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MRCOG PART 2 SBAs and EMQs

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notes334
EMQ1478
SBA2084
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Obesity

Obesity Posted by A H.

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