TEALE FENNING

chinnu · Joined: 06 Jan 2009 Posts: 105 Location: KSA

Q. A 25 yr old woman in her first pregnancy books for antenatal care at 12 weeks amenorrhoea with a BMI over 40kg/m2.

A. Given her obesity justify which specific measures should be taken during her antenatal care? (8 marks)

B. How would you manage her labour? (9 marks) and early postnatal period. (3 marks )

Nick Raine-Fenning · Posted: Fri Jan 16, 2009 9:31 am Post subject:

Hi Chinnu

Excellent essay questions there. Let's give them a week and see how people get on.

Come on everybody - we need to get busy - it's exam time again!

N

bluesky · Guest

(A) recognize high risk pregnancy
multidisciplinary approach, should be booked under obstetric consultant
referral to anaesthetist, dietician referral
dietary restriction not advised in pregnancy, aim to maintain body weight.
general advice about exercise, folic acid 5 mg
NT screening but can be difficult due to high BMI
serum screening and 20 week scan for congenital abnormalities, scan can be difficult,explanation to mother,has to be done by an experienced person
with high BMI there is increased risk of congenital abnormalities
GTT at 28 weeks
high risk of pre-eclampsia, BP check with appropriate cuff.
symphysiofundal height doesnot carry much significance,
scan for EFW if suspicion of macrosomia but can be difficult and has 15 % error
Scan for presentation at 37 weeks if unsure of presenting part on palpation

(B) Labour:
Notify consultant obstetrician and anaesthetist once admitted to delivery suite
scan for presenting part if difficult on palpation
careful review of partogram to detect dysfunctional labour
senior and trained person to be present at delivery as high risk of shoulder dystocia
operative vaginal delivery by consultant obstetrician
Caesarean section has to be done by consultant obstetrician, good haemostasis and suturing of subcutaneous layer to prevent wound infection
teds advisable during labour

Early postnatal period:
early mobilization, adequate fluids if C section, teds and adequate dose of clexane for thromboprophylaxis
prophylactic antibiotics may be required after caesarean section to prevent infection
blood sugar monitoring of baby to detect hypogylcemia
breastfeeding should be encouraged

nmurthy · Joined: 18 Nov 2008 Posts: 2

mOST OF THE POINTS ARE COVERED
am adding the others...........
Dating scan-Transvaginal as TAS may not be technically feasible.
Growth scans, as difficult SFH monitoring
Informing theatres(of EDD),porters,making arrangements for special chair,couch for use in the clinic,labourward,spl hoists,theatre table,operation tray to include long and broad retractors.

In labour-early epidural(may need long needle,may take multiple attempts),IV access for the same reason,
IAS/EXTERNAL Toco--difficult;may need internal monitoring
Difficult vaginal examination

C/S:Anaesthesia:High risk of failed intubation
SX:technically difficult,may need more than one assisstant
Lanes and retractors needed
Incision-Pfannenstiel-above the pannus;Consider vertical.
consider darins
Interrupted to skin
Uterotonics as high risk of PPH

Postnatal
Breast feeding is appropriate
Thromboprohylaxis until fully mobile to reduce the risk of TED regardless of the mode of delivery;
effective suitable contraception

manoj · Joined: 22 Jun 2008 Posts: 87

bluesky
you have covered most of the points
I would add avoid dehydration and immobility in all 3 parts of the answer and antenatal thromboprophylaxis if any prolonged immobility.
Postnatal recommendation to reduce BMI before embarking for next pregnancy.

rpwalavalkar · Posted: Wed Jan 28, 2009 6:56 am Post subject:

nicely handled every one, that's a pass surely --

can some one elaborate on foetal risks?
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

manoj · Joined: 22 Jun 2008 Posts: 87

Antenatal risk of preterm labour with prematurity associated with polyhydramnios and macrosomia.
Risk of IUGR and related complications.
Foetal risks related with macrosomia like shoulder dystocia, erbs palsy, stillbirth.
High risk of instrumental/caesarean delivery and related trauma.
Neonatal risk of jaundice, hyoglycaemia, hypocalcaemia.
Long term risk of diabetes, obesity and cardiovascular risk in adulthood.

rpwalavalkar · Posted: Wed Jan 28, 2009 8:29 pm Post subject:

nice, now that completes the answer.

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

rpwalavalkar · Posted: Wed Jan 28, 2009 8:31 pm Post subject:

OK, so what if the stem was pre-conception counselling.

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

manoj · Joined: 22 Jun 2008 Posts: 87

preconception counselling:

Reduce body weight - Diet , Exercise, Metformin, Bariatric surgery
Folic acid 5mg/day atleast 12 weeks preconception.
Appropriate contraception untill planning for pregnancy.

chinnu · Joined: 06 Jan 2009 Posts: 105 Location: KSA

Thank you all for the contributions.
Just a couple of additions.
Role of metformine for weight loss is not established.
Morbid obesity along with any other risk factor for hypertensive disease is an indication for Aspirin 75 mg/day from 12 wks of gestation.

manoj · Joined: 22 Jun 2008 Posts: 87

chinnu · Joined: 06 Jan 2009 Posts: 105 Location: KSA

Thank you.
I presume the gestation is taken from 12 wks to influence the secondary wave of trophoblstic invasion.
( ref. RCOG consensus views from 53rd Study Gp .)

rpwalavalkar · Posted: Sat Feb 28, 2009 10:32 pm Post subject:

manoj and chinnu,

you both have valid reasonings for the aspirin.

i will start aspirin at positive preg test. one needs to also think of the risk of TED in the morbidly obese when pregnant.

on that note, will you give her clexane ??

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

chinnu · Joined: 06 Jan 2009 Posts: 105 Location: KSA

Well I imagine,If BMI is the only risk factor,Aspirin and TED stockings should do. However if any additional risk factor is present then Clexane in high prophylacitc doses should be given. Pls correct me IF I am wrong.

Nick Raine-Fenning · Posted: Sun Mar 01, 2009 11:48 am Post subject:

absolutely ... aspirin and TEDs are more than sufficient for most patients including those with a past personal history of thromboembolism and even for many with a FHx but no personal history (aside from the nasties ... ATIII and Protein C deficiency).