Early Intervention in Pregnancy

Transcription

1 Early Intervention in Pregnancy Dr Lucy Mackillop Obstetric Physician Honorary Senior Clinical Lecturer Women s Centre Oxford University Hospitals NHS Foundation Trust TVSCN conference 17 th January 2017

2 Early Intervention Risk assess Mother Non-pregnancy associated co-morbidities Pregnancy associated conditions Risk Assess Fetus Screening for aneuploidy Screening bloods Growth scans Optimise health of Mother Healthy life style Smoking cessation Flu vaccination Optimise medical/psych conditions Optimise medications Prophylaxis e.g. VTE, pre-eclampsia Optimise health of Fetus Optimise health of Mother Vitamins such as folic acid Pertussis vaccination

3 The Challenge Prevalence of medical conditions is increasing The complexity of often multi-co-morbidities is increasing More women on long term medications More disease specific guidelines are being published recommending early intervention

4 The changing face of the obstetric population The prevalence of medical conditions complicating pregnancy is increasing. Older mothers Obesity epidemic (20% of pregnant women) Often co-morbidities/increasing complexity Heart disease & Stroke Type 2 Diabetes Hypertension Malignancy osteoarthritis Birth defects Pre-eclampsia/ gestational diabetes Complications at delivery Gall bladder & Liver disease Psychological Ill-health Childhood obesity Adult cardiovascular disease

5 60% of all women dying had a pre-existing medical co-morbidity (excluding obesity and suicide)

6 Epilepsy AEDs and Malformation Patterns

7 Epilepsy Epilepsy commonest serious neurological disease 1% of UK population More women died from epilepsy than from pre-eclampsia in the UK in the last 2 MBRRACE-UK reports Anti-epileptic Drugs and Congenital Malformations Sodium Valproate has 2-3 times the risk of malformations compared to other AEDs particularly given as part of polytherapy Tomson T, Dattino D. Lancet Neurol 2012;11: Dose response Tomson T, EURAP. Lancet Neurol. 2011;10: Lower IQ in children born of mothers on valproate Evidence to support better seizure control, fewer on polytherapy, lower dose treatment, fewer on Valproate, better compliance when PRE-CONCEPTION COUNSELLING Kanako Abe, Seizure 2014, 23,

8 Diabetes

9 Affects of Diabetes on Pregnancy Maternal and Fetal Risks Miscarriage Congenital Malformations Premature delivery Polyhydramnios Pre-eclampsia Gestational Hypertension Pyelonephritis Hypoglycaemia (ass with maternal and fetal death) Diabetic Ketoacidosis (50% fetal mortality) Unexplained intra-uterine death Rate 26.8 per 1000 (RR 4.7) 1 Neonatal risks Birthweight (macrosomia and intrauterine growth restriction) Respiratory Dysfunction Hypoglycaemia Polycythaemia and Jaundice Necrotising entercolitis Hypocalcaemia and Hypomagnesaemia 1. CEMACH

10 Risk of congenital malformations type 1 diabetes NICE 2008 Diabetes in Pregnancy Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%), if this is achievable without causing problematic hypoglycaemia. Reassure women that any reduction in HbA1c level towards the target of 48 mmol/mol (6.5%) is likely to reduce the risk of congenital malformations in the baby. Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant because of the associated risks. High dose Folic Acid NICE 2015 Diabetes in Pregnancy

11 Venous Thromboembolic Disease

12 VTE (n) Distribution of VTE in pregnancy and puerperium VTE incidence: 1 st trimester: 10.1% 2 nd trimester: 10.4% 3 rd trimester: 28.4% 49.3% of VTE occurred during the first 6 weeks postpartum Antepartum Weeks Delivery Postpartum Jacobsen et al. Am J Obstet Gynecol 2008;198(2):233.e1 7

13 Number of deaths 60 27% Fatal Maternal PE Postnatal Antenatal st 2nd 3rd & 4 5 & 6 Antenatal trimester Postpartum week Data from CMACE/MBRRACE Maternal deaths enquiries, UK

14 Contributors to 1 st trimester EVENTS ~40% pregnancies unplanned Delay in risk assessment MW booking 10 weeks Delay in instituting thromboprophylaxis GPs unable to prescribe GPs unsure about prescribing 1 st trimester risk factors IVF/OHSS Hyperemesis Hospital admissions/surgical procedures

15 Maternal Medical Risk Assessment Multiple guidelines Across several disciplines Requires medical knowledge Requires prescribing ability

16 Maternal Medical Risk Assessment VTE risk prescribe LMWH DM risk refer or GTT at 28 weeks Hypertension risk - prescribe aspirin High Dose Folic Acid Requirement for referral maternal or fetal, medical or obstetric Vit D Smoking cessation Mental health assessment Vaccinations

17

18 Maternal Medical Risk Assessment Electronic completion Supported by an advice service Pilot phase July-Sept 2014 Improve timely and appropriate referral Ensure correct prescriptions are issued Provide better communication between us

19 Conclusion 1 Pre-conception or early intervention in pregnancy increasing prevalence of medical conditions Public health initiatives Increasingly complex comorbidities Increasing evidence of substandard care contributing to indirect maternal deaths Cross speciality education Better/more timely Communication

20 Conclusion 2 Primary care lead identification women with medical problems With epilepsy With diabetes High risk of VTE: (On oral anticoagulants/previous VTE) Cardiac Disease Ensure they have up to date preconception and contraception advice Standardise early medical risk assessment to ensure appropriate referral and timely prescriptions

21 Thank you