Transcript Slide 1
Dr Colette Sparey
Consultant Obstetrician & Clinical Director for Women’s Services
Alison McIntyre
Maternity Matron for Community and OPD Supervisor of Midwives
Obstetrics update for GPs
hypertension proteinuria vaccinations what to do with a chickenpox contact hyperemesis mastitis Vit K drops or injection anything else that has changed in the last few years
Hypertension - pre-pregnancy
Pre-pregnancy Good control Avoid ACE inhibitors if possible Usual health advice weight diet folate supplements
Hypertension – antenatal
Early pregnancy Change to safe drug as soon as pregnancy confirmed, if not already taking one e.g. labetolol, methyldopa Refer for Consultant led antenatal care Start low dose aspirin if: Chronic hypertension, renal disease, diabetic, SLE/APLS >1 of 1st pregnancy, 40+, BMI ≥35, FH PET, twins
Hypertension – antenatal
DBP ≥90mmHg needs referral to hospital SBP ≥160mmHg needs referral to hospital Higher BP = urgent referral Most cases managed via ANDCU Symptoms/signs to be concerned about headache (with hypertension) vomiting visual disturbances epigastric pain SGA/ FM
Hypertension - postnatal
Postnatal Expect BP in first few days Will (should!) not be discharged from ward until BP controlled ≤140/90mmHg Should have a plan of care for next six weeks Gradual reduction of anti-hypertensives GP FU at 2 weeks if still on anti hypertensive
Hypertension – postnatal
Definitions and management of new onset hypertension in Community Description Definition Action
New Hypertension DBP 90-99mmHg Severe Hypertension DBP 90-99mmHg & significant symptoms OR SBP ≥150mmHg OR DBP ≥ 100mmHg SBP ≥160mmHg OR DBP ≥ 100 with/without symptoms Hospital step up assessment within 24 hours Same day hospital assessment Immediate admission
Hypertension –
postnatal up to two weeks Care plan for all women on anti-hypertensives FU with CMW Frequency of BP monitoring Thresholds for reducing/stopping treatment Indications for referral to primary/secondary care Self-monitoring of symptoms Review with GP at two weeks If bloods abnormal on discharge, repeat at 2 weeks or as clinically indicated
Hypertension – 2-6 weeks PN
Stop/ medication if BP ≤140/80mmHg by 2 weeks PN Reduce in stepwise manner Recheck BP weekly for two weeks after medication discontinued Up to 13% of women with PET may have underlying chronic hypertension
Hypertension – 6-8 weeks PN
6 week check with GP Has hypertension resolved Has proteinuria resolved Might there be underlying hypertension/renal disease Arrange screen for antiphospholipid antibodies at 3/12 PN if delivered prior to 34 weeks gestation because of PET If proteinuria still present Send urine for PCR Offer review at 3 months to assess renal function Consider referral to Renal Physician
Hypertension - breastfeeding
No known adverse effects
on breastfed babies Labetolol* Methyldopa Nifedipine* Enalapril Captopril Atenolol Metoprolol Insufficient evidence of the safety for breastfed babies Angiotensin II receptor blockers Amlodipine ACE inhibitors (other than enalapril or captopril) *Assess adequacy of feeding in babies at least daily for first two days
Proteinuria -
In the absence of hypertension From 20 weeks gestation onwards 1+ - CMW review in one week ≥2+ - Refer ANDCU within 48 hours Unlikely to be UTI, hence rationale for referral ≥1+ with symptoms – refer ANDCU on same day Significant proteinuria 300mg/l/24hrs PCR 30mg/mmol Once documented, no need to repeat quantitative assessment
Chickenpox
VZV maternal mortality Maternal morbidity Fetal varicella syndrome Neonatal varicella Common childhood infection 90% UK pregnant women seropositive for VZV IgG Less so in women from sub/tropics
Chickenpox
Vaccination? Consider pre-pregnancy or postnatal in non-immune women Live vaccine so avoid pregnancy for three months post vaccine No reports of FVS in vaccinated women who conceive within this period
Chickenpox – what to do with a contact
History to confirm significance to contact susceptibility of patient Bloods to confirm VZV immunity Non-immune, significant exposure give VZIG asap – can give up to 10 days after contact 2 nd dose may be needed if repeat exposure within 3 weeks
Chickenpox –
pregnant woman with rash Contact GP immediately Avoid contact with susceptible others Symptomatic treatment and hygiene Oral acyclovir if present <24 hours and >20 weeks pregnant Use with caution before 20 weeks Discuss risks/benefits VZIG no benefit once rash developed
Chickenpox – who to refer to hospital
Chest symptoms Neurological symptoms Haemorrhagic rash or bleeding Dense rash Immunosuppression Consider if Smoker Chronic lung disease Taking steroids In latter half of pregnancy
Chickenpox – fetal risks
No increased risk of miscarriage in 1 st trimester FVS in <1% before 20 weeks Tiny risk 20-28 weeks No risk >28 weeks Consider referral to FM at least 5 weeks after infection and not before 16 weeks Limb hypoplasia/atrophy, scarring Microcephaly, hydrocephalus Ocular abnormalities – cataracts, micropthalmia IUGR
Chickenpox – at term
Avoid delivery <7 days after rash
Reduces risk of neonatal varicella
If baby born <7 days after rash or maternal rash within 7 days after birth
give neonatal VZIG Treat with acyclovir VZIG no use in neonatal VZV
Hyperemesis Gravidarum
Severe or protracted vomiting sufficient to cause fluid, electrolyte or nutritional imbalance 0.1-1% of pregnancies Onset always in 1 st trimester Remember ptyalism spitting Remember thiamine (Wernicke’s) Nausea & vomiting is normal in early pregnancy and requires reassurance only
Hyperemesis
Referral only if persistent vomiting and ketonuria <14 weeks gestation Treated on day case basis in MAC Ketones 0/1+ Home with oral anti-emetic promethazine 25mg qds cyclizine 50mg tds prochlorperizine 5mg tds PIL Dietary advice Expedite booking appointment GP to follow up
Hyperemesis
Ketones ≥2+ IV fluids Antiemetics (as above but IM or oral) Home Second presentation >5 days since last one, treated as outpatient <5 days since last one, may need admission
Mastitis
Inflammation caused by milk stasis Symptoms Redness, pain, lumpy breast Flu-like symptoms Often upper-outer quadrant but may be whole breast Tired & tearful Predisposing factors Suboptimal attachment Engorgement Blocked duct Pressure from tight clothing
Development of mastitis
-------Infection may be present ------- if untreated ABSCESS Hardness BLOCKED DUCT Begins as small palpable lump Mother feels well Tenderness Redness LOCALISED INFLAMMATION Increasing discomfort but generally well Fever Flu-like symptoms SYSTEMIC RESPONSE Hard, red lobe(s) Severe pain Mother feels ill TIME
An orientation to breastfeeding for General Practitioners
UNICEF UK Baby Friendly Initiative 2006
Mastitis - management
Continue breastfeeding Good breast drainage crucial Increase frequency of feeds Express between feeds/after feeds/before feeds Try diff positions (chin towards affected area) Breast massage Ensure clothing not too tight If this doesn’t work quickly give antibiotics Flucloxacillin 500mg qds Clindamycin 300mg qds if penicillin allergic Ibuprofen to reduce inflammation/for pain Medical review if not settled within 48 hours
Mastitis - abscess
Localised swelling, erythema, pain/tenderness Purulent discharge from nipple Systemic symptoms Pus swab USS – needle aspiration under USS control I&D only for loculated abscess or those which fail to respond to needle aspiration Antibiotics for 7-10 days Severe infection – admit and give IV antibiotics
Vaccinations
Seasonal flu/H1N1 Campaign every autumn Recommend to all pregnant women Safe Pertussis All pregnant women at 28 weeks gestation Advised to contact GP CMW supplying list of pregnant women to GP surgeries
Vitamin K – oral or IM
Aim – to prevent VKDB IM 0.5-1mg at birth Possible link with childhood cancer, little evidence Oral day 1, 1, 4 & 8 weeks of age Issues of compliance and efficacy Early onset VKDB IM & oral similar Late onset VKDB IM vit K no cases Oral 1.2-1.8 per 100,000
Sepsis
Leading cause of maternal mortality in most recent confidential enquiry Topic because of recent GAS outbreak Relevant to GPs both antenatally and postnatally
Sepsis - antenatal
Risk factors Obesity Immunosuppression Anaemia GBS carriage Invasive procedures Cervical cerclage PPROM Contact with GAS Black or other ethnic minority group
Sepsis – clinical symptoms
Fever or rigors D&V – may indicate endotoxin production Rash Abdominal/pelvic pain & tenderness Offensive PV discharge Productive cough Urinary symptoms
Sepsis - signs
Pyrexia Hypothermia Tachycardia Tachypnoea Hypoxia Hypotension Oliguria Impaired consciousness Failure to respond to treatment Signs may not always be present and are not indicator of severity Should trigger urgent referral to secondary care
Sepsis - postnatal
Additional risk factors Impaired GTT/DM Vaginal trauma, caesarean section, wound haematoma RPC Causative organisms GAS (strep pyogenes) Responsible for almost 50% of maternal sespsis deaths in 2006-2008 E coli Staph aureus Strep pneumoniae MRSA
Sepsis – postnatal symptoms
Fever/rigors – may be absent if self-medicating D&V Breast engorgement/redness Rash Abdo/pelvic pain Wound infection Offensive vaginal discharge Productive cough Urinary symptoms Delayed uterine involution, heavy lochia General non-specific
Sepsis –
indications for hospital admission Pyrexia >38 0 C Sustained tachcardia >90bpm RR >20bpm Abdominal or chest pain D &/or V Uterine or renal angle pain Women generally unwell or seems unduly anxious or distressed Early presentation (<12hrs) more likely to be strep esp GAS Severe continuous pain suggests necrotising fasciitis
Group A Strep
Group A Strep
Sepsis – prevention & prophylaxis
All pregnant and recently delivered women should be warned of signs and symptoms of genital tract infection and how to prevent transmission Any GAS identified during pregnancy should be treated aggressively Warn close household contacts about symptoms of GAS and advise to seek medical attention should symptoms develop
Everything else
Predictive genetic testing especially not in children Caesarean section please don’t offer/recommend to anyone
Advice
please feel free to ask if in doubt phone delivery suite