General early pregnancy care

Question 1

Counsel an obese patient about risks to pregnancy

Answer 1

• Maternal risks: miscarriage, GDM, PET, VTE, CS, PPH, infections, reduced BFing
• Anaesthetic difficulties
• Fetal: NTD, congenital heart disease, SGA, macrosomia, shoulder dystocia, SB
• Neonatal/long term: obesity

Question 2

Antenatal management plan for obese patient

Answer 2

First trimester

• GWG: 5-9kg
• Diet and exercise advice.
  
  • 30 mins activity/day
• Supplements: high dose folic acid, iodine
• Low dose aspirin and calcium.
• Vaccinations
• Food hygiene and safety
• Combined first trimester screening

Second trimester:

• Anatomy scan 18-20 weeks
• 24 weeks OGTT

Third trimester:

• Midtrimester bloods: FBC, ferritin, red cell antibody screen
• Serial growth scans
• Anaesthetic review.
• IOL:
  
  • Extreme obesity BMI >50: IOL 38-39/40
  • Class III obesity BMI ≥40: IOL 39/40

Intrapartum:

• Labour in hospital.
• IVL, FBC, G&H
• Confirm presentation with USS
• CEFM
• Inform OT if >120kg
• Anticipate shoulder dystocia
• Active 3rd stage management

Postpartum:

• Antenatal: weight loss prior to next pregnancy
• Breastfeeding: support
• Contraception
• DVT: clexane
• Emotional support

Question 3

Vaccination recommendations during pregnancy:

Answer 3

• Influenza:
  
  • Recommended any time.
  • Why: increased risk of maternal ICU admission and mortality. Miscarriage, IUGR, PTB, perinatal death. Passive immunity for baby up to 6 months.
• Pertussis:
  
  • Recommended from 28 weeks
  • Why: passive immunity transferred to baby to provide protection
• COVID-19 vaccination:
  
  • Any time during pregnancy
  • Why: 5 x ICU, 22 x maternal death, IUGR, PTB, PET, VTE
• Not safe in pregnancy:
  
  • Live attenuated vaccines: rubella, VZV. Avoid conception for 28 days following vaccination.