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This is a long case.

Please take a history, ask for examination findings and discuss your management plan with the patient.


Zahra Mohammed Ibrahim is a 36-year-old Somali refugee who arrived in Australia 18 months ago. She presents with a two-month history of missed periods and is asking for a pregnancy test. Your practice nurse has completed a urine pregnancy test that is positive.

The following information is on her summary sheet:

  • Past medical history

  • G9P6M2

  • Miscarriage (nine months ago)

  • Hepatitis B (HBeAg negative)

  • Latent TB (completed nine months isoniazid therapy under guidance of TB clinic)

  • Medication

  • Nil prescribed

  • Allergies

  • Nil known

  • Immunisations

  • Completed standard refugee catch-up schedule

  • Family history

  • Unknown

  • Social History

  • Alcohol—nil

  • Smoking—nil

  • Lives with husband and six children (ages 2–12)

  • Cervical screening

  • None recorded.


You have presented today because you think you are pregnant. Your last period was about eight weeks ago (you are uncertain of the exact dates). You speak Somali and have very little English, although attend English classes three days per week when the children aren’t at home sick. Please accept an interpreter if offered, and if not, give single-word answers or feign confusion.

You are happy about the pregnancy but a little worried because of your miscarriage last year. You have had one other miscarriage 10 years ago when you were living in a refugee camp. You did not seek any preconception counselling and are not taking any medications or vitamin tablets. Large families are normal in your culture. You are mildly concerned about where you are going to fit another child in your three-bedroom housing commission home.

You have been pregnant many times before but have not delivered in Australia. Your previous deliveries have been at home or in a refugee camp without medical assistance. You have delivered naturally without complications in the past. You have little knowledge regarding what to expect in an Australian system.

You’ve never heard about Down syndrome screening but would never terminate a pregnancy. You would accept any child that you were given.

You are feeling well other than occasional mild nausea.

You have hepatitis B and have only a superficial understanding of this, knowing that it could affect your liver (which you understand is something inside your belly but don’t really know much more than this). You have had blood tests and an ultrasound 12 months ago and were told everything was okay; you have not been back to see your doctor since then.

Your two older children were also diagnosed with hepatitis B on arrival in Australia. Your husband was told he was immune to hepatitis B, and your younger children were vaccinated on arrival in Australia. ...

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