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Izzy Stable is a lady who is currently 28 weeks pregnant. She is being seen in a consultant-led antenatal clinic. A handwritten medication list is below:

  • Aspirin 75mg from 10 weeks pregnant
  • Iron tablets
  • Folic acid
  • Pregnancy multivitamins.

Please take a history focusing on the patients risk factors in pregnancy. Please elicit her concerns about her pregnancy so far.

You are Izzy Stable, a 45 year old lady who is 28 weeks pregnant. This is your first pregnancy, therefore you are really nervous! You are pregnant with twins, which was twice the (pleasant) surprise. In general, you are rather anxious about your pregnancy, as you have been trying for 10 years to get pregnant. You finally became pregnant following your first round of IVF.

ICE You have had 5 miscarriages over the past 10 years so you can’t help but worry that this may happen again. Although you had IVF you do not like to tell people about it as you really wanted to get pregnant naturally. This is because you believe that getting pregnant should be a natural process: not interfered with though medicine. However, you became so desperate after 10 years that you and your partner decided to give IVF a try. You really were willing to try anything: you had even consulted a psychic by that point!

You were really happy that the IVF worked, however since becoming pregnant you worry about every little thing, as you just want to do the absolute best for your babies. You have been to see your GP at least every other week with concerns. However, your doctor keeps telling you that they are normal things: things that you do not need to worry about. You just can’t help yourself! You are not normally an anxious person and think this will go away after the delivery. You just want everything to be ok. You really struggled after your miscarriages, particularly the two late miscarriages at 20 and 21 weeks.

Despite all this, you are over the moon to be pregnant. You plan on breastfeeding. You have done lots of reading about breastfeeding and you know it’s the best thing to do for both you and the babies. You have also started planning the nursery! There is a strong history of twins in your family, nevertheless you were still very surprised to find out you were having twins!

PC You did multiple pregnancy tests after the IVF, as soon as you found out you were pregnant you went to see your GP. After your dating scan, which showed twins, you were referred to the consultant-led team.

HPC The pregnancy has gone well so far. You had a lot of morning sickness for the first 12 weeks but you have got over this now. You have had many scans in your pregnancy, they have all been normal. You chose not to have Downs’ Syndrome screening. You know you have a higher risk with your age and because you are having twins, but as you want to keep the babies anyway, you don’t see the point. Everything was normal at the abnormality scan. You have your blood pressure tested regularly, looking for signs of pre-eclampsia (you are a well-read patient so you know exactly what this is). Your twins have 2 placentas and 2 separate sacs to live in. They are both growing well and are similar sizes. You have not had any bleeding or pain during the pregnancy.

Past Obstetric History 5 miscarriages Age 36; miscarriage at 8 weeks Age 37; miscarriage at 20 weeks Age 40 miscarriage at 10 weeks Age 41 miscarriage at 8 weeks Age 43 miscarriage at 21 weeks No cause for miscarriages found.

Past Gynae history: You were previously on the COCP until age 35, when you decided to get pregnant. You previously had a regular cycle of 28 days with 6 days bleeding. You have never experienced intermenstrual bleeding. Moreover you have never really had vaginal discharge, apart from the occasional episode of thrush.

You have had an STI. You are up to date with smears; you last had one about a year ago and they have always been normal.

FH You have a sister who has Down’s syndrome, but nothing else comes to mind.

SH You live with your partner. You both work full time. You work in a health food shop and your partner works for the national trust as a park warden. You plan on working until 34 weeks if possible.

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.

Bonus points for the student if they check with the patient if she is happy for IVF to be written in the notes. It is a legal requirement to get permission from the patient to write about IVF in the patients notes.

Further possible questions for this student can include the following: - What are the risk involved in a twin pregnancy? What can we do to reduce these risks? - Tell me about the use of folic acid in pregnancy? - What is pre-eclampsia? - How do we manage pre-eclampsia? - Please tell me what investigations you would like to undertake for this patient. - How would you manage this patient?