Advanced age pregnancy

History
Doctor: Hi Jane, I'm Dr. Lea, I'm your GP for today. What brings you here today?
Jane: I'm here because I took a home pregnancy test and I'm a bit worried about the risks of
this pregnancy for me and my baby.
D: Okay, I understand you have some doubts about this pregnancy. I am here to assist you
with your doubts. I just have a few questions for you, is that alright?
J: Sure doctor.
o Period history
D: When was your last menstrual period?
J: I had it 8 weeks ago.
D: Is your cycle regular? Do you have any problems with your periods?
J: Yes, my cycles are regular. No problems with my period.
o Social history
D: Do you have a stable partner right now?
J: No, I broke up with my partner 6 months ago, I thought we were going steady, but
things didn't really work out.
D: Okay, but you are willing to continue with this pregnancy?
J: Yes doctor, as long as I get the assurance from you that it is safe for me to carry on
with this pregnancy.
D: Do you have someone to support you during this pregnancy?
J: Yes, my mother and sister lives nearby. I could rely on them to help me through this
pregnancy.
(If no support, D: I will refer you to a social worker who could help you find support
for your during your pregnancy)
D: How are your finances? Will you be able to support yourself for this pregnancy?
J: Yes, I have a stable job, and it provides adequately for my needs.
(If no finances, D: I will refer you to Centrelink who can assist you with money matters
that could help you during your pregnancy)
o Sexual history
D: Do you have any history sexually transmitted infections?
J: No doctor.
D: When was you last pap smear and what was the result?
J: I had it last year, results were normal.
D: Were you using any contraceptives before?
J: I was using combined OCPs before, but I stopped it a year ago because I thought I
wouldn't get pregnant anymore
o General wellbeing
D: How is your diet and exercise?
J: I eat moderately, but I'm mostly just sedentary, doing my office job.
D: Sensible, regular, non-contact exercise is also important, let's arrange for another
session to talk about lifestyle modifications. Do you smoke, drink alcohol, or take
recreational drugs, take any medications or over the counter medications?
J: No doctor, none of those.
o SADMA
 D: Do you smoke, drink alcohol, take any recreational drugs, medications or over the
counter medications or any allergies?
J: No I don't smoke or take drugs or medications, but I drink occasionally.
D: Alright, remember that drinking alcohol is not safe during pregnancy, so no alcohol
while you're pregnant okay?
Thank you for the information Jane, I'll just talk to my examiner.
D: Any history of medical or surgical illness?
J: No doctor, I've been pretty healthy.
D: Do you have any family history of birth defects?
J: No doctor.
▪ Physical Exam
D: (to examiner): What is the BP, PR, RR, temp and O2 sat of my patient? What is her BMI?
E: BP is 110/80, PR 80, RR, 15, temp 36.8, sats 99% room air. BMI is 24.
▪ Diagnosis and Management
D: (to patient) Okay Jane, I would just like to do an office pregnancy test for you just to
confirm your pregnancy.
D: (to examiner): I would like to know the results of the pregnancy test.
E: Pregnancy test result is positive.
D: (to patient): Okay, now that we've confirmed your pregnancy, I would like to arrange
some blood tests for you: FBE, blood group and Rh factor, BSL, urine dipstick and urine
microscopy culture and sensitivity, UEC, vitamin D estimation, rubella, varicella serology and
STI screening.
because of your advanced age, I will need to refer you to the high risk pregnancy clinic
where you will be seen by the obstetrician and you will have regular antenatal checks every
8 weeks during the 1st trimester, every 4 weeks upto 28 weeks, every 2 weeks upto 36
weeks, and every week upto your delivery. During each visit, weight and BP will be recorded
so any alterations will be noted.
I will also start you on folic acid 0.5mg for the next three months. You don't have to worry
so much because many women at your age go through a normal pregnancy and delivery. It
is not automatic that you or the baby will have complications. But since you are concerned, I
could tell you more about that.
For you, in your early stages of pregnancy, you can have a miscarriage or an ectopic
pregnancy, a condition where the fertilized egg is lodged elsewhere in your reproductive
tract other than the uterus where it should normally be.

However,an ultrasound at 8 weeks called a dating scan will be done to confirm your dates
and also rule out an ectopic pregnancy. You can also have pre-eclampsia, a condition where
there is a sharp rise in blood pressure, weight gain and kidney stress which shows up as
protein in the urine; gestational diabetes mellitus, or placenta previa. Placenta is the part
that connects you to your baby. It is normally at the upper pole, but when it attaches to the
lower part, it could lead to bleeding.

Towards the end of your pregnancy, you can have preterm labor, prolonged labor, or
increased chance of induction or C-sections.
For the baby, he/she can have a risk for heart defects, kidney defects, neural tube defects
which are defects in the spinal cord and the brain.
However, the most important complication is Down syndrome. With increasing age,
chances of down syndrome also increase. It’s one of the commonest genetic defects in the
baby. But Don’t worry we can easily detect that by doing some hormonal tests and
procedures. We will do some screening test and diagnostic test during your 1st and 2nd
trimester to find that out. Screening test: Hormone and Nuchal translucency.
There are two diagnostic tests: chorionic villus sampling or CVS and amniocentesis. (CVS is
done between 11-14 weeks. A needle guided by ultrasound will be passed from down below
and a portion of the placenta will be taken and analyzed for chromosomal/genetic defects.
Risk for miscarriage is associated with this procedure, about 1 in 100. Amniocentesis is done
between 15-18 weeks. A needle guided by ultrasound is passed into your tummy to your
womb and a portion of fluid in the bag surrounding the baby will be taken and analyzed for
genetic defects. Risk for miscarriage is 1 in 200. )
Other than those, for a healthy pregnancy I advise you to take a healthy balanced diet rich in
fruits, vegetable, cereals and bread, drink ample amount of fluid about 2 liters per day, and
adopt a sensible, regular and non-contact exercise. Take your folic acid regularly. I'll arrange
a review with you once your blood test results are in. If you experience any unusual pain or
bleeding, call for an ambulance immediately. I will also give you reading materials for your
further information. Do you have any other questions?
J: Doctor what is the chance of me getting a baby with Down syndrome in a next pregnancy?
D: The risk is that of the risk for your age plus 1%. For example at 40 years old, the risk is 1%,
so the risk for a Down syndrome baby in your next pregnancy is 2%.
J: Thank you doctor.
D: Thank you, Jane. I'll see you on our next review.
 Twin Pregnancy
32 year old Mary attends your GP clinic. She is 20 weeks pregnant and has come to discuss the results of
the ultrasound scan that she did 1 week ago. The ultrasound showed a twin pregnancy with each fetus
having a separate amnion and chorion.

TASKS
1. Take a further relevant history
2. Explain the ultrasound results to her
3. Discuss your further management regarding her pregnancy

APPROACH
▪ History
o Was this a planned pregnancy? Is this your first pregnancy?
o Was this a natural conception, or did you go in for artificial methods of conception?
o How is your pregnancy going so far?
o Are you experiencing any problems such as tummy pain, bleeding from down below,
burning or stinging on passing urine, fatigue, headache, blurring of vision & swelling,
fever/malaise?
o Have you started feeling the babies kicking?
o During the early weeks of pregnancy, any exaggerated vomiting, any nausea?
o Did you do all your antenatal tests? How were the results?
▪ Routine first visit tests
o FBE
o Blood group and antibody screen
o Rubella antibody status
o Syphilis serology
o Midstream urine
o Chlamydia
o HIV
o Hepatitis B and C serology
o Varicella
o Cervical cytology/Pap smear
o Screening for Down syndrome (if >35 years old)
▪ Ultrasound at 18 to 20 weeks?
o General well-being questions:
▪ Are you taking your folic acid? When did you start taking it? (folic acid 0.5mg/day 3
months before and 3 months after)
▪ Are you eating a healthy balanced diet? Do you drink a lot of fluids?
▪ Are you taking any vitamin or mineral supplementation?
▪ Any change in appetite? Have you noticed weight gain/loss?
▪ Do you have a regular exercise routine?
▪ Do you open your bowels regularly? Any problems with your bowels?
▪ Are your influenza and pertussis vaccinations up to date?
 o Any family history of multiple pregnancy?
o SADMA
▪ Do you smoke?
o How long have you been smoking? How many per day?
▪ Do you drink alcohol?
o What kind? How often? How much per session?
▪ Do you take any recreational drugs?
o What kind? How often?
▪ Do you take any prescription or over the counter medications?
o What medication? For what reason? Who prescribed it?
▪ Do you have any known allergies?
o Do you take any medications for this?
o Any past history of any medical illness especially clotting problems (thromboembolic
disease), diabetes, epilepsy, thyroid problems, or high blood pressure?
o Do you have good support?
o Have you done your pap smear? What were the results?

▪ Diagnosis and Management

How are you feeling about your pregnancy?
There are different types of twin pregnancies. The type that you are having is more favorable
because each of the babies has a separate placenta as well as a separate bag of its own. These are
actually independent twin pregnancies, and usually carries a better prognosis. It is very likely that
these could be non-identical twins.
I know that you are a bit concerned about this pregnancy, but let me reassure you that many
women who have twin pregnancies go through a normal pregnancy and will have healthy, normal
babies. But we need to monitor you as well as the babies for certain complications. The
complications we have to look out for you are first, anemia, you can feel a bit tired and exhausted
as the pregnancy goes by; there is also a risk of high blood pressure and pre-eclamptic toxemia
where there is a sharp rise in blood pressure with leakage of proteins into the urine; there is also a
higher chance of developing Diabetes during pregnancy; also as your tummy will be a bigger
towards the end of your pregnancy, you may feel a little short of breath and experience back pain;
you may also have antepartum hemorrhage or bleeding during pregnancy, cord prolapse, and a
greater risk of postpartum hemorrhage. The complications in the babies are: low birth weight,
intrauterine growth retardation of one baby, birth defects, and malpresentation. But we will
monitor you and your babies for these complications. I will refer you to the high risk pregnancy
clinic for better management. You need to go for more frequent antenatal checks: every 2 weeks
until 28 weeks and weekly until you deliver. During each visit, your weight will be recorded and
your BP will be monitored. A sweet drink test will be done at 28 weeks to check for any
Gestational Diabetes, a repeat blood test to check for anemia, ultrasound screening every 2
weeks from 28 weeks, CTG to look at the wellbeing of the baby twice a week from 34 weeks, and
a bug test will be done as well.
Delivery will be planned at 38 weeks. There are two options for you: one is to do a C-section, and
two is a normal vaginal delivery. However, normal vaginal delivery can be done only if certain
criteria are met:
o The first baby should be in cephalic presentation
o The second baby should be less than 500 grams compared to the first baby (if the second
baby is big, it will obstruct the passage of the first baby)
 The delivery should be done in a tertiary hospital, under the guidance of a specialist. Continuous
monitoring of the babies will be done via CTG during the delivery.
How far are you living from the hospital?
It is better to stay near to the hospital during the last weeks of pregnancy because there is a
greater chance of you going into premature labor because of this twin pregnancy.
You need to take a healthy balanced diet, and take iron, calcium and folic acid supplements.
Just in case you develop tummy pain, bleeding and excessive discharge from down below, blurring
of vision, headache, excessive vomiting, regular painful contractions, please go to the ED
immediately.
It is always advisable to maintain kick charts for the baby as well so we can monitor the wellbeing
of the baby.

Gestational Diabetes
Your next patient at your GP is 29year old, who is 28 weeks pregnant. She returns to you for the results
of GCT done 2 days back. The value of plasma glucose level in GCT is 9.1 mmol/L after 1 hour.

TASKS
1. Further relevant history
2. Explain result to the patient
3. Further management

APPROACH

▪ History
▪ Greet the patient
▪ Congratulate
▪ Start with general pregnancy related questions
o How is your pregnancy going so far? Any issues in your pregnancy? Any tummy pain? Any
bleeding or discharge from down below? Is the baby kicking well?
o Diabetes questions: Any symptoms of frequent urination? Do you feel more thirsty
nowadays? Any recurrent skin or vaginal infections? Any numbness or tingling sensation in
your extremities?
o Pre-eclampsia questions: any headaches, blurring of vision, edema or swelling?
o Routine antenatal history: Any blood test and blood group done? Down syndrome
screening? Folic acid? Ultrasound at 18 weeks? Any complications in the position of the
placenta?
 o How is your diet? Activity and exercise?
o Any smoking, alcohol?
o Do you have good support?
o Any other medical and surgical illness? Any medications?
o Any family history of diabetes?

▪ Management
The results of the sweet drink test, the value is a bit high which could be due to a condition called
gestational diabetes. That is when your blood sugar level goes high during pregnancy. But the test
that we did for you is just a screening test, so we need to do a confirmatory or diagnostic test now
called the glucose tolerance test, which will tell with certainty if you have gestational diabetes or
not.

You need to come for this test after fasting, and a blood sample will be taken. You will then be
given a sweet drink and then blood samples will again be collected at 1 hour and 2 hour intervals.
Any one of these values come out abnormal, the GTT is considered to be positive.

During pregnancy, the placenta secretes certain hormones like human placental lactogen, beta
HCG, and cortisol, all of which has got anti-insulin properties. And insulin is the hormone that
keeps your blood sugar level under control. Usually during pregnancy, your production of insulin is
heightened up, however in your case, it isn't the case.

If your blood sugar doesn’t get controlled, complications can happen in your or the baby.
Complications for you include polyhydramnios. This is a condition where the fluid in the bag
surrounding the baby becomes high. Due to this, you could also go into preterm labor or
premature rupture of membranes, or membranes rupture before labor pains sets in. There is also
increased chance of induction or C-section. Another complication is pre-eclampsia, which is a
condition where there is a sharp rise in blood pressure with leakage of proteins in the urine. Next
is placental abruption, which is a condition where the placenta separates from the womb resulting
in bleeding.

In your baby, complications include macrosomia or big baby. He can also have birth defects like
neural tube or nervous system defects, heart defects, and vertebral defects. And if the blood sugar
level gets uncontrolled for a long time, the baby can even go for intrauterine growth retardation.
There can be complications after birth as well, such as low blood sugar levels in the baby. He can
also develop respiratory distress syndrome or difficulty in breathing, and a high incidence of
jaundice or yellowing of the skin.

It is still possible to avoid these complications as long as we keep your blood sugar level under
control. I will refer you to the high pregnancy clinic where you will be seen by the obstetrician, the
diabetic physician, the dietician and the diabetic educator.

The first thing to do is a strict diet control for 2 weeks. You will be given a diet chart by the
dietician and you need to monitor your blood sugar level 3-4 times a day, and record that in a
diary. Your aim is to maintain the blood sugar level between 4-6 mmol/litre before meals. If the
diet control is not working, the diabetic physician will decide to start you on insulin. Again, you
have to monitor your blood sugar level 3-4 times/day. You will monitor you blood sugar using a
 glucometer. This and the proper administration of insulin will be taught to you by the diabetic
educator. You will be monitored for diabetic control by doing an HbA1c. You may also be seen by
the ophthalmologist and the nephrologist if necessary.

You need to have weekly antenatal checks from 30 weeks, ultrasound at 32 weeks and then 4
weekly, CTG weekly from 32 weeks.

You can go in for a normal vaginal delivery if everything goes on well with her antenatal checks,
but it should be at term at the latest. During delivery, your blood sugars will be checked
intermittently and insulin injections will be given as needed. The baby will be monitored by
continuous CTG.

After delivery, there is a high chance that your blood sugar level will come back to normal because
the hormones present during pregnancy will now be gone. You can already stop insulin injections
when that happens. Your baby however will be checked by the pediatrician and monitored for low
blood sugar levels.
Once you have gestational diabetes, there is a 30-60% chance, that you could develop diabetes
later in life. We will repeat an OGTT, 6 weeks after delivery, and then a blood sugar level 3 yearly.

Epilepsy in pregnancy

26 year old who is a known epileptic, presents to your GP clinic for advice regarding her chances and
preparation to become pregnant. She is on sodium valproate, and had been seizure free for the last 2
years.

TASKS
1. Counsel the patient appropriately

APPROACH
▪ History
Doctor: Hi Laura! I'm Dr.X, one of the GPs in this clinic, what can I help you with today?
Laura: Doctor I've been epileptic for the past 5 years, I would like to ask for some advice
regarding my chances and preparation for pregnancy.
D: I see Laura, I'm happy to help you with that, but I'll have you answer some questions
beforehand, is that alright?
L: Sure doctor.
D: You said you've been diagnosed with epilepsy for 5 years, do you know what type?
 L: My doctor said it's a focal epilepsy.
D: Okay, when did you last see your neurologist? Do you go for regular checks? What was
his last advice to you?
L: Yes doctor, I see him regularly. He started me on this medication, Na Valproate, and it's
been doing well for me. I've been seizure-free for 2 years now.
D: Alright. Has this been your medication or usual dose ever since? Do you experience any
side effects with this drug?
L: Yeah. It's been this since the start, no side effects.
o Period history
D: Okay, when was your last menstrual period?
L: It was 3 weeks ago.
D: Is it regular? Normal length of cycles?
L: Yes.
D: Is it a mild, moderate, or severe bleeding during periods? Do you experience pain
or clots during your periods?
L: Just a moderate bleed, no problems.
o Sexual history
D: Are you currently sexually active? Do you have a stable partner?
L: Yes, my boyfriend and I have been together for 3 years.
D: Do you use any form of contraception?
L: Yes, I used combined OCPs in high dose because of my medication.
D: Alright. Do you have any previous miscarriages or pregnancies?
L: No.
D: Any history of sexually transmitted infections? When was your last pap smear and
what was the result?
L: No. It was 1 year ago, result is normal.
o SADMA
D: Do you smoke, drink alcohol or use any recreational drugs?
L: No.
D: Alright. Have you been diagnosed with any medical or surgical illness in the past
other than your epilepsy? Do you take any other medications or over the counter
medications?
L: No.
▪ Diagnosis and Management
D: Alright, thank you for those information, Laura. As for your doubts regarding your
chances and preparation for pregnancy considering your condition, it would be reassuring
for you to know that 80 - 90% of people with epilepsy go through a normal pregnancy and
delivery. The chance of you having a seizure during pregnancy is only around 10 - 20%, and
risk during labor is only 1 - 2%. Aside from that, you've mentioned that you have been
seizure-free for 2 years which is in fact one of the criteria we consider for planning for
pregnancy in epilepsy.
There could be certain complications for you and the baby due to the antiepileptic
medications that you are taking or just in case you experience a seizure attack. You may
experience vaginal bleeding especially in the 3rd trimester as antiepileptic medications
decrease vitamin K in your blood which is necessary for blood clotting. You may also
experience a condition we call abruptio placenta. Normally placenta separates from the
womb after the baby's delivery, but just in case it happens during pregnancy, this is abruptio
placenta. There could be pain and bleeding and the baby could also become unwell. Another
complication is preterm labor or labor before 37 weeks or premature rupture of the bag of
water, and increased risk of induction and C-section.
Complications in the baby is mainly neural tube defects or defects in the brain and spinal
cord, heart and skeletal malformations, intrauterine growth retardation, and if you go into
premature labor, prematurity of the baby. Once the baby is born, the baby can have a
condition called hemorrhagic disease of the newborn or bleeding tendencies because of the
decrease in vitamin K.
D: When are you planning to get pregnant Laura?
L: Probably 7 months from now, doctor.
D: Alright, that's a fair amount of time to prepare. So before you get pregnant, I will refer
you to the neurologist who will do one of three things, either 1, a supervised safe
withdrawal of medication over 3 to 6 months; or 2, if stopping the medication is not
possible, a change in medications from sodium valproate to any new generation anti-
epileptic like lamotrigine which carries the risk of less birth defects in the baby compared to
sodium valproate; or 3, if medication cannot be changes from sodium valproate, the
neurologist will keep the medication below 1g/day, because above 1 g/day, it carries a high
risk of birth defects to the baby. I will also start you on high dose folic acid 5g/day 3 months
before you get pregnant and 3 months after you get pregnant. I will also do your antenatal
blood checks now like FBE, blood group and Rh factor, BSL, urine dipstick and urine
microscopy culture and sensitivity, UEC, vitamin D estimation, rubella, varicella serology and
STI screening.
Once you become pregnant, I will refer you to high risk pregnancy clinic where you will be
seen by the neurologist, obstetrician and me as your GP. You should continue taking your
antiepileptic medication as well if it is indicated by the neurologist. Your baby will be
monitored for neural tube defects or defects in the spinal cord and brain by looking at the
AFP in your blood at around 16 - 20 weeks, and an ultrasound at 18 and 34 weeks to look for
acrania or absence of skull bones. Detection rate of these tests is around 95%. You will also
take the sweet drink test at 26 weeks, bug test at 36 weeks, and blood levels of the
medication will be monitored once in each trimester. I will start you on vitamin K, 20mg/day
orally during the last month of your pregnancy.
If everything goes well for you and the baby, you could attempt for a normal vaginal delivery
but it should be in a tertiary hospital under specialist guidance. You and the baby will be
continuously monitored during the delivery. Your baby will then be checked by the
pediatrician after delivery and will be given vitamin K injection 1mg to prevent bleeding. You
are encouraged to breastfeed your baby since only small amounts of the medication are
secreted in breast milk.
The risk of your baby having epilepsy is slightly higher in general population which is 3-3.5%.
I will give you reading materials for further information and will arrange a review with you
after your neurologist consult. Do you have any other questions at this point, Laura?
L: None doctor, thank you very much.
D: Thank you Laura, I'll see you next time.
 Elective induction of labor

24 years old presents to your GP clinic. She is 35 weeks pregnant and requests you to induce labor in her
as her husband is leaving overseas on a business trip.

TASKS
1. Relevant history
2. Examination findings from examiner
3. Respond to patient request

APPROACH
▪ History
o When is your husband leaving?
o Do you have enough support?
o Antenatal history
o Any headache, swelling, blurring of vision
o Any medical or surgical issues?
o Have you done your pap smear? What was the result?
o Is the baby kicking well?

Please ask all Obstetrics Question in the history.

▪ Physical exam
o General appearance: pallor, edema
o Vital signs: BP, temperature
o Abdomen: fundal height (35cm), fetal heart rate (normal), fetal lie, fetal presentation
(cephalic)
o Pelvic exam:
o Office tests

▪ Management
I can clearly imagine the concerns of your husband, the time of delivery is very important as he is
one of the best persons who can offer you psychological support at that time. Have you had a
discussion with your husband if he could delay his trip for 8 weeks? With you consent can I have a
discussion with your husband? (the patient says that it is not possible for the husband to delay his
trip)
Induction of labor needs to be considered when the risk benefit analysis indicates that delivering
the baby is a safer option for the baby, mom or both, rather than continuing the pregnancy and
when there are no indications for a C-section or contraindications for a vaginal delivery. Induction
of labor is not an easy or a quick procedure. It has several complicated steps.
The conditions where an induction of labor is done is:
In the mom:
o If it is a post-date pregnancy
o Has premature rupture of membranes (do IOL after 36 completed weeks)
 o Maternal conditions like uncontrolled high blood pressure, diabetes
In the baby:
o If the baby is not growing well or has IUGR
o Has infections like chorioamnionitis where the membranes around the baby gets infected
There are also contraindications for inductions of labor is:
o A big baby
o Abnormal presentation of the baby (oblique or transverse)
o Previous 2 C-sections
o A classical or vertical C-section
The risks associated with IOL are:
o Induction of labor can fail, necessitating an emergency C-section
o When you do the artificial rupturing of the membranes, the cord can sometimes relapse, or
the cord can become compressed between the birth canal and the baby's head, thereby
decreasing the oxygen supply to the baby
o The medications that we use to induce labor can cause a non-rhythmic contractions of the
uterus which can lead to uterine damage to the muscles that support the pelvis, uterus, and
vagina predisposing to incontinence and prolapse.
o After IOL, there is a chance of post-partum hemorrhage or excessive bleed as the uterus
might not contract properly
The most important complication is in the baby:
o Prematurity in the baby is another complication of early IOL
o The baby can develop breathing difficulties, feeding difficulties, difficulty in maintaining the
blood sugar levels of the baby and the body temperature
The more that the baby is inside the womb, the better the outcomes of delivery. So induction of
labor is not most appropriate for you and the baby. Inducing labor involves making your baby and
your body do something that it is not yet ready to do. So having said that, induction of labor is not
indicated for social reasons.
I can give you reading materials regarding induction of labor and the complications associated
with that, and you can even give a medical certificate to the husband with her consent.

One of her friends had an IOL at 35 weeks, and she and her baby are well: there may be
indications in her that necessitated IOL, that is why it was done. But we never do an IOL for social
reasons.
 Postpartum Pyrexia – Mastitis

28years old mom of a 5week old baby, comes to your GP with complaints of tiredness and fever since
the past 2 days.

TASKS
1. Focused history
2. PE from examiner
3. Diagnosis and Management

Differential Diagnosis:
▪ Breast: Mastitis/Breast abscess
▪ Birth canal: endometritis, episiotomy wounds, laceration that has become infected
▪ Bladder: UTI
▪ URTI
▪ DVT

Positive points in the history: 2 days history of symptoms, continuous fever, no rash, can feel a lump in
the right breast, lump has been there for the past 2 days, slowly increasing in size, painful when she
touches the lump, it is warm, the nipple feels a bit sore,
Positive points in the PE: positive lymph nodes in the right axilla, tender, temp 38, abdomen soft and
non-tender, lump at the upper inner quadrant of the right breast, skin over the lump is reddish, local rise
of temperature over the area, regular borders, consistency is firm, mobile lump, normal uterine size

APPROACH
▪ History
o Congratulations on the pregnancy. How is your baby doing?
o Since how long are you having the fever? Is it a continuous fever or an on and off fever?
Have you recorded the temperature? Any rash? Any runny nose, cough or colds?
o Are you breastfeeding your baby? Any problems with breastfeeding? Any lumps that you
have in your breast? How long have you been feeling the lump? Is the lump increasing in
size? Is it warm and painful to touch? Any other lumps that you can feel in the same breast
or in the opposite breast? Do you have a sore or cracked nipple on that side? Any blood-
stained or purulent discharge from the nipple? Is the baby being positioned to the breast
correctly? Has somebody taught you the correct positioning of the baby during
breastfeeding?
o Did you have any conditions during your pregnancy or was your pregnancy uneventful?
What type of pregnancy did you have? Any cuts made down below? Any tears that you had
at the time of delivery? Any abnormal foul smelling discharge from down below? Have you
stopped bleeding? Are you having any tummy pain?
o Any burning or stinging while passing urine? Any chills or rigor? Any constipation that you
are having? Do you open your bowels regularly?
o Any calf pain or swelling?
 o Rule out depression: Do you have a good support from your partner to look after the baby?
Are you enjoying your motherhood?
o Do you eat a healthy diet?
o Do you smoke, drink alcohol or take recreational drugs?
o Have you done your pap smear? What was the result?
o Any medical or surgical conditions in the past?

▪ Physical Exam
o General appearance: pallor, edema, lymphadenopathy, is it tender? dehydration
o Vital signs: temperature
o Breast: compare right with the left breast, look for any visible lumps in the right breast, size,
shape of the lump, color of the skin over the lump, inspect the nipples for any cracked
nipple, palpate for local rise in temperature, confirm the site, palpate the borders if well-
defined or not, palpate the consistency, mobility of the lump, any fluctuations, examine the
same breast for any other lumps, and the opposite breast as well
o Abdomen: any abnormal distention, any mass, on palpation, do you still feel the uterus in
the tummy or has it involuted already? Any other mass or tenderness in the tummy?
Auscultate for the bowel sounds
o Pelvic exam
• Inspection of the vulva and vagina: abnormal discharge, bleed, episiotomy wounds or
lacerations
• Speculum: cervix healthy or not, OS open or closed, discharge or bleed from the cervix
• Per vaginal exam: uterine size, CMT, tenderness, adnexal mass and tenderness
o Office test: UDT, BSL

▪ Diagnosis and Management

Most likely you've got a condition called Mastitis of the right breast. This is the cause of your fever
and tiredness. Mastitis is an infection of the interlobular connective tissue of the breast caused by
bacteria, and the bacteria that usually causes this is staph and e. coli.
Where did these bugs come from? It usually enters into the breast if there are any cracks in the
nipple, from the baby's mouth or from the surrounding area of your skin and this condition will
worsen if there is poor milk drainage from the affected breast. The usual cause of the cracked
nipple is due to poor positioning of the baby to the breast.
You need to continue breastfeeding from the affected side, the milk is not affected by the bugs,
and if any bugs come in contact with the milk, the bugs will be neutralized by the baby's tummy.
Put the baby on the affected side first so the breast will be drained completely. Before
breastfeeding, you can put some hot washers on the breast, so that the milk ducts will dilate, and
during breastfeeding, you can massage the lumps towards the nipple. And after breastfeeding,
you can put some cold washers on the breast. Take plenty of fluids, and take adequate rest.
I need to put you on antibiotics such as cephalexin, or flucloxacillin 500mg QID, for 7-10 days, and
analgesics such as Panadol. I will give you reading materials regarding proper breastfeeding
techniques.
Just in case that there is no improvement in your symptoms, the lump is increasing in size,
becomes more painful, you have high spikes of temperature, report to ED immediately. I will
arrange review with you in 1 weeks time.

Breast abscess management:

 Do an ultrasound if you have doubts whether it is mastitis or breast abscess. If it is breast abscess,
she required referral to the hospital.
If it is a small breast abscess: do an aspiration of the abscess
If it is reasonably big: do surgical drainage under anesthesia
Curve-like incision over the breast to drain the abscess. Discharge will be sent for microscopic
culture and sensitivity. Put in a drain for 2 days.
Antibiotics and painkillers. Go in for a temporary weaning from breastfeeding. Make sure the
breast is empty by using a breast pump.

Mobile head at term

Jane who is 28 years, who is 40 weeks pregnant is referred to you at your GP by the midwife as the
midwife is concerned that the baby's head is not getting engaged.

TASKS:
1. Further history
2. Examination findings from the examiner
3. Management with the patient

Causes of mobile head:

▪ Occipitoposterior position
▪ Cephalopelvic disproportion
o Big baby
o Birth defects in the baby
o Pelvic bone deformities (osteomalacia, Rickets)
o Uterine abnormalities
o Fibroids
▪ Polyhydramnios
▪ Placenta previa

Positive points in the history: all normal

Positive points in the PE/Investigations: fundal height is 40cm, FHR normal, longitudinal lie with
cephalic presentation, baby's head is 2-3 cm above the pelvic brim,

APPROACH
▪ History
o How is your pregnancy so far? Is this your first pregnancy? (key point) any tummy pain, any
bleeding or discharge from down below? Is the baby kicking well?
o Antenatal history:
 • Do you go for regular antenatal checks?
• Blood group and Rh? Have you had your blood checks done?
• Ultrasound at 18 weeks? Repeat ultrasound at 32 weeks? Is it a single baby? Any birth
defects in the baby? Have they commented on the position of the placenta? Any
excess fluid in the bag surrounding the baby? Any benign growths or fibroids in the
uterus?
• Sweet drink test at 26/28 weeks? Bug test at 36 weeks?
o Any headache, blurring of vision, any swelling? (preeclampsia symptoms)
o Any other medical or surgical illness? Any medications taken?
o Do you have a good support?
o Do you smoke, drink alcohol or take recreational drugs?

▪ Physical Exam
o General appearance: pallor, LN
o Vital signs: BP
o Abdomen: fundal height, FHR, lie and presentation, is the baby's head engaged or not? (key
point)
o Pelvic exam:
• Inspection of the vulva and vagina: bleed, discharge, rash, vesicles
• Speculum: os is open or closed? Discharge or bleed from the cervix?
• Don't go in for a per vaginal exam as a GP
o Office test: UDT (rule out proteins), BSL

▪ Diagnosis and Management

From the history and examination, I can see that the baby's head is still not engaged, or it has not
gone into the pelvis. Usually we expect the baby's head to get engaged by 36-38 weeks, if it is a
first pregnancy thereby preparing the baby to come out during labor. At the moment, many
pregnant women whose baby's head has not yet engaged, when they go into labor, because of the
uterine contractions, the baby's head will get engaged eventually and will have a normal vaginal
delivery. But, there could be certain conditions which can prevent the baby's head from getting
engaged and one of the most common causes is an occipitoposterior position. Normally, the
position of the baby is occipitoanterior when the back of your baby's head will be towards your
front. However, in occipitoposterior, it is the oppositive, the back of the baby's head is towards
your back as well. Because of this, the baby usually has a de-flexed head or the baby cannot tuck
his chin towards his chest. The de-flexed head presents into the pelvis, with a wider diameter,
making it more challenging to descend. Even if the baby is in an occipitoposterior position, you can
still have a normal vaginal delivery, but the delivery will be a bit prolonged.
You will be given adequate and proper hydration and excellent pain relief during that time. But
just in case the labor does not progress well, or if the baby becomes unwell, then a C-section
needs to be done. Another possibility is a cephalopelvic disproportion, which could be due to a big
baby or a narrow birth canal. Also, polyhydramnios could be a possibility where there is a lot of
fluid surrounding the baby, but unlikely in your case because your fundal height corresponds to
your gestational age. It can also be due to a placenta previa, when the placenta gets attached to
the lower pole of uterus preventing the baby's head from coming down, but unlikely also in your
case as this should have been detected during your repeat ultrasound, and usually the delivery
should have been done by around 37/38 weeks by C-section. Another possibility is fibroids, but
this should have been detected as well by the ultrasound. What I think is that the head might go
down within the next few days. I would like to refer you to the specialist. Have an ultrasound
 done, to find the cause if any. And also if the pregnancy is prolonging beyond 40 weeks, then a
Doppler ultrasound needs to be done as well to check the placental perfusion because after 40
weeks, the blood supply in the placenta can be interfered or there can be placental calcification.
CTG should be done now, and also 2 times per week if the pregnancy is progressing. You will
checked for cephalopelvic disproportion by the specialist. If it is positive, then delivery will be
done by C-section. Meanwhile, maintain baby kick charts. And just in case you develop any tummy
pain, any bleeding or discharge from down below or if you think that the baby is not kicking well,
please report to the ED immediately. I will give you reading materials regarding mobile head at
term. I will arrange a review with you after you are seen by the specialist.

Vaginal Birth after Caesarean Section

Case: your next patient at your GP is Jenny, a 28 year old lady, who had previous delivery by CS 2 years
back. She's 8 weeks pregnant now, and wants to discuss about possibilities of having a vaginal birth this
time.

TASKS
1. Take relevant history
2. Ask examiner for previous medical and surgical notes of the C-section
3. Discuss possibility of a vaginal birth this time with the patient

C section: maximum of 3 C sections

▪ Can't advise a vaginal birth after 2CS procedures
▪ Type of C-section is important
▪ Must ask for the baby's weight: may have CPD ==> narrow pelvis ==> cannot go for a VBAC
▪ History of other uterine/pelvic surgeries

Advantages of vaginal birth

▪ Can have any number of deliveries
▪ Shorter stay in the hospital
▪ Pain duration will be less

History: current

APPROACH
▪ History
o I read from my notes that you are 8 weeks pregnant, is this a planned pregnancy for you?
Congratulate her
o How did you confirm your pregnancy? Home pregnancy test, no antenatal checks so far ==>
confirm the pregnancy!
• I will do a confirmatory office PT as well
o When did you have your LMP? 8 weeks ago
o Are your periods regular?
o Do you have any breast tenderness? Morning sickness? Yes
 o How long have you been off your contraception?
o Do you have any tummy pain, or bleeding, or discharge from down below?
o How's your diet? Do you regularly exercise?
o SADMA
o I have read that you had a previous C section done. When was it done? 2 years ago
• Was it an elective or emergency C section? Emergency C-section was done
• Why was it done? Sort of obstruction during the labor
▪ Think of CPD! Do you know the weight of your baby at birth? 4.2kg
• What type of C-section was done on you? [draw a photo]
▪ The scar is along the lower border: bikini cut ==> likely a transverse C section
• Did you have any complications during your previous pregnancy? Like high blood
pressure or diabetes that you had?
• Did you have any complications after the surgery like any excessive bleeding?
Infections? Or any complications? Clotting in your veins?
• Did you have any other surgeries done on your womb apart from the c section? None
o Do you have enough support for this pregnancy
o PMH
o FH

• Examiner
o What is the reason for the c section: obstructed second stage of labor
o What is the cause of the obstructed labor? Was there any cephalopelvic disproportion
[KEYPOINT]: the baby was big, but the pelvis was adequate
o At what gestational age was the C-section done?
o What is the type of C-section done? [key point]: low uterine segment
• Vertical ==> high risk of rupture
o Any complications during or after surgery?
o How long until the patient was discharged from the hospital (normally should be 3 days)
o Any previous uterine/pelvic surgeries done to her? [key point]
o How was the condition of the baby after birth?

• Counselling
o Vaginal birth after a c section is an option for all women who had a previous c section
provided that the indication of the previous c section does not recur and in many women,
successful vaginal birth could be achieved safely for both mom and the baby. The success
rate of vaginal birth after c section is 55-85%.
o In your case the previous c section was done as the baby was a little big and your labor was
not progressing smoothly. But this is not a recurring condition and your baby might not be
that big this time. And from the notes, your pelvis is not narrowed but quite roomy as well.
At present, you do not have any contraindications for the vaginal birth, and other points in
favor for it is the type of C-section, which is a lower segment C section, and also you don't
have any previous uterine surgeries.
o You are in the early weeks of pregnancy now, and as the pregnancy progresses, if any
complications develop in you like uncontrollable high blood pressure, diabetes, or bleeding
during pregnancy, placenta previa, then a C-section needs to be considered again. Also
certain complications in the baby like the big weight of the baby, or any abnormal
presentation or lie of the baby in the womb can also lead to a C-section.
 o There are certain advantages of the vaginal birth over the C-section. It avoids the risk of C-
section like complications of anesthesia, excessive bleeding, infection of the womb, and also
injury to other organs. The pain during the delivery will be short, and also you will have a
shorter duration of stay in the hospital.
o [Key point] If you have one successful vaginal birth after a C-section, you can go in for any
number of vaginal births afterwards.
o VBAC carries risks as well. These include failure of the vaginal birth which will necessitate an
emergency C-section, and there is a risk of scar rupture (1:200), and a chance to develop
endometritis or infection of the womb. Repeated C-sections can lead to placenta accreta, a
condition where the placenta grows deep into the C-section scar of your womb. If you have
one more C-section, the next deliveries should always be by C-section and it is advisable not
to have more than 3 C-sections.

• Further Management
o Confirm management
o Do all antenatal blood checks
o Start on folic acid
o Advice regarding down syndrome screening
o Needs to go for a shared antenatal care with ultrasound done at 18 and 32 weeks, sweet
drink test at 26-28 weeks. During each visit you will be monitored for any complications.
And if any complications happen, you will be managed at the high risk pregnancy clinic.
o [KEYPOINT] I need to arrange for a specialist consultation at 26 weeks for discussion about
the possible mode of delivery, and another at 36 weeks for a definite decision.
o During delivery, you and the baby will be continuously monitored and the delivery should be
done in a tertiary hospital, under specialist guidance. You can also have excellent pain relief
options like an epidural at the time of delivery. You will be continuously watched for any
possible rupture due to the previous CS you had.
o Here are reading materials regarding VBAC to give you more insight about this.
o Please observe to eat a healthy diet, and engage in regular exercise. Please avoid smoking,
alcohol, or recreational drug use.
o I will arrange a review with you once your blood tests are out
o Are you happy with this plan?

o HOME VBAC: not usually advised. Only if it is supervised by a specialist

 Home Birth Advice

Next patient at your GP, a 25 year old primigravida who is 30 weeks pregnant. Until now, her pregnancy
has been uneventful. Her 18 weeks ultrasound revealed a single baby, proper position of the placenta.
Her OGTT was normal. She has come to see you today to discuss with you home birth options.

TASKS
1. Take a further history from the patient
2. Examination findings from the examiner
3. Advice regarding home birth

▪ History
Ask the reason why she wishes to have a home delivery
Home delivery is a good option, but there are certain concerns. Labors are very unpredictable and
can go wrong at any time. In a hospital, interventions will be there. It doesn't always necessarily
mean that she would have a C-section, as doctors wouldn’t do unnecessary procedures on her.
"Know your midwife program" - only one midwife who will monitor her from the beginning
Family birth suites - home-like environment attached to the hospital run by midwives

APPROACH
▪ RAPPORT
▪ History
o How is your pregnancy going so far?
o Any tummy pain, bleeding, water discharge from down below?
o Is the baby kicking well or not?
o Signs of preeclampsia: any headache, blurring of vision, any edema?
o When was your last antenatal check? Are you reviewed regularly?
• Do you know your blood group? Down syndrome screening done?
• Ultrasound at 18 weeks done? Results?
• Folic acid taken
o How's your diet? Do you regularly engage in physical exercise?
o SAD
o PMH
o FH
o Why do you prefer a home birth? [KEY POINT] her friend had a home birth 2 weeks back and
she said it was a wonderful experience for her. And she prefers to have a home birth so that
she'll be in a familiar environment and not surrounded by strangers, and she need not go
anywhere once the contractions start. The doctors may also put her on unnecessary
interventions like a C-section.
• I will discuss this in detail with you, but before that is it ok if I examine you?

• Physical Examination
o GA: pallor, edema (PICCLED)
 o VS: BP
o ABDOMEN
• Fundal height; 30cm
• Fetal heart rate: normal
• Fetal lie: longitudinal
• Fetal presentation: cephalic
o OFFICE TESTS: UDS, BSL

• Counselling
I can understand that you want a home delivery as you have said that it can be a more familiar
environment for you where you could feel more comfortable, but home birth has got certain
limitations which I will discuss with you now. As I can see, until now your pregnancy has been
going very well but you still have 8-9 weeks to go before your delivery. Just in case you or your
baby develop any complications like a sharp rise of blood pressure in you, any bleeding, if you
have an early rupture of membranes, or a preterm labor, that is you go into labor before 36
weeks, then home birth is NOT advised. At any time if the baby becomes unwell or if the baby
kicks become less, a home delivery is not advisable. The complications are more likely to happen
during your first pregnancy rather than the subsequent ones.
Now coming to labor, all labors are unpredictable, and complications at the time of labor
sometimes cannot be foreseen. The first thing we have to consider is whether your pelvis is roomy
or not, and as you have no previous deliveries, we do not know how the pelvis is going to behave.
There could be fetal distress at the time of labor (baby can be unwell at the time of labor), or
there could be a cord prolapse when the membranes rupture, or at any stage the labor can
become obstructed. There could be excessive bleeding during and after delivery as well. So it is
always safe to have a delivery at the hospital especially your first delivery, as if any complications
arise, they will be tackled with utmost efficiency. At the hospital, all the necessary equipment are
there to monitor you and your baby's well-being. At no stage will unnecessary interventions be
done unless absolutely necessary.
But by the end of the day, it is your choice and if you're quite sure that you want to have a home
birth, the we need to make a back-up plan in consultation with the specialist. For that, I need to
know how far you are living away from the hospital, The transport facilities available for you, and
if you have enough support.
I can enroll you to the Know Your Midwife Program. The same midwife will take care of your
pregnancy and also your delivery and after delivery as well. She will be knowing everything about
you as well--your pregnancy, conditions, etc. but just in case you need to have a look at the
hospital maternity ward, I can arrange for that as well.
Another option is to give delivery at birth centers or family birth suites which is a home-like
maternity care facility. A kind of half-way between the home and the hospital. And it is always
attached to a hospital and is run by a team of midwives. The suite offers a relaxing environment
but with a full equipment. Your family members can also be there with you during the time of
delivery. And just in case any complications happen, you will be taken to the hospital immediately.
But the only problem is that, they cannot give you epidurals during your labor, but what they can
offer you is non-medical pain relief regimens.
I can refer you to a specialist who will be the best person to discuss this with you. And I can also
give you reading materials regarding this.
I can fix up another appointment with you, and if you wish you can bring your partner along as
well.
Do you have any questions?
 C-section Counselling
You are at your GP when 25 year old, at her 20th week of her first gestation presents to you with a
request of C-section to be done as she does not want a vaginal delivery.

TASKS
1. Take a further history
2. Counsel the patient

APPROACH
▪ History
o How is your pregnancy going so far?
o Why do you prefer a C-section over a vaginal delivery? Scared of the pain associated with
the vaginal delivery
(Must focus on pain relief options in counselling. Explain that pain duration in c
section is more)
o Have you started to feel the baby kicks? Any tummy pain, discharge, or bleeding, from down
below?
o Are you having regular antenatal checks? Do you know your blood group? Blood tests done?
o Down syndrome screening done? Ultrasound done at 18 weeks? ==> no ultrasound so far.
(address this in the management--I will arrange for an ultrasound now and give you a
referral for that)
o SAD
o PMH
o Past Obstetrics Hx
o FH
o Do you have enough support for this pregnancy?

• Counselling:
Thank you so much for all the information.

Vaginal birth is a natural method of delivery, whereas as you know, C-section is a surgery where
we put a cut in the lower part of your tummy and your womb to deliver the baby, and the
afterbirth putting you into sleep. We usually go for a C-sections if there are definite indications.

C section can be done in a planned or an elective way when there are certain indications like
placenta previa, cephalopelvic disproportion if detected early in the pregnancy (due to
abnormalities in the baby---when there is a big baby, or abnormalities in your pelvis--like if there is
a narrow pelvis), any abnormal lies of the baby (transverse or oblique), previous2 CS or a vertical
CS, multiple pregnancies. (Explain each term)

An emergency CS can be done in the following situations: if the baby becomes unwell, or if there is
arrested labor at any point in time. if the patient has got eclampsia, or if the cord prolapses.
C-sections also carries certain complications to you and to your baby. Immediate complications
can be: risk of anesthesia--breathing difficulties, bleeding problems, injury to the surrounding
structures like the bowel or the bladder. These complications are rare when done by a trained
obstetrician. You may develop clots in your legs after the surgery, or develop infection in the
womb (endometritis) later. For complications in the baby, he can go in for respiratory distress,
breathing problems are more common in C-section babies compared to the babies delivered via
vaginal delivery.

Disadvantages you may have with a C-section include: there is a longer duration of pain that you'll
have when compared with vaginal birth. With vaginal birth, you have the pain at the time of
delivery but for a C-section, the pain continues for the next few days until the healing of the
wound takes place. C-section would entail a longer stay in the hospital (3-5 days), and there can
be problems with future attempts of vaginal birth like scar ruptures.

Here are some advantages of the vaginal birth over a C section: there are no complications like
bleeding or risk of anesthesia, or infection from the womb. The pain duration is less. You will have
a shorter hospital stay. Recovery is quick, and you can have any number of future vaginal
deliveries.

However, there are some risks with vaginal birth as well. These include a failure which can lead to
a C-section, there could also be some damage to the pelvic floor muscles that can lead to future
complications like incontinence. But it can very well be managed if you start doing pelvic floor
muscle strengthening exercises after delivery.

As I know that you are concerned with the pain associated with the vaginal birth, there are
excellent pain relief options that are available for you at the time of labor. It could be
pharmacological or non-pharmacological.
o Pharmacological options:
• epidural, where anesthetic drugs will be introduced into the outer covering of your
spine which can numb the nerves to your womb and also the muscles surrounding it.
And it can be topped up anytime.
• Second pain relief options are injections of pethidine
• Third is by giving nitrous oxide and oxygen inhalation via mask
o Non-pharmacological methods
• Using TENS (transcutaneous electrical nerve stimulation) where 2 electrodes are placed
on either side of the spine and a small electric current will be passed which can inhibit
the pain fibers.
• Certain positions during labor can also reduce the pain
• Deep breathing techniques can also be used as well
• Hydrotherapy can also be done, which is giving birth while on water
You are only at 20 weeks, and there is still a long way to go. If any complications will occur, we
may go ahead with the C-section if indicated. But again, by the end of the day, it is your choice. If
you still think that C-section is the best option for you, I'll arrange an appointment with the
specialist, and the specialist can discuss this further with you.
Now, I'll give you a referral for the ultrasound scan, reading materials regarding vaginal birth and c
section, and also pain relief options that are available during your labor and delivery.
 PIECE OF ADVICE: Do not sound like you are favoring any specific options. Talk about advantages
and disadvantages of both options.

OTHER CASE: reason they give you: incontinence following vaginal birth
Vaginal birth is not alone is not a cause of incontinence. If you have other causes like chronic
constipation, extra weight gain, and menopause, all these can contribute to incontinence as
well. But vaginal birth can lead to weakness to the pelvic floor muscles, but if you start
strengthening exercises to the pelvic floor muscles, called the KEGEL exercises, 6 weeks after
delivery, you can prevent this to a certain extent.
There are post-natal classes you can enroll into, who will teach you the Kegel exercises.

Thalassemia Minor
40 year old who was 28 weeks pregnant visits your GP to get the results of the blood tests that you had
ordered for her during the last visit. Her OGTT was normal, but her FBE showed a low hemoglobin, and
low MCV. Iron studies were found to be normal.

TASKS
1. Take a further history
2. Discuss your most probable diagnosis and further management with the patient

When the MCV is low, the size of the RBCs is decreased. The picture you get here is a microcytic
hypochromic anemia. There are two reasons for this during pregnancy that comes in the AMC are: iron
deficiency anemia and thalassemia.
Thalassemia key questions: her descent, and her partner's descent

Positive points in the history: she is of Italian descent, her partner is also of Italian descent, father
seems to be anemic but she is not sure,

APPROACH
▪ History
o How has been your pregnancy going so far?
o Are you experiencing any problems such as excessive vomiting, tummy pain, bleeding
from down below, burning or stinging on passing urine, fatigue, headache, blurring of
vision & swelling, fever/malaise?
o Is the baby kicking well?
o Symptoms of anemia:
• Are you feeling tired, any chest pain, funny racing of the heart, are you feeling short of
breath, any dizziness?
 • Prior to pregnancy, have you experienced any of these symptoms?
o Pregnancy history
• Did you do all your antenatal tests? How were the results?
▪ Routine first visit tests
o FBE
o Blood group and antibody screen
o Rubella antibody status
o Syphilis serology
o Midstream urine
o Chlamydia
o HIV
o Hepatitis B and C serology
o Varicella
o Cervical cytology/Pap smear
o Screening for Down syndrome (if >35 years old)
▪ Ultrasound at 18 to 20 weeks?
o Any past history of medical illness? Any kidney or liver disorders?
o Thalassemia questions:
• Where is your country of origin? (key point) (Thalassemia is common in
Mediterranean countries: Greek, Italian, Middle Eastern, Turkish; Asian, African)
• What about your partner's country of origin? (key point)
o Any family history of anemia?
o Any history of miscarriage and bleeding disorders?

▪ Diagnosis and Management

The investigation results show that the sweet drink test is normal which means that you do not
have Diabetes during pregnancy. Your full blood test results however show that you have low
levels of hemoglobin, which is the red pigment or protein in your red blood cells that carry oxygen
to different parts of your body, and the size of your red blood cells is also reduced. This sort of a
picture can be seen in two conditions: first is iron deficiency anemia, but the iron studies that we
have done for you has turned out to be normal; another condition is thalassemia. Thalassemia is a
group of inherited blood disorders where there is defective production of hemoglobin. This
happens when the genes are mutated and they are permanently altered. This is a lifelong
condition. What you are having is a minor version of this condition, or what we aptly call as
Thalassemia minor. In this condition, you do not experience symptoms other than anemia. Usually
there is no risk for you during pregnancy, except for the anemia that could become prominent
during your later pregnancy. It is more likely that the baby will be born healthy. We need to
confirm this by doing certain blood tests called hemoglobin electrophoresis. It would be better to
get your partner tested as well because we can better predict if the baby will be having
Thalassemia as well. If you alone have Thalassemia minor, there is a 50 percent chance of the baby
becoming normal, and 50 percent chance as well of having Thalassemia minor. However, if both of
you have Thalassemia minor, there is a 50 percent chance of the baby having Thalassemia minor,
and 25% chance of having Thalassemia major, and 25% chance of becoming normal.
I will refer you to the hematologist for further assessment. We need to start you on folic acid
5mg/day and it will be given throughout the pregnancy. (key points)
I will also refer you to the high risk pregnancy clinic. I will refer you for genetic counselling as well.
If everything goes well for you and the baby, you can go in for a normal vaginal delivery.
I will give you reading materials regarding Thalassemia, and I will arrange a review with you when
the results of the hemoglobin electrophoresis come in.
 Twin Pregnancy
32 year old pt attends your GP clinic. She is 20 weeks pregnant and has come to discuss the results of
the ultrasound scan that she did 1 week ago. The ultrasound showed a twin pregnancy with each fetus
having a separate amnion and chorion.

TASKS
1. Take a further relevant history
2. Explain the ultrasound results to her
3. Discuss your further management regarding her pregnancy

APPROACH
▪ History
o Was this a planned pregnancy? Is this your first pregnancy?
o Was this a natural conception, or did you go in for artificial methods of conception?
o How is your pregnancy going so far?
o Are you experiencing any problems such as tummy pain, bleeding from down below,
burning or stinging on passing urine, fatigue, headache, blurring of vision & swelling,
fever/malaise?
o Have you started feeling the babies kicking?
o During the early weeks of pregnancy, any exaggerated vomiting, any nausea?
o Did you do all your antenatal tests? How were the results?
▪ Routine first visit tests
o FBE
o Blood group and antibody screen
o Rubella antibody status
o Syphilis serology
o Midstream urine
o Chlamydia
o HIV
o Hepatitis B and C serology
o Varicella
o Cervical cytology/Pap smear
o Screening for Down syndrome (if >35 years old)
▪ Ultrasound at 18 to 20 weeks?
o General well-being questions:
▪ Are you taking your folic acid? When did you start taking it? (folic acid 0.5mg/day 3
months before and 3 months after)
▪ Are you eating a healthy balanced diet? Do you drink a lot of fluids?
▪ Are you taking any vitamin or mineral supplementation?
▪ Any change in appetite? Have you noticed weight gain/loss?
▪ Do you have a regular exercise routine?
▪ Do you open your bowels regularly? Any problems with your bowels?
▪ Are your influenza and pertussis vaccinations up to date?
o Any family history of multiple pregnancy?
o SADMA
 ▪ Do you smoke?
o How long have you been smoking? How many per day?
▪ Do you drink alcohol?
o What kind? How often? How much per session?
▪ Do you take any recreational drugs?
o What kind? How often?
▪ Do you take any prescription or over the counter medications?
o What medication? For what reason? Who prescribed it?
▪ Do you have any known allergies?
o Do you take any medications for this?
o Any past history of any medical illness especially clotting problems (thromboembolic
disease), diabetes, epilepsy, thyroid problems, or high blood pressure?
o Do you have good support?
o Have you done your pap smear? What were the results?

▪ Diagnosis and Management

How are you feeling about your pregnancy?
There are different types of twin pregnancies. The type that you are having is more favorable
because each of the babies has a separate placenta as well as a separate bag of its own. These are
actually independent twin pregnancies, and usually carries a better prognosis. It is very likely that
these could be non-identical twins.
I know that you are a bit concerned about this pregnancy, but let me reassure you that many
women who have twin pregnancies go through a normal pregnancy and will have healthy, normal
babies. But we need to monitor you as well as the babies for certain complications. The
complications we have to look out for you are first, anemia, you can feel a bit tired and exhausted
as the pregnancy goes by; there is also a risk of high blood pressure and pre-eclamptic toxemia
where there is a sharp rise in blood pressure with leakage of proteins into the urine; there is also a
higher chance of developing Diabetes during pregnancy; also as your tummy will be a bigger
towards the end of your pregnancy, you may feel a little short of breath and experience back pain;
you may also have antepartum hemorrhage or bleeding during pregnancy, cord prolapse, and a
greater risk of postpartum hemorrhage. The complications in the babies are: low birth weight,
intrauterine growth retardation of one baby, birth defects, and malpresentation. But we will
monitor you and your babies for these complications. I will refer you to the high risk pregnancy
clinic for better management. You need to go for more frequent antenatal checks: every 2 weeks
until 28 weeks and weekly until you deliver. During each visit, your weight will be recorded and
your BP will be monitored. A sweet drink test will be done at 28 weeks to check for any
Gestational Diabetes, a repeat blood test to check for anemia, ultrasound screening every 2 weeks
from 28 weeks, CTG to look at the wellbeing of the baby twice a week from 34 weeks, and a bug
test will be done as well.
Delivery will be planned at 38 weeks. There are two options for you: one is to do a C-section, and
two is a normal vaginal delivery. However, normal vaginal delivery can be done only if certain
criteria are met:
o The first baby should be in cephalic presentation
o The second baby should be less than 500 grams compared to the first baby (if the second
baby is big, it will obstruct the passage of the first baby)
The delivery should be done in a tertiary hospital, under the guidance of a specialist. Continuous
monitoring of the babies will be done via CTG during the delivery.
How far are you living from the hospital?
 It is better to stay near to the hospital during the last weeks of pregnancy because there is a
greater chance of you going into premature labor because of this twin pregnancy.
You need to take a healthy balanced diet, and take iron, calcium and folic acid supplements.
Just in case you develop tummy pain, bleeding and excessive discharge from down below, blurring
of vision, headache, excessive vomiting, regular painful contractions, please go to the ED
immediately.
It is always advisable to maintain kick charts for the baby as well so we can monitor the wellbeing
of the baby.

Pre-pregnancy advise with Type 1 Diabetes Mellitus

You are working in the primary care facility of a teaching hospital. Your patient is a woman aged 24
years (para 0, gravida 0), a known diabetic for 15 years and well controlled on insulin. She has come to
see you for counselling and advice about possible future pregnancies.

TASKS
1. Take any further relevant history you require
2. Advise the patient of the information she needs to be given for pre-pregnancy counseling

APPROACH
▪ I understand that you are here to seek advice regarding future pregnancies. Are you planning to
be pregnant anytime soon? Let me ask you some questions to identify some factors in your life
▪ And I can see from your notes that you have been diabetic for 15 years, could you tell me more
about it?
o ASSESS DM SEVERITY & CONTROL (must be symptom free, with good control for at least 3
months)
• When was your last check-up for your diabetes? Do you regularly have check-ups?
• How is your blood sugar control? DO you regularly monitor your sugar levels? What
are your recent blood test results?
• Have you ever had any hypoglycemic episodes or low blood sugar level episodes?
▪ If yes--were you admitted in the hospital? Any complications (hypoglycemic
coma)
• Do you feel thirsty all the time, go to the toilet to urinate more often?
• Any concerns about your water works? Have you seen a kidney specialist?
• Any blurring of vision? Have you been referred to an eye specialist?
• Any infections from down below?
o 5P's: I will be asking you some sensitive and personal questions to identify some factors
which can affect your pregnancy, and rest assured everything will be kept confidential. Will
that be ok?
• Is this your first time to go for a prenatal check-up?
• Any concerns with your periods? Do you get it every month? How many days do you
usually bleed? How heavy is your bleeding? Any pain during your periods?
• Are you in a stable relationship? Any history of STIs? Do you practice safe sex?
 • Are you on the pill or other forms of contraception?
▪ When were you last on the pill?
• Have you ever been pregnant before?
▪ If yes, ask for details (when, how many times, complications, etc)
• When was your last pap smear?
▪ PATIENT ADVISE
o It's good that you are planning to become pregnant and that you came here for advice
regarding your pregnancy. However, you should be aware that having diabetes in pregnancy
proves to have a high risk for complications both for you and for your baby. The state of
being pregnant itself has anti-insulin effects which tend to further worsen your diabetic
state. But don't worry too much, as you did the right thing to have a consult here first
before becoming pregnant. We can do our best to minimize the possibilities of all of these
complications from happening as long as proper blood sugar control prior and during
pregnancy is achieved.
o From your history, it can be seen that you seem to have a fair control over your blood sugar
levels. An initial test that I can do for you to confirm this is the HBA1c blood test together
with your regular blood sugar level checks in your diary to give an assessment of your blood
sugar control. We need to keep your sugar levels within 5-7mmol/L to reduce the risk of
complications for you and your baby
o But to give you further assessment, I will refer you to a diabetic specialist who will check
your general state and check for complications of diabetes. He might do investigations such
as renal function tests, 24 hour urinary protein checks. I will also refer you to an eye
specialist to assess for your vision, as diabetes can often affect your vision as part of the
complications of the disease. So with this, it is very important that you do not get pregnant
until you have reached optimal control of your blood sugar levels.
o Providing all of your tests are normal, then we can now plan for your pregnancy. I will then
start you with folic acid which you will take from the time pregnancy is attempted until at
least 12 weeks of your pregnancy.
o We can already do your basic tests for pregnancy now as part of your general assessment.
We can do blood group testing, indirect coombs test, full blood examination, urine
microscopy and culture, and also an STI screening tests which include hepatitis screening,
VDRL, rubella serology and HIV testing with your consent. We can also arrange for your pap
smear now as your last pap was done 3 years ago.
o Once you become pregnant, You will be referred to the high risk pregnancy clinic where you
will be managed by a multidisciplinary team consisting of a diabetic specialist and an
obstetrician.
• Your insulin requirement will increase to keep your sugar levels controlled and keep
the fetal malformation rate to a minimum, and to keep the size of your baby (avoid
macrosomia) to an acceptable level.
• Your iron and folic acid tablets will be continued during your pregnancy
• You will have a planned delivery at around 38-40 weeks, either by induction or by c-
section. Earlier delivery might be necessary if problems might occur during your
pregnancy
o Despite all of the adequate care during pregnancy, you must still be aware of the
complications related to diabetes in pregnancy. Sorry for the medical terms I have to say to
you but you need to be aware of these. Your pregnancy can be complicated by preeclampsia
or a sharp rise in BP during pregnancy, polyhydramnios or an excessive water inside your
womb which can predispose to early labor or early rupture of these bag of water, and a big
 baby necessitating early labor or c-sections. There is also an increased risk of unexplained
fetal death in late pregnancy, and possible breathing difficulties in the baby after delivery.
o I can imagine that this must be very distressing for you, but I am here to give you all the
information you need before you proceed with your pregnancy. I am here to support
whatever decision you make, and if you do decide to proceed with pregnancy, we will look
after you and do the best we can to minimize these complications.
o Here are reading materials for you to give you more insight about your condition.
o I will arrange a review again with you once I receive your results.
Condition 110 Fundus greater than dates
Your patient is a 26-year-old primigravida. She has been attending the general practice where you are
working and seeing the doctors there in a shared care arrangement with a specialist in a major city 30
km away. She is not due to see the specialist again for a further six weeks. All appeared to be normal up
to and including her last visit at 26 weeks of gestation, when the symphysis-fundal height was 28 cm.
Today, four weeks later at 30 weeks of gestation, the symphysis fundal height is 40 cm, and a weight
gain of 6 kg has occurred during the four week time interval.

TASKS:
1. Take any further relevant history you require.
2. Ask the examiner about the relevant findings on examination and the results of specific previous
investigations which you believe would have been performed.
3. Advise the patient of the diagnosis and subsequent management.

APPROACH
▪ History
o I read from the notes that you are now at your 30th week of pregnancy. How is your
pregnancy so far?
o Is the baby kicking well? Did you do your antenatal checks, blood tests and blood group and
Rh typing? Have you done your pap smear? What was the result? Have you done your down
syndrome screening? Did you take your folic acid? How was your ultrasound at 18 weeks?
Was it a single pregnancy? Was there any uterine fibroids seen? Was correct dating
confirmed on ultrasound? What was the result of your sweet drink test at 28 weeks?
o I also read from the notes that you gained a substantial amount of weight since 4 weeks
back, and your fundal height seems to be much larger than your age of gestation. What was
your initial weight prior to pregnancy? Do you know your weight right now?
o Diabetes questions: Any symptoms of frequent urination? Do you feel more thirsty
nowadays? Any recurrent skin or vaginal infections? Any numbness or tingling sensation in
your extremities? Have you been tested for diabetes previously?
o Pre-eclampsia questions: any headaches, blurring of vision, edema or swelling, proteins or
glucose in the urine?
o Any past history of medical or surgical illness?
o Do you have any family history of diabetes?
o Any smoking, alcohol or recreational drugs? Any medications taken?
o Do you have a good support?
▪ Physical Exam
o General appearance: pallor, edema, lymph node enlargement, BMI
o Vital signs
o Systemic examination
• CNS/CVS/Respiratory
• Abdomen: fundic height, FHR, lie, presentation, uterine tenderness, fluid thrill
• Pelvic examination
▪ Inspection of the vulva and vagina
▪ Speculum: is the cervix closed or open? Is there discharge or bleeding?
▪ Investigations
 o Blood group and Rh typing? Indirect Coombs test
o Urine test: protein and glucose
o Sweet drink test at 28 weeks
o FBE: hemoglobin
o Ultrasound at 18 weeks: single baby?

▪ Diagnosis and Management

From the history and examination, most likely the cause why your uterus is larger than it should
be is polyhydramnios or an excessive amount of amniotic fluid. There are other causes as to why
your uterus may be larger than it should be such as wrong dating, multiple pregnancy,
macrosomic or big baby, or uterine fibroids. However, these are unlikely because your ultrasound
at 18 weeks have confirmed your dates, a singleton pregnancy, there is no evidence of diabetes,
and there were no fibroids detected on your ultrasound. However, I will need to refer you back to
the specialist now or within the next few days, and we need to confirm the diagnosis by doing an
ultrasound which would also look for the possible cause of the excessive amount of amniotic fluid,
such as fetal malformation of the central nervous system, gastrointestinal system, abdominal wall,
or a benign tumor (chorioangioma) of the placenta. Other causes are diabetes and fetal infection
with cytomegalovirus and toxoplasmosis. That is why we would also need to do a glucose
tolerance test, a confirmatory test, to exclude diabetes since the glucose challenge test that you
did before is only a screening test.
Polyhydramnios can cause problems in late pregnancy and labour including malpresentation,
premature rupture of the membranes, premature labour, and placental abruption following
membrane rupture. As you are already at 30 weeks of gestation, it would probably beneficial for
you to take an extra bed rest to prevent premature delivery. However, if at any time you feel that
you might be in premature labor, you should immediately go to the ED. Depending also on the
assessment of the specialist, she may decide to give you prophylactic steroid therapy to reduce
the likelihood of respiratory distress in the baby in the event that delivery will occur before 34
weeks of gestation.
I will give you reading materials about polyhydramnios for further insight.

Condition 133 Fundus less than dates

Your next patient is a 28-year-old primigravida who works as a nurse in a renal transplant unit. You have
been looking after her pregnancy since the first trimester. You are seeing her in a general practice
setting in a shared care arrangement with the local obstetric hospital. All appeared to be normal up to
and including her last visit at 30 weeks of gestation, when the symphysis-fundal height was 28 cm.
Today, four weeks later, the symphysis-fundal height is 29cm and there appears to be a reduced amount
of liquor present.

TASKS:
▪ Take any further relevant history you require.
▪ Ask the examiner about relevant findings likely to be evident on general and obstetric
examination and available investigation results.
▪ Advise the patient of the diagnosis and subsequent management including any further
investigations you would arrange.
APPROACH
▪ History
o I read from the notes that you are currently in your 31st week of pregnancy now, and your
fundal height seems to be smaller than expected and there is reduced amount of liquor in
your tummy.
o How is the baby? Is the baby kicking well? Are the fetal movement same as it was before?
o Possible causes of small fundus:
• Are your dates certain? Did you do your ultrasound at 18 weeks? What was the
result?
• Were you ever diagnosed with hypertension or renal disease? Ever been diagnosed
with lupus or arthritis or any thrombotic disorder in the past?
• Pre-eclampsia questions: any headaches, blurring of vision, edema or swelling,
proteins or glucose in the urine?
• Do you have pets at home? Did you have any contact with dogs or cats?
o Routine antenatal history: Any blood test and blood group done? Down syndrome
screening? Folic acid? Any complications in the position of the placenta? Sweet drink test at
28 weeks?
o Do you smoke, drink alcohol or take recreational drugs?
o Do you have enough support at home? Who do you live with?
▪ Physical Exam
o General appearance: pallor, edema, lymph node enlargement, BMI
o Vital signs
o Systemic examination
• CNS/CVS/Respiratory
• Abdomen: fundic height, FHR, lie, presentation, is the head engaged, uterine
tenderness
• Pelvic examination
▪ Inspection of the vulva and vagina
▪ Speculum: is the cervix closed or open? Is there discharge or bleeding?
o Office test: UDT for proteins
▪ Investigations
o CMV antibody testing
o Toxoplasma antibody testing
▪ Management
From history and physical examination, most likely your baby is having an intrauterine growth
restriction. This is when the baby is not able to grow properly inside the womb. This is why your
fundal height is less than expected and you have reduced amount of liquor. The reason for this,
and its severity need to be assessed by some investigations such as ultrasound examination to
confirm the size of the baby, to look for the amniotic fluid volume, and to see whether there is any
obvious congenital abnormality which might explain the IUGR. Ultrasound will probably need to
be repeated each 2-3 weeks. A Doppler study could also be done to assess the blood flow in the
umbilical cord which supplies the needs of the baby. A cardiotocographic evaluation will be done
as well twice a week from now until the time of delivery to assess and monitor the condition of
the baby.
There are many causes why IUGR could happen. It could be due to karyotypic abnormalities or
problems in the genetic makeup of the baby, kidney disease, pre-eclampsia or abnormal, abrupt
elevation of the patient's blood pressure with leakage of proteins into the urine,
or congenital infections due to CMV or toxoplasmosis or placental dysfunction. That is why, in
addition to the ultrasound, Doppler and CTG, we would also do a serum urea, uric acid, and
creatinine to look for evidence of renal compromise, lupus anticoagulant and anticardiolipin
antibodies, antibodies for toxoplasmosis, and amniocentesis to assess the karyotype of the baby
and to rule out toxoplasmosis in the specimen as well.
Your baby will most probably be delivered via caesarean section and will be done prior to your
due date. The timing of this will depend on the ultrasound evaluation, the CTG record and the
amount of growth which occurs subsequently.
But do not be too stressed, as long as the baby does not become deprived of oxygen and becomes
acidotic, and does not have a congenital malformation or a congenital infection, the long-term
prognosis for the baby is satisfactory.