Hot topics in Obstetrics

1. Hot topics in Obstetrics Dr Jane Rutherford Consultant in Maternal and Fetal Medicine QMC

4. NOTTINGHAM PRIMARY CARE TRUSTS NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST OBSTETRIC CLINICAL GUIDELINES

5. Fetal Varicella Syndrome • Exposure in the first 20 weeks of pregnancy • 1% before 12 weeks; 2% between 13 and 20 weeks • Skin scarring in a dermatomal distribution • Limb hypoplasia and/or paresis • Low birth weight • Less commonly microcephaly, neurological anomalies and eye defects

6. Varicella in pregnancy • Varicella pneumonia in 5-14% of adults • Mortality and morbidity higher in pregnancy • More common in smokers

7. VZIG for Varicella Contacts • A seronegative pregnant woman with a significant contact should be offered VZIG. • The outcome in pregnant women is not adversely affected if the administration of VZIG is delayed up to 10 days. • Clinical chickenpox will still develop in a proportion of women given VZIG but may be attenuated. • Women who have had contact with chickenpox (regardless of whether or not they have received VZIG) should be asked to notify a health professional if a rash develops.

8. Aciclovir • Oral aciclovir may be given to women who present in the first 24 hours of rash or are more than 20 weeks pregnant.

9. Down’s syndrome screening • Nuchal translucency • Serum (triple) screening • Oestriol • Free βHCG • AFP

10. Nuchal translucency

11. Down’s syndrome screening • National screening committee guidelines • A detection rate of at least 60% with a false positive rate of 5% or less (by April 2004/5) • A detection rate of greater than 75% with a false positive rate of less than 3% (by April 2007) • http://www.screening.nhs.uk/downs

12. Down’s screening • The quadruple test :Second trimester test based on the measurement of AFP, uE3, free beta-hCG (or total hCG), and inhibin-A together with the woman’s age. • The serum integrated test

13. The combined test: First trimester test based on combining nuchal translucency measurement with free beta-hCG, pregnancy-associated plasma protein A (PAPP-A) and the woman’s age. • The integrated test: nuchal translucency measurement and PAPP-A in the first trimester with the quadruple test in the second - better performance than the combined test if good quality NT measurement is available and the woman is prepared to wait until the second trimester for results.

15. Parvovirus B19 • Erythema infectiosum • Fifth disease • Droplet transmission • Viraemia 6-8 days after exposure and persists for 7 days • Fever, rash (slapped cheek), arthropathy

16. Parvovirus

17. Parvovirus • May be associated with fetal loss or hydrops • Risk of fetal loss highest in first 20 weeks – approx 10% • After 20 weeks fetal loss risk <1%, risk of hydrops 0.3%

18. Parvovirus serology • IgM can be detected 10 days after exposure and lasts for 3 months • IgG is a marker of past infection

19. Exposure to parvovirus • Check immunity • If IgG/IgM negative repeat in 3 weeks • If IgG negative and IgM positive • Counsel that risks are low • If > 20 weeks refer for hydrops screening • If hydrops detected, consider intrauterine transfusion

21. www.rcog.org.uk

22. Obstetric Cholestasis • In UK 0.7% of pregnancies in multi-ethnic populations • 1.2–1.5% of women of Indian-Asian or Pakistani-Asian origin. • Prevalence is influenced by genetic and environmental aspects and varies between populations. • In Chile 2.4% of all pregnancies are affected with 5% prevalence in women of Araucanian-Indian origin.

23. Obstetric Cholestasis • Multifactorial condition • Intense pruritus in the absence of a skin rash • Abnormal liver function tests (LFTs) • Remits following delivery. • Need to exclude other causes of pruritus and of abnormal LFTs.

24. Obstetric Cholestasis • Fetal risks • spontaneous prematurity, • iatrogenic prematurity • intrauterine death • Increased meconium stained liquor

25. Risk of Stillbirth with OC • Early studies suggest increased rate • Most recent studies show no difference in stillbirth compared to normal population but no studies looking at untreated OC • Risk of stillbirth in untreated OC is unclear

26. Management • Ultrasound is not useful in preventing stillbirth • Intrauterine death may be a direct cardiac effect of bile acids • CTG may be useful but limited • Early delivery (?)

27. Management of OC • Emollients: aqueous cream with menthol • Antihistamines • Ursodeoxycholic acid • Vitamin K Follow up 50% recurrence risk

28. www.apec.org.uk

30. Risk Assessment early in Pregnancy • Before developing an antenatal care plan you must identify the presence of any of the following factors that predispose women in a given pregnancy to pre-eclampsia (grade B/C) • First pregnancy (almost triples risk) • Previous pre-eclampsia (7 times risk in a second pregnancy) • ≥ 10 years since last baby (almost triples risk) • Age≥40 years (almost twice the risk) • Body mass index ≥ 35 (Doubles risk) • Family history of pre-eclampsia (mother or sister) (almost triples risk) • Booking diastolic blood pressure ≥ 80mmHg • Proteinuria at booking (≥ on more than one occasion or ≥300mg/24h) • Multiple pregnancy (almost triples risk) • Underlying medical conditions: • Pre-existing hypertension • Pre-existing renal disease • Pre-existing diabetes • Presence of antiphospholipid antibodies (significantly increases risk)

31. Offer women referral for specialist input to their antenatal care plan if they have one of the following (grade D/good practice point) ·Previous pre-eclampsia ·Multiple pregnancy ·Underlying medical conditions ·Pre-existing hypertension or booking diastolic blood pressure ≥ 90mm Hg ·Pre-existing renal disease or booking proteinuria (≥ + on more then one occasion or ≥ 300mg/24h) ·Pre-existing diabetes ·Presence of antiphospholipid antibodies ·Any two other risk factors

37. Group B Strep www.gbss.org.uk

38. GBS • Vaginal commensal in 25 – 30% of women • Does not need to be treated when found on HVS • Does require treatment when found in urine

39. Screening for GBS • Standard HVS – 50% false negative rate • Enriched culture medium (ECM)– LVS and rectal swab: considered the “gold standard”. More reliable than HVS • ECM only available privately c. £40

40. GBS • Women who have GBS on a swab at any time require IV antibiotics in labour (penicillin) • 2 hours prior to delivery • If mother does not receive antibiotics and neonate has no signs of infection then observations for 24 hours • If mother does not have antibiotics and there are signs of sepsis then neonate will receive antibiotics.