Perinatal Health 540/17 Flashcards
- Pregnancy and weight loss
Research has found that achieving a loss of 5–10% of body weight, whatever the weight of a woman, has significant positive effects for fertility (this is also extremely relevant for women with polycystic ovarian syndrome). For most women, this is a relatively achievable loss of approximately 4–5 kg, and may be more appropriate than trying to achieve a BMI in the healthy weight range. However, further health benefits come from greater losses and are enhanced by increasing physical activity.2
While there is no high-level evidence, expert opinion recommends that women are weight stable for a period of time (12–24 months) prior to becoming pregnant, depending on relative amount of weight loss.4 Being weight stable will ensure Jo is not catabolic and that her fetus is not affected by rapid maternal weight loss, and gives Jo enough time to achieve her weight-loss goals. If she becomes pregnant before this time, closer surveillance of maternal weight and nutritional status may be beneficial, and serial ultrasound monitoring of fetal growth should be considered. Sometimes, difficult conversations about delaying conception need to be held, as well as discussing this with young women before they start to plan for a family.
- Diet and pregnancy
The World Health Organization (WHO) recommends that all health professionals support women to have healthy dietary behaviours before, during and after pregnancy, to optimise health outcomes for mothers and their infants. Eating in line with national dietary guidelines reduces the risk of poor health outcomes for mothers, including unhealthy gestational weight gain, gestational diabetes mellitus, anaemia, preeclampsia, preterm birth and miscarriage.
Furthermore, having a healthy diet also reduces the risk of poor health outcomes for infants, such as preterm birth, low birth weight, and risk of chronic diseases later in life. Nutrition clearly plays a key role in Jo’s perinatal health and providing nutrition care is an important part of preconception healthcare by GPs.
Thanks to fetal programming (the developmental origins of health and disease), the importance of having a healthy diet before, during and after pregnancy is well recognised. Fetal programming explains how nutrition in (very) early life plays a role in the development of many adult chronic diseases, such as heart disease, type 2 diabetes mellitus, lung conditions, and even some forms of cancer. The once popular idea of the ‘parasitising’ fetus – that a growing baby does not miss out on nutrients – is now known not to be true. (Barker Hypothesis)
From history and times of famine, we know that women are affected less than their infants and that conditions in the womb can influence a baby’s health later in life.
- Pregnancy and supplements
Folic acid and iodine are the only essential micronutrients to supplement for all women during preconception. Folate is essential for healthy growth and development for a baby, and reduces the chance of neural tube defects (eg spina bifida). For most women, daily supplementation with 400 μg folic acid is recommended for women one month before and three months after conception (ie in the first trimester of pregnancy). However, women who start pregnancy with a BMI >30 kg/m2 should consume a 5 mg folic acid supplement because of an increased risk of neural tube defects. Although a supplement is useful to guarantee this intake, it is still important to focus on eating a diet rich in folate, including green leafy vegetables, fruit, and breads and cereals fortified with folate. In Australia, iodised salt has been used for breadmaking (excluding organic bread and home mixes) since 2009; therefore, a well- balanced diet including wholegrain breads will contribute to sufficient folate intake.
Iodine is also essential. It is a nutrient needed in only very small amounts. Guidelines advise all pregnant women take a daily supplement that contains 150 μg of iodine to support metabolism, growth and development (especially of a baby’s brain) Women will consume some iodine from their diet; breads/ cereals, vegetables (depending on the quality of the soils they’re grown in) and fish are good sources. Although iodised salt, as the name suggests, contains iodine, for overall health, it is not recommended to add additional salt to the diet. In Australia, breadmaking flour has been fortified with iodine, in addition to folate, since 2009 as a public health strategy to deliver these nutrients; therefore, a well-balanced diet including wholegrain breads will contribute to sufficient iodine intake.
Finally, women with a BMI >30 kg/m2 are at increased risk of vitamin D deficiency, so testing should be considered and supplementation given if required.
No evidence for male supplements to aid fertility; opposed to just a healthy diet.
- Pregnancy and weight gain
recommended gestational weight gain of 11.5–16.0 kg for women with a pre-pregnancy BMI in the normal range.
This limited gestational weight gain should be encouraged via healthy diet and regular aerobic exercise, not calorie restriction.
Variations in the quality and quantity of nutrients consumed by mothers during pregnancy can have permanent effects on a developing fetus. A healthy, balanced diet (plus a supplement that contains folic acid and iodine) is essential for good maternal and infant health.8 Early in pregnancy, the quality of the diet can influence how a baby’s organs develop. Later in pregnancy, diet influences baby’s growth and brain development.
Mater Mothers’ Hospitals’ ‘Nine Months of Nutrition’ web series, you can also direct her to the Australian Dietary Guidelines website, ‘Eat for Health’, which outlines the number of serves for her to aim for from each food group to get the right balance of nutrients for a healthy pregnancy. You should also discuss regular exercise throughout pregnancy, such as walking, swimming and other non-contact sports.
- Postnatal breast pain- History
You should first obtain a history of the pain:
- ?referring to nipple pain, breast pain or both?
- How long has the pain been present?
- How would she describe the pain?
- How is she feeling in general (ie fever, aching, other systemic symptoms of inflammation)?
- Are there any exacerbating and relieving factors?
- Is there an associated lump?
Then, enquire whether she is continuing to breastfeed and, if so, ask how it is going:
- How often does the baby feed?
- How long do feeds last?
- Does the baby have any top-ups with formula or expressed milk?
- Are the baby’s weight gains satisfactory?
Finally, ask about other medical issues, including past breast pathology/ surgery, psychosocial issues and sources of support.
- Postnatal Breat pain- examination
Signs to look for on examination include:
- General appearance: is she febrile or unwell?
- Skin of the nipples and breasts: are there signs of dermatitis or cracks/abrasions on nipple/areola?
- Breasts: are they erythematous, inflamed, hard or tender? Is there a palpable mass? If so, assess size, location and fluctuance. Figure 1 shows a wedge-shaped area of inflammation and Figure 2 a swollen, hard inflammed area.
- Nipple and Breast Pain DDx
Nipple pain can be due to:
- poor attachment – this is unlikely at this stage (as the baby is four months of age)
- infection, such as nipple thrush, which may follow antibiotics use
- an itchy erythematous rash, which is likely to be dermatitis (Figure 3)
- nipple vasospasm, which presents as nipple blanching, often associated with the cold
- white spot (blister or blockage on nipple tip).
Breast pain can arise from:
- blocked duct – an area of breast is hard and tender
- mastitis – an area of breast is red, hard and tender and systemic symptoms are present (ie fever, myalgia, headache, nausea, anxiety)
- breast abscess – a localised collection of pus that usually develops a week or so after acute mastitis
- breast thrush – radiating pain following antibiotics, usually associated with sensitive nipples
- nipple vasospasm – breast pain as well as nipple pain may occur, usually associated with exposure to cold, or sensitivity to cold (eg Raynaud’s phenomenon)
- musculoskeletal pain – tender pectoral muscles or, rarely, Tietze’s syndrome (tender costochrondral junction).
- Mastitis Treatment
Antibiotics are indicated if systemically unwell and symptoms have been present for longer than 24 hours.
Antibiotic guidelines recommend flucloxacillin 500 mg four times a day for five days, or longer if required, if not have a penicillin allergy. (Cephalexin 500 mg orally every six hours for at least five days can be used for patients who are allergic to penicillin or clindamycin 450 mg orally every eight hours in cases of severe penicillin allergy).
Non-steroidal anti-inflammatory drugs, such as ibuprofen 400 mg every four to six hours, are recommended to decrease the inflammatory symptoms.
Non-pharmacological measures of applying cold compress, expressing to improve milk drainage and resting are also beneficial.
Some women find a warm compress or warm shower immediately before the feed can help with milk flow. Positioning the baby’s chin towards the blockage may also assist.
Improvement is expected by 48 hours of antibiotic treatment, so if the patient’s symptoms are worsening or not improving, consider intravenous antibiotic therapy in hospital.
- Recurrent mastitis
Usually, mastitis occurs in about the first six weeks postpartum, and is usually a single event.
When mastitis is recurring, it is important to consider the possible causes, to prevent further recurrences. Ask about each episode of mastitis:
• What was happening in the previous 24 hours or so?
- What part of the breast was affected?
- How was it managed each time?
- Does patient have any ideas about possible causes?
Table 1 lists factors associated with recurrent mastitis.
In many cases, a pattern emerges after taking a careful history. For example, each episode follows the baby sleeping longer at night; a long car trip; interrupted feeds; or wearing a particular piece of clothing. In other cases, the location of the problem on the breast may indicate an area with poor flow due to previous scarring or possibly a narrow duct.
The baby should also be examined. An obvious tongue-tie may not have been released because feeding was thought to be going well, as the mother had no nipple pain and the baby was gaining adequate weight.
The general practitioner can work with the family to identify ways to avoid the predisposing factors. Occasionally, if one breast continues to be problematic, the woman can gradually ‘retire the breast’ and continue feeding on the other breast.
- Mastitis - Inx
Milk culture is not indicated routinely, but if the patient is not improving after 48 hours of antibiotics, or mastitis is recurrent, a clean catch specimen of milk should be sent for culture and sensitivity.
First, the nipple and areola is wiped with a sterile water wipe and the first few drops of milk discarded.
The usual organism in mastitis is Staphylococcus aureus, which is usually resistant to penicillin and often also erythromycin. Failure to respond to treatment may indicate methicillin- resistant S. aureus (MRSA), although this is uncommon in Australia.
Breast ultrasonography is also indicated if an area of breast remains firm and/or red, or in large breasts, to rule out a deep abscess. If mastitis recurs in different parts of the breast(s), ultrasonography is unlikely to be of benefit. If an abscess is detected, this can usually be managed by needle aspiration with ultrasound visualisation. Figure 4 shows the appearance of a breast after aspiration of two abscesses. Incision and drainage are rarely required, and it is not necessary to stop breastfeeding
- Mastitis - complementary medicine
New probiotics, which are various strains of Lactobacilli isolated from human milk, are being marketed to prevent and/or treat mastitis. Further evidence is required before their usefulness can be determined.
In many cultures, breast massage is practised to encourage milk production and prevent blockages. Massage can be light and can be directed towards the axilla to encourage drainage of excess fluid drainage, or towards the nipple to encourage milk flow. Women with recurrent lumpy breasts may be encouraged to experiment with self- massage as a first-line management strategy.
- New pregnancy screening and management
menstrual cycles and whether she has been taking hormonal contraceptives.
- If irregular cycles, or recently stopped taking hormonal contraceptives, and is unsure about the exact date of her last period she may need a dating scan.
There are several medical conditions that can have an impact on pregnancy or can be affected by the pregnancy itself.
history of
- diabetes,
- thyroid disease and
- asthma.
- any past history or family history of birth malformations or diseases that run in the family, suggesting a genetic disorder.
- medication history should be sought, asking about prescribed and over-the-counter medications. Any medications that could be potentially harmful to the fetus should be ceased if possible; this may require liaison with specialists.
- smoking and alcohol history is important as smoking and alcohol are preventable causes of a wide range of adverse outcomes for the mother and child.
- Asking about her husband’s medical and family history is also useful.
You should enquire if Josie has been taking vitamins, especially folate and iodine. It is recommended that pregnant women take at least 400 μg of folate for one month prior to conception and for the first trimester, and 150 mg of iodine during pregnancy.
smoking cessation and other questions about lifestyle, alcohol, exercise and diet.
Current Australian antenatal guidelines advise that the safest option for women who are pregnant is to abstain from alcohol, given its adverse effects on the fetus.
An important part of antenatal history-taking is to enquire about domestic violence, which can occur during pregnancy.
In an Australian survey of 400 pregnant women, 20% had experienced violence during pregnancy.
Enquiring sensitively during each trimester is encouraged, as multiple assessments for domestic violence during pregnancy increase reporting.
Most women find it acceptable for health professionals to ask them about experiences of domestic violence and some women may not disclose to health professionals unless asked directly.
A vaccination history should be taken and enquiry about previous exposure to infectious disease, especially measles, mumps, rubella and varicella, should be recorded.
Immunisation in pregnancy should also be discussed and influenza immunisation offered at any time in pregnancy, and a pertussis booster during the third trimester.
- Screening during pregnancy
Early in pregnancy, all women should be offered appropriate written information about weight gain in pregnancy.1 However, repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced, as maternal weight change is not a clinically useful screening tool for detection of growth restriction, macrosomia or pre-eclampsia.
Blood pressure should be recorded now and at every antenatal appointment.
- Pre-eclampsia is a major cause of maternal and perinatal morbidity and mortality, and elevated blood pressure is one of the first signs of the condition. Early detection is important as underlying conditions can progress rapidly
To identify conditions that can have an impact on pregnancy
- breast examination should be offered, as well as a
- thyroid,
- cardiovascular and
- respiratory examination,
- First Antenatal appointment
At the first antenatal appointment, or prior to 10 weeks of pregnancy, the following investigations should be performed:
- Confirmation of pregnancy with urinary or serum beta human chorionic gonadotropin (ß-hCG), with referral for a dating ultrasound scan if there is uncertainty regarding dating of the pregnancy or risk factors for ectopic pregnancy
- Urine dipstick for protein (send for urinary protein:creatinine ratio if ≥1+ proteinuria)
- Midstream urine for asymptomatic bacteriuria
- Full blood evaluation and electrophoresis, if appropriate
- Human immunodeficiency virus test
- Hepatitis B test
- Syphillis serology
- Blood group and antibody screen
- Rubella serology
- Varicella serology if no definite history of chickenpox or varicella immunisation
Vitamin D test:
- screening should be offered to women with limited exposure to sunlight (eg because they are predominantly indoors or usually protected from the sun when outdoors), or who have dark skin. It should also be offered to women who have a pre- pregnancy BMI of >30 kg/m2. These women may be at increased risk of vitamin D deficiency and will benefit from supplementation for their long-term health.
First trimester screening tests:
- At the first antenatal visit, women should be given information about the types, purpose and implications of testing for chromosomal abnormalities to enable them to make informed choices about whether or not to have the tests.
- The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guidelines for antenatal care state that serological screening for hepatitis C may be offered according to a woman’s risk factors or universally, depending on local health urisdiction policies so practitioners will need to check the guidelines of their local services.6 Patient who are identified at high risk of infection with hepatitis C virus are outlined in Box 1.
- Antenatal Care and Visits
Pregnancy is commonly managed in general practice. The World Health Organization recommends that expectant mothers receive antenatal care at least four times during pregnancy. Australian guidelines for antenatal care recommend having the first antenatal visit within the first 10 weeks of pregnancy and 7–10 follow-up visits.
This can differ between shared care hospitals but visits should increase as women progress in their pregnancy (eg at least one visit by week 12, every four weeks up to week 28, every two weeks up to week 36 and every week thereafter up to delivery). Problems in pregnancy that are commonly managed in general practice include nausea and vomiting, upper respiratory tract infections, vitamin and nutrition deficiency, and depression and anxiety.
In Australia, pregnant women have a number of options regarding antenatal care and birth in the public or private health system. Women can choose to see a GP and an obstetrician at a public antenatal clinic through a shared care program, which has been shown to reduced waiting times and improve caregiver continuity.
- N&V in pregnancy
Nausea and vomiting in pregnancy (NVP) affects many women in the first trimester of pregnancy. The underlying pathophysiology is not clear, but it is likely to involve multiple factors, including metabolic, endocrine, placental, gastrointestinal and environmental factors.
The severity of NVP varies, ranging from mild, occasional nausea to hyperemesis gravidarium, which can result in dehydration and ketonuria and requires admission to hospital. Severe NVP does increase the risk of low birth weight and pre-term birth.
Symptoms of NVP are more severe in multiple and molar pregnancies, and should be investigated with quantitative testing for levels of ß-hCG and ultrasonography, if appropriate. Onset of NVP after nine weeks of gestation is also less frequent and other causes such as gastrointestinal, genitourinary condition, neurological conditions and endocrine disorder should be excluded.
Dietary advice, lifestyle modification and non-pharmacological remedies, including ginger, tend to be the first choice for most women. Vitamin B6 has been recommend in the past, but there is limited evidence of efficacy and concerns about safety with doses above 200 mg.
Iron tablets may worsen NVP and suspending use may be beneficial.
Taking vitamins for three months before conception is also recommended as this may reduce the severity of NVP.
Pharmacotherapy is often seen as a last resort in the treatment of NVP by both practitioners and women themselves.16 This is despite good safety data for the use of antiemetics such as doxylamine (Catergory A), metoclopromaide (Catergory A) and ondansetron (Catergory B1).16 Doxylamine is available as an over-the-counter antihistamine treatment. The Therapeutic Goods Administration has designated doxylamine as a category A drug in pregnancy;18 however, brands of doxylamine succinate still carry warning labels for use in pregnancy. In women with persistent vomiting, the additional use of acid-reducing therapy such as ranitidine (Catergory B1) 150–300 mg twice daily orally or rabeprazole (Catergory B1) 20 mg twice daily orally can be considered. Early treatment of significant symptoms is important, as it is believed to prevent progression to hyperemsis gravidarum and decrease the likelihood of hospitalization. A management algorithm for nausea and vomiting in pregnancy is outlined in Figure 1.
When a woman presents with NVP it is important to explore the physical and psychosocial impact of the symptoms on her life, and reassure her about the safety of her treatment option.
- Pre pregnancy obesity and HTN
Weight loss
It is important to monitor weight and encourage women in making lifelong and sustainable lifestyle changes around nutrition and exercise. Appropriate referral to a dietitian or exercise specialist should be offered. Sharon had raised the issue of her weight earlier on, so this is an opportune time to aid her in her weight loss goals.
Medication adjustment and blood pressure control
As ACEIs are contraindicated in pregnancy, now is the ideal time for medication to be reviewed and changed. This will allow time for her blood pressure to be stabilised and dosage adjustment made. The ideal first-line choice would be to start labetalol and titrate to an optimal dose. Other options are shown in Table 1.
Other drugs to avoid include diuretics, beta-blockers other than labetalol or oxprenalol, as these may be associated with fetal growth restriction, and calcium channel blockers other than nifedipine, which can cause maternal hypotension and fetal hypoxia.
Specialist review is indicated if any baseline investigation is abnormal or if blood pressure is difficult to control.
Patient will need to present to her GP early for confirmation of pregnancy and referral to a high-risk pregnancy clinic for her antenatal care. Ideally, she should be seen by 12 weeks gestation for commencement of aspirin for pre-eclampsia prophylaxis. Depending on the high-risk service, she may also require review by the obstetric physician.
