Panel discussion Shared Maternity Care Workshop

Transcription

1 Panel discussion 2018 Shared Maternity Care Workshop

2 Panel members Dr Elske Posma Head of Obstetrics, Western Health Dr Jacqui Van Dam Head of Obstetrics, Werribee Mercy Dr Ines Rio Head of GP Liaison, Royal Women s Hospital 2

3 Our patient Amy 27 y.o. Presents at 6 weeks gestation for first visit G1P0 Taken pregnancy multivitamins Phx unremarkable Fhx she says no issues. 3

4 Initial tests Shortcut in your pathology tab for 1 st antenatal visit. Should you order thyroid function tests on this lady? 4

5 What if her family history was different? What if her Mother had thyroid trouble she had an operation and is now on medication. Sister also had thyroid trouble in her pregnancy. Should you order thyroid tests? 5

6 You order tests TSH 4.2mlU/L So TFT are added T4 13pmol/L T3-3pmol/L When do you order Thyroid antibodies? 6

7 What do you do next? 7

8 Refer to RANZCOG Guidelines RANZCOG - Subclinical hypothyroidism and Hypothyroidism in Pregnancy Take home messages Not for universal TFTs TFTs if hx thyroid disease, autoimmune disease (DM, celiac), strong FHx thyroid disease If order TSH do after 6 weeks Use lab TSH levels for pregnancy and if none use Pre pregnancy rate < 6 weeks Rest 1st trimester 2.5 2nd/3rd trimester 3.0 Hypothyroidism is if: t4 and t3 low or TSH >10 Treat and monitor Subclinical hypothyroidism evidence for treatment not clear Ensure iodine 150mcg day Thyroxine 50-75mcg day Stop thyroxine after birth? more likely to dev hypothyroidism later in life 8

9 What if Amy was G3P2 with PHx pre-eclampsia Would you start aspirin this pregnancy? 9

10 When is low dose aspirin indicated? When should it be started? What time of day should it be taken? 10

11 Work issues Amy works in a warehouse business. Office duties and pick packing. Pick packing standing, lifting, climbing ladders Boss is difficult and wants clear guidelines from the GP 11

12 How specific would you be providing a certificate to modify her duties? What is the evidence? 12

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14 Amy has her wk ultrasound Placenta low lying with inferior margin 1.5 cm from the internal os No PV bleeding or post- coital bleeding Amy wants to go overseas for a month What is your advice? 14

15 Ultrasound service calls we made a mistake the placenta is covering the os What is your advice now about: Travel Sex Work When do you repeat the ultrasound? What is the risk of placenta praevia? 15

16 Take home messages US now best done at weeks Advice depends on bleeding and how low placenta is If covering os high risk no sex, limited travel near hospitals and almost certainly praevia 16

17 U/S provider calls- we made a mistake. Too many Amy s! Placenta not low lying. Brad books a babymoon surprise to Vietnam and Cambodia. Amy thought Hepburn Springs for spa treatments would be more relaxing. Travel booked for 28 wks gestation 17

18 Amy is worried: Is she safe to fly? What about vaccinations? Are they safe? Is the food safe? What about blood clots? Her mum is worried: What about zika? Would the spas at Hepburn Springs be safer? 18

19 Take home messages Risk of travels depends on: Gestation Individual pregnancy and pre-existing health conditions Travel mode Destination (infectious diseases, toxins, available maternity care, insurance) Risk of activities Zika Check website CDC, Dept of Health - Australia Can be present in sperm for 6 months risk on return Most asymptomatic infection Serology seek advice, beware of cross reactivity with dengue and yellow fever, routine serology not recommended in asymptomatic patients 19

20 39 weeks she has had enough Finished work Sore back Uncomfortable Can t sleep Worried about the labour and pain Friend told her to ask for an induction She wants a caesarean What do you say? 20

21 What are the risks of induction vs awaiting onset of labour? Is there a role for VE and stretch and sweep? What if she is GBS positive? What are the pros and cons for caesarean section? 21