know, whether she already had her 1^st trimester scan to check viability, number of babies, exact weeks of pregnancy based on scan dating and down’s screening.  If she has not had them, we should arrange immediately to have a base measurement.  If she missed the scan for nuchal translucency or 1^st trimester serum screening, we have to offer and arrange for her to 2trimester serum screening.  She needs anomaly scan around 18 and 20 weeks.  She needs extra scan at 34 weeks to assess growth and liquor in view of high BMI.  Also she needs glucose tolerance test between 24 and 28 weeks to assess for gestational diabetes.  Discuss with her the high risk of thrombosis, and any admission to hospital, she would need thromboprophylaxis.  She should be aware, avoid dehydration.  Each visit to hospital or midwifery clinic, she needs blood pressure to be checked using appropriate cuff size and urine analysis for protein to screen for PET.  Anasthetic assessment should be requested and make sure plan of analgesia in labour documented.  Plan and mode of delivery should be discussed around 36weeks.  Discuss with the patient to aim for spontaneous labour and vaginal delivery unless there is an obstetric indication for caesarean section.  She should deliver in a consultant led hospital unit.  She needs intravenous access in early labour itself.  She should be cared by ST6 and above or equivalent level by anesthetist and also senior obstetric registrar and consultant to be involved during her delivery if instrumental delivery or caesarean is needed.  Both anesthetic registrar and Obstetric registrar should be alerted as soon as patient is being admitted to hospital for delivery.  Refer the patient to dietician to help with diet and avoid excessive weight gain during the antenatal period.

A)    This patient is high risk case of VTE as three factors are present; paraplegia (immobility), pregnancy and obesity class III (morbid obesity).Enquire if this pregnancy is by spontaneous conception or by assisted reproduction which further increase risk of VTE.

 History has to be taken regarding previous episodes of VTE, family history of VTE (Ist degree relative <40 yr) and if before pregnancy on anticoagulation with warfarin or LMWH. Enquire about the level of spine injury, if any medical records available, any surgery done in the past. If she is a case of DM, HTN or renal disease and if controlled on drugs or not. Ask for the symptoms of hyperemesis, which may lead to dehydration and further VTE. If she is use to smoking or not.

Clinical examination is of paramount importance to decide the plan of further management. BP has to assessed in right arm in semi-recumbent position with proper size cuff(in acc.to arm circumference), Chest/CVS examination to look for evidence of any dysfunction, abdominal examination to see if uterus is palpable or not. Spine examination is very important to see any local infection/ trophic ulcer (to decide the anaesthesia during delivery), kyphosis or scoliosis if present; may make lithotomy position difficult during delivery.

Investigations include routine antenatal investigations; Blood group,FBC, urine protein dipstick test, spot protein: creatinine test, fasting blood sugar,RFT and thrombophilia screen. TVS should be performed to assess the fetal growth as TAS may be difficult to assess due to obesity.

B)    She should receive antenatal care in consultant –led unit. Prospective management plan must be discussed with the couple about  thrombo-prophylaxis during pregnancy, antenatal care and mode of delivery. Multidisciplinary team must be involved in her care including consultant obstetrician, anaesthetist, dietician,trust nominated expert in thrombosis in pregnancy .

Provide written information leaflets about the risks in her pregnancy and how to take care of  herself. Start LMWH (in accordance to weight) immediately and counsel her that she need it to be administered postnataly for 7 days. Start 5mg folic acid and 10ug Vitamin D throughout her pregnancy(Obesity causes vitamin deficiency).

Weight reduction is not advisable during pregnancy but diet has to be regulated on consultation of dietician. Perform routine antenatal tests; FBC, Urine protein dipstick test, spot protein: creatinine test. TVS, to assess the fetal growth. OGTT at 24-28 week with 75 gm oral glucose. Regular BP monitoring has be done at community level,3 weekly from 24-32 week and every 2 weekly from 32 week till delivery.

She should be advised of regular wearing of thrombo-embolic deterrent stockings.She should have an assessment by a qualified professional in the third trimester to determine manual handling requirements and tissue viability issues . Ensure  her of required equipments like ultrasound couches, lateral transferring equipments, large labour chairs  would be a help to her during labour. She should be assessed by consultant anaesthetist so as to decide the mode of anaesthesia which suits her during labour. Counsel her and respect her wish about the mode of delivery. Counsel her that elective CS would be most suitable to her.

As per hx she is morbid obese with immobility, so there is increased risk of morbidity & mortality to her & to her fetus. I will ask her any present complaints like breathlessness, or any issue related to pregnancy. I will ask her any treatment like folic acid 5mg started or not as it reduces risk of NTD if started in initial 12 wks. similarly I will confirm any drugs like statin ,ACE etc taking for obesity & cronic HT respectively as these drugs should be stopped in pregnancy. I will ask her any personal or family hx of thromboembolism as she is more prone to thromboembolism. Similarly I will ask for any fm hx of PIH ,which is a risk factor for PIH in this pregnancy. I will ask her any hx of PCOS as it is common in obese pt & risk for miscarriage, which may help in counseling .Fm hx of thrmbophilia may help in future management of thrmboprophylaxis. I will conform if any smoking hx, as it increases the risk of pregnancy complications.I will take her BP,WT,as a base line.I will examine her CVS & RS system & if required referred to related specialist ,as risk of cvs more in obese pt. I will palpate uterine size ,may be difficult because of obesity.I will conform her any scan (dating),Rt ANC screen test,etc.

B)I will counsel her & give information about the increased risk of obesity on pregnancy like miscarriage ,NTD ,PIH, preterm labor ,Stillbirth. she may require frequent ANC visit & USG for assessement of fetal parameters. Difficulties may arise during labor for CTG , so she may require int monitoring. Increased risk of failed epidural & intubation are possibility .She may develop GDM, preeclmpsia in this pregnancy so she should be followed up in consultant care unit. I will start aspirin 75 mg daily till delivery as she has two moderate risk factors for preeclampsia,& it reduces the risk (NICE). I will start her Vit D 10 mg daily, as it is commonly deficient in obese patient & I will tell her she will require to take in entire pregnancy & lactation.I will offer her quadruple test or triple test screening test for aneuploidy , if not done in 1st trimester(combined test).I will inform her about anomaly scan at 20 wks & 24 wks cardiac outflow tract as obese pt are increased risk of fetal cardiac disease. Growth scan will be advised from 28 wks ,3 to 4 wks interval as ,she is of risk of macrosomic fetus.

            Similarly OGTT(75 gm),will be advised to be done at 24 to 28 wks. She will be required to have anaeasthetic consultaion during 3rd trimester,for planning of analgesia or anaesthesia in labour & delivery & paln should be recorded. Multidisciplinary care like neonatologist ,senior midwive,OT staff should be informed about the case ,& need of persons, equipments should be in place & at the time of need ,be available. Similarly her WT should be measured in 3rd trimester ,for planning of delivery & need of instrunments like trolly, bed, OT table, lateral transfer equipments. Her pressure points over the body , should be assessed in each visit, as the risk of bedsores a possibility. I will assess her in each visit about the risk for thromboembolism & if required thromboprophylaxis would be started. Otherwise it should be recorded in her notes about Postpartum thromboprophylaxis for 7 days at least, may need to extend .All details of plan of management of delivery will be recorded in her notes. I will provide her information leaflet for further information & knowledge.

1. I would take a detailed history asking about the details of accident she had including the site and extent of injury she suffered. I would enquire about her mobility and any associated co-morbidities such as bowel and bladder dysfunction as this will put her at high risk of recurrent UTI and increase her risk of pre-term labour. I will ask if she has to have any operative procedures after the accident such as laparotomies or any orthopaedic procedures. I will enquire if she has other co-morbidities such as hypertension or diabetes or history of thrombosis. I will ask if she needs extra help for day to day work at home as this will give an idea regarding her mobility. Her thoughts on being pregnant should be explored and any psychological needs explored. I will also enquire in a non-judgemental way how she is going to cope with pregnancy and labour and with baby afterwards and if she has support at home. Then I will check her BP using appropriate sized cuff,  test urine for leucocyte and nitrates and send mid-stream urine if it is positive.  I will also assess her risk of thrombosis and start on Clexane 40 mg if she has 3 or more moderate risk factors.

1. She should remain under consultant led care. Multidisciplinary team involvement is necessary including physiotherapist, social services. I will start her on Aspirin 75 mg to reduce her risk of developing pre-eclampsia and vitamin D 10 mcg and advice to continue throughout pregnancy. She will need to continue vitamin D post natally as well if she plans to breast feed. If she does suffer with bladder dysfunction, I will ensure MSU gets sent every month and any infection treated promptly to reduce her risk of pre-term labour. I will refer her to anaesthetist. I will also get physiotherapist involved to assess her mobility and put plan in notes. She will have GTT at 28/40 to rule out diabetes. Her risk of thrombosis will need reassessing in 3^rdtrimester. She will have her BP and urine checked 3 weekly until 32 weeks and then 2 weekly until delivery. I will also request growth scan at aroung 34 weeks to rule our growth restriction as her obesity might make assessment by palpation difficult. Mode of delivery should be discussed at around 36 weeks; however, caesarean section should be reserved for obstetric causes. I will also inform theatre practitioner and labour ward in-charge, informing them of expected due date and extent of disability this woman has. This is to ensure that appropriate hoist and equipment is available when she arrives on Labour ward. I will advise her compression stockings to reduce her risk of DVT. I will also inform GP and her mid-wife of the plan and document clearly in notes.  

A)

Elicit the reasons for her being wheelchair bound. A spinal cord injury(SCI) will alter perception of labour and predispose to autonomic hyper-reflexia if the lesion is above T6. Pelvic trauma with resulting pelvic deformity may preclude vaginal delivery. Assess her risk of venous thrombo-embolism (VTE). A prior history of VTE, first degree relative with VTE or personal history of thrombophillia increases risk of VTE in pregnancy. A history of diabetes mellitus and hypertension is more common in obese patients. A social history eliciting details of help available at home and whether she is in need of financial aid. Assess her ability to perform basic tasks like maintenance of personal hygiene and degree of mobility at home. Symptoms of bladder and bowel dysfunction are present in SCI.

Examination findings include blood pressure checked using an appropriate sized cuff. Examine her skin looking for pressure ulcers. A neurological examination would be done. Assess her ability to adopt the lithotomy position. Difficulty abducting or rotating her lower limbs at the hip or flexing her hip while in the lateral position may make achieving a vaginal delivery difficult.

B)

Adopt a consultant led multi-disciplinary approach involving obstetricians, orthopaedic and neurosurgeons, medical social workers, dieticians, district health nurses, her general practitioner and physiotherapists. Achieving epidural anaesthesia, intubation at general anaesthesia and intravenous access may be difficult and warrants antenatal anaesthetic assessment. Offer psychological counseling services. Advise that frequent shifts in position would prevent pressure ulcers. Advise against weight loss and dietary restriction in pregnancy as this may predispose to fetal growth restriction. Advise her that obesity increases the incidence of adverse events. These include pre-eclampsia, macrosomia, stillbirth, operative intervention, anaesthetic risk, birth related genital tract trauma, shoulder dystocia and increased perinatal mortality. Offer influenza vaccination if in ‘flu’season as obesity and pregnancy are risk factors. Offer vitamin D supplementation(10micrograms daily and continue while breastfeeding) as obesity in pregnancy predisposes to vitamin D deficiency. Offer antenatal Low Molecular Weight Heparin prophlylaxis to be started as soon as is possible to be continued 6 weeks post partum. Her blood pressure would be measured at each visit. A Doppler of the uterine artery Doppler waveform would be done at 22-24 weeks gestation. Notching has a high positive predictive value for pre-eclampsia and IUGR. Start aspirin 75mg daily and continue until delivery.  Aspirin reduces the incidence of pre-eclampsia. An OGTT should be done at 24-28weeks as her obesity is a risk factor for gestational diabetes. Serial fetal growth scans would be done 2-4weekly from 24 weeks as an obese abdomen makes Symphysio fundal height measurements inaccurate. Recalculate her BMI in the third trimester.

Attendant staff should be alerted of her deficit and of the increased risk of traumatic injury while moving her.

Aim for a spontaneous vaginal delivery with caesarean section indicated for obstetric reasons. Caesarean section would be preferred if the patient is unable to adopt the lithotomy or lateral positions for labour or if there is significant pelvic deformity.

DEAR PAUL

About aove case you give mark when answer is to start  LMWH in antenatal peroid and you give mark also when the answer is no need to antenatal LMWH because of presence of just to risk factors

Please what is the true answer