ANTE-NATAL CARE
Pre-conception counselling advice – GP setting
Questions to ask? Advise to do Vaccinations
1. Planned vs unplanned vs concealed pregnancy 1. Family planning ® Fertility awareness + contraception concerns 1. MMR
a. LMP + assoc. symptoms è calculate EDD (social and financial support) 2. DPT (preconception
2. Birth plan (public vs private, MW-led, GP-led, OBs-led, shared care) 2. Healthy SNAP + S / A/ D + sleep or 27-36 wks)
3. PMHx (e.g. HTN, T1DM, epilepsy, PCOS, endometriosis, ectopic) o Record BMI, Vitals (BP) and pre-pregnancy weight 3. Flu
a. Assess VTE risk - blood film, Hb electrophoresis 3. Supp. Folic acid (NTD): 0.4-0.5mg ( 1 mth prior) 4. Varicella (28 days
4. Sexual & Menstrual (previous STI, PCOS, fibroids, fertility issues) o 5mg if T1DM, epilepsy, Hx of NTD prior to conception
4. Supp. 150µg Iodine daily = (prevent cretenism) as live vaccine)
a. STI,BBV ((C+G, HIV) ® NAAT or PCR urine)
5. Supp. 400µg Vitamin D daily = (↑Ca resorb = reduce bone loss) 5. Pneumococcal
5. OB/GYN Hx (GDM, PIH, PPH, pre-eclampsia)
(high-risk woman)
a. ABO +Rh type, GxPy, delivery and complications 6. Avoid – Cat litter (toxo), undercooked meats (salmonella), soft
cheese (listeriosis), pate (XS vit A – teratogenic) 6. Hep B (high-risk
6. Meds OTC meds, anti-epileptics, anti-HTN, anti-coags, anti-BSL) woman)
7. FHx (Hx of NTD, CF, Fragile X, Tay-Sachs) 7. Food advice
7. HPV (before
8. SHx: Substance abuse (illicit, smoking, alcohol) 8. Minimise flying (<32 weeks) ® VTE
conception – not
a. Allergy and IUTD 9. SAFE SEX during pregnancy)
b. Mental health = A+ D, DFV 10. Refer to Jean Hailes website for more info
PMHx: Effect of chronic disease & environmental factors
Diabetes / HTN Hypothyroidism Epilepsy Rheumatoid Smoking Alcohol
obesity (1st trimester) Arthritis
Most common • Pre-term • Cognitive impaired Pregnancy worsens seizure • Flares up during • IUGR, NO SAFE –
• High glucose levels = • IUGR • pre-term control due to pregnancy and after • M/C or stillbirth QUANTITY OR TYPE
teratogenic in 1st • Placental • LBW • Additional stress delivery • Pre-term labour / OF ALCOHOL
trimester (HbA1C < 7) abruption • Lack of sleep delivery • M/C
• Placental abruption
Pregnancy issues • Pre-eclampsia • Hormonal changes • Placental abruption • SGA
Sx • M/C + stillbirth
• LGA - Shoulder • Fetal death • Altered med regimes • Pre-eclampsia • Pre-term
dystocia • Fetal Alcohol
• Cleft lip or palette
• Pre-eclampsia Long-standing HTN Pregnancy issues Spectrum
• SIDS
• GDM – retinopathy, renal Disorder (CP,
Ø M/C + stillbirth
disease, LVH microencephaly)
• Wt loss, PA, diet • Educate • TFT screen for • Folic acid 5mg – reduce Well-controlled for > • Counselling • Counselling – stop
• sleep (OSA) • Labetalol, CaB, pregnant woman risk of neural tube defect 3/12 before falling • Nicotine patches drinking
• Meds – metformin + alpha blockers • 25-50mcg • Control epilepsy ideally pregnant
GLP-1 • Avoid ACEi/ARB Levothyroxine with 1 drug before • Hydroxychloroquine
and thiazides (crosses placenta)– falling pregnant (1st line)
• Bariatric surgery
titrate dose • Safe drugs • Sulfasalazine
• Optimise BSL control accordingly
Mx Levetiracetam, lamotrigine • Corticosteroids (for
• AIM: TSH < 2.5 and carbamazepine flare-ups)
• Avoid Na valproate Avoid
*NB: hyperthyroid = high and phenytoin Ø MTX
maternal + neonate (teratogenic,
morbidity M/C and
congenital
issues)
Medications History: è MotherSafe CALL HELPLINE 1800 647 848
Drug’s effect on fetus/embryo depends on:
1 specific drugs properties AND
2 GA at time of exposure
Meds SAFE? Pregnancy issue Newborn issue
NO – unless 3rd trimester – PDA closure & delays labour
NSAID
RA flare
, IUGR & hypoglycemia of newborn
BB NO
bradycardia in newborn
• Teratogenic ® M/C • hypocalvaria (incomplete formation of skull bones)
ACEi /ARB NO • Kidney damage or renal
failure (oligohydramnios)
Neonatal abstinence syndrome (3-72 hrs after birth) = irritable, febrile, tachypnoea and poor feeding
Opiates Depends
NB: benzodiazepines = 1st trimester – cleft palette è 3rd trimester – floppy baby syndrome
• Bleeding during pregnancy • IUGR, congenital malformation (craniofacial problems - Nasal hypoplasia)
Warfarin NO (e.g. PPH, ICH, fetal • Internal bleed (ICH and intra-abdo bleed)
haemorrhage) • Maternal = APH, PPH
Na Valproate NO NTF + developmental delay
• 1st trimester = CHD (E.g. • Breastfeeding (toxic)
No (use ebstein’s anomaly –
Lithium
lamotrigine) tricuspid lower on R) side of
heart)
• 1st trimester = CHD, or Neonate = withdrawal
congenital malformation symptoms
Specialist
SSRI (paroxetine)
advice
• 3rd trimester = Persistent
HTN
Vit A derivative® highly
Isotretinoin NO teratogenic ® M/C + congenital
defects
Certain ABx (SAFE moms take really good care) è Sulfonamides,
and anti- NO aminoglycosides, fluoroquinolones, erythromycin, metro, tetra, MEDICATIONS THAT CROSS IN BREAST MILK
fungals ribavirin, griseofulvin, chloramphenicol
• ABX = metro, chloramphenicol, tetracyclines (yellow teeth in infants)
• Chemo = MTX, cyclophosphamide
• Psych = diazepam and Li (mood stabiliser)
, INFECTIONS DURING PREGNANCY (TORCH and others)
CNS Cardiac Hearing loss Vision loss MSK/ SKIN GI Screened routinely + Rx
Toxoplasmosis • Hydrocephalus Sensorineural chorioretinitis Rash HSM No SCREEN è Anti-parasitic (1 year regime)
(Toxoplasma • Intracranial Hearing loss Jaundice = pyrimethamine + sulfadazine
calcifications Ø Hydrops, IUGR
gondii parasite)
• Seizures
Triad = 2x head,
1x eye
Other Seizures myocarditis Late syphilis Interstitial Maculopapular rash H-M Yes – antenatal screen to give penicillin to
(> 2yo) keratitis Early syphilis (< 2yo) Early reduce congenital syphilis in foetus
(syphilis – old) syphilis
frontal bossing and
(zika – new) saddle nose (if late) (< 2yo)
Mental retardation – PDA Sensorineural Cataracts Blueberry muffin rash HSM Yes – extra precautions during pregnancy
Rubella learning disability Pulm. Artery Hearing loss (blue dots on the babies Jaundic and vax post-natally if infected
(togavirus) Microencephaly stenosis skin from extramedullary e Ø Supportive care
“mild and self- erythropoiesis) Ø MMR vaccine du
limiting disease” LN of occipital and post-
auricular glands
CMV (most • Pre-term / IUGR myocarditis Sensorineural chorioretinitis HSM Ø No - glandular fever-like
common) • Microencephaly Hearing loss Jaundic illnessè sore throat, lethargy, fever
e and LN
“pregnant woman • Calcifications
Ø Anti-virals = IV ganciclovir or oral
in contact w/ sick • Seizures + CP –
valganciclovir
child at daycare” intellect disabled
Seizures Myocarditis XS lacrimation Vesicular lesions H-M Ø If untreated with acyclovir:
HSV
Myocardial conjunctivitis Mouth ulcers Ø CNS with or w/o mouth ® mimic
Childbirth (95%) dysfn neonatal sepsis or meningitis
“skin-eye-mouth” Ø Disseminated disease
Varicella / • Pre-term / IUGR chorioretinitis Limb hypoplasia Exposure during pregnancy
• Microcephaly Skin changes along Ø SAFE if previously had chicken pox
chicken pox
• Hydrocephalus deramtomes (skin scar) Ø Acyclovir (within 24 hrs of Sx or >m 2o
Ø Pustules / wks GA)
vesicles on • Learning disability
Ø IV varicella Ig (within 10 days or
mother exposure)
• Microcephaly Flu-like symptoms of pregnancy
Congenital Zika • Cerebellar Ø Tests viral PCR and antibodies to Zika
syndrome atrophy virus
Ø NO cure
*Listeria = (raw milk / processed meats) ® granulomatous infantisepsis è M/C + neonatal sepsis è disseminated abscess to skin + lung ® 6g Ampicillin PO /day coverage
**Parvovirus (5th disease) ® 1st and 2nd trimester è infects reticulocytes = STOP erythropoiesis (14 day) ® severe fetal anaemia + fetalis hydrops (heart failure)
Ø Comp. of fetalis hydrops = maternal pre-eclampsia like syndrome (mirror syndrome – TRIAD of: 1) severe heart failure + 2) placental oedema + 3) maternal oedema
Ø IgM parvovirus (past 4 weeks infection) and IgG (LONG-TERM IMMUNITY)
UTI in PREGNANCY
1. Progesterone = SMC relaxant è Upper urinary tract dilatation, reduced peristalsis, detrusor muscle relaxed = increased bladder capacity
2. mechanical obstruction from the gravid uterus,
3. ↑ eGFR ® increases co BY 30% and increases renal blood flow by 50% è mild hydronephrosis and renal calyceal dilatation
4. changes in composition of urine (glycosuria)
Asymptomatic Bacteriuria Acute Cystitis Acute Pyelonephritis
High-level bacterial growth on urine culture in the absence of UTI UTI of bladder secondary to bacterial infection inflammation of the kidneys due to
Define symptoms from skin or rectum into the urethra bacterial infection
• Screened for in early pregnancy
• E.coli (most common: 70 % cases) • Dysuria • Fever > 38oC
• GBS (10%) ® GBS UTIs- important to detect as it increases the • Polyuria • Flank pain
risk of premature ROM and preterm labour, as well as GBS sepsis • Strangury – URGE sensation • Nausea/ vomiting
Cause in the neonate • Increased urinary urgency • Costovertebral angle tenderness
• Other: Klebsiella (gram -ve anaerobe) Enterobacter, Proteus • • Pyuria
Nb: anatomical changes during pregnancy allow pathogens to move
• Dehydration
quickly from bladder to kidney (+++ pyelonephritis risk)
• Hx of previous UTI (prior to pregnancy or at early stage) • Untreated bacteriuria
• Anatomical abnormalities of urinary tract (inc. nephrolithiasis) • Age < 20 years
Specific • Pre existing DM / GDM • Nulliparity
RF • Increased parity • Smoking
• Low SES + ATSI • Late presentation for ANC
• Advanced age • Sickle cell trait
• Urine dipstick • Urinalysis+ Urine MCS Same as cystitis for both
o Proteins (pre-eclampsia) + Nitrites/leucocytes (UTI) • FBC/EUC Dx criteria:
Specific • Mid-stream urine ® M/C/S @ 12-16 wk booking visit • Blood cultures 1) Symptoms
Ix Dx criteria: • Serum lactate 2) Confirmed bacteriuria
• > 10.5 CFU/mL (of same bacteria stain from 2x consecutive • KUB USS 3) Sx of cystitis/pyelonephritis
samples) • Assessment of fetus ( CTG)
Undetected = 30% will develop pyelonephritis è preterm labour, LBW If M/C/S ® GBS +ve • AKI
or maternal sepsis Ø TREAT like GBS positive from low vaginal • Anaemia
Comp. • Rx asymptomatic bacteriuria to reduce risk of ascending swab • Septic shock
infection and reduce risk of pre-term labour • ARDS
Drug Dose Timing A/E IV therapy
Nitrofurantoin 100mg oral bd Avoid 3rd trimester and prior to Neonatal haemolysis (esp. G6PD def.) • Ceftriaxone,
“macrodantin” delivery Pulmonary fibrosis • Amoxicillin+ Gentamicin
Prophylaxis (PO)
Cefalexin 500mg oral bd Safe during 3rd trimester
Mx (2nd line) • Nitrofurantoin,
• Cefalexin
Co-amoxiclav 875/125mg oral bd Safe during all trimester NEC
• Trimethoprim
(2nd line)
Trimethoprim 300mg oral daily Not 1st trimester (provide 5mg folic NTD (as stops folate synthesis) ®
acid supp. if last resort) spinal agenesis + congenital malform
