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Emma Marr is a lady who is presently 30 weeks pregnant, and has come to clinic as she has been classed as a ‘high risk pregnancy’.

Please take a history, focusing on the patient’s risk factors in pregnancy, including any efforts to reduce this risk in pregnancy. Ensure to elicit her ideas, concerns and expectations regarding the current pregnancy. Perform the appropriate examination and discuss the case with the examiner.

You are Emma Marr, a 32-year-old lady who is 30 weeks pregnant with her 3 child. You are in a consultant-led clinic as you are overweight and needed an emergency C-section in your last pregnancy with a general anaesthetic. You have a BMI of 35.

ICE This is your 3 child. You had your second child 5 years ago. You had a very difficult delivery and were rushed for an emergency C-section as there was something wrong with your son’s heart rate. At the time you didn’t really understand what the problem was: you just wanted him to get better. You found this experience very scary and felt that it caused problems with initially bonding with Tommy. Unfortunately, your difficult time did not end there. Your scar became infected and you were hospitalised and then bedbound for about 5 weeks. You really don’t want this to happen again. Since then you have lost 6st as you hoped this may help. You know that being overweight was not good in your last pregnancy, so you waited a little while to lose some weight for this pregnancy. You are really worried about needing an emergency C-section again. Therefore, you would like to know if you can have a planned C-section: this way you think that everything will go much more smoothly and you won’t need the general anaesthetic. You expect that if you had a general anaesthetic again that you would have another traumatic experience. You would like to breast feed this child.

HPC You were trying to get pregnant for a few months, and therefore you are really happy to be pregnant. During this pregnancy you have been tested for diabetes, but this has been negative. You were referred to the consultant led clinic when you found out you were pregnant as you are overweight.
You have not had any problems in pregnancy so far: just a bit of morning sickness for the first few weeks. You have had no bleeding or pain during the pregnancy. You have had your dating scan and the abnormality scan. These were normal. You chose not to have the Down’s Syndrome screening, as you feel that this would not influence your thoughts on this pregnancy at all.

Past Obstetric History: You have had two previous deliveries. Susan: born at 40 weeks weighing 3.2 kg, there were no problems during the pregnancy or delivery, she did not need any special care baby involvement, he development has been normal and is now 8 years old. You were under consultant led care for this pregnancy due to your weight. You were able to breast feed Susan. Tommy: born at 42 weeks. During the pregnancy you had gestational diabetes which had to be managed with insulin, this went away after delivery. You had to be induced and then labour progressed very slowly. They put one of those Heart rate monitors on his head, then he had problems with his heart rate, leading to an emergency C-section. His development has been normal. And is now a happy 5 year old. You had a termination of pregnancy at 16 as you felt you would not be able to look after a baby at that age.

Past Gynae history: You have previously been on the combined pill. You had a regular cycle on this, featuring five days of light bleeding, with no bleeding in between periods. You have never really had vaginal discharge, apart from the occasional episode of thrush. You are up to date with your smears: you had your last had one about a year ago and they have always been normal.

DH and Allergies You took folic acid for about 6 months before you got pregnant, while you were trying, as you knew from your previous pregnancies that you needed to do this. However, this was the lower dose one as you did not realise until you came to the GP that you should be on a special high dose folic acid, so you took the high does from about 3 weeks, and are still taking it now. Pregnancy multivitamins.
No known drug allergies.

FH You were adopted and do not know about your family history. Your partner tells you that there has been no problems in pregnancy on his side.

SH You live with your partner and your 2 children. He is the father to all your children. You both work full time, you are an English teacher and plan on going on maternity leave in 4 weeks. He is a Police officer. Both your parents and his help out with the childcare. Neither you or your partner drink and you give up alcohol a year ago to help with your weight loss.

Please observe the student taking the history and performing the examination. The student should take an obstetric history, ensuring they focus on why the patient is under consultant lead care, as well as their previous obstetrics history and their ICE. The student should use empathy appropriately and approach the subject of obesity in pregnancy sensitively.

Further possible questions for this student may include the following: - What risks are associated with obesity in pregnancy? - What can we do to reduce these risks? - What advice should we give to the patient regarding weight loss during pregnancy? - Tell me about the use of folic acid in pregnancy. - Please tell me what investigations you would like to undertake for this patient. - How would you manage this patient?