1. The Antenatal clinic Year 2 Lent Term

2. For each of the cases Think about the factors which might affect the pregnancy or labour Make some recommendations to the patient

3. 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

5. 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

6. Case 2 A 39 year old is 14 weeks pregnant with her 6 th pregnancy She weighs 120kg She wants to have her baby at home

7. 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

8. 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:

10. 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

11. 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

12. 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

13. 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)

14. 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?

15. 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)