Essay 286 - Obesity

A) I will inform the ptient  regarding the diagnosis ofgestational diabetes.I  will provide her accurate information regarding the risks associated with obesity and diabetes in pregnancy and how these risks can be minimized .Diabetes  and obesity poses her on  risk of developing  pre eclampsia. Risk of Fetal macrosomia , ultrasound limitations for diagnosing anomalies,potential difficulties during labour for fetal monitoring, , shoulder dystocia  and emergency CS  should be discussed.She should be followed and give birth in consultant led unit with a Multidicsiplanary team  involving anaesthetist/endocrinologist/dietician and diabetic nurse .Patient should be given advice about healthy eating and appropriate exercise by a trained dietician( written information diet charts and caloric requirement).It will help  the women to control her  blood sugar and optimize weight gain during pregnancy  .Home blood sugar monitoring (HBSM) fasting and one hour post meal with targets.(fasting 3.9-5.9 mmol/land one hour post meal 7.8 mmol/l) and  should be followed in specialized diabetes in pregnancy clinic every  two weeks , and weekly in third trimester.This regular follow up in this obese woman  will help to identify  uncontrolled suger levels  earlier,and to start hypoglycemic treatment  if needed.She should be given information regarding hypoglycemic symptoms .Blood pressure should be measured by  using appropriate size cuff to avoid any error and urine checked  for proteinurea on each visit .Patient should be advised for symptoms of preeclampsia ,and to report hospital if feeling unwell. Her cuff size should be documented.Serial ultrasound is required to moniter growth of fetus as abdominal  fat may interfere with SFH (sympheseal fundal height).Antenatal consultation with obstetric Anaesthetist  to get details regarding difficulties in intravenous access,regiona analgesia ,resiting epidural ,and  complication of general anaesthesia difficult intubation,risk of aspiration.Anaesthesia management plan should be documented in medical record of women.Patient should accessed by a qualified  professional  staff  to determine  manua l handling requirements for child birth{  beds ,operating tables appropriate size TEDS, lateral transfer equipments} and to consider tissue viability issuesAppropriate care plan of lady positioning ,repositioning ,skincare ,avoiding pressure sores should be documented.Remeasuring of patient BMI/weight in third trimester will allow appropriate plan to be made for equipment and personelle required for labor and deleivery.

B)Intrapartum care.

Intravenous access in early labour.I will moniter blood suger  / start insulin glucose regeimen if she is on insulin. Inform the anaesthetist ST level 6 or above to evaluate for regional analgesia  and document it. Continous midwifery care  and need fetal scalp electrode  for fetal heart rate monitering or ultrasound as hand held Doppler and external fetal monitoring may  be difficult. A  senior obstetrician ST level 6 or above should review her progress. Operating theater alerted if suspected delay in labour. Consultant on call should be informed.Instrumental deleivery   should be by consultant or supervised directly by consultant if trainee is not enough experienced.Active management of  third stage of labour as high risk of postpartum heamrhage

.Postpartum 

early mobilaztion  good hydration TEDS and LMWH FOR 7 days.Encourage for breast feeding and provide lactational consultation  and support for maintanece of breastfeeding.I  wil provide nutritional  advice by trained  professional  for weight optimization before embarking on next pregnancy and will advice her to continue effective contraception.. She should be be advised to do glucose tolerance test at six week post natal .She should be advised a regular follow up by GP if 6 weeks  glucose test normal  to screen for type 2 DM.I will advise her to have annual screening for cardio metabolic risk factors ,weight management, and life style advice

A 34 year old woman has a glucose tolerance test at 28 weeks gestation because her BMI is 42 kg/m2. Fasting blood glucose is 6.9 mM and 2h glucose level is 11.6 mM. (a) Discuss your subsequent antenatal care [10 marks]. (b) Vaginal birth is planned and she presents in spontaneous labour at 37 weeks. Discuss your intra-partum and post-partum care [10 marks].

a) This lady has two main antenatal issues, class III obesity as well as gestational diabetes. 

I would take a further history to evaluate for additional risk factors for thromboembolism as well as pre-eclampsia. I would also ask about additional co-morbidites such as hypertension. 

I would explain the risks of these conditions in pregnancy. For obesity, there is increased risk of pre-eclampsia, thromboembolism, dysfunctional labour caesarean section, wound infection, anaesthetic complications, postpartum haemorrhage and maternal mortality. There is also an increased risk of fetal macrosomia, shoulder dystocia, stillbirth and perinatal mortality, and greater difficulty with antenatal ultrasound surveillance. For gestational diabetes, there is also an increased risk of pre-eclampsia, fetal macrosomia, shoulder dystocia and stillbirth. In addition, there is a higher chance of induced labour, as well as neonatal risks of respiratory distress syndrome, polycythemia, jaundice, hypoglycemia and hypocalcemia.

I would advise her that good glycemic control reduces the risks associated with gestational diabetes, and on limiting pregnancy weight gain to 7-11kg to mitigate the risks associated with obesity. Weight loss and dieting are not recommended during pregnancy

I would refer her to the dietician for dietary advice for glycemic and weight control. If she has additional risk factors for thromboembolism, I would start her on low molecular weight heparin adjusted for body weight. I would also advise her on monitoring of fasting and post-prandial blood glucose levels, aiming for 3.5-5.9mmol/L pre meals and less than 7.8mmol/L post meals. If she is unable to achieve these targets after 1-2 weeks of exercise and diet control, I would refer her to the joint pregnancy and antenatal clinic to start basal-bolus insulin. I would also start 10mcg vitamin D supplementation. 

I would also refer her to the anaesthetist for assessment including evaluating venous assess, reginonal anaesthesia and potential general anaesthetic complications. An anaesthetic plan should be documented in her hand-held and hospital notes. I would also refer her to an appropriately qualified person to evaluate manual handling requirements.

I would monitor her for pre-eclampsia 3 weekly from 24 weeks then 2 weekly from 32 weeks till delivery by using an appropriately sized blood pressure cuff and urine dipstick for proteinuria. I would also monitor fetal growth every 4 weeks, looking for fetal macrosomia and polyhydramnios. Delivery should be offered from 38 weeks. 

B) This lady should be delivered in a consultant-led unit with neonatal resuscitation facilities. She should have continuous midwifery care, and obstetrician and anaesthetist of ST6 level and above should be available for delivery. The anaesthetist on duty should also be informed if delivery is anticipated and theatre staff should be informed if the lady weighs above 120kg and operative intervention in theatre is required. 

Early venous access and epidural should be offered. Her blood sugar should be monitored with the aim of keeping blood glucose levels between 4-7mmol/L, and an insulin infusion may be commenced if these targets are not achieved. A dextrose drip should be given together with the insulin infusion and potassium replacement should be considered. If there is difficulty with fetal monitoring, a fetal scalp electrode may be used or ultrasound for detection of fetal heart. 

If the patient is on prophylactic low molecular weight heparin. this should be stopped for at least 24 hours prior to insertion of the epidural catheter. 

Staff should anticipate shoulder dystocia as well as postpartum haemorrhage. The third stage of labour should be managed actively. 

Postpartum, the neonate should stay with the mother unless there are medical indications for separation such as respiratory distress. Early feeding then regular feeding should be encouraged to reduce the risk of neonatal hypoglycemia. The neonate should be tested for hypoglycemia and blood glucose should be maintained >2mmol/L. The patient should continue on thromboprophylaxis for 6 weeks if she received antenatal thromboprophylaxis, otherwise should have it for 7 days postpartum. Any antenatal insulin may be stopped once the placenta is delivered.

The patient should have a fasting glucose done 6 weeks postpartum and be advised of her increased risk of developing diabetes (at least 40-60% in the next 10-15 years) and have annual screening for type 2 diabetes with her GP. She should be encouraged to breastfeed and be given the necessary support. 

Contraception should be discussed. Suitable options while breastfeeding include progesterone only pills, implanon, intra-uterine devices and depo-provera. The latter may be less favoured in her case due to its potential for causing weight gain. 

(a) The woman should be managed in consultant-led unit under the care of multidisciplinary team consisting of consultant obstetrician, endocrinologist, anaesthetist, specialist midwife and dietician. The woman should be counselled about the diagnosis of gestational diabetes mellitus (GDM) and its implications on her pregnancy (increased risk of macrosomia, polyhydramnios, preterm birth, sudden intrauterine death especially poor glycemic control). In view of these, the woman should be informed that she needs to be followed up more regularly.  She should be referred to dietician to ensure healthy diet. Fasting and 1-hour postprandial glucose should be monitored with the aim of achieving 3.5 - 5.9 mmol/L for fasting glucose. If this failed despite diet modification for 2 week, then insulin (isophane) or metformin should be initiated. Serial growth scan of the fetus should be carried out every 4 weeks as fetal growth is very difficult to be assessed clinically in view of morbid obesity and the woman is at risk of carrying a macrosomic fetus. 

Her blood pressure should be monitored with appropriate size every 3 weeks until 32 weeks and then 2 weekly thereafter in view of increased risk of developing pre-eclampsia. The risk of venous thromboembolism (VTE) should be assessed during each admission to hospital. Subcutaneous low molecular weight heparin (LMWH) adjusted to bodyweight should be initiated if there is additional risk factors. Referral to anaesthetist should be made antenatally as there is potential difficulty in siting of branula and epidural. The risk of general anaesthesia is also increased in women with morbid obesity. Referral for manual handling and assessment of tissue viability should also be made. 

The woman should be weighed during each visit and BMI should be calculated. Scan should be arranged at 37 weeks to determine presentation as abdominal palpation in patient with morbid obesity is inaccurate. Oral Vitamin D 10 mcg daily should be continued throughout pregnancy as obese woman are at risk of reduced bone mineral density. Her plan of delivery should be clearly documented in the hand-held antenatal note. Her delivery should be at consultant-led unit and delivery should be considered from 38 weeks onwards

(b) Ultrasound scan to look for presentation should be performed if it has not been done recently as presentation is difficult to determine clinically in woman with morbid obesity. Consultant obstetrician should be informed because of the high-risk nature of the pregnancy. Early referral to senior anaesthetist should be made , so that early siting of branula and epidural can be performed. The risk of VTE should be reassessed and to consider to start LMWH adjusted to bodyweight if additional risk factors are present. During labour, thromboembolic deterrent (TED) stocking should be applied and good hydration should be maintained. If the woman is on insulin for her diabetes, insulin sliding scale should be initiated and glucose level should be aimed at 4-6 mmol/L. Blood should be sent for group and save as this woman has increased risk of operative deliveries. Progress of labour should be properly charted in the partogram as she is at risk of prolonged first and second stage of labour. If operative vaginal delivery becomes necessary, it should be performed in the theater as it is associated with higher risk of failure and it should be performed by senior personnel. Theater staff should be informed as proper bed needs to be prepared. Caesarean section should be performed by senior registrar or consultant obstetrician as it is technically difficult. Continuous fetal heart monitoring should be in place and if tracing is difficult abdominally, then fetal scalp electrode should be applied for continuous monitoring. During delivery, senior registrar and midwife should be present as there is increased risk of shoulder dyctocia. There is increased risk of postpartum haemorrhage and therefore active third stage of management should be carried out.

After delivery, the woman should be started on LMWH adjusted to bodyweight if not started yet. Subcutaneous LMWH should be given for at least 7 days after delivery or 6 weeks if additional risk factors are present. The woman should be put on TED stockings, ensure good hydration and advise early mobilization. The woman should be supported on initiation and maintenance of breast feeding as this woman has higher risk of failure in breastfeeding. It is also important to identify that there is increased risk of postnatal depression and therefore she should be well supported and high-index of suspicion should be present. Fasting blood sugar should be done 6 weeks after delivery and if it is normal, it should be carried out annually in view of increased risk of developing diabetes mellitus in the future. The woman should be advised on healthy lifestyle, for instance, weight reduction, healthy diet and regular exercise. Advice on contraception should be given. There is no contraindication to start any contraception with the exception of combined oral contraceptive pills as it is under UK medical eligibility criteria of 3 for those with body mass index of  more than 35 kg/m2. 

Upon delivery, the baby should be monitored in the hospital for at least 24 hours before being discharged to the community. Early feeding should be encouraged to reduce the risk of hypoglycemia in the baby. The baby should be kept with the mother for breastfeeding on demand unless there is poor suckling or hypoglycemia whereby admission to neonatal unit becomes necessary. The GP should be informed to ensure continuity of care

A) Patient needs to be seen in a multidisciplinary clinic with obstetrician, endocrinologist, dietician, diabetes nurse specialist. Need to explain the diagnosis of gestational diabetes: diabetes caused by pregnancy, from now on will require regular blood glucose monitoring, will initially require treatment by diet modification (reduction in fatty and sugary foods, concentrating on low glycaemic index carbohydrates as main source of energy) and exercise, may require medical treatment if unable to control blood glucose level either with metformin or glibenclamide (tablet) or insulin (injections) or both. Needs to be instructed in self-monitoring of blood glucose levels. Needs to be informed that good control of blood glucose levels will reduce maternal and fetal risks.
Increased risks to the mother: pre-eclampsia, shoulder dystocia resulting in perineal trauma, obstructed labour requiring caesarean section, diabetes in future pregnancies and later life. Increased risks to baby: macrosomia (increases risk of shoulder dystocia or obtructed labour), polyhydramnios (increases risk of preterm labour and cord prolapse), neonatal respiratory distress (may require neonatology review or admission to unit), neonatal hypoglycaemia (will require blood sugar monitoring after delivery and early feeding, may require admission to neonatal unit), increased risk of obesity in later life, stillbirth.
Antenatal care required: regular review 1-2 weekly in multidisciplinary antenatal clinic for blood sugar, blood pressure and urinalysis monitoring, will require growth scan(s) and may early induction of labour if requiring metformin or insulin later on in pregnancy.
B) Will require hourly intrapartum blood sugar monitoring and continuous cardiotocograph, may require insulin sliding scale in labour if blood sugars high (>7) or on insulin antenatally. Careful assessment at all vaginal examinations for signs of obstructed labour. Obstetric team on labour ward to be involved in patient care and alert to risk of shoulder dystocia. Postpartum to stop all diabetic treatment including diet and any medications, baby to be monitored for hypoglycaemia. Will require 6 week postpartum fasting blood glucose level to ensure not requiring ongoing treatment for underlying type 2 diabetes. Should have yearly assessment for glucose resistance by GP, in future pregnancies will need referral to diabetic team and either early glucose tolerance test or blood sugar monitoring to identify whether developing gestational diabetes again. Encourage weight loss, healthy diet and exercise to reduce the risk of developing gestational or type 2 diabetes in the future. In future pregnancies should take 5mg folic acid rather than 300mcg.

This women is considered as high risk because of morbid obesity & gestational diabetes.further management would be with multidisciplinary team involving diabetologist,obstetrician and a specialist diabetic nurse. this women is at increased risk of macrosomia,polyhydramnios,increased rate of induction of labour,shoulder dystocia,other birth trauma.this should be explained to women,and advised these complications can be reduced with good glycemic control ®ular fetal surveilance.so she should be offered diet modifications like carbohydrates of low glycemic index.,lean protein ,oily fish with more of polyunsaturated fats.&exercise of atleast 30 mts everyday.for a minimum of 2 weeks . if this measures fails to control sugar she needs hypoglycaemic therapy in the form of oral hypoglycaemic drugs or insulin.scan should be done 4 weekly from 28 wks for fetal weight & liqour volume.If the abdominal circumference is more than 70th centile ,hypoglycaemic therapy should be initiated.. She should be advised to monitor sugar frequently with fasting and 1 hr postprandial with every meal . Target should be to maintain fasting between 3.5to 5.9mmol/lt and 1hr pp less than 7.8 mmol..because of her morbid obesity she is prone for preeclampsia, thromboembolism,macrosomia, labour complications,difficulties in monitoring antenatally,during labour ,difficulty with anaesthesia.Regular  monitoring  of blood pressure with a large cup 2-3 weekly from 28to 32 weeks & 2 weekly from 32 weeks is recomended.Throught pregnancy risk factors for thromboembilism assessed & if 2or more additional risk factors present may require antenatal thromboprophylaxis.  Anaesthetic consultation offered antenatally. Weight should be measured in 3rd trimester and appropriate measures taken for equipments like appropriate bed, trolleys arranged. Delivery should be planned around 38 weeks because of GDM in a consultant led unit with 24 hrs facilities for intensive neonatal care . Possible neonatal complications & early parenting & breast feeding should be counselled in antenatal period. 

Intrapartum management in consult led unit . as soon as she is admitted in labour senior obstetrician and anaesthetist informed. sugar levels should be checked every hour and sugar levels maintained between 4to 7 mmol. IV access and epidural should be sited early.continuous electronic fetal monitoring needed & early recourse to fetal scalp electrode and ultrasound if difficulty experienced by abdominal monitoring . care should be taken to maternal positioning to avoid skin complications like bed sores.Theatre persional informed  to arrange appropriate cot, transport if necessity arise for surgery.active management of 3rd stage bec of more likelyhood of postpartum haemorrhage

postnatally all hypoglycaemic should be stopped. mother encouraged to breast feed.neonate should be monitored for hypoglycaemia. Other tests for hypocalcemia, hypomagnesimia,polycythemia are indicated if there are signs of these complications. Thromboprophylaxis in the form of early ambulation, TED stockings . Low molecular weight heparin for 7days if additional risk facors for 7 days even if delivered vaginaly. dose dhould be adjusted acc to bodywt. follow up at 6 weeks with fasting gluose and annually thereafter to detect type 2 dm. counselling about reduction in weight, healthy life style.there is 60% chance of becoming type 2 diabetic within 5 yrs.counselled about risk of baby developing diabetes, obese & other cardiovascular problems. 

SAQ   BMI 42

A   As she is high risk pregnancy with BMI 42 and diabetes diagnosed at 28 weeks which is most likely gestational diabetes but it could be undiagnosed type 2 diabetes. She should have antenatal care by multidisciplinary unit involving consultant endocrinologist, consultant obstetrician with interest in diabetes, specialist nurse, dietician, nephrologist, ophthalmologist, consultant anaesthetist, and neonatologist. She should be assessed in diabetic clinic for assessment of her blood sugar levels and its control by dietary adjustment and insulin injections. She should be assessed for her baseline renal and retinal function as pregnancy has deteriorating effects on these systems. Her fasting blood sugar level are maintained between 3.9-5.9mmol/l and 1 hour postparandial levels <7.8 mmol/l. The tight control of blood sugar levels is associated with improved  maternal and perinatal outcome by reducing the risk of fetal macrosomia,  preterm delivery, IUD, stillbirth, shoulder dystocia, and increased operative delivery. She should be informed about risk of hypoglycemia with tight insulin control and its management. She is given written information about  risks diabetes and morbid obesity on pregnancy and monitoring of blood sugar levels and insulin injections. She is offered regular 1-2 week visits to diabetic clinic for assessment of her diabetic control and change in insulin requirement. She is offered 4 weekly scans for fetal growth and liquor volume as the complicated diabetes  with microvascular disease is associated with fetal growth retardation. She is monitored for risk of developing preeclampsia and venous thromboembolism. She is offered antenatal corticosteroids at 32-34 weeks as she is at risk of preterm delivery. She should be assessed around 34-36 weeks of pregnancy by consultant obstetrician for plan about mode of delivery which should be documented and agreed between consultant and woman. She should be offered elective delivery after 38 completed weeks  if fetal growth  is normal as there is risk of fetal macrosomia and associated complications of shoulder dystocia and operative delivery. Consultant anaesthetist should assess her needs for analgesia and anaesthesia, should an operative delivery occurs and the plan should be documented. An appropriately trained professional should assess her mobility and handling requirements and special instruments required in theatre.

B   She presents at 37 weeks with spontaneous labour, obstetrician should assess the patient for diabetic control, her insulin requirement during labour if blood sugar levels are high. The patient should be assessed for uterine contractions, clinical size of baby, lie, presentation, and engagement of fetal head. Fetal heart rate is continuously monitored by electronic fetal heart rate monitor because of increased risk of fetal distress. If there is difficulty in palpation ultrasound scan is used for presentation and FHR. Vaginal examination is performed to assess progress of labour. Early venous access and early epidural analgesia is considered during early stage of labour. One to one care is ,encouragement and support is given during labour.  Aim is normal vaginal delivery if progressing normally but operative vaginal delivery or caesarean section can be done if delayed progress or fetal compromise is diagnosed depending upon clinical circumstances. During second stage of labour, shoulder dystocia is anticipated and appropriate trained staff should be available for management. During third stage of labour active management  done with injection syntocinon given 5IU IM, early cord clamping and controlled cord traction. 

After delivery  the baby should be seen by neonatologist expert in resuscitation. The baby kept warm and dry and breast feeding is established within 30 minutes and then 2-3 hourly. The baby is monitored at 1hour and 2 hour for colour, tone, respiration, tone, movement, reflexes, nasal flare and then monitored at 2 hourly interval for 12 hours. Baby is kept for 24 hours because of increased risk of hypglycemia, respiratory distress syndrome, jaundice, hypocalcemia, polycythemia. Mother blood glucose levels are checked as there is decrease in insulin requirement  30- 40% in post partum period. As she is high risk for thromboembolism, she is given heparin for 7 days postpartum and encouraged for early mobilization and graduated compression stocking. If she has an increased risk of endometritis and wound infection so treated with appropriate antibiotics if she developes signs and symptoms of it. She is advised contraception depending upon her desires and clinical circumstances, combined hormonal contraceptives will have more risks then benefits. She is advised fasting blood glucose  at  6 weeks postpartum and she has 30-40% risk of developing type 2 diabetes mellitus.     

I would explain to her that she is diagnosed as gestational diabetes & its implications  .Pregnancy needs holistic treatment for diabetes  & obesity and management strategies to reduce complications  due to GDM & obesity & optimise outcome.Her Antenatal care needs to be consultant led , Ideally in a joint diabetic clinic for glycemic management with input from diabetologist, nutritionist,  diabetic nurse.

Pt needs to be counselled on the maternal risks of obesity  namely  preeclampsia, VTE, induced labour , increased risk of Caeserean ,anaesthetic complications ,perineal tear ,post partum hemorrhage & fetal risks of increased miscarriage, neural tube defects, fetal  macrosomia.I would counsel her on risks  due to GDM like  fetal macrosomia,birth trauma (to mother and baby),induction of labour or caesarean section,transient neonatal morbidity,neonatal hypoglycaemia,obesity and/or diabetes developing later in the baby’s life and that these risks can be reduced by good glycemic control.

Advice on diet by a qualified dietician with carbohydrates of low glycemic index,balance on unsaturated & saturated fats and exercise. I would educate woman that lifestyle modifications will optimise glycemic control in most of women. Advice on intake of Vitamin D 10mcg/d in pregnancy & breast feeding as she is at risk of deficiency..

Oral hypoglycaemic agents or insulin injections may be needed if diet and exercise do not control blood glucose levels even after 2 weeks or ultrasound demonstrates fetal abdominal circumference > 70 percentile.Regular insulin, the rapid acting insulin analogues aspart and lispro, and/or the oral hypoglycaemic agents metformin  and glibenclamide  may be considered.

I would advice women on self-monitoring of blood glucose by fasting &  1 hour after meals  three times & bedtime   and  aim for a fasting blood glucose of between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose below 7.8 mmol/litre. Safe disposal of needles educated.Diabetic consultation every 2 weeks to optimise sugar control.

I would advice woman on the  risks of hypoglycaemia and hypoglycaemia unawareness, educate  woman and their partners or family members on the use of oral glucose solutions and glucagon for hypoglycaemia.

 Appropriate size  BP cuffs are used for blood pressure measurements & regular urine dipstick  for proteinuria done as high risk for preeclampsia at every visit.   Risk assessment for VTE done if 2 or more additional risk factors present thrombo prophylaxis with LMWH done adjusted for weight.

I would explain the limitations of  clinical assessment of fetal growth in obese woman (Symphysio fundal height) .Offer her regular ultrasound  monitoring for fetal growth & Amniotic volume at 28weeks  and repeat every 4 weeks  as she is at high risk of macrosomia due to diabetes & obesity. Ultrasound diagnosis of fetal anomalies & measurements may also be difficult, limitations explained to patient.

At 36 weeks review with consultant anaesthetist to discuss difficulty in venous access, intubation or regional anesthesia. Anaesthetic plan in labour discussed & documented in notes. Assessment by an appropriate qualified  personnel for manual handling requirements for childbirth like appropriate sized theatre or labour table, lateral transfer equipments .

Offer induction of labour at 38weeks in  normally grown fetus as there is increased risk of stillbirths beyond . If patient has declined induction , i would offer tests of fetal wellbeing by Cardiotocogram  & amniotic fluid volume assessment biweekly . Advise on the risks and benefits of vaginal birth, induction of labour and caesarean section   if the  baby has macrosomia identified by ultrasound.

Intrapartum care)

She should be advised to deliver in a  consultant led obstetric unit  where availability for advanced neonatal resuscitation and anaesthetic care  available as she is  more likely to develop complications of shoulder dystocia, postpartum hemorrhage , requiring immediate intervention .

Duty  anaesthetist  to be informed  as soon as she is is admitted  to review her antenatal anaesthetic notes to asses any difficulty anticipated & for senior involvement.

I would establish early intravenous access and epidural citing by anaesthetist .

Continuous midwifery care in labour & continuous electronic fetal monitoring needed. If external monitoring is difficult may require fetal scalp electrode placement or ultrasound assessment of fetal heart.

I would monitor  her capillary blood glucose on an hourly basis and maintained  between 4 and 7 mmol/litre to prevent neonatal hypoglycemia. Intravenous dextrose and insulin infusion is recommended if her  blood glucose is not maintained at between 4 and 7 mmol/litre. 

An obstetrician & duty anaesthetist at specialist trainee year 6 or above &  signed of as competent need s to attend any operative vaginal delivery or abdominal delivery , otherwise the consultant on call to attend or be immediately available.

Partogram & vigilance for signs of slow progress of labour & recognising signs of shoulder dystocia. Active management of third stage of labour done as she is  at high risk of postpartum hemorrhage. 

Postpartum care)  Early dedicated breast feeding support needed to overcome  difficulties in  lactation .

Early mobilisation , hydration, thromboprohylaxis with LMWH adjusted for weight & TEDS advised for a 7 days.  Appropriate perineal care advised .

She as advised to stop taking hypoglycaemic medication immediately after birth & blood glucose tested before transfer into community care . Diet chart by dietician on adequate caloric intake and healthy foods  to avoid hypoglycemic spells.

Baby needs to be monitored for signs of hypoglycaemia & blood glucose testing  carried out at 2–4 hours after birth.

She is advised on optimisation of weight by diet & exercise before embarking on next pregnancy. Contraceptive options are offered & written information provided.

She is counselled on future recurrence risks of gestational diabetes in subsequent pregnancies ( 66% ) and lifetime risk of Type II diabetes 70% , and on life style modification to reduce the risks . Screening for diabetes done 6 weeks postpartum by fasting blood glucose  followed by annual screening.

a)      Diagnosis is gestational diabetes as her 2 hour postprandial is >11.1.

Recognise that  she is a high risk pregnant woman  as she has gestational diabetes and obesity. Explain the diagnosis to her and need for multidisciplinary care with input from medical obstetric  clinic,GP,community midwife ,dietitician ,diabetic nurse and  anaesthetist .Hospital birth should be planned.

Maternal risks  include hypoglycaemic attacks, preeclampsia , venous thromboembolism, increased obstetric interventions,postpartum haemorrhage ,wound infection and risk of Type 2 Diabetes Mellitus in the longterm.

Fetal risks include increased risk for congenital anomalies such as cardiac anomalies,sacral agenesis , renal anomalies,miscarriage,macrosomia,prematurity , stillbirth and shoulder dystocia .

Her blood sugar levels needs to be controlled by diet and exercise as first line and if not by metformin and insulin .Regular input from  dietitician is needed for dietary  advice to control blood sugars.Weight loss in pregnancy is not recommended to manage her high BMI. She should eat a high fibre,low fat and low sugar diet.She needs to have regular meals with midmorning snack and mid-afternoon snack and prior to bedtime . She should  be taught  by her diabetic nurse about checking  her blood sugar levels  fasting and one hour postprandial  and maintaining a diary so that the diabetic nurse can check it during each appointment  and make adjustments  to her treatment accordingly. Her fasting should be maintained between 3.5-5.9  mM  and one hour post prandial < 7.8mM. Regular blood tests should also be done to monitor  renal and liver functions .She is at risk of hypoglycaemia  especially if hyperemesis  while on metformin/insulin and should be provided with a glucagon kit. Family members also should be taught about the signs of hypoglycaemia such as palpitations,dizziness and tremor and need to give her IM glucagon or snacks and drinks rich in sugar instantly.She needs more frequent antenatal  clinic visits and needs monitoring for preeclampsia by checking BP using appropriate cuff and urine protein during each visit.Her size of BP cuff should be documented in the notes to avoid error in monitoring BP during each visit.Her risk for venousthromboembolism should be reassessed during inpatient admission if any and consider thromboprophylaxis with heparin. She needs to be seen by  anaesthetist antenatally to assess anaesthetic risks during labour such as difficulties in IV cannulation,regional anaesthesia, resiting epidurals ,risk of aspiration and failed intubation during GA. Intrapartum and postpartum management plan  including manual handling, lifting , availability of adequate equipment  and staff should be documented. Serial ultrasound monitoring for fetal growth  and estimated fetal growth should be done in third trimester  to look for macrosomia .She should be informed of the inaccuracies of ultrasound  findings and possibility of undiagnosed congenital anomalies  due to her BMI . Recheck her BMI in third trimester as possibility of  further increase in BMI.

If blood sugar levels are controlled and estimated fetal weight less than 4.5kg spontaneous vaginal delivery can be allowed.If estimated fetal weight >4.5 kg ,Caesarean section is recommended at 36-37weeks. Corticosteroids should be given if risk of preterm labour at gestation less than 34+6 weeks.IOL can be done if blood sugar levels not controlled  and estimated fetal weight less than 4.5kg  at 36-37 weeks to prevent still birth.

b)Recognise that she is a high risk woman in labour. Offer pain relief and epidural. Anaesthetist should be informed on admission. Obtain IV access and send blood for FBC and Group and Screen  as risk of obstetric interventions .Review her  notes for  control of blood sugar levels ,medications if any  and documented plan for labour.Monitor her blood sugar levels in labour and if not controlled seek advice from medical team.If she is already on insulin,I would change her into insulin sliding scale and regularly monitor her blood levels for adjusting the dose of insulin.She needs continuous  fetal monitoring by  fetal scalp electrode due to technical difficulties for monitoring in light of her high BMI.Manual handling and lifting should be done as per documented plan in the notes.Vaginal examinations to assess the progress of labour can be difficult  and senior assistance should be asked if needed.Senior Obstetrician should be present at the delivery as risk of shoulder dystocia.Active management of third stage of labour to prevent postpartum haemorrhage.If Caesarean section is indicated for obstetric reasons,Consultant  obstetrician ,Consultant anaesthetist and extra staff members  should be available in the theatre. Difficult  instrumental delivery should be avoided .Neonatalogist should be informed to attend the baby as risk of hypoglycaemia and other congenital anomalies.Prophylactic antibiotics  is needed to prevent wound infection if episiotomy/Caesarean section and needs review by tissue viability team.

Post partum monitor blood sugar levels and metformin/insulin should be stopped.Encourage early breast feeding to prevent hypoglycaemia for the newborn and if any difficulties breast feeding support should be provided.Ressess the risk for venousthromboembolism and start thromboprophylaxis with LMW heparin  for 7 days. Offer TEDs stockings,good hydration and early mobilisation.Arrange oral glucose tolerance test at 6-8 weeks and  inform the risk of developing Type 2 Diabetes Mellitus .Advise life long yearly  followup with GP for checking blood sugar levels.Offer adequate contraception and advise to attend  preconception  clinic for weight reduction and healthy lifestyles  before planning subsequent pregnancy.

Dear Dr. Paul,

My mistake I had pasted the rough work also. 

The above answer starts from A)

Please don't correct the matter which is above A)

A)

This woman has gestation diabetes mellitus with Class III obesity. I will explain to her resk of being garding the diagnosis of gestational diabetes mellitus and its implication to her and her fetus. She is at increased risk of getting venous thromboembolism, pregnancy induced hypertension and pre eclampsia. The baby is at risk of being macrosomia and sudden intrauterine death. There is need for vigilant surveillance to reduce the risks to mother and baby. She will require regular 2-weekly antenatal visit to monitor her glucose control, preferrabl by home glucose monitoring. Aim of premeal glucose level is less or equal to 5.3mmol/L and post meal of 6.7mmol/L. Referral to dietitian will be made to advise her on caloric intake and proportion of carbohydrate in her meals to maintain euglycaemia. As this is GDM, there is no need for eye assessment. . Blood pressure and urine for albumin need to be checked every fortnight to detect PIH and pre eclampsia. The management of GDM and obesity is multidisciplinary including obstetrician, dietitian, diabetic counsellor and diabetic nurse as well anaesthetist. Early referral to anaethetist is important to assess intubation risk in the event of operative delivery intra-partum as well as getting intravenous access. Fetal growth will be monitored 2-weekly to detect large for gestational age baby  and polyhydramnios which could reveal uncontrolled GDM. If blood glucose control is not satisfactory with diet modification, she may require oral hypoglycaemia agent such as metformin, although she may also need insulin if still poorly control. Delivery is considered at 38 weeks in her as risk of IUD increases with advancing gestation. 

B) During the intra-partum period, she will need special equipment and bed for transferring to the labour ward or operating theater due to obesity. Epidural analgesia should be offered as planned earlier during anaesthetic referral as she has higher risk of operative vaginal delivery and Caesarean section. Capillary blood should be monitored hourly for glucose with an aim of 4-7mmol/L.She may  required insulin and dextrous solution and  potassium during labour especially if she had required insulin duirng the antenatal period. The abdomen needed to be assessed to estimate fetal weight though it may not be accurate and supected large baby should be assessed by scan. If baby is estimated more tha  4.5 kg, caesarean section may be offered after couselling. Fetal monitoring will be difficult due to thick abdominal wall and invasive fetal electronic monitoring may be needed. There is increased risk of shoulder dystocia due to macrosomia baby. 

Post natally, she has higher risk of getting wound infection, be it episiotomy, perineal wound or caesarean wound. Antibiotic may be required. Low molecular weight heparin will be given for 7 days to reduce risk of venous thromboembolism. Advice on initiating and maintaining breastfeeeding will be given. Combined hormonal contraception will increase her risk of venousthromboembolism, I would therefore advised intrauterine device or injectables. She will require repeat fasting blood sugar in 6 weeks' time. 

a.

She should be seen in a specialist multidisciplinary diabetes antenatal clinic.  Members of the MDT should include a maternal medicine obstetrician, endocrinologist, dietician, diabetes specialist nurse and diabetes specialist midwife.  She should be informed of the diagnosis of gestational diabetes and the risks associated with it.  These risks include fetal risks such as macrosomia, late still birth, preterm delivery, neonatal hypoglycaemia and respiratory distress, and maternal risks of shoulder dystocia, pre-eclampsia, and increased caesarean section rate.

Dietary advice should be offered, a low fat, low glycaemic index diet is recommended.  Calorie restriction of 25kcal/kg/day is appropriate as her BMI is greater than 27.  30 minutes exercise per day is recommended.  She should be informed that the majority of women can be managed with diet and lifestyle measures to control their gestational diabetes.  She should be instructed on how to check her fasting and 1 hour postprandial blood glucose levels using home blood glucose monitoring. The target levels are 3.5-5.9 mmol/l fasting and <7.8mmol/l 1 hour postprandial.  Post-prandial readings correlate better to outcomes.  She should be provided with a sharps box for safe disposal of the sharps.  If home blood glucose monitoring shows persistent hyperglycaemia then hypoglycaemic therapy should be commenced.  The first line is metformin.  Insulin is used as second line therapy, a four times daily basal bolus regime is preferred as it gives better glycaemic control.  Doses should be adjusted according to postprandial blood glucose readings.

She should have full hospital care for the rest of her pregnancy, with diabetic reviews every 1-2 weeks.  She should have her BP checked with the appropriate size cuff at each visit and also urinalysis performed at each visit as she is high risk for developing pre-eclampsia.  A growth scan should be organised as soon as possible after diagnosis and then subsequent scans at 4 weekly intervals to assess fetal growth and well-being.  This will aid the planning of time and mode of delivery. 

She should be referred for an anaeathetic assessment due to her BMI>40.  VTE risk assessment should take place at every visit.  If her risk score is greater than 3 then she should be offered prophylactic weight adjusted LMWH.  At 36 weeks gestation she should be reweighed and have a manual handling assessment.  A plan for labour and delivery should be made and clearly documented in the notes.

b.

She should be looked after in labour by a midwife experienced in looking after ladies with gestational diabetes.  As her BMI is >40 the consultant obstetrician oncall and the anaesthetist should be informed of her admission.  IV access should be obtained and bloods sent for FBC, U+E, glucose and group and save, U+Es should be repeated every 4 hours in labour.  She should be on a bed that is suitable for her weight.  Continuous electroninc fetal monitoring should be recommended as there is increased risk of fetal distress, an FSE may need to be used due to difficulties recording the fetal heart with the external transducer due to her BMI. There should be a documented plan in her notes with regards to management of her diabetes in labour.  She will require hourly blood glucose monitoring with target BM of 4-7mmol/l  If she has been on insulin antenatally then she will require an insulin sliding scale in labour with 500ml 5%dextrose and 20mmol potassium given over 8 hours.  She should have 4 hourly vaginal examination in labour with the use of a partogram to ensure that she is making adequate progress.  If the progress crosses the action line then interventions such as ARM and syntocinon infusion can be considered, however augmentation must be discussed with the consultant oncall. If the CTG is pathological then FBS should be performed or delivery expedited.  If operative vaginal delivery or caesarean section is needed then the consultant obstetrician should be present and a senior anaesthetic trainee should perform the anaesthetic.  Active management of the third stage with oxytocin and CCT is recommended to reduce the risk of PPH.

Following delivery of the placenta insulin and oral hypoglycaemics should be stopped.  VTE risk assessment should take place and if the score is greater than 2 then 7 days of weight adjusted prophylactic LMWH should be offered.  She should also be advised regarding early mobilisation and adequate hydration and the use of compression stockings.  Breastfeeding is recommended to reduce the risk of neonatal hypoglycaemia and baby’s blood sugar should be monitored.  Prior to discharge maternal blood sugar should be taken to ensure normoglycaemia. 

A 6 week fasting blood sugar should be performed to rule out pre-existing diabetes.  Annual fasting blood sugars should be offered due to the increased risk of type 2 diabetes.  She should be counselled about the risk of future diabetes (40-60%) and offered lifestyle advice regarding diet and exercise.  She should be advised regarding weight loss and offered referral to a weight management programme.  Contraception should be discussed, a progesterone only method such as cerezettr or nexplanon would be appropriate.

THE  LADY IS MORBIDLY  OBESE  AND IS DIAGNOSED AS  GESTATIONAL DIABETIES  AT 28 WKS  .IWILL CHECK FROM  HISTORY  AND ANTENATAL  RECORD  WHETHER SHE IS LONG STANDING  DIABETIC OR NOT  IF DIABETIES  IS LONG STANDING  I WILL CHECK FOR RETINOPATHY ,NEFHROPATHY,NEUROPATHY AND ANOMALY SCAN.

HER PREGNANCY  WILL BE CATAGORISED AS HIGH RISK BECAUSE OF 2 MAIN RISKS  OBESITY AND GDM.

I WILL EXPLAIN RISKS TO THE PATIENT OF DEVELOPING PRE ECLAMPSIA VENOUS THROMBOEMBOLISM  AND INCREASED RISK OF OPERATIVE DELIVERY AND C/SECTION.FETAL RISKS INCLUDE ,POLYHYDROMNIOS (AND ITS RELATED RISKS), PRETERMLABOUR (MAY BE SPONTANEUS  OR ITROGENIC).INCREASED CHANCES OF ADMISSION TO  NICU,AND INCREASED PERINATAL MORTALITY.SHE WILL BE MANAGED IN CONSULTANT LED UNIT BY A MULTIDISCILINARY  TEAM INCLUDING  OBSTETRITION .DIETITION,DIABETOLOGIST, AND SPECIALIST NURSE.

SHE  WILL BE EXPLAINED  FOR DIABETIC  DIET(PROVIDED WITH RECMENDED LEAFLET)SHE WILL BE PROVIDED WITH GLUCOSE  STRIPS  AND TAUGHT HOW TO MONITOR HER OWN GLUCOSE .HER FASTIN WILL BE MAINTAINED  BETWEEN   3.5-5.9 MMOLS .HER ONE HOUR  GLUCOSE  SHOULD BE BELOW 7.8 MMOL.SHE  WILL BE ADVISED TO CHECK FASTING  AND THREE  1HR POST MEAL LEVELS .IF SHE IS STARDED ON INSULINE  BED TIME LEVEL SHOULD ALSO BE CHECKED.IN   MOST OF  PATIENT  GDM IS CONTROLLED BY DIET ONLY  BUT IF NOT  CONTROLLED SHE WILL BE STARTED ON 

INSULINE

THE  LADY IS MORBIDLY  OBESE  AND IS DIAGNOSED AS  GESTATIONAL DIABETIES  AT 28 WKS  .IWILL CHECK FROM  HISTORY  AND ANTENATAL  RECORD  WHETHER SHE IS LONG STANDING  DIABETIC OR NOT  IF DIABETIES  IS LONG STANDING  I WILL CHECK FOR RETINOPATHY ,NEFHROPATHY,NEUROPATHY AND ANOMALY SCAN.

HER PREGNANCY  WILL BE CATAGORISED AS HIGH RISK BECAUSE OF 2 MAIN RISKS  OBESITY AND GDM.

I WILL EXPLAIN RISKS TO THE PATIENT OF DEVELOPING PRE ECLAMPSIA VENOUS THROMBOEMBOLISM  AND INCREASED RISK OF OPERATIVE DELIVERY AND C/SECTION.FETAL RISKS INCLUDE ,POLYHYDROMNIOS (AND ITS RELATED RISKS), PRETERMLABOUR (MAY BE SPONTANEUS  OR ITROGENIC).INCREASED CHANCES OF ADMISSION TO  NICU,AND INCREASED PERINATAL MORTALITY.SHE WILL BE MANAGED IN CONSULTANT LED UNIT BY A MULTIDISCILINARY  TEAM INCLUDING  OBSTETRITION .DIETITION,DIABETOLOGIST, AND SPECIALIST NURSE.

SHE  WILL BE EXPLAINED  FOR DIABETIC  DIET(PROVIDED WITH RECMENDED LEAFLET)SHE WILL BE PROVIDED WITH GLUCOSE  STRIPS  AND TAUGHT HOW TO MONITOR HER OWN GLUCOSE .HER FASTIN WILL BE MAINTAINED  BETWEEN   3.5-5.9 MMOLS .HER ONE HOUR  GLUCOSE  SHOULD BE BELOW 7.8 MMOL.SHE  WILL BE ADVISED TO CHECK FASTING  AND THREE  1HR POST MEAL LEVELS .IF SHE IS STARDED ON INSULINE  BED TIME LEVEL SHOULD ALSO BE CHECKED.IN   MOST OF  PATIENT  GDM IS CONTROLLED BY DIET ONLY  BUT IF NOT  CONTROLLED SHE WILL BE STARTED ON INSULINE  THE  CHOICES  ARE  REGULAR  SHORT  ACTING  INTERMEDIATE  AND LONG  ACTING  INSULIN. METFORMINE  MAY  ALSO BE CONSIDERED.SHE SHOULD BE EXPLAINED  SIGNS AND  SYMPTOMS OF  HYPOGLYSEMIA  AND HER FAMILY TAUGHT  ABOUT ITS MANAGMENT. SHE IS  HIGH RISK FOR PREECAMPSIA AND HER  BP ANDURINE PROTIENS  WILL BE CHECKED  AT EACH  ANTENATAL VISIT (VISITS WILL BE READJUSTED  ACCORDING TO CONTROL OF DIABETES AND DEVELOPMENT OF COMPLICATIONS) FOR MEASURMENT OF BP APPROPRIATE SIZE CUFF WILL BE USED. SHE WILL BE   ADVISED TO TAKE 75 MG ASPIRINE AND  10 uGM VITAMIN D DAILY.

AT 32 WKS SHE WILL HAVE  ANESTHETIST  CONSULTATION AND A DISCUSIIONREGARDING  TIME  ,MODE PLACE OF DELIVERY . THE DISCUSSION WILL BE DOCUMENTED.FOR OBESITY APPRPRIATE  ARRANGMENTS WILL BE MADE FOR  MANUAL HANDLING  AND DELIVERY OR OPERATION BED. 

B. SHE IS PRESENTED IN  LABOUR  FOR  PLANNED VAGINAL BIRTH . AS ALREADY PLANNED HER DELIVERY WILL BE CONDUCTED  IN A CONSULTANT BASED  UNIT  WITH APPROPRIATE  ARRANGEMENTS REGARDING OBESITY AND INSTRUMENTAL  DELIVERY AND C/SECTION.MULTIDISCIPLINARY  TEAM  IS INVOLVED  (SENIOR OBTETRITION, DIABETOLOGIST, ANESTHETIST, MIDWIFE AND SPECIALIST  NURSE).AT ADMISSION  I WILL EXAMINE HER VITAL SIGNS; ABDOMIN FOR LIE , PRESENTATION,POSITION ,FETAL HEART,AND VAGINAL EXAMINATION FO BISHOP SCORRING .CONTINOUS ELECTRONIC  FHR MONITORING WLL BE CARRIED OUT AND ONE TO ONE CARE PROVIDED.I/V LINE WILL BE MAINTAINED.ANESTHETIST AND  OR STAFF INFORMED ABOUT POSSIBLE INSTRUMENTAL DELIVERYOR C/SECTION.IF SHE IS ON INSULINE  INSULINE  INFUSION MAY BE NEEDED . CAPPILLARY  GLUCOSE WILL BE MAINTAINED BETWEEN 4-7MMOL.VAGINAL DELIVERY IS  PREFFERED  .C/SECTION FOR OBSTETRIC REASONS .IF C/SECTION ANTIBIOTICS ACCORDING TO UNIT PROTOCOL.SHE IS AT HIGH RISK OF  PPH BECAUSE OF OBESITY 3RD STAGE WILL BE MANAGED ACTIVELY .IF PATIENT ON INSULINE IT  WILL BE STOPPEDIN GDM. (IN CASE OF  DM  REDUCED). NEONATE WILL BE BRAEST FED AS SOON AS POSSIBLE  AND APPROPRIATE ADVISE  REGARDING BREAST FEEDING  GIVEN. NEONATE MONITORED  FOR SIGNS OF HYPOGLYSEMIA ,JAUNDICE ,HYPOTHERMIA,POLYCYTHEMIA.GTT CARRIED OUT AT 6 WKS  AND REFERRED TO DIABETOLOGIST IF STILL DERANGED.SHE WILL BE EXPLAINED  REGARDING RISK OF DEVELOPMENT OFTYPE 2  DIABETES.ADVSE REGARDING LIFE STYLE MODIFICATION ,EXERCISE, WT REDUCTION WILL BE GIVEN SUPPORYED BY WRITTEN INFOMATION.REGARDING  CONTACEPTION PROGESTERONE  ONLY AND INTRAUTERINE METHODS CAN BE GIVEN.ADVISE REGARDING PRECONCEPTION COUNCELLING AND PREGNANCY CARE FOR FUTURE WILL BE GIVEN

a)  The lady has morbid obesity along with gestational diabetis.Her pregnancy is a high risk one and needs multidisciplinary approach consisting of a consultant obstetrician ,an endocrinologist,a consultant anaesthetist,and a specialist midwife.I will inform the patient about her diagnosis and inform her that she has an increased risk of developing pregnancy induced hypertension,increased risk of induction of labour,postpartum hemmorhage thromboembolism.Patient must be told that her fetus is at risk of developing macrosomia,increased risk of  congenital abnormalities due to maternal obesity,shoulder dystocia and birth traumas.In the neonatal period there is increased risk of hypoglycemia,hyperbilirubinemia which may neccesiate neonatal unit admission. Patient should be made aware of the importance of good glycemic control as this can reduce maternal and fetal risks significantly.The aim should be to keep her fasting plasma glucose between 3.5mMol/ltr -5.9mMol/ltr and one hour postprandial below 7.8mMol/ltr.She should be advised to monitor fasting and one hour post prandial sugars at home.She should be advicedby a dietician regarding diet and exercise for optimum weight gain in pregnancy.Her calory should be restricted to 25 kilocalorie/kgbw/day.If with diet restriction her sugars are not controlled after 2 weeks she should be put on oral hypoglycemics or insulin after discussing with an endocrinologist.Iwill ensure that the patient is taking vitamin D supplementation 10micrograms and this should be continued throughout pregnancy and breastfeeding.Her BP should be checked at each visit and the size of the cuff should be noted in her antenatal notes.Her hepatitis B,HIV,Rubella and syphilis screening results should be known.She should be seen in the antenatal period by a consultant anaesthetist so that he can explain the possible risks of anaesthesia and also counsel the patient regarding potential difficulties in iv access ,intubation or siting of regional anesthesia.Ultrasound assessment of fetus should be done for growth and amniotic fluid assessment every 4 weeks starting from 28 weeks to 36 weeks to rule out macrosomia and polyhydramnios but the patient must know that fetal surveillance may be difficult due to obesity.A plan of delivery should be formulated jointly by the obstetrician and the anaesthetist and necessary staff should be involved in determining the size of ot table ,lateral transfer equipments.All these plans and measurements should be documented in her antenatal notes.She should be assessed for any further risks of thromboembolism and should be given thromboprophylaxis if necessary.b)     The patient should deliver in a tertiary care centre under an obstetric consultant.As soon as she gets admitted in labour she should be seen by the obstetric consultant.Her antenatal notes should be reviewed and any potential difficulties should be assessed.The on duty anaesthetist should see her as sooon as possible so that the consultant anaesthetist's notes can be reviewed,the patient can be assessed and encouraged for early epidural analgesia and iv access.If needed the consultant anaesthetist should be alerted.She should receive one ot one midwifery care and her labour should be judiciously monitored.Early identification of dysfunctional labour can reduce perinatal and maternal morbidity.Due to her obesity if electroning fetal monitoring is difficult the help of ultrasound or fetal scalp electrode may be taken to monitor fetal heart rate.In labour her plasma glucose should be maintained at 4-7mMol/l.A glucose insulin infusion should be started according to unit protocol and cappilary glucose monitoring should be done.Shoulder dystocia is a risk in this case and so experienced staff should be available.Active management of third stage of labour should be done to reduce the risk of postpartum hemorrhage.If caesarean section is needed it should be done by an obstetrician experienced in operating on an obese patientwith extra attention towards asepsis and hemostasis A pediatrician should attend the delivery.Preoperative antibiotic prophylaxis should be given. In the post partum period she should be encouraged to breastfeed within 30 mins of delivery to avoid the risk of neonatal hypoglycemia.Obesity is associated with poor initiation and continuation of breastfeeding and so a lactation expert may be needed.She should receive prophylactic low molecular weight heparin irrespective of mode of deliveryfor 7 days.Insulin and oral hypoglycemics should be discontinued if she was on them and sheshould be followed up with a fasting blood sugar after 6 weeks,and if it is normal then she should be followed up yearly.She should be given contraceptive advice and told to avoid COCP. she should be told to lose weight before her next pregnancyand should be informed that the risk of GDM in the next pregnancy is as high as 65%.Written information should be provided.

Inform the patient  about diagnosis of gestational diabetes.She needs multidisciplinary involvement of obstetrician , anesthetist,endocrinologist,specialist midwife and a dietitian .Give information on the additional risks for her[pre eclampsia,thromboembolism,induction of labour,operative delivery] and for fetus like fetal macrosomia, birth trauma, transient neonatal morbidity ,hypoglycemia and perinatal mortality.Advise her about diet, weight control and exercise.Tell her self monitoring of blood glucose and agreed an individualized target.Check blood glucose fasting and 1hour after every meal.Aim is for  a fasting blood glucose of between 3.5 and 5.9mmol/l and 1 hour postprandial blood glucose below 7.8mmol/l.Contact with diabetic care team every 1-2 week to assess glycemic control.Oral hypoglycemic agents[metformin,glibenclamide]  and or regular insulin or short acting analogues[aspart and lispro]may be needed if diet and exercise fail to control blood glucose levels. .Offer her concentrated oral glucose solution if start insulin.Advise on the risks of hypoglycemia and hypoglycemia unawareness.Assess for risk of thromboprophylaxis and offer low molecular weight heparin[ LMWH] if 3 or more risk factors are present.BP should be checked with an appropriately sized cuff at each visit.Regular screening for preeclamsia should be done during pregnancy.Ultrasound monitoring of fetal growth and amniotic fluid volume every 4 week from now[ 28] to 36 weeks.At 36 weeks offer information and advice about timing mode and management of birth,analgesia and anesthesia.An anesthetic assessment by an obstetric anesthetic should be done .Informed and documented discussion about possible intrapartum complications like slow progress of labour,shoulder dystocia and emergency caesarean section should be considered along with management strategies.
B]birth should be in a consultant led obstetric unit.Duty anesthetist should be informed when patient is admitted to labour ward if delivery or operative intervention is anticipated.An obstetrician and an anesthetist at speciality training year 6 post or equivalent should be informed and available for her care including any operative vaginal or abdominal delivery.Continuous midwifery care in established labour should be provided. Appropriate equipments and gowns should be available.Monitor blood glucose hourly and aim to maintain between 4-7 mmol/l.Consider IV dextrose and insulin if blood glucose not maintained at target range.Continuous CTG monitoring for fetus.Active management of third stage should be recommended for her and documented in notes.
Immediately stop the hypoglycemic therapy after delivery.Advise her on symptoms of hypoglycemia.Test the baby blood glucose level after 2-4 hours or if he or she has signs of hypoglycemia.Test for polycythaemia,hyperbilirubinaemia , hypocalcaemia, hypomagnesaemia and echocadiography if clinically indicated.Encourage breast feeding as soon as possible to prevent hypoglycemia and then 2-3 hourly until blood glucose levels are maintained at 2mmol/l or more.Early mobilization ,hydration,TED stockings and LMWH for at least  seven days.Advise the patient about diet and exercise for weight control.Fasting blood glucose at 6 weeks post natal to diagnose diabetes.Contraception should be discussed.All information should be in a clear and documented form.

She is a high risk antenatal patient being type three obese and gestational Diabetic. Her antenatal care will be under a multidisciplinary team comprising of senior obstetrician, senior anaesthetist, diabetologist, diabetic nurse, dietician and specialist midwife. She will be explained regarding the diagnosis and its implications on her pregnancy and fetus . Explain how good glycaemic control and limiting the pregnancy weight gain will improve the maternal and perinatal outcome. GDM is associated with risk of PET,Thromboembolism,polyhydramnios and increased chances of induced and operative delivery for mother.Fetal macrosomia,shoulder dystocia,sudden IUD,neonatal respiratory distress and neonatal hypoglycaemia increase perinatal mortality.

Explain her limitations of clinical and ultrasound assessment [for congenital anomalies] due to obesity, provide her with written information. Advice from Dietician to control pregnancy weight gain by proper diet, also recommend light exercise. Self monitoring of blood glucose will be agreed with the woman with an aim to maintain fasting blood sugar between 3.5-5.9mmol/litre and 1hour post-prandial  <7.8mmol/litre. If the blood sugar control with diet modification and exercise is not satisfactory, consider hypoglycaemic therapy with metformin/glybenclamide or insulin. Advice her to monitor fasting  blood glucose ,one hour postprandial blood glucose and at bedtime if on insulin.

 Frequent antenatal visits 1-2 weekly will involve BP check by the proper sized cuff that should be documented, urinalysis for proteinuria  for PET.She will be prescribed Vitamin D 10mcg/d. Regular fetal growth monitoring by serial growth scans at 28 weeks and every four weeks to look for macrosomia and  liquor volume Antenatal assessment by a senior Anaesthetist [ for expected complications due to high BMI like difficulty in IV causation, epidural or failed intubation ] will be done .The anaesthetist plan to be documented in her notes. Consider her for LMWH antenatally  if she has additional risk factors for thromboembolism. The  consultant obstetrician  assessment and the delivery plan to be documented in her notes. Assessment to be done by the appropriate qualified personnel regarding  manual handling equipment which will be needed during childbirth eg  proper sized table, trolley and lateral shifting equipment . Elective induction of labour at 38 completed weeks as high risk of stillbirth beyond this period.

b. She will be in a consultant led unit for delivery . The neonatal resuscitation facilities should be available. The senior anaesthetist will be informed when she is in labour and early citation of IV canula done. Maintain good hydration, TED’s, assess blood glucose levels every hour to keep levels between 4-7mmol/litre. Dextrose and insulin infusion along with potassium replacement maybe started to achieve this. Continuous fetal monitoring by  CTG and midwifery care is needed  in labour. Inform OT staff when she comes in labour.  Any operative vaginal delivery or C.S should be done by a senior obstetrician as risk of macrosomia ,  prophylactic antibiotic given at preincision  during  C.S to avoid infection. Active management of the third stage of labour will be done to take care of PPH. Neonatologist should attend the delivery.

In the postnatal period, encourage early ambulation, TED’s  and thromboprophylaxis  by LMWH  for seven days.Early breastfeeding is encouraged ,neonatal blood sugar checked after 2-4 hours to monitor for hypoglycaemia.Look for respiratory distress or hypocalcaemia in  neonate. Check maternal blood glucose levels and stop hypoglycaemic therapy  post natally.

She will be counselled regarding appropriate  contraception [ POP,IUD.] Fasting blood glucose levels will be checked  6 weeks postnatally . Regular annual screening by G.P for type two diabetes is recommended as 70% increased risk.  Prepregnancy counselling  before any  future pregnancy to optimise weight by exercise and  diet control and to counsel regarding the increased risk of GDM 66%. Written information to be provided and discuss the importance of lifestyle modification.

This patient has gestational diabetes. She will be counselled about the increased risk associated with uncontrolled gestational diabetes.   These include fetal macrosomia shoulder dystocia, caesarean delivery and perinatal morbidity and mortality. These risks are reduced by good control which can be achieved in most cases by an appropriate diet and exercise.

 She will be managed by a multidisciplinary team  including obstetrician, diabetologist diabetic nurse and dietitian.. She would need increased monitoring and would be seen every one to two weeks in clinic. The target for glcaemic control is fasting plasma glucose between 3.5 and 5.9 mmol/l and one hour post prandial of less than 7 mmol/l. Her risk for venous thromboembolism will be reassessed.

If adequate control is not attained with diet and exercise, she will be offered metformin or glibenclamide orally or regular insulin injections according to her preference. She will be advised to monitor her blood sugar daily for fasting value, one hour after meals, and at night before going to bed if she is on insulin.

ultrasound will be done every four weeks from 28 weeks to monitor fetal growth and liquor volume. Her BMI will be recalculated in the third trimester.

At the 36 week visit she will be counselled about clinical findings and plan for delivery  either vaginally or by  caesarean section   at 38 weeks will be made with her. If she prefers spontaneous onset of labour, monitoring of fetal well being will be offerred from 38 weeks while awaiting labour.

Review by a consultant anaesthetist will be arranged at around 36 weeks for assessment and planning of intrapartum analgesia or anaesthesia. arrangements will be made with appropriate staff with regard to providing a suitable operating table, manual handling equipment and staff for patient transfer peripartum. during All plans for delivery and analgesia/anaesthesia will be documented in the notes . She will be given written information .

b) Delivery will take place in an obstetric led unit with access to theatre and advanced neonatal rescuscitation  24  hours a day.continuous midwifery care will be provided. The obstetrician and anaesthetist managing her should be trained up to at least ST6 level.An appropriate bed for her weight will be provided. Protocol for tissue handling, positioning and repositioning schedules will be adhered to. Ultrasound may be needed to confirm fetal lie and presentation as well as cardiac activity because of her obesity

The anaesthetist will be informed. He will assess  her early regarding type of anagesia as documented in the antenatal notes. Intravenous access and epidural catheter, if requested, will be sited early. Progress of labour will be monitored and managed by the obstetrician on duty. Fetal scalp electrode will be used to monitor the fetus during labour because of difficulty to properly monitor using the abdominal probe.

Blood sugar will be monitored every hour with the aim of maintaining values between 4 and 7 mmol/l. Inravenous dextrose and insulin will be used to achieve this level if needed as hyperglycaemia can cause fetal distress and hypoxia.

Active management of third stage will be done to reduce the increased  risk of postpartum haemorrhage. Insulin will be sopped immediately after delivery. The baby will be fed within 30 minutes to reduce the risk od hypoglycaemia. Aim for blood glucose more than 2 mmol/l in the neonate. 

The neonate will be kept with the mother unless  there is difficulty with feeding or maintaining blood glucose levels. the baby will then be transferred to SCBU.

Fasting Blood sugar will be checked in the mother  the following day to exclude persistent hyperglcaemia. She will be discharged once blood sugars are within normal range, for follow up by GP and community midwife. A letter will be sent to the GP with regard to monitoring of blood glucose with fasting blood glucose at 6 weeks post-natal visit and yearly thereafter because of the risk of developing type 2 diabetes. She will be encouraged to lose weight before another pregnancy and ton use appropriate reliable contraception

Morbid obesity is associated with increased risk of maternal and perinatal morbidity and mortality.This woman should be managed in a multidisciplinary care consisting of a Consultat Obstetrician with special interest in Diabeted,Senior midwife,Senior Aneathetist,Dietician.In view of her abnormal GTT values ,she should be started on a regime of diet and exercise for 1-2 weeks initially.She should be counseled that there is a 10—20% chance of her requiring insulin if her blood sugars are not contolled.She should be counseled about the risks of fetal macrosomia,polyhydrmanios,shoulder dystocia ,cesarean section,intrauterine fetal death withuncontrolled blood sugars.She should be started on vitamin d supplement of 10mg daily if she is not on one already as obesity is associated with increased risk of vitamin d deficiency.Both obesity and diabetes are associated with increased risk of preeclampsia,hence her BP should be measured with an appropriate sized cuff every 3 weeks till 32 weeks and then every 2 weeks thereafter along with urine protein.Growth scan along with lioqur volume should be done every 4 weeks starting from28 weeks,32weeks, and 36 weeks.She should be seen by a Consultant Anaethetist at 36 weeks to assessthe woman and make a plan for analgesia/anaesthesia required in labor/cesarean section as obesity is associated with increased risk of failed intubations,failed epidural.A plan of delivery should be made by the Consultant Obstetrician and documented in her notes.Cesarean section should be for obstetric indications.A risk assessment for thromboembolic disease should be made and documented in her notes.TED stockings should be prescribed antenatally to the woman as prophylaxis for thromboembolic disease.Low molecular weight heparin should be prescribed in case of any admissions antenatally.

B.Whenever the woman attends in labor,Consultant Obstetrician and a ST6 level Aneasthetist or equivalent should be alerted.Senior midwife should be available.An IV access should be gained due to difficulty in advanced labor if required.Fetal heart rate should be monitored continuously and a fetal scalp electrode applied in case there is any difficulty in recording fetal heart due to maternal habitus.Staff should be alerted to the possibility of shoulder dystocia.Blood should be grouped and saved.OT staff should also be alerted earlier in case of any operative intervention  to ensure safe manual handling  and availability of appropriate equipment.Epidural should be encouraged early in labor.Adequate hydration should be maintained.Vaginal examinations should be done every 4 hours and preferably by the same person and findings recorded on a partogram as obesity is associated with increased risk of prolonged labor.Blood sugars should be checked hourly in labor and if needed a combination of infusion dextrose and insulin should be given .Third stage of labor should be managed  actively with controlled cord traction and prophylactic 10 units oxytocin intramuscular to prevent postpartum haemorrhage.Delivery should be attended by a Paediatrician.Neonate should be monitored for signs of hypoglyaemia,,hyperbilirubinaemia,polycythemia.Postpartum the woman is at increased risk of thromboembolism,hence she should be advised to mobilize,maintain adequate hydration.She should be prescribed TED stockings and started on low molecular weight heparin for  days.Breastfeeding should be encouraged.She should be advised that most likely she will need  to discontinue her hypoglycemic medication depending on her blood sugars.Appropriate contraception should be advised .Her Glucose tolerance test should be repeated 6 weeks postpartum due to a  more than 50% risk of diabetes later in life.

 KRA

A.

I would explain to her she has gestational diabetes (GD).  I would tell the risks of GD including foetal macrosomia, birth trauma and themselves and baby, induction of labour caesarean section, neonatal hypoglycaemia, jaundice, respiratory distress, peri-natal death, risk of baby developing obesity/diabetes in later life and that this risk can be reduced with good glycaemic control.

I would tell her that her raised body bass index pus her at risk of developing hypertensive disorders, venous thromboembolism, anaesthetic complications, difficulty with foetal monitoring, dysfunctional labour and wound infection.  I would make an immediate referral for her to be seen in a joint multidisciplinary clinic consisting of the consultant obstetrician, consultant endocrinologist/diabetes specialist, diabetic nurse and dietician.

I would recommend contact with the diabetic team every 1-2 weeks to assess glycaemic control, measure her blood pressure and perform urinalysis because of the risk of hypertensive disorders.

I would tell her that lifestyle measures like restricting or lowering calorie intake and moderate exercise at least 30 minutes daily helps with glycaemic control.  I would aim for a fasting blood sugar of between 3.5-5.9mmol/litre and 1 hour post prandial blood glucose level below 7.8mmol/litre.

I would give her a glucometer for self monitoring a record book for her blood glucose values for review.  I would start her on insulin or Metformin if lifestyle measure do not maintain glucose targets over a period of 1-2 weeks.

I would arrange serial growth scans from 28, 32 and 36 weeks because of the risk of foetal macrosomia.

I would arrange an anaesthetic review at 36 weeks to offer advice about analgesia and anaesthetic during labour.  I would offer induction of labour at 38 weeks or caesarean section if indicated.

B  Intrapartum:

I would establish an intravenous access for possible infusion of fluids if epidural required for pain relief or if need to start sliding scale.  I would take blood for full blood count and group+save in case cross-matching of blood required because of the risk of post partum haemorrhage.

I would commence her on continuous cardiograph monitoring because it is a high risk pregnancy.  I would monitor her blood glucose hourly and aim to maintain it between 4 and 7 mmol/litre to prevent neonatal hypoglycaemia.  I would start her on sliding scale if her blood glucose is greater than 7mmol/litre or if she had insulin antenatally.  I would perform a vaginal examination four hourly to assess progress of labour from the start of regular contractions.  I would actively manage the third stage of labour because of the risk of post partum haemorrhage.

Postpartum:  I would advise early mobilisation, wearing of ted stockings, hydration and thromboprophylaxis with LMWH for 7 days.  I would advise her to stop taking her hypoglycaemic medication after delivery.  I would advise the baby is fed after birth and blood glucose checked 2-4 hours after birth because of the risk of hypoglycaemia.  I would offer contraceptive advice and weight loss diet and exercise.

I would tell her she is at risk of recurrence of GD in subsequent pregnancy and in her lifetime and will offer fasting blood sugar 6 weeks post partum and then annually.

The values of blood glucose are indicate a gestational diabetes mellitus ( GDM ) as secondary of morbid obesity. This diagnosis should be explained to the patient and the risks to the patient and the fetus. Multidisciplinary team should be involved including dietician, diabetic specialist and midwifes. Special protocol management in the unit for GDM should be achieved.

Good maternal blood glucose control is useful to reduce the risks of GDM by diet or insulin if not controlled by diet during two weeks. Increase the number of clinic visits and measure BP and proteinuria to detect of hypertention and pre eclampsia . FBC, U&E , creatinine , LFT and uurinalysis for any infection, proteinuria or bacteruria.

Fetal ultrasound growth and Umbilical Artery Doppler should be done to detect any FGR and estimated fetal weight ( EFW) to detect any macrosomia . Assessment the risk factors for thromboembolism  and thromboprophylaxis should be given antenataly if there were more three risk factors.

Plane for labour and delivery should be discussed with the patient at around 36 weeks with respect the wishes of the patient and documentation should be clear . Also, the anesthesia assessment should be offered .

Induction of labour at 38 weeks reduces the risks of macrosomia and its coplications and improve the pregnancy outcome. Cesarean Section can be offered at 39 weeks or when EFW is more than 4.5 k.g.

This high risk patient should be delivered in the hospital under senior level supervision. Explanation risks of normal delivery should be clear such as shoulder dystocia, cervical and vaginal lacerations , increased perinatal morbidity and mortality comparing with CS which has less risks for the neonate but with higher risk for the mother. Good control of glucose during labour by using Insulin scaling ( between 4 – 7 mmol/l )with multidisciplinary team . IV access which is difficult to do and take group & save for cross matching . Adequate regional analgesia is important which is very difficult because of obesity. Contionous fetal monitoring by internal electrode should be offered. Use Parthogram is useful to identify arrested labour .

Observation of vital signs in postpartum period is important because the risk of PPH. Continue observation of blood sugar with reduce the dose of insulin. Thromboprophylaxis should be offered for 7 days or more if there are more risk factors. Prophylactic antibiotic is useful to reduce the rate of  infection after delivery by CS. Encourage breastfeeding should be arranged.

Good education about the GDM before discharge and the risk of continue DM type 2 in future and recurrence in next pregnancy. Follow up appointment and check FBS after 6-8 weeks and then annually.

Reduce weight is important before next pregnancy with suitable counseling.

Contraceptive advice should be offered without estrogen because the risk of DVT , and the most suitable is POP, Depo prover ,IUS or IUD .

This patient is diagnosed with Gestational diabetes along with morbid obesity, this patient should have multidisciplinary care involve obstetrician , anesthetist , endocrinologist , specialized diabetic nurse & dietician. Patient should be counslled regarding the importance of exercise & healthy life style , as well as increased risk of fetal macrosomia & the associated birth trauma risk also regarding increased risk of operative delivery as well as increased risk of prenatal morbidity & mortality & risk of baby to have obesity in childhood. This patient should be followed up in the Specialized diabetic clinic every I -2 week ,also should be advised regarding self-blood glucose monitoring , she should check her blood glucose fasting &1 hour after every meal with aim to keep fasting blood glucose level between 3.5-5.9 & postprandial less than 7.8mmol/l. if blood glucose will not  controlled by life style modification, diet & exercise, then patient should be started on oral hypoglycemic medication ,rapid act insulin is in performance to use , patient should be taught how to use insulin , also should be advised to check her blood glucose every night before to go to bed ,also should be advised regarding the risk of hypoglycemia symptoms & signs should be explained for patient & her family, concentrate glucose should be provided in case of hypoglycemic episodes will come up.

Fetal growth should be monitored from 28 to 36 week of gestation to detect fetal macrosomia .close blood pressure monitoring with the right size cuff & urine analysis each visit aiming to detect preeclampsia as this patient is at increased risk. This patient should have her BMI rechecked in the 3^rdTrimester as well as she should be reviewed by consultant anesthetist prior to delivery .also this patient should be delivered in consultant led care unit with appropriate neonatal care & resuscitation.

Plan of delivery should be made around 36 week & clearly documented in the patient note ,consultant obstetrician should be involved in this patient care. if the fetal macrosomia suspected plane of delivery after 38 week should be made whether by induction or caesarean section, otherwise patient should be seen on weekly basis with  fetal wellbeing  monitoring

INTRAPARTUM  & POST PATUMCARE:

Once patient admitted in labour consultant or senior anesthetist should be  informed , I/V acess should be put in early stage of labour as well as patient will be for active management of 3^rdstage labour & that should be clearly documented in the patients note. patient should have her capillary blood glucose moninting on hourly basis, with aim to be between (4-7mmol/l), Dextrose /insulin infusion may be needed  if blood glucose uncontrolled, pain may cause hyperglycemia ,consider adequate analgesia .

Continues midwifery support will be required as well as continues fetal monitoring. If caesarean section is indicated Theatre staff should be informed as well as the caesarean section should be carried out by senior obstetrician or consultant &senior anesthetist , if general anesthesia is required blood glucose should be taken every 30 min from conducting time if GA until baby will born, per incision antibiotics should be given , subcoutose layer should be closed.

Once baby will born blood glucose should be monitoring  every 2 to 3 hours also baby should be fed every 3 min to avoid risk  neonatal hypoglycemia ,aim is to keep neonatal blood glucose >=2mmol/l, if failed to keep blood glucose above 2 despite proper feeding or  baby is not feeding properly or develop clinical signs of hypoglycemia,   tubal feeding or  intravenous Dextrose should be considered. Baby should not discharged before 24hr from birth to community care & before establish proper feeding & the neonatal team will be happy regarding over all babys clinical situation.

Mother should stop hypoglycemic medication immediately post delivery, also should be supported with  breast feeding& advised that breast feeding will help baby to avoid hypoglycemic events , lactation nurse should be involved .

Patient should be put on thromboprphylaxis for 7 days regard less mode of delivery, encourage moblilization & advice to wear TED stocking.

Discuss with patient contraception before discharge COCP is not advised , long acting progesterone should be considered

Patient blood glucose should be checked before discharge as well as at 6 week postpartum follow up & then annuallyalong with screening of the cardivasculr risks, patient should be advised regarding increase risk ofGDM recurrence up to 66% also risk of type 2 DM 70% &5-10% risl of type 1 DM. Advice  for life style change , diet & exercise & to optimize weight preconception ally .