TEALE FENNING

bronwyn · Posted: Sun Jan 21, 2007 9:21 pm Post subject: Obesity

Here's one I spotted for last time....
it didn't come up then but may now! Wink

A 23 year old primiparous woman with a BMI of 45 is referred to your antenatal clinic by her community midwife
a) What are the maternal risks to this pregnancy & how would you reduce them? (10)
b) What are the fetal risks to this pregnancy and how would you reduce them? (6)
c) What would you advise her about after delivery? (4)

Another possible stem
d) Describe in detail how you manage a case of shoulder dystocia (6)
_________________
Bronwyn Bell
SpR
Portsmouth

Abik · Posted: Mon Jan 22, 2007 3:04 pm Post subject:

Tricky one Bron - Thanks!!

OK - the bubbles!

First and most marks for the maternal risks.
Divide into antenatal/intrapartum/postpartum.
AN - Gest DM therefore random blood sugars? OGTT? - no evidence that screening those with risk factors helps. ? wait for huge baby?!
VTE risks esp if other factors in history. How to reduce - mobility? screen with history ie FH of VTE may prompt thrombophilia screen.

IP- Anaesthtic risks with GA = intubation difficult therefore increased risk of aspiration, with regional = more difficult therefore increased risks of failure/cord damage?/dural tap?
?reduce by arranging anaesthetic review.
Risks of obstructed labour = increased intervention, perineal damage with instrumentals, poor wound healing. increased LSCS = increased difficulty, damage to bladder/wound healing/VTE/blood loss.
Reduce by involving senior obstetricians if instrumental/LSCS and senior anaesthetists.

PP- VTE therefore use LMWH if any other risk factors arise. Wund healing should probably go here?

Can also put F.A.R.T.! (folate, alcohol/smoking, rubella and teratogens as these will reduce her risks.

Foetal risks - less marks but still divide as above.
AN - Difficulties in anomaly scanning due to BMI, amniocentesis would be a nightmare! Foetus also at risk from gest DM as more likely to be LFD, polhydraminios therefore exposed to prematurity/abruption risks.

IP - I would put risk of shoulder dystocia here as it is rarely a risk to maternal phsyical health (could send them loopy I suppose!) reduction in this risk? I know some would advocate delivery earlier if baby looks massive but I don't think there's any evidence to support this and it is not going to be easy to estimate weight in this patient. I think the best you can do is be aware of the risk and perhaps review protocols when she is in labour?
Also risks of inadequate monitoring (lets hope it's not twins - although we may not have noticed!!) this can be reduced by the use of an FSE. (or stick her in the pool and hope she does it by herself!!!)

PPCan't think of any for baby?

After delivery advise her not to have any more!? Contraception, I mean!
to loose weight and reduce her risks.

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

I think this would be a clear pass!
May I just add to AN maternal risks increaseds risk of hypertension problems therefore regular checks (BP, urine) in 3rd trimester may allow for early detection. (0.5 points)
And difficulties in biochemical screening in 2nd trimester
Intrapartum you have covered everything! Anaesthetics, dysfunctional labour, malpresentations, difficulties monitoring, instrumentals, caesarean..
After delivery? sterilization! Again you have covered everything! VTE basically contraception and diet or referal to dietician before planning for next one. Also it is quite unethical to ask her to loose weight whilst pregnant! (I've seen that, don't laugh!)

Abik · Posted: Mon Jan 22, 2007 6:06 pm Post subject:

Thanks Wolverine.
What are the issues with biochemical screening? Can't think!
And are malpresentations more likely or just impossible to detect?!!
Abi

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Maternal weight is a factor affecting serum markers: 20kg increase in maternal weight associated with 17% decrease in MSAFP, 7% decrease in MSuE3 and 16% decrease in MSHCG. (I don't think I have to write it like that though in the exams...)
Other factors include IDDM, multiple pregnancy, Ethnicity, smoking, parity, ART
Yes malpresentations are more difficult to detect rather than more likely to occur. Is it the same with IUGR? I think both: Obesity is a risk factor for placenta insufficiency and IUGR and it is difficult to detect therefore serial growth USS monthly in third trimester

mridulaben · Posted: Tue Jan 23, 2007 9:59 am Post subject:

Also add difficulty in assessment of fetal growth.
Prolonged pregnancy is common, IOL higher
CTG monitoring, may need FSE
Increased risk of still birth
Increased operative delivery
DIFFICULT TO ACCOMODATE ON OT TABLE Laughing

Difficult GA/ Epidural, Venous line
More post op wound inf, resp inf. FAT stitch , long operating time
Proper intraop assistance

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

for intra op if she needs LSCS ....

use of proper retractors, the roller guaze trick to keep the overhang of the abdo away, longer instruments and low threshold for drains..

Nick Raine-Fenning · Posted: Sat Jan 27, 2007 4:13 pm Post subject:

bronwyn · Posted: Mon Jan 29, 2007 9:00 pm Post subject:

A few more points I had on my marking scheme:

Fetal risks include a three fold increased risk of miscarriage.
There is a definite risk of neural tube defects thought to be related to poor absorption of folic acid and higher metabolic demands.
There is conflicting evidence regarding the association between obesity and congenital malformations including CNS, cardiac great vessels, ventral wall and other intestinal defects.
There is a four fold increased risk of antepartum stillbirth in obese women related to rapid fetal growth and functional limitations of the placenta.
Long term risks for the fetus include increased risk of subsequent obesity. Fat mom

fat babe
The cardiovascular system can be compromised by diastolic dysfunction due to reduced myocardial perfusion
There is an increased occurrence of cholellithiasis accompanied by an increased risk of cholesystectomy in the first year postpartum
conditions.
Common operative complications include wound complications such as infection and dehiscence, chest problems such as atelectasis & hypoxaemia & pneumonitis.
Endometritis, UTI’s, PPH, postpartum anaemia & prolonged hospitalisation are more common in the obese.
Successful VBAC rates are lower in the obese woman.
There is a reduction in breastfeeding frequency partly due to mechanical difficulties and reduced prolactin response to suckling. Support & encourage breastfeeding.
Postpartum retention of weight is proportional to weight gain in pregnancy.
Associations with negative self and body image, potentially predisposing to poor mental health.
Ensure folate supplementation for all overweight and obese women and consider a higher dose of 5mg a day if BMI>40kg/m2
Advise on long term risks of obesity, hypertension and DM.
Advise weight loss prior to next pregnancy. (if you're feeling brave!!)
_________________
Bronwyn Bell
SpR
Portsmouth

docsubhi · Joined: 03 Sep 2007 Posts: 59 Location: london

another possible stem could be

Discuss the problems encountered by the carers / health care proffessionals due to her BMI

Nick Raine-Fenning · Posted: Sun Aug 17, 2008 8:05 pm Post subject:

A bad back! Shocked

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

[/list]difficulty in obtaining blood samples and giving iv access, performing trans-abdominal ultrasound scans, giving epidurals and spinals and palpating the gravid uterus for fetal presentation.
personal injuries due to lifting the patient, eg when transferring her from bed to theatre table.
Performing a section may require extra assistants to obtain adequate access into the peritoneal cavity.
Adequate equipment needs to be available, including an operating table and delivery bed that can safely hold her wheight and extra long epidural and spinal needles.
intubation may be difficult and senior anaesthesist must be present.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

nice stem maud and a good answer too.

just a quick fact -- most standard OT tables take up to 135 kgs with out a problem. there are newer ones available for bariatric surgery that can take up to 500 kgs = 1102 lbs.

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol