The UCLH Women

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The UCLH Womens Health17th annual GP study day
16th September 2009
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Obstetric case discussions
Dr Elisabeth Peregrine Consultant Obstetrician
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A 40 year old primip attends for her routine 31
week check and has a BP of 150/100 and 1
proteinuria
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• History
• Headache / blurred vision / odema
• Nausea and vomiting / epigastric pain
• Personal history of ? BP
• Family history of ? BP
• Booking BP

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• Examination
• Repeat BP
• Abdominal exam including SFH tenderness
• Odema
• Reflexes
• Investigations
• Urine dipstick
• Management
• Refer to Maternal Fetal Assessment Unit (MFAU)
  08.00-19.00
• 020 7380 9573

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• Management in MFAU
• Review of obstetric notes
• Symptom enquiry
• Serial BP measurement
• Abdominal palpation
• Urine dipstick
• If mean BP 170/110 then to LW
• If mean BP gt140/90 then
• FBC / UE / urate / LFTs
• CTG
• Urine PCR if 1 proteinuria
• 24 hour urine if PCR gt 30mg/mmol
• Ultrasound

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• Management in MFAU
• Mean BP 140/90, no protein
• discharge to community BP / urine 1/52
• Mean BP lt 150/95, no protein, normal Ix
• see MFAU 1/52
• Mean BP 150/95, no protein, abn Ix
• Medical review
• Admit
• Or twice weekly MFAU
• Mean BP gt 140/90 and protein
• Medical review
• Admit
• Or twice weekly MFAU ( if PCR lt30 BP lt160/100)

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• Management of hypertension
• To prevent intra-cerebral haemorrhage
• gt170/110
• Methyldopa
• Loading dose 500-700mg
• 250mg tds to max 3g a day
• Good safety profile
• Labetalol
• 100mg bd up to max 2.4g a day
• Concern re SGA
• Nifedipine
• 10mg SR bd up to max 80mg a day

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• Principles of management / delivery
• Diagnosis
• /- anti-hypertensives
• Monitoring maternal and fetal well-being
• Laboratory tests
• USS for growth, amniotic fluid, /- dopplers
• /- prophylactic steroids
• Delivery when
• When maternal risks exceed fetal risks
• When risk of intrauterine death exceeds risk of
  delivery and prematurity

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A 23 year old multip states at her booking visit
that her last baby was on the neonatal unit with
a group B strep infection after the delivery.
What is your management?
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Previous Group B Strep infection

• Normal antenatal care
• Normal obstetric management
• IV antibiotics in labour / once SROM
• No benefit of CS

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Group B Strep

• Early onset 0.5-1.5 per 1000 LB
• 5-10 die
• 25 of women colonised in vagina / intestine
• lt 1 of these babies become infected
• IV Abs to those with risk factors reduce
  incidence
• But no evidence screening in UK is effective as
  sensitivity of a vaginal swab is 50
• Antenatal treatment if in urine only

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Group B Strep

• Treat if
• GBS infection in a previous baby
• GBS detected in the vagina at any time in the
  current pregnancy
• GBS detected in the urine at any time in the
  current pregnancy
• fever in labour
• prolonged rupture of the membranes, gt 18 hours at
  term
• Aim for at least 2 hours prior to delivery

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A 35 year old primip is reviewed at her 34 week
visit and is found to have a symphyseal fundal
height of 38cm What is your management?
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Clinical large for gestational age

• Confirm measurement
• Compare to previous SFH
• Confirm had screening for gestational diabetes
• Review at 36 week visit
• But if there is
• Sudden increase in SFH
• Tense abdomen
• Difficult to feel fetal parts
• Tightenings
• Refer to MFAU

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Clinical large for gestational age

• No benefit of ultrasound in low risk women (NICE)
• Inaccuracy of ultrasound
• No benefit in outcome
• Exception is in diabetic pregnancies
• If ultrasound normal reassure
• If AC or EFW gt 97th centile for GTT
• If GTT normal and EFWlt 4.5kg then normal care
• No benefit of induction of labour
• Polyhydramnios will be referred to FMU

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Antenatal Care at UCLH

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Access to antenatal care

• UCLH encourages women to access maternity
  services as early in possible in pregnancy so
  that maternity booking can take place at 8 10
  weeks gestation.
• Referrals are accepted by the following methods
• GP referral by post
• GP referral by fax [phone]
• GP referral by telephone [phone]
• GP referral by email to 1st.antenatal.appointment
  s_at_uclh.nhs.uk
• Women can self refer by any of the means above

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Antenatal care schedule for women who are healthy and whose pregnancies remain uncomplicated Antenatal care schedule for women who are healthy and whose pregnancies remain uncomplicated Antenatal care schedule for women who are healthy and whose pregnancies remain uncomplicated Antenatal care schedule for women who are healthy and whose pregnancies remain uncomplicated
Antenatal visits Antenatal visits Visit location professional Reason for visit
Nulliparous (no previous delivery gt 23 weeks 80 96 weeks Parous (at least one previous delivery at gt23 weeks) 80 96 weeks Hospital or community midwife Hospital or community based visit Identify women who may need additional care and plan pattern of care for pregnancy Measure height, weight and calculate body mass index Measure blood pressure and routine urinalysis Offer routine antenatal booking screen (see page 11) Offer screening for Downs Syndrome Offer ultrasound scan for gestational age assessment and ultrasound screening for structural anomalies and pregnancy complications Give verbal and written information on topics such as diet and lifestyle considerations
110 136 weeks 110 136 weeks Ultrasound Screening Unit Floor 1, EGA Wing Gestational age assessment Screening for structural anomalies, Downs syndrome and pregnancy complications
16 weeks 16 weeks Hospital or community midwife Hospital or community based visit Review, discuss and record the results of screening tests Measure blood pressure and routine urinalysis Give verbal and written information on the anomaly scan
200 216 weeks 200 216 weeks Ultrasound Screening Unit Floor 1, EGA Wing Ultrasound scan to screen for structural anomalies within the baby and to assess location of the placenta
25 weeks Not required GP or midwife Hospital or community based visit Measure blood pressure and routine urinalysis Measure and record sympyhsis-fundal height
28 weeks 28 weeks GP or midwife Hospital or community based visit Measure blood pressure and routine urinalysis Offer second screening for anaemia, atypical red-cell antibodies and random blood glucose Offer Anti-D prophylaxis to women who are RhD negative Measure and record sympyhsis-fundal height Offer antenatal classes Mat B1 certificate
31 weeks Not required GP or midwife Hospital or community based visit Review, discuss and record the results of screening tests taken at 28 weeks Measure blood pressure and routine urinalysis Measure and record symphysis-fundal height
34 weeks 34 weeks Hospital or community midwife Hospital or community based visit Measure blood pressure and routine urinalysis Measure and record symphysis-fundal height Offer third screening for anaemia and atypical red-cell antibodies Give information on preparation for labour and birth, including the birth plan, recognising active labour and coping with pain
36 weeks 36 weeks GP or midwife Hospital or community based visit Measure blood pressure and routine urinalysis Measure and record symphysis-fundal height Check position of baby if breech refer to MFAU Give written and verbal information on breastfeeding, vitamin K prophylaxis, newborn screening and post-natal self care
38 weeks 38 weeks GP or midwife Hospital or community based visit Measure blood pressure and routine urinalysis Measure and record symphysis-fundal height Give written and verbal information on management of prolonged pregnancy Call MFAU 020 7380 9573 to arrange 41 week appointment
40 weeks Not required GP or midwife Hospital or community based visit Measure blood pressure and routine urinalysis Measure and record symphysis-fundal height Further discussion about management of prolonged pregnancy offer membrane sweep
41 weeks 41 weeks Maternal Fetal Assessment Unit, Floor 1, EGA Wing Measure blood pressure, routine urinalysis and calculate body mass index Measure and record symphysis-fundal height Ultrasound scan to assess fetal well-being and risk assessment for spontaneous labour Offer induction of labour Offer membrane sweep
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• Thank you
• Any Questions?