Pre-Pregnancy Counselling (July 14)
- 10 domains of assessment
- Clinical assessment
- Med hx
- Past jobs hx
- Genetic/FHx
- Medication use
- Vaccinations - MMR, DPT, Varicella, Influenza
- Lifestyle changes
- Folic acid and iodine supplementation
- Smoking/etoh/ illicit drugs
- Healthy environment
Management of Obesity in Pregnancy - Adverse outcomes AN
AN
- IGT/GDM
- MC
- SB
- PET
- VTE
- OSA
- Maternal death
- Abn in foetal growth and development
Management of Obesity in Pregnancy - Adverse outcomes intrapartum
- IOL, prolonged labour, FTP
- Instrumental, CS and PPH
- SD
- Difficulties with heart rate monitoring
- Difficulties with analgesia
- Use of GA
Management of Obesity in Pregnancy - Anaesthetic risks
- Difficulty w position
- Difficulty w catheter siting and increased risk of dislodgement
- Difficulty maintaining airways
- Increased need for ICU post op
Management of Obesity in Pregnancy - Adverse outcomes PP
- Delayed wound healing
- Increased wound infection
- Greater likelihood of needing support with maintenance and establishment of BF
- PND
- Long term neonatal consequences: composition, weight gain, obesity
Obesity - 8 preconception domains
- Identify/monitor weight/recommend lifestyle changes
- Discuss risks of obesity on fertility/preg outcomes
- Inform even modest increase in BMI associated w worse outcomes
- Daily exercise
- Consider bariatric surgery (decreased mat risk, ? increase IUGR)
- Folate (5mg if BMI >30), iodine supplementation
- Deprrssion assessment
- HINI vaccine
Obesity - GWG Ranges per BMI
30 - 5-9
Obesity - 9 AN domains
- Document BMI and refer
- Monitor GWG
- Vitamin supplementation
- OGTT - early and at 28/40
- Anaesthetic referral
- PET surveillance
- IUGR surveillance w USS
- Previous CS - less success, higher risk
- Start or continue exercise
Obesity - Intrapartum
- IV line for those w BMI > 40
- Awareness of increased risk SD and PPH
- Alert OT for weight > 120kg
Obesity - Post Partum
- VTE prophylaxis
- Breastfeeding support
- Advice and referal for weight management post partum
Major RF for PPH (7)
Placenta praevia Placental abrutpion Multiple pregnancy PET/Gest HTN Delivery by em CS Retained placenta Mediolateral episiotomy
Minor RF PPH
Previous PPH Asian Obesity Anaemia CS IOL Operative vaginal delivery Prolonged labour Macrosomia Pyrexia in labour Nullip > 40y
Early vs delayed cord clamping term infants
Early:
- Less jaundice/phototherapy
- Lower mean Hb
- Iron deficiency persistent to 6/12
Early vs delayed cord clamping preterm infants
Early:
- More blood transfusion
- More IVH
- No studies beyond discharge from hospital
Chronicity of Hep B w neonatal infection
40%
Risks of Hep B on pregnancy
- Neonatal transmission
- Acute - minima;
- Chronic - increased LFTs
- Cirrhosis (usually amenorrhoea w advanced cirrhosis):
- IUGR
- PTB
- FDIU
- Choreo
- PIH
- Abruption
- PPH
- 15% have hepatic compensation
Rationale for HBV Rx in pregnancy
- Prevent maternal complications (25% die from HBV, 40% HCC)
- Prevention of perinatal transmission
(Usually Telbivudine)
Risk of foetal/neonatal transmission
AN 5% (abruption, TPL or invasive procedures), Intrapartum 95%
No intervention 90%
W HBIG and vaccine at birth and 1 months of age ~5%
House hold members, sexual partners and children with Hep BsAg + woman
Should all be screened and vaccinated if not already immune
Prevalence of HBV infection
1%
Majority are people from an area of high prevalence
Definition chronic HBV
HBVsAg + > 6/12 after exposure
How can HBV be prevented?
- Vaccine - children, contacts, HCW
- Safe blood products
- Prevention of vertical infection
- Sexual prevention
IS HBV vaccine safe in pregnancy
Yes
It is safe and effective
Only use if recommended e.g. post exposure and non-immune (give w immune globulin also)
Is invasive testing safe in pregnancy?
- Higher rate of transmission, but not extensively studied. Likely higher in women with a high viral load.
- Likely higher w CVS and amnio
- Consider NIPT
- Careful counselling re risks involved
