RANZCOG Guidelines Flashcards
Pre-Pregnancy Counselling (July 14)
- 10 domains of assessment
- Clinical assessment
- Med hx
- Past jobs hx
- Genetic/FHx
- Medication use
- Vaccinations - MMR, DPT, Varicella, Influenza
- Lifestyle changes
- Folic acid and iodine supplementation
- Smoking/etoh/ illicit drugs
- Healthy environment
Management of Obesity in Pregnancy - Adverse outcomes AN
AN
- IGT/GDM
- MC
- SB
- PET
- VTE
- OSA
- Maternal death
- Abn in foetal growth and development
Management of Obesity in Pregnancy - Adverse outcomes intrapartum
- IOL, prolonged labour, FTP
- Instrumental, CS and PPH
- SD
- Difficulties with heart rate monitoring
- Difficulties with analgesia
- Use of GA
Management of Obesity in Pregnancy - Anaesthetic risks
- Difficulty w position
- Difficulty w catheter siting and increased risk of dislodgement
- Difficulty maintaining airways
- Increased need for ICU post op
Management of Obesity in Pregnancy - Adverse outcomes PP
- Delayed wound healing
- Increased wound infection
- Greater likelihood of needing support with maintenance and establishment of BF
- PND
- Long term neonatal consequences: composition, weight gain, obesity
Obesity - 8 preconception domains
- Identify/monitor weight/recommend lifestyle changes
- Discuss risks of obesity on fertility/preg outcomes
- Inform even modest increase in BMI associated w worse outcomes
- Daily exercise
- Consider bariatric surgery (decreased mat risk, ? increase IUGR)
- Folate (5mg if BMI >30), iodine supplementation
- Deprrssion assessment
- HINI vaccine
Obesity - GWG Ranges per BMI
30 - 5-9
Obesity - 9 AN domains
- Document BMI and refer
- Monitor GWG
- Vitamin supplementation
- OGTT - early and at 28/40
- Anaesthetic referral
- PET surveillance
- IUGR surveillance w USS
- Previous CS - less success, higher risk
- Start or continue exercise
Obesity - Intrapartum
- IV line for those w BMI > 40
- Awareness of increased risk SD and PPH
- Alert OT for weight > 120kg
Obesity - Post Partum
- VTE prophylaxis
- Breastfeeding support
- Advice and referal for weight management post partum
Major RF for PPH (7)
Placenta praevia Placental abrutpion Multiple pregnancy PET/Gest HTN Delivery by em CS Retained placenta Mediolateral episiotomy
Minor RF PPH
Previous PPH Asian Obesity Anaemia CS IOL Operative vaginal delivery Prolonged labour Macrosomia Pyrexia in labour Nullip > 40y
Early vs delayed cord clamping term infants
Early:
- Less jaundice/phototherapy
- Lower mean Hb
- Iron deficiency persistent to 6/12
Early vs delayed cord clamping preterm infants
Early:
- More blood transfusion
- More IVH
- No studies beyond discharge from hospital
Chronicity of Hep B w neonatal infection
40%
Risks of Hep B on pregnancy
- Neonatal transmission
- Acute - minima;
- Chronic - increased LFTs
- Cirrhosis (usually amenorrhoea w advanced cirrhosis):
- IUGR
- PTB
- FDIU
- Choreo
- PIH
- Abruption
- PPH
- 15% have hepatic compensation
Rationale for HBV Rx in pregnancy
- Prevent maternal complications (25% die from HBV, 40% HCC)
- Prevention of perinatal transmission
(Usually Telbivudine)
Risk of foetal/neonatal transmission
AN 5% (abruption, TPL or invasive procedures), Intrapartum 95%
No intervention 90%
W HBIG and vaccine at birth and 1 months of age ~5%
House hold members, sexual partners and children with Hep BsAg + woman
Should all be screened and vaccinated if not already immune
Prevalence of HBV infection
1%
Majority are people from an area of high prevalence
Definition chronic HBV
HBVsAg + > 6/12 after exposure
How can HBV be prevented?
- Vaccine - children, contacts, HCW
- Safe blood products
- Prevention of vertical infection
- Sexual prevention
IS HBV vaccine safe in pregnancy
Yes
It is safe and effective
Only use if recommended e.g. post exposure and non-immune (give w immune globulin also)
Is invasive testing safe in pregnancy?
- Higher rate of transmission, but not extensively studied. Likely higher in women with a high viral load.
- Likely higher w CVS and amnio
- Consider NIPT
- Careful counselling re risks involved
What are the predictors of perinatal transmission?
- HBeAg status (+ ~80% transmission, - ~20% transmission)
- Viral load (>108IU/mL)
What is the role of antivirals in pregnancy for HBV? (RANZCOG statement)
- it is emerging as a possible means of reducing viral load and subsequent perinatal transmission in those at high risk of immunoprophylaxis failure
- currently no clear guidelines
- management should be individualised
- refer to specialised hep B clinic for immediate decision making and long term follow up
- known association with post partum flare
What is the recommended MOD for pts with HBV?
MOD has not been shown to affect transmission
Invasive procedures should be avoided
What are the recommended infant immunisations for the prevention of HBV in ANZ?
RR transmission w vaccine and HBIG 0.08
RR transmission w vaccine only 0.28
Monovalent vaccine for ALL infants at 0,2,4,6 months
HepBSAg + HB IG 100IU (separate thigh to the vaccine) one the day of birth
Test baby at 9-12 months for HBVsAg and sAb > refer to paed
What about high risk preterm and LBW infants? (<32/40)
Do not respond as well to the vaccine
4 dose regeime (0,2,4,6) then either check the titre at 7/12 and give booster as required, or just give a booster at 12/12.
IS there a difference in HBV infection between bottle fed and breast fed infants?
No difference provided appropriate immunoprophylaxis given at birth
What long term follow up and care should women with HbsAG + receive?
Close monitoring for several months post partum to monitor flare
lifelong follow up for complications of liver disease and HCC
ASID - when the Rx w Lamivudine/Tenofovir or Telbivudine
HbsAg + > HBV DNA
If > log 7 from 30/40 recommend antiviral Rx, stopping between 4 and 12 weeks post partum
Effects Hep E Virus pregnancy
high mortality
15-20% fulminant hepatic failure
mortality 5%
predilection for pregnancy
Parvo B19 - % of population immune
~50% (30-60)
Parvo B19 - % of pregnancies affected
3%
Symptoms of maternal infection Parvo b19 = erythema infectiosum = slapped cheek = 5th disease
Adults rarely develop the facial rash
Usually limb arthropathy x 1-2/52
viraemia from 1/52 post exposure for 1/52
not infectious after onset of rash/arthralgia
Pregnancy effects of Parvo B19
- Anaemia > 3% usually 5/52 after infection > 1/3 death. 1/3 resolution. 1/3 IUT.
- Foetal loss - 10% w infection 20/40
Does Parvo cause congenital anomalies?
No
