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The UCLH Women’s Health 17 th annual GP study day

The UCLH Women’s Health 17 th annual GP study day. 16 th September 2009 . Obstetric case discussions. Dr Elisabeth Peregrine Consultant Obstetrician . A 40 year old primip attends for her routine 31 week check and has a BP of 150/100 and +1 proteinuria. History

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The UCLH Women’s Health 17 th annual GP study day

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  1. The UCLH Women’s Health17th annual GP study day 16th September 2009

  2. Obstetric case discussions Dr Elisabeth Peregrine Consultant Obstetrician

  3. A 40 year old primip attends for her routine 31 week check and has a BP of 150/100 and +1 proteinuria

  4. History • Headache / blurred vision / odema • Nausea and vomiting / epigastric pain • Personal history of ↑ BP • Family history of ↑ BP • Booking BP

  5. Examination • Repeat BP • Abdominal exam including SFH & tenderness • Odema • Reflexes • Investigations • Urine dipstick • Management • Refer to Maternal Fetal Assessment Unit (MFAU) 08.00-19.00 • 020 7380 9573

  6. Management in MFAU • Review of obstetric notes • Symptom enquiry • Serial BP measurement • Abdominal palpation • Urine dipstick • If mean BP ≥ 170/110 then to LW • If mean BP >140/90 then: • FBC / U&E / urate / LFTs • CTG • Urine PCR if ≥ +1 proteinuria • 24 hour urine if PCR > 30mg/mmol • Ultrasound

  7. Management in MFAU • Mean BP ≤ 140/90, no protein: • discharge to community: BP / urine 1/52 • Mean BP < 150/95, no protein, normal Ix • see MFAU 1/52 • Mean BP ≥ 150/95, no protein, abn Ix: • Medical review: • Admit • Or twice weekly MFAU • Mean BP > 140/90 and protein: • Medical review • Admit • Or twice weekly MFAU ( if PCR <30 & BP <160/100)

  8. Management of hypertension • To prevent intra-cerebral haemorrhage • >170/110 • Methyldopa • Loading dose 500-700mg • 250mg tds to max 3g a day • Good safety profile • Labetalol • 100mg bd up to max 2.4g a day • Concern re SGA • Nifedipine • 10mg SR bd up to max 80mg a day

  9. Principles of management / delivery • Diagnosis • +/- anti-hypertensives • Monitoring maternal and fetal well-being • Laboratory tests • USS for growth, amniotic fluid, +/- dopplers • +/- prophylactic steroids • Delivery when: • When maternal risks exceed fetal risks • When risk of intrauterine death exceeds risk of delivery and prematurity

  10. A 23 year old multip states at her booking visit that her last baby was on the neonatal unit with a group B strep infection after the delivery. What is your management?

  11. Previous Group B Strep infection • Normal antenatal care • Normal obstetric management • IV antibiotics in labour / once SROM • No benefit of CS

  12. Group B Strep • Early onset 0.5-1.5 per 1000 LB • 5-10% die • 25% of women colonised in vagina / intestine • < 1% of these babies become infected • IV Abs to those with risk factors reduce incidence • But no evidence screening in UK is effective as sensitivity of a vaginal swab is 50% • Antenatal treatment if in urine only

  13. Group B Strep • Treat if: • GBS infection in a previous baby • GBS detected in the vagina at any time in the current pregnancy • GBS detected in the urine at any time in the current pregnancy • fever in labour • prolonged rupture of the membranes, > 18 hours at term Aim for at least 2 hours prior to delivery

  14. A 35 year old primip is reviewed at her 34 week visit and is found to have a symphyseal fundal height of 38cm What is your management?

  15. Clinical large for gestational age • Confirm measurement • Compare to previous SFH • Confirm had screening for gestational diabetes • Review at 36 week visit • But if there is: • Sudden increase in SFH • Tense abdomen • Difficult to feel fetal parts • Tightenings • Refer to MFAU

  16. Clinical large for gestational age • No benefit of ultrasound in low risk women (NICE) • Inaccuracy of ultrasound • No benefit in outcome • Exception is in diabetic pregnancies • If ultrasound normal reassure • If AC or EFW > 97th centile for GTT • If GTT normal and EFW< 4.5kg then normal care • No benefit of induction of labour • Polyhydramnios will be referred to FMU

  17. Antenatal Care at UCLH

  18. Access to antenatal care UCLH encourages women to access maternity services as early in possible in pregnancy so that maternity booking can take place at 8 – 10 weeks gestation. • Referrals are accepted by the following methods: • GP referral by post: • GP referral by fax 020 7380 9754 • GP referral by telephone 020 7380 9400 • GP referral by email to: 1st.antenatal.appointments@uclh.nhs.uk • Women can self refer by any of the means above

  19. Thank you Any Questions?

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