The Antenatal clinic

Year 2 Lent Term

For each of the cases

• Think about the factors which might affect the pregnancy or labour

• Make some recommendations to the patient

Case 1

• A 22 year old primigravida has had a series of ultrasound scans for growth after the midwife thought she was “small for dates”

• Bp 110/60 urine clear

• Smokes 20/day

Factors to discuss• Smoking: increases risk of growth

restriction, placental abruption, stillbirth, pre-term labour

• Falling growth rate of fetal abdominal circumference

• ? Other investigations for fetal well-being e.g liquor volume, Doppler blood flow

• ?give steroids to mature fetal lungs• Deliver early

Case 2• A 39 year old is 14 weeks pregnant with

her 6th pregnancy

• She weighs 120kg

• She wants to have her baby at home

Factors to discuss• Age: increases risk of PET, VTE• “Grand multiparity”: increases risk of VTE,

malpresentation, PPH• Weight: increases risk of macrosomia, GDM,

VTE, difficulty in fetal and maternal assessment

• Home delivery not advisable for reasons above but not illegal if she insists

• Offer GTT at 28 w and consider thromboprophylaxis

Case 3• This 24 year old is having her second

baby and had a “triple test” which showed a raised α-fetoprotein level. An ultrasound scan has been carried out at 18 weeks gestation:

The slide shows anencephaly

• The patient is referred for a second opinion in a fetal medicine unit

• The patient is advised the diagnosis is incompatible with life and is offered termination of the pregnancy with mifepristone and misoprostol

Case 4• Mrs C , aged 38y, has just found out she is

expecting twins after her ultrasound scan at 9 weeks. She has had 2 previous normal deliveries at term.

• She wants to know what this means for her pregnancy and delivery

For her:

• Greater risk of anaemia, pre-eclampsia in pregnancy

• Closer monitoring of pregnancy with ultrasound etc

• Higher risk of operative delivery

• Risk of Post-partum haemorrhage

For the babies

• Aim to distinguish between di-chorionic and mono-chorionic

• Greater risk for mono-chorionic of twin-to-twin transfusion

• Risk of pre-term labour, malposition

• Higher risk of fetal loss (x5)

Case 5• Mrs C is expecting her first baby and didn’t

know she had diabetes before she got pregnant. A GTT was arranged as she weighs 125kg and her grandmother has type 2 diabetes

• Her 2h blood sugar is 12.4mMol/l

• She is now 28 weeks pregnant. Advice, please?

She has gestational DM• Monitor blood sugars with glucometer

• Advise about diet- avoid refined carbs

• Aim for BS 4-7.8 If > 7.8 start Metformin

• If still elevated start insulin

• Monitor fetal growth (increased risk of macrosomia)

• Offer delivery 38-39w (increased risk of late stillbirth)