Mater Mothers Hospital Alignment 2

Mater Mothers Hospital

Alignment 2

May 14, 2016

Alignment 2 by Mater Alignment Program is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Housekeeping

• Toilets

• Fire exits

• Phones on silent

http://www.materonline.org.au/whats-on/professional-development/gp-maternity-shared-care-alignment

http://creativecommons.org/licenses/by-sa/4.0/





Good morning and welcome

Time Task Who

9 am Welcome, housekeeping, learning

objectives

Dr Wendy Burton

9:10 Models of Care, Private Practice

Midwives

Anne Williamson, GPLM

Dr Wendy Burton

9:25 Preconception planning Dr Amie Hanlon

10:20 Fertility Dr Amie Hanlon

11:10 Diabetes in Pregnancy Dr Amie Hanlon

11:30 Lunch

Tour of the hospital (optional)

All







Break for lunch

Time Task Who

12:25 pm Preterm labour, Premature Rupture of

Membranes

Dr Wendy Burton

Claire Maguire

12:40 Post Partum care case work All

12:50 Case Presentations and group

discussion Dr Rob Butler

1:25 Infectious diseases in pregnancy Dr Rob Butler

2:15 Ectopic pregnancy Dr Rob Butler

2:45 Afternoon Tea All







Welcome back—last session

Time Task Who

3:15 Updates Dr Wendy Burton

3.35 pm Breastfeeding Kathleen Goldsmith, LC

4:05 Neonatal cases All

4:15 Neonatal examination Dr David Cartwright

Dr Andrea McGlade

4:40 Common neonatal presentations Dr Andrea McGlade

4:55-5.00pm Conclusion All







Learning Objectives

The Advanced Alignment content has been

sourced from feedback provided by the more

than 1 000 GPs who have completed an

alignment since Nov 2008.

The topics that came up repeatedly were

preconception, fertility, postpartum and neonatal

care, breastfeeding and complications in

pregnancy.







Learning Objectives

By the end of these sessions, you should have a

better understanding of the issues, concerns

and available services for women or their

children with

• preconception, fertility or breastfeeding issues

• complications in pregnancy

• common and/or important post partum and

neonatal presentations







Our thanks go to...

• The Alignment Team

• The Mater Mothers Hospital

• BSPHN for supporting the GP role and for

sponsoring today

• Our presenters, past and present

• Those GPs who provided verbal or written

feedback about our program







This presentation is available online

www.materonline.org.au/whats-on/professional-development/gp-

education/resources

It will be updated as required, so may vary in appearance from the

power point you viewed when you attended the alignment program

From www.materonline.org.au go to Shared Care Alignment, find

program resources and look for the most recent Alignment 2 (note

we run three programs, Alignment 1, 2 and, starting this year,

Alignment 3!)






http://www.materonline.org.au/whats-on/professional-development/gp-education/resources







http://www.materonline.org.au/


Online resources

www.materonline.org.au/services/maternity/health-professional-information/guidelines-and-policies

brochures.mater.org.au

www.health.gov.au/antenatal

www.ranzcog.edu.au

www.health.qld.gov.au/qcg

www.nhmrc.gov.au/your-health/egenetics/health-practitioners/genetics-family-medicine-australian-handbook-general-prac

www.beyondblue.org.au

www.asid.net.au

www.gplearning.racgp.org.au/

www.adips.org

www.bsphn.org.au

www.brisbanenorthphn.org.au/page/news-and-events/metro-north-maternity-gp-alignment-program-resources/






http://www.materonline.org.au/services/maternity/health-professional-information/guidelines-and-policies










http://brochures.mater.org.au/

http://www.health.gov.au/antenatal

http://www.ranzcog.edu.au/

http://www.health.qld.gov.au/qcg

https://www.nhmrc.gov.au/your-health/egenetics/health-practitioners/genetics-family-medicine-australian-handbook-general-prac


















http://www.beyondblue.org.au/

http://www.asid.net.au/

http://gplearning.racgp.org.au/

http://www.adips.org/

http://www.gmsbml.org.au/

http://www.brisbanenorthphn.org.au/page/news-and-events/metro-north-maternity-gp-alignment-program-resources/




















www.materonline.org.au

This is a 36 page summary of the essential principles underlying GP maternity shared care.









This is a 306 page comprehensive, evidence based document focusing primarily on first trimester care. The 8 page summary is particularly helpful and there are specific chapters on care for ATSI and rural and remote women.









Module 2 addresses care in the second and third trimesters of pregnancy and provides guidance on core practices, lifestyle considerations, clinical assessments, common conditions and maternal health tests for healthy pregnant women.








www.health.qld.gov.au/qcg/

QHealth has a number of evidence based guidelines and education resources available online






http://www.health.qld.gov.au/qcg/


Click through to www.bsphn.org.au

This hyperlink takes you to the Maternity Share Care page






http://www.bsphn.org.au


http://www.bsphn.org.au/education

-events/maternal-shared-care/






http://www.bsphn.org.au/education-events/maternal-shared-care/










Mater Models of care

Anne Williamson, RM, GPLM


Mater Models of Care

MMH has a number of specialised models of care.

Identification of indigenous status, refugee

background, social risk, drug and alcohol use or

previous pregnancy loss will assist with triage to

the appropriate clinic

Women may choose to have GP share care but

their booking appointments and assessment will

occur in the specialist clinic







Antenatal Clinics, Models of Care






www.matermothers.org.au/hospitals/mater-mothers-hospital/choosing-your-maternity-care

http://www.matermothers.org.au/hospitals/mater-mothers-hospital/choosing-your-maternity-care












http://brochures.mater.org.au/Home/Brochures/Mater-Mothers-Hospital/Mater-Midwives-Partnership-Program.aspx#top






http://brochures.mater.org.au/Home/Brochures/Mater-Mothers-Hospital/Mater-Midwives-Partnership-Program.aspx













Midwifery Group Practice

• This is a midwifery led model of care (MOC) that

works in close collaboration with an obstetrician.

They accept women with various levels of risk,

including suitable women wishing to have a vaginal

birth after caesar (VBAC)

• The RBWH has the birth centre with a similar MOC

and a public water birth option BUT it is a ballot

system and if women live outside the RBWH

catchment, they are not accepted at RBWH







Midwifery Group Practice

• MGP is for Medicare eligible women who live in the Mater Mothers catchment

• It is not suitable for women who require an interpreter

• MGP is for women planning a vaginal birth

• MGP accept women with various levels of risk, including suitable women wanting vaginal birth after caesarean section

• Women have an allocated midwife they can contact by mobile

• The booking appointment is at the woman‘s home

• Antenatal appointments and education are conducted in a group setting







Midwifery Group Practice • The allocated midwife or one of her colleagues will care

for the woman during the birth and postnatally

• Women are usually discharged home on the day they give birth

• Young Mothers Group Practice (YMGP) is for women <21 especially those with complex social needs

• All women including MGP have an obstetric booking appointment

• MGP midwives work in consultation with an obstetrician

This is a high-demand model of care so get the referrals in EARLY! (as soon as the due date is

established)







www.mater.org.au/Home/Hospitals/

Mater-Mothers-Hospital/Choosing-your-maternity-care

• Information is available online for women

regarding their options for antenatal care

• Please inform women of their different options

and indicate on the referral form which model of

care they have chosen






http://www.mater.org.au/Home/Hospitals/Mater-Mothers-Hospital/Choosing-your-maternity-care













Preconception Care

Dr Amie Hanlon MBBS FRANZCOG

Staff Specialist, Mater Mothers Hospital


Preconception Counseling is about having a mindful approach to preparing for and starting a family. By intentionally preparing your

physical body and opening yourself, heart and soul, you “give birth” to yourself as a mother.







Does it work?

• There is a lack of research and evidence except

for some specific areas







What are we trying to do?

• Identify risks and act to minimise them

• Optimise health

• Educate







Do women and health professionals

value preconception care?

YES!!!







Does it work?

Infertile couples identified & treated sooner

Earlier access to STI screening and genetic counselling

Smoking cessation & ↑ infant birthweight

↓congenital abnormalities







Who should we offer it to?

• Likely benefits for both high and low risk women

• Highly valued by patients

• Consider as part of your regular health check-

ups

• ?at PAP smear time







Aspects of Pre-pregnancy Care

• Review of medical and family histories

• Detecting, treating and preventing infections

• Addressing lifestyle factors, nutrition and environmental

exposures







Review of medical and family histories

• Diabetes

• Hypertension

• Epilepsy

• Thyroid

• Thrombophilias

• Mental illness

• Cardiac disease

• Autoimmune disorders







Review of medical and family histories

• Medication review

• Ethnic origin

• Family history • NTDs

• CF

• Fragile X

• Tay-Sachs

• Thalassaemia

• Sickle cell

• PKU • Consanguinity







Personal Obstetric History

• What happened in her previous pregnancy and

what can we do to prepare?

– GDM

– Hypertension

– IUGR

– Labour and Delivery story







Detecting, treating and preventing infections

• Chlamydia

• Toxoplasmosis

• Varicella Zoster

• Rubella

• CMV

• HSV

• HBV, HCV

• HIV

• Syphilis

• Influenza

• Bordetella Pertussis







Detecting, treating and preventing infections

• Avoid feeding raw/undercooked meats to pets, avoid cat faeces/litter, wear gloves when gardening

• Hygiene

• Care with urine, saliva, nappies of young children

• Screen STIs

• Vaccinations

• VZV

• Pertussis

• Rubella

• Flu-Vax







Addressing lifestyle factors, nutrition

and environmental exposures

• Avoid alcohol

• Quit smoking, avoid passive smoking

• Avoid cannabis

• Limit caffeine intake

• Review exposures to toxins in household, workplace or at

recreational activity







Folic Acid • 0.5mg daily for at least one month before

conception and continuing at least until 12

weeks of gestation

• 5mg if at increased risk

– Anticonvulsant use

– Pre-pregnancy DM

– Previous child or family Hx of NTD

– ? Obese women







Iodine

• Australia is classified by WHO as a mildly iodine

deficient nation

• NHMRC recommends dietary supplementation

of 150mcg of iodine prior to or as soon as

possible after finding out they are pregnant and

continuing through pregnancy and lactation







B12

• Vegetarians and Vegans should be

supplemented during pregnancy and lactation

• RDI – 6mcg/day







Vitamin D

• Test and/or supplement high risk women

• High rates of deficiency in Australia

• Esp. veiled women, dark skinned women, obese

women and those who use sunscreen regularly

or who get little sunlight exposure

• Changes to Medicare rules mean that a rebate

only applies if risk/eligibility criteria are met,

which are likely to be women who have a lack of

sun exposure or deeply pigmented women.







Other Vitamins

• No evidence to support routine supplementation

• Vit A – harmful

• Vit C and E – of no benefit







Iron

• Increased demands during pregnancy

• Discontinuing iron-containing multivitamins for the

period that women have symptoms of nausea and

vomiting may improve symptoms

• Routine supplementation not recommended but

have a low threshold for suspecting and

supplementing

– Vegetarians

– Multiple pregnancy







Calcium

• Cochrane suggests benefit of calcium

supplementation in reducing incidence of

hypertensive disorders and preterm labour

• Benefit greater in those with low baseline

calcium intake

• Intake should be 1300mcg/day

• If starting supplement – 1000mcg daily







Other minerals • No evidence to support routine supplementation

with Mg, Fl, Zn or rare minerals

• No evidence to support use of other nutritional

supplements – (eg. Omega 3 fatty acids etc.)







Exercise and Weight

• Moderate intensity aerobic exercise (swimming, running,

aerobics, cycling) has no negative effect of mother or

baby in a normal health pregnancy

• No association with miscarriage, congenital

malformations, ectopic, PPROM, placental insufficiency,

IUGR or IUFD (multiple studies!!)







Exercise and Weight

• One study has actually shown that physically fit

women who ran or did aerobics during their

pregnancy had fewer medical interventions

during labour

• Fewer studies on weight training but no adverse

findings with light to moderate weight training

(free weights or machines) and some suggestion

of benefit at reducing low back discomfort (due

to increased core strength)







Addressing lifestyle factors, nutrition

and environmental exposures • Avoid

• soft cheeses

• Un-pasteurised milk

• Pate

• raw eggs

• hot dogs

• deli meats

• undercooked meats

• reheated left-overs

• Aim for normal BMI through regular exercise and balanced nutritious diet

• Avoid predatory fish • Wash fruit and vegetables







Introducing Jane • Jane is a 24yo receptionist who presents for a

discussion about contraception.

• She has never been pregnant and has been a patient of your practice on and off for a number of years although her last visit was 3 years ago when she presented with a sinus infection.

• She tells you that she has recently moved in with her boyfriend of 18 months. She thinks that she and her partner might consider starting trying for a baby in the next year or so but are not ready just yet to have a baby.

• While they have been using condoms for contraception, they have occasionally had unprotected sex.







What would you consider?

• General issues?

• What to discuss?

• Anything to arrange?







Preconception Care and Fertility

Small Group Work • 6 groups

– 10 mins

• Consider the cues

– Hypothesise re the specific issues that may unfold

– How might you address these?







Lisa

• Lisa is a 30yo accountant who presents for her routine Pap smear

• She is a longstanding patient of your practice and comes to see you regularly for her smears

• She is overweight, with a BMI of 37 which you have discussed previously. She has never been pregnant and is currently single, but has recently met what she hopes to be the man of her dreams

• During your consultation she brings up that she is very interested in having children and is worried about ―time running out‖







Maddie

• Maddie is 19yo Type I diabetic who has been under your care since childhood

• She works part time in the local child care centre

• It has been a struggle to work with Maddie to control her diabetes during her teen years

• You last saw her 8 months ago and she presents needing prescriptions

• She is sexually active in a new relationship and when you ask if she is planning on having a baby, she shrugs and says, ―whatever. . . .‖







Melissa

• Melissa is a 42yo G3P2M1. Her children are 10 and

12 and both pregnancies were complicated by GDM

• Her father has recently been hospitalised with a

myocardial infarct at the age of 64 and she decided to

come in for a check-up

• Her BP has always been good and her BMI is normal

• She stopped her OCP 2 year ago after reading in a

blog that she was at risk of clots

• She remains sexually active but considers that at her

age she is unlikely to fall pregnant and she isn‘t really

worried if she did







Wai Lin

• Wai Lin is a 38yo CEO of a large international

hotel chain and is new to your practice

• She presents requesting a prescription for the

OCP to allow her to skip her period for her

upcoming wedding in a couple of months

• She is using condoms for contraception at

present. She is a longstanding smoker, and

travels regularly for work

• She is planning children, but not right now







www.alcohol.gov.au/internet/alcohol/publishing.nsf/Content/wwtk






http://www.alcohol.gov.au/internet/alcohol/publishing.nsf/Content/wwtk




Jessica • Jessica is a 29 year old who is well known to your

practice. She presents for some preconception advice, having stopped her OCP 3 months ago. She has been tracking her periods (there‘s an App for that!) and has looked into websites such as Fertility Friend and is wondering if she should purchase an ovulation kit.

• Her history is unremarkable apart from a distressing episode of depression for which she was briefly hospitalised in her late teens. She was medicated for several years but was able to successfully wean off medication four years ago and no longer sees her psychiatrist.

• There is a family history of diabetes, coeliac disease and bipolar disorder







Amina

• Amina is a 22yo veiled woman from Somalia who

speaks very little English

• She presents accompanied by her husband, Ahmed,

who translates for her. He is a FIFO worker

• They were married 2 months ago and are keen to fall

pregnant

• They present requesting advice but appear quite shy

• Amina‘s last bloods on file show a Hb of 95 with a

low MCV and follow-up testing confirmed a

thalassaemia trait.







Mater Preconception Care Clinic

• Midwives administer tool

• Consult regarding

additional issues







Study

• Compare outcomes of pregnancies • women who have had a pre-conception consultation VS

• women who did not

• 8 GOALS OF PERICONCEPTION HEALTH

1. FOLIC ACID 5. OPTIMIZE MEDICAL

CONDITION

2. WEIGHT MANAGEMENT

6. GENETIC SCREEING AND

COUNSELING

3. VACCINATION (RUB, VZV,HBV,

FLU) 7. REPRODUCTIVE RISK

ASSESSMENT

4. CEASE SMOKING, ALCOHOL,

DRUGS 8. PSYCHOSOCIAL

INTERVENTION







Preconception care at Mater Australian and New Zealand Journal of Obstetrics and Gynaecology 2014; 54: 510–514

Background: To date, there is a lack of evidence to suggest that a systematic and coordinated

approach to prepregnancy care might make a difference.

Aims: To evaluate whether women who receive preconception care through a structured approach will

be more likely to be healthy around the time of conception compared with women who plan their

pregnancy but have not been exposed to preconception care.

Methods: A case control study was undertaken of women who attended the preconception care

service and subsequently conceived, received maternity care and gave birth at Mater Health Services

Brisbane between January 2010 and January 2013. Pregnancy information and birth outcomes for

each woman who attended the service were matched with those of three women who reported that

they had planned their pregnancy but did not attend the service. Records were matched for

prepregnancy BMI, age, parity, prepregnancy smoking status and number of health conditions.

Results: Pregnant women who attended preconception care were more likely to have received

adequate peri-conceptual folate, to report being vaccinated against influenza and hepatitis B, to have

consulted with a specialist with the specific aim of optimising a pre-existing health condition and to

report less weight gain up until booking. Preterm birth and hypertensive disorders of pregnancy were

less common amongst women who had attended preconception care, and there were trends towards a

decreased incidence of gestational diabetes, LGA and fetal anomalies.

Conclusion: These preliminary data provide some optimism that a comprehensive preconception care

service may positively influence maternal and neonatal outcomes.







But Aime, I only have 15 minutes...!

Covering the basics:

• Pap Smear, breast examination (if not within 18/12)

• Cardiac auscultation

• Antenatal screen

– FBC, Blood group/Ab, Rubella/Syphilis/Hep B/Hep

C/HIV +/- VZV

• Further bloods and imaging as determined by history

Review appointment to discuss results and provide

• Nutrition advice

• Alcohol and smoking cessation advice







Folate

• Folate, Folate, Folate, Folate, Folate,






• 0.5 mg Vs 5 mg Folate, Folate, Folate

• Iodine, Calcium and Vit D







Infertility—the GP workup

• 15% of couples are affected by subfertility or infertility

• For women who are 25-35 years old, there is a 20% per cycle pregnancy rate; 85-90% are pregnant within 12 months

• Medical evaluation goals for the subfertile/infertile couple are to

– Find a cause

– Provide a realistic prognosis

– Provide options for treatment

• GP role involves

– Educating in normal reproductive physiology

– Initial assessment and work-up

– Referral if/when appropriate







Infertility/Subfertility

Female factors

• Age

• PCOS

• Obesity (>25, 3 x risk)

• PID

• Endocrine/Auto-immune

• Endometriosis

• Medications/smoking

• Ovarian failure

• Structural defect/fibroids

Male factors

• Smoking (incl pot)

• Drugs (e.g.

anabolic steroids)

• Varicocoele

• Heat

• Insecticides, CHC

• Y chrs deletions

• Structural defects







Female History

• Primary/Secondary (GPMET*), duration, contraception

• Cycle – menarche, LNMP, regularity, dysmenorrhoea, menorrhagia, intermenstrual bleeding, midcycle – pain/mucus, premenstrual syndrome

• Sexual – activity, dyspareunia, post coital bleeding

• Gynae History – Pap, STD, Breast Examination (opportunistic health screening)

• Infectious Hx – Rubella, VZV, Hep B,C,HIV, PID, Syphilis

• PMHx, PSHx, Treatments, Other, Allergies

• Preconception care issues as per previous slides

*Gravida, Parity, Miscarriages, Ectopics, Terminations







Female Examination

• Ht, Wt, BMI, BP, HR, Waist circumference (ideal<80 cm)

• Weight change

• Endocrine – thyroid, PCOS (acne, hirsutism), galactorrhoea

• Cardiorespiratory

• Abdominal (surgical scars)

• Speculum – Cervix/Pap, +/- VE







Female Investigations • Mid-luteal Progesterone (Day 21)

• AN Screen – FBC, blood group/Ab, Serology – Rubella, VZV

• Baseline (Day 3) –

– LH/FSH (during/after menstruation) or AMH (not cycle dependant, thought not to be affected by the OCP)

– Thyroid

– Pituitary, Drugs – Prolactin

– PCOS - SHBG, Androgen profile, ?OGTT/Lipids

• Tubal patency (Day 5-10) – HSG (Hysterosalpingogram, X-ray + dye ~ $346 cost, rebate ~$100), sonohysterogram (USS + saline ~$1220, rebate ~ $600, Pelvic USS included)

• Pelvic USS (Day 5-10)– ovaries, structural lesions, ? fibroids







AMH

• The new kid on the block

• Thought to be a measure of ovarian reserve

• May be elevated in women with PCOS

• Needs to be interpreted with care – the levels fall

progressively with age and the use of an AMH

nomogram will assist with understanding the

value of a reading in an individual woman







AMH Nomogram www.sciencedirect.com/science/article/pii/S0015028210024106






http://www.sciencedirect.com/science/article/pii/S0015028210024106


Male History

• Primary/Secondary, duration

• Sexual – activity, dysfunction

• Male Hx – STD, testicular injury, epididymo-orchitis

• Infectious Hx – Hep B,C,HIV

• PMHx, PSHx, Treatments, Other, Allergies

• Diet, Lifestyle, Smoking, Supplements







Male Examination

• Ht, Wt, BMI, BP, HR, Waist circumference (ideal<90 cm)

• Cardiorespiratory

• Stature, shave

• Surgical scars – abdominal/inguinal/testicular

• Size – testes, epididymis, spermatic cord, hernia, penis







Male Investigations

• Semen analysis (>2ml, >20M/ml, motility, morphology)

• If needed

– FSH, LH, Testosterone

– Consider Karyotype







Summary

• Infertility – sterility/subfertility, primary/secondary

• One year regular unprotected intercourse, unless clinical indications of underlying pathology, e.g. menstrual irregularity, significant pelvic symptoms, scrotal injury/surgery, advanced maternal age > 38.

• Couples should initially have 3 sets of tests: semen analysis, bloods and imaging of the pelvis to assess ovaries, uterus and tubal patency (Pelvic USS + SHG or USS + HSG)

• Treatment

– cause-based (diagnosis/treatment)

– symptomatic (IVF secures the pregnancy)







Case work

• You have 10 min







Lisa

Lisa is a 30yo accountant who presents for her routine Pap smear. She is a

longstanding patient of your practice and comes to see you regularly for Pap

smears. She is overweight, with a BMI of 37 and you have had discussions with

her about this previously. She has never been pregnant and is currently single

but has recently met what she hopes to be the man of her dreams. During your

consultation she brings up that she is very interested in having children and is

worried about ―time running out‖.

Lisa comes back 2 years later for her next smear. Her

relationship didn‘t last and she is now very worried about

whether she will ever have children.







Maddie

Maddie is 19yo Type I diabetic that has been under your care since

childhood. She works part time in the local child care centre. It has been a

struggle to work with Maddie to control her diabetes during her teen years.

You last saw her 8 months ago and she presents needing prescriptions.

She is sexually active in a new relationship and when you ask if she is

planning on having a baby, she shrugs and says, ―whatever. . . .‖

Maddie is now 24 and has her life in order. Her

diabetes is well controlled and she got married 6

months ago. She fell pregnant on her honeymoon but

sadly had an ectopic. She has not been on

contraception since then, she continues to try to fall

pregnant and notes her cycles have been irregular.







Melissa Melissa is a 42yo G3P2M1. Her children are 10 and 12 and both pregnancies

were complicated by GDM. Her father has recently been hospitalised with a

myocardial infarct at the age of 64 and she decided to come in for a check-up.

Her BP has always been good and her BMI is normal. She tells you that she

stopped her OCP 2 year ago after hearing that she could be at risk of clots. She

remains sexually active but considers that at her age she is unlikely to fall

pregnant and she isn‘t really worried if she did.

Melissa presents a month later. Her father died and

she is devastated. She has decided that she would

really like another child.







Wai Lin

Wai Lin is a 38yo CEO of a large international hotel chain and new to your practice. She presents requesting a prescription for the OCP to allow her to skip her period for her upcoming wedding in a couple of months. She is using condoms for contraception at present. She is a longstanding smoker, and travels regularly for work. She is planning children but not right now.

Wai Lin presents 12 months later. She stopped using contraception 5 months ago and is worried about not being pregnant. She read on the internet that she needs an early referral for IVF. She has cut down on her smoking, but still drinks fairly regularly. Her cycles are regular.







Jessica Jessica is a 29 year old who is well known to your practice. She presents for some preconception advice, having stopped her OCP 3 months ago. She has been tracking her periods (there‘s an App for that!) and has looked into websites such as Fertility Friend and is wondering if she should purchase an ovulation kit. Her history is unremarkable apart from a distressing episode of depression for which she was briefly hospitalised in her late teens. She was medicated for several years but was able to successfully wean off medication 4 years ago and no longer sees her psychiatrist. There is a family history of diabetes, coeliac disease and bipolar disorder.

Jessica presents 14 months later, having failed to conceive. She did not follow your advice about seeing her psychiatrist, in part because she considers that time to be behind her and also because it is not something she has shared with her partner. She would like a referral to a fertility specialist, but has heard that they use hormones and she is concerned that this may affect her mood.







http://cope.org.au






http://cope.org.au/


Management of mental illness

in the perinatal period

If public specialist assessment is required:

Metro South Acute Care Services (1300 MH

CALL = 1300 64 22 55) offer initial triage and

assessment for severe or complex

presentations. They can also provide expert

advice on management and advice around

medications







Management of mental illness

in the perinatal period

Options continued..

• Mental health assessment and plan if required and manage/refer as appropriate e.g. medication, psychology review privately, via ATAPS (no/low gap) through your PHN for women with a health care card (or experiencing financial hardship) or under Medicare (gap payments usual) or psychiatrist referral.

• A number of psychiatrists offer a one-off assessment with ongoing care returning to the GP.

• Belmont Private Hospital offers the GP Liaison Assessment Service, Ph 1800 700 274, which is a prompt referral option.







Take home message

• Perinatal mental illness is a significant cause of morbidity and mortality, affecting maternal and neonatal outcomes, the health of families and of the community.

• A woman will have an EPDS completed at her booking in appointment. As per the PHR (Pregnancy Health Record) please administer again by 34 weeks, at 6 weeks post partum and prn

• Identification and appropriate treatment is essential to promote optimal outcomes

• Suicide is the leading cause of maternal death in the developed world

• In Qld in 2011, suicide was the number one cause of maternal mortality within a year of the end of pregnancy*

• *Source: Qld Maternal and Perinatal Quality Council







Amina

Amina is a 22yo veiled woman from Somalia who speaks very little English. She presents accompanied by her husband, Ahmed, who translates for her. He is a FIFO worker. They were married 2 months ago and are keen to fall pregnant. They present requesting advice but appear quite shy. Amina‘s last bloods on file show a Hb of 95 with a low MCV and follow-up testing confirmed a thalassaemia trait.

It is now 13 months later and Amina and Ahmed see you following their third miscarriage. Amina avoids eye contact and says nothing during the consultation.







www.health.qld.gov.au/multicultural/default.asp






http://www.health.qld.gov.au/multicultural/default.asp




http://www.materonline.org.au/services/refugee-services/

mater-refugee-complex-care-clinic






http://www.materonline.org.au/services/refugee-services/mater-refugee-complex-care-clinic















Management • Organise a 2nd appointment

– without partner if possible

• Resources

– Domestic Violence Hotline

1800 811 811 http://www.dvconnect.org/

• Facilitate early referral to hospital

– Flag concerns/suspicions

– Enable social worker support






http://www.dvconnect.org/


Diabetes in Pregnancy

• Why do all my GTT reports now talk about ―old‖

and ―new‖ criteria?

• What is the current ―best practice‖?







Old Criteria/Traditional Approach

• GCT on everyone at 26-28 weeks

– 75g glucose load, non-fasting

– If 1hr BSL >7.9, then proceed to . . .

• GTT

– Fast for test, 75g glucose load

– If fasting >5.4 or 2hr >7.9 . . . .

• THEY HAVE DIABETES







This works!!!

• ACHOIS study showed

– Reduced incidence of serious perinatal

complications

– At the expense of more IOL and more

admissions to neonatal nursery

– No difference in LSCS rate







Are the diagnostic levels right?

• In effect since 1991

• Extrapolated from adult medicine

• Are we setting the arbitrary line in the wrong

place?







HAPO study

• Data on pregnancy outcomes from 25000

women plotted against GTT results

• Demonstrated

– Linear relationship between risk and glucose

intolerance

– Likely that our diagnostic cut-offs were

missing a substantial number of affected

pregnancies







Linear relationship • How and where do we set the bar?

Yep, the IADPDSG – very helpful as a pnemonic!!!







Recommendations from expert group

• Early testing

– Low risk – random BSL or fasting BSL

– High risk – GTT

• (obese, previous GDM, PCOS, previous

macrosomia, high risk ethnic group)

• Screen everyone at 26-28wks with GTT

• Change to the new criteria (based on the HAPO

data)







What the Mater is doing

• We tried the early screening thing for low risk

women (random or fasting BSL) for a while but had

absolutely no positives so have decided to ditch it.

• Latest is to also offer HbA1C at booking for those in

a high risk group as an alternative to GTT (GTT still

first choice but HbA1C also OK)

• Still recommend all get screened with GTT at 26-28

weeks (unless early screening already positive)

• New diagnostic criteria adopted







Currently -

• Not everyone in favour of the international

recommendations

• RANZCOG and ADIPS agreed to implement the

new criteria from Jan 2015

• GP college is dragging it‘s feet!







Welcome back from lunch

Time Task Who


Membranes

Dr Wendy Burton

Claire Maguire













• Preterm labour (PTL)

• Premature Rupture of Membranes (PROM)

• Preterm Premature Rupture of Membranes (PPROM)

PTL, PROM, PPROM:

What referral to make or test to do

when?







Pregnancy complications

• Sandra, age 30 years, is a healthy G1P0 who presents

for her scheduled appointment at 28 weeks. She

mentions that over the past 12 hours she has noticed

small amounts of clear fluid leaking onto her underwear.

The following issues need to be considered:

• Does she have PROM?

• Is the fetus viable?

• Is there infection?

Sandra should have a comprehensive assessment, such

as would be done at the PAOU







Diagnosis PPROM

• Temperature – chorioamnionitis (chorio)

• Maternal and fetal pulse rate – chorio

• Uterine tenderness – chorio/abruption

• Fetal Heart Rate – confirm fetal viability

• Speculum exam – confirm rupture of membranes, colour

of liquor, dilatation of cervix.

• DO NOT PERFORM a digital examination unless the

woman is about to deliver

• Swabs/urine—Chlamydia, Neisseria, lower vaginal swab,

Group B Strep (GBS), E.coli







Management PPROM

• Best practice care of PPROM involves transfer to tertiary unit if safe

• Consider

– Steroids if less than 36-38 weeks (depending upon mode of delivery)

– MgSO4 if less than 30 weeks and labouring

• If labouring

– IV antibiotics (penicillin) or known GBS +ve

– Tocolysis – nifedipine orally

• If not in labour

– Erythromycin PO







PPROM outcomes

• Most deliver within the first 7 days

• If undelivered, they may be managed as an outpatient

• Positive GBS status – induction of labour (IOL) offered at 34 weeks

• Negative GBS status – IOL offered at 37 weeks

• Breech presentation carries a risk of cord prolapse and head entrapment – Caesarean Section offered with rescue steroids prior to surgery

• If the baby is delivered remotely, arrange transfer* to a tertiary unit along with the placenta

• *via Qld Retrieval Service if in a rural or remote area








• Melanie—healthy 26 year old G1P0

• Uncomplicated pregnancy to date

• 38 weeks pregnant

• Presentation = small amounts of clear fluid

leaking onto her underwear for the past couple

of days

• No abdominal pain or tightening

• What are the issues that need to be considered?







Pregnancy concerns

• Katie—healthy 32 year old G2P1

• Previous pregnancy and delivery were normal

• This pregnancy has been uncomplicated

• 35 week presentation with frequent, intermittent abdominal pain which feels like labour

• Reviewed by PAOU yesterday, diagnosed as having Braxton Hicks contractions and sent her home without a PVE

• Katie does not think she is having Braxton Hicks and would like you to assess her cervix

• What do you do?








• Krystal—healthy 28 year old G1P0

• 33 weeks presentation

• Uncomplicated pregnancy

• Presents with painful abdominal tightenings for

the past couple of days.

• At first these were erratic and uncomfortable

• Now painful, more frequent, lasting longer

• What are the issues that need to be considered?







Summary of routine tests

Abdominal pain Is she in PTL?

Digital examination can be done if clinically indicated however be aware it may interfere with tests for PTL

Speculum examination – cervix dilated? ROM? – Swabs – Specific testing e.g. Actim partus – Cervical length on USS

If PTL likely arrange transfer* for management • Tocolysis • Steroids • If in labour IV antibiotics (penicillin) • If not in labour, antibiotics not indicated *via Qld Retrieval Service if in a rural or remote area www.health.qld.gov.au/qcg/html/publications.asp






http://www.health.qld.gov.au/qcg/html/publications.asp


Qld Maternity and Neonatal

Clinical Guidelines







Post partum care

Time Task Who


Membranes

Dr Wendy Burton

Claire Maguire













Post Partum Care

• You have 10 min for case work

• Each table will need a scribe and a presenter

• Your time starts now







Blue Group Post partum care

• Julia is a G1P1 who had uncomplicated

pregnancy, a straightforward delivery and post

partum course. She is now 6 days post partum

and presents for her routine visit, along with

baby Jack. They have booked two

appointments, 15 min for Julia and 30 min for

Jack.

• What do you complete for Julia’s checkup?







Systems based approach to Post Partum Care

Post Partum check at 5-10/7

History:

• Adacel/Boostrix

• Breasts

• Complications, calves, contraception

• Delivery

• EPDS prn

• Feeding








Examination:

• Abdominal examination to monitor uterine

involution; wound check if LSCS

• Breasts +/- BP

• Careful inspection of perineum if vaginal delivery







Contraception options at 5-10/7 pp

– Abstinence

– Condoms

– Minipill

– Depo/Implanon

– NOT COCP, even if not planning to breastfeed

– NOT IUCD







Red group, post partum care

• Megan is a G1P1 who had well controlled GDM,

a vaginal birth and third degree perineal tear

• Now 6 weeks post partum, she presents for her

routine visit

• Baby Jasmine has the following appointment for

6 week review and immunisations

• What do you complete for Megan’s checkup?








Post Partum check at 6/52

History:

• Adacel/Boostrix

• Bladder, bowels, breasts

• Calves, contraception

• Delivery debrief prn

• EPDS

• Feeding

• Gestational Diabetes follow up prn

• Hypertension follow up prn








Examination:

• Abdomen

• Breasts, BP

• Consider Pap smear, inspect perineum if

tear/episiotomy







Perineal care

• After 6 weeks postpartum for women with anal sphincter injury and those reporting symptoms of anal sphincter dysfunction: – Refer to gynaecologist or uro-gynaecologist or

colorectal surgeon – Care considerations may include:

– Endoanal ultrasound

– Anorectal manometry – Consideration of secondary sphincter repair

– Refer to physiotherapist for assessment and individualised PFMT to help manage pelvic floor dysfunction

Source: Queensland Maternity and Neonatal Clinical Guidelines Program http://www.health.qld.gov.au/qcg/








Perineal Care Queensland

Maternity and Neonatal Clinical

Guidelines Program www.health.qld.gov.

au/qcg/










Green Group Post partum care

• Anna is a G1P1 who had uncomplicated pregnancy, a straightforward delivery and post partum course. She is now 5 days post partum and presents for her routine visit, along with baby Trinity. As you commence your routine post partum check, you enquire about feeding and Anna reports that Trinity is unsettled and not feeding well, so this morning she has given Trinity a formula top up.

• How do you manage Anna’s checkup?







Mater breastfeeding advice

• Go to www.brochures.mater.org.au from there you

access the Mater Mothers Hospital link and you will

find a number of topics, including the following:

• Antenatal breastfeeding advice

• Breastfeeding your new baby

• Breastfeeding support centre

• Breastfeeding, blocked ducts and mastitis

• Breastfeeding, expressing and taking your preterm

baby home






http://www.brochures.mater.org.au/


Online breastfeeding options • www.breastfeedinginc.ca/content.php?pagename=videos






http://www.breastfeedinginc.ca/content.php?pagename=videos




Additional services for

families

www.childrens.health.qld.gov.

au/community-health/child-

health-service/early-feeding-

support-drop-clinics/






http://www.childrens.health.qld.gov.au/community-health/child-health-service/early-feeding-support-drop-clinics/























Private face to face or telephone services

• ABA 1800 686 268 www.breastfeeding.asn.au

• Lactation consultants:

• www.lcanz.org/find-a-consultant-qld.htm

• Mater Breastfeeding Support Centre Ph 3163 8200

• Possums Clinic






http://www.breastfeeding.asn.au

http://www.lcanz.org/find-a-consultant-qld.htm








Yellow group, Post partum care

• Nicole is a G1P1 who had a normal pregnancy

and uncomplicated vaginal delivery. She

presents at 5 weeks requesting a checkup,

looking pale and tired, reporting that she is still

bleeding very heavily, with pain, blood clots and

regular flooding.

• What do you check?







Orange group, Post partum care

• Carol, a G2P2 whose GTT was positive at 28 weeks

and who you have not seen since you referred her

back to ANC, had a LSCS, delivering a bonny babe

weighing an impressive 4 900 g (10 lb 12 oz). She

is 8 days post partum and presents looking flushed

and moving slowly. Her mother is looking after the

baby and her husband has brought her into your

rooms. Your preliminary observations reveal a temp

of 39.2, BP 105/68 and PR of 112 bpm.

• What is your approach?







Pink group, Post partum care

• Jessie, age 32 years, is a G3P2M1 who had a

natural birth with a private Obstetrician 6 weeks ago.

Jessie has presented for Joshua‘s immunisations

and well baby check. Her husband Pete is with

them and when you complete her EPDS (it wasn‘t

done by her obstetrician…) he shakes his head and

looks concerned as Jessie gives you her answers.

Her score is 11 and she answered ―Never‖ to Q10.

• What do you do?







Infections in pregnancy

Time Task Who


Membranes

Dr Wendy Burton

Claire Maguire













Infections in pregnancy

Dr Rob Butler MBBS FRANZCOG

VMO, Mater Private Hospital

Senior Lecturer & Examiner, University of Queensland

Eve Health

Shop 5, 199 Grey Street

South Bank QLD 4101

Telephone 1300 383 432 Facsimile 07 3332 1990

Email [email protected]

Website www.evehealth.com.au






mailto:[email protected]

http://www.evehealth.com.au/


Rationale and approach

• Focus on common pathogens likely to be

encountered in primary care

• What do patients want to know?

– ―Do I really have this infection?‖

– ―What will it do to me?‖

– ―What will it do to my baby?‖

– ―Can it be treated?‖

– ―What are the long-term consequences?‖







Outline

• Systemic infections

– Pyelonephritis/Listeria/Influenza

• Local infections/colonisation

– GBS/Bacterial vaginosis

• The congenital infections

– ‗TORCH‘/Varicella/Parvovirus

• Vertical transmission

– HIV/Hepatitis B&C/HSV







Outline

• Systemic infections

– Pyelonephritis/Listeria/Influenza

• Local infections/colonisation

– GBS/Bacterial vaginosis

• The congenital infections

– ‗TORCH‘/Varicella/Parvovirus


– HSV

– Extra slides after talk: Syphilis/Rubella/HepB/HepC/HIV







Screening – to check or not?

Recommend Not recommended

MSU m/c/s CMV

Hep B Toxoplasma

Hep C Parvovirus

HIV Herpes Simplex

Syphilis +/- GBS

Rubella

Varicella (if no +ve history)







UTI/Pyelonephritis

• Increased susceptibility to UTI in pregnancy

– Impaired bladder emptying

– Increased residual volume

– Increased vesicourethral reflux

– Ureteric stasis & hydronephrosis

– Increased urine glucose & alkalinity

• Classification

– Asymptomatic bacteriuria

– Cystitis

– Pyelonephritis







Asymptomatic bacteriuria

• Uncontaminated, culture +ve MSU

• No clinical infection

• Incidence ~15%, of these:

– 30% progress to pyelonephritis

– Screening/treatment is recommended







Pyelonephritis

• Incidence 3-4%

• Clinical

– UTI symptoms + loin pain/back pain

– Fever/dehydration

– Electrolyte/creatinine disturbances

– Haematuria with ketones/leuks/nitrites

– Raised WCC not reliable – CRP more useful

• USS KUB/Blood cultures

• Consequences

– Preterm birth (PTB)

– Renal injury/sepsis/DIC







Listeriosis

• Listeria monocytogenes – Gram +ve, facultative anaerobe

• Source

– Uncooked foods – seafood/dairy/coleslaw

– Re-heated meats

• Clinical:

– Fevers/‘flu-like illness

– Blood cultures/genital swabs confirm Listeria

– Trans-placental spread







Listeriosis

• Consequences

– Not teratogenic

– 1st trimester, miscarriage rate 50%

– 2nd/3rd trimester, pregnancy loss 40-50%

• Treatment

– Amoxyl/ampicillin and gentamicin

– Delivery depending on gestation







Influenza

• Pregnant women are at high risk of sequelae from ‗flu – Exacerbated by smoking/asthma – Vaccine not contra-indicated in pregnancy, at any

gestation • NNT = 5 • Passive IgG protects baby in first 6 months

• Birds and swines: – Particularly severe infections – Relenza/Tamiflu (neuraminidase inhibitors) – Admission, support and treatment of bacterial

superinfection – Screening relaxed/vaccine available since 7/2009

• But guideline includes ‗pregnant women‘ in the early treatment group during CONTAIN/PROTECT phases







Group B Strep

• Common commensal of the GIT

• Prevalence of genital tract colonisation = 20%

• Consequences of infection

– Mother

• Chorioamnionitis

• Endometritis

– Baby

• Sepsis/meningitis/CP/neonatal death







Group B Strep

• If carriage… 50% colonisation of neonate

• However, rate of infection is still only 3/1000

without prophylaxis







Group B Strep

• So, who to treat?

– Screen all (USA/NSW) – anorectal/LVS at 37/40 (currently developing bedside assay)

Vs

– Risk factor based prophylaxis • Previous perinatal infection

• Any +ve swab or urine culture in this pregnancy

• Gestation <37 weeks

• ROM > 18hrs, when in labour

• Intrapartum pyrexia







Group B Strep

• How and when to treat:

– Intrapartum only (unless PPROM with +ve swabs) • Benzylpenicillin

• Clindamycin

– Ideally at least 2 hours before delivery

– If inadequate prophylaxis, baby requires bloods and observation

• Remember, severe anaphylaxis in 1:100 000

• NNT for screening 1:400 vs risk factor approach 1:300







Bacterial Vaginosis

• Polymicrobial overgrowth, causing vaginitis

– Gardnerella vaginalis is most commonly implicated

• Prevalence is ~20% in pregnant population

• Symptoms; discharge/odour, especially after intercourse/irritation

• Diagnosis

– Amsel Criteria • pH>4.5

• Clue cells

• Amine ‗whiff‘ test

• Characteristic thin, grey discharge adherent to vaginal walls

– Nugent score on microscopy







Bacterial Vaginosis

• Consequences

– Not teratogenic

– Associated with preterm labour/PPROM/endometritis

• Studies (major conclusions);

– Asymptomatic, incidental detection in pregnancy does not require treatment

– If detected AND there is a history of preterm birth, treatment reduces risk of subsequent PTB (from PPROM)

• Treatment; metronidazole/tinidizole







Congenital Infections ‘TORCH’

• Toxoplasmosis

• Syphilis

• Rubella

• CMV

• Varicella

• Parvovirus







General principles

• Most cause a non-specific viral-like syndrome +/-

rash

• Most avoided by food hygiene/hand hygiene advice

• Serology is mainstay of diagnosis

– If IgG +/IgM -, there is evidence of past exposure

– If IgG +/IgM +, there MAY be acute infection

• Retest with different IgM assay

• IgG level over time

• IgG avidity index







Risk of impact on fetus by trimester







General ultrasound features

• IUGR, especially with normal symmetry and

polyhydramnios (although could also be oligo)

• Intra-cranial calcifications (especially toxo)

• Hydrocephalus

• Microcephaly

• Echogenic bowel

• Hydrops







General neonatal syndrome

• Death

• Cerebral palsy

• Delayed developmental milestones

• Chorioretinitis

• Sensory neural deafness

• Haematological consequences

– Anaemia/thrombocytopenia/hepatosplenomegally

• Skin scarring/rash







Points on individual pathogens…

• Toxoplasmosis

• Varicella

• CMV

• Parvovirus







Toxoplasma gondii

• Parasitic protozoa

• Cats are not

the enemy!







Lifecycle







Toxoplasmosis

• Sources

– Raw, undercooked meat/unwashed vegetables

– Garden dirt

• Chance of infection is:

– Low in 1st T (but sequelae are high if infected)

– Moderate in 2nd T (sequelae moderate risk)

– High in 3rd T (but sequelae are low if infected)

• Investigate further with USS/amniocentesis

• Treat with spiramycin or pyramethamine/sulphadoxine (with folinic acid)







Varicella – antenatal exposure

• Herpes virus

• ‗Exposure‘ = sharing home/face to face >5mins

• Check serology if no reliable history of chicken pox

• If –ve IgG, and…

– Exposure < 96hrs, give Zoster Immunoglobulin (ZIG)

– Exposure >96hrs, no ZIG but Acyclovir if risk factors

for maternal complications (>20/40, smoker, asthma)

– Vaccination not recommended during pregnancy;

recommend vaccination post partum in an IgG

negative woman








• 10 day incubation; infectious from 2 days prior, to last scab

• If well and…

– < 24hrs, give acyclovir

– > 24hrs, observe (admit if high risk)

• If unwell, admit to ICU for IV acyclovir – pneumonitis is a severe complication (mortality 40% untreated)

• Try to delay delivery for 7 days (passive Ig)

• Risk of transmission to the fetus (fetal varicella syndrome)

– < 12/40: 0.5%

– 12-20/40: 2%

– > 20/40: Negligible







CMV

• Herpesvirus (largest virus in this group)

• Most common cause of congenital infection (0.5-2%)

• High risk groups (annual seroconversion rate):

– 2-3%, general population (healthcare workers included)

– 10%, childcare workers

– 20-30%, parents of children in childcare

• If infected…

– 1st trimester: 10% infection rate, 90% of these symptomatic

– 2nd half of pregnancy: 90% infection rate, 10% of these

symptomatic







CMV – no good news…

• The bad news:

– Sensitivity of amniocentesis PCR is 45% <20 weeks

• Improves 6 weeks after infection (which takes us to viability)

• Even worse news:

– The test result does not predict the degree of impairment

• The worst news…

– CMV may persist, or reactivate

• Risk of infection > 10% for 2 years

• Return to baseline at 4 years

• Screening is not recommended







Parvovirus B19

• 60% of women are immune but untested, which leaves an overall risk of congenital infection of…

– 20% if exposed at home

– <10% if community exposure

• Consequences

– 10% extra pregnancy loss < 20/40

– 3% develop hydrops (anaemia), of which…

• 1/3 IUFD; 1/3 resolve with intrauterine transfusion (IUT); 1/3 resolve spontaneously

• USS 1-2 weekly up to 12 weeks,

cordocentesis/IUT







Vertical transmission

• HSV

• Hep B

• Hep C

• HIV

• Unlike the congenital infections, these are:

– Less associated with congenital syndromes

– a significant cause of maternal morbidity







HSV

• 20% of population are sero-positive for HSV II

• Primary infection >30 weeks gestation:

– Vertical transmission is 30% following SVD

– Very small risk of trans-placental infection (<5%)

• Secondary infection and active lesions at birth:

– Vertical transmission is 0.5% following SVD

– If no lesions, risk is negligible (?danger of shedding)

– Why not screen for shedding??







HSV - management

• Treat primary lesion with therapeutic acyclovir

• Prophylaxis should be offered if recurrent (>3) outbreaks

• Caesarean recommended for recent primary/active HSV

• Most cases of neonatal infection, no history of lesions

– Only 10-25% of sero-positive women report a history of herpes

– Localised (eyes/mouth)

– CNS or disseminated; mortality 20-30%, severe morbidity







Take-home messages

• Never rely on the result of a single test

– Repeat weeks apart/another assay/IgG avidity

• Don‘t screen for infections if the result doesn‘t help clinical management

• Public health implications

– Isolate, contact-tracing

• Breastfeeding is only contra-indicated

in HIV, and encouraged for passive

Ig in others

• Wash your hands!!







Thank you

• Subsequent slides contain notes on:

• * Syphilis

• * Rubella

• * Hep B/C

• * HIV







Syphilis

• Gram –ve spirochete

• Complicated to diagnose

– Specific tests (TPPA/FTA-ABs/syphilis EIA)

– Non-specific tests (VDRL/RPR titre)

– Generally if 1st+ve, confirm with 2nd

Primary Secondary Latent Tertiary

Low Moderate Low Negligible

– IM procaine penicillin (desensitise if allergy)







Syphilis

• Neonatal risk is…

– Negligible if successful treatment <12 weeks

gestation

– Possible if >12 weeks gestation, to 4 weeks

pre-delivery

– High if treatment <4 weeks pre-delivery

• Neonatal management and testing is complex

and beyond scope of today…







Rubella

• RNA togavirus

• Usually vaccinated, but common to have low-immunity

– <30 = low titre in pregnancy (booster post-partum)

• If maternal infection, fetal risk depends on trimester:

– <8 weeks = 90-100%

– 8-12 weeks = 50%

– 12-20 weeks = 20%

– >20 weeks = <1%

• Supportive treatment, consider termination in 1st T

• Amnio/CVS may be used, but studies not conclusive







Hep B

• Screening with HBsAg

– If +ve, confirm with HBeAg (high risk carrier) or anti-HBeAb

– DNA if still unsure

– LFTs

• Referral to liver clinic (most treatment can wait)

• Without prophylaxis, vertical transmission > 90% if eAg +ve

– Give neonate HBV vacc and Ig + neonatal/paeds followup

– Caesarean is not protective

• Infection in pregnancy/low titre: Give HBIg and vacc x 3







Hep C

• Screening with Hep C Abs

– If +ve, some guidelines suggest HepC RNA (??usefulness)

• Referral to liver clinic (most treatment can wait)


– <1% if RNA –ve

– 5% if RNA +ve

– But…

• management/followup is the same

• Caesarean is not protective

• Avoid fetal blood sampling/electrodes/

ventouse







HIV

• Multi-disciplinary principles of management • Antenatal

– New diagnosis (screen +ELISA) – confirm with Western Blot

– Regular assessment of CD4/RNA viral load/LFT – Test for TORCH/other STIs – Antenatal HAART (ZDV usually maintained)

• Delivery/post-natal – Intrapartum IV ZDV prophylaxis (avoid PROM) – C/S traditional - there is the option of SVD if well

controlled/-ve load in light of increasing evidence of safety

– Breastfeeding contraindicated







Zika virus

• The Center for Disease Control in the US has

concluded ―that a causal relationship exists

between prenatal Zika virus infection and

microcephaly and other serious brain

anomalies.‖ http://www.nejm.org/doi/full/10.1056/NEJMsr1604338






http://www.nejm.org/doi/full/10.1056/NEJMsr1604338

http://www.nejm.org/doi/full/10.1056/NEJMsr1604338


Zika Virus: Symptoms

• Incubation: 3-12 days

• 20% Symptomatic

– Mild lasting ~ 1 week

• Low-grade fever

• Arthralgia (small joints: hands/ feet), myalgia

• conjunctivitis

• Headaches

• Rash – maculopapular

– Exclude other viral illnesses based on travel history







Zika Virus: Diagnosis

• Index of Suspicion:

– Symptomatology

– Travel History

• Diagnostic testing

– Exclude other viruses: Serology • poor specificity for Flaviviruses

– Reverse-transcriptase (RT)-PCR • Blood: 1 week

• Urine: 2 weeks







Zika Virus: Testing

• Diagnostic testing

– No commercially available testing kits

• Who?

– Mothers: • Symptomatology + Travel History within 2 weeks

– Neonates: • Children with microcephaly or intracranial calcifications born to mothers

with travel history

• Children born to mothers suspected to have had Zika virus

• Testing Recommendations

– Exclude dengue and chikungunya

– Reverse-transcriptase (RT)-PCR thru QldHealth • Blood: 1 week

• Urine: 2 weeks







Zika Virus: Pregnancy

• Limited understanding of Outcomes

• No evidence that pregnancy alters susceptibility

– Flaviviruses

• Typically not teratogenic/pathogenic

• Few case reports of congenital anomalies arising

out of Flavivirus infection

– Zika

• ? Frequency of vertical transmission

• ? Rate of abnormality after infection







Zika virus: Pregnancy outcomes

• Abnormalities reported

– Brain: Microcephaly and intracranial abnormality • Brain atrophy; calcification

– Placenta: calcification • Fetal growth restriction

• ? Few reported cases until now

– Underreporting

– Endemic disease with early age at exposure for immunity before pregnancy

– Rare disease

– More virulent strain







Managing the risk

• Prevention

– Public Health • Prevent vector becoming endemic in our mosquito

population

• Control mosquito populations

– Patient • Avoid travel to endemic areas

• Reduce mosquito bites (Aedes aegypti– daytime) – Insect repellants containing DEET, picaridin and IR3535

are safe to use in pregnancy







Interim recommendations for reducing the risk of sexual transmission of Zika virus CDC: Date published: 18 February 2016







MFM Referral

• Who?

– All suspected maternal Zika virus cases • Test all symptomatic pregnant women with travel history within 2

weeks – RT-PCR notification

• Request?

– Tertiary level Growth scan q4 weekly • MFM role: Triage when not symptomatic; baseline biometry then

serial growth monitoring; requires 20 week fetal anomaly scan if not done

– Detail all relevant information on referral

• Antenatal Care

– Continue locally unless congenital abnormality suspected

– Neonatal testing







www.health.gov.au






http://www.health.gov.au/


Zika

With the Summer Olympics to be held in Rio from August 5-21 and the Paralympics from September 7-18, clearly there are particular public health challenges.







Ectopic pregnancy

Time Task Who


Membranes

Dr Wendy Burton

Claire Maguire













Ectopic pregnancy a few pointers

Outline

• Early pregnancy assessment

• Management options for ectopic pregnancy

• Follow-up and management of next pregnancy

• Unusual cases







A classic presentation…

• Jodie, 24yo G1P0, LNMP 6 weeks ago

• +ve urine HCG

• Considerations

– Clinical picture (pregnancy symptoms/pain/bleeding)

– Planned pregnancy? Folate? Antenatal screening?

– Serum B-HCG 800

– USS:

• Left ovary 2cm vascular structure, c/w corpus luteum

• Endometrium 18mm, no gestational sac seen







What now?

• LNMP dates correlation with HCG?

• Clinical assessment – abdominal pain?

• Repeat HCG – timing?

• Repeat imaging – timing?







Another scenario

• Ms A.A, 22yo G1P0T1

• Referred to consultation rooms with 5 weeks

continuous bleeding

– Elective TOP 3 months earlier (was told ‗very

early pregnancy‘ at time of D&C)

– Depot provera at the time of procedure, no

repeat dose, using condoms as well

– Mild abdo pain







Another scenario

• USS:

– 5 x 5cm left adnexal heterogeneous mass with limited vascularity, adjacent to ovary

– Thin and uniform endometrium and normal right adnexa

– Small amount of free fluid in the POD

• Possibilities?

– B-HCG +ve, quantitative = 1030







Classic symptoms and risk factors

• Triad of:

– Amenorrhoea, 6-8 weeks post LNMP

– Abdominal pain (and especially shoulder/rectal)

– Bleeding

• Most significant risk factors:

– Previous ectopic pregnancy

– Pregnancy associated with emergency

contraception/POP/IUDs

– Tubal surgery/infection/PID







Ultrasound: Correlation with B-HCG

• IUP can usually be seen with B-HCG levels

above 800

• A threshold of 1500 will detect 98% of IUPs

– Pitfall; multiple pregnancy

• Higher thresholds will result in more missed

ectopics

• An IUP almost always excludes ectopic

(heterotopic awareness when risk factors)







Appropriate rise in HCG

• B-HCG usually doubles every 48hrs between 5-

8 weeks gestation in a viable IUP

– If the B-HCG is slowly rising by < 50%, it is

usually a non-viable IUP, or ectopic (99%

accuracy)

– Consider multiple or molar pregnancy in

rapidly rising levels

– Single isolated level is less useful for

uncertain clinical scenarios







What about progesterone?

• High levels (> 65nmol/L) help exclude ectopic

(only 2.5% are ectopic above this level)

• Low levels (< 15nmol/L) predict non-viable IUP

(<1% will be ongoing viable IUP)

• Progesterone differentiates viable from non-

viable pregnancy, but not ectopic from

miscarriage

• Clinical/B-HCG criteria are usually sufficient







Rare sites

• Around 5% of ectopic pregnancies will be:

– Cornual

– Ovarian

– Caesarean scar

– Abdominal

– Cervical

• The major issues with these are:

– High and appropriately rising B-HCG/progesterone

– Large size and catastrophic rupture if undiagnosed







Management options

• Expectant

– If falling B-HCG and stable patient, especially PUL

• Medical (methotrexate) criteria

– Stable patient, proven ectopic

– B-HCG < 5000 associated with success >90%

– No C/I to use and reliable follow-up

– Useful for ‗rare site‘ locations (infusion protocol)

• Surgical

– 95% ‗cure‘ rate







Importance of follow-up

• Especially if PUL or medical management

• Follow B-HCG weekly until –ve (one

measurement is adequate if not GTD)

• Anti-D, vaccinations

• Opportunity for contraception/pre-conception

discussion







What about next time - prognosis?

• Fertility outcomes

– Pregnancy rates 65-85% per year

– Referral for fertility assessment if > 12/12, and

will likely require IVF

• Recurrence is ~15%

– Salpingectomy ~ 10%

– Salpingotomy ~15-20%

– Methotrexate ~15-20%







What about next time - Mx?

• Early diagnosis of pregnancy, symptom

awareness

• Serum quantitative B-HCG level

– If <1500 and asymptomatic, repeat 2-3 days

– If rising appropriately, TV USS when B-HCG >

1500

– If rise <50%, consider miscarriage or ectopic

and refer early (allows for all options of

management)







Interesting Case – Ms LT

• 28yo G2 P0 E1 (previous PUL – MTX)

• PV bleeding, abdominal pain

• Observations stable

• B-HCG

– 31/05: 16 800

– 05/06: 36 000

• USS – 25 x 25 x 30mm right cornual ectopic

pregnancy







Options for treatment

• Expectant?

• Medical?

– IM MTX – OR 5.5 for failed therapy if B-HCG > 5000

– IV MTX

– Direct injection

• Surgical?

– Wedge resection • Open

• Lap

– Hysteroscopic







Medical management

• MTX by IV infusion

• F/U clinically stable

• B-HCG

– 12/06: 50 000

– 13/06: 45 000

– 15/06: 50 000

• Impression – failed medical management

• Multi-disciplinary decision for surgical management







Follow-up

• B-HCG

– 22/06: 1630

– 29/06: 284

– 06/07: 65

– 13/07: 17

– 27/07: <5







Management issues next time…

• Early diagnosis

• Recurrence

• Placentation

• Delivery

– Timing

– Mode







Summary

• B-HCG and clinical correlation

• Traditional B-HCG patterns can be unreliable

• Keep in mind the rare cases

• Anti-D

• Refer early for ultrasound next pregnancy, but

not too early!

• Recurrence of ectopic pregnancy, 10-15%







Welcome back—last session

Time Task Who





Dr Andrea McGlade








Alignment updates A quick summary of changes and issues that have arisen since the program commenced in 2008


Testing for Diabetes in Pregnancy

• Early OGTT (HbA1c if not tolerated e.g. due to

nausea/vomiting) for high risk women

• No glucose challenge testing and no random BSL

• Routine OGTT (24 – 28 weeks) for all women not

previously noted as abnormal

• OGTT diagnostic criteria have changed as of January 1

2015

• Prompts are built into the referral template (please

ensure you have the most current version)







GDM Flowchart

(page 36)







Gestational Diabetes Mellitus

Tight sugar control is recommended;

• fasting BSLs of < 5.0

• 1 hour post prandial of < 8.0

• 2 hour post prandial of < 7.0

The figures vary, but women with GDM have

~ 60% risk of developing Type 2 DM in the

next 10 years, hence the following

recommendations







Postnatal care of women with GDM

Recommendations:

• Oral glucose tolerance testing (OGTT) six–twelve weeks postpartum to exclude diabetes (cc MMH please)

• Follow up HbA1c testing at least every three years, annually if planning a pregnancy (this now attracts an annual Medicare rebate for high risk patients)

• Repeat HbA1c or OGTT prior to or OGTT early in next pregnancy

• Follow up of impaired fasting glucose by twice yearly checks for frank diabetes in addition to assessment of other risk factors of macrovascular disease







Education Resources

• Booklets /Pamphlets • Demonstrations (e.g. food models, blood glucose meter) • Useful websites

• You2: www.you2.org.au • Diabetes Australia www.diabetesaustralia.com.au • Australian Diabetes Educators Association

www.adea.com.au • Australasian Diabetes in Pregnancy Society

www.adips.org • Queensland Clinical Guidelines

www.health.qld.gov.au/qcg/html/education.asp#videoconference






http://www.you2.org.au/

http://www.diabetesaustralia.com.au/

http://www.adea.com.au/

http://www.adips.org/

http://www.health.qld.gov.au/qcg/html/education.asp



The catchment area • Mater Mothers Hospital is a private hospital contracted by Queensland

Health to conduct an agreed number of public births per year. Mater

Mothers is both a tertiary referral centre and a local hospital for women

within its catchment. Due to high demand Mater Mothers is unable to

accept routine low risk referrals from outside the catchment area.

Consideration is made for indigenous women and women requiring a

specialist drug and alcohol service

• Women who may require tertiary care should be referred by the GP to

their local health service, where their care may commence, if within the

capacity of the local hospital, or appropriate referrals organised if not.

Please communicate with the MMH GP Liaison if you are at all

uncertain, or if time is critical

• Catchment restrictions do not apply to insured women choosing to birth

at Mater Mothers Private. The GP refers to a private obstetrician and the

woman contacts the Private Booking Office on 3163 8847. A list of

private obstetricians is available at www.materonline.org.au






http://www.materonline.org.au


www.materonline.org.au/

Women living within the

catchment area will be

accepted, however proof of

address is required.








www.materonline.org.au/services/

maternity/health-

professional-information/

guidelines-and-policies





















Please consider signing up

• Mater Health Services have created a web site

for where, among other things, women can look

at the models of care available at MMH. Women

who do not have a GP can use this tool to locate

an aligned GP. If you consent being on this list,

a patient could search for and find you on the

mater.org.au site.







www.mater.org.au/Home/Hospitals/Mater-Mothers-Hospital/

Choosing-your-maternity-care/Shared-care-GPs






http://www.mater.org.au/Home/Hospitals/Mater-Mothers-Hospital/Choosing-your-maternity-care/Shared-care-GPs


















Please remember to include the woman’s BMI in your referral—that helps the hospital with triage and the researchers with their project







Please watch out for AOTC

We will keep you updated e.g. about changes to the GDM

pathway, guideline alterations, education events. AOTC,

including past editions, is available online http://www.materonline.org.au/whats-on/professional-development/gp-

education/resources















Thyroid disease Known thyroid

disease?

Routine testing not

recommended (test > 30 years old, family Hx thyroid

disease, coeliac disease)

Repeat TSH, add T3 | T4 +

antibodies

No further testing

50μg thyroxine

No

TSH > 2.5

Normal

TSH > 2.5 +/- antibodies

Repeat TSH in 4/52

↓ to 25 μg/d

TSH > 2.5 TSH < 0.4

Hyper or hypo?

Endocrine RIVCheck TFT 6-8/

52ly

TSH should be < 2.5↑ thyroxine by 30% once pregnant

↓ thyroxine post partum

Yes

Hyper

Hypo

TSH < 2.5 antibody +ve

TSH usually drops 1st trimester

TSH < normal range

Referral not needed

Physician review +/- referral

Free T3 | T4 elevated

Free T3 | T4 normal

Repeat TSH @ 18, 26 + 34/52 and adjust

dose prn

TSH low

50 μg thyroxine

↑ to 75 μg/d

Watch this space –we’re working on a flow chart to make life simpler!







READ AOTC!!!







www.materonline.org.au/






http://materonline.org.au/


MAH referral information







Waitlist information







QHealth referral template

This is a helpful document, with decision support built in. An electronic version is available for MD3 on www.gmsbml.org.au and is a supplied template on BP (QHealth Maternity). You can download a paper copy at www.health.qld.gov.au/caru/pathways/docs/mater_refer.pdf






http://www.gmsbml.org.au

http://www.health.qld.gov.au/caru/pathways/docs/mater_refer.pdf






Online education resources

QHealth has a range of power points, video

conferences, knowledge assessments and

flowcharts available online which flow from

their Maternity and Neonatal Guideline work.

GP relevant topics include Obesity, Early

Pregnancy Loss, Vaginal Birth after caesarean

section (VBAC), Breastfeeding initiation, Neonatal Examination and Neonatal Jaundice

http://www.health.qld.gov.au/qcg/html/implementation.asp#Education






http://www.health.qld.gov.au/qcg/html/implementation.asp

http://www.health.qld.gov.au/qcg/html/implementation.asp


www.health.qld.gov.au/qcg/html/education.asp#videoconference












Who is responsible for abnormal results?

The clinician who orders the test is responsible for the follow up and prompt referrals when appropriate

• Although a copy of the result is sent to MMH, it is entered into their system without being seen and is only reviewed when the woman comes for an appointment or contacts the hospital for advice

• There are guidelines for consultation and referral and managing abnormal results available in sections 6 and 12 of the MMH GP Maternity Shared Care Guideline www.materonline.org.au/services/maternity/health-professional-information/guidelines-and-policies
















Referral process

• Women with medical conditions should be referred to an

obstetrician on the antenatal referral template. The obstetrician

will consult and refer to the obstetric medicine specialist

• If an already booked woman develops a medical condition

during her pregnancy, please fax a letter to ANC (not another

antenatal referral form) including the relevant clinical details, so

that the appropriate referrals can be organised

• If you are uncertain, or if the woman requires urgent review,

phone the consultant, registrar via switch (3163 8111) or the GP

Liaison Midwife on telephone 07 3163 1861 (you can leave a

message) email [email protected] or mobile 0466 205 710.








The referral pathway

• All women, regardless of their medical or obstetric risk, should to be referred to their local obstetric hospital. A comprehensive referral will allow the hospital staff to triage appropriately and where necessary, the local obstetricians will liaise with or refer women onto MMH

• Should a woman booked with another hospital develop a complication, contact her local obstetric service so that they can make the appropriate arrangements







Pertussis immunisation

• From April 2015, Qld Health are funding Adacel for

women in the third trimester of each pregnancy

• The evidence supports a move from a cocooning

strategy to a passive immunity strategy

• Due to the rapid decline in antibody titres,

vaccination is recommended with each pregnancy to

provide maximal protection to every infant; this

includes pregnancies which are closely spaced (e.g.

< 2 years)

• 10 Australian babies died from pertussis from 2006-

2012 and another died in 2015 in WA







www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home

• By immunising women during pregnancy, the infant

benefits from in utero transfer of antibodies

• Pertussis antibodies peak a couple of weeks after

immunisation and then fall rapidly, while transplacental

antibody transfer is most efficient from 30 weeks

onwards

• Immunising women from 28-32 weeks gestation is

recommended, however immunising any time in the third

trimester is beneficial

• Vaccination of mothers at least 7 days before delivery

reduced pertussis disease by 91% in infants <3 months

of age






http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home




Pertussis issues for baby

What about blunting?

• Studies have shown lower levels of anti-pertussis antibodies

at 7 months of age in children born to women vaccinated with

dTpa during pregnancy, compared to children of mothers who

were not vaccinated. However, when children were given a

booster dose of DTPa-containing vaccine at 12–18 months of

age, levels of anti-pertussis antibodies 1 month later were

similar irrespective of whether the child‘s mother was

vaccinated during pregnancy or not.

• From March 2016, an extra DTPa booster dose has been

funded by the Queensland Immunisation Program for children

aged 18 months







Pertussis immunisation

• Qld Health is no longer funding Pertussis vaccination for fathers or extended family members/household contacts of newborns

• The Australian Technical Advisory Group on Immunisation recommends vaccination every 10 years for the following groups:

– fathers

– extended family members

– household contacts

– medical staff







Serological testing for varicella immunity

from infection and/or vaccination

• Screening for varicella immunity (from natural infection) or a past history of vaccination should be undertaken as part of pre-pregnancy planning and varicella vaccine given to non-immune women prior to conception.

• Testing to check for seroconversion after varicella vaccination is not recommended. Commercially available laboratory tests are not usually sufficiently sensitive to detect antibody levels following vaccination, which may be up to 10-fold lower than levels induced by natural infection.

• Protection (commensurate with the number of vaccine doses received, see 4.22.4 Vaccines above) should be assumed if a child or adult has documented evidence of receipt of age-appropriate dose(s) of a varicella-containing vaccine.

www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-4-22






http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-4-22








Mater Shared Electronic Health

Record

• MHS have an electronic alternative to the Pregnancy

Health Record (PHR)

• There are 3 component parts: Hospital, Mater Doctor

Portal and Mater Patient Portal







Mater Doctor Portal

Mater Doctor Portal for GPs and private obstetricians (external clinicians)







Your next steps…

For further information about these projects contact:

[email protected]

1800 228 470

Or indicate your interest on the feedback form for

this session








www.materonline.org.au/getattachment/Services/Maternity/Health-Professional-Information/Guidelines-and-

Policies/MMH_AntenatalAppointmentSchedule.pdf

18-20 week visit

• Review morphology scan and follow up/referrals prn

• Organise follow up of placental position prn

• Confirm EDC, if not already done

24 weeks

• Routine AN assessment ? Additional care required

• Fundal height and health promotion/parent education

28 weeks

• As above + FBC, Blood group antibodies, GTT +/- antiD

• Discuss infant feeding, Vit K and Hep B

• Discuss and commence birth plan

• Consider discharge planning

• EPDS routinely administered between 28-34 weeks or prn






http://www.materonline.org.au/getattachment/Services/Maternity/Health-Professional-Information/Guidelines-and-Policies/MMH_AntenatalAppointmentSchedule.pdf










Don’t forget… 31 weeks

• As above, review results and follow up prn

• Confirm consent for Vit K, Hep B

34 weeks

• AntiD prn

• Repeat USS if low lying placenta on morphology scan

• Routine assessment, reassess schedule

• Discuss birth plan

38 & 40 weeks

• Routine assessment

• Confirm understanding of the signs of labour and indications for admission to hospital







Please don’t forget to enquire or inform

women about….

• Breastfeeding intentions and availability of

support e.g. ABA, Mater Breastfeeding Support

Centre, brochures.mater.org.au

• Vit K and Hep B

• Birthing plans

• When to come to hospital/ring labour ward

• Post natal checks







http://brochures.mater.org.au/Home/Brochures/Mater-Mothers-

Hospital/Information-for-parents-about-labour-and-birth






http://brochures.mater.org.au/Home/Brochures/Mater-Mothers-Hospital/Information-for-parents-about-labour-and-birth


















Are you aware...? c) Special Conditions – Shared Care and Ante-natal Care

• GPs who treat obstetric cases (including the provision of Ante-

natal Care) but who are not insured for obstetrics (under the GP

Obstetrics or GP Rural Obstetrics Categories) must adhere to the

following minimum guidelines to ensure their entitlement to

indemnity is maintained under the Policy:

Shared Care Guidelines (summarised)

• Women are to have their full antenatal screening tests

• Women are to be referred to an obstetrician, GP obstetrician or

obstetric hospital clinic by 20 weeks

• Women must have a review by an obstetrician/GP

obstetrician/obstetric hospital clinic at 36 weeks and again at term







Categories of Insurance Guide

www.miga.com.au • Should any problems occur before 36 weeks, the

obstetrician/GP obstetrician/hospital clinic must be advised and consulted

• The delivery of the baby must rest with the consultant/obstetric hospital

• If you are required to adhere to more restrictive Shared Care Guidelines which apply in your State, region, hospital or clinic, then those guidelines must also be complied with to maintain your entitlement to indemnity

• GPs are covered in an emergency situation but must have obstetric cover if they wish to be involved in inductions, management of labour or deliveries

• If you are a GP Obstetrician and you wish to deviate from the relevant Shared Care Guidelines which apply, you must hold GP obstetric insurance, regardless of whether the delivery is in the public or private system.






http://www.miga.com.au/

http://www.miga.com.au/


Moving on….

Time Task Who





Dr Andrea McGlade









Mater on line breastfeeding advice

• Go to www.brochures.mater.org.au from there you access the Mater Mothers Hospital link and you will find the following topics:

• Antenatal breastfeeding advice

• A guide to breastfeeding

• Breastfeeding support centre

• Breastfeeding support centre – equipment

• Breastfeeding, expressing and taking your preterm baby home






http://www.brochures.mater.org.au/

Breastfeeding

Mater Mothers’ Breastfeeding Support Centre


• Milk is formed in alveoli and carried by ducts to the nipple.

• The lobes are not neatly arranged around the

nipple but intertwined like roots of a tree.

• Clusters of secretory alveoli form a lobule that drains into the ductule. Ductules from 20-40 lobules join to form the lactiferous duct.

• Between 4 and 18 milk ducts exit the nipple

The lactating Breast







Lactating breast…..

• As well as glandular tissue the breast also has

connective and fat tissue around the lobes.

• Each lobe is separated by adipose tissue, blood

vessels, nerves and lymphatics.







Basics of Milk Production

• Milk supply doesn‘t start out as a demand and

supply process.

• During pregnancy and the first few days

postpartum milk supply is hormonally driven.

(Endocrine control system).







Endocrine Control

• Lactogenesis 1 – breasts start producing colostrum from around 16 weeks. Progesterone inhibits milk secretion.

• Lactogenesis 2 – milk will increase in volume around 30-40 hours after birth and the delivery of the placenta.

• These stages occur whether a mother breastfeeds her baby or not.

• The impact of expressing and breastfeeding in the first 4 days has a major impact on ongoing supply issues long term.







Autocrine Control of Milk Synthesis

• After Lactogenesis 2 there is a switch to ‗local

control‘.

• This maintenance stage is called Lactogenesis

3.

• Milk removal is the primary control mechanism

for supply.

• Prolactin receptors are only laid down in the first

6 weeks. Frequent breast stimulation during this

time is essential for ongoing adequate supply.







What does current research

tell us about milk production?

• Milk contains a small whey protein called Feedback Inhibitor of Lactation (FIL).

• When the breast is full and more FIL is present, productions slows.

• When the breast is emptier, and less FIL is present, production speeds up.







Storage Capacity

• Mother‘s with large or small storage capacities

can still produce plenty of milk for their baby.

• However – a mother with a large storage

capacity may be able to go longer between

feeds without impacting on her supply or her

baby‘s growth.







Positioning and Attachment







Recognising nutritive sucking

Really good drinking Nibbling

www.breastfeedinginc.ca






breastfeedinginc.ca


Common breastfeeding problems

Low milk supply •Is it really low supply or issues with milk transfer?

•Does the baby appear to ‗drink‘ at the breast?

•Wet and dirty nappies? / lactose Overload ?

•Age of baby? / reflux ?

•Mother‘s medical history.

•Encourage parents to identify nutritive drinking-

ABA links and videos available







Using Medication to Increase Supply

• Domperidone is known to increase pituitary prolactin secretion and human milk production. This is not a long term solution, medication should be associated with effective breast drainage and an effective feeding plan.

• Fenugreek is a common herbal preparation that has been shown to increase milk supply.







Blocked Ducts and Mastitis

• Reddened area or segment of breast which becomes tender, hard and painful.

• If a fever is also present - the Mother has mastitis and may require antibiotics.

If untreated/poor drainage. An abscess may develop that can be Diagnosed via Ultrasound.







Management of Blocked Ducts and Mastitis







Painful or damaged nipples

• Most likely cause is

poor latch.

• ? Thrush

• ? Infection

• ?Tongue-tie

• ?vasospasm

secondary to nipple

compression.







How To Get Help • Mothers requiring further assistance with

are able to book an appointment at the Mater Mothers’ Hospital Breastfeeding Support Centre. This no cost appointment is available for all mothers with children up to six months of age.

• Australian Breastfeeding Association 1800 686 2 686 (1800 mum 2 mum)







Breastfeeding Support Centre

Level 7, Mater Mothers Hospital

Raymond Terrace, Brisbane

PH- 3163 8847







Recognising nutritive sucking

Really good drinking Nibbling

www.breastfeedinginc.ca






breastfeedinginc.ca


Neonatal examinations and presentations

Time Task Who





Dr Andrea McGlade









Blue Group Neonatal care

• Julia is a G1P1 who had uncomplicated pregnancy, a straightforward delivery and post partum course. She is now 6 days post partum and presents for her routine visit, along with baby Jack. They have booked two appointments, 15 min for Julia and 30 min for Jack.

• What do you complete for Jack’s checkup?







Red group, post partum care

• Megan is a G1P1 who had well controlled GDM,

a vaginal birth and third degree perineal tear

• Now 6 weeks post partum, she presents for her

routine visit

• Baby Jasmine has the following appointment for

6 week review and immunisations

• What do you complete for Jasmine’s checkup?







Neonatal Examination –

Systematic Approach

• Top to toes (as per Red Book checklist)

• Growth parameters: weight, length, HC

• Hips, Heart, Hernias, Eyes are the key elements

Thanks to Dr Julie Beak, paediatrician, for providing most of the following slides







www.health.qld.gov.au/qcg/documents/g-newexam.pdf






http://www.health.qld.gov.au/qcg/documents/g-newexam.pdf






The tricky bits....

• Examination of red reflex in an infant who won‘t open their

eyes

• Auscultation of the heart in a crying infant (or for that

matter, a crying child)

• Uneven thigh creases

• Clicky Vs Clunky hips

• CDH Vs DDH – why the change?

• How much jaundice is too much jaundice?







Green group Neonatal care

• Rebecca is a G1P1 who had uncomplicated pregnancy, a straightforward delivery and post partum course. She is now 6 weeks post partum and presents for her routine visit, along with baby Olivia. Rebecca is worried something is wrong with Olivia’s hip as the nurse at the chemist has commented that Olivia has a “clicky” hip. As you undress Olivia ready for her examination, you notice a small inguinal lump.

• How do you conduct your examination?

• What do you advise?







DDH

• More common in girls (8 in 10 cases)

• Affects 1:1000

• 1 in 4 normal children have unequal skin folds

• Looking for a clunk, not a click

• USS recommended to age 4-6/12, X-ray thereafter

• Check hips at birth, 6/52 and 6/12

High risk hips:

• Breech

• Low liquor volume

• DDH in a 1st degree relative

Organise USS of hips for high risk children at 6-12 weeks (corrected) even if the examination is normal







Inguinal hernias

• Boys > girls

• Right > left

• Indirect (direct rare in children)

• Incarceration risk greater in the first 6 months and in premature infants

6-2 rule • Baby less than 6 weeks old – operate within 2 days

• Less than 6 months – within 2 weeks

• Less than 6 years – within 2 months







Umbilical hernias

• More pronounced with crying

• Easily reducible

• Usually close in the first 3 years

• Consider surgery if still present as school

commences







Yellow group Neonatal care

• Caden presents for his 6 week check up and he is going well and growing well. His physical examination is unremarkable except for retractile testes. The RHS milks down well, but the LHS is more difficult to locate.


• What is the current management of undescended testes?







The scrotum...

• Undescended testes – present in 3% of neonates, ¾

will resolve spontaneously by 3-6 months. If still

present at > 6 months, surgery will be required.

Optimal age for surgery ~ 12 months

• Retractile testes usually do not require an operation—

follow up until the position of the testis is certain

• Hydroceles transilluminate, don‘t empty, you can feel

the spermatic cord above and they usually resolve on

their own. If not resolved by 15-18 months, they are

unlikely to do so and surgery may be required







So do paediatric surgeons...

Request/require ultrasound scans for

• Hernias?

Maybe, but don‘t delay a referral in a neonate

• Undescended testes?

No! An experienced paediatric surgeon has a

much better pick up rate than USS.

• Hydroceles?

No!







Orange group Neonatal care

• Rosie presents for her 5-10 day check on day 9. She is a settled child, which is a welcome relief for her parents who had a fussy first child, Adam, who is now 5 years old. Her birth length was 53 cm, weight 3810 and HC 35 cm. Your examination reveals a drowsy, jaundiced, otherwise normal full term infant whose length is 51.4 cm (despite repeated efforts to replicate the birth length!), wt 3650, HC 36.2.








Neonatal Jaundice

Statewide guideline

www.health.qld.gov.au/qcg/documents/g_jaundice.pdf

If in any doubt, order a serum BR and investigate further prn. Cut off level for action >200-250






http://www.health.qld.gov.au/qcg/documents/g_jaundice.pdf


Jaundice







Pink group Neonatal care

• Oliver is the first child of Michelle (age 38) and Bob (age 40) and was delivered 3 weeks ago at term by LSCS for failure to progress and fetal distress. His Apgars were 7 and 9 and they were discharged on day 4. Oliver, Bob and Michelle have booked in to see you as he is a fussy child, who cries a lot.

• Where do you start and if the examination is normal, what do you advise?






The unsettled baby in the first 16 weeks:

what to do

With thanks and acknowledgement to Dr Pamela Douglas MBBS FRACGP PhD IBCLC The Possums Clinic www.possumsonline.com Associate Professor (Adjunct), Centre for Health Practice Innovation, Griffith University Senior Lecturer, Discipline of General Practice, The University of Queensland

306

http://www.possumsonline.com/

Overview

307

1. Why is infant crying a problem? 2. Baby’s health 3. Mother’s health 4. Feeds

5. Sensation

6. Sleep

1Wolke D, Samara M, Alvarez Wolke M. Meta-analysis of fuss/cry durations and colic prevalence across countries. 2011: Presented at the 11th International Infant Cry Research Workshop, 18-10 June 2011, Netherlands

308

1

Why is crying a problem?

309

1Wake M, Morton-Allen E, Poulakis Z, Hiscock H, Gallagher S. Prevalence, stability, and outcomes of cry-fuss and sleep problems in the first 2 years of life: prospective community-based study. Pediatrics. 2006;117:836-842. 2Odom E, Scanlon K, Perrine C, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatics. 2013;131:e726-732.

‘Normal’ and self-limiting but 1 in 5 families report excessive crying1

Many more start formula due to unsettled behaviour2


Why is crying a problem?

310

↑risk of: Behavioural problems in later childhood1,2

Premature weaning3

Child abuse4

Postnatal depression5

1Schmid G, Wolke D. Preschool regulatory problems and attention-deficit/hyperactivity and cognitive deficits at school age in children born at risk: different phenotypes of dysregulation? Early Human Development. 2014;90:399-405. 2Winsper C, Wolke D. Infant and toddler crying, sleeping and feeding problems and trajectories of dysregulated behavior across childhood. Journal of Abnormal Child Psychology. 2013;2013:DOI 10.1007/s10802-10013-19813-10801.

3Howard C, Lanphear N, Lanphear B, Eberly S, Lawrence R. Parental responses to infant crying and colic: the effect on breastfeeding duration. Breastfeed Med. 2006;1(3):146-155.

4Reijneveld SA, van der Wal M, Brugman E, Hira Sing R, Verloove-Vanhorick S. Infant crying and abuse. Lancet. 2004;364:1340-1342. 5Vik T, Grote V, Escribano J, Socha J, Verduci E, Fritsch M, et al. Infantile colic, prolonged crying and maternal postnatal depression. Acta Paediatr. 2009;8:1344-1348.






Baby’s Health

• Exclude medical conditions –Hx & exam, no

routine investigations unless Hx & exam indicate

• ? Cow‘s milk allergy (CMA)

• Vomiting is usually normal (consider pyloric

stenosis, UTI, enteropathy) & peaks at 4/12

• Normal weight gain in breastfed babies = 200-

250 grams/week

• Many babies cry due to poor satiety despite

adequate weight gain

• Feed spacing in breastfed babies not a solution

Baby’s health: GORD?

312

Proton pump inhibitors No better than placebo1

Increase risk of infection2

Predispose to food allergies3,4

1van der Pol R, Smits MJ, van Wijt MP, Omaria TI, Tabbers MM, Beninga MA. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011;127:925-935. 2Orenstein S, Hassall E, Furmaga-Jablonksa W, Atkinson S, Raanan M. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. Journal of Pedatrics. 2009;154:514-520. 3Trikha A, Baillargeon J, Kuo Y, Tan A, Pierson K, Sharma G, et al. Development of food allergies in patients with gastroesophageal reflux disease treated with gastric acid suppressive medications. Pediatric Allergy and Immunology. 2013;24:582-588. 4Merwat SN, Spechler SJ. Might the use of acid-suppressive medications predispose to the development of eosinophilic esophagitis? Am J Gastroenterol. 2009;104:1897-1902.

Baby’s health: Allergy?

313

Signs of CMA Constipation Blood in stool Skin rashes – urticarial, eczema

CMA may cause oesophagitis (GORD) but takes time to develop (older infants and children)

CMA is the only allergy linked with cry-fuss problems in first 16 weeks

Bergmann MM, Caubet J-C, McLin V, Belli D, Schappi M, Eigenmann P. Common colic, gastroesophageal reflux and constipation in infants under 6 months do not necessitate an allergy work-up. Pediatric Allergy and Immunology. 2014:doi: 10.1111/pai.12199. Muraro A, Halken S, Arshad SH, Beyer K, Dubois AEJ, Du Toit G, et al. EEACI Food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy 2014;69:590-601.

Baby’s health: Allergy?

314

After all other domains addressed: Breastfed babies may benefit from trial of 2

week maternal elimination diet Formula-fed fussy babies improve with

extensively hydrolysed formula1

1Allen KJ, Davidson GP, Day AS, Hill DJ, Kemp As, Peake JE, et al. Management of cow's milk protein allergy in infants and young children: an expert panel perspective. J Paediatr Child Health. 2009;45:481-486.


Baby’s health: Other treatments?

315

No benefit from Homeopathic medicines1,2

Acute respiratory problems Acupuncture3

‘Infacol’ (simethicone)4

Herbal preparations5

1Aviner S, Berkovitch M, H D. Use of a homeopathic preparation for 'infantile colic' and an apparent life-threatening event. Pediatrics. 2010;125:318-323. 2Glatstein M. Choking caused by a homeopathic drug in a previously healthy infant. Canadian Family Physician. 2013;59:848-850. 3Landgren K, Kvorning N, Hallstrom I. Feeding, stooling and sleeping patterns in infants with colic - a randomized controlled trial of minimal acupuncture. BMC Complementary and Alternative Medicine. 2011;11:93. 4Hall B, Chesters J, Robinson A. Infantile colic: a systematic review of medical and conventional therapies. Journal of Paediatrics and Child Health. 2012;48:128-137. 5Perry R, Hunt K, Ernst E. Nutritional supplements and other complementary medicines for infantile colic: a systematic review. Pediatrics. 2011;127:720-733.






Mother’s health

316

Cued care Screen for postnatal depression Healthy biopsychosocial rhythms

Mother’s health

317

Exclude medical conditions (e.g. anaemia, hypothyroidism)

Screen with Edinburgh Postnatal Depression Scale

Daylight Physical activity Focus on meeting own needs out of the house during day

Cued care Screen for postnatal depression Healthy biopsychosocial rhythms

Feeds

318

Identify and manage feeding problems No feed spacing

Feeds Functional lactose overload1,2

319

Not enough cream causes: Frothy poo Tight tummy Copious belches and

flatus Very frequent waking Excessive feeding

1Smillie CM, Campbell SH, Iwinski S. Hyperlactation: how 'left brained' rules for breastfeeding can wreak havoc with a natural process. Newborn and Infant Nursing Reviews. 2005;5:49-58. 2Evans K, Evans R, Simmer K. Effect of the method of breastfeeding on breast engorgement, mastitis and infantile colic. Acta Paediatr. 1995;84(8):849-852.

Feeds Poor satiety

320

If breastfeeding impaired milk transfer not enough cream insufficient milk supply If bottle-feeding impaired milk transfer not enough cream (breastmilk) Breast and formula feeding feed spacing

http://gallery.hd.org/_exhibits/baby/_more2006/_more05/breastfeeding-4-four-month-old-baby-girl-closeup-1-DHD.jpg

Feeds Poor satiety

321

Positional instability1,2 causes: Poor satiety

Cry-fuss behaviours Very frequent waking Excessive feeding

Back arching Feeding refusal

1Smillie CM. How infants learn to feed: a neurobehavioral model. In: Watson CG, editor. Supporting sucking skills. New York: Jones and Bartlett Learning; 2012. p. 83-104. 2Colson SD, Meek JH, Hawdon JM. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev. 2008;84:441-449.

http://gallery.hd.org/_exhibits/baby/_more2006/_more05/breastfeeding-4-four-month-old-baby-girl-closeup-1-DHD.jpg

Sensory

322

Healthy caregiver biopsychosocial rhythms Physical contact 10 hrs/day (awake or asleep)

With permission “Mummy and me yoga”, www.yogababy.com.au

Sensory A healthy sensory diet

323

Babies need a rich and healthy sensory diet

Sight Taste Touch Hearing Smell Vestibular Proprioceptive Acquired through Caregiver pursuing enjoyable social activities outside the house Outdoor activities e.g. walking Physical contact Sibling activity

Babies often cry because they hunger for change in sensory environment (often misinterpreted as ‘tired cue’)

Sensory Other approaches?

324

Pacifiers don’t interfere with breastfeeding duration1

The following do not make infants more settled: Massage2

Manipulative therapies (including craniosacral therapies)3,4

Wrapping5

↑hip dysplasia Poorer weight gains6

Jaafar SH, Jahanfar S, Angolkar M, Ho JJ. Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2011:Issue 3. Art. No.: CD007202. DOI: 007210.001002/14651858.CD14007202.pub14651852. 2Bennett C, Underdown A, Barlow J. Massage for promoting mental and physical health in typically developing infants under the age of six months. Cochrane Database of Systematic Reviews. 2013;4:CD005038. doi: 005010.001002/14651858.CD14005038.pub14651853. 3Ernst E. Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials. The International Journal of Clinical Practice. 2009;63:1351 - 1353. 4Posadzki P, Ernst E. Is spinal manipulation effective for paediatric conditions? An overview of systematic reviews. Focus on Alternative and Complementary Therapies. 2012;17:22-26. 5Clarke N. Swaddling and hip dysplasia: an orthopaedic perspective. Archives of Disease in Childhood. 2014;99:5-6. 6Bystrova K, Matthiesen AS, Wistrom AM, Ransjo-Arvidson A, Welles-Nystrom B, Vorontsov I, et al. The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Human Development. 2007;83:29-39.

1Wolke D, Samara M, Alvarez Wolke M. Meta-analysis of fuss/cry durations and colic prevalence across countries. 2011: Presented at the 11th International Infant Cry Research Workshop, 18-10 June 2011, Netherlands

325

1

Sleep

326

1 1

vulnerable maternal personality

increased risk of postnatal depression

327


Sleep

328

Postnatal depression correlates with poor maternal sleep

efficiency, not number of times of waking in the night.1,2

1Dorheim SK, Bondevik GT, Eberhard-Gran M, Bjorvatn B. Sleep and Depression in Postpartum Women: A Population-Based Study. Sleep. 2009;32:847-855. 2Goyal D, Gay CL, Lee K. Fragmented maternal sleep is more strongly correlated with depressive symptoms than infant temperament at three months postpartum. Arch Womens Ment Health. 2009;12:229-237.







Sleep

329

Marathon feeds and excessive night-waking signal a feeding

problem






Sleep needs are highly variable between babies, and in any one baby

from day to day

330

Galland BC, Taylor BJ, Elder DE, Herbison P. Normal sleep patterns in infants and children: a systematic review of observational studies. Sleep Medicine Reviews. 2012;16:213-222.

Sleep Safe sleep

331

Supine Safest place to sleep baby day and

night is in same room as caregiver Paradox: Putting baby to sleep in separate room

(<6/12) puts baby at increased risk of SIDS

Bed-sharing does not appear to increase risk if done safely1

1Bergman AB. Bed sharing per se is not dangerous. JAMA Pediatrics. 2013;167:998-999.

Resources For parents

332

Community resources The Possums Clinic www.possumsonline.com includes Song and Sensory Programs Group Sessions

Community Child Health Services Australian Breastfeeding Association Helpline PANDA 1300 726 306 Web-based SIDS and Kids www.isisonline.org.uk http://www.mothersmatter.co.nz/ www.beyondblue.com.au www.bottlebabies.org Books The Discontented Little Baby Book Dr Pamela Douglas Becoming Mum Dr Koa Whittingham

http://www.possumsonline.com/

http://www.isisonline.org.uk/

http://www.mothersmatter.co.nz/

http://www.beyondblue.com.au/

http://www.bottlebabies.org/

Douglas PS, Whittingham K. Response to 'Sleeping like a baby? Infant sleep impact on care givers and current controversies'. Journal of Paediatrics and Child Health. 2015;51:234. Whittingham K, Douglas P. Optimising parent-infant sleep in the first 6 months: a new paradigm. Infant Mental Health Journal. 2014;35:614-623. Douglas P. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry alot in the first few months overlooks feeding problems. J Paediatr Child Health. 2013;49:e252-256. Douglas P, Hill PS. Behavioural sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J Dev Behav Pediatr. 2013;34:497–507. Douglas P, Shirley B. How to Treat: The Crying Baby. Australian Doctor. 2013; 24 May 31-38. Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013;81:816-822.. Douglas PS. Re-thinking 'posterior' tongue-tie. Breastfeed Med. 2013;8(6):1-4. Douglas P, Miller Y, Bucetti A, Hill PS, Creedy D. Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first three to four months of life ("The Possums Approach"): effects on cry-fuss behaviours and maternal mood. Australian Journal of Primary Health. 2013; 18:332-338. Douglas P, Mares R, Hill P. Interdisciplinary perspectives on the management of the unsettled baby: key strategies for improved outcomes. Australian Journal of Primary Health. 2012;18:332-338. Douglas PS, Hill PS. The crying baby: what approach? Curr Opin Pediatr. 2011;23:523-529. Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772. Douglas P. The rise and fall of infant reflux. Griffith Review. 2011;32:241-254. Douglas PS, Hill PS, Brodribb W. The unsettled baby: how complexity science helps. Arch Dis Child. 2011;96:793-797. Douglas P, Hiscock H. The unsettled baby: crying out for an integrated, multidisciplinary, primary care intervention. Med J Aust. 2010;193:533-536. Douglas PS. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Med Hypotheses. 2005;64:887-898.

333


www.possumsonline.com






http://www.possumsonline.com


www.childrens.health.qld.gov.au/community-health/child-health-service/






http://www.childrens.health.qld.gov.au/community-health/child-health-service/










Common neonatal presentations

Time Task Who





Dr Andrea McGlade









Common neonatal presentations

• Tongue tie

• Skin rashes

• Nappy rash

• Plagiocephaly

• The circumcision question







Tongue Tie







Tongue Tie : Definition

• congenital anomaly where short, lingual frenulum or a

highly attached genioglossus muscle restricts tongue

movement

• definition not standardised, so wide variation of opinion

regarding clinical significance and optimal management

(eg. snip vs. observe)







Tongue Tie : Clinical Features

• Inability to lift the tongue

to the upper dental alveolus

• Inability to protrude tongue

• >1-2 mm past the lower central

incisors

• Impaired side-to-side movement







Tongue Tie : Potential Sequelae

• Difficulty breastfeeding (poor latch, maternal nipple pain)

• Speech articulation difficulty (NOT speech and language

delay)

• Mechanical problems (inability to lick the lips or sweep

food debris from the teeth)







Tongue Tie: Indications for Surgery

• Breastfeeding difficulty

• Articulation problems

• Psychological problems

• Periodontal disease







Tongue Tie : Surgery

• Given lack of consensus about surgery, decision should

be made on a case-by-case basis with involvement of the

parents

• Frenotomy should be performed by appropriately trained

personnel







Neonatal Skin Rashes







What is this rash?







Erythema Toxicum Neonatorum

• harmless neonatal skin condition

• erythematous base with a central tiny yellow papule, seen anywhere - except the palms and soles

• lesions are packed with eosinophils, and there may be accompanying eosinophilia in the blood count.

• cause unknown, no treatment is required

• usually disappears after 1-2 weeks, but can come and go until 3 months of age







What is this rash?







Milaria

• prickly heat, sweat rash

• many red macules with central papules, vesicles or

pustules

• may be on the trunk, nappy area, head or neck







What is this rash?







Milia

• epidermal inclusion cysts

• pearly, yellow 1-3mm diameter papules on face, chin, and

forehead

• 50% newborns

• usually resolve in first month without treatment, but may

persist for several months







What is this rash?







Seborrhoeic Dermatitis

• mild baby oils (eg. Aveeno, Hamilton‘s bath oil),

then moisturise (sorbolene)

• brush cradle cap softly to remove scales

• if fails to improve, can try steroid ointments







What are these?







Capillary malformations • Common (40% newborns)

• Small flat patches pink or red, poorly defined borders

• Nape of neck (stork mark), forehead ( angel kiss),

eyelids and scrotum

• Worse with crying

• Not associated with extracutaneous findings







What is this rash?







Infantile Eczema

• infants often have widely distributed eczema,

cheeks often first affected

• skin is often dry, scaly, with small scratch

marks made by sharp baby nails

• nappy area is often spared due to moisture

retention of nappies (but they can still get

nappy rash)







Eczema Distribution by age







What is this rash?







Irritant Nappy Dermatitis

• Rash confined to convex surfaces of the

buttocks, perineal area, lower abdomen, and

proximal thighs, sparing the intertrigous creases

• Caused by combination of factors, irritation to

the skin by urine, faeces, excessive heat, and

occlusion

• Beware secondary Staph or Candida infection







Irritant Nappy Dermatitis :

Prevention and Treatment • Nappy off!!!

• Change nappy frequently

• Wash bottom at each change

• Use emollient (aqueous cream) and barrier cream (zinc oxide, eg. Sudo-cream)

• Low potency topical steroid (hydrocortisone) in more significant cases







What is this rash?







Candidal Dermatitis

• starts off in deep flexures with widespread

erythema on the buttocks (beefy red color)

• also raised edge, sharp marginisation and white

scale at the border lesions, with pinpoint pustulo-

vesicular satellite lesions

• treat antifungal, can add low potency steroid for a

few days







What are these?







Infantile Haemangioma • Most common benign tumours of infancy

• Begin as barely visible telangieactasia or red macules and grow

into 0.5-4cm bright red partially compressible tumours

• 60% occur on head and neck area

- if neck area, consider intra-tracheal lesions

- if multiple, consider systemic lesions (eg. Liver haemangioma)

• Most spontaneously resolve by age 5 years; if aggressive growth

or significant size, may consider treatment with propanolol (vs.

intralesional steroids or laser)







Common neonatal discussions







Plagiocephaly







Plagiocephaly

• Deformational plagiocephaly is a non -surgical problem most often related to a supine sleeping position

• Conservative measures to prevent ongoing pressure to the affected area is main premise of treatment

- physiotherapist often very useful

- encourage ― tummy‖ time when awake

- alternate direction head is facing when laid to sleep

• Occasionally helmet is required (before 8 months); GB Orthopaedics, and Brisbane Prosthetics and Orthotics







Plagiocephaly Helmets







Plagiocephaly helmets

Helmet therapy in infants with positional skull deformation: randomised controlled trial

BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2741 (Published 1 May 2014)

http://www.bmj.com/content/348/bmj.g2741

"Positional" or "deformational" plagiocephaly or brachycephaly are the result of head moulding when a foetus or infant lies in a persisting head posture. It has become much very more prevalent since the recommendation that babies should not be placed in the prone position for sleeping to help avoid SIDS. Such positional moulding of the head can produce quite dramatic flattening in the occipital region associated with misalignment of the ears and other compensatory skull changes. Parents are commonly very concerned about these perceived abnormalities.

The study was an RCT of 84 infants with moderate to severe skull deformation. They excluded those with syndromic causes, craniosynostosis and muscular Torticollis.

In short the study showed no benefit from the use of helmets.






http://dx.doi.org/10.1136/bmj.g2741

http://dx.doi.org/10.1136/bmj.g2741




Pathological Plagiocephaly

• Occasionally related to torticollis, refer to

physio in first instance orthopaedic

surgeon

• If concerned re craniosynostosis, get a

plain skull X-Rays and refer to plastic

surgeon or neurosurgeon







Circumcision

• Undertaken for religious and cultural reasons for

many thousands of years

• Based on current available evidence, RACP do

not recommend routine infant circumcision in

Australia and New Zealand







To Circumcise or not to Circumcise

Potential benefits

• Connectedness for particular socio-cultural groups

• Decreased risk of some diseases

Potential harms

• Contravention of individual rights

• Loss of choice

• Loss of function

• Procedural/psychological complications







Contraindications to circumcision

• Hypospadius and other congenital anomalies of penis

• Chordee(ventral angulation penis)

• Buried penis

• Sick and unstable infants

• Personal/family history bleeding disorder

• Inadequate expertise/facilities







Circumcision Complications

• 1-4%

• Haemorrhage

• Fistula formation

• Infection

• Penile amputation

• Meatal stenosis

• Secondary phimosis or chordee

• Poor cosmetic appearance







Role of circumcision in preventing

disease • UTI: circumcision provides some benefit in preventing UTI

in boys, particularly in those with underlying anomalies of

the urogenital tract

• STI/HIV: in low prevalence populations such as Australia

and NZ circumcision does not provide significant

protection against STI‘s and HIV, and is less effective than

safe sex practices

• HPV: may reduce risk, but more benefit from HPV vaccine

• Penile cancer: decreases risk (but rare to begin with)

• Doesn‘t decrease prostate cancer







A few extras….

Labial fusion

• Usually presents between 3-6 months of age

• Irritation + low oestrogen levels thought to be the

cause

• Typically resolves spontaneously once out of

nappies

• Consider oestrogen cream if still present as

puberty approaches or if urination is affected or

UTIs occurring







Flat feet

• When the arch on the inner border of the foot is

not as high

• Normal development in 97% of children

• Insoles or arch supports do not make a

difference

• Walking barefoot before the age of 6 years helps

develop normal foot arches as the feet mature Thanks to Dr Haseena Mohamed for this and the following 2 slides







In-toeing

• Due to internal rotation of the

femur at the hip joint

• Occurs in 1 in 6 children

• Usually corrects in children

under 8 years old

• Prevent children from sitting

in the W-position







Knock knees

• All children have bow legs until the age

of 2 years

• After this they become knock kneed between 3-4

years

• Legs slowly straighten to adult shape by 10-12

years

• Important to exclude rickets due to vitamin D

deficiency as a cause







http://metrosouth.health.qld.gov.au/oral-health










http://metrosouth.

health.qld.gov.au/

dental-health

-children






http://metrosouth.health.qld.gov.au/dental-health-children












www.childrens.health.qld.gov.au






http://www.childrens.health.qld.gov.au/


LCCH

• Children should be referred to their local service

where available and appropriate

• New referral templates, to replace the MCH and

RCH templates, are available to download from

www.childrens.health.qld.gov.au/referapatient/

• Further information about the services available

at LCCH is also available on this website






http://www.childrens.health.qld.gov.au/referapatient/




Please be aware of PEDS

• As of July 1, 2015, new Red Books (the paediatric

personal health record) incorporate a parents‘

evaluation of developmental status (PEDS) into the

questions at 6, 12, 18 months, 2 ½ and 4 years

• Parents who raise concerns should be directed into

appropriate follow up services e.g. use

www.raisingchildren.net.au to check the child‘s

developmental status against milestones or use the

Red Flags tool and refer publically or privately prn






http://www.raisingchildren.net.au


PEDS

• BSPHN is partnering with local childcare centers

in the roll out of PEDS = Parents‘ Evaluation of

Developmental Status to try and identify early if

a child has a developmental delay

• Watch the newsletter for upcoming events which

will inform you about this evidence based tool

and how to interpret the information it provides

• BSPHN is also hosting Paediatric Pathways on

June 4, 2016 at LCCH







In conclusion….

The Mater Mothers Alignment program has

created a significant number of resources which

are available online for all to use and to share

We have worked with our colleagues in other

hospitals and in general practice to create affiliated

programs at Beaudesert, Logan, Redland, RBWH,

Redcliffe/Caboolture, Nambour, Ipswich and

Emerald Hospitals

Please use and share these resources







Available now….

• Online options to realign

• Bridging option for GPs who complete an

Alignment event at an affiliated hospital

• VOPP of some of the presentations

• Video clips with Dr Treasure McGuire,

pharmacologist







GPs referring to MSHHS? Online resources including power points with

information on local referral pathways are hosted

at www.bsphn.org.au/education-events/

maternal-shared-care/






http://gmsbml.org.au/education-events/maternal-shared-care/










GPs referring to MNHHS? Contact information for the MNHHS Alignment:

Brigid Wheaton Program Coordinator Metro North

Maternity GP Alignment Program

Phone: (07) 3646 4421

Email: [email protected]

Online resources are currently being hosted at

http://www.brisbanenorthphn.org.au/page/news-and-

events/metro-north-maternity-gp-alignment-program-

resources/



























Contact details

Maternity Share Care issues?

• GP Liaison Midwife Phone: 3163 1861

• E-mail: [email protected]

• Mobile: 0466 205 710

•If you are uncertain about the best approach to

take in caring for or referring a woman, or if she

requires urgent review, phone the on call consultant

(3163 6009), registrar (3163 6611) or the GPLM








Contact details

Alignment status, contact details & evaluation enquiries?

Sarah Renals

Phone 3163 1967

Email [email protected]

Training & RACGP enquiries?

Mater Marketing

Phone: 07 3163 1524

Email: [email protected]









Item numbers for MSC

16500 Rebate $40.10 ($47.15) Antenatal Attendance

16591 Rebate $121.30 ($142.65) “Planning and management of a pregnancy that has progressed beyond 20 weeks provided the fee does not include any amount for the management of the labour and delivery if the care of the patient will be transferred to another medical practitioner, payable once only for any pregnancy that has progressed beyond 20 weeks, not being a service to which item 16590 applies” (16590 = planning to undertake the delivery for a privately admitted patient)







Don’t forget…

• To complete your feedback document

• To complete your questionnaire – the pass mark

is 80% and yes, you can mail it in

• To get your pass for the car park!

• Do expect up to 8 weeks for processing of the

paperwork






Happy 5th Birthday, MMH Alignment!

Mater Mothers Hospital Alignment 2

Documents

Transcript of Mater Mothers Hospital Alignment 2