1. Pregnancy care in women with BMI>35 Dr S Sharma, Dr A Mahmud and Dr N Manheri-OthayothUniversity Hospital of Wales, Cardiff UK Pregnancy care in women with BMI>35 Dr S Sharma, Dr A Mahmud and Dr N Manheri-Othayoth - University Hospital of Wales, Cardiff UK AIM To re-audit the care of pregnant women with BMI>35STANDARDS 2008Cardiff and Vale NHS Trust Policy and Guideline for management of women with high BMI dated 2008 2010CMACE/RCOG Joint Guideline - Management of Women with Obesity in Pregnancy - March 2010 METHODS Prospective audit Proforma developed Duration: 12th May 2011 to 20th June 2011 Cases identified: 36 All Inpatients with BMI>35 were included Results analysed Compared to previous Audit 2008 (74 cases – 1 year) Demographic Distribution Age 70% 18-30yrs 2008 55.5% 18-30yrs 2011 Parity Booking BMI ANC - Referral to healthy living classes Folic acid and vitamin D supplementation CMACE/RCOG Women with a BMI ≥30 wishing to become pregnant should be advised to take 5mg folic acid supplementation daily, starting at least one month before conception and continuing during the first trimester of pregnancy. B C Health professionals should take particular care to check that women with a booking BMI ≥30 are following advice to take 10 micrograms Vitamin D supplementation daily during pregnancy and while breastfeeding. 32 80% GTT 2008 ANC - GTT GTT performed in 34 cases(97.1%) - 1 case could not attend due to child care issues - 1 case note from other hospital no mention of GTT ANC - GTT For BMI >45 or previous GDM - 2 cases performed at 9 weeks - 1 case at 18 weeks - 1 case at 25 and 29 weeks For BMI 36 - 44 - 2 cases performed at 12 and 14 weeks - rest mostly at 26 - 28 weeks None performed at 14 weeks (as per guidelines) ANC Anaesthetic Review BMI 36-44 4 cases at gestation 31- 34 weeks BMI> =45 5 cases at gestation 32-34 weeks Pregnant women with a booking BMI ≥40 should have an antenatal consultation with an obstetric anaesthetist, so that potential difficulties with venous access, regional or general anaesthesia can be identified. An anaesthetic management plan for labour and delivery should be discussed and documented in the medical records. CMACE/RCOG Pregnant women with a booking BMI ≥30 should be assessed at their first antenatal visit and throughout pregnancy for the risk of thromboembolism. Antenatal and post delivery thromboprophylaxis should be considered in accordance with the RCOG Clinical Green Top Guideline No. 37. 41 Antenatal Thromboprophylaxis Out of 36 women 5 were prescribed aspirin or Enoxaparin as per thromboprophylaxis policy One case of 36 BMI missed h/o DVT B Aspirin BMI 42BMI 44BMI 37BMI 38 Enoxaparin BMI 78 Both = PIH/PET Antenatal-6 Intrapartum-4 GDM Dietary-3 IDDM-2 15 out of 36 = 41.6% Obstetric Medical Problems ANC Review at 36 weeks: - Out of 36 cases 31 were reviewed in ANC (86.1%) 80.5 - USG was done in 29 cases (80.5%) while EFBW was stated in 5 cases only Intrapartum Sheet: - Blank 14 cases - Complete 10 cases - 50% Completion 14 cases 78% 2008 USG 7% 2008 60% in 2008 Intrapartum Care TEDS in labour: - 20 cases had TEDS in all - 2 cases of SVD - 18 cases of C-section or Instrumental delivery Weight on Admission: - Only 3 cases - 1st case BMI = 78 Repeat 83 - 2nd case BMI = 56 Repeat 61 - 3rd case BMI = 40 Repeat 44 3 cases in 2008 (13.8%) Intrapartum care – IOL (19) Mode of Delivery Normal delivery 14 38.8% Instrumental: 4 forceps 2 ventouse 16.4% Caesarean section 16 44.4% SVD 43% C/s 42% Instrumental 15% 2008 Intrapartum Complications 16% PPH 2008 Overall Blood Loss Baby Weight Postnatal Thromboprophylaxis (36) Postnatal Thromboprophylaxis (21) Only 4 cases had clexane prescribed BD All women with a BMI ≥40 should be offered postnatal thromboprophylaxis regardless of their mode of delivery. CMACE/RCOG 58.3% 48% cases in 2008 CONCLUSION 36 cases in 38 days indicates the proportion of large BMI women that deliver at UHW We are following trust guidelines in most cases i.e. Early booking GTT, Anaesthesia review, 36 week follow-up, etc. We still are falling short on: 1. Documentation 2. Assessment Referral to healthy living/weight loss Vitamin D & Folic Acid Intrapartum sheets Thromboprophylaxis Weight on Admission 36 week USG Primi 36% 2008 RECOMMENDATIONS Knowledge and awareness of BMI Guideline is essential Documentation on Intrapartum sheet vital Friday teaching – as guideline updates Update current Health Board Guideline Re-Audit Wide implementation of new Thromboprophylaxis Risk Assessment tool PPH1 Raised BP in labour7(19%) Raised Temperature6 Difficult Toco/CTG monitoring3 Meconium5 Shoulder Dystocia3 Folic acid Dose GivenNot mentioned 400ug 13 23 5mg 0 36 Vitamin D Given Not mentioned 4 32 B IndicationExamplesNumber Medical reasonsPIH/PET/GDM5 PostdatesVBAC7 Obstetric reasonsSROM/PROM/Unstable lie6 Patient requestRecurrent miscarriage1