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

Questions