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What’s new in obstetrics?

What’s new in obstetrics?. Miss Audrey Ryan Consultant Obstetrician & Gynaecologist Dorset County Hospital Foundation Trust November 2009. We’re all still having babies…. GPs and obstetrics?. Direct referral Antenatal day assessment. Messages from Confidential Enquiry.

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What’s new in obstetrics?

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  1. What’s new in obstetrics? Miss Audrey Ryan Consultant Obstetrician & Gynaecologist Dorset County Hospital Foundation Trust November 2009

  2. We’re all still having babies…

  3. GPs and obstetrics? • Direct referral • Antenatal day assessment

  4. Messages from Confidential Enquiry • Pre-conception care – especially for ART and including obesity • Access to care – NB migrant women, social exclusion • Systolic hypertension requires treatment

  5. Optimise medical condition Medication review – ACE inhibitors, statins, antidepressants, Metformin Asthma Inflammatory bowel disease Epilepsy (5mg Folate) Mental health – suicide leading cause of maternal death ’97-’02

  6. Diabetes HbA1c: predictor of miscarriage, anomaly and adverse pregnancy outcome - <6 advised, 6-10 higher risk, >10 consider ToP 5mg Folate Medication review – Statins, ACE inhibitors, insulin regime, oral anti-diabetic agents

  7. Epilepsy • If seizure free at conception, 90% will stay seizure free • Fetal risks • Of seizures: IUD, CP, learning difficulties • Of medication: teratogenicity • Maternal risks • Folate • Vitamin K • Medication – avoid valproate and aim for single therapy (6% 1 drug, 10-15% 2 drugs)

  8. Depression • Examine reasons for starting in first place • Need to reduce dose gradually (liquid preps) • Untreated depression: low birthweight, preterm birth, low Apgars, problems in later life – best thing for baby is that mother is well • Which medication? TADs vs SSRIs Fluoxetine > Citalopram/Sertraline>Paroxetine – congenital anomalies, withdrawal

  9. Domestic violence • 30% begins in pregnancy • 40-60% continues in pregnancy • 19 women in last report murdered • “Have you ever been hit, punched, kicked or in any way abused by someone close to you?” • Preterm labour, perinatal death, obstetric haemorrhage

  10. The big issue……

  11. Obesity – BMI >35 – the risks Fetal: stillbirth tripled, anomalies at least doubled (so 5mg Folate), macrosomia (x4) Maternal: Gestational diabetes (x4), Hypertension and PET (x5), Thrombosis,infection Induction, Caesarean Section (x3) haemorrhage, 3rd and 4th degree tears Anaesthetic risks

  12. In the news… • Screening – the future: Non Invasive Prenatal Diagnosis (NIPD): free fetal nucleic acids in maternal blood • Current NHS use: fetal Rhesus status, fetal sex • ?Down’s syndrome (Trisomy 21) ?5 years • Sequenom Ltd (USA) – ‘data mishandled’

  13. Swine flu in pregnancy – the problem • Most make a good recovery, but higher risk of severe complications (esp respiratory, mostly in 2nd and 3rd T) • Risk of hospitalisation 3-4x higher • Co-morbidity increases risk (obesity, diabetes, chronic illness)

  14. Swine flu vaccination • Lancet 2008: evidence of excess mortality in 2 previous influenza pandemics supports vaccinating in any trimester during a pandemic • vaccine reduces risk of woman and neonate catching swine flu • no evidence of risk from vaccines (European Agency for the Evaluation of Medicinal Products) • Use Pandemrix (single dose)

  15. Swine flu - management in pregnancy • Fluids + paracetamol (not NSAIDS or OTC cold remedies), but watch for pneumonia • Early antivirals – zanamivir (Relenza) 1st choice; if complicated, oseltamivir (Tamiflu) • Antibiotics - if co-morbidity / LRTI signs / severe tonsillitis/sore throat, (Augmentin, 5/7) • Don’t forget differential diagnosis eg PE • UK Teratology Information Service asks for notification of pregnant women on antivirals

  16. Swine flu when breastfeeding • Breastfeeding should be continued if at all possible, even when the mother is affected by swine flu. • Treat breastfeeding mothers with oseltamivir (but don’t switch if started zanamivir prior to delivery)

  17. Summary • Midwifery guided care BUT • Prescription – pre and ante-natally • Pre-conception management • Pregnancy care – with support from secondary care

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