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You are an F1 working in the antenatal clinic and you have been asked to take a booking history from this 34 year old lady with a BMI of 35. Her name is Jenna Till.

Please take a booking history from Jenna and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are a 34 year old lady called Jenna Till. You have come to the antenatal clinic today because your midwife has identified you as a high risk pregnancy due to your weight.

HPC: Your last period was 15 weeks ago and you have had a dating scan today which told you that you are 14 weeks pregnant. This is your third child and although the pregnancy was not planned, overall you are happy to be pregnant again. You found out by taking a home test after you missed your period and your GP then confirmed it. You have had some morning sickness but no more than in your previous pregnancies and you have been trying to eat and drink as normal to keep your energy levels up. Your breasts are a little tender but nothing you didn’t expect. You have had no abdominal pain or bleeding that you can think of.

POH: You have two children and this is the fourth time you have been pregnant. The first time you were pregnant was when you were 16 and you had a termination where you took a pill at 10 weeks. There were no complications following this. The second time you were pregnant was 13 years ago (when you were 21). You had a girl weighing 8lb 2oz at 39 weeks. It was a normal vaginal birth and you only had a small tear. Your daughter is developing normally and doing well at school. You did not experience any problems during the pregnancy that you can think of.

The third time you were pregnant was 8 years ago (when you were 26). You had another girl, this time weighing 9lb 3oz at 38 weeks. You had put quite a bit of weight in between pregnancies so the midwife had to do a “sugar test” because of your size. The test showed that your sugars were high and you had to make sure you ate really healthily to control them. You had an epidural and they had to “give you a snip” down below during the labour because her shoulder got stuck, but your stitches healed well and you have had no problems with continence. Your daughter is developing normally and doing well at school.

PGH: Your periods started when you were 13 and are regular, bleeding 5/28. They are not too heavy or painful. Your smears are up to date and have all been normal. You have never had any STIs. You were previously on the Depot injection for contraception but that was many years ago! Nowadays, you and your partner just use condoms – you think one must have broken in order for you to get pregnant!

PMH: You had asthma as a child but it rarely bothers you nowadays.

DH: You have been taking folic acid 400mcg since you found out you were pregnant. You are allergic to penicillin (you get a rash).

FH: Your mother was diagnosed with type 2 diabetes last year. She currently takes tablets to manage it but you can’t remember what they are called.

SH: You live at home with your partner and two daughters. They are all very excited at the prospect of having another sibling! Your partner is a lorry driver and can be away quite a lot but you all manage well. You are a social worker which can be very stressful at times. However, you love your job and they have been very good about maternity leave in the past so you are not worried.

You smoked a few cigarettes as a teenager but never since and you enjoy a bottle of rosé on a Friday night although you have not drank since finding out you were pregnant.

ICE: You know you are a high risk pregnancy due to your size and some of the issues in your last pregnancy. You are a bit worried about what the increased risks are and how they might affect your baby. You have just come to have your scan and booking history and maybe find out a bit more about what will be happening in your pregnancy.

Observe the student take a booking history from the patient. It may be relevant to do an abdominal examination but at 14 weeks an obstetric examination would not be relevant. Ask the student to summarise this woman’s history.

Points for discussion: • What tests will this lady require at her booking visit? • What risk factors does this lady have that would make her a high risk pregnancy? • What extra aspects of care will she require? • What is the pathophysiology of gestational diabetes? • What are the potential risks to mother and baby in gestational diabetes? • How do we manage gestational diabetes? • What are the criteria for carrying out an oral glucose tolerance test at 24-28 weeks? • What are the risks of being overweight or obese for both mother and baby? • What condition is the patient describing during the labour of her second daughter? What are the potential risk factors for this condition and the potential risks to mother and baby of this condition? How do we manage this condition acutely?