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suji
Joined: 01 Jul 2007
Posts: 4
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 Posted: Wed Jul 04, 2007 9:27 am Post subject: Obstetric mngment of 42yr old multip - 7th pregnancy |
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Hey all
I am Suji, a new member here. Have been goin through all the topics and discussions. Am taking up my exam in September.
Have just written down a question and my plan in points, only. Can you please correct the same? Will write as answer after getting some hints. Thanx!
42 yr old woman comes to your ANC at 15/40 in her 7th pregnancy. Justify your antenatal and intrapartum care? 
Plan
2 problems - Older age & 7th pregnancy
Antenatal
- Increased frequency of intercurrent medical disease, especially, Diabetes, Hypertension, Anaemia and their concurent morbidity
- Increased risk of miscarriage - spontaneous and induced
- Icreased risk of ectopic pregnancy
- Increased risk of fetal chromosomal aneuploidy / Downs risk (1 in 80)
- Increased risk of developing Gestational Diabetes mellitus
AP Care
- High risk pregnancy
- Early booking - confirm IU pregnancy / accurate dating
- Multidisciplinary management with Physicians, Diabetologist, dietitians
- frequent BP checks / look for protenuria
- Investigations - Routine booking + special according to pre-existent medical problem
- offer serum screening / USS (NT & 1st tri screen--so can opt for TOP if needed, early)
- Frequent checks for glycosuria
- ? O GTT
- General advice on Smoking / alcohol / folic acid
(not mentioning Rubella as most likely she would have had it in one of her prev 6 pregnancies) 
Intrapartum
- Increased preterm labour - both iatrogenic and spontaneous
-- Increased risk of macrosomia and its concurrent problems in accurate diagnosis / labour (CPD/ SHoulder dystocia/ difficult delivery/ perineal trauma/ birth injuries / perinatala morbidity)
- Increased risk of abnormal presentations - face/breech/ transverse lie
- Risk of primary uterine inertia, prolonged pre-labour, failure to progress
- Increased risk of FHR abnormalities
- Increased risk of Placenta previa, Abruption
- Risk of Uterine rupture, PPH ( PP Hystetrectomy)
- Instrumental delivery and risks
- CS - due to abnormal presentation or uterine inertia
- Risk of Still birth
- Increased maternal & perinatal morbidity
- Anesthetic risks - due to concurrent medical problem
- Increased risk of maternal mortality
(CEMACH - MM for over 40yr - 35.5 / 100,000 maternities vs 20.7/100,000 in 35-39 yr old)
IP care
- Deliver in pregnancy unit under Consultant care with facilities for Emergency CS .
- Ensure p[lacental position / fetal size and well being
- Review H/o regarding mode of previous deliveries and any complications in them
- Ensure fetal presentation -- CS for obstetrics indications
? - WOuld it be necessary to advice CS if this is a Breech - in case she has had 6 prev NVD ??
- Early iv access / blood for x mmatch ready
- Partogram to assess labour progeess and plan intervention on time
- Syntocinon can be used - cautiously - risk of uterine rupture
- CEFM for fetus
- Anticipate problems - SHoulder dystocia / PPH
Am sure I have missed many points , but am not able to think ahead of this. Please correct !
Suji |
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Xerxes I
Century Club
Joined: 01 Mar 2007
Posts: 228
Location: Winchester
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| Posted: Sat Aug 30, 2008 1:28 pm Post subject: |
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Hi Suji,
You have probably long passed the exam and are laughing!! anyway, good question.
I would give serious consideration to thromboprophylaxis in view of her age. |
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rpwalavalkar
Teale Fenning Administrator
Joined: 20 Jul 2006
Posts: 966
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| Posted: Sun Aug 31, 2008 9:06 am Post subject: Re: Obstetric mngment of 42yr old multip - 7th pregnancy:rol |
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Hi Suji,
welcome. this is a very topical question and a scenario we will all face time and again.
may i suggest a few things.. your question says patient is 15/40 coming to your ANC
| Quote: | | - Early booking - confirm IU pregnancy / accurate dating |
the booking will have already happened with the MW considering she is now been sent to your ANC.
| Quote: | | - offer serum screening / USS (NT & 1st tri screen--so can opt for TOP if needed, early) |
the patient is already 15/40, so if NT and 1st trim screen, not already done, you can't include it now.
| Quote: | - Frequent checks for glycosuria
- ? O GTT |
when will you do it? how freq will you repeat?, what tests will you do?
other points to consider --
birth plan - deli in consultant unit, active stage 3, --- document this in notes
optimum management of anemia + prophylactic iron, to improve reserves in case of pph.
r
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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region |
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rpwalavalkar
Teale Fenning Administrator
Joined: 20 Jul 2006
Posts: 966
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| Posted: Sun Aug 31, 2008 9:16 am Post subject: |
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also --
agree with Xerxes I about the thromboembolism.
will add,
increased risk of twins and the problems arising from that.
increased risk of trophoblastic disaease.
r
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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region |
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rpwalavalkar
Teale Fenning Administrator
Joined: 20 Jul 2006
Posts: 966
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| Posted: Sun Aug 31, 2008 9:22 am Post subject: |
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the intrapartum is great.
r
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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region |
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