Beattie, J Antenatal

8/8/2019 Beattie, J Antenatal

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65,000Goodfellow Symposium, Auckland March 09

What isyour role?

www.moh.govt.nz/maternityOr

0800 252464

Section 88 PrimaryMaternity Services Notice

2007


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Aims to encouragecontinuity of GP

involvement in thecare of women.

Non-LMC first trimesterservices (DB10)Informing the woman regarding heroptions for choosing a LMC

Providing appropriate informationand education about screeningandoffering referrals to a provider for theappropriate screening tests

Providing written informationincluding screening test results andrelevant health information

Non-LMC first trimesterservices

Pregnancy care and advice

Care and advice if threatened oractual miscarriage.

Assessment care, and adviceprovided in relation to atermination of pregnancy

Non-LMC first trimesterservices

$110

$150 if threatenedmiscarriage or planningtermination

One fee claimed perwoman per enrolling PHO

Urgent pregnancy care(DB12 &13)

$40 normal hours

$60 out of hours

Per visit

General Practioners can register toaccess free secure information aboutreferral to DHB services.

Most DHB services on Healthpoint haveGP specific information that can only be

viewed once a registered GP has signed in.

www.healthpoint.co.nz


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Blood testsSwabsScansPhysicalLife Style

In any programme there is an irreducibleminimum of false positive and

false negative results.Thus, there is the potential to cause harm

during screening.

False reassurance False negativeRaised anxiety False positive

Dr Graham Parry 2008

Five Standard tests

Polycose

Glucose Tolerance Test

Maternal Serum Screen 1 & 2

HIV

Despite what we are doing

there is no decrease in numbers of T21 babies bornBut an increase in diagnostic tests

Maternal age is not a sufficientscreening test by itself.

Women should not be referred for invasivediagnostic tests

based on maternal age aloneJuly 2008

How important is Down syndrome to the woman?

Do they know what Down syndrome is?

Do they want screening?

Cultural aspects

Source: Dr Graham Parry SAMCL presentation2008


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Results show that it is now possibleto obtain a high level of detection

(8 or 9 out of every 10 affected pregnancies)With a false-positive rate (12%)

For women who present for the first time in thesecond trimester,

the quadruple test (MSS2) is the test of choice,

Serum, Urine & Ultrasound Screening Study 2003

Wald et alFirst and second trimester antenatal screening for Downs syndrome: the results of the Serum, Urineand Ultrasound Screening Study (SURUSS). Health Technology Assessment 2003; Vol. 7: No. 11

Maternal Serum Screening test in the 1st trimester(MSS1) taken between 9 and 11 weeks. Costs $120

Nuchal Translucency (NT) Scan by an accreditedpractitioner @ 11 weeks & 3 days 13 weeks & 6 days

MSS2 test in the 2nd trimester taken between 14 and18 weeks. Free

Positive result >1 in 300 offer amniocentesis orCVS

With treatment transmission is< 1% to unborn child

Without treatment transfer rate isapproximately up to 30%

NZ has no reported cases of verticaltransmission of HIV in women treatedin pregnancy

To treat women already infected andprevent ongoing infection to others

Source: Tracey Senior Antenatal HIV Co-ordinator CMDHB 2008

All Pregnant women to be offeredHIV test

Document decline or accept in notes

Failure to offer may be see as failure toidentify risk (section 88) & lead to:Medical misadventure by ACC Breachof the H&D code



Anticipate approx 10 confirmed HIV +vewomen in Auckland

Result phoned to requestor by laboratory

Phone Community HIV team for advicebefore giving result

Inform woman of result face to face

Source: Donna Raymond Antenatal HIV Co-ordinator ADHB 2008


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Dealing with confirmedHIV +ve resultAll information onwww.healthpoint.co.nz

Community HIV Teamlocated @ Auckland CityHospital

Mon-Fri 9-5 09 375 7077

Gestational Diabetes Mellitus (GDM)complicates 5-8% of all pregnancies inNew Zealand.

Universal screening is recommended

Early Polycose or GTT instead ofPolycose for those with several riskfactors

Source: GDM in New Zealand technical report, March 2007

Source: Susan Duckmanton, Diabetes Midwife Specialist, Tall Poppies article 2006

Previous GDM

Glycosuria at booking

Polycystic ovary disease

HbA1c is recommended


Combined Risk FactorsRequiring GTT

Age over 30

Obesity

Family Hx Especially maternal mother

High Parity

Source: Susan Duckmanton, Diabetes Midwife (CMDHB)

Combined Risk FactorsRequiring GTT

Previous Macrosomic baby &shoulder dystocia.

Unexplained still birth, pre-eclampsia, pre-term birth

Chronic hypertension



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ChlamydiaGonorrhoeaGroup B StrepTrichomoniasisBacterial Vaginosis

Early trans-abdominal USSto detect gestational age from 6weeks onwards

Nuchal Translucency (NT)

@ 11/40 + 3 13 /40+ 6

Anatomy 18-20 weeks

As required: Growth, Fetallie, Placental position,Biophysical profile (BPP)

Customized growth chartsavailable at:www.gestation.net

Pre-eclampsia can progress to a lifethreatening situation in, on averagetwo weeks from diagnosis.

Risk assessment is required early inpregnancy

Offer referral before 20 weeks forspecialist input to their antenatal careif they have one of the following:

The pre-eclampsia community guideline: how to screen for and detect onset of pre-eclampsia in the community.Milne et al BMJ 2005; 330; 576-580

Previous pre-eclampsia

Multiple pregnancy

Underlying medical conditions:

Presence of antiphospholipidantibodies

The pre-eclampsia community guideline: how to screen for and detect onset of pre-eclampsia in the community.Milne et al BMJ 2005; 330; 576-580


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First Pregnancy

10 years since last baby

Age 40

Body mass index 35

Family history of pre-eclampsiaThe pre-eclampsia community guideline: how to screen for and detect onset of pre-eclampsia in the community. Milne et al BMJ

2005; 330; 576-580

24 hour collect is themost reliable

Protein creatinine ratiolevels 30mg/mmol onrandom urine

The pre-eclampsia community guideline: how to screen for and detect onset of pre-ec lampsia in the community.Milne et al BMJ 2005; 330; 576-580

The prevalence of smoking in women of childbearingage (15-39years) ranges from 26-29%.

The rates vary significantly across ethnic groups, with

Maori rates between 39-61%,Pacific between 27-47%,

and Pakeha, 22-27%.

ource: New Zealand Smoking Cessation Guidelines 2007 pg 21 Data from 2006

FertilityPlacenta

Unborn babyPregnancy

New born babyBreast feeding

Infant Care ChoicesYoung Child

Professional PracticeSource: Education for Change, Safe Start 2008

Risks

SUDI / Asphyxia 200%

Sm all for dates 200%

Stillbirth 100%

Ectopic pregnancy 90%

Preterm Labour 70%

Placenta Previa 60%

PlacentalAbruption

60%

Cleft Lip 35%

Miscarriage 25%

Infertility 25%

Principles

Dose effect applies:less smoking, less risk

Becoming smokefreeat any time inpregnancy reduces therisk

Becoming smokefreein the first trimesteralmost reverses the risk.

Early intervention isbest

Source: Personal communication A/Prof L McCowan courtesy of Education for Change, Safe Start 2008


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InternationalRecommendations:Benefits of NRT faroutweigh the risksof smoking duringpregnancywww.nzgg.org.nzSource: Education for Change, Safe Start2008

Nicotine breaks down more quickly inpregnancy so higher NRT doses may be neededto achieve smokefree success

NRT removes harmful exposure to carbonmonoxide and the 4000 other chemicals

NRT relieves cravings, has a slower delivery andis less addictive than smoking

Source: Dempsey et al Vol 301, Issue 2 594-59 8, May 2002. Courtesy of Education forChange, Safe Start 2008

Source: Tomasina Stacey, Presentation at NZCOM conference ,Auckland, September 2008

Women of a normal BMI who put on more than16kgs during pregnancy have an increased rateof:

PreeclampsiaFailed inductionLarge for gestational age

Body Mass Index(weight in kgs height in ms)Not perfect but the easiest in context


Measure height to get an accurate BMI

BMI >30 Advise a weight gain of


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StillbirthNeonatal death

Large for gestational age

Small for gestational age

Shoulder dystocia

Congenital abnormality

Reduced rate ofbreastfeeding


Pregnancy is atime of

high risk.Violence often

begins orescalates in

pregnancy.Ministry of Health 2001

POLICE 111

CYFS (Children) 0508 FAMILY

VICTIM SUPPORT 0800 VICTIM

WOMENS REFUGE 09 378 1893

PREVENTING VIOLENCE inthe HOME (PVH) 0508 DVHELP

Levels of referral 1 & 2The LMC may recommend ormust recommend to the womanthat a consultation with aspecialist is warranted.

Level 3The LMC must recommend to thewoman that the responsibility forher care be transferred.

Guidelines for consultationavailable @

www.moh.govt.nz/moh.nsf/indexmh/maternity-section88notice

20 weeks Obstetric

If in doubt CALLWere friendly

The more information you cansend with the woman the better- especially copies of scans


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Concealed pregnancy

Appears to be 35-36 weekspregnant

Epileptic taking one medication

No seizures for 2 years now

Pre-pregnancy BMI of 16 andhas gained little weight

Dr Graham ParryDr Vivien WongTracey Senior & Donna Raymond Antenatal HIVco-ordinatorsSusan Duckmanton Diabetes MidwifeLesley Dixon New Zealand College of MidwivesDr Lesley McGowanTomasina Stacey Research midwifeStephanie Cowan Change for our children (formerlyEducation for Change)Clare Kirby Midwife Educator

Beattie, J Antenatal

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