DIETARY ADVICE THIRD TRIMESTER • Increased total protein intake at 28/40 by increasing dietary protein to 50g/day. • 32/40 - further increase to 60g total protein - 0.9g/kg/day. Growth scan at 28/40 - abdominal circumference, head circumference and femur length as well as foetal, weight were all on 50th centile; four-weekly repeat growth scans showed good interval growth and always remained close to the 50th centile. PLAN FOR LABOUR • Induction of labour likely on estimated date of delivery, i.e. at 40/40 if the patient had not delivered naturally by then. • 10% IV dextrose to start on admission with medications, plus oral glucose polymer solution, to provide external calories for the effort of labour. • Regular anti-emetics administered to avoid vomiting and also IV antibiotics and paracetamol given to mother to prevent or damp down any metabolic stress.
PERI-PARTUM DIETARY MANAGEMENT PLAN • 2,500kcal if possible during labour/post labour. • ‘Sliding scale’ SOS25/snacks to meet above. • 25-30g protein daily peri-partum. • Low protein/high carbohydrate snack and meal options previously discussed. • Ensure fully prepared - glucose polymer in her hospital bag; low protein foods on standby. BEFORE DISCHARGE AND POST DISCHARGE • IV dextrose continued until eating and drinking well and was replaced with oral glucose polymer drinks until day five to six. • Ammonia monitoring - this was done daily day one to seven post-delivery. • Six- to 12-hourly ammonia monitoring if any increase occurred (there was one small increase only). • Discharge home on was on day 10 (the discharge was complicated by the daughter’s OTC status looking positive and in fact this was confirmed via genetics subsequently - neonatal ammonia levels are difficult to interpret). • Follow-up was three times per week in first week post discharge, and twice weekly ammonia levels for one month postpartum - the involution of the uterus (a large release of endogenous collagen, i.e. protein into the blood stream) can occur anytime between one and eight weeks post-delivery. I can report that there were no subsequent metabolic decompensations since the one described here. Metabolic stability has been achieved for the time being for this patient
www.NHDmag.com November 2017 - Issue 129
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