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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
notes	336
EMQ	1502
SBA	2115

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for marking please		Posted by narmin B. Sat Jan 29, 2005 04:24 am
A 30 year old is referred for antenatal care at 10 weeks gestation. She weighs 120 KG with a body mass index 38 but has no other risk factors. Justify your antenatal and intrapartum care with specific reference to her obesity. Obesity is associated with increased maternal and fetal complications. Therefore shared antenatal care by a consultant obstetrician and community midwife and GP is required. History of previous pregnancies and complications such as shoulder dystocia, postpartum bleeding should be asked as there is a risk of recurrence and necessary precautions can be taken. Blood pressure should be checked by using an appropriate size cuff for correct measurement. An early transvaginal scan should be arranged for determining gestational age as LMP is not reliable and irregular periods are more common in obese women. Counselling the mother about the complications of pregnancy with obesity is important. These complications are fetal macrosomia, gestational and overt diabetes, shoulder dystocia, higher rate of instrumental and operative delivery and post partum bleeding. Strict diet is not recommended, but an advice should be sought from a dietician to avoid excessive weight gain. Anomaly scan at 18-20 weeks may be difficult due to obesity and repeat anomaly scan should be arranged if necessary. Urineanalysis and random blood sugar and patient?s symptoms are not sensitive tests for detection of diabetes. Therefore a 75 gram glucose tolerance test at 28 and 32 weeks should be arranged. Abnormal results need referral to diabetic clinic for advice on diet or insulin therapy. Observation for signs and symptoms of pre-eclampsia such as high blood pressure, proteinuria, headache, visual disturbances and epigastric pain is required as obese women are at higher risk of developing pre-eclampsia compared to normal weight women. This woman should be seen by the anaesthetist during the antenatal period as complication of anaesthesia such as failure of intubation is more common. Estimation of the fetal weight by ultrasound scan within 10% of the actual size of the fetus is possible. The other advantages of scan is determining of the fetal presentation which can be difficult to assess by palpation due to obesity. If the antenatal period was uneventful she should be allowed to wait for normal delivery. However in the presence of a large for date fetus, some obstetricians recommend induction of labour at 37-38 weeks to avoid excessive fetal weight gain and traumatic delivery. The benefits of this practice has not confirmed in randomised controlled trails. Hospital delivery should be recommended due to possibility of complications. An experienced midwife should be allocated for her care. Epidural is an ideal form of anaesthetic for this woman as there is possibility of instrumental and operative delivery. Due to the difficulty in monitoring of the fetal heart with abdominal transducers, use of fetal scalp electrode is preferable. Since there is a risk of shoulder dystocia, a registrar or consultant should attend for delivery especially if there was a history of previous shoulder dystocia. Active management of the third stage of labour is necessary as it can reduce postpartum bleeding. Because caesarean section can be technically difficult and also there is a risk of post partum haemorrhage, a senior obstetrician should perform the operation. Even in some cases there may be a need for an extra assistant for adequate exposure of the operating area. Because of the risk of thromboembolic disease, postnatal thromboprophylaxis with subcutaneous low molecular weight heparin and using thromboembolic deterrent stockings (TEDS) is required for 4-5days post delivery or until full mobilisation. Operative morbidity such as post operative uterine and wound infection are more common and prophylactic antibiotics such as a dose of intravenous Augmentin should be given during the operation.
		Posted by SWATI M. Sun Jan 30, 2005 09:53 am
Woman should be counselled regarding the increased maternal risk of developing gestational diabetes,hypertensive disorders of pregnancy and thromboembolism due to obesity.There is increased perinatal morbidity and mortality due to fetal macrosomia,shoulder dystocia or growth restriction if develop complication of hypertension. History regarding parity ,weight of previous babies should be taken into account to predict fetal weight as increased risk of macrosomia.Family history of diabetes, hypertension, thromboembolism should be asked as increased risk of developing these complications. Early dating ultrasound scan is important to calculate and monitor growth ,as it can be affected .Screening of fetal anomaly should be offered in the same manner as routine but interpretation of maternal serum alpha fetoprotein may pose problem as levels will be on lower due to obesity. She should be screened by 50 gms oral glucose challenge test at 24 to 28 weeks of pregnancy for gestational diabetes.Other tests such as urinary glucosuria or random blood sugar have low sensitivity.She should be conselled regaring increased number of antenatal visits particularly late pregnancy for monitoring blood pressure and proteinuria as at increased risk of developing hytertensive disorder.For measurement of the blood pressure large cuff should be used .Fetal growth should be monitored by serial ultrasound growth scans every 2-4 weeks to predict fetal weight.If she develops any additional risk factor for thromboembolism such as hyperemesis,hypertension or need for admission and rest,appropriate thromboprophylaxis should be adviced.Anaesthetic consultation should be arranged for discussing labour analgesia and anaesthesia . During labour,vigilance needed for fetopelvic disproportion as increased risk of disproportion due to macrosomia.Experienced person should be present at delivery as risk of shoulder dystocia.Continuous electronic monitoring is indicated if develop complications of GDM or preeclampsia.Problems may arise during caesarean delivery due to anaesthesia(epidural anaesthesia is preferred than general),increased risk of having wound infection, thromboembolism.Prophylactic antibiotics and appropriate thromboprophylaxis should be adviced by calculating risk profile.General measures for thromboprophylaxis such as avoiding dehydration,minimizing bed rest should be observed . Thromboprophylaxis with TED stockings and low molecular weight heparin for 3-5 days should be adviced after vaginal delivery and no additional risk factor for thromboembolism.
		Posted by vijaya L. Mon Jan 31, 2005 05:29 am
Pregnancy in an obese woman should be considered as high risk. History obtained regarding the outcome of previous pregnancies is helpful in predicting the complications in the present pregnancy. Her dietary habits and exercise schedule are noted and she should be advised to take a balanced diet with regular moderate exercise and should avoid severe restriction of diet. Consultant led care is recommended because she is at risk of developing pregnancy complications like pre-eclampsia, gestational diabetes, urinary tract infections, preterm labour and large for dates baby. Early pregnancy ultrasound is recommended, so that exact gestational age guides the management of pregnancy complications. Pre-eclampsia is screened for by measuring the blood pressure at every visit along with checking urine for protenuria. Appropriate cuff should be used to avoid false high readings. Gestational diabetes is screened for at booking, around 24 weeks and again at 32 weeks with either timed glucose or glucose challenge test. Asymptomatic bacteruria should be looked for early in the pregnancy. Foetal growth should be monitored by the ultrasound as palpation and symphysio-fundal height measurements are not reliable. Even ultrasound monitoring can be technically difficult because of the excess adipose tissue. In the absence of complications, majority of the obese women deliver vaginally. But experienced obstetrician should attend the labour anticipating and being ready for shoulder dystocia and PPH. Establishment of local protocols and fire drills help in improving the perinatal outcome. Rate of cesarean section is slightly increased in obese women probably because of the pregnancy related problems. Anaesthetic assessment is necessary in the presence of medical complications. Regional anaesthesia is preferred to general anaesthesia. Pfannensteil incision is preferred to midline as closure is easy and gives good cosmetic effect. It is said to associated with higher rate of wound infection and prophylactic antibiotics are necessary. Single layer enbloc closure may decrease the wound dehiscence. Early ambulation should be recommended and thromboprophylaxis with heparin should be considered till full ambulation. Neonate should be monitored for hypoglycemia. Dietary restrictions can be introduced in the post natal period.
		Posted by Nibedita R. Fri Feb 4, 2005 06:45 am
Obesity should be considered as high risk pregnancy as is associated with increased maternal and fetal morbidity and mortality. Risk to the mother includes hypertension, preeclamsia, gestational diabetes, venous and pulmonary thromboembolism, increased operative delivery, PPH, infection, wound dehiscence and increased mechanical distress. Fetal complications are macrosomia and increased morbidity due to birth injury (shoulder dystocia), hypoglycaemia. Increased risk of IUGR if pregnancy is complicated by hypertension. Pregnancy should be managed by close liaison between consultant obstetrician, dietician, anaesthetist, neonatologist, experienced midwife and GP. Risks assessment can be done from obstetric history: parity, mode of delivery, birth weight, shoulder dystocia. Family history of diabetes, hypertension, cardiovascular disease and VTE. Personal history of cigarette smoking and alcoholism, which would increase risk of VTE. Booking scan to assess gestational age as pregnancy during a period of oligomenorrhoea or amenorrhoea is common and also to assess subsequent growth of fetus as clinical assessment is difficult and inaccurate. Dietary advice should be sought from a dietician in a high BMI clinic. A balanced diet is advisable as dietary restriction to prevent excessive weight gain can impair fetal growth. Blood pressure should be measured by an appropriate size calf to minimise over /under estimation. BP should be checked at booking and at every visit to detect any rise at the earliest to take necessary precaution. Investigations include: FBC, MSU (UTI more common due to poor local hygiene), urine dipstix for protein and urine for glycosuria in every antenatal visit. Timed laboratory blood glucose estimation should be made at the booking visit and at 28 weeks gestation and when glycosuria of 1 or more is detected. If FBS >6mmol/L and 2 hr PPBS is >7mmol/L a 75 gm two hr oral GTT should be performed. At 20 weeks, fetal anomaly scan is recommended but the assessment may be limited by excessive abdominal fat, which should be explained beforehand. Limitation on fetal growth monitoring clinically and localisation of FHR is difficult. Serial growth scan 2-4 weekly is recommended. At 38 weeks, scan to approximate estimation of fetal weight, presentation and liquor volume. Indications for elective Caesarean section at around 39 weeks are malpresentation and macrosomia (>4.5 kg). Vaginal delivery in a hospital would be the aim. Experienced midwife and senior obstetrician should be involved for labour monitoring from the beginning and consultant obstetrician would be informed. Progress of labour may be difficult to assess due to difficulty in proper positioning of the patient as well as difficulties in pelvic examination. Intrapartum fetal monitoring is also difficult and FSE may be required. Prolonged restriction to the bed is prohibited and adequate hydration should be maintained to prevent VTE. Adequate labour analgesia has to be maintained preferably by epidural. Progress of labour may be delayed due to poor maternal effort and an increased risk of instrumental delivery. Difficulties in delivery as lithotomy position could not be maintained properly. High index of suspicion when there is delay in delivery of shoulder. Regular drills and protocols help the labour ward staff to be prepared for shoulder dystocia in such a women. Caesarean section if required for fetal distress or poor progress of labour, which should be done by a senior obstetrician. Anaesthetist assessment should be done before, as intubation and epidural catheter placement both are difficult. Caesarean section associated with intraoperative difficulties, meticulous haemostasis should be achieved as high chance of wound haematoma. Prophylactic antibiotic would be of help to prevent wound infection and dehiscence. Thromboprophylaxis for 3-5 days or until full mobilization, adequate hydration and TED stockings for both vaginal and Caesarean section would be employed to minimize risk of thromboembolism.