Dr Colette Sparey Consultant Obstetrician & Clinical Director for Women’s Services

1. Dr Colette Sparey Consultant Obstetrician & Clinical Director for Women’s Services Alison McIntyre Maternity Matron for Community and OPD Supervisor of Midwives

2. 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

3. Hypertension - pre-pregnancy • Pre-pregnancy • Good control • Avoid ACE inhibitors if possible • Usual health advice • weight • diet • folate supplements

4. 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

5. 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

6. 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

7. Hypertension – postnatal

8. 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

9. 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

10. 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

11. Hypertension - breastfeeding

12. 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

13. 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

14. 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

15. 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 • 2nd dose may be needed if repeat exposure within 3 weeks

16. 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

17. 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

18. Chickenpox – fetal risks • No increased risk of miscarriage in 1st 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

19. 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

20. Hyperemesis Gravidarum • Severe or protracted vomiting sufficient to cause fluid, electrolyte or nutritional imbalance • 0.1-1% of pregnancies • Onset always in 1st trimester • Remember ptyalismspitting • Remember thiamine (Wernicke’s) • Nausea & vomiting is normal in early pregnancy and requires reassurance only

21. 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

22. 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

23. 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

24. Development of mastitis -------Infection may be present ------- if untreated  ABSCESS Hardness Tenderness Redness Fever Flu-like symptoms TIME LOCALISED INFLAMMATION Increasing discomfort but generally well SYSTEMIC RESPONSE Hard, red lobe(s) Severe pain Mother feels ill BLOCKED DUCT Begins as small palpable lump Mother feels well An orientation to breastfeeding for General Practitioners  UNICEF UK Baby Friendly Initiative 2006

25. 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

26. 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

27. 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 Vaccinations

28. 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

29. Sepsis • Leading cause of maternal mortality in most recent confidential enquiry • Topic because of recent GAS outbreak • Relevant to GPs both antenatally and postnatally

30. Sepsis - antenatal • Risk factors • Obesity • Immunosuppression • Anaemia • GBS carriage • Invasive procedures • Cervical cerclage • PPROM • Contact with GAS • Black or other ethnic minority group

31. Sepsis – clinical symptoms • Fever or rigors • D&V – may indicate endotoxin production • Rash • Abdominal/pelvic pain & tenderness • Offensive PV discharge • Productive cough • Urinary symptoms

32. 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

33. 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

34. 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

35. Sepsis – indications for hospital admission • Pyrexia >380C • 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

36. Group A Strep

37. Group A Strep

38. 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

39. 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

40. Questions