8/8/2019 Beattie, J Antenatal
1/10
65,000Goodfellow Symposium, Auckland March 09
What isyour role?
www.moh.govt.nz/maternityOr
0800 252464
Section 88 PrimaryMaternity Services Notice
2007
8/8/2019 Beattie, J Antenatal
2/10
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
8/8/2019 Beattie, J Antenatal
3/10
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
8/8/2019 Beattie, J Antenatal
4/10
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
8/8/2019 Beattie, J Antenatal
5/10
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
8/8/2019 Beattie, J Antenatal
6/10
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
8/8/2019 Beattie, J Antenatal
7/10
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
8/8/2019 Beattie, J Antenatal
8/10
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
8/8/2019 Beattie, J Antenatal
9/10
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 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
8/8/2019 Beattie, J Antenatal
10/10
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