29-year-old primigravida with BMI of 35kg/m2 with an uneventful antenatal period is admitted at 38 weeks gestation in labour…

A 29-year-old primigravida with BMI of 35kg/m² with an uneventful antenatal period is admitted at 38 weeks gestation in labour.
On admission to the hospital, she was 6 cm dilated and parameters in the partogram was within the normal range. On her insistence, an emergency caesarean section was performed and a healthy baby girl weighing 2.8 kg was delivered. The surgery and the postoperative period were uncomplicated, and she was discharged after 72 hours.

While at home she experienced episodic chest pain and difficulty in breathing. On the 10^th postoperative day she collapsed after complaining of severe chest pain. She was pronounced dead on arrival at the hospital.

Outline the measures, which could have prevented this death. (45 marks)

Optimizing BMI during antenatal period

Counsel the patient regarding mode of delivery during antenatal period and if any concerns regarding vaginal delivery address them as appropriate.

Allow to progress through normal vaginal delivery with adequate pain relief

Identify this as a high risk for venous thromboembolism patient

Thromboprophylaxis of low molecular weight heparin for 10 days post partum period.

Antiembolic stockings during postpartum period with increased hydration.

Patient advice prior discharge to seek immediate care for warning signs

Give three reasons how a rising caesarean section rate could increase the maternal mortality. (15 marks)

Increase the chance of puerperal infections

Increase incidence of placenta previa & abnormally invasive placenta in next pregnancy

Increase incidence of uterine rupture in next pregnancy

What are the factors that contribute to the increasing caesarean section rate due to non-medical reasons? (20 marks)

Fear of pain,

Fear of medical litigation, and organizational, economic, social and cultural factors have all been implicated in this trend.

Other factors such as differences in style of professional practice,

What are the steps, which can be taken to reduce non-medically indicated caesarean section? (20 marks)

1. Educational interventions for women- identify the causes for requesting elective caesarean sections and address them as appropriate e.g. counselling, referring to psychologist

2. Clinical guidelines and second opinion- in cases of doubtful indication and maternal request seems to be more, getting a second opinion could address the issue

3. Clinical guidelines, audit and feedback

4. Collaborative midwifery-obstetrician model of care

5. Financial strategies

4. The sustainable development goals (SGDs) are a collection of 17 global goals set by the united nations general assembly in 2015 for the year 2030.

What are the sustainable development goals? (20 marks)

The Sustainable Development Goals (SDGs) are a collection of 17 global goals set by the United Nations General Assembly in 2015 for the year 2030. The SDGs are part of Resolution 70/1 of the United Nations General Assembly, the 2030 Agenda.

The Sustainable Development Goals are

No Poverty
Zero Hunger
Good Health and Well-being
Quality Education
Gender Equality
Clean Water and Sanitation
Affordable and Clean Energy
Decent Work and Economic Growth
Industry, Innovation, and Infrastructure
Reducing Inequality
Sustainable Cities and Communities
Responsible Consumption and Production
Climate Action
Life Below Water
Life On Land
Peace, Justice, and Strong Institutions
Partnerships for the Goals.

The Post-2015 Development Agenda was a process from 2012 to 2015 led by the United Nations to define the future global development framework that would succeed the Millennium Development Goals. The SDGs were developed to succeed the Millennium Development Goals (MDGs) which ended in 2015. The gaps and shortcomings of MDG Goal 8 (To develop a global partnership for development) led to identifying a problematic “donor-recipient” relationship. Instead, the new SDGs favor collective action by all countries.

Describe the sustainable development goals relevant to obstetrics and gynaecology and the set targets of each such sustainable development goals. (30 marks)
Discuss the measures and actions you would propose to adopt in Sri Lanka to achieve the set targets given in 4.2 above. (50 marks)

5. A recently married couple of which one partner has been diagnosed of a cancer comes to your gynaecology clinic. They plan to embark on a pregnancy in the future and wish to discuss all fertility preservation options available to them. They are not happy to divulge further information about the cancer due to personal reasons.

Briefly explain what is meant by “fertility preservation in cancer patients” and its importance. (30 marks)

Cancer survivors at reproductive age are increasing due to early detection of malignancies and advanced treatment options. Cancer itself can damage the DNA and affect the gametes. And also chemotherapy and radiotherapy also adversely affect the dividing cells specially the gametes. Therefore, while curing the malignancy, preserving the fertility is important.

Describe briefly the comprehensive multidisciplinary teamwork and supports available for this purpose. (20 marks)

Aim is reducing the exposure of cancer, reduce the iatrogenic damage to gonads either from radiotherapy or chemotherapy and preserving gametes or embryos in vitro. Therefore, multidisciplinary team comprising oncologist, fertility specialist, gynaecologist, onco-surgeon, counsellor, clinical geneticist and the family needs to have a discussion prior commencing treatment.