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

    Source: Tracey Senior Antenatal HIV Co-ordinator CMDHB 2008

    Source: Tracey Senior Antenatal HIV Co-ordinator CMDHB 2008

    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

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

    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

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

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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

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

    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

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

    Pregnancy is atime of

    high risk.Violence