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BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> ESSAY 250 - Obesity & pregnancy
ESSAY 250 - Obesity & pregnancy Posted by PAUL A.
Tue Jan 1, 2008 02:45 pm
A 34 year old primigravida is referred to the antenatal clinic at 8 weeks gestation. She has a BMI of 40 but is otherwise well. (a) What will you tell her about the antenatal risks associated with obesity? [5 marks]. (b) How would you modify her antenatal care to minimise the risks associated with obesity? [7 marks]. (c) She presents in spontaneous labour at 38 weeks gestation. How would you modify her intra-partum care? [4 marks]. (d) Justify your post-natal care given that she had a normal vaginal delivery [4 marks].
Posted by Sahathevan S.
Wed Jan 2, 2008 01:15 am
A 34 year old primigravida is referred to the antenatal clinic at 8 weeks gestation. She has a BMI of 40 but is otherwise well.

(a) What will you tell her about the antenatal risks associated with obesity? [5 marks].

Obesity during pregnancy is a risk factor for adverse pregnancy outcomes. The complications of obesity during pregnancy includes: increased risk of miscarriage, increased need for caesarean sections, operative vaginal deliveries, increased risk of pre-eclampsia and thromboembolism.
Risks to the fetus include increased risk of congenital anomalies, preterm delivery, macrosomia , stillbirth and perinatal mortality. Potentially there are also long-term obesity problems for the child.
Hypertensive disorders which include Chronic Hypertension and Pre-eclamsia is five fold increase in obese women.
Gestational diabetes is common ( 3 fold increase ) in obese women of increasing age and the risk is also increased in Morbid obesity (BMI >40) which is about 10 %.

(b) How would you modify her antenatal care to minimise the risks associated with obesity? [7 marks].
There needs to be an open discussion regarding her care and about the risks involved during pregnancy. While it is useful to follow protocol and guidelines in place for her management as she is obese pregnant.
She should be identified as high risk (as BMI >30) and require increased obstetric surveillance so that she should be under consultant care. Multidisciplinary input should be sought, which involves dietician, Obstetrician and Anesthetist and Pediatrician. Dietician referral for dietary advice is important.
She should be refereed to early USS ( Ultra sound scan )for dating and detail anomaly uss to be arranged.

Maternal blood pressure is difficult to determine when the maternal upper arm is fat therefore large cuff should be used to avoid falsely high or low readings. Also regular antenatal visit and BP checking is important.

If there is any suspicion of growth restriction serial ultrasound should be arranged. Glucose tolerance test to be arranged at 26 wks to screen gestational diabetes.

Antenatal Anesthetic review may be benefit for anticipation of problems such as difficult intubations, aspiration pneumonia, difficult epidural/spinal therefore it is advisable to ensure the presence of experience anesthetist if regional or general anaethethesia needed.

(c) She presents in spontaneous labour at 38 weeks gestation. How would you modify her intra-partum care? [4 marks].

It may be difficult to site an infusion canula in a fat limp and to site an epidural canula.if there are any problem anticipated siting a canula in advance desirable. CTG montoring may be difficult due to body habitus therefore Fetal scalp electrode could be used.
If caesarian section is required an experienced Obstetrician and Anesthetist should be involved as it maybe hazadous for this morbid obese woman.
There is also a need for additional equipment such as specially adapted operating tables and surgical equipment. These problems need to be recognised so that a plan for core delivery of these women will be formulated.
Delay in wound healing and haematoma formation is more common in obese women therefore aseptic procedure, prompt homeostasis and, prophylactic antibiotics and general hygiene are the usual precautions should be taken to prevent infection
Labour ward should be prepared to manage shoulder dystocia with following the protocols and regular drills.

Postpartum Hemorrhage is a recognized complication in obese women; active management of third stage may be warranted.


(d) Justify your post-natal care given that she had a normal vaginal delivery [4 marks].

Obesity is risk factors for thromboembolism therefore risk should be assessed for thromboprophylaxis after the delivery.
Early ambulation and adequate hydration post delivery should be encouraged. Patient may need support with breast feeding as limited mobility is common.

Advised should be given regarding weight lost for next pregnancy also long term potential risk of obesity such as diabetes and hypertension .

Contraception should be discussed. COCP is contraindicated as BMI 40.


Posted by Anna A.
Wed Jan 2, 2008 10:21 am
a)She is classified as morbid obesity and she should know that it is associated with higher perinatal and maternal mortality and morbidity. She is exposed to invasive investigation like transvaginal scan for dating scan as abdominal scan may be difficult with thick abdomen. She is at higher risk to develop gestation diabetes mellitus thus early assessment of modified glucose tolerance test should be carried out (around 24-26 weeks). Maternal obesity is also associated with macrosomic baby which lead to higher operative delivery. She is also at higher risk to develop PIH, an appropriate size of BP measurement should be used. VTE is another risk should be informed to her and risk factor for VTE should always be assessed especially during admission or early pregnancy assessment. Written information, follow-up and contact detail should be provided.
b)Referral to dietician is appropriate for balance diet but weight loss is not desirable as it is associated with low birth weight. Risk assessment of VTE should be carried out especially if she require for admission. Antenatal thromboprophylasis may be needed if she has more than 3 moderate risk factors. Measurement of BP with appropriate cuff size and assessment of urine protein should be ensured. Modified glucose tolerance test should be subjected at 24-26 weeks POA and repeat later if found to be normal. Frequent visit is necessary and ultrasound assessment for lie and presentation may be required if there is difficulty to asses the lie and presentation of the fetus. Serial growth scan should be arranged at least every 4 week to look for macrosomic features. Early referral to anesthetist is prudent if there is difficulty to get venus access and discussion about method of anaesthesia can be arranged as the anticipation of difficult intubation.
c)Reassessment of VTE risk factor should be done. Ensure adequate hydration and avoid prolonged immobilization. Adequate analgesia is required, preferably epidural as this pregnancy is associated with higher operative delivery. Progress of labour should follow partogram and early recognition of primary uterine dysfunction is important and action should be taken to avoid poor progress. Fetal scalp monitoring may be required if abdominal CTG tracing is poor. The presence of senior obstetrician and experienced midwife are important as there is higher risk of shoulder dystocia. Operative delivery is hazardous, presence of senior obstetrician and senior anesthetist are essential to anticipate difficult surgery and intubation. Active third stage management should be applied with the use of syntometrine if no contraindication as here is increased risk of post partum haemorrhage.
d)Early ambulation and good hydration should be ensured. Combined contraceptive pills are relative contraindication. Mirena or IUCD would be most appropriate for the patient. Advised for weight reduction before embark another pregnancy.
Posted by Amen H. H.
Wed Jan 2, 2008 03:38 pm
a] Obesity is associated with increase incidence of fetal loss and fetal congenital maleformation.

Also there is increase incidence of pregnancy induced hypertension and pre-eclampsia.

Gestational diabetes mellitus also increased.

Risk of venous thromboembolism increased also.

The fetus can develop deviation from normal growth, it could be macrosomic or IUGR, with increase incidence of IUD, preterm labour and prematurity.

b]
Weight loss is usually not advised during pregnancy, although an advice from dietitian is required about healthy food can be considered.

Dating scan via TV/US at booking will help accurate calculation of gestational age because later on the symphysiofundal level will be not helpful because of obesity.

More frequent visits are advised with monitoring of blood pressure with appropriate size cuff for early detection and treatment of PIH.

GTT at 26 weeks gestation can help detecting GDM, also testing MSU for glucose in urine and detecting UTI which is associated with DM.

Serial growth scan is advised from 28 weeks gestation every two weeks to monitor fetal growth.

We provide Patient information leaflet.

c]Close monitoring of the mother and the fetus in consultant -led unit, with assessing progress of labour because obesity is associated with poor progress of first and second stage.

Fetal scalp monitoring is more appropriate than abdominal monitoring.

Ceasarean section is advised for obstetrical causes like fetal macrosomia ( wt > 4.5 Kg) to minimise risk of shoulder dystocia, also if there is IUGR.

d]We advice for early mobilization and good hydration to minimise risk of venous thromboembolism, also we encourage the use of thromboembolic deterrent stocking.

We give advices about breast feeding and suitable contraceptives in view of her obesity.

We also encourage for a dietary counselling to help her reaching an ideal BMI for her height and age.
Posted by N S.
Wed Jan 2, 2008 07:23 pm
(A)I will inform the patient about the inaccuracy in dating scan due to high BMI and may need to perform trans vaginal uscan for accuracy. Difficulty at the time of detail anomaly scan. In correct monitoring of Blood pressure monitoring and need to use properly calibrated instrument with correct size cuff.There is Increased risk of developing preeclampsia , gestational diabetes and Increased risk of developing DVT.Increased risk of still birth fetal macrosomia and increased perinatal mortality. Difficulty in the assessment of the growth of the fetus and the presentation of the baby.
(B)Multidisciplinary team including the consultant obstetrician, specialist midwife ,dietician,neonatologist and anaesthetist review. If facilities available the refer patient to the bariectric clinics.Advice regarding healthy balanced diet and light exercise .Strict advice not to plan weight loss regimen while pregnant.Early booking at ANC and arrange fetal anomaly scan. Offer GTT at 28 wks and if family history of diabetes then arrange GTT earlier. Risk assessment of the patient should be done and if required to start on prophylactic LMWH to reduce the risk of DVT.Monitor BP with correct instrument and check urine sample at every visit for protein and glucose.It is difficult to assess fetal growth through symphysio fundal height therefore Arrange growth scan to check for fetal growth, though it may not be very accurate.Good communication between community midwife GP and obstetrics team to ensure good standard of care is achieved.

(C)Proper assessment of the labour, ensure mobility, good hydration and provision
nutrition during labour . Adequate analgesia should be provided to the patient.
Continues fetal monitoring during labour and if difficult to monitor fetal heart with
Abdominal transducer then use Fetal scalp electrode. Maintain the partograph to monitor the progress of labour. Obstetrics and anaesthetic consultant should be aware of the patient in delivery suite because of potential risk of difficulty in delivery for example shoulder dystocia and PPH risk of instrumental deliveries and LSCS,or may be the need for a possible acute situation eg prolong fetal bradycardia leading to the need for GA LSCS.Proper delivery bed and theatre table should be available for this patient.

(D)After the normal vaginal birth patient should be reassessed for the risk of DVT & PE following that thromboprophylaxis should be considered. Early mobilization should be encouraged. Advice regarding balanced diet and exercise should be provided to the patient . Counselling regarding the contraception should be provided and help the patient chosing the right method appropriate for her. Information leaflet regarding different support group for the weight loss should be provided. Patient should be made aware of increase risk of hypertension, diabetes and heart disease with obesity.
Posted by ramya V.
Wed Jan 2, 2008 10:43 pm
a,Pregnancy in the presence of marked obesity leads to an increase in the incidence of complications of pregnancy such as hypertensive disorders of pregnancy,gestational diabetes mellitus,increased risk of venous thromboembolism,genital tract and urinary tract infections
For the baby there is an increased incidence of neural tube defects,abnormalities of growth such as macrosomia ,IUGR,. late fetal death,birth trauma and increased risk of obesity in the long run
b,It is a high risk pregnancy and a multidisciplinary approach involving an obstetrician,anesthetist,physician and dietician should be sought
Appropriate dietary advice should be givev with counselling by a dietician if necessary
should aim for modest weight gain however weight loss during pregnancy is not recommended
A dating scan should be done byTVS scan
A detailed anomaly scan should be done at 18-20wks of gestation.The limitations of serum screening and ultrasound assessment due to marked obesity should be explained
An appropriate size cuff should be used for measurement of BP
screening for GDM should be performed at 28 wks and repeated at 32-34wks if necessary
As symfysiofundal height measurement is inappropriate serial growth scans should be done during third trimester to monitor fetal growth due to risk of macrosomia and IUGR
An anesthetic assessment should be done at 28-34 wks as a safeguard due to increased aneasthetic intervention in these patients
Delivery should be planned in a hospital under consultant led care
Risk for thromboembolism should be assessed and in the presence of additional risk factors or inpatient admission appropriate thromboprophylaxis should be started
Screen and treat for ant UTIs or genital tract infections
c,Anticipate shoulder dystocia so senior obstetrician,aneastetist,exoerienced midwife should be alerted and the local protocols and firedrills shoukdbe rehearsed
Adequate bed ,lighting,analgesia should be ensured
If external monitoring is difficult FSE should be applied
Increased risk of failure to progress and failed instumental delivery
Increased risk of operative morbidity with its attendant increased operative morbidity
aneastetic difficulties due to difficult position,with GA difficulty in maintaining airway ., with spinal aneastesia difficult to site correctly
Adequate operating tables and appropriate instruments should be ensured
Adequate skin preparation ,prophylactic antibiotics 1.5gcefuroxime, good hemostasis will helpnreduce post operativewound infection s
Due to increased risk of PPH third stage of labour should be managed actively
If caesarian delivery thromboprophylaxis with LMWH 80mg enoxaparin daily until discharge and 40mg enoxaparin daily for 2wks until full mobility is ensured
d,following vaginal delivery thromboprophylaxis with LMWH for 3-5days alongwith TED stockings ,adequate hydration and early mobilisation should be encouraged
Breastfeeding should be encouraged as there is dereased likelihood of childhood obesity ,protection against infections and allergies,and helps lose weight
As BMI is 40 COCP is not advised Mirena or IUCD may be an alternative
Should be advised about weight loss before embarking on another pregnancy
Appropriate advice regarding diet and exercise should be given
Should be explained about the long term health risks of obesity
Posted by Srivas  P.
Wed Jan 2, 2008 11:28 pm
(a) This woman is morbidly obese and this increases risks to herself and the baby. The risks to her may be from thromboembolism, cardio vascular complications, Gestational diabetes mellitus, urinary infections.

The fetal risks are due to increased likelihood of miscarriages, congenital anomalies due to age related risks as well as due to obesity. Increased possibility of premature labor, spontaneous and iatrogenic, IUGR and stillbirths especially if she has superadded preecclamsia or GDM.

(b) She should be followed up in a consultant led unit with multidisciplinary care comprising senior obstetrician, senior anesthetist, senior sonologist and Dietician. She should get 5mg Folic acid as she has higher chances of NTD?s. Her diet should be controlled by dietician but weight reduction is not advised in pregnancy.

Her pregnancy should be dated by TVUS and further antenatal assessments may need more often TA-USG or even at every antenatal visit as clinical assessments by palpation and symphysio-pubic mesurements may be unsatisfactory. Senior sonologist and higher resolution USG machine may be needed. Biochem analysis done to detect Down syndrome tends to be lower with extreme obesity and lower threshold for values is taken and CVS/amniocentesis is more reliable to detect abnormalities. Taking BP can be difficult-large cuff covering atleast 2/3rd of her arm should be used to avoid fallacious readings. Automated BP devices on wrist or finger could be additional help.

She should have OGTT at booking and at 28weeks. Regular urine to detect possible urinary infection and BP readings for possibility of PIH. Extreme obesity alone even without other risk factors puts her at high risk for VTE and she should get thrombo prophylaxis antenatally with LMWH from present gestation to full gestation and to be continued post delivery also. Should be encouraged to use TED stockings also. Advanced planning should be done antenatally for difficult labour, difficulty in intubation for GA or siting an epidural catheter and senior anaesthetist should review her around 34 weeks. Extra help at moving her to theatre should be planned as also bigger OT table and lifting devices if possible.

(c)Senior Obstetrician, senior anesthetist, experienced mid wife, extra personnel to help during delivery or to move her if necessary should be available. Epidural catheter may be sited early in labor for analgesia and to avoid difficult EA or GA in emergency. Intravascular access should be established. Should have continuous CTG and preferably monitored by scalp electrode. She is at higher risk of having prolonged and dysfunctional labor. Increased chances of having C.S./instrumental deliveries, increased risk of perineal injuries due to big baby and shoulder dystocia should be anticipated and necessary drills should be well practised. Pneumatic calf compressors should be used in labor and at C.S

(d) Encourage early ambulation, deep breathing exercises. Avoid dehydration. Continue postnatal thromboprophylaxis with LMVH for 6 weeks along with TED stockings. She should be told about signs and symptoms of VTE and told to report if she is breathlessness or has calf pain, immediately to emergency. She should be encouraged to breast feed and may need help in holding the baby or sit up and help should be on hand.

She should be advised to reduce weight before planning next pregnancy. Oral contraceptives are contra indicated whereas progesterone only contraception can be taken. All information should be given in written for her to take home and read. Leaflets provided.
Posted by Hala T.
Thu Jan 3, 2008 02:10 am
She should be informed about the increase incidence of both maternal and perinatal morbidity and mortality . The risk to the mother is in the form of gestational diabetes mellitus , pregnancy induced hypertension and thromboembolism.
The risk to the fetus is in the form of macromsomia leading to shoulder dystocia and increase rate of caesarean section . There is also, increase risk of growth restriction , congenital malformations and antepartum stillbirth.
She should be aware of difficulties of the prenatal diagnosis , if needed, in the form of chorionic villous sampling and amniocentesis.
b) Dating scan is essential through vaginal ultrasound if difficult abdominal ultrasound and to confirm viability. The woman should be advised to see dietician. Dietary advice is appropriate but achieving weight loss during pregnancy is not .
Her blood pressure should be measured in the booking visit by appropriate cuff and allthrough antenatal period to be well monitored , as the risk of preeclampsia is high.
Assessment of risk of thromboembolism and thrombo-prophylaxis to be started if needed.
Screening of gestational diabetes and glucose tolerance test should be offered at 27 weeks gestation and if normal to be repeated later. Assessment with senior anaesthetist should be carried out to avoid intrapartum anaesthetic complications and anticipation of problems.
Abdominal examination is difficult in determining of symphseal fundal height , fetal lie, presentation and liquor amount and detecting fetal heart rate .Ultrasound assessment in late second and third trimesters to avoid these problems.Detailed anomaly scan is offered at 18-20 weeks gestation , but it is suboptimal for the decreased organ visualization due to increase layer of adipose tissues of maternal abdominal wall.
Serial growth scan is essential for assessmet of large for date and also, growth restriction.
Estimated fetal weight is of limited value ,especially with the morbid obese woman c) Senior midwife , obstetrician ,anaesthetist and neonatologist should attend the delivery.
Regular drills and protocols help the labour ward to be prepared for shoulder dystocia in such patient. Specific resources such as additional blood products, a large operating table and extra personnel in the delivery room is essential prior to delivery. Maternal and fetal monitoring is essential once the patient in delivery room. Assessment the ability for hip abduction to allow vaginal delivery and allow McRobert\'s manouvre for shoulder dystocia.
Fetal scalp electrode for internal fetal monitoring ,as difficulty of external one. Venous access and epidural anaesthesia unless contraindicated, or failure of epidural insertion , general anaesthesiamay be intiated if required. Maternal blood pressure should be closely
monitored. Delivery should be conducted by senior obstetrician for problems of shoulder dystocia and for possibility of instrumental vaginal delivery. There is increased risk of third stage complications such as vaginal and cervical lacerations. All these could be dealt with a senior obstetrician and anaesthetist.
The postpartum heamorrhage and risk of infection , endometritis should be avoided by use of prophylactic oxytocin and antibiotics respectively.
The potential risk of pressure sores following the delivery for such obese woman should be avoided by turning her in bed with leg exercises. The lifting of the patient should be cautious for any mis-hap may occur.
d)Early mobilization , adequate hydration , thrombo-propylaxis should be the priority in this high pontential risk for thromboembolism development.Thrombemolic deterrent stocking is advised for this woman,with postpartum physiotherapy.Breast feeding should encouraged. Contraception should be prescribed and supplemented prior to discharge.
Dietary advice should be given and the woman to undertake weight loss prior to next pregnancy. She should be advised on long term risks of obesity, hypertension and diabetes
and information leaflet given to her.
Posted by Amen H. H.
Thu Jan 3, 2008 11:41 am
I want to ask DR PAUL please , is there space limitation ? which may suit the marking system ?
Posted by SAIMA A.
Thu Jan 3, 2008 02:21 pm
I will tell her that obesity is associated with maternal and fetal complications in pregnancy.She is at increase risk of developing diabetes and hypertension in pregnancy.Similarly, she will be more prone to develop clots in legs with its associated complications.There is increase chance of instrumental and operative deliveries due to obesity.Her fetus will be at increase risk of developing macrosomia,IUGR and shoulder dystocia.I will provide her with information leaflets regarding pregnancy associated with obesity.
Her antenatal care should be consultant led with multidisciplinary approach involving obstetrician,midwife,dietician,anaesthetist. she should be referred to dietician for proper dietary advice as weight loss is not recommended during pregnancy.Transvaginal ultrasound should be done for dating and viability of pregnancy.Blood pressure should be measured with large cuff to avoid false results.Oral glucose challenge test and later at 24-26 weeks gestation OGTT should be advised.Regular antenatal visits is needed for early dignosis of gestational diabetes and hypertensive disorders of pregnancy and associated complications. Risk assessment for venous thromboembolism should be done initially and later especially during admission in hospital for hyperemesis or other reasons.Routine downs screening should be offered and anomaly scan should be done at 18-20 weeks gestation.Regular growth scan are needed for early detection of macrosomia in diabetes or IUGR in hypertension and also due to difficulty in assessing symphysial fundal height. She should be reviewed by anaesthetist in third trimester.
Fetal monitoring will be difficult due to obesity and fetal scalp electrode may be applied for fetal monitoring.Partogram should be followed to assess dysfunctional labour.I/V access would be difficult. Adequate analgesia in form of epidural should be provided although it may be difficult to site epidural catheter.Senior obstetrician and midwife should be present at time of delivery due to increase risk of shoulder dystocia.Special operating tables and bed may be needed in case of caesarean section.Obesity is also associated with problem in intubation for G/A and other anaesthetic complications such as aspiration pneumonitis and atelectasis.Caesarean section is associated with increased morbidity due to thromboembolism and wound infection. Thromboprophylaxis is needed in case of instrumental delivery or caesarean section.
Risk assessment for postnatal thromboprophylaxis should be done to avoid venous thromboembolism(VTE).Early mobilistion and hydration should be encouraged to avoid DVT and VTE.Breast feeding should be encouraged .Before discharge contraception should be discussed .Oral contraceptive pills should be avoided due to morbid obesity.Progesterone only pills are associated with higher failure rates in obese women so higher dose should be prescribed.Levonorgesterol intra uterine system and copper IUCD are other options for her.She should be advised to enroll in wight loss programme to avoid long term complications of obesity and she should be provided with details of support groups,internet site addresses and written information about obesity and its implications.
Posted by PAUL A.
Fri Jan 4, 2008 01:27 am
Obesity during pregnancy is a risk factor for adverse pregnancy outcomes. The complications of obesity during pregnancy includes: increased risk of miscarriage, increased need for caesarean sections you were specifically asked about ANTENATAL risks , operative vaginal deliveries ? antenatal?? , increased risk of pre-eclampsia and thromboembolism You were not asked to write a list. This is a post-grad exam and you will not get marks for simply writing a list unless you were specifically asked to LIST .
Risks to the fetus include increased risk of congenital anomalies, preterm delivery, macrosomia , stillbirth and perinatal mortality are these ANTENATAL risks? . Potentially there are also long-term obesity problems for the child. Read the question ? ANTENATAL RISKS
Hypertensive disorders which include Chronic Hypertension and Pre-eclamsia is five fold increase in obese women you mentioned pre-eclampsia earlier .
Gestational diabetes (1) is common ( 3 fold increase ) in obese women of increasing age and the risk is also increased in Morbid obesity (BMI >40) which is about 10 %.

(b) How would you modify her antenatal care to minimise the risks associated with obesity? [7 marks].

There needs to be an open discussion regarding her care and about the risks you were asked about risks in (a), not in (b) involved during pregnancy. While it is useful to follow protocol and guidelines in place for her management as she is obese pregnant.
She should be identified as high risk (as BMI >30) and require increased obstetric surveillance so that she should be under consultant care she has already been referred . Multidisciplinary input should be sought, which involves dietician, Obstetrician and Anesthetist and Pediatrician what is the role of the paediatrician in her antenatal care? . Dietician referral for dietary advice is important.
She should be refereed to early USS ( Ultra sound scan )for dating and detail anomaly uss to be arranged presumably you will do dating scan and anomaly scan in all women. This is not a modification .

Maternal blood pressure is difficult to determine why should this be difficult? You simply need an appropriate cuff when the maternal upper arm is fat therefore large cuff should be used to avoid falsely high or low readings. Also regular antenatal visit and BP checking is important applies to all women .

If there is any suspicion of growth restriction how would you suspect IUGR? Clinical assessment is of limited value and she should have growth scans not just when you suspect IUGR serial ultrasound should be arranged. Glucose tolerance test to be arranged at 26 wks to screen gestational diabetes (1) .

Antenatal Anesthetic review (1) may be benefit for anticipation of problems such as difficult intubations, aspiration pneumonia, difficult epidural/spinal therefore it is advisable to ensure the presence of experience anesthetist if regional or general anaethethesia needed.

(c) She presents in spontaneous labour at 38 weeks gestation. How would you modify her intra-partum care? [4 marks].

It may be difficult to site an infusion canula in a fat limp and to site an epidural canula.if there are any problem anticipated siting a canula in advance desirable. CTG montoring may be difficult due to body habitus therefore Fetal scalp electrode could be used (1) .
If caesarian section is required an experienced Obstetrician and Anesthetist should be involved as it maybe hazadous for this morbid obese woman.
There is also a need for additional equipment such as specially adapted operating tables and surgical equipment. These problems need to be recognised so that a plan for core delivery of these women will be formulated.
Delay in wound healing and haematoma formation is more common in obese women therefore aseptic procedure, prompt homeostasis and, prophylactic antibiotics and general hygiene are the usual precautions should be taken to prevent infection
Labour ward should be prepared to manage shoulder dystocia (1) with following the protocols and regular drills.

Postpartum Hemorrhage is a recognized complication in obese women; active management of third stage may be warranted.


(d) Justify your post-natal care given that she had a normal vaginal delivery [4 marks].

Obesity is risk factors for thromboembolism therefore risk should be assessed for thromboprophylaxis after the delivery there is sufficient information in the question for you to undertake a risk assessment and present a recommendation for thromboprophylaxis .
Early ambulation and adequate hydration post delivery (1) should be encouraged. Patient may need support with breast feeding as limited mobility is common.

Advised should be given regarding weight lost for next pregnancy (1) also long term potential risk of obesity such as diabetes and hypertension .

Contraception should be discussed (1) . COCP is contraindicated as BMI 40.

You have sufficient knowledge to write an answer that would pass but your technique needs to be improved
Posted by PAUL A.
Fri Jan 4, 2008 01:42 am
a)She is classified as morbid obesity and she should know that it is associated with higher perinatal and maternal mortality and morbidity. She is exposed to invasive investigation like transvaginal scan is this an antenatal RISK? for dating scan as abdominal scan may be difficult with thick abdomen. She is at higher risk to develop gestation diabetes mellitus thus early assessment of modified glucose tolerance test should be carried out (around 24-26 weeks) you were asked about the risks ONLY in part (a). You were not asked about how you will address these risks until part (b) . Maternal obesity is also associated with macrosomic baby which lead to higher operative delivery. She is also at higher risk to develop PIH (1) , an appropriate size of BP measurement should be used. VTE is another risk (1) should be informed to her and risk factor for VTE should always be assessed especially during admission or early pregnancy assessment. Written information, follow-up and contact detail should be provided.
b)Referral to dietician is appropriate for balance diet but weight loss is not desirable (1) as it is associated with low birth weight. Risk assessment of VTE should be carried out especially if she require for admission. Antenatal thromboprophylasis may why MAY? be needed if she has more than 3 moderate risk factors. Measurement of BP with appropriate cuff size (1) and assessment of urine protein should be ensured. Modified glucose tolerance test should be subjected at 24-26 weeks POA ? meaning and repeat later if found to be normal. Frequent visit is necessary and ultrasound assessment for lie and presentation may be required if there is difficulty to asses the lie and presentation of the fetus when should this be done? . Serial growth scan should be arranged at least every 4 week to look for macrosomic features (1) also looking for IUGR . Early referral to anesthetist is prudent if there is difficulty to get venus access she should be referred for anaesthetic assessment not just when there is poor venous access and discussion about method of anaesthesia can be arranged as the anticipation of difficult intubation.
c)Reassessment of VTE risk factor should be done. Ensure adequate hydration and avoid prolonged immobilization (1) . Adequate analgesia is required, preferably epidural NO ? obesity is not an indication for epidural analgesia as this pregnancy is associated with higher operative delivery. Progress of labour should follow partogram and early recognition of primary uterine dysfunction is important and action should be taken to avoid poor progress. Fetal scalp monitoring may be required if abdominal CTG tracing is poor (1) . The presence of senior obstetrician and experienced midwife are important as there is higher risk of shoulder dystocia (1) . Operative delivery is hazardous, presence of senior obstetrician and senior anesthetist are essential to anticipate difficult surgery and intubation. Active third stage management should be applied with the use of syntometrine if no contraindication as here is increased risk of post partum haemorrhage.
d)Early ambulation and good hydration should be ensured (1) . Combined contraceptive pills are relative contraindication. Mirena or IUCD would be most appropriate for the patient (1) . Advised for weight reduction before embark another pregnancy (1)

good answer
.
Posted by PAUL A.
Fri Jan 4, 2008 01:55 am
a] Obesity is associated with increase incidence of fetal loss and fetal congenital maleformation. (1)

Also there is increase incidence of pregnancy induced hypertension and pre-eclampsia.

Gestational diabetes mellitus also increased (1) .

Risk of venous thromboembolism (1) increased also.

The fetus can develop deviation from normal growth, it could be macrosomic or IUGR (1) , with increase incidence of IUD, preterm labour and prematurity.

b]
Weight loss is usually not advised during pregnancy, although an advice from dietitian is required about healthy food can be should be given considered.

Dating scan via TV/US at booking required for all women will help accurate calculation of gestational age because later on the symphysiofundal level will be not helpful because of obesity.

More frequent visits are advised with monitoring of blood pressure with appropriate size cuff (1) for early detection and treatment of PIH.

GTT at 26 weeks gestation can help detecting GDM (1) , also testing MSU for glucose in urine and detecting UTI which is associated with DM.

Serial growth scan is advised from 28 weeks gestation every two weeks 4 weeks if growth is normal to monitor fetal growth (1) .

We provide Patient information leaflet.

c]Close monitoring of the mother and the fetus in consultant -led unit, with assessing progress of labour because obesity is associated with poor progress of first and second stage.

Fetal scalp monitoring is more appropriate this is not more appropriate but should be used if external monitoring is inadequate than abdominal monitoring.

Ceasarean section is advised for obstetrical causes like fetal macrosomia ( wt > 4.5 Kg) how accurate is fetal weight assessment? to minimise risk of shoulder dystocia, also if there is IUGR.

d]We advice for early mobilization and good hydration to minimise risk of venous thromboembolism (1) , also we encourage the use of thromboembolic deterrent stocking.

We give advices about breast feeding and suitable contraceptives in view of her obesity ? what would be suitable? .

We also encourage for a dietary counselling to help her reaching an ideal BMI for her height and age.

More detailed answer required and you need to put your statements in context
Posted by PAUL A.
Fri Jan 4, 2008 03:00 am
(A) I will inform the patient about the inaccuracy in dating scan due to high BMI High BMI does not make dating scans inaccurate and may need to perform trans vaginal uscan for accuracy. Difficulty at the time of detail anomaly scan. In correct monitoring of Blood pressure monitoring and need to use properly calibrated instrument with correct size cuff. this is not a COMPLICATION There is Increased risk of developing preeclampsia , gestational diabetes and Increased risk of developing DVT (1) do not write a list .Increased risk of still birth not antenatal risk fetal macrosomia and increased perinatal mortality. Difficulty in the assessment of the growth of the fetus and the presentation of the baby (1) .
(B)Multidisciplinary team including the consultant obstetrician, specialist midwife ,dietician,neonatologist and anaesthetist review (1) . If facilities available the refer patient to the bariectric clinics ? meaning .Advice regarding healthy balanced diet and light exercise .Strict advice not to plan weight loss regimen while pregnant (1) . Early booking at ANC she has already been referred and arrange fetal anomaly scan. Offer GTT at 28 wks (1) and if family history of diabetes then arrange GTT earlier when? . Risk assessment of the patient should be done and if required to start on prophylactic LMWH to reduce the risk of DVT (1) .Monitor BP with correct instrument cuff size and check urine sample at every visit for protein and glucose.It is difficult to assess fetal growth through symphysio fundal height therefore Arrange growth scan to check for fetal growth, though it may not be very accurate (1) .Good communication between community midwife GP and obstetrics team to ensure good standard of care is achieved.

(C)Proper assessment of the labour, ensure mobility, good hydration and provision
nutrition during labour this is controversial but not advised in an obese woman . Adequate analgesia should be provided to the patient.
Continues fetal monitoring during labour and if difficult to monitor fetal heart with
Abdominal transducer then use Fetal scalp electrode (1) . Maintain the partograph to monitor the progress of labour. Obstetrics and anaesthetic consultant should be aware of the patient in delivery suite because of potential risk of difficulty in delivery for example shoulder dystocia and PPH risk of instrumental deliveries and LSCS,or may be the need for a possible acute situation eg prolong fetal bradycardia leading to the need for GA LSCS very long sentence and meaning is lost .Proper delivery bed and theatre table should be available for this patient.

(D)After the normal vaginal birth patient should be reassessed for the risk of DVT & PE following that thromboprophylaxis should be considered should it be administered to a woman with a BMI of 40 after a normal delivery? . Early mobilization should be encouraged (1) good hydration . Advice regarding balanced diet and exercise should be provided to the patient . Counselling regarding the contraception should be provided and help the patient chosing the right method appropriate for her what are her options given her BMI? . Information leaflet regarding different support group for the weight loss should be provided (1) . Patient should be made aware of increase risk of hypertension, diabetes and heart disease with obesity ensure pre-conception counselling before next pregnancy

Your statements need to be more specific ? you should commit yourself rather than hedge your bets.
.
Posted by PAUL A.
Fri Jan 4, 2008 03:16 am
a,Pregnancy in the presence of marked obesity leads to an increase in the incidence of complications of pregnancy such as hypertensive disorders of pregnancy,gestational diabetes mellitus,increased risk of venous thromboembolism,genital tract and urinary tract infections you were not asked to LIST the complications
For the baby there is an increased incidence of neural tube defects,abnormalities of growth such as macrosomia ,IUGR,. late fetal death,birth trauma and increased risk of obesity in the long run You have written another list. Are birth trauma and long-term risk of obesity ANTENATAL RISKS?
b,It is a high risk pregnancy and a multidisciplinary approach involving an obstetrician,anesthetist,physician why do you need a physician? and dietician should be sought
Appropriate dietary advice should be givev with counselling by a dietician if necessary
should aim for modest weight gain however weight loss during pregnancy is not recommended (1)
A dating scan should be done byTVS scan (1)
A detailed anomaly scan should be done at 18-20wks is this a modification? Would you not do this if she had a BMI of 24? of gestation.The limitations of serum screening and ultrasound assessment due to marked obesity should be explained
An appropriate size cuff should be used for measurement of BP (1)
screening for GDM should be performed at 28 wks and repeated at 32-34wks if necessary (1) how will you decide if it is necessary?
As symfysiofundal height measurement is inappropriate serial growth scans should be done during third trimester to monitor fetal growth due to risk of macrosomia and IUGR (1)
An anesthetic assessment (1) should be done at 28-34 wks as a safeguard due to increased aneasthetic intervention in these patients
Delivery should be planned in a hospital under consultant led care
Risk for thromboembolism should be assessed and in the presence of additional risk factors or inpatient admission appropriate thromboprophylaxis should be started (1)
Screen and treat for ant UTIs or genital tract infections
c,Anticipate shoulder dystocia so senior obstetrician,aneastetist,exoerienced midwife should be alerted (1) and the local protocols and firedrills shoukdbe rehearsed
Adequate bed ,lighting,analgesia should be ensured
If external monitoring is difficult FSE should be applied (1)
Increased risk of failure to progress and failed instumental delivery you were asked about intrapartum care, not about risks
Increased risk of operative morbidity with its attendant increased operative morbidity
aneastetic difficulties due to difficult position,with GA difficulty in maintaining airway ., with spinal aneastesia difficult to site correctly
Adequate operating tables and appropriate instruments should be ensured
Adequate skin preparation ,prophylactic antibiotics 1.5gcefuroxime, good hemostasis will helpnreduce post operativewound infection s
Due to increased risk of PPH third stage of labour should be managed actively
If caesarian delivery thromboprophylaxis with LMWH 80mg enoxaparin daily until discharge and 40mg enoxaparin daily for 2wks what is the basis for this recommendation? You have been given her BMI but not her weight. How did you arrive at a dose? What is the evidence to support treatment for 2 weeks? (-1) until full mobility is ensured
d,following vaginal delivery thromboprophylaxis with LMWH for 3-5days (1) alongwith TED stockings ,adequate hydration and early mobilisation (1) should be encouraged
Breastfeeding should be encouraged as there is dereased likelihood of childhood obesity ,protection against infections and allergies,and helps lose weight
As BMI is 40 COCP is not advised Mirena or IUCD may be an alternative (1)
Should be advised about weight loss before embarking on another pregnancy (1)
Appropriate advice regarding diet and exercise should be given
Should be explained about the long term health risks of obesity

You should not write a list unless specifically asked to do so
Posted by PAUL A.
Fri Jan 4, 2008 04:06 am
(a) This woman is morbidly obese and this increases risks to herself and the baby. The risks to her may be from thromboembolism, cardio vascular complications, Gestational diabetes mellitus, urinary infections you were not asked to write a list. The question was: What would you tell her?? Will you simply give her a list? .

The fetal risks are due to increased likelihood of miscarriages, congenital anomalies due to age related not asked about age-related risks risks as well as due to obesity. Increased possibility of premature labor, spontaneous and iatrogenic, IUGR and stillbirths not antenatal especially if she has superadded preecclamsia or GDM.

(b) She should be followed up in a consultant led unit with multidisciplinary care comprising senior obstetrician, senior anesthetist (1) , senior sinologist ?? and Dietician. She should get 5mg Folic acid as she has higher chances of NTD?s ? value at 8 weeks?? . Her diet should be controlled by dietician but weight reduction is not advised in pregnancy (1) .

Her pregnancy should be dated by TVUS (1) and further antenatal assessments may need more often TA-USG or even at every antenatal visit as clinical assessments by palpation and symphysio-pubic ??? mesurements may be unsatisfactory. Senior sonologist and higher resolution USG machine may be needed. Biochem analysis done to detect Down syndrome tends to be lower with extreme obesity and lower threshold for values is taken and CVS/amniocentesis these are diagnostic tests abd cannot be compared with serum screening. BMI is taken into account in serum screening (-1) is more reliable to detect abnormalities. Taking BP can be difficult-large cuff (1) covering atleast 2/3rd of her arm should be used to avoid fallacious readings. Automated BP devices on wrist or finger could be additional help.

She should have OGTT at booking and at 28weeks (1) to detect GDM, testing at 28 and 34 weeks more appropriate. No indication for testing at booking unless you suspect pre-existing diabetes . Regular urine to detect possible urinary infection and BP readings for possibility of PIH. Extreme obesity alone even without other risk factors puts her at high risk for VTE and she should get thrombo prophylaxis antenatally with LMWH from present gestation to full gestation and to be continued post delivery also NO ? BMI of 40 on its own is not an indication for antenatal heparin . Should be encouraged to use TED stockings also why? See RCOG guidelines for thromboprophylaxis . Advanced planning should be done antenatally for difficult labour, difficulty in intubation for GA or siting an epidural catheter and senior anaesthetist should review her around 34 weeks why wait till 34 weeks? Any problems with doing this earlier? . Extra help at moving her to theatre like what? There is no reason why personnel ordinarily available should not be adequate should be planned as also bigger OT table and lifting devices if possible.

(c)Senior Obstetrician, senior anesthetist, experienced mid wife, extra personnel to help during delivery or to move her if necessary should be available. Epidural catheter may be sited early in labor for analgesia and to avoid difficult EA or GA in emergency. Intravascular access should be established. Should have continuous CTG and preferably monitored by scalp electrode (1) FSE should be used if external monitoring is inadequate . She is at higher risk of having prolonged and dysfunctional labor. Increased chances of having C.S./instrumental deliveries, increased risk of perineal injuries you were not asked about risks but HOW YOU WOULD MODIFY YOUR CARE due to big baby and shoulder dystocia should be anticipated and necessary drills should be well practised. Pneumatic calf compressors should be used in labor ? evidence?? Do you use these in your unit for women in labour? How do hey mobilise?? (-1) and at C.S

(d) Encourage early ambulation, deep breathing exercises WHY? . Avoid dehydration. Continue postnatal thromboprophylaxis with LMVH for 6 weeks along with TED stockings WHY 6 WEEKS? See RCOG Guidelines . She should be told about signs and symptoms of VTE and told to report if she is breathlessness or has calf pain, immediately to emergency. She should be encouraged to breast feed and may need help in holding the baby why should this be necessary? or sit up and help should be on hand.

She should be advised to reduce weight before planning next pregnancy. Oral contraceptives are contra indicated whereas progesterone only contraception can be taken (1) ? dose . All information should be given in written for her to take home and read. Leaflets provided.

You have written several statements that are clearly outside RCOG guidelines and standard practice. It is also apparent that you may not have encountered a woman with a BMI of 40 as you do not appreciate the level of independent activity that they are capable of.
Posted by Dr seema jain J.
Fri Jan 4, 2008 05:19 pm
a) This lady who has come to me is a ?HIGH RISK? pregnancy because of the maternal risks & fetal risks associated with it.
The maternal risks, include increased risk of miscarriage (3 fold), gestational hypertension, pre-eclampsia, gestational diabetes and vascular thromboembolism all of which increase by 2-3 fold. There also is an increased chance of preterm delivery and operative delivery (vaginal as well as abdominal)
The fetal risks associated include increased chance of having a baby with congenital anomalies, macrosomia (1.5 ? 2 times increase independent of risk of gestational diabetes) and increased incidence of antepartum still birth.

b) I would encourage her to see the dietician (for diet modification and not for diet control) since the time of booking. An early ultrasound dating of pregnancy followed by serial ultrasound helps in monitoring the growth of the baby (in view of the difficulty in discerning the uterine size per abdomen). Fortnightly visits (in view of being a High risk pregnancy) may be recommended with accurate blood pressure measurement (using an appropriate sized cuff) and a glucose tolerance test for screening of diabetes at 28 weeks of pregnancy. A target scan at 19-20 weeks pregnancy by a senior sonologist would be suggested to rule out any congenital anomaly (because of the difficulty in scanning in view of thick abdominal wall). If this lady has any other risk factor (pre-eclampsia, previous history of thromboembolism, thrombophilia), antenatal thrombophophylasxis (with aspirin or heparin) will be considered. Compression stockings & ambulation may be considered in absence of any other risk factor. Uterine color Doppler to check for fetal-placental compromise if any secondary to hypertension may be done to decide important about the mode/timing of delivery.

c) When she presents in spontaneous labour apart from seeing her pregnancy records, I will ensure whether she has been on thromboprophyloasis and the timing of the last dose. A delivery equipped with senior nursing staff (who are well versed in management of shoulder dystolia if it occurs) and a consultant on premises will be kept informed. Early access to inravenous line will be ensured (probable chances of difficulty in access later on) and an insertion of epidural catheter early in labor will be considered irrespective of the attempted mode of delivery. A continuous cardiotocography for labour monitoring will be done since it is difficult to gauge the uterine activity clinically. In case of cesearean, a senior consultant would be informed if general anesthesia is needs to be given (as difficult intubation is anticipated).

d) The postnatal care will comprise mainly of thromboprophylaxis (irrespective of whether she has taken antenatal thromboprophylaxis or not) for 5 days (with LMWH 5000 units twice a day). The removal of epidural catheter shall be done after 4 hours of the last dose of heparin.
The mother may be referred to an expert in breast feeding to help her since the chances of difficulty in breast feeding are high in these women.
Proper wound care( episotomy) is needed. Contraception in the form of intrauterine method or POPS will be suggested. I will also counsel the women to lose weight (so that the BMI is <= 30) before planning her next pregnancy.
Posted by Farina A.
Sat Jan 5, 2008 01:21 am
Incidence of obesity epidemic is increasing in the UK, having significant effects on maternal morbidity and mortality in addition to the cost implications on NHS. A recent confidential inquiry for maternal mortality has shown that 35% of maternal deaths are associated with morbid obesity.

a) The antenatal risks of obesity that should be told to the patient are:
1) Difficulty in dating due to usual history of prolonged cycles which is even difficult in clinical examination and transabdominal ultrasound. Dating can be estimated accurately through transvaginal sonography in expert hands.
2) May need special obesity instruments (like B.P. cuff)
3) Higher risk of hypertension and diabetes.
Incidence of diabetes increases upto 9 fold during pregnancy with obesity.
4) Incidence of IUGR and macrosomia is also increased that could be due to i the conditions like hypertension and diabetes.
5) Incidence of still birth and congenital anomalies is also increased due to the risk of diabetes and IUGR.
6) Risk of myocardial infarction is well known in obesity and diabetes outside pregnancy and is increased with pregnancy, mimicking with the normal physiological symptomatology of pregnancy ? Like epigastric pain.
7) This pregnancy is at risk of thromboembolism and may require thromboprophylaxis.

b) During her antenatal care a transvaginal dating scan can minimize the problem for estimating gestational age - Every visit should be arrange with a sinologist to estimate normal fetal growth - More frequent antenatal visits may detect hypertension and diabetes earlier and management in coordination with the physicians ? Special instruments may be required (obesity B.P. apparatus) if she is not a diabetic from the beginning, a glucose tolerance test an adequate subsequent management with the physician can minimize the risks of diabetes ? Referral to a dietician is a good option as caloric reduction is not advisable during pregnancy ? This pregnancy is at risk of postdated pregnancy and induction of labour, so adequate patient counseling is desirable.

c) During intrapartum period this patient is at risk of difficulty in detection of fetal heart rate so a scalp electrode may be needed for fetal monitoring ? Difficult application of epidural anesthesia due to increased subcuticular fat is also a problem. Higher doses of analgesia may be required.
These patients are at a higher risk of emergency LSCS due to prolonged first stage of labour, CPD, fetal distress and fetal macrosomia. If CS is deemed necessary, anesthetist may face difficulty in spinal anesthesia. 65% of these patients received general anesthesia in a study. Poor access to the tissues may require a midline longitudinal incision and the patient may face its complications. Exteriorization of the uterus may be difficult to see the angles of the uterine incision which may extend during a difficult delivery.
Provided the patient is suitable for vaginal delivery, incidence of instrumental vaginal delivery, perineal injury, shoulder dystocia are increased, so a senior obstetrician may attend the delivery to avoid and deal with the possible complications.

d) Postnataly she is at risk of perineal wound infection and thromboembolism. Prophylactic antibiotics and low molecular weight heparin is advisable for three days, compression stocking for six weeks may reduce the risk of DVT early mobilization and hydration also reduces the risk of DVT. Adequate control of hypertension and diabetes in collaboration with the physicians may be required. Breastfeeding is encourage weight reduction is advised.
Oral contraception is usually not a first choice. Barrier contraception is with least side effects but higher user failure rate ? so IUCD is the contraception of choice. A general advice about lifestyle modification, diet and exercise is beneficial.
Posted by PAUL A.
Sat Jan 5, 2008 03:09 pm
She should be informed about the increase incidence of both maternal and perinatal morbidity and mortality . The risk to the mother is in the form of gestational diabetes mellitus , pregnancy induced hypertension and thromboembolism do not write a list .
The risk to the fetus is in the form of macromsomia leading to shoulder dystocia and increase rate of caesarean section not ANTENATAL risks . There is also, increase risk of growth restriction , congenital malformations and antepartum stillbirth (1) .
She should be aware of difficulties of the prenatal diagnosis , if needed, in the form of chorionic villous sampling and amniocentesis.
b) Dating scan is essential through vaginal ultrasound (1) if difficult abdominal ultrasound and to confirm viability. The woman should be advised to see dietician. Dietary advice is appropriate but achieving weight loss during pregnancy is not (1) .
Her blood pressure should be measured in the booking visit by appropriate cuff (1) and allthrough antenatal period to be well monitored , as the risk of preeclampsia is high.
Assessment of risk of thromboembolism and thrombo-prophylaxis to be started if needed.
Screening of gestational diabetes and glucose tolerance test should be offered at 27 weeks gestation and if normal to be repeated later (1) . Assessment with senior anaesthetist should be carried out to avoid intrapartum anaesthetic complications and anticipation of problems (1) .
Abdominal examination is difficult in determining of symphseal fundal height , fetal lie, presentation and liquor amount and detecting fetal heart rate .Ultrasound assessment in late second and third trimesters to avoid these problems.Detailed anomaly scan is offered at 18-20 weeks gestation , but it is suboptimal for the decreased organ visualization due to increase layer of adipose tissues of maternal abdominal wall.
Serial growth scan is essential for assessmet of large for date and also, growth restriction (1) .
Estimated fetal weight is of limited value ,especially with the morbid obese woman c) Senior midwife , obstetrician ,anaesthetist and neonatologist should attend the delivery.
Regular drills and protocols help the labour ward to be prepared for shoulder dystocia in such patient. Specific resources such as additional blood products do you do this just because she has a BMI of 40?? Which blood products are you referring to? , a large operating table and extra personnel in the delivery room is essential prior to delivery. Maternal and fetal monitoring is essential once the patient in delivery room would this not be the case if she had a normal BMI? . Assessment the ability for hip abduction to allow vaginal delivery and allow McRobert\'s manouvre for shoulder dystocia Which test do you use to make this assessment?? What would you do if this was inadequate? Do a C/S?? (-1) .
Fetal scalp electrode for internal fetal monitoring ,as IF difficulty of external one. Venous access and epidural anaesthesia unless contraindicated obesity is not an indication for epidural , or failure of epidural insertion , general anaesthesiamay be intiated if required. Maternal blood pressure should be closely
monitored. Delivery should be conducted by senior obstetrician there isno reason why a midwife should not undertake vaginal delivery with support as needed. The majority of women have no complications for problems of shoulder dystocia and for possibility of instrumental vaginal delivery. There is increased risk of third stage complications such as vaginal and cervical lacerations. All these could be dealt with a senior obstetrician and anaesthetist.
The postpartum heamorrhage and risk of infection , endometritis should be avoided by use of prophylactic oxytocin and antibiotics respectively ? in a woman with a normal delivery?? (-1) .
The potential risk of pressure sores following the delivery for such obese woman should be avoided by turning her in bed with leg exercises (1) . The lifting of the patient should be cautious for any mis-hap may occur ?? do you really mean ANY?? .
d)Early mobilization , adequate hydration , thrombo-propylaxis should be the priority in this high pontential risk for thromboembolism development would ou administer heparin? For how long? .Thrombemolic deterrent stocking is advised for this woman,with postpartum physiotherapy.Breast feeding should encouraged. Contraception should be prescribed and supplemented ? meaning?? What would you prescribe? prior to discharge.
Dietary advice should be given and the woman to undertake weight loss prior to next pregnancy (1) . She should be advised on long term risks of obesity, hypertension and diabetes
and information leaflet given to her.
Posted by PAUL A.
Sat Jan 5, 2008 03:23 pm
I will tell her that obesity is associated with maternal and fetal complications in pregnancy.She is at increase risk of developing diabetes and hypertension in pregnancy (1) .Similarly, she will be more prone to develop clots in legs with its associated complications (1) .There is increase chance of instrumental and operative deliveries not ANTENATAL due to obesity.Her fetus will be at increase risk of developing macrosomia,IUGR and shoulder dystocia not antenatal .I will provide her with information leaflets regarding pregnancy associated with obesity.
Her antenatal care should be consultant led with multidisciplinary approach involving obstetrician,midwife,dietician,anaesthetist (1) . she should be referred to dietician for proper dietary advice as weight loss is not recommended during pregnancy (1) .Transvaginal ultrasound should be done for dating and viability of pregnancy (1) .Blood pressure should be measured with large cuff (1) to avoid false results.Oral glucose challenge test and later at 24-26 weeks gestation OGTT should be advised is there a difference between an oral glucose challenge test and an OGTT? .Regular antenatal visits is needed for early dignosis of gestational diabetes and hypertensive disorders of pregnancy and associated complications. Risk assessment for venous thromboembolism should be done initially and later especially during admission in hospital for hyperemesis or other reasons (1) .Routine downs screening should be offered and anomaly scan should be done at 18-20 weeks gestation.Regular growth scan are needed for early detection of macrosomia in diabetes or IUGR in hypertension and also due to difficulty in assessing symphysial fundal height (1) . She should be reviewed by anaesthetist in third trimester.
Fetal monitoring will be difficult due to obesity and fetal scalp electrode may be applied for fetal monitoring (1) .Partogram should be followed to assess dysfunctional labour.I/V access would be difficult. Adequate analgesia in form of epidural should be provided is epidural the only form of adequate analgesia? Who decides if analgesia is adequate? although it may be difficult to site epidural catheter.Senior obstetrician and midwife should be present at time of delivery due to increase risk of shoulder dystocia (1) .Special operating tables and bed may be needed in case of caesarean section.Obesity is also associated with problem in intubation for G/A and other anaesthetic complications such as aspiration pneumonitis and atelectasis.Caesarean section is associated with increased morbidity due to thromboembolism and wound infection. Thromboprophylaxis is needed in case of instrumental delivery or caesarean section is it not needed if she has a normal delivery? .
Risk assessment for postnatal thromboprophylaxis should be done to avoid venous thromboembolism(VTE) would you administer prophylaxis if there were no other risk factors? .Early mobilistion and hydration should be encouraged to avoid DVT and VTE (1) .Breast feeding should be encouraged .Before discharge contraception should be discussed .Oral contraceptive pills should be avoided due to morbid obesity.Progesterone only pills are associated with higher failure rates in obese women so higher dose should be prescribed.Levonorgesterol intra uterine system and copper IUCD are other options for her (1) .She should be advised to enroll in wight loss programme (1) to avoid long term complications of obesity and she should be provided with details of support groups,internet site addresses and written information about obesity and its implications.

good answer
Posted by PAUL A.
Sat Jan 5, 2008 03:39 pm
a) This lady who has come to me is a ?HIGH RISK? pregnancy because of the maternal risks & fetal risks associated with it.
The maternal risks, include increased risk of miscarriage (3 fold), gestational hypertension, pre-eclampsia, gestational diabetes and vascular thromboembolism would you simply list the complications to her? all of which increase by 2-3 fold. There also is an increased chance of preterm delivery and operative delivery not ANTENATAL (vaginal as well as abdominal)
The fetal risks associated include increased chance of having a baby with congenital anomalies, macrosomia (1.5 ? 2 times increase independent of risk of gestational diabetes) and increased incidence of antepartum still birth (1) .

b) I would encourage her to see the dietician ( for diet modification and not for diet control ?? difference ) since the time of booking. An early ultrasound dating of pregnancy followed by serial ultrasound helps in monitoring the growth of the baby (in view of the difficulty in discerning the uterine size per abdomen) (1) . Fortnightly visits (in view of being a High risk pregnancy) may be recommended with accurate blood pressure measurement (using an appropriate sized cuff (1) ) and a glucose tolerance test for screening of diabetes at 28 weeks of pregnancy (1) . A target scan at 19-20 weeks pregnancy by a senior sonologist would be suggested to rule out any congenital anomaly (because of the difficulty in scanning in view of thick abdominal wall). If this lady has any other risk factor (pre-eclampsia, previous history of thromboembolism, thrombophilia), antenatal thrombophophylasxis (with aspirin or heparin) will be considered. Compression stockings & ambulation may be considered in absence of any other risk factor. Uterine color Doppler to check for fetal-placental compromise if any secondary to hypertension may be done to decide important about the mode/timing of delivery ?? how does this help you decide mode of delivery?? (-1) .

c) When she presents in spontaneous labour apart from seeing her pregnancy records, I will ensure whether she has been on thromboprophyloasis and the timing of the last dose. A delivery equipped with senior nursing staff ? midwifery (who are well versed in management of shoulder dystolia if it occurs) and a consultant on premises will be kept informed. Early access to inravenous line will be ensured (probable chances of difficulty in access later on) and an insertion of epidural catheter early in labor obesity is NOT an indication for epidural. will be considered irrespective of the attempted mode of delivery. A continuous cardiotocography for labour monitoring will be done since it is difficult to gauge the uterine activity clinically in these cases, the tocograph is usually inadequate and one has to rely on the midwife palpating contractions . In case of cesearean, a senior consultant would be informed if general anesthesia is needs to be given (as difficult intubation is anticipated) are there senior and junior consultants? Would you only inform the consultant if GA was required? .

d) The postnatal care will comprise mainly of thromboprophylaxis (irrespective of whether she has taken antenatal thromboprophylaxis or not) for 5 days (with LMWH 5000 units twice a day) (1) a standard dose would over / under treat some women . The removal of epidural catheter shall be done after 4 hours of the last dose of heparin.
The mother may be referred to an expert in breast feeding to help her since the chances of difficulty in breast feeding are high in these women.
Proper wound care( episotomy) is needed. Contraception in the form of intrauterine method or POPS will be suggested (1) . I will also counsel the women to lose weight (so that the BMI is <= 30) before planning her next pregnancy (1) .
Posted by PAUL A.
Sat Jan 5, 2008 03:58 pm
Incidence of obesity epidemic is increasing in the UK, having significant effects on maternal morbidity and mortality in addition to the cost implications on NHS. A recent confidential inquiry for maternal mortality has shown that 35% of maternal deaths are associated with morbid obesity this is a waste of your time & space. The examiner does not have extra marks to give for a new part of the question set by yourself .

a) The antenatal risks of obesity that should be told to the patient are:
1) Difficulty in dating due to usual history of prolonged cycles which is even difficult in clinical examination and transabdominal ultrasound. Dating can be estimated accurately through transvaginal sonography in expert hands.
2) May need special obesity instruments (like B.P. cuff)
3) Higher risk of hypertension and diabetes.
Incidence of diabetes increases upto 9 fold during pregnancy with obesity.
4) Incidence of IUGR and macrosomia is also increased that could be due to i the conditions like hypertension and diabetes.
5) Incidence of still birth and congenital anomalies is also increased due to the risk of diabetes and IUGR.
6) Risk of myocardial infarction is well known in obesity and diabetes outside pregnancy and is increased with pregnancy, mimicking with the normal physiological symptomatology of pregnancy ? Like epigastric pain.
7) This pregnancy is at risk of thromboembolism and may require thromboprophylaxis.

DO NOT NUMBER YOUR ANSWER. Part (a) was about risks, not about how the risks can be addressed.

b) During her antenatal care a transvaginal dating scan (1) can minimize the problem for estimating gestational age - Every visit should be arrange with a sinologist sonographer ? there is no indication for scanning in every visit to estimate normal fetal growth - More frequent antenatal visits may detect hypertension and diabetes earlier and management in coordination with the physicians ? Special instruments may be required ( obesity B.P. apparatus does this have a medical name?? ) if she is not a diabetic from the beginning, a glucose tolerance test when will you do the GTT? an adequate subsequent management with the physician can minimize the risks of diabetes ? use a full stop (.) at the end of a sentence Referral to a dietician is a good option as caloric reduction is not advisable during pregnancy this is incorrect ? weight reduction is not advised (-1) ? This pregnancy is at risk of postdated pregnancy and induction of labour, so adequate patient counseling is desirable.

c) During intrapartum period this patient is at risk of difficulty in detection of fetal heart rate so a scalp electrode may be needed for fetal monitoring (1) ? Difficult application of epidural anesthesia due to increased subcuticular fat is also a problem. Higher doses of analgesia may be required.
These patients are at a higher risk of emergency LSCS due to prolonged first stage of labour, CPD, fetal distress and fetal macrosomia. If CS is deemed necessary, anesthetist may face difficulty in spinal anesthesia. 65% of these patients received general anesthesia in a study. Poor access to the tissues may require a midline longitudinal incision and the patient may face its complications. Exteriorization of the uterus may be difficult to see the angles of the uterine incision which may extend during a difficult delivery.
Provided the patient is suitable for vaginal delivery, incidence of instrumental vaginal delivery, perineal injury, shoulder dystocia are increased, so a senior obstetrician may attend the delivery to avoid and deal with the possible complications (1) .

d) Postnataly she is at risk of perineal wound infection and thromboembolism. Prophylactic antibiotics where is this recommendation from? What is the evidence? (-1) and low molecular weight heparin is advisable for three days (1) , compression stocking for six weeks may reduce the risk of DVT early mobilization and hydration (1) also reduces the risk of DVT. Adequate control of hypertension and diabetes in collaboration with the physicians may be required. Breastfeeding is encourage weight reduction is advised.
Oral contraception is usually not a first choice is it a second choice? Should they be used in a woman with a BMI of 40 in the post-natal period?? . Barrier contraception is with least side effects but higher user failure rate ? so IUCD is the contraception of choice. A general advice about lifestyle modification, diet and exercise is beneficial.
Posted by PAUL A.
Sat Jan 5, 2008 04:00 pm
I want to ask DR PAUL please , is there space limitation ? which may suit the marking system ?

Your answer should be 750 words max. The length of each part should be in proportion to the number of marks
Posted by Mahmud  K.
Sun Jan 6, 2008 10:11 pm
Because of high BMI in early pregnancy she has around a threefold increased risk of pre-eclampsia. There is a three to four fold increased risk of gestational diabetes.Also she has a threefold increased risk of venous thrombosis. All these risks escalate with her degree of obesity.
There is a two-to threefold increased risk of fetal abnormality like spina bifida, omphalocele and heart defects. Obesity may associated with an increased risk of first trimester and recurrent miscarriage .it is well known to be associated with macrosomia and has been reported to more than double the risk stillbirth and neonatal death.

It considered a high risk pregnancy and it may take multidisciplinary approach to care plan involving obstretician, primary care physicians, anaesthetists, neonatologists, midwives.
Low dose aspirin prophylaxis should be considered for prevention of pre-eclampsia. Whether this makes a difference to the incidence of the pre-eclampsia in this women is uncertain.Glucose tolerance test at 24 weeks time should be arranged for detection of GDM.
Large cuffs should be used for these women to avoid falsely high or low blood pressure reading.
There is a need to folic acid supplementation and screen for fetal abnormality by serum screening and by detailed ultrasound scan .A transvaginal ultrasound scan may be preferable due to struggle to image the fetus through bulky maternal tissues.
Clinically it is often difficult to estimate fetal growth, determine the presenting fetal part, detect fetal heart, or recognize the presence or absence of hydramnions. If there is suspicion of growth restriction, serial ultrasound should be arranged .Antenatal weight gain should be minimised. She need dietician referral for dietary habits and behavioural changes .But dietary restriction is not advisable.
Failed regional blocks and difficult or failed intubation are more common, especially in the morbidly obese group. The anaesthetists must be involved early.
Obese women are at increased risks of dysfunctional labor and have a higher risk of chephalopelvic disproportion.So the rate of emergency caesarean section is significantly higher in this women. Ensure that experienced personnel senior obstretician and senior midwife should be present during labour. Shoulder dystocia also common in obese women. Regular drills and protocols help the labour ward to be prepared for shoulder dystocia in such patient. Advance site a canula may need because mechanical difficult to site an infusion in a fat limb.

Following delivery increase chance of postpartum haemorrhage . Active management for third stage of labour should required. Because of higher risk of thromboembolism she need early ambulation post-delivery .hromboembolic deterrent stockings and low molecular heparin prophylaxis should be required. An obese women is likely ,to need extra support for breastfeedingr because there is reduced chance of success at breastfeeding. She need prepregnancy counselling for weight reduction ,nutritional stabilization and vitamin supplementation for next pregnancy to minimise the risks.Long term contraception should be considered .However combined oral contraceptives are a relative contraindication.

Posted by PAUL A.
Sun Jan 6, 2008 11:33 pm
Because of high BMI in early pregnancy she has around a threefold increased risk of pre-eclampsia. There is a three to four fold increased risk of gestational diabetes (1) .Also she has a threefold increased risk of venous thrombosis (1) . All these risks escalate with her degree of obesity.
There is a two-to threefold increased risk of fetal abnormality like spina bifida, omphalocele and heart defects. Obesity may associated with an increased risk of first trimester and recurrent miscarriage (1) .it is well known to be associated with macrosomia and has been reported to more than double the risk stillbirth and neonatal death not ANTENATAL .

It considered a high risk pregnancy and it may take multidisciplinary approach to care plan involving obstretician, primary care physicians, anaesthetists (1) , neonatologists, midwives.
Low dose aspirin prophylaxis should be considered for prevention of pre-eclampsia. Whether this makes a difference to the incidence of the pre-eclampsia in this women is uncertain On what basis would you consider this? What is the evidence that aspirin is of any use in obese women? The blanket classification of women as HIGH / LOW risk is of little clinical use and results in women being given inappropriate treatments. Aspirin is not without side-effects (-1) .Glucose tolerance test at 24 weeks time should be arranged for detection of GDM would you repeat it if normal? .
Large cuffs (1) should be used for these women to avoid falsely high or low blood pressure reading.
There is a need to folic acid supplementation and screen for fetal abnormality by serum screening and by detailed ultrasound scan do these not apply to women with a normal BMI? .A transvaginal ultrasound scan may be preferable due to struggle to image Poor language the fetus through bulky maternal tissues.
Clinically it is often difficult to estimate fetal growth, determine the presenting fetal part, detect fetal heart, or recognize the presence or absence of hydramnions. If there is suspicion of growth restriction, serial ultrasound should be arranged you have already stated that clinical assessment is difficult ? how then would you suspect IUGR? . Antenatal weight gain should be minimised. She need dietician referral for dietary habits and behavioural changes . But dietary restriction is not advisable why not? Why is it wrong to restrict consumption of certain foods? .
Failed regional blocks and difficult or failed intubation are more common, especially in the morbidly obese group. The anaesthetists must be involved early (1) . Obese women are at increased risks of dysfunctional labor and have a higher risk of chephalopelvic disproportion.So the rate of emergency caesarean section is significantly higher in this women. Ensure that experienced personnel senior obstretician and senior midwife should be present during labour. Shoulder dystocia also common in obese women. Regular drills and protocols help the labour ward to be prepared for shoulder dystocia in such patient what will you do when she presents in labour? . Advance site a canula may need because mechanical difficult to site an infusion in a fat limb.

Following delivery increase chance of postpartum haemorrhage . Active management for third stage of labour should required. Because of higher risk of thromboembolism she need early ambulation ? good hydration post-delivery .hromboembolic deterrent stockings and low molecular weight heparin prophylaxis should be required for how long? . An obese women is likely ,to need extra support for breastfeedingr because there is reduced chance of success at breastfeeding. She need prepregnancy counselling (1) for weight reduction ,nutritional stabilization and vitamin supplementation for next pregnancy to minimise the risks.Long term contraception should be considered .However combined oral contraceptives are a relative contraindication BMI >39 is absolute contraindication, especially post-partum .
Posted by PAUL A.
Tue Jan 8, 2008 03:59 am
A good candidate should

(a)
? Explain that the majority of woman have an uncomplicated pregnancy (1)

Explain the following risks:

? Increased risk of miscarriage and fetal anomalies (1)

? Increased risk of medical complications especially gestational diabetes & hypertensive disorders (1)

? Increased risk of VTE (1)

? Difficulties assessing fetal growth and presentation; increased risk of fetal macrosomia (1)

(b) With respect to modifications to antenatal care

? TV scan likely to be required to date pregnancy, assess viability and perform nuchal scan (1)

? Provide dietary advice to limit weight gain during pregnancy but weight loss is not recommended (1)

? Refer for anaesthetic assessment (1)

? Ensure appropriate cuff is used to measure BP (1)

? Screen for gestational diabetes (1)

? Clinical assessment of fetal growth of limited value ? monitor using serial growth scans although value is also limited (1)

? Ultrasound assessment of fetal presentation in late pregnancy (1)

? Avoid immobility and dehydration and consider thrombo-prophylaxis during any admission (1)

(c ) With respect to modification of intra-partum care

? Request early anaesthetic assessment (1)

? Avoid immobility and dehydration. Assess risk of pressure sores and use appropriate mattress (1)

? Scalp electrode might be needed for fetal monitoring (1)

? Consider risk of shoulder dystocia and ensure expertise available especially during vaginal operative delivery for delay in second stage (1)

(d) With respect to post-partum care after vaginal delivery

? Avoid immobility and dehydration to minimise VTE risk (1)

? Heparin thrombo-prophylaxis for 3-5 days (1)

? Discuss contraception to avoid unplanned pregnancy (1)

? Discuss need for pre-pregnancy counselling and weight reduction before next pregnancy (1)
Posted by Idris O.
Wed Jan 9, 2008 02:14 am
a)I would inform her obesity is associated with difficulty in clinical diagnosis of pregnancy. With advancing pregnancy it may be difficult to evaluate the size of the fetus, determine the presenting part, detect fetal heart or recognise the presence or absence of hydramnios. There is an increased risks of hypertension, pre-eclampsia and eclamsia. There may be difficulty in accurate measurement of BP. There is also an increased risk of GDM and UTI. She is at risk of cardiac disease and DVT. The fetal risks include congenital malformation which include cardiac and omphalocoele There is difficulty in interpretation of serum screening for Down?s syndrome.
There is an increased risks of miscarriage, preterm labour which may be due to the medical problem or as a consequence of the congenital malformation. She is at increased risk of big baby from obesity itself or if develop GDM or IUGR if develop PET.
There is an increased risk of antepartum stillbirth at term. I would document this discussion and provide her with information leaflet.

b)I would advice her to book in a consultant led unit. I would arrange nuchal scan for Down?s syndrome due to difficulty in interpretation of serum screening. At each antenatal clinic she would have her BP taken with a big cuff and urinalysis for protein , leucocytes and nitrites and m/s/u for m/c/s if necessary. I would treat UTI promptly. I would counsel her about warning sign of PET like headache, blurring of vision and epigastric pain and to report in the hospital immediately.
I would arrange uterine artery Doppler at 22-24wks for screening for PET and IUGR. She would have serial growth scan, liquor volume and presentation from 24 weeks. I would arrange an OGTT at 24 and 28wks. I would counsel her on fetal movement due to the risk of antepartum stillbirth. I would assess her risk of thromboembolism and provide appropriate thrombo-prophylaxis in conjunction with an haematologist.
I would refer her to the dietitician about her diet and exercise so that she gain modest weight in pregnancy as weight loss is not desired. I would also refer her to the consultant anaesthetist to discuss pain relief in labour and cannulation as there is an increased risk of operative intervention.

c)This is an high risk labour and needs the presence of the most experience obstetrician and senior anaesthetist. If there is anticipated difficulty in siting a cannula or epidural, this may have to be performed early. There is an increased risk of primary and secondary dysfunctional labour and oxytocin may have to be used early to correct this. There is an increased risk of operative delivery both vaginal and c-section. Difficult instrumental vaginal delivery should be avoided. The risk of macrosomia and shoulder dystocia can be reduced by rehearsing the drills and protocols for the management of shoulder dystocia and delivery by the most experienced obstetrician. If a c-section is required adequate asepsis and haemostasis and prophylactic antibiotics to prevent infection.
Oxytocics should be used in the management of the 3rd stage to reduce risk of PPH. The perineum should be checked for any perineal tears and this should be promptly repaired with an aseptic technique.

d)I would provide her with TEDS and appropriate thromboprophylaxis because of risk of DVT despite VD. Early ambulation post delivery would be encouraged. I would counsel her on tight control of her weight before the next pregnancy and refer her to a dietitician for advice on diet and exercise.
I would advice her on long term contraception. The COC pills is relatively contraindicated. This is to enable her to loose weight before the next pregnancy.
I would follow up any medical problem like hypertension, PET or GDM in the puerperium. If have GDM, I would arrange a GTT at 3/12 because may have type 2 DM.

Posted by Azza S.
Wed Jan 9, 2008 11:54 am
This primaegravida has morbid obesity. There is increase risk of morbidity and mortality to the mother and the fetus. Proper dating of pregnancy is required as early intervention may be required. Abdominal and pelvic examination may be difficult and uninformative because of obesity. Abdominal ultrasound [uss] may also be difficult. She may need detailed uss in a tertiary unit as serum tests for anomaly risk is difficult to interpret in obese patients.
She is at increased risk of pregnancy induced hypertension [PIH], gestational diabetes millets[GDM] thromboembolismic disease[TED] macrosomia & operative delivery. Large size cuff is needed to measure BP GTT to detect GDM, urine dipsticks. USS is needed for presentation viability as per abdomen may be difficult as well as uss for growth after 28 weeks every 4 weeks. Weight reduction is not advised during pregnancy but referral to dietician for advice on healthy food is needed Intravenous access may be difficult as well as anesthesia, arrange for anaesthesitist review..Operative risk is increased with obesity.
This is high risk pregnancy and should be followed in consultant led unit. Screen for PIH, GDM and TED. Follow .up growth by serial uss. Bp check with proper size cuff as well as urine dipstick. With macrosomia a consultant may advice induction of labour at 37-38 weeks
Intrapartum advice epidural analgesia as there is increase risk of operative delivery. Advice mobilization and good hydration as well as graduated stocking. Estimate TED risk. Abdominal CTG may not detect the fetal heart trace so scalp electrode should be applied. Apartogram to follow up progress of labour Senior obstetrician & midwife supervision is needed. Anticipate shoulder dystocia Do active management of the third stage of labour.
Postnatal watch for hydration early mobilization Advice graduating stocking Encourage breast feeding. Hormonal contraception is not advised in this patient but mirena or IUCD can be advised .advise weight reduction. Support group. Written information on long term risks
Posted by Toyin A.
Wed Jan 9, 2008 09:20 pm
Her BMI of 40 makes her morbidly obese which has fetal and maternal antenatal risks.
I will tell her these risks include difficulty with imaging ultrasound accurately with both dating and anomaly scans,so she may need to reattend for 2nd scan to complete anaomaly detection.
I will tell her her risk of miscarriage is increased as is fetal anomalies.
I will tell her the risk of pregnancy induced hypertension and preeclampsia is increased due to her weight.
I will tell her the chance of developing gestational diabetes is higher due to her increased BMI.
I will tell her that the risk of thromboembolic disease is higher as obesity is a risk factor in addition to pregnancy.
I will tell her the risk of a large or macrosomic baby is higher secondary to her increased weight,and this may impact on how she delivers eventually.

b)i will recommend shared antenatal care with regular hospital antenatal clinic reviews to help minimise these risks and advise her against midwifeled care (or home births).
I would advise 2 weekly manual blood pressure checks with a large cuff so as to pick up any change in blood pressure-this can be done in community or hospital-aswell as urine dip for protein at every visit,to pick up preeclampsia.
I will advise urine dip for glucose at every visit and a random blood sugar with her booking bloods. A formal oral glucose tolerance test at 28 weeks may be done if any abnormalities arise.
I will have a low threshold for growth scans especially if clinical difficulty in detecting small or large babies due to body habitus.Serial growth scans may be warranted but need not be routine.
I will have an anaesthetic assessment done antenatally to discuss with her any potential problems with regional or general anaesthesia should she need them in labour.
I would arrange a dating scan in 1st trimester to accurately date her pregnancy thus reducing risk of unnecessary induction of labour post term which may more likely fail in her case.
A scan for presentation at 36-37 weeks gestation to rule out malpresentation which may be more easily missed clinically due to her BMI.

c)i would advise applying a fetal scalp electrode once her membranes are ruptured if there is difficulty with external fetal heart rate monitoring due to her size.
She is at risk of dysfunctional labour so a partogram should be used and syntocinon augmentation started without delay if slow progress is diagnosed.
A quick scan for fetal presentation on her admission to rule out a malpresentation that may have been missed antenatally due to her size.
She is at risk of postpartum haemorrhage due to poor uterine contractility secondary to obesity,so early intravenous access,full blood count,blood group and save serum should be done and the 3rd stage managed actively.

d)she is at increased risk of thromboembolic disease so I would recommend early mobilisation,adequate hydration and TED compression stockings.If she has an additional risk factor like prolonged labour>12 hrs,subcutaneous fragmin 5000iu od for 5 days will be needed.
i would discuss contraception before her discharge and advise to avoid combined oral hormonal contraception as her BMI is a contraindication.
Encourage to lose weight before further pregnancy to minimise risks and encourage her to see GP for dietician referral.
Encourage breastfeeding as this aids loss of pregnancy weight.

Posted by Toyin A.
Wed Jan 9, 2008 09:23 pm
Sorry Paul i also meant to add at the end of part a)- i would reassure her that most pregnancies with increased BMI progress without any problems
Posted by Lekshmi B.
Fri Jan 11, 2008 11:24 am
a) I will tell her that she has an increased risk of miscarriage in her early pregnancy. There is also high risk of developing hypertensionand type II diabetes in pregnancy. Risk of venous thromboembolism is also high. The risk of congenital anomalies in the baby is increased and so is the risk of macrosomia, which can result in shoulder dystocia and subsequent surgical intervention . Surgery if required will be difficult to perform and can have difficulties in administering anaesthesia. Risk of wound infection and post partum hemorrhage is increased.

B) i will advise her to take 5 mg folic acid to reduce the risk of neural tube defects. She will be put on TED stockings and advised to avoid dehydration and prolonged immobilisation to reduce the risk of VTE. Patient will be seen by the consultant. Dietician will be consulted to advise on reduced calorie intake. Detailed anomaly scan will be done to rule out major nomalies. uterine artery Doppler to screen for hypertension and if raised BP is detected, early treatment to reduce complications. Early screening for diabetes by HBA1C at 8 wks and thereafter 4-6 weekly and 75 gm OGTT at 26 wks. Suitable BP Cuff and exmination cot for the patient will be arranged. Serial growth monitoring scans for the fetus will be done.

C) After a general and obstetric examination, to confirm labour, a large bore cannula will be inserted, and blood drawn for grouping and saving. Any difficulty in getting venous access, The help of anaesthetist will be sought. Anaesthesia checkup will be done to assess the feasibility of regional anaesthesia. Theatre staff will be informed and the needed BP cuff and operation cot will be arranged. Continious CTG monitoring will be done as intermitten auscultation may not be effective. If any emergency surgery is planned, Senior consultant and senior anaesthetist will be made available. Active management of third stage to reduce risk of PPH. Post operative thromboprophylaxis will be instituted with low molecular weight heparin

D) I will advice her regarding early mobilisation, need to avoid dehydration, early treatment of infection and need to continue TED stockings to reduce the risk of VTE. She will be given contraceptive advice . COCP will be avoided due to increased VTE risk . IUCD can be used after six weeks. Progesterone preparations can be used but risk of irregular bleeding is there. She will also be advised to reduce weight by suitable diet control and exercise before attempting next pregnancy.
Posted by Toyin A.
Tue Jan 15, 2008 03:41 pm
Paul,could my answer please be marked or is it too late past when the question was posted? thank you
Posted by PAUL A.
Thu Jan 17, 2008 01:56 am
a)I would inform her obesity is associated with difficulty in clinical diagnosis of pregnancy. With advancing pregnancy it may be difficult to evaluate the size of the fetus, determine the presenting part, detect fetal heart (1) or recognise the presence or absence of hydramnios. There is an increased risks of hypertension, pre-eclampsia and eclamsia. There may be difficulty in accurate measurement of BP. There is also an increased risk of GDM (1) and UTI. She is at risk of cardiac disease is she? Which disease? and DVT (1) . The fetal risks include congenital malformation which include cardiac and omphalocoele There is difficulty in interpretation of serum screening for Down?s syndrome why? BMI is taken into account .
There is an increased risks of miscarriage (1) , preterm labour which may be due to the medical problem or as a consequence of the congenital malformation. She is at increased risk of big baby from obesity itself or if develop GDM or IUGR if develop PET.
There is an increased risk of antepartum stillbirth at term. I would document this discussion and provide her with information leaflet.

b)I would advice her to book in a consultant led unit. I would arrange nuchal scan for Down?s syndrome due to difficulty in interpretation of serum screening nuchal scan on its own should not be used as a screening test ? see SURUSS trial . At each antenatal clinic she would have her BP taken with a big cuff (1) and urinalysis for protein , leucocytes and nitrites and m/s/u for m/c/s if necessary when is this necessary? . I would treat UTI promptly. I would counsel her about warning sign of PET like headache, blurring of vision and epigastric pain and to report in the hospital immediately.
I would arrange uterine artery Doppler at 22-24wks for screening for PET and IUGR where is the evidence that this is of any use in obese women? In studies on uterine artery Dopplers, was obesity an entry criterion?? . She would have serial growth scan, liquor volume and presentation from 24 weeks what is the relevance of presentation at 24 weeks? . I would arrange an OGTT at 24 and 28wks GDM is likely to occur in the late third trimester therefore 28 & 34 weeks is ore appropriate . I would counsel her on fetal movement due to the risk of antepartum stillbirth you will cause unnecessary anxiety ? there is no evidence that movement counts / kick charts are of any use . I would assess her risk of thromboembolism and provide appropriate thrombo-prophylaxis (1) in conjunction with an haematologist.
I would refer her to the dietitician about her diet and exercise so that she gain modest weight in pregnancy as weight loss is not desired (1) . I would also refer her to the consultant anaesthetist (1) to discuss pain relief in labour and cannulation as there is an increased risk of operative intervention.

c)This is an high risk labour and needs the presence of the most experience obstetrician and senior anaesthetist. If there is anticipated difficulty in siting a cannula or epidural, this may have to be performed early. There is an increased risk of primary and secondary dysfunctional labour and oxytocin may have to be used early to correct this. There is an increased risk of operative delivery both vaginal and c-section. Difficult instrumental vaginal delivery should be avoided. The risk of macrosomia and shoulder dystocia can be reduced by rehearsing the drills and protocols for the management of shoulder dystocia and delivery by the most experienced obstetrician how does this reduce the risk? It may reduce the impact of the event but does not alter the probability of the even happening . If a c-section is required adequate asepsis and haemostasis and prophylactic antibiotics to prevent infection.
Oxytocics should be used in the management of the 3rd stage to reduce risk of PPH. The perineum should be checked for any perineal tears and this should be promptly repaired with an aseptic technique you were not asked to describe your care. You ere asked about what you will do differently. Will you not use aseptic technique / inspect perineum in a woman with a normal BMI? .

d)I would provide her with TEDS and appropriate thromboprophylaxis because of risk of DVT despite VD what is appropriate? . Early ambulation post delivery would be encouraged hydration . I would counsel her on tight control of her weight before the next pregnancy and refer her to a dietitician for advice on diet and exercise (1) .
I would advice her on long term contraception. The COC pills is relatively contraindicated. This is to enable her to loose weight what is? Not prescribing the pill? before the next pregnancy.
I would follow up any medical problem like hypertension, PET or GDM in the puerperium. If have GDM, I would arrange a GTT at 3/12 because may have type 2 DM.

You seem to follow every correct statement with an inappropriate one, making it impossible for the examiner to award marks.

You need to post your answer BEFORE the marking scheme is posted at the end of the week
Posted by PAUL A.
Thu Jan 17, 2008 02:08 am
This primaegravida has morbid obesity. There is increase risk of morbidity and mortality to the mother and the fetus. Proper dating of pregnancy is required as early intervention may be required. Abdominal and pelvic examination may be difficult and uninformative because of obesity. Abdominal ultrasound [uss] may also be difficult. She may need detailed uss in a tertiary unit as serum tests for anomaly risk is difficult to interpret in obese patients if she said to you: What risks am I running due to my weight? Is this what you will tell her? .
She is at increased risk of pregnancy induced hypertension [PIH], gestational diabetes millets[GDM] thromboembolismic disease[TED] macrosomia & operative delivery. Large size cuff is needed to measure BP GTT to detect GDM, urine dipsticks do not write a list . USS is needed for presentation viability as per abdomen may be difficult as well as uss for growth after 28 weeks every 4 weeks. Weight reduction is not advised during pregnancy but referral to dietician for advice on healthy food is needed Intravenous access may be difficult as well as anesthesia, arrange for anaesthesitist review..Operative risk is increased with obesity presume this is the end of (a) ? you have still not told her what the risks are .
This is high risk pregnancy and should be followed in consultant led unit. Screen for PIH, GDM and TED how do you screen for TED or PIH? . Follow .up growth by serial uss. Bp check with proper size cuff (1) as well as urine dipstick. With macrosomia a consultant may advice induction of labour at 37-38 weeks what is te evidence that this improves outcome? (-1)
Intrapartum advice epidural analgesia as there is increase risk of operative delivery obesity is NOT an indication for epidural . Advice mobilization and good hydration as well as graduated stocking (1) . Estimate TED risk. Abdominal CTG may not detect the fetal heart trace so scalp electrode should be applied (1) . Apartogram to follow up progress of labour Senior obstetrician & midwife supervision is needed. Anticipate shoulder dystocia Do active management of the third stage of labour.
Postnatal watch for hydration early mobilization (1) Advice graduating stocking Encourage breast feeding. Hormonal contraception is not advised ? progestogen ?only??? in this patient but mirena or IUCD can be advised .advise weight reduction. Support group you need to write in complete sentences ? the examiner is not looking for key words / phrases. . Written information on long term risks
Posted by PAUL A.
Thu Jan 17, 2008 03:58 am
Her BMI of 40 makes her morbidly obese which has fetal and maternal antenatal risks.
I will tell her these risks include difficulty with imaging ultrasound accurately with both dating and anomaly scans,so she may need to reattend for 2nd scan to complete anaomaly detection.
I will tell her her risk of miscarriage is increased as is fetal anomalies (1) .
I will tell her the risk of pregnancy induced hypertension and preeclampsia is increased due to her weight.
I will tell her the chance of developing gestational diabetes is higher due to her increased BMI (1) .
I will tell her that the risk of thromboembolic disease is higher as obesity is a risk factor in addition to pregnancy (1) .
I will tell her the risk of a large or macrosomic baby is higher secondary to her increased weight,and this may impact on how she delivers eventually (1) although there are no marks for style, beginning every sentence with I will? does not convey a mature approach.

b)i will recommend shared antenatal care with regular hospital antenatal clinic reviews to help minimise these risks and advise her against midwifeled care (or home births).
I would advise 2 weekly manual blood pressure checks with a large cuff (1) so as to pick up any change in blood pressure-this can be done in community or hospital-aswell as urine dip for protein at every visit,to pick up preeclampsia.
I will advise urine dip for glucose at every visit and a random blood sugar with her booking bloods. A formal oral glucose tolerance test at 28 weeks may be done if any abnormalities arise may be or should be? .
I will have a low threshold for growth scans especially if clinical difficulty in detecting small or large babies due to body habitus how reliable is clinical examination to use as a basis for deciding whether to scan? .Serial growth scans may be warranted but need not be routine.
I will have an anaesthetic assessment done antenatally (1) to discuss with her any potential problems with regional or general anaesthesia should she need them in labour.
I would arrange a dating scan (1) ? logic ? you have already discussed third trimester issues in 1st trimester to accurately date her pregnancy thus reducing risk of unnecessary induction of labour post term which may more likely fail in her case.
A scan for presentation at 36-37 (1) weeks gestation to rule out malpresentation which may be more easily missed clinically due to her BMI.

c)i would advise applying a fetal scalp electrode once her membranes are ruptured if there is difficulty with external fetal heart rate monitoring due to her size (1) .
She is at risk of dysfunctional labour so a partogram should be used and syntocinon augmentation started without delay if slow progress is diagnosed.
A quick scan what is the indication for rushing? Surely you will impress if you are detailed and thorough rather than quick for fetal presentation on her admission to rule out a malpresentation that may have been missed antenatally due to her size.
She is at risk of postpartum haemorrhage due to poor uterine contractility secondary to obesity,so early intravenous access,full blood count,blood group and save serum should be done and the 3rd stage managed actively.

d)she is at increased risk of thromboembolic disease so I would recommend early mobilisation,adequate hydration (1) and TED compression stockings.If she has an additional risk factor like prolonged labour>12 hrs will you consider a 13h labour in a primip as prolonged? Do RCOG guidelines set time limit for post-partum heparin? ,subcutaneous fragmin 5000iu od for 5 days will be needed.
i would discuss contraception before her discharge and advise to avoid combined oral hormonal contraception as her BMI is a contraindication (1) .
Encourage to lose weight before further pregnancy to minimise risks and encourage her to see GP for dietician referral (1) .
Encourage breastfeeding as this aids loss of pregnancy weight.
s Posted by PAUL A.
Mon May 7, 2012 01:36 am

s