MRCOG PART 2 SBAs and EMQs
Course PAID | ||
notes | 336 | |
EMQ | 1502 | |
SBA | 2115 |
Essay 286 - Obesity
OBESITY Attia R 08.07.2013 11.57AM |
Posted by Attia R. |
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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 |
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Posted by LY Y. |
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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. |
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Essay 286-obesity |
Posted by JUN JOY C. |
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(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 |
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Obesity essay |
Posted by Francina S. |
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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. |
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Emq obesity |
Posted by sonu G. |
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(A) Her care should me managed by a multidisciplinary team consisting of obstetrician with special interest in diabetes,diabetic physician,diabetic nurse,Anaesthetist,dietician . She should be informed about the risks of GDM on mother and her baby. Maternal risks PET,preterm,macrosomia ,increased risk of c.section,perineal tears . Fetal risks- hypoglycemia,hyperbilirubinemia,still birth. Made aware the importance of good control of diabetes for good outcome. Serial growth scan every 4wkly and bp and urine check in each visit. Refer to dietician for dietary advice,commence insulin and monitor B.M and safe disposal of sharps are explained. Review by Anaesthetist during her antenatal period Discuss early induction 37-38 wk depending on diabetic control. Give written information,make appropriate documentation of the discussion. (B)I.V access + bloods(g&s) Start sliding scale,hourly BM Early involvement of Anaesthetist ,offer epidural has high chance of instrumental/ c.section. Clear fluid only allowed. Monitoring may be problem due to high BMI hence FSE should be considered. TEDS and adequate hydration should be maintained. Early identification of slow progress,shoulder dystocia and perineal tear and take adequate timely measure. Make sure paediatriacian available during delivery. Postpartum-stop insulin and BM measure.support breast feeding and commence ASAP. Baby should be observed for 24 hrs for any hypos.,stay with mother unless needs I've fluid ,abx or has any respiratory problem which is more commonly seen In baby of diabetic mom. Thromboprophylaxis for at least 7 days. GTT in 6 wks. Communicate to GP and further annual follow up as there is risk of type 2 diabetes. Inform chances of GDM high in subsequent pregnancies will require early GTT.(16wk) Refer to dietician,advice on contraception,and to loose wt befor next pregnancy. | ||
Posted by deva priya dhar M. |
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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. |
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Posted by NAZIA H. |
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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.
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Posted by drpadmaja V. |
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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.
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Obesity |
Posted by Julie A. |
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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.
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Posted by SARADA C. |
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