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MRCOG PART 2 SBAs and EMQs

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Essay 194 - Obesity & Pregnancy

Posted by Remi A.
This woman is morbidly obese,which could have adverse for the outcome of her pregnancy.Hence, appropriate modification to her antanatal care,delivery and postnatal care would be essential to achieve a good outcome.

Obesity remains a major contributor to maternal morbidity and mortality, as shown in the CEMACH[2000-2002]report-35% of women that died in the last triennum were obese.

The possible effect of obesity on outcome of the pregnancy and the need for modification in care should be explained in a sensitive,nonpatronising way to the woman.
Dietary advice should be given to avoid excessive weight gain in pregnancy[Dietitian referral],but weight loss is not appropriate during pregnancy.

Dating Scan should be done by transvaginal scan,in case there is difficulty with transabdominal scan.
As she is at increased risk of gestational Diabetes[GDM].she should be screened for GDM at 26-28/40 using the 50g Glucose challange test.She is also at increased risk of pregnancy induced hypertension-Blood pressure measurement at each antenatal visit should be by appropriately size cuff[covering 2/3 of upper arm] to ensure accuracy of reading..
Obese is a moderate risk factor for thrombosis,so she should be considered for antenatal thromboprophylaxis in form of LMW heparin if there are two other moderate risk factors eg intercurrent illness,prolonged immobilisation,admission for hyperemisis etc.
If there are difficulty with fetal growth monitoring by palpation,ultrasound assessment should be used during antenatal visits.
As she is at increased risk of having a macrosomic baby,she should have ultrasound estimation of fetal weight near term[taking into consideration 20%+/- accuracy of this]This may help to plan her mode of delivery.
Senior midwife,senior obstetrician should be available for her delivery,because of increeased risk of shoulder dystocia.
Fetal scalp electrode should be used for fetal monitoring,in case there is difficulty with abdominal monitoring.
Senior Anaesthetist should be invovolved because there may be difficulty with venous access,and intubation in case of ceaserean section.
Ceaserean section is indicated for obstetrics reason only,and should be performed by a senior obstetrician,because of there may be difficulty.
Post delivery-thromboprophylaxis in form of LMW Heparin because of increased risk of VTE.
Breastfeeding should be encouraged.
Appropriate contraception should be provided and weight loss encouraged before next pregnancy.
Information leaflets and contact of support groups like weight watchers should be provided.
Posted by Sarwat F.
Management of this woman will include taking into account all the complications associated with obesity and formulating a management plan. Risk assessment is done at the time of booking noting morbid obesity. Various problems associated with obesity include difficulty in clinical diagnosis of pregnancy and subsequent monitoring. Abdominal palpation for the size of the fetus will be difficult and a senior person should be involved in her assessment. Ultrasound assessment can be done if there is uncertainty in assessing the fetal size. Monitoring maternal blood pressure can be difficult as a standard cuff size can give falsely high or low readings. Larger cuffs are used for woman with high BMI. It is not advisable to restrict dietary intake during pregnancy as it is associated with impaired fetal growth. In case of suspicion of fetal growth restriction, serial ultrasound can be arranged to monitor pregnancy. Obesity is also associated with medical disorders like high blood pressure and diabetes. Blood pressure is measured at each visit and woman is explained about any signs and symptoms of high blood pressure like headache and vomiting. Latent diabetes is common in woman with high BMI. A glucose tolerance test can be arranged at 26 weeks however there is insufficient evidence to recommend this in every woman with raised BMI.
Various intrapartum complications of obesity include difficult intravenous access, difficult epidural, problems with monitoring baby with external transducers which will increase the need for fetal scalp electrode. If there are any problems anticipated, siting the cannula in advance is desirable. There is increased risk of shoulder dystocia and senior most person able to deal with this problem should attend delivery. Regular drills and protocols help the labour ward to be prepared for incidents like shoulder dystocia. If there is a need for caesarean section all the complications of surgery and anaesthesia are increased. Senior obstetrician and anaesthetist are required for management of labour and delivery. Delayed healing due to sweating or haematoma formation is common in obese woman. Strict aseptic technique, adequate hemostasis, prophylactic antibiotics and hygiene are all the precutions to reduce the risk of infection. Paediatrician must be present at the time of delivery as the risk of low apgar score, macrosomia, shoulder dystocia are all increased in woman with raised BMI.
Postnatally obesity is a risk factor for deep vein thrombosis, early ambulation is encouraged. Risk assessment is done to identify any other risk factors associated with DVT and to identify the need for heparin. TED stockings can be provided. Woman is advised tight contro of weight before planning for next pregnancy and appointment with dietition is arranged to help her reduce weight. Regarding contraception COC pills are considered as a relative contraindication, injectable progesterone or IUD can be inserted at her postnatal visit.
Posted by Balakrishnan V.
Obesity in pregnancy is associated with many antenatal, intrapartum and post partum complications. The patient should be counselled in detaile to ensure good antenatal followup and compliance. Weight reduction in pregnancy is not encouraged but she should be seen by a dietician to have a plan of meeting required calories while avoiding fatty food.
There will be some modifications in her antenatal care as her high BMI makes it a high risk pregnancy. She should have a consultant led antanatal care. Routine abdominal palpation for symphysiofundal height measurement and hearing fetal heart sound by sonic aid will be difficult due to fat anterior abdominal wall. The fetal growth and well being will have to be assessed by ultrasound scan in each antanatal visit. Transvaginal scan may has to be used as resolution of abdominal scan will be poor.
She is more prone to medical problems in pregnancy due to her obesity like pregnancy induced hypertension,gestational diabetes and thromboembolism. For her blood pressure measurement large cuff of sphygnomonometer should be used to get accurate reading. She should be checked for glycosuria and offered oral glucose tolerance test at 32 weeks of gestation. She should be advised to take moderate exersice daily like walking for 30 minutes.
Due to her obesity there is increased risk of her baby to be large for dates especially if she developed gestational diabetes. There is risk of shoulder dystocia in labour therefore senior obstetrician and midwife should be available for her delivery. CTG monitoring will be difficult and fetal scalp electrode may has to be used.
In case she needed caesarean section, it carries more morbidity due to her obesity. Senior anaesthetist and obstetrician should be available to minimize anaesthatic and surgical complications. Intubation will be difficult due to fat neck in case of general anaesthesia. Adequate asepsis, prophylactic antibiotics and good haemostasis is important to lower the risk of wound haematoma and delayed healing. Thromboprophylaxis is mandatory whatever the mode of delivery is. She should be given TEDS and subcutaneous low molecular weight heparin 40 mg once for six weeks post partum.
She should be encouraged to breast feed and proper contraception given before her discharge. COCP are relatively contraindicated due to her obesity. She should be councelled to strictly reduce weight before planning next pregnancy.

Posted by Kishor S.
Weight of 140 kg with BMI of 39 puts her in the high risk pregnancy category because obesity is associated with increased both maternal and perinatal morbidity and mortality. The risks involve pregnancy complications (PIH, gestational diabetes, preterm labour, thromboembolism), fetal complications (NTD, macrosomia), labour complications (shoulder dystocia, perineal injury, increased CS), anaesthetic complications and difficulty in epidural anaesthesia. In addition, there is difficulty in monitoring the pregnancy and fetus (difficulty in palpation of uterus, fetal parts and auscultation).

During this visit, history of additional risk factors will be enquired. They include smoking, alcohol intake, family history of diabetes and thrombophilias. BP will be taken using an appropriate large cuff as small cuff will give false higher readings in obese individual.

Initial investigations will include Hb, blood group ABO & Rh, rubella antibody (in case of doubt in previous immunization), VDRL, urine sugar. She will be counseled and offered to test for HBSAg, MSU (for asymptomatic bacteriuria)
Since she is potentially diabetic, oral GTT will be done instead of GCT. If it is normal, it will be repeated at 32 - 34 weeks as diabetogenic state peaks during late pregnancy. USG will be done for dating irrespective of last menstrual period (necessary for screening of fetal anomaly and ensuring consistency of gestational age assessments) and rule out multifetal pregnancy.

Dietary counseling with the involvement of dietician will be done. Dietary restriction is not recommended but at the same time a balance control is required. Calorie intake should range between 2000 to 2500 kcal and she will be best guided by the dietician. She will be given information about the benefits of eating a variety of foods during pregnancy which she can get on net at: Eating While You Are Pregnant
http://www.eatwell.gov.uk/agesandstages/pregnancy/whenyrpregnant/ She will be advised that a moderate course of exercise during pregnancy is not associated with adverse pregnancy outcomes.

She will be counseled and offered screening for DS and NTD. The scan at 12 wks may include NT if she desires for Down?s screening that time. Otherwise, she will be offered more reliable serum quadruple test at 16 to 18 weeks. A congenital anomaly ultrasound scan will be done at 18 to 20 weeks.

Antenatal visit schedule will be modified as and when any complication arises during the course of pregnancy. Difficulty in clinical monitoring of fetal growth in terms of uterine size, liquor volume, fetal presentation and fetal heart is expected and she will require repeated ultrasound scan for the same. At 36 weeks plus, USG scan will be necessary to ascertain presentation. During this time she will be assessed by the anaesthetist for preoperative check up, in case she requires CS.

During labour, intra-partum monitoring may be difficult, and should be managed by experienced midwife making sure that obstetrician is available. Caesarean section, if required, to be done under direct guidance of consultant as there may be intra-operative difficulties. Antibiotic prophylaxis will be given as there is post operative risk of infection and wound dehiscence. Thromboprophylaxis will be given in any type of delivery, vaginal or CS.

During every visit she will be given information, with an opportunity to ask and discuss supported by written information to enable her informed decision making.
Posted by Ebeinheizer S.
This obese patient pose extra pregnancy and purperial risks compared to others. Apart from routine anteatal care per local protocal (e.g. Tucker\'s guideline), she would need extra antenatal and postanatal attention.

Even though she has no past medical history,she is more prone to develop gestational diabetes,gestational hypertension and pre-eclampsia.There is also a risk of hypercholesterolaemia. These has to be monitored from first trimester right through purperium where she can remain diabetic and/or hypertensive if it develops antenataly.Urine sugar and protein analysis at every antenatal visit gives early warning of potential diabetes and pre-eclampsia.Diabetic screening can be performed early,14-16 weeks,using fasting blood glucose and glucose tolerance tests to determine those who need referal to diabetic clinic and insulin treatment.Strict glycaemic control reduces incidence of macrosomia.Blood pressure monitoring needs large sized cuff.If elevated,monitoring would be dictated by severity,need for anti-hypertensive,proteinuria and blood results for pre-eclampsia.

She would also be offered serum screening at around 16 weeks and detailed anomaly scan at around 20 weeks.Serum screening determines risks for spina bifida and chromosomal anomalies such as Trisomy 21.If increased risk,she can be offered invasive procedures such as amniocentesis.Detailed anomaly scan could also detect structural abnormality if any.Intervention would be determined by parental choice after adequate counselling.

Obesity makes palpation to estimate fetal growth very difficult.So, she would need regular fetal growth ultrasound at 4 weekly intervals from 24 weeks,closer if any aberrant growth pattern.She is as greater risk for fetal macrosomia.In some cases,there is also risk of IUGR.Early induction of labour at term would be necessary for babies with ultrasound measurements above the 95th centile to reduce the risks of dystocias in labour.

Obesity increases anasthetic and surgical risks.Referral to anasthetic clinic to discuss epidural, spinal and general anaesthesia would be necessary.Technical difficult for anasthesia prepares both the anaesthetist and patient for potential problems.

Patient can be allowed to go post-dates and induction of labour as any other patient if no complications ante-nataly. The labour ward team need to pay particular attention to increased risk of labour dystocia and shoulder dystocia if she has a macrosomic baby.Pain relief using morphine might need higher dose.In the event of caesarean section,technical operative difficulty and greater risks of post-operative complications such as difficult access,atelectasis and thromboembolism would need early senior obsterician/anaesthetist involvement.TED stockings,prophylactic heparin,adequate hydration and early ambulation would be necessary even after normal delivery,let alone operative.

During puerperium,general health issues need to be addressed even though it should have been hinted right from the start.Weight reduction,healthy diet and lifestyle modification such as exercise should be encouraged.Referral to obesity clinical and dietician would be necessary.Long term risks of hypertension,diabetes,atherosclerosis,heart disease and pelvic floor weakness should be explained alongwith written information.Contraception,avoiding COCP which carries higher risk of thromboembolism,could be IUCD or progesterone based products can be offered.
Posted by SWATI M.
Pregnancy with obesity is associated with maternal risks of developing hypertensive disorders,gestational diabetes,having operative delivery,anaesthetic problems,postpartum haemorrhage and thromboembolism.The perinatal morbidity and mortality is increased due to fetal macrosomia and shoulder dystocia or IUGR if develops hypertension.
Family history of diabetes ,hypertension and thromboembolism should be enquired as it increases risk of having these further.
She should be adviced a consultant led care as high risk.At booking ultrasound scan should be performed for dating as fetal growth may be affected on either side.Increased number of antenatal visits should be adviced to monitor her blood pressure by appropriate sized cuff.She should be referred to the dietician for advice to avoid excessive weight gain.Strict dieting is not advisable during pregnancy.Oral glucose challenge test should be performed at 28 weeks and repeated again at 32 weeks if normal.Appropriate thromboprophylaxis such as minimizing bed rest and maintaining adequate hydration should be adviced if she needs in-patient care antenatally .
Fetal growth should be monitored by serial ultrasound scans at 2 ? 4 weeks interval from 24 weeks as difficult to judge fetal size clinically.At term scan should be done for fetal presentation .Anaesthetic review should be organized to discuss labour analgesia .
Continuous electronic fetal monitoring is recommended during labour as difficulties in monitoring by other methods and by scalp electrode once membranes rupture.Labour should be monitored by partogram with 4 hour action line to recognize failure to progress at earlier stage.Senior personnel should be present at time of delivery as risk of shoulder dystocia.
If she needs caesarean section,precautions such as proper haemostasis,use of transverse abdominal incision,closure of skin by staples and use of prophylactic antibiotics should be taken to minimize risk of wound haematoma and infection .
Third stage should be managed actively to minimize PPH.
Appropriate thromboprophylaxis should be offered which includes early ambulation and adequate hydration during labour .Use of prophylactic heparin for 3 ? 5 days postpartum along with this after vaginal delivery if additional risk factor for instance preeclampsia or if she undergoes caesarean section.
Provide contraception advice, COC pills are relatively contraindicated as further increase in risk of thromboprophylaxis.
She should be provided with information and support at all times during her management to make informed choice.
Posted by OJO AJIBADE  .
This lady is morbidly obesse and obesity increases the perinatal mortality /morbidity rate.Also her weight will increase as the pregnancy progresses making clinical evaluation of the patient more difficult.
Accurate estimate of the gestationa age will be difficult and may not be possiple except through the transvagina scan.Physical examination such estimating the fundal height for growth;presentation;detection of polyhydramnios and other pelvic masses will be difficult. A large BP cuff appropriate to arm size should be used for Bp recording to prevent erroneous high value reading.
Dietary advise with the help of a dietician will be offered but keeping in mind that weight loss during pregnancy is not advisable to prevent growth deficit in baby.There will be difficulty in siting cannula or in taking blood for routine blood investigation.It is advisable to site the cannula during the antenatal period if some emergency procedure is being anticipated.
Siting an epidural in labour will be difficult and a senior anaesthetic help will be necessary. Although there is no medical or surgical disorder she will be screened for gestational diabetes which they are prone to developing at 26 weeks. Aside from the routine urine for protinuria and glycosuria ; routine serial growth scan will be done from 30 weeks to assess fetal growth.
During the intrapartum; monitoring thr fetoes will be difficult with the CTG although fetal scalp elecrode may be applied to the fetal scalp. I will aim for vagina delivery and anticipate shoulder dystocia as obese women prone to have macrosomic baby for which adequate preparation will be in place.
If Caeserian Section become necessary it will be very difficult and senior collegues help will be sought.They are prone to developing wound dehiscence; hematomas and infection.However this can be reduced with intapartum antibiotics and good surgical techniques.
Post operatively; prophylasix will be given for venous thromboembolism( clexane or innohep ;calculated based on their weight);TED Socks;good hydration and encourage early mobility.
There is no contraindication to breastfeeding and contraception will be discussed though combined pills is a relative contraindication.
Posted by Zaharuddin R.
The main problem of the patient is morbidly obese. Discussion regarding further management during pregnancy should be clearly explained to the patient to achieve good compliance. Referral to dietitian for proper calorie intake and to avoid excessive weight gain and to avoid weight reduction during pregnancy.

Appropriate exercise during pregnancy and adequate fluid intake with avoidance of excessive bed rest not only good as healthy lifestyle in pregnancy but it may reduce risk of deep vein thrombosis (DVT). Subcutaneous heparin and intravenous hydration is indicated if the patient is hospitalized of any reason to avoid DVT.

Healthy life style during pregnancy should be advised like stop smoking and reduced or stop alcohol intake. These good habits should be continued after delivery.

The patient should be counseled that she is at increased of gestational diabetes mellitus and pregnancy-induced hypertension.

Proper size of blood pressure (BP) cuff is needed for BP monitoring as small cuff will cause false high BP. Balance-type weight scale is recommended for this patient as spring-type scale may give inaccurate reading and misleading for weight monitoring during pregnancy.

Modified glucose tolerance test (MOGTT) is should be done on first antenatal booking as the patient is at increased risk of diabetes mellitus. If MOGTT is normal at booking, it should be repeated at 24-28 weeks gestation.

Fetal growth monitoring is difficult for the patient. Symphysio-fundal height measurement is not appropriate for the patient as thick abdominal wall, unable to palpate uterine fundus and difficulty in palpating fetal part and presentation as pregnancy progressing. These problems could be overcome by serial ultrasound of the fetus during antenatal check up. It is time consuming and high cost.

Obese lady like the patient has difficulty in blood taking and setting up venous access (if needed) as her vein is not prominent compared to lean lady. Experience phlebotomist is needed for any blood taking and venous access.

During labour, partogram should be charted properly as poor progress of labour may be a sign of big baby. Estimation of fetal weight is not accurate either by palpation or ultrasound. The patient should be hydrated well by intravenous infusion of normal saline to avoid dehydration and DVT post delivery. Hydration could be monitored by clinical examination and urine ketone.

Epidural analgesia could be difficult to be inserted due to the patient is unable to position herself during the procedure. Other options are intamuscular pethidine or entonox inhalation. Anaesthesist should be referred earlier during early labour to anticipate difficulty in assessing airway if general anaesthesia is needed. Experience anaesthesist is needed to insert epidural analgesia during labour as pain relieve and for operation (if needed).

The patient could have difficulty in pushing during second stage of labour. She is at increase risk of operative instrumental delivery due to poor maternal effort. All staff of labour ward should be warned that risk of shoulder dystocia of the fetus. Senior members of labour ward should be in the labour ward during her labour.

Post delivery regardless mode of delivery, the patient should be encourage to take adequate fluid intake or intravenous infusion of normal saline to ensure good hydration. Subcutaneous heparin is advisable till a week post partum and the patient is ambulating well. These measures are important as the patient is at high risk to develop DVT post partumly. Symptoms of DVT should be warned such as calf pain, unilateral calves swelling or pale lower limb.

Breast feeding on demand should be encouraged as it is not only good for the baby but it also good for the patient for weight reduction and resume pre-pregnancy weight faster. Referral to endocrinologist and dietitian monitoring should be continued due to morbidly obesity.

Hormonal contraception such as combined oral contraceptive pill (COCP) is contraindicated as unacceptable risk of DVT. Intrauterine contraceptive device or condom is good choice of contraception.

Written information regarding obesity in pregnancy should be given to the patient to make her more understanding and compliance to the treatment.
Posted by SANGEETA P.
High BMI is associated with general risks to the health as well as risks during antenatal, intrapartum and post natal period.This lady is booking with 140 kg, BMI of 39, which puts her to morbidly obese category and has increased perinatal morbidity and mortality associated.
At her booking visit she should have all normal booking bloods and dating scan and due to the high BMI it may be difficult to get the informations by transabdominal scan so she will need to have transvaginal scan for dating and viability.She should have multidisciplinary care and should have the planning made for her entire period.She should have an appointment with the dietician, though she is not encouraged to reduce weight in pregnancy but shoud have an advise regarding the healthy food during pregnancy considering her weight.She shoulld be given an oppurtunity to see the anaethetist sometime during antenatal period so that she can have a detailed discussion regarding the epidural in labour , its difficulties in citing and the problems which may encurr during surgery.
She is at high risk of pregnancy induced hypertension so should have close monitoring of her blood pressure by appropriate size cuff.She is at increaded risk of gestational diabetes so should be booked for glucose tolerance test at 26-28 weeks.She has high risk of thrombo embolism so should be encoraged to have active and helthy lifestyle, avoiding prolonged bed rest.Having high BMI as the only risk factor is not an indication for antenatal thromboprophylaxis but if she has any other associated risk factor, she will require thromboprophylaxis.
Presentation and the growth of the baby will be difficult to monitor clinically so she should have regular growth scan.
During labour again it will be difficult to assess progress of labour, clinically it will be difficult to assess the presentation, decent of presenting part.Fetal heart will be difficult to be monitored through abdominal transducer of the CTG so she should have fetal scalp electrode application.
She should be attended by the senior anaethetist if she requires epidural for pain relief.Instrumental delivery can be difficult so the senior staff should be on alert.She is for high risk for shoulder dysticia and senior staff should be alerted on time.If sge sustains perineal tears it may be difficult to examine and suture them properly in the room.
If she undergoes for cesarean section, it may be associated with high degree of surgical and anaethetic risks and either senior staff should be performing the scetion or directly supervising the junior staff. there is no evidence of leaving a prophylactic drain but if any suspecion regarding the hemostasis, should have a drain.
Post ceasarean section she should be watched for PPH,,blood pressure and pulse monitoring.She should have thromboprophylaxis according to the local hospital protocols.Fractionated low molecular weight heparin is normally used in most hospitals.
Post delivery before discharge she should have a discussion regarding contraception and should be encouraged to reduce the weight before embarking on to the next pregnancy.
Posted by Rishit H.
r Paul,
I am sending my answer for the first time. Kindly correct it and give your valuable advice to improve in future.
Thanking You,

Rishit


Thanking You,

Rishit

ANSWER

This patient, by the virtue of her obesity, is at an increased risk of complications antenatally, intrapartum and postpartum. These complications are
both foetal and maternal.In order to improve the outcome of her pregnancy,
preventive measures and steps for early recognition and treatment along
with skilled care is a must. This can be best acheived wihin a team of
obstetrician, midviwes, her general practitioner and a dietician.
First and foremost clinical diagnosis may be difficult, it may be
difficult to establish viablity and dating of the pregnancy without a transvaginal
scanning.As the pregnancy proceeds, it may be difficult to evaluate the
size of the foetus, determine the prenting part, detect foetal heart rate or
recognize the presence or absence of hydroamnios.Hence this may neccesitate serial growth scans. There is increased risk of foetus to be large for gestational age, for which ultrasound would be of immense help.
Dietary advice is of help ,so refferal to a dietician is appropriate.Diet restriction may cause growth restriction,So is not advisable.Maternal complications as preeclampsia, gestational diabetes and thromboembolic phenomenon may develop during pregnancy.Blood pressure measurement using standard cuff may give erroneously high reading ,appropriate size cuff should be used. A screening for gestational diabetes to be done at 26 weeks gestation. During labour chances of prolonged labour, intrumental vaginal delivery and caesarian section are high. Initially it may be difficult to site an infusion in a fat limb and to site an epidural cannula.If anticipated ,should be placed well in time.If caesarian section required it should be done by a senior obstetrician and a senior anaesthetist, as intubatipon may be hazardous. If macrosomia anticipated , adequate trained staff and protocols for shoulder dystocia should be performed. Obesity is a risk factor for thromboembolism. Early ambulation postdelivery should be encouraged. If surgery performed ,thromboprophylaxis should be considered.Stockings would be added help. Delayed wound healing and haematoma is common, so adequate sepsis and haemostasis, prophylactic antibiotics and adequate hygiene is mandatory.The newborn with low apgar score and problems due to macrosomia are more frequent so neonatologist should be informed in time , to plan adequate care of the baby.Advice regarding control over diet before next pregnancy to be given. Oral combined contraceptives are relative contraindications. Written information regarding support group like weight watchers and continual of dietary advice should be given.
Posted by Sreekala S.
Maternal BMI of 39 makes this a high risk pregnancy and therefore should be under consultant led care.An ultrasound scan should be done as soon as possible to correctly date the pregnancy and to get a baseline against which fetal growth can be compared to. It may be necessary to get a transvaginal scan if the abdominal scan is technically difficult. The woman should be counselled that there is a high risk of Gestational Diabetes, Pre eclampsia, IUGR, macrosomia, thromboembolism, infection and anaesthetic risks during the pregnancy.
She should be referred to a dietician for advice. At each antenatal visit, BP should be checked with a larger cuff and urine checked for protein and glucose.Anomaly scan should be performed by an experienced sonologist as it may be difficult to interpret the findings due to the maternal build. An oral glucose tolerance test should be performed at 26 weeks to detect Gestational Diabetes.
Serial growth scans may be required as it can be difficult to monitor the growth of the baby by abdominal palpation alone
She should have an anaesthetic review before delivery so that pain relief in labour could be discussed along with discussion about anaesthetic risks.It may be difficult to intubate her if General anaesthesia is required.
During labour an experienced midwife, a senior obstetrician and a senior anaesthetist should be involved in her care. An intravenous access may be difficult and therefore it is advisable to site a venflon early in labour and group and save the blood as there is an increased operative risk. Continuous CTG monitoring is required during labour. Scalp electrode may be required if the trace is difficult to obtain abdominally. Adequate pain relief should be given during labour. Shoulder dystocia should be anticipated and a senior obstetrician, anaesthetist and paediatrician should be available at delivery. If a caesarean section is required, then more staff may be required to transfer the patient. A bigger operative table may be needed. An extra assistant may be needed for retraction of the tissues. An experienced obstetrician should perform the caesarean section as it can be a difficult section. Prophylactic antibiotics should be given as there is an increased risk of wound infection.
Thromboprophylaxis should be considered in the form of Low molecular weight heparin or TED stockings following a normal vaginal delivery. LMWH and TEDS should be given following an operative delivery.
Post natally the woman should be advised to loose weight and informed of the risk of Gestational Diabetes in future pregnancies and type 2 DM later in life. Advice on contraception should be given at discharge.
Posted by Tanzeem Sabina C.
Dear Paul,
this is my first attempt that I can send to you finally. Please check. Thanks.
Woman with obesity in pregnancy (BMI of 39) is associated with increased risk of maternal and perinatal morbidity and mortality. Obesity remains a major cause of maternal mortality: 35% women with died in the last triennium-(CEMACH 2000-02 report).
She should be seen by dietician to avoid excessive weight gain in pregnancy but weight loss is not appropriate during pregnancy.
She has more risk to PIH ( pregnancy induced hypertension), GDM ( gestational diabetes mellitus), Thromboembolism, increased risk of macrosomic baby and its sequels ( shoulder dystocia, increased need for caesarean section), difficulties in fetal and maternal monitoring and growth scanning.
Early Dating is needed by transvaginal scan, if there is difficulty in transabdominal scan.
Her blood pressure should be monitored by large and appropriate size cuff to ensure proper BP recording, as there is more chance of PIH and difficulty in BP monitoring.
As there is more chance of GDM, she needs to be screened for GDM by Glucose Challenge Test at 26-28 weeks of gestation.
It is difficult to measure symphyso-fundal height, fetal lie, presentation, liquor volume and auscultation of fetal heart rate by abdominal palpation due to fat, these should be assessed by ultrasound scan at late trimester. Especially growth scans at every 2-3weeks to detect fetal macrosomia. This may help to plan her mode of delivery and any special needs.
Senior and experienced midwife and obstetrician should be available during delivery as there is more chance of shoulder dystocia.
If there is difficulty in abdominal monitoring by CTG, fetal scalp electrode may be needed.
Caesarean section may be needed due to big baby or other obsttric cause, in that case senior obstetrician and senior anesthetist should present to reduce operative and anaesthetic complications. Aseptic precaution, prophylactic antibiotics and good haemostasis is needed to reduce the risk of wound haematoma and infection.
Obesity is a risk factor for thromboembolism, adequate fluid intake, early mobilization and TED stockings are necessary. LMWH may be needed by assessing other risk factors for thromboembolism, specially in case of caesarean section.
Breast feeding should be encouraged and proper contraception should be given before discharge. COCP is relatively contraindicated due to obesity. She should be advised to tight control of her weight before next pregnancy with the help of dietitian.