Case 1
A 26-year-old G1 P0 woman at 39 weeks’ gestation is admitted to the hospital in labor. She is noted
to have uterine contractions every 7 to 10 minutes. Her antepartum history is significant for
a nonimmunerubella status. On examination, her blood pressure (BP) is 110/70 mm Hg, and heart
rate (HR) is 80 beats per minute (bpm). The estimated fetal weight is 7 lb. On pelvic examination,
she has been noted to have a change in cervical examinations from 4-cm dilation to 7 cm over the
last 2 hours. The pelvis is assessed to be adequate on digital examination.
1)Stage of labor?
2)What is your next step in the management of this patient?
1. Based on the information provided, the patient is likely in the active phase of the
first stage of labor, as she has progressed from 4 to 7 cm dilation over the last 2 hours
and is experiencing regular uterine contractions.
2. The next step in the management of this patient would depend on several factors,
including the presence or absence of fetal distress, the patient's pain level and desire
for pain management, and the progress of labor. Generally, the following
interventions may be considered:
* Assess fetal well-being using electronic fetal monitoring (EFM) to check the fetal
heart rate and pattern.
* Evaluate the patient's pain level and consider pain management options, such as
epidural anesthesia or systemic analgesics, based on her preferences and medical
history.
* Encourage and support the patient's efforts to push during the second stage of
labor, which typically begins when the cervix is fully dilated (10 cm).
* Monitor the patient's vital signs, including BP, HR, and respiratory rate, and manage
any abnormalities as needed.
* Administer prophylactic antibiotics if the patient's rubella status is confirmed and
her membranes rupture.
* Consider the possibility of cesarean delivery if there are concerns about fetal
distress, failure to progress, or other complications that may arise during labor.
Case 2
A 31-year-old woman attends a routine antenatal appointment at 28 weeks’ gestation. She is para 2
having had two term vaginal deliveries previously, with the same partner. Her children are aged 4
and 2 years and weighed 3.7 and 3.6 kg respectively at birth. She reports no antenatal concerns,
there is no abdominal pain, no vaginal bleeding and good fetal movements are reported. Initial
antenatal booking blood tests were normal, as were the first-trimester nuchal screen and 20- week
anomaly scans. She is a non-smoker and has abstained from alcohol during the pregnancy.
Examination The woman appears well with no signs of oedema. Her BMI is 24. Blood pressure is
115/74 mmHg. The symphysiofundal height is 24 cm. The fetus is felt to be a cephalic presentation.
Auscultation with hand-held Doppler confirms the fetal heartbeat to be 150/min.
INVESTIGATIONS
Urinalysis: negative.
Ultrasound: biparietal diameter and femur length are on the 10th centile. Abdominal
circumference and estimated fetal weight are below the fifth centile. The liquor volume is normal.
Umbilical artery resistance index is within normal range.
1)What are the possible causes of the small fetal size and what further investigations would
you propose?
2) How would you manage this pregnancy from now?
1. There are several possible causes of small fetal size, including but not limited to:
* Fetal growth restriction (FGR): This occurs when the fetus fails to achieve its growth potential
due to placental insufficiency, maternal factors, or fetal abnormalities.
* Maternal factors: These include chronic hypertension, pre-eclampsia, renal disease, smoking,
drug abuse, malnutrition, and certain infections.
* Fetal chromosomal abnormalities: These may affect fetal growth and development, particularly
in the case of trisomy 13, 18, or 21.
* Placental abnormalities: These may interfere with fetal blood supply and nutrient delivery, such
as placental previa, abruption, or infarction.
* Multiple gestation: This may result in smaller fetal size due to limited space and resources.
Further investigations that may be proposed in this case include:
* Doppler ultrasound to assess blood flow in the umbilical artery and other fetal vessels.
* Serial ultrasound scans to monitor fetal growth and estimate fetal weight.
* Maternal serum alpha-fetoprotein (MSAFP) and human chorionic gonadotropin (hCG) levels to
screen for fetal chromosomal abnormalities.
* Amniocentesis to obtain fetal karyotype and rule out chromosomal abnormalities.
2. The management of this pregnancy would depend on the underlying cause of the small fetal
size and the presence or absence of fetal compromise. In general, the following measures may be
considered:
* Close monitoring of fetal growth and well-being, including regular ultrasound scans and fetal
heart rate monitoring.
* Optimization of maternal health, including management of any underlying medical conditions,
smoking cessation, and nutrition counseling.
* Consideration of early delivery in case of fetal compromise or worsening growth restriction,
typically by induction of labor or cesarean delivery.
* Referral to a maternal-fetal medicine specialist for further evaluation and management, if
necessary.
Case 3
A woman attends the antenatal day assessment unit to discuss the result of her glucose tolerance test.
She is 42 years old and this is her sixth pregnancy. She has previously had three caesarean sections,
one early miscarriage and a termination of pregnancy. All booking tests were normal as were her
11–14-week and anomaly ultrasound scans. She is now 26 weeks’ gestation and her midwife
arranged a glucose tolerance test because of a family history of type 2 diabetes (her father and
paternal aunt). Examination The body mass index (BMI) is 31 kg/m2. Blood pressure is 146/87
mmHg. The symphysiofundal height is 29 cm and the fetal heart rate is normal on auscultation.
INVESTIGATIONS
Urinalysis: glycosuria ++
Glucose tolerance test (75 g glucose drink):
Pretest fasting blood glucose: 6.4 mmol/L
2 h blood glucose following glucose load: 11.3 mmol/L
1)What is the diagnosis and on what criteria can this be made?
2)What are the principles of management for this patient?
1. The diagnosis in this case is gestational diabetes mellitus (GDM), which is defined
as glucose intolerance with onset or first recognition during pregnancy. The criteria
for diagnosis include:
* Fasting plasma glucose ≥5.1 mmol/L
* 1-hour plasma glucose ≥10.0 mmol/L
* 2-hour plasma glucose ≥8.5 mmol/L
In this case, the patient's 2-hour plasma glucose following a 75 g glucose load was
11.3 mmol/L, which exceeds the diagnostic threshold.
2. The principles of management for GDM include:
* Dietary modification: This includes counseling on healthy eating habits, portion
control, and avoidance of high-sugar and high-fat foods. A registered dietitian should
be involved in this process to provide individualized recommendations.
* Exercise: Regular physical activity is recommended to help control blood glucose
levels and promote overall health. Patients should aim for at least 30 minutes of
moderate-intensity exercise on most days of the week.
* Blood glucose monitoring: Patients should be taught how to monitor their blood
glucose levels at home and how to interpret the results. This may involve regular
fasting and postprandial glucose testing, as well as periodic hemoglobin A1c testing
to assess long-term glycemic control.
* Pharmacotherapy: Insulin is the preferred medication for controlling blood glucose
in GDM, as it does not cross the placenta and has a long track record of safety and
efficacy in pregnancy. Other oral hypoglycemic agents, such as metformin or
glyburide, may be considered in certain cases, but their safety in pregnancy is less
well-established.
* Fetal surveillance: Patients with GDM are at increased risk of fetal macrosomia,
stillbirth, and other complications. Therefore, regular fetal growth scans and
non-stress tests may be recommended to monitor fetal well-being.
* Delivery planning: The timing and mode of delivery should be individualized based
on factors such as gestational age, fetal size, and maternal health. Induction of labor
or cesarean delivery may be considered in certain cases to minimize the risk of fetal
or maternal complications.