Maternity Shared Care Resource

Maternity
Shared Care
Resource
For General Practitioners
An Initiative of Medicare Local Tasmania Ltd
______________________________________________________
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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Section 1: Indications for Consultative Review
and Collaborative approach to Shared Care
Should be seen as early as possible in pregnancy by
consultant
Section 2: Maternity Care: Contact Telephone and Fax
Termination of
Numbers
Pregnancy: Contact Telephone and Fax
Numbers
Section 3: Guide for Antenatal Visits:
First Antenatal Visit
Booking in Appointment for Antenatal Patients at the QV OPD
Subsequent Antenatal Visits including Investigations
Section 4: Foetal Screening
Section 5: Folate & Iodine / Multivitamins
Information
Maternity
Shared
Care
Resource
Vitamin D Information, Nausea & Vomiting Treatments in
Pregnancy, Breast Feeding Information, Commonly asked
lifestyle questions in Pregnancy, Internet sites for accessing
patient information
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Section 6: Information relating to Infections &
Immunisations in Pregnancy:
Cytomegalovirus Infection; Listeriosis; Herpes Simplex Virus;
Varicella Zoster Virus; Rubella; Group B Streptococcus
Screening;
Slap-cheek Syndrome (Parvo-virus)
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Section 7: Miscarriage Criteria
Termination of Pregnancy
Miscarriage & Perinatal Death Counselling
Section 8: Guidelines for the use of
Rh D Immunoglobulin in Obstetrics
Section 9: 6 Week Postnatal Check:
Peri Natal Depression; GTT Follow-Up; Pre- Pregnancy
Counselling, HIV, Hep C Testing Information
Section 10: Misc. Information:
Prescribing Medicines in Pregnancy database, FGM,
Circumcision, Genetic Services
Appendices: LGH Clinical Protocols
A: Antenatal Care, B: Vitamin D Deficiency, C: Iron Deficiency
Anaemia, D: Management of Women with Nausea and Vomiting,
E: Chlamydia Screening, F: Exposure and Management of Rash
Illness, G: Pregnancy Assessment Clinic Referral, H: Rh D
Immunoglobulin (Anti-D)
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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This resource was developed to assist GPs participating in Maternity Shared Care with the
Queen Victoria Unit (QV) (including the Outpatients Department). The resource provides
information and guidelines to assist GPs but should not replace clinical judgment.
The resource has been developed as a living document and therefore changes to any or all
sections are expected and users should keep this in mind when using the resource.
Acknowledgements
Acknowledgement is made to the following people and organizations for their much
appreciated initial contributions and support for the Maternity Shared Care Resource.
Maternity Shared Care Resource
Reference Group
Dr Anne Wilson
Dr Julie Ostberg
Dr Robin Bailey-Smith
Sue Saltmarsh
Obstetricians
Dr Susan Winspear
Dr Christine Manley
Dr John Grove
Dr Amanda Dennis
NUM QV Outpatients Department
Janette Tonks
Pharmacist
Anne Todd
Administration Support
Donna Harman
Staff of General Practice North/Tasmania Medicare Local - North
Funding
Tasmania Medicare Local Ltd.
Disclaimer.
Every effort has been made to provide information that is accurate and up-to-date at the time
of publication. However, neither Tasmania Medicare Local - North nor the committees
warrant that the information that is contained herein is in every respect accurate or complete,
and they are not responsible for any errors or omissions, or the results obtained from the use
of such information.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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Introduction
This resource is your guide to Maternity Shared Care antenatal management in Northern
Tasmania with deliveries being at the Queen Victoria Unit (QV), Launceston or at the NESM
Hospital at Scottsdale. This includes Maternity Shared Care Guidelines and resources for
use when participating in Maternity Shared Care.
The concept for this resource was derived from the “The Protocol Booklet Obstetric Shared
Care for general practitioners” a joint initiative between Adelaide Central & Eastern Division
of General Practice, Adelaide Western Division of General Practice, North Western Adelaide
Health Service, (The Lyell McEwin Hospital Campus, The Queen Elizabeth Hospital
Campus) and Women’s & Children Hospital Campus.
Obstetric Medical Indemnity Insurance
It is important that each GP participating in Maternity Shared Care check with their insurance
company to ascertain indemnity coverage for Shared Care (including shared care with
midwives if appropriate)
Maternity Shared Care
Women attending the QV for management of their pregnancy and delivery, have the option
of having a major part of their antenatal care with their GP. This is dependent upon:
•
Their wishes
•
Agreement by GP
•
Agreement by the hospital after assessment of risk factors (Section 1)
While it is not a condition that the doctor holds RANZCOG membership, he/she should have
some knowledge and interest in maternity care and be familiar with the maternity shared care
protocols. For interested doctors, it is possible for them to spend some time in an antenatal
clinic. GP’s need to be credentialed by the hospital prior to an attachment at the QV OPD
and are able to obtain CPD and Women’s Health points for the clinical attachment. GPs will
be paid and have their medical indemnity covered by the LGH whilst working in the clinical
areas. Contact Tasmania Medicare Local (TML) - North or Dr Amanda Dennis (Director of
Women’s & Children’s Services, LGH) for further details.
Contributions:
As this is a living document, any contributions or enquiries are welcomed and may be
directed to Tasmania Medicare Local - North.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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Shared Care = Shared Responsibility
The following guidelines are current guidelines for Tasmania Medicare Local - North
Maternity Shared Care and it is strongly recommended that these be followed. Section 1
provides lists of indications for consultative review and collaborative approach to Share Care.
All pregnant women should be referred as soon as possible to the QV OPD (Out
Patient’s Department) for early assessment. Also some risk factors/medical conditions
require assessment prior to conception e.g. stabilisation of diabetes, hypertension, epilepsy.
A referral form developed by Tasmania Medicare Local - North must be completed for all
patients being referred to the QV OPD (click here for referral – LGH Obstetrics/Gynaecology
Referral). The referral form is to be addressed to the preferred consultant but the patient
should be made aware that they might not necessarily see that particular consultant. GPs are
able to ring the clinic to ascertain when the preferred consultant conducts the clinic. For
urgent referrals GPs can contact the antenatal clinic and discuss with the antenatal clinic
staff. QV OPD referral forms are also available from Tasmania Medicare Local - North as a
paper based version.
Hand Held Antenatal Record
The Hand Held Antenatal Record has been developed as part of the
Maternity Shared Care Program. This booklet is integral to the
communication process within the Shared Care Program.
Please complete the ‘Hand Held Antenatal Record’ at each visit. It is
also important that all details of the visit are recorded in the patient notes.
GPs - please remind patients to take their booklet with them to every visit with health
professionals, including when presenting to labour ward and for elective caesarian sections
(anaesthetist’s request). Anaesthetists have indicated that they like to have information
available including weight, allergies, past medical/surgical history and screening results.
Booklets are updated bi-annually; please check that you are using the most current versions.
The latest version is June 2012.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 1
Indications for Consultative Review and Collaborative
Approach to Shared Care
Should be seen as early as possible in pregnancy by consultant
MEDICAL CONDITIONS
Anaesthetic difficulties:
- previous failure or complication (e.g. difficult intubation,
failed epidural)
- malignant hyperthermia or neuromuscular disease
Autoimmune disease
Cardiovascular disease/hypertension
Infectious Diseases cont:
- Herpes genitalis: primary infection
- Herpes genitalis: recurrent infection
- Toxoplasmosis
- Tuberculosis: active tuberculosis or a history of tuberculosis
- Syphilis:
◦ positive serology and treated
◦ positive serology and not yet treated
◦ primary infection
Drug dependence or misuse:
- use of alcohol and/or other drugs
- medicine use: the effect of the drugs on the pregnant woman
and the unborn child, lactation and/or neonate.
Information is available from Mothersafe 1800 647 848
Endocrine:
- diabetes mellitus, pre-existing insulin dependent or non-insulin
dependent
- gestational diabetes
- If there is a history of viral, microbial or parasitic infections
whether active or a previous medical history then medical
consultation is required.
Maternal Age (under 14 and older than 45 years)
Maternal Weight > 100kg or BMI <17 and >35
Neurological:
- Epilepsy, without medication or in the past without treatment and
no seizures in the last 12 months
- thyroid disease
- Epilepsy, with medication or seizure in the last 12 months
- hypothyroidism
- Subarachnoid haemorhage, aneurysms
- hyperthyroidism
- Multiple sclerosis
- Addison’s Disease, Cushing’s Disease or other endocrine
disorder requiring treatment
- AV malformations
Gastro-Intestinal:
- Hepatitis B with positive serology (Hbs– AG+)
- Hepatitis C
- Inflammatory bowel disease including Ulcerative Colitis and
Crohn’s Disease
Genetic - any condition
Haematological:
- Thrombo-embolic process: any underlying pathology and the
presence of a family medical history
- Coagulation disorders
- Anaemia at booking irrespective of how treated or whether it
responds to treatment. Anaemia is defined as Hb<9g/dl
Infectious Diseases:
- HIV infection
- Rubella
- Cytomegalovirus
- Myasthenia gravis
- Spinal cord lesion (para or quadriplegia)
- Muscular dystrophy or Myotonic dystrophy
History of Mental Health Disorders:
- Care during pregnancy and birth will depend on the severity and
extent of the mental health disorder
Renal Function Disorder:
- Disorder in renal function, with or without dialysis
- Urinary tract infections
- Pyelitis
Respiratory Disease:
- Asthma mild
- Asthma moderate (i.e. oral steroids in the last year and
maintenance therapy)
- Severe lung function disorder
System/Connective Tissue Diseases:
- Parvo virus infection
These include rare maternal disorders such as:
- Varicella/Zoster virus infection
systemic lupus erythematous (SLE), anti-phospholipid syndrome
(APS), scleroderma, rheumatoid arthritis, periarteritis nodosa,
Marfan’s syndrome, Raynaud’s disease and other systemic and rare
disorders.
Antenatal Care: LGH Protocol 1.1-09WACS
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 1 cont’d
Indications for Consultative Review and Collaborative
Approach to Shared Care
Should be seen as early as possible in pregnancy by consultant
Previous Obstetric History
- Active Blood Group Incompatibility
(Rh, Kell, Duffy, Kidd)
- ABO-incompatibility
- Hypertension in the previous pregnancy
Pre-existing Gynaecological Disorders
-
Pelvic floor reconstruction. This refers to
colpo-suspension following prolapse, fistula and/or
previous rupture
- Cervical abnormalities:
-
- Pre-eclampsia in the previous pregnancy
- Eclampsia
- Recurrent miscarriage (3 or more times)
-
- Uterine abnormalities:
-
Pre-term birth (<37 weeks) in a previous
pregnancy
Cervical incompetence (and/or Shirodkar
procedure)
- Placental Abruption
- Forceps or vacuum extraction
- Caesarean section
Cervical amputation
Cervical cone biopsy
Cervical surgery with or without subsequent
vaginal birth
-
Myomectomy/hysterotomy
Bicornuate uterus
Intra Uterine Contraceptive Device (IUCD) in
situ
- Infertility treatment
-
Pelvic deformities (trauma, symphasis rupture,
rachitis)
- Female Genital Circumcision
- Fetal growth disturbance
- Asphyxia (defined as an APGAR score of <7
at 5 minutes)
- Perinatal death
- Child with congenital and/or hereditary
disorder
- Postpartum haemorrhage as a result of:
- Episiotomy
- Cervical tear
- Other causes (>1000ml)
Antenatal Care: LGH Protocol 1.1-09WACS
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 2
Maternity Care: Contact Telephone & Fax Numbers
LGH/QV:
LGH – DEM Triage
Ph: 6348 7405
Fax: 6348 7382
Labour Ward
Ph: 6348 8960
Fax: 6348 8959
QV OPD
Ph: 6348 8980
Fax: 6348 7886
Booking-in Appointments
Ph: N/A
Fax: 6348 7886
Pregnancy Assessment Clinic
Ph: 6348 8946
Fax: 6348 8899
LGH Pathology
Ph: 6348 7690
Fax: 6348 7695
Birchall-Meares Post Natal Unit
Ph: 6332 4830
Fax: 6332 4933
Private Imaging:
I-MED Northern Imaging
Ph: 6336 6336
Fax: 6334 3335
MIA Tasmania (Rush Taylor & Partners)
Ph: 6233 1733
Fax: 6228 0341
Private Pathology:
Launceston Pathology
Ph: 6334 3636
Fax: 6334 2273
Calvary St. Vincent’s Campus
SAMSAS (South Australia)
Ph: (08) 8161 7285
Fax: (08) 8161 8085
Private Consultants:
Dr Toly Pavlov
Calvary St Luke’s Sessional Consulting Rooms
16 Lyttleton Street,
Launceston TAS 7250
Ph: 6334 3488
Fax: 6334 4242
Ph: 63 330344
Fax: 63 330944
Ph: 6343 0999
Fax: 6343 0966
Other Useful Contacts:
Sexual Health /HIV Clinic
Ph: 6336 2216
Fax: 6331 3454
Family Planning
Ph: 6343 4566
Fax: 6343 6766
Dr Bill Watkins Hobart IVF
Ph: 6224 1808
Fax: 6224 1548
Dr Christine Manley
Dr Amanda Dennis
19 Lyttleton Street,
Launceston TAS 7250
Dr Frank Clark
13 Wilson Street,
South Launceston TAS 7249
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 2 cont’d
Termination of Pregnancy: Contact Telephone and Fax Numbers
Termination of Pregnancy
Due to lack of resources at the LGH, GPs are advised to refer patients to one of the following
for termination of pregnancy:
HOBART
Fertility Control Clinic
9 Main Road
Moonah
Ph: 6278 1406
Fax: 6278 1449
Ph: 6224 5888
Fax: 6224 5899
Ph: 6331 8333
Fax: 6331 8668
Hobart Gynaecology
First Floor
1A Victoria Street
Hobart
LAUNCESTON
Specialist Gynae Centre
Suite 4/7 High Street
Launceston
MELBOURNE
By going to www.betterhealth.vic.gov.au/ and keying in ‘abortion’ to the search engine will
lead to a great deal of information on all aspects of pregnancy termination and related
issues. It also includes a list of public and private providers in Victoria.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 2 cont’d
UNPLANNED PREGNANCY
Counselling
Decision to Terminate
Surgical Termination
>13/52
www.betterhealth.vic.gov.au
<13/52
Decision to continue with
pregnancy and
routine Antenatal Care
Medical Termination
www.betterhealth.vic.gov.au
Gynae Centre - Launceston
Hobart Gynaecology - Hobart
Fertility Control Clinic - Moonah
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 3
Guide for Antenatal Visit
Antenatal Care: LGH Protocol 1.1-09WACS
(All details should be documented in the hand held record and written in the patient’s notes)
History
•
•
Document history including patient problems
Always ask about foetal movements
Blood Pressure
Should be recorded at every antenatal visit. Should be taken with the woman sitting down with feet
supported. Measurements taken after two or three minutes resting in that position. A standard cuff
should be used for women with an arm circumference of 33cm or less. A large cuff is recommended
for an arm circumference greater than 33cm. Hypertension is defined when the systolic blood pressure
is 140mmHg and /or diastolic blood pressure (Korotkoff V) is 90mmHg or there is an increment rise of
30mmHg systolic or 15mmHG diastolic.
Body Mass Index (BMI)
BMI should be calculated at the first visit based on pre pregnancy weight. Dietetic advice on healthy
weight gain should be given. Women with a BMI >30 are regarded as high risk and will require
discussion with registrar/consultant regarding their suitability for midwifery care.
Urinalysis
A mid-stream urine (MSU) specimen is recommended to be included in the antenatal screening to
screen for asymptomatic bacteriuria. Routine urinalysis should be done for women with diabetes, renal
disease, documented intrauterine growth restriction (IUGR) or autoimmune disease. When
hypertension is suspected due to an elevated blood pressure reading, urinalysis should be performed
for the presence of protein.
Symphyseal Fundal Height Measurement
Is an assessment of uterine size used as an indirect measure of fetal growth. A measurement from the
fundal height to the symphasis pubis should be taken at the antenatal visits from 20 weeks. If the fetus
appears either small (3cm below expected) or large (3cm above expected) for gestational age then
referral to a consultant or registrar is indicated. Ultrasound scan for assessment of fetal growth and
AFI should be undertaken if fundal height more than 3cm below expected. GTT may be appropriate if
fundal height more than 3cm above expected.
Palpation
All women in the third trimester should have the uterus palpated to determine fetal lie and
presentation. A fetus noted to be other than in longitudinal lie with a cephalic presentation at 36 weeks
gestation or with a mobile presenting part at 40 weeks must be referred to the consultant or registrar.
Auscultation of Fetal Heart Rate (FHR)
Auscultation of Fetal Heart Rate is of no known clinical benefit. However, it maybe of psychological
benefit to mothers. Fetal movement on palpation or reported by the woman will confirm the fetus is
alive.
Smoking
At every antenatal visit the woman should be asked about her smoking behaviour. The benefits of
quitting at any stage in pregnancy should be emphasized.
Complications
All complications should be discussed with the patient. Where concern exists, consultation with QV
OPD/Obstetrician/O&G Registrar is advised.
Shared Care = Shared Responsibility
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 3 cont’d
Guide for Antenatal Visit continued
Indications for consultation during pregnancy:
Uncertain duration of pregnancy by amenorrhoea
>20 weeks
• Addison’s, Cushing’s or other endocrine disorders
Laparotomy during pregnancy
Gastroenterology:
Cervix cytology CIN
• Hepatitis B with +ve serology (HbsAG+)
Mental health disorders
• Hepatitis C
Hyperemesis gravidarum
• Inflammatory bowel disease including Ulcerative Colitis &
Crohn’s disease
Ectopic pregnancy
Hernia nuclei pulposi (slipped disc)
Antenatal screening
Haematological:
Suspected fetal abnormalities
• Thrombosis
Pre-term rupture of membranes
• Coagulation disorders
Gestational hypertension
• Anaemia at booking in or close to term
Preeclampsia
Infectious diseases:
Eclampsia
• HIV infection
Chronic hypertension
• Rubella
Blood group incompatibility
• Toxoplasmosis
Coagulation disorders
• Cytomegalovirus
Recurring vaginal blood loss
• Parvo virus infection
Placental abruption
• Varicella/Zoster virus infection
Size/date discrepancies
• Tuberculosis: an active tuberculosis process
Post-term pregnancy
• Herpes genitalis:
Threat of or actual pre-term birth
◦ Primary infection
Incompetent cervix
◦ If late in pregnancy
Symphasis pubis dysfunction
◦ Recurrent
• Syphilis:
Multiple pregnancy
Non cephalic presentation at birth
◦ Positive serology & treated
Failure of head to engage at full term
◦ Positive serology & not yet treated
No prior antenatal care
◦ Primary infection
Baby for adoption
Renal function disorders:
Fetal death in utero
• Urinary tract infections
Fibroids
• Pyelitis
Endocrine:
Respiratory Disease:
• Diabetes mellitus or gestational
diabetes mellitus (GDM)
• Asthma
• Thyroid disease
Antenatal Care : LGH Protocol 1.1-09WACS
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 3 cont’d
First Antenatal Visit/s: (over 1 or 2 appointments)
(All details should be documented in the hand held record and written in the patient’s notes)
Examination
•
Complete History (as per Hand Held Antenatal Record) see below
Past Obstetric History
Year
Birth Weight
Sex
Details
Antenatal History
LMNP
EDC (dates)
EDC (scan)
Past Medical/Surgical History:
Family History (including clotting disorders)
Allergies:
Medications: (include OTC)
Recreational Drug Use:
Smoking:
Alcohol:
Date of last Pap smear:
Physical Examination:
Result:
Risk Factors:
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 3 cont’d
First Antenatal Visit/s: continued
(All details should be documented in the hand held antenatal record and written in the patient’s notes)
•
•
•
Examination
Risk assessment – (see Section 1)
Explanation of shared care, timing of visits to both GPs and QV OPD and
explanation of clinic visit – see Visits Schedules
Routine Booking Investigations:
•
FBE
•
Ferritin - see Iron Deficiency Anaemia in Pregnancy Protocol
•
Blood group and antibody screen
•
Fasting BSL or GTT (if high risk)
•
Rubella titre (if ≥ to 30 = immunity for approx. 2 years)
•
Vitamin D (for high risk women) – see Vitamin D Deficiency in Pregnancy
Protocol.
•
R.P.R/TPHA (Syphilis Screen Serology)
•
Hepatitis B serology
•
Hepatitis C – offer to all women (Pre and Post test counseling strongly advised)
•
HIV – offer to all women, if woman declines check for possible risk factors, (Pre and
Post HIV counseling mandatory by law)
•
MSU – self taken after washing urethral area with water
•
Chlamydia – low vaginal self swab – see Chlamydia Screening in Pregnancy Protocol
Note: Patients must be informed as to which tests are being performed.
Note: Please ensure that the laboratory concerned (including LGH Pathology) is
requested to send a copy of blood results to antenatal clinic QV OPD or GP
(depending upon who orders the tests).
If of Asian or Mediterranean descent then also do:
•
Haemoglobin Electrophoresis
•
Serum Ferritin
If FBE shows microcytosis do:
•
Haemoglobin Electrophoresis regardless of racial group
•
Serum Ferritin
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 3 cont’d
First Antenatal Visit/s: continued
This schedule is recommended by the WACS – LGH and is intended as a guide only.
Gestation
6 to 8 weeks
GP
10 to 12 weeks
ANC
14,16, 24,28,32 GP/ANC
20 weeks ANC
26 weeks
GP/ANC
28 weeks ANC
34 weeks ANC
36 weeks ANC
38, 40 weeks GP/ANC
41 weeks
ANC
2 week Postnatal GP
6 week Postnatal GP
GP to confirm pregnancy
Referral to named consultant at the ANC
First ANC visit to book in
Clerical booking in
Midwifery booking in:
• Review past medical & obstetric history
• Depression screening
• Calculate pre-pregnancy BMI
• Advice given on diet, exercise, smoking, drug and alcohol use
• Cessation intervention (e.g. QUIT) should be offered to all pregnant women who
smoke or have recently quit.
• Identification of Rh negative women for anti D prophylaxis
• Breastfeeding information and education is given and referral to the lactation
consultant or breastfeeding workshop made.
• Information on antenatal classes.
Antenatal Screening:
• Routine antenatal screening bloods (Rh, group & antibodies, Fasting BSL or
GTT, FBC, rubella, RPR, HIV, Hep B, Hep C and Vitamin D assay) should be
offered and arranged if not yet done.
• Offer Chlamydia screening – LVS with dry sterile swab - Chlamydia Screening
Protocol
• Dating scan – if required
• Prenatal diagnosis screening
• Book 18 week morphology scan
Antenatal psychosocial assessment by social worker by referral for women
identified as at risk.
Review by ANC medical staff
GP notification attendance and antenatal management plan
Routine antenatal check
Doctors visit
• FBC & Iron studies, Antibodies
• Referral for Glucose Tolerance Test (if not diabetic).
If a woman is diagnosed as having gestational diabetes her care should continue
in the antenatal endocrine clinic in conjunction with the diabetes clinic for
education and advice.
• Recommend iron supplements if Hb<110.
• Breastfeeding & Antenatal Classes at QV OPD (arranged at “Booking In”
session)
Prophylactic anti D 625 IU for all Rh negative women
Prophylactic anti D 625 IU for all Rh negative women
Routine antenatal check and
• FBC if Hb<110 at 26 weeks
• Antibodies if Rh negative and has not had prophylactic anti D
• Screening for :
- Group B Streptococcus (GBS) vial low vaginal/rectal
- Chlamydia – LVS with dry sterile swab
Routine antenatal check
Consultant led ANC visit
Discussion /planning for induction of labour
Optional check for mother & baby
Discuss Pertussis vaccine for new parents & grandparents
Check for mother & baby and commence immunisations for baby– see link below
http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0020/37037/Immunisation_Schedule_for_Children_in_Tas
mania_2011.pdf
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
MATERNITY SHARED CARE RESOURCE – Tasmania Medicare Local - North
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SECTION 3 cont’d
Booking In for Patients at the
Queen Victoria Outpatients Department
1.
Named referral to a consultant at the QV OPD is required as soon as patient’s
pregnancy confirmed (click here for referral – LGH Obstetrics/Gynaecology Referral).
2.
LMP, tests ordered, full postal address, previous surname, whether interpreter and
which language is required and other relevant information are encouraged on the
referral. Referrals are viewed for urgency and appointments are made in the
appropriate time. Therefore it is important to include any relevant information.
Reason for a named referral – facilitates secondary referral to other specialists e.g.
NT, CVS and Amniocentesis in Launceston, can currently only be performed in the
private sector.
3.
The booking in appointment will be posted to the patient within a couple of weeks.
4.
Midwifery appointment
Midwifery interview to determine obstetric, medical and surgical history and to discuss
any midwifery concerns. Advice is given on diet, exercise, routine tests, the services
provided by the QV OPD, breastfeeding and childbirth education classes. Antenatal
options * are discussed for patients to decide on what care they would prefer. *These
options include:
Shared Care
Team Midwifery
Wednesday morning midwives clinic
Young mums clinic for women under the age of 22
These options are for low risk patients only. Please see next page for complete list of
services provided.
5.
Where possible patients will see the consultant they have been referred to on the
same day or within a suitable time.
What happens at this appointment:
• Risk assessment
• Discussion and referral for prenatal screening if required.
• Routine blood tests and morphology scan organized
• Routine Breastfeeding & Antenatal classes organized
The QV OPD will follow up all tests generated from these appointments. Patients will
be recalled to the clinic if results require follow up and discussion.
6.
Ongoing appointments are made.
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Booking In for Patients at the
Queen Victoria Outpatients Department
Services Provided by the QV OPD
•
Antenatal Clinic for High Risk patients
•
Endocrine Clinic (Multi-disciplinary team)
•
Twin Clinic
•
Team Midwifery provides antenatal, intrapartum and postnatal care, thus
providing continuity of care. Patients not suitable for Team care are those that
will require a caesarean section, present to clinic after 26 weeks or become
high risk.
•
Wednesday morning Midwives Clinic provides antenatal care and postnatal
care by midwives working in those areas. These midwives are not rostered on
Labour Ward. Patients not suitable are those who become high risk. Will accept
any patient at any stage of pregnancy.
•
Booking In Clinic
•
Young Mums Clinic
•
Pregnancy Assessment Clinic
•
Childbirth Education
•
Antenatal Exercise Classes
•
Practical Parenting Skills Workshop
•
Breastfeeding Workshop
•
Young Mums Parenting Classes (help for pregnant adolescents)
•
Extended Midwifery Service. Provides midwifery care mostly in the postnatal
period for a limited time only until CHAPS (Child Health & Parenting Service)
take over.
•
Caesarian Section Workshop
•
Physiotherapy Classes
•
Tours of Maternity Unit
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Subsequent Antenatal Visits
(All details should be documented in the hand held record and written in the patient’s notes)
1.
History and examination as previously outlined
2.
Antenatal Investigations. (Ask laboratory concerned, including LGH Pathology, to
send copy of all results to antenatal clinic QV OPD)
At present RANZCOG suggest that screening for Down Syndrome be offered to every
pregnant patient. This should be done as either a Nuchal Translucency Ultrasound plus 1st
Trimester Maternal Serum Screening Test or 2nd Trimester Serum Screening. One or the
other should be performed, not both. The 19 to 20 week morphology scan should not be
used for Down Syndrome screening.
If the pregnant woman is interested in screening for spina bifida, the highest degree of
accuracy is achieved by performing alpha-fetoprotein at 15 to 19 weeks, combined with a
good quality 19 to 20 week ultrasound. Remember, alpha-fetoprotein is part of a 2nd
trimester maternal serum screen but not part of the 1st trimester serum screening
Alternatively between 14 – 20 weeks (2nd Trimester) screening through SAMSAS
includes AFP.
The 19 to 20 week ultrasound should be offered as screening for structural abnormalities,
confirming dates and placenta location.
The major scenario where this differs is a twin pregnancy. Maternal serum screening (1st and
2nd trimester) is not accurate under these circumstances and screening for Down Syndrome
is best performed with Nuchal Translucency (NT) ultrasound alone.
Note: Women should be counselled before having foetal screening and the possible
implications explained e.g. amniocentesis/termination of pregnancy. Also give patient
information leaflet, provided by SAMSAS. Go to Foetal Screening for more information.
10 weeks - Foetal Screening
•
Offer MSST (prior to Nuchal Translucency (NT) only) 10 weeks 0 days – 13 weeks 6
days.
•
Offer NT ultrasound scan at 11 weeks 0 days – 13 weeks 6 days. Please note, that if
done for screening abnormalities, the MBS item No. 55704 HIC rebate will be
available. There will be an “out of pocket” expense – check with provider.
•
Offer/arrange 2nd trimester Maternal Serum Screening Test (MSST) at 14 – 20 weeks 6
days or Alpha-fetoprotein (AFP) 15 – 19 weeks to assess risk of neural tube defects.
Give patient request form to have test at appropriate time (accurate gestation date
essential for MSST).
•
Offer and arrange morphology ultrasound scan 19 - 20 weeks
MBS screening items: http://www9.health.gov.au/mbs/search.cfm?q=55707&sopt=S
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Subsequent Antenatal Visits continued
(All details should be documented in the hand held record and written in the patient’s notes)
15 – 20 Weeks – MSST (Maternal Serum Screening Test) or AFP (Alpha-fetoprotein)
(for Neural Tube Defects)
•
Request form provided at 10 week visit as above.
19 – 20 Weeks – Morphology Scan
MBS screening items: http://www9.health.gov.au/mbs/search.cfm?q=55707&sopt=S
Options:
•
LGH
•
Northern Imaging
Appropriate request form given to the patient at 10 – 12 week visit or Booking In visit.
24 Week Antenatal Visit
•
Organise for 26-28 week blood tests if not already done so by the QV OPD.
26 Weeks – Blood (Ensure that copies of test results are sent to QV OPD/GP)
•
FBE & iron studies, not just Hb (request serum to be held in case ferritin assay needed)
•
Blood Group Antibodies on ALL patients
•
GTT (if not diabetic)**
**Note: Refer to QV OPD Endocrine Clinic if positive.
•
Breastfeeding & antenatal classes at QV OPD. Arranged at Booking In visit.
28 Weeks
•
All Rh negative patients given prophylactic Anti D injection at LGH pathology.
Appointment arranged by QV OPD.
34 Weeks
•
Discuss Group B Streptococcus screening – Go to Section 6 for more information.
•
Breast check during 3rd trimester
•
All Rh negative patients given 2nd dose of prophylactic Anti D as at 28 weeks.
36 Weeks – Usually a QV OPD visit
•
Multigravida Rh negative Blood group antibodies or if antibody screen positive
•
Group B Streptococcus swab taken (option to self-swab).
Ask Laboratory concerned (including LGH pathology) to send copy of
ALL results to QV OPD/GP
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SECTION 4
1st Trimester Screening
(To calculate risk for Down Syndrome and Chromosomal abnormalities – trisomy 13 and 18).
This screening is a combination of a blood test and Nuchal Translucency ultrasound. Blood
test should be taken between 10 weeks 0 days and 13 weeks 6 days, preferably one week
before Nuchal Translucency ultrasound which is between 11 weeks 5 days and 13 weeks 6
days.
Nuchal Translucency ultrasound can be performed from a crown rump length of 45mm to
84mm. This either 11 weeks 0 days to 13 weeks 6 days (by Australian Society of Ultrasound
Medicine measurements) or 11 weeks 5 days to 14 weeks 1 day (by Foetal Medicine
Foundation figures).
What can Nuchal Translucency detect?
85% of trisomy 21
82% of trisomy 18
89% of Turner syndrome
61% of triploidy
74% sex chromosome abnormalities
65% of other chromosome abnormalities
60% major structural abnormalities including CHD
Prognosis in other abnormalities
Prediction of twin transfusion syndrome in monochorionic twins
Options for Prenatal Diagnosis of Down Syndrome
1.
•
•
•
No Screening Tests
0% Screen Positive
0% Detection Rate trisomy 21
0% Other abnormalities detected
2.
•
•
•
Maternal Age
15% Screen Positive
30% Detection Rate trisomy 21
0% Other abnormalities detected
3.
•
•
•
•
•
•
11 – 14 Week Nuchal Translucency
7% Screen Positive
89% Detection Rate trisomy 21
90% Other Aneuploidy
10% NTD
60% Structural
70% CHD
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1st Trimester Screening continued
4.
•
•
•
•
•
•
Nuchal Translucency Ultrasound plus 1st Trimester Screening
4.5% Screen Positive
91.5% Detection Rate Trisomy 21
95% Detection of Other Aneuploidies
10% Neural Tube Defects
60% Structural Abnormalities
70% Cardiac Abnormalities
5.
•
•
•
•
•
Maternal Serum Screening (15 – 20 weeks) (Ultrasound dated Pregnancy)
7% Screen Positive
80% Detection Rate trisomy 21
50% Other Aneuploidy
90% NTD
5% Structural
6.
•
•
•
•
•
•
19 – 20 Week Scan
10 – 15% Screen Positive
50% Detection Rate trisomy 21
50% Other Aneuploidy
75% NTD
50% Structural
25% CHD
What is associated with a high NT with a normal Karyotype?
•
CHD
•
Diaphragmatic hernia
•
Genetic syndromes
•
Exompholos
•
Arthrogryposis
•
Unexplained stillbirth
Please see SAMSAS website for information sheets and forms on
Nuchal Translucency.
http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html
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How/Where to Refer for 1st Trimester Screening
1.
Dr Christine Manley (Obstetrician)
Boatwright House
19 Lyttleton Street,
Launceston TAS 7250
Phone: 6333 0344
Fax:
6333 0944
PROCESS
Give patient the SAMSAS pre-test information:
http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html#InfoFamilie
s
Two request forms are required, one for the blood analysis and one for the ultrasound.
Blood Analysis (Maternal Serum Test)
The blood test needs to be taken be taken between 10 weeks and 13 weeks 6
days, preferably one week prior to the nuchal translucency (NT) scan, and can be
taken at Launceston Pathology.
•
Request blood test (5 – 10ml clotted blood sample) using the “South Australian
Maternal Serum Antenatal Screening Program” (SAMSAS) request form.
http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/documents/SAPat
hologySAMSASForm3247Av2_000.pdf
•
The test request is ‘first trimester screening’
•
Ask patient to sign permission for SAMSAS to receive copies of their reports
•
Request that SAMSAS pathology send a copy of the blood results to Dr Christine
Manley
•
Arrange for blood to be collected 1 week prior to ultrasound appointment so that
the results can be issued to the patient at the time of the ultrasound.
•
Ultrasound Scan
• Complete request (provided by Dr Manley) for the NT ultrasound & consultation.
• Request Nuchal Translucency screening and a consultation.
• The scan is performed between 11 weeks 5 days and 13 weeks 6 days
• Please note, that if done for screening abnormalities, the HIC rebate will be
available http://www9.health.gov.au/mbs/search.cfm?q=55704&sopt=S
• Send request form to Dr Christine Manley’s rooms
QVOPD will ONLY receive results if cc’d on the request forms.
COST
Patient should be advised to contact the rooms for details of costs involved.
NB: patient WILL be given results at time of ultrasound if blood tests requested
and performed in correct manner
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How/Where to Refer for 1st Trimester Screening
2.
South Australian Maternal Serum Antenatal Screening Program (SAMSAS).
Information is available at:
http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html
PROCESS
Give patient the SAMSAS pre-test information:
http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html#InfoFamilies
Two request forms are required, one for the blood analysis and one for the ultrasound.
Blood Analysis (Maternal Serum Test)
• The blood tests needs to be taken between 10 weeks and 13 weeks 6 days,
preferably one week prior to the NT scan and can be taken at Launceston
Pathology.
• Request blood test (5 – 10ml clotted blood sample) using the “SAMSAS Program”
request form: Please print this form off and then complete http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/documents/SAPathology
SAMSASForm3247Av2_000.pdf
•
•
The test request is ‘first trimester screening’
Ask patient to sign permission for SAMSAS to receive copies of their reports.
Ultrasound Scan
• The scan is performed between 11 weeks and 13 weeks 6 days and is performed
at
Northern Imaging:
5 Frederick Street
Launceston Tas 7250
•
Complete ‘Northern Imaging’ request form for Ultrasound. The measurement will
only be taken if the referral clearly states ‘First Trimester screening’ or ‘NT
scanning’ in the clinical data.
•
Ensure that SAMSAS is cc’d to receive a copy of the scan results.
Note: that if done for screening abnormalities, the HIC rebate will be available:
http://www9.health.gov.au/mbs/search.cfm?q=55704&sopt=S
This ultrasound information is then sent to SAMSAS where it is combined with the
Maternal Serum Test to provide the fetal risk assessment.
COST
•
Blood test Medicare only
•
Ultrasound Scan Gap - Please check when making appointment
QVOPD will ONLY receive results if cc’d on the request forms.
NB: patient WILL NOT be given results at time of ultrasound
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How/Where to Refer for 1st Trimester Screening
3.
MIA Tas - Rush, Taylor & Partners
Hobart Private Hospital
Cnr Argyle & Collins Street
Hobart TAS 7000
Phone: 6212 2001
Pt. Bookings: 1800 000 985
Fax: 6212 2022
PROCESS
Give patient the SAMSAS pre-test information:
http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html#InfoFamilies
Two request forms are required; one for the blood analysis and one for the
ultrasound.
Blood Analysis (Maternal Serum Test)
•
The blood test needs to be taken between 10 weeks and 13 weeks 6 days,
one week prior to the NT scan and can be taken at Launceston Pathology.
•
Request blood test (5 – 10ml clotted blood sample) using the “SAMSAS
Program” request form:
http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/documents/SAPatholog
ySAMSASForm3247Av2_000.pdf
•
The test request is ‘first trimester screening’
•
Ask patient to sign permission for SAMSAS to receive copies of their
reports.
Ultrasound Scan
•
The scan is performed between 11 weeks and 13 weeks 6 days and is
performed at
Hobart Private Hospital:
Cnr Argyle & Collins Street
Hobart Tas 7000
•
Complete ‘MIA’ request form for Ultrasound. These pads can be obtained
from MIA Tas by phone (6212 2001) or online at
http://www.ril.com.au/RIL/client/ContactUs/c_orderReferralPads.jsp?region=Southern%20Tasmania&Exp
and=1&categoryName=For%20Referrers&subCategoryName=Order%20Referral%20Pads
•
Ensure that SAMSAS is cc’d to receive a copy of the scan results.
Please note, that if done for screening abnormalities, the HIC rebate will be
available.
This ultrasound information is then sent to SAMSAS where it is combined with the
Maternal Serum Test to provide the fetal risk assessment.
COST
Patient needs to check when making appointment for costs involved.
QVOPD will ONLY receive results if cc’d on the request forms.
NB: patient WILL NOT be given results at time of ultrasound
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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1st Trimester Screening continued
Amniocentesis information
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Amniocentesis?Open
Document
Chorionic Villus Sampling information
http://www.thewomens.org.au/ChorionicVillusSamplingCVS
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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SECTION 5
General Information
Recommended Vitamin Supplements: These products all contain Folate, Iodine & D3
Blackmore’s Pregnancy & Breastfeeding Gold Multivitamin
•
Provides iodine to promote healthy development of baby's brain, eyesight & hearing.
•
Provides a daily dose of 500 µg of folic acid that may reduce the risk of brain and/or
spinal cord birth defects such as spina bifida and anencephaly if taken daily for 1
month prior to conception and during pregnancy.
•
Provides vitamin D3 to support calcium absorption to assist with healthy development
of baby's bones.
•
Provides omega-3 essential fatty acids to promote healthy development of baby's brain
& eyesight.
•
Provides overall nutritional support with 17 nutrients including 10 vitamins, 6 minerals,
and omega-3 fatty acids.
Nature’s Own Pregnancy Platinum Multivitamin
Nature’s Own Pregnancy Platinum Multivitamin is a comprehensive formulation providing
daily nutritional support to mother and baby. It contains a selection of 20 key ingredients,
including fish oil, that are important for the development of the baby as well as the increased
physiological demands on the mother’s body. This formula contains folic acid, which, if taken
daily for one month before conception and during pregnancy, may reduce the risk of having a
child with spina bifida/neural tube defects. Folic acid is needed for the synthesis of DNA and
is important in periods of rapid cell growth. Iodine has been included in this formula to assist
the development of baby’s brain during pregnancy and lactation. A selection of B vitamins
has been included to support a healthy nervous system and brain function, to support
mother’s increased energy requirements and to help maintain general well-being as you deal
with the physical and emotional stresses of pregnancy. Vitamin B6 may also help to relieve
the intensity of nausea during pregnancy. This formula contains zinc to support the immune
system and vitamin C to promote healthy gums and skin during pregnancy. Vitamin D3 has
also been included to assist with the absorption and use of calcium and phosphorus which
are vital for the development of bones and teeth.
No added yeast, gluten, lactose, artificial flavours, artificial sweeteners or dairy products
Elevit with Iodine
Elevit with Iodine is a once-daily vitamin and mineral supplement for pregnancy. It is
based on a formulation clinically proven to reduce the risk of neural tube defects like
spina bifida by 92%.2
Elevit with Iodine contains the highest levels of iron, folic acid and iodine in
combination than any other pregnancy multivitamin available in Australia.
It also contains a range of ingredients to help meet your changed nutritional
requirements throughout conception, pregnancy and breastfeeding.
What's more, unlike some pregnancy supplements, Elevit with Iodine is a once
daily tablet.
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General Information continued
Iodine Information
http://www.dhhs.tas.gov.au/service_information/information/iodine
Iodine: (June 2010): New NHMRC Recommendation: Iodine
Supplementation Essential For Pregnant and Breastfeeding Women
The National Health and Medical Research Council (NHMRC) has released a new statement
recommending that all pregnant and breastfeeding women take iodine supplements to help
make sure that a baby’s brain and nervous system develop normally.
Iodine is an essential nutrient required for thyroid hormone synthesis, which is vital to ensure
normal development of the brain and nervous system before birth, in babies and young
children.
Insufficient iodine can cause learning problems for babies and young children, result in
reduced intelligent quotient (IQ), affect their physical development and hearing.
It is therefore very important that pregnant and breastfeeding women get enough iodine.
The NHMRC has released a new statement recommending all women who are pregnant,
breastfeeding or considering pregnancy, take an iodine supplement of 150 micrograms (μg)
each day.
Supplements of 150μg/d of iodine are safe and effective for pregnant and breastfeeding
women.
The National Iodine Nutrition Survey (2006) results suggest that Australians do not get
enough iodine.
While measures such as the mandatory fortification of bread do increase iodine intake in the
general population, iodine requirements during pregnancy and lactation to support the
neuropsychological development of the foetus and baby are substantially greater.
Evidence from recent Tasmanian research has confirmed that iodine fortification of bread is
insufficient to meet the needs of pregnant women.*
The Tasmanian Thyroid Advisory Committee and Population Health (Department of Health
and Human Services) want to ensure that all health professionals in Tasmania are aware of
the need for pregnant and breastfeeding women to take iodine supplements in accordance
with NHMRC advice.
Currently there are no specific commercial iodine supplements on the market. However,
there are a number of commercial vitamin and mineral supplements designed for pregnancy
and lactation that have the recommended amount (or close to) of iodine. It is hoped that
increased demand for an iodine only supplement will lead to increased availability over time.
Further information including a literature review can be viewed on the NHMRC website by
using the link - http://www.nhmrc.gov.au/publications/synopses/new45_syn.htm
For further information about this matter please do not hesitate to contact Judy Seal,
Principal Advisor, Public Health Nutrition on 6222 7731 or via email [email protected]
* Burgess JR, Seal JA, Stilwell GM, Reynolds J, Taylor ER, Parameswaran V. A case for universal salt
iodisation to correct iodine deficiency in pregnancy: another salutary lesson from Tasmania. The
Medical Journal of Australia 2007; 186:574-576
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Government
Media
Statement
15 June 2010
DR JOHN BURGESS
Chair, Tasmanian Ministerial Thyroid Advisory Committee
&
DR ROSCOE TAYLOR
Director of Public Health
CALL FOR PREGNANT, BREASTFEEDING WOMEN TO BOOST IODINE INTAKE
Tasmanian women who are pregnant or breastfeeding have been advised by health experts
that they need to take iodine supplements to safeguard the normal development of their
babies.
Chair of the Tasmanian Ministerial Thyroid Advisory Committee Dr John Burgess and
Director of Public Health Dr Roscoe Taylor said there was evidence that Tasmanian women
who were pregnant or lactating were not getting enough iodine in their diet.
Drs Burgess and Taylor said recent findings from the National Iodine Nutrition Survey
showed that Tasmanian women were not alone, with the Australian population being mildly
iodine deficient.
However, Drs Burgess and Taylor warned that the health consequences were greater for
pregnant and breastfeeding women and their babies.
They said that iodine was an essential nutrient to ensure normal development of the brain
and nervous system in babies and young children.
And they said that iodine deficiency during pregnancy and breastfeeding could have a
negative effect on the brain and nervous system of infants and children and result in a lower
IQ.
Drs Taylor and Burgess said that, for this reason, the National Health and Medical Research
Council (NH&MRC) was recommending that all women who are pregnant, breastfeeding, or
considering pregnancy, take an iodine supplement of 150 micrograms each day.
“That is why we have written to all Tasmanian health professionals who come into contact
with these women, bringing the NH&MRC guideline to their attention so they can make it a
part of their case management of the women we need to target,” Dr Taylor said.
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He said measures such as the mandatory iodine fortification of bread were excellent for the
general population, but were not enough for these women.
“Most foods in Australia contain only small amounts of iodine, making it difficult for pregnant
and breastfeeding women to get enough iodine through food alone.”
Dr Burgess said that while bread fortification did increase iodine intake in the general
population, iodine requirements during pregnancy and lactation to support the
neuropsychological development of the foetus and baby were substantially greater.
“Therefore, these women need to be taking the daily 150 microgram iodine supplement,” he
said.
“This is recommended under national guidelines as safe and effective for pregnant and
breastfeeding women, and will help ensure the health of their babies.
“The main concern is that if iodine intake falls below this recommended level, the thyroid
cannot produce enough hormones and a range of deficiency disorders can occur.
“This is of particular concern during pregnancy because abnormal function of the mother’s
thyroid has a negative impact on the nervous system of the unborn baby.”
Dr Burgess said that women with pre-existing thyroid conditions should seek advice from
their medical practitioner prior to taking a supplement.
Drs Burgess and Taylor said that reasons suggested for the recurrence of iodine deficiency
in Australia included reduced use of iodine-based cleaning products by the dairy industry and
less household use of iodised salt (caused by a gradual increase in consumption of
commercially processed foods containing non-iodised salt).
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General Information continued
Vitamin D:
See LGH Clinical Protocols – Vitamin D Deficiency in Pregnancy.
Also refer to the “How much sun - Cancer Council Tasmania” at
www.cancertas.org.au/index.php/download_file/view/199
Folate in a healthy diet:
http://www.betterhealth.vic.gov.au/BHCV2/bhcArticles.nsf/pages/Pregnancy_and_diet?OpenDo
cument
Patient information can be accessed from the following website:
http://www.dhhs.tas.gov.au/children
Pregnancy Birth & Baby Helpline
www.healthdirect.org.au/pbb
Nausea and Vomiting
See LGH Clinical Protocols – Management of Women with Nausea and Vomiting in Pregnancy
Health Provider Education Websites:
Think GP: http://thinkgp.com.au/education
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General Information continued
Breastfeeding Information:
QV Outpatient Breastfeeding Clinic (to 2 weeks postnatal only)
Phone: 6348 8934
Fax: 6348 8924
ABA Website – www.breastfeeding.asn.au
Text: Hale, T (2010) “Medications and Mothers’ Milk”, Pharmasoft Publishing, Amarillo, Tx
(TML has 2 copies of the 2008 version)
Monash Obstetric and Breastfeeding Drug Information Centre
Phone: (03) 9594 2361
Medication website – http://toxnet.nlm.nih.gov/
Child Health and Parenting Service (CHAPS), Regional office
Phone: 6336 2130
24 hour breastfeeding helpline 1800 MUM 2 MUM
A NATIONAL toll free 24 hour helpline, staffed by Australian Breastfeeding Association
volunteers across Australia, is now available. For free, confidential breastfeeding advice and
support, women can call 24 hours a day.
Call 1800 MUM 2 MUM (1800 686 2 686) toll free from landlines in Australia. Further
breastfeeding information is available from the Australian Breastfeeding Association web
site, www.breastfeeding.asn.au.
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General Information continued
Some Commonly Asked Questions in Pregnancy
Drugs
•
Avoid unnecessary medication but DO NOT stop necessary medication without
prior discussion.
•
Fever or pain should be treated with Paracetamol (not Aspirin)
•
Alcohol – abstinence is currently advised as no safe level has been determined.
•
Recreational drugs – to be avoided
Exercise
A moderate exercise program is desirable.
Do not take up a new sport.
Overheating should be avoided.
The peak heart rate should be limited to less than 140 beats/minute.
Contact sports (basketball, hockey) and sports where falling is common (horseriding, snow and water skiing) should not be performed after the first trimester.
•
It is advisable to reduce exercise intensity 25-30% and to always warm up and
cool down. Women who continue to exercise strenuously, especially into the third
trimester, have an increased risk of low birth weight.
•
For 3 months after delivery continue to adhere to these exercise guidelines. Avoid
swimming until bleeding has stopped.
•
Breastfeeding women should increase their fluid intake further when exercising.
•
•
•
•
•
Body Temperature
•
Normal core temperature should not exceed 380c.
To avoid this:
•
Any febrile illness should be treated with Paracetamol in appropriate doses.
•
Women should not exercise in hot, humid conditions.
•
Women exercising in pools should ensure the temperature is <28-30oc.
•
Avoid hot spas and saunas.
Morning Sickness:
This can be managed by:
•
Eating small, frequent meals and drinking plenty of fluids
•
Vitamin B6, 25 mg up to 3 times a day
•
Refer to (Pregnancy Assessment Clinic) PAC if dehydrated.
Heartburn
This can be helped by:
•
Eating small, frequent meals
•
Avoiding fatty foods, coffee, tea, alcohol
•
Sleeping propped up or tilting head end of bed up
•
Use of antacids as appropriate
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SECTION 5 cont’d
General Information continued
The Dentist
•
Good dental hygiene is important in pregnancy and it is advisable to attend the
dentist for a checkup if you have not had one in the last six months.
Sexual Intercourse
Sexual activity can normally continue according to the couple’s wishes.
Sexual intercourse should be avoided for the first six weeks after delivery to allow
healing at placental site.
•
•
Foetal Movements
If the number of foetal movements felt is reduced for 12 hours or absent for 2 hours, you
should contact the QV (Labour Ward) to arrange assessment.
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SECTION 6
Infections & Immunisations in Pregnancy
Cytomegalovirus Infection
Enterovirus
Hepatitis B
Hepatitis C
Herpes Simplex Virus
Human Immunodeficiency Virus
Listeria
Mycobacterium Tuberculosis
Parvovirus
Rubella
Streptococcus – Group B
Toxoplasma
Treponema Pallidum (Syphilis)
Varicella-Zoster Virus
For general information on all of the above infections, refer directly to
Management of Perinatal Infections – Australasian Society for Infectious Diseases
2002.
http://www.asid.net.au/downloads/Management%20of%20Perinatal%20Infections%20ASID%202002
%20rev%202007.pdf
Chlamydia Screening in Pregnancy
See LGH Clinical Protocols – Chlamydia Screening in Pregnancy
Exposure and management of rash illness in pregnancy. Parvovirus B19, rubella
See LGH Clinical Protocols – Exposure and Management of Rash Illness in Pregnancy
Group B Strep Screening (GBS)
Group B Strep Screening has been reintroduced into the antenatal protocol. The screening
will be taken at 36 weeks with the swabs being taken during the 36 week hospital
appointment.
GPs will need to check at the 37 week visit that the GBS screening was undertaken at the
hospital. If not, the GP will need to arrange for the swab to be taken.
A low vaginal to perianal swab should be taken. The pregnant woman herself can adequately
take this swab if she desires.
A copy of the results should be sent to the QV Antenatal Clinic/GP.
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SECTION 6 cont’d
Infections & Immunisations in Pregnancy continued
Immunisations:
Influenza
The NHRMC, 2003 make the following recommendation:
The benefits of influenza immunisation in preventing influenza during the second or
third trimester (1 to 2 hospitalisations prevented per 1000 women immunised)
outweigh the risks of giving an inactivated vaccine in early pregnancy (no evidence of
congenital malformations or other damage to the fetus). It is therefore recommended
that influenza vaccine be offered in advance to women planning a pregnancy, and to
pregnant women who will be in the second or third trimester during the influenza
season, including those in the first trimester at the time of vaccination. 24, 25
24. Neuzil KM, Reed GW, Mitchel EF, et al. Impact of influenza on acute cardiopulmonary
hospitalizations in pregnant women. American Journal of Epidemiology 1998;148:1094-102.
25. Irving WL, James DK, Stephenson T, et al. Influenza virus infection in the second and third
trimesters of pregnancy: a clinical and seroepidemiological study. British Journal of Obstetrics
and Gynaecology 2000;107:1282-9.
Boostrix/Adacel (pertussis)
The NHRMC, 2003 make the following observations:
The overall mortality from pertussis is 0.03% but the mortality in hospitalised babies
under 6 months of age is substantially higher (3.5%). Both hospitalisation and deaths
are likely to be underestimated as infants,3 particularly if preterm, may either present
without characteristic symptoms or be misclassified as sudden infant death
syndrome. Pertussis causes hypoxic encephalopathy, which can result in brain
damage and death. The most common cause of death in pertussis infection is
pertussis pneumonia, sometimes complicated by seizures and encephalopathy.2
And the subsequent recommendation:
Before planning pregnancy, or for both parents as soon as possible after delivery of
an infant, (preferably prior to hospital discharge), unless contraindicated (expert
opinion).10 This recommendation is based on evidence from a study of infants
hospitalised with pertussis around Australia in 2001, which indicated that parents
were the presumptive source of infection in over 50% of cases.16
2. Pertussis. In: Atkinson W, Harrison S, Wolfe C, Nelson R, editors. Epidemiology and
prevention of vaccine-preventable diseases. 7th ed. Atlanta, GA: Centers for Disease Control
and Prevention, U.S. Department of Health and Human Services; 2002.
10. Campins-Marti M, Cheng HK, Forsyth K, et al. Recommendations are needed for
adolescent and adult pertussis immunisation: rationale and strategies for consideration.
Vaccine 2001;20:641-6.
16. Morris A, Ridley G, McIntyre P, et al. Hospitalised pertussis in infants. [presentation]. Joint
Scientific Meeting - Royal Australian College of Physicians and Royal College of Physicians of
Thailand. Brisbane, Australia May 6-8, 2002.
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SECTION 7
Termination and Miscarriage Information
See LGH Clinical Protocol – Pregnancy Assessment Clinic Referral
General Practitioner Referral to Pregnancy Assessment Clinic (PAC)
(also referred to as Attachment 4 in LGH Clinical Protocol)
PAC
Ph: 6348 8946
Fax: 6348 8899
The Pregnancy Assessment Clinic is available to manage women with early pregnancy
bleeding (<20 weeks gestation). It is also the appropriate referral point for women with a
confirmed non-viable pregnancy.
The Pregnancy Assessment Clinic is available Monday to Friday between 0900 and 1630.
The service is unavailable on public holidays.
For women who are stable, after hours referral should follow the referral process outlined
below.
Unstable women should be referred immediately to the Department of Emergency Medicine
if less than 14 weeks gestation or if greater than 14 weeks gestation to Ward 4B.
Referral Process
Referral form is available on TML North website:
http://www.gpnorth.com.au/resources/category/3/clinical-templates?start=20
History
• LMP
• Relevant history e.g. previous ectopic, prior presentations, collapse prior to
presentation
Confirmation of Pregnancy
• By either documented serum or urinary BHCG or ultrasound confirming pregnancy
• Otherwise perform urinary or serum BHCG
Assessment of Pain and Bleeding
Vital Signs
• BP, pulse, temperature
If BP < 90/50, pulse > 100 or temperature > 37.5°C then refer to DEM
• Assess PV loss
If soaking a sanitary pad in 40 mins or passing large clots then refer to DEM
• Assess pain
If pain is absent or central cramping pain then PAC referral
If pain is moderate or severe or adnexal then refer to DEM
Referral to PAC
• Phone 6348 8946 - an answer phone is available after hours
• Fax PAC referral and results of any relevant investigations (FBC, blood group or prior
USS results) 6348 8982
• Please indicate nominated specialists for private patients – mark “Private Patient”
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Department of Health and Human Services
PREGNANCY ASSESSMENT UNIT
Launceston General Hospital
Level 3, QVOP
Charles Street, Launceston. Tas. 7250
Ph: (03) 6348 8946 Fax: (03) 6348 8899
REFERRAL FORM
PREGNANCY ASSESSMENT UNIT
Referred to
________Dr A Dennis ________Dr A Pavlov _________Dr F Clarke
Date_______/______/_____
PATIENT DETAILS
Surname__________________________
First Name________________________
Address:
_________________________________________________________
_____________________________________________________________________
D.O.B _____________________ Phone __________________Mobile__________
G___ P___
Gestation___________
REASON FOR REFERRAL
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
PROCEDURE/S REQUIRED (please tick)
CTG
BP
U/A
Notification of results prior to client discharge
REFERRING DOCTOR DETAILS
Doctor _____________________________________________________
Address
_____________________________________________________
Phone ______________
Fax
_______________
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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SECTION 7 cont’d
Termination and Miscarriage Information continued
Miscarriage/Perinatal Death Counselling
Stillbirth and Neonatal Death Support (www.sands.org.au) offer many local services for
parents, families and health professionals…
SANDS is there… promoting awareness, knowledge, support and understanding following
the death of a baby from the time of conception through to infancy.
SANDS Contacts: www.sands.org.au Ph: 03 9517 4470
Pregnancy Loss Australia, (formerly known as the Teddy Love Club Pregnancy and
Infant Loss Support) is an Australia wide support program for bereaved families who suffer
the loss of their baby or babies at any time during pregnancy or after birth. This
includes miscarriage, stillbirth, termination of pregnancy for foetal abnormality and neonatal
death.
PLA contacts: www.pregnancylossaustralia.org.au Ph: 1800 824 240 Free call bereavement
support
Please note this support line is available form 9am-6pm. If you would like to speak
with someone urgently please leave a message.
Bonnie Babes Foundation (www.bbf.org.au) provides a 24 hour, national grief counselling
service to Australian families who have lost a baby. The Foundation’s trained counsellors will
provide grief counselling for any member of the family or friends grieving after pregnancy
loss including miscarriage, stillbirth, premature-birth loss, genetic termination and neonatal
death.
The Bonnie Babes Foundation has a free publication titled “You are part of our lives and will
always live in our hearts”. This book contains information that can help families cope in their
time of grief. Many hospitals have copies of this book.
Bonnie Babes Foundation Contacts: www.bbf.org.au; E: [email protected]
Ph: 03 9758 2800; Fax: 03 9758 2833
Click here to return to TOP flow chart and also to contact numbers
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SECTION 8
Guidelines for the use of Rh D Immunoglobulin in
Obstetrics
For general information on:
When to give
Discussion guidelines
Administration and documentation – checklist
Notes
References
Go to: http://www.thewomens.org.au/RhDImmunoglobulininObstetrics
For specific LGH information, refer to the attached Appendix H – Rh D Immunoglobulin (Anti-D).
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SECTION 9
Postnatal Checks
Enquire if the Neonatal Screening Test (Heel Prick or Guthrie Test) has been performed,
especially if they have been discharged early and living in a rural area, and if not then refer
baby to the postnatal ward LGH (4O). It is advisable to ring the ward prior to returning. The
window of opportunity is from 48 hrs and before 7 days old. The pathology labs do not have
the cards for testing.
It is optional for mother and baby to also visit the GP two weeks after delivery for a check up.
A 6 week check-up for mother and baby is strongly recommended to ensure the mother is
recovering from her pregnancy and is coping with the baby and the baby is progressing
satisfactorily. The QV OPD is not able to provide clinics for the 6 week post natal check,
therefore it is expected that GPs will perform the 6 week postnatal check for both the mother
and baby.
Usual checks for the mother are:
•
•
•
•
•
•
•
•
•
Weight
Breasts (see also Section 5 - Breast Feeding)
Urine
Perineum
Blood Pressure
Signs/symptoms of Postnatal Depression (see Guide to Management overleaf)
Cervical Smear (expect an increased inflammation rate)
Gestational Diabetes Mellitus (GDM) follow up - see below
Vaccinations for Pertussis (adacel or boostrix). Recommended for both parents and close family
(grandparents).
A guide should be given to contraception, exercise, diet, muscle tone and feeding issues
(see Section 5 Breast Feeding).
Gestational Diabetes Mellitus (GDM) follow up should occur at the 6 week post natal
check. A GTT should be arranged with the results cc’d to the Diabetes Centre. It is
recommended that the patient is placed on a GDM register at the practice and recalled at
12monthly intervals for monitoring and a GTT. Diabetes prevention advice should also be
provided.
Counselling should be considered at this time in preparation for next pregnancy on such
issues as:
•
•
•
•
•
•
•
Medication review and what to avoid in pre pregnancy
Check/advice on rubella/chicken pox immunity
Check on routine vaccination status
Check risk factors
Check/advice on STDs
http://www.dhhs.tas.gov.au/sexualhealth/fact_sheets
Counselling on Hep C & HIV
Recommendations on Folate & Iodine in the pre pregnancy period
The baby should:
•
Be fully examined and the form (in the record book given to the mother at birth) is to be
completed.
•
The six week immunisation schedule should also be discussed (refer to Immunisation
Handbook 9th Edition www.immunise.health.gov.au ).
For information on the Tasmanian Immunisation Schedule for Children:
http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0020/37037/Immunisation_Schedule_for_Children_in_Tasmania_2011.pdf
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SECTION 9 cont’d
6 Week Postnatal Check continued
Post Natal Depression Information
http://www.beyondblue.org.au/index.aspx?link_id=94.575 for general information
http://www.beyondblue.org.au/index.aspx?link_id=7.102 for health professionals information
http://www.beyondblue.org.au/index.aspx?link_id=7.102&tmp=FileDownload&fid=1237 to download
the Edinburgh Postnatal Depression Scale (EPDS)
http://www.beyondblue.org.au/index.aspx?link_id=7.102&tmp=FileDownload&fid=1278 for the
Management Guide for Tasmania.
Royal Women’s Hospital website for Psychotropic medicines in the peri- and post-natal
period.
This is one of the Victorian developments under the National Perinatal Depression Initiative.
http://www.ppmis.org.au/
PPMIS provides up-to-date, evidence based and peer-reviewed information on the use of
psychotropic medicines in the peri and post natal period. This website contains medicine
profiles, summaries of individual psychotropic medicines along with articles on congenital
malformation, pregnancy and neonatal outcomes and postnatal and breastfeeding
information; patient medicine information fact sheets and links to other resources.
Local Referral Options – Patient Pathways – Perinatal Depression Management (attached
as a separate document on this webpage).
Northern Tasmanian Psychologists web page listing areas of special interest and
appointment waiting periods: www.northtaspsychologists.com
Safe Sleeping Practices and SIDS
Information sheets for parents are available on the DHHS website at:
www.dhhs.tas.gov.au/service_information/information/safe_sleeping
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SECTION 10
Miscellaneous Topics
Prescribing Medications in Pregnancy – TGA database:
As part of the recent website upgrade, the TGA has developed a new, searchable database
for use by health professionals prescribing medicines to pregnant women. The database can
be found at www.tga.gov.au/hp/medicines-pregnancy.htm.
The 'Prescribing medicines in pregnancy' database replaces the booklet 'Prescribing
medicines in pregnancy - an Australian categorisation of the risk of drug use in pregnancy'.
The booklet was first published in 1989, with the latest edition published in 1999, and
subsequent updates added as amendments on the TGA website. Unlike the booklet, the new
database is searchable by generic name (or part of the generic name), and by classification
using a drop-down list.
Once the user finds the relevant medicine, clicking on the medicine name will display the
pregnancy category, an explanation of the category and, if available, a safety statement
specific for the medicine or medicine group (Figure).
The database contains over 1200 individual entries, including all new medicines and any
changes of pregnancy category for existing medicines. A separate page lists the therapeutic
goods exempted from pregnancy classification.
Other pages on the TGA website with information relevant to prescribing medicines in
pregnancy include the PI documents (https://www.ebs.tga.gov.au) and the Australian Public
Assessment Reports.
Female Genital Mutilation:
http://www.thewomens.org.au/FGMPublicationsandWebsites
Circumcision:
http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Circumcision?open
Genetic Services:
Specialist Clinics holds Genetic clinics approximately every 6 weeks with the geneticist as
well as clinics with a genetic counselor about every 4-6 weeks. These clinics are coordinated from Hobart by Jo Burke - she will be able to answer any questions.
[email protected]
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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SECTION 11
Appendices
LGH Clinical Protocols
Appendix A
Antenatal Care
WACSClinProc 1.1/09
Appendix B
Vitamin D Deficiency in Pregnancy
WACSClinProc 1.24/08
Appendix C
Iron Deficiency Anaemia in Pregnancy
WACSClinProc 1.25/09
Appendix D
Management of Women with Nausea
and Vomiting in Pregnancy
WACSClinProc 1.13/07
Appendix E
Chlamydia Screening in Pregnancy
WACSClinProc 1.23/09
Appendix F
Exposure and management of rash illness
in pregnancy
WACSClinProc 1.15/07
Appendix G
Pregnancy Assessment Clinic Referral
WACSClinProc 1.20/08
Appendix H
Rh D Immunoglobulin (Anti-D)
WACSClinProc 3.2/09
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Appendix A Antenatal Care
Next Appendix
WACSClinProc 1.1/09
See LGH Protocol – Women and Children’s – Antenatal Care (attached as a separate
document on this webpage).
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Appendix B Vitamin D Deficiency in Pregnancy
WACSClinProc 1.24/08
Title:
Vitamin D Deficiency in Pregnancy
Description: Screening and management of vitamin D deficiency in pregnancy.
Introduction
Vitamin D is important for calcium metabolism, bone growth and mineralization. Around 90%
of our vitamin D requirement comes from exposure of skin to sunlight. The average diet
contains only 10% of our requirements – insufficient to prevent deficiency.
There is a high prevalence of vitamin D deficiency in winter and spring in Australia. A recent
study found the prevalence of vitamin D deficiency to be 67.3% during this period in
Tasmania. In winter and spring in Tasmania the combination of low ambient ultraviolet
radiation and an increased amount of clothing worn makes it difficult to achieve adequate
vitamin D status without dietary supplementation.
People with darker skin produce less vitamin D for a given sunlight exposure. Women, who
wear veils or headscarves, are housebound and newly arrived refugees are at risk of vitamin
D deficiency.
Vitamin D deficiency in mothers is the most important causative factor for vitamin D
deficiency in infants.
Sunlight as a Source of Vitamin D
Daily exposure of hands, face and arms most days is recommended for adequate
endogenous vitamin D synthesis. The exposure times vary depending on geographical
location. Deliberate sun exposure between 1000 and 1400 in summer (1100 and 1500
daylight saving time) is not advised.
Recommended sun exposure times (minutes) for people with moderately fair skin
Hobart
Dec to Jan
at 1000 or 1400
7-9
July to Aug
at 1000 or 1400
at 1200
40-47
29
Exposure time for people with highly pigmented skin would be 3-4 times great.
Vitamin D Deficiency
Women with vitamin D deficiency are at risk of:
• Osteomalacia
• Accelerated osteoporosis due to hyperparathyroidism
• Muscle weakness
Babies of women with vitamin D deficiency during pregnancy are at risk of:
• Hypocalcaemia
• Rickets
• Myopathy
• Reduced intrauterine long bone growth
Screening
Pregnant women should be offered vitamin D screening at booking.
For a risk women, commence maintenance dose:
• 1000u OsteVit-D daily (over the counter medication)
OR
• Ostelin 25mcg daily
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix B Vitamin D Deficiency in Pregnancy cont’d
Next Appendix
WACSClinProc 1.24/08
Check the report of the vitamin D assay by the next appointment.
Vitamin D Assay Result
< 25nmol/L
26 nmol/L – 70nmol/L
>70nmol/L
Management
Increase to 2000 units/day
Continue maintenance dose D 1000u
Discontinue vitamin D
Women should be encouraged to continue taking vitamin D after the birth of their baby.
Review Date: Annually verified for currency or as changes occur, and reviewed every 3
years, January 2012.
Dr A Dennis
Co-Director (Medical)
Women’s & Children’s Services
Sue McBeath
Co-Director (Nursing & Midwifery)
Women’s & Children’s Services
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix C Iron Deficiency Anaemia in Pregnancy
Next Appendix
WACSClinProc 1.25/09
Title:
Iron Deficiency Anaemia in Pregnancy
Description: Antenatal screening and treatment of anaemia in pregnancy
Purpose
Anaemia is a common problem for pregnant women and has been linked with adverse
pregnancy outcomes such as preterm birth and low birth weight, as well as maternal
mortality and morbidity.
Iron deficiency anaemia is the most frequent form of anaemia in pregnant women. Other
causes of anaemia include folate and vitamin B12 deficiency, haemoglobinopathy and
haemolytic anaemia.
Antenatal Screening for Anaemia in Pregnancy
FBC and ferritin should be performed on all women at their first antenatal visit. Serum ferritin
provides an estimation of maternal iron stores. Iron studies should be requested for all
women who have a low haemoglobin (<105g/L) and low ferritin (<15ug/L). Launceston
General Hospital pathology department may be able to perform this test on the previous
sample if contacted.
Treatment of Iron Deficiency Anaemia in Pregnancy
Oral Iron
In women with mild to moderate iron deficiency anaemia treatment with oral ferrous iron ≥
60mg/day is the initial therapeutic option in the first and second trimester. FBC and ferritin
should be reassessed in four to six weeks.
Intravenous Iron
Treatment with intravenous iron results in a faster increase in haemoglobin and
replenishment of body iron stores. Intravenous iron reduces the need for blood transfusions.
Intravenous iron infusion should be considered when:
• Oral iron fails to increase haemoglobin
• Hb is less than 105g/L and Ferritin less than 15ug/L in any trimester beyond 14
weeks
• Moderate to severe iron deficiency in the third trimester
Dietary Education
All women should be provided with information and education on the NHRMC Dietary
Recommendations for Australians. It has been suggested that dietary measures alone are
unlikely to provide sufficient iron for women with iron deficiency (Milman 2008).
Special Considerations
Special consideration should be given to women who are:
• intolerant of oral iron
• have a malabsorption condition (e.g. irritable bowel syndrome)
• are vegetarians
• have other causes of anaemia (e.g. Thalassemia, sickle cell disease)
• multiple pregnancy due to increased iron requirements
• multiple episodes of bleeding in pregnancy
• at increased risk of bleeding associated with pregnancy or delivery:
o
o
•
e.g. placenta praevia or accrete
Previous history of large PPH
Bleeding disorders e.g. Von Willebrand disease
o
contraindication to iron therapy
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Appendix C Iron Deficiency Anaemia in Pregnancy cont’d
Dr A Dennis
Co-Director (Medical)
Women’s & Children’s Services
Next Appendix
WACSClinProc 1.25/09
Sue McBeath
Co-Director (Nursing & Midwifery)
Women’s & Children’s Services
Date: 10/09/09
REFERENCES
South Australian Department of Health Perinatal Clinical Guideline ‘Anaemia in pregnancy' viewed on
June 23, 2009 online: http://www.health.sa.gov.au/ppg/Default.aspx?tabid=95
McLean, E, Cogswell, M, Egli, I, Wojdyla, D & Benoist, B 2008, ‘Worldwide prevalence of anaemia,
WHO Vitamin and Mineral Nutrition Information System, 1993-2005', Public Health Nutrition, vol.12,
no. 4, pp. 444-454.
Milman, N 2008, ‘Prepartum anaemia: prevention and treatment', Ann Hematol, vol. 87, pp. 949-959.
Wheeler, S 2008, ‘Assessment and interpretation of micronutrient status during pregnancy',
Proceedings of the Nutrition Society, vol. 67, pp.437-450.
Zhou, S, Gibson, R, Crowther, C & Makrides, M 2009, ‘Should we lower the dose of iron when treating
anaemia in pregnancy? A randomized dose-response trial', European Journal of Clinical Nutrition, vol.
63, pp. 183-190.
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Appendix D Nausea and Vomiting
Table of Contents
Next Appendix
WACSClinProc 1.13/07
Title:
Nausea and Vomiting
Description: Management of women with nausea and vomiting in pregnancy
Purpose
• 80 – 85% of pregnant women experience nausea during pregnancy.
• 52% of these women vomit. Severity varies greatly.
• For the majority of women these symptoms resolve by 12 to 14 weeks.
• The emotional, social and psychological impact can be marked.
• Hyperemesis gravidarum is described as persistent vomiting accompanied by weight
loss, ketonuria and dehydration.
• The exact pathogenesis of hyperemesis remains unknown.
• 1% of women with nausea and vomiting will develop the pathological condition of
hyperemesis gravidarum.
Mild to Moderate Nausea and Vomiting
• Dietary advice
• Maintain hydration
• Folate supplement 0.5mg once daily
• Nausea:
o Pyridoxine (vitamin B6) 10 to 25 mg
o Ginger 250mg 6/24 orally
o Acupuncture or acupressure
• Nausea and Vomiting:
o Promethazine 12.5-25 mg orally eight hourly
o Metoclopramide 10 mg orally eight hourly
o Prochlorperazine 5 mg orally eight hourly or 25mg suppository per rectum
twelve hourly
Hyperemesis Gravidarum
• Maternal observations
• Urinalysis – SG and ketones
• Weight
• Investigations:
o Bloods for electrolytes, urea and creatinine and liver function tests.
o Consider serum free T4 concentration.
o Consider ultrasound scan to exclude gestational trophoblastic disease and
multiple pregnancy
• Rehydration with IV Hartmann’s solution or Normal Saline avoiding dextrose until
thiamine (vitamin B1) replacement therapy provided.
• Continue intravenous fluids until urinalysis negative for ketones
• Electrolyte replacement as required
• First line anti-emetics such as:
o Promethazine IV or IMI four hourly
o Metoclopramide 10 mg IV TDS
o Prochlorperazine 25mg PR BD or 12.5mg IMI six hourly
• Ranitidine 150mg orally BD or 50mg IVI TDS
• Thiamine 100mg orally daily
If no response to first line anti-emetics:
• Ondanestron 2-4 mg IV or IM 8hourly if no response to first line anti-emetics.
• Ondanestron 4mg Wafer orally 12 hourly or daily
For severe hyperemesis:
• Hydrocortisone 100mg 12/24 IV or prednisolone 50mg once daily orally reducing over
10-14 days.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix D Nausea and Vomiting cont’d
Next Appendix
WACSClinProc 1.13/07
Advice for women with nausea and vomiting in pregnancy
• Eat a diet high in complex carbohydrates (such as bread, rice, potatoes) and protein,
low in fat.
• Drink plenty of fluids
• Eat five to six small meals a day, including a late-evening snack. Low blood sugar
can cause nausea and shakiness. Sucking on hard sweets maybe helpful.
• Try eating a small snack before getting up.
• Eat many small meals each day but avoid lying down immediately after eating
• Get plenty of rest. Being overly tired can set off nausea.
• Consider taking a ginger supplement
• Limit stressful events.
• Avoid noxious odours that trigger vomiting, cigarette smoke and tastes that trigger nausea,
such as coffee.
• Consider acupuncture or acupressure to assist in relieving nausea.
Review Date: Annually verified for currency or as changes occur, and reviewed every 3
years via Policy and Procedure working group coordinated by the Clinical and Quality
improvement midwife. Nov. 2009
Dr A Dennis
Co-Director (Medical)
Women’s & Children’s Services
Sue McBeath
Co-Director (Nursing & Midwifery)
Women’s & Children’s Services
Date: July 2007
ATTACHMENT 1 – PATHOLOGY RESULTS: Abnormalities may or may not be present
• Electrolyte imbalance – hypokalemia and metabolic alkalosis
• An increase in hematocrit, including hemoconcentration due to plasma volume
depletion. The degree of hemoconcentration may be underestimated unless the
physiologic decline in hematocrit seen in normal pregnancies is considered
• Abnormal liver enzyme values occur in approximately 50% of women who are
hospitalised with hyperemesis. The most striking abnormalities is an increase in
serum aminotransferase. Alanine aminotransferase (ALT) is typically elevated to a
greater degree than aspartate aminotransferase (AST). Values for both are typically
only mildly elevated. Serum amylase and lipase may increase as much as five-fold
and are of salivary rather than pancreatic origin. The degree of abnormality in liver
tests correlates with the vomiting; the highest elevations are seen in women with the
most severe or protracted vomiting. Abnormal liver biochemical tests resolve
promptly upon resolution of the vomiting.
• Mild hyperthyroidism, possibly due to high serum concentration of HCG which has
thyroid stimulating activity. Some women have elevated serum free t4 concentrations
and therefore met the definition of hyperthyroidism.
ATTACHMENT 2 - REFERENCES
Funai, E 2006, ‘Hyperemesis gravidarum’, UpToDate,
Online: A password is required for this database. Use EPOCH to access
http://uptodateonline.com/utd/content/topic.do?topicKey=pregcomp/27432&selectedTitle=1~23&sourc
e=search_result
Jewell, D & Young, G 2003, ‘Intervention for nausea and vomiting in early pregnancy,’ Cochrane
Review,
Online: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000145/frame.html
Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier
Australia
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix E Chlamydia Screening in Pregnancy
Next Appendix
WACSClinProc 1.23/09
Title:
Chlamydia Screening in Pregnancy
Description: Screening and management of Chlamydia in pregnancy
Rationale
Chlamydia trachomatis infection is the most common notifiable sexually transmitted bacterial
infection worldwide. It is prevalent among sexually active young women and if undiagnosed
and untreated, can result in complications such as pelvic inflammatory disease, ectopic
pregnancy and infertility.
Symptoms
Up to 80% of women infected with chlamydia are asymptomatic. In symptomatic women,
vaginal discharge, dysuria, irregular periods, intermenstrual bleeding, break through
bleeding, post coital bleeding or pelvic pain may occur.
Clinical Risk Factors
• Women less than 25 years of age
• Any unprotected sexual intercourse
• New sexual partner in previous 3 months
• Previous history of or other concurrent STI
• Sexual contact with a partner with proven or suspected infection with chlamydia
• Previous infant with chlamydia infection.
Screening
All antenatal women should be offered screening for chlamydia at booking in and again at 36
weeks gestation. Screening can be undertaken by low vaginal swab using a dry sterile swab.
Alternatively, a urine specimen can be collected. The urine must be a first void specimen and
not mid-stream urine. The specimen should be collected at least two hours post the previous
void.
Women attending the Pregnancy Assessment Unit with early pregnancy loss should also be
offered chlamydia screening.
Treatment
The currently recommended treatment for uncomplicated Chlamydia infection during
pregnancy is
• Azithromycin 1g (macrolide antibiotic) orally as a single dose
*Dose needs to be repeated if vomiting occurs within 3 hours of administration.
Alternative Regimen includes:
• Erythromycin ethylsuccinate 800mg BD for ten days
Erythromycin is associated with gastrointestinal side-effects and a lower compliance rate with
completion of treatment.
Women should be:
• Advised to abstain from sexual intercourse for 7 days after single dose therapy or
until completion of a ten day regimen and until all their sexual partners have been
treated.
• Given education about sexually transmitted infections (STIs) and their transmission
and to be encouraged to reduce the risk of further STIs through use of condoms.
Partner Notification and Treatment
Sexual partners of the women should be referred for testing and treatment regardless of the
absence of symptoms to prevent re-infection. Women should be instructed to inform their
partner(s) and provided with a ‘contact letter’ (see appendix 2). Partner(s) will need to access
their General Practitioner or the Sexual Health Services for investigation and treatment.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix E Chlamydia Screening in Pregnancy cont’d
Next Appendix
WACSClinProc 1.23/09
Sexual Health Services
Provide confidential sexual health service with no cost for the client. STI testing, information
and antibiotic treatment, when required, is also provided free of charge.
42 Canning Street
Launceston TAS 7250
Ph: 6336 2216
Sexual health information is available online:
http://www.dhhs.tas.gov.au/sexualhealth/fact_sheets
Review Date: Annually verified for currency or as changes occur, and reviewed every 3
years. January 2012
Dr A Dennis
Co-Director (Medical)
Women’s & Children’s Services
Sue McBeath
Co-Director (Nursing & Midwifery)
Women’s & Children’s Services
REFERENCES
Centre for Disease Control and Prevention 2006 Sexually Transmitted Diseases Treatment Guidelines
Online:
http://www.cdc.gov/std/treatment/2006/urethritis-and-cervicitis.htm#chlamdiag
Joanna Briggs Institute 2002 Evidence Summary: Genital Chlamydia Trachomatis: Management
Online:
http://www.jbiconnect.org/connect/docs/cis/es_html_viewer.php?SID=5591&lang=en&region=AU
New South Wales Department of Health 2005 Guideline Screening for Sexually Transmissible
Diseases (STDs) and Blood Borne Viruses (BBVs) in Pregnancy Online:
http://www.health.nsw.gov.au/policies/GL/2005/GL2005_024.html
Royal Australian and New Zealand College of Obstetricians and Gynaecologist College Statement
2008 Antenatal Screening Tests: http://www.ranzcog.edu.au/publications/collegestatements.shtml
Antibiotic Therapeutic Guidelines 2006 Genital (Reproductive) Tract Infections Online:
http://proxy9.use.hcn.com.au/
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix F Exposure and management of rash illness
in pregnancy
Next Appendix
WACSClinProc 1.15/07
Title:
Exposure and Management of Rash Illness in Pregnancy. Parvovirus
B19, rubella
Description: Exposure B19 and Rubella Exposure in Pregnancy
Purpose
Viral illness during pregnancy can have detrimental effects on the developing fetus. Apart
from varicella in the seven days before delivery, the infections which may have a specific
impact on the fetus (rubella, parvovirus B19, varicella zoster) only do so if infection occurs in
the first 20 weeks of gestation. All women with a non-vesicular rash should be investigated
for rubella and parvovirus B19.
Definition
Significant exposure is defined as living in the same household, or direct face-to-face contact
for at least 5 minutes, or being in the same room for at least one hour.
Parvovirus B19
There are a wide range of potential consequences of parvovirus B19 infection, ranging from
minor febrile illness to erythema infectiosum (slapped cheek syndrome), generalised rash
illness, arthralgia and persistent infection in the immunocompromised.
Parvovirus B19 infection is common, with some 50 -60% of adults having been infected. No
vaccine or preventive measures are available and increased incidence occurs every three to
four years, largely in schoolchildren.
Pregnant woman with significant exposure to parvovirus should have serum collected, as
soon as possible after contact, and tested for parvovirus B19 specific IgG and IgM.
Failure to detect parvovirus B19 specific IgM excludes infection in the four weeks prior to
collection of the serum. Hence, infection cannot be excluded if investigation commences
more than four weeks after the onset of rash.
If parvovirus B19 IgM is detected in the first 20 weeks of pregnancy, confirmation is required
by an alternative assay. Repeat testing will demonstrate a decline in IgM reactivity and
provide an additional confirmation method.
Parvovirus B19 is a small single-stranded DNA virus and a potent inhibitor of erythropoieses.
Infection during pregnancy can cause several serious complications in the fetus, such as
fetal anaemia, neurological anomalies, hydrops fetalis and fetal death.
If maternal infection has occurred, ultrasound investigation of the fetus and measurement of
the peak systolic flow velocity of the middle cerebral artery are sensitive non-invasive
procedures to diagnose fetal anaemia and hydrops. Ultrasound scanning of the fetus is
started at 4 weeks post onset of illness or date of seroconversion, and then at 1 -2 weekly
intervals until 30 weeks gestation.
An increase in middle cerebral artery (MCA) peak systolic velocity results from increased
cardiac output and decreased velocity of fetal blood in the response to anaemia. Referral to a
fetal medicine unit for fetal intrauterine transfusion can improve the outcomes.
Rubella
The risk to the fetus is primary rubella in the first 16 weeks of gestation with major and varied
congenital abnormalities being associated with infection in the first trimester, and a lesser
risk, limited to deafness, in the fourth month. Rubella infection prior to the estimated date of
conception or after 20 weeks carries no documented risk, and rubella between 16 and 20
weeks gestation carries a minimal risk of deafness only.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix F Exposure and management of rash illness
in pregnancy cont’d
Next Appendix
WACSClinProc 1.15/07
If a woman has had one of the following, she should be reassured that the likelihood of
rubella is extraordinarily remote, that specific investigation is not required, but to return if a
rash develops
•
at least two previous rubella antibody screening tests which have detected antibodies
•
at least two documented doses of rubella vaccine
•
one documented dose of vaccine followed by rubella antibody screening test which has
detected antibodies.
If rubella susceptibility is possible, a serum should be obtained as soon as possible after
contact. It should be tested rubella-specific IgG and IgM. If rubella-specific IgG is detected,
and rubella-specific IgM is not detected there is no evidence of recent primary rubella. In a
pregnant woman with the onset of a rash in the previous 10 days, if a low concentration of
rubella specific IgG is detected, a further serum should be requested even if a rubellaspecific IgM is not detected.
If primary rubella is confirmed by laboratory tests in the first 12 weeks of pregnancy the risk
of congenital defects is very high and termination of pregnancy should be offered.
Prenatal diagnosis may be useful to assess the risk to the fetus when rubella occurs during
12 - 18 weeks gestation, when laboratory diagnosis is inconclusive and when rubella
reinfection occurs before 12 weeks gestation. Amniotic fluid is the preferred sample as
amniocentesis is less invasive than feta blood sampling.
Review Date: Annually verified for currency or as changes occur, and reviewed every 3
years via Policy and Procedure working group coordinated by the Clinical and Quality
improvement midwife. Nov. 2009.
Dr A Dennis
Co-Director (Medical)
Women’s & Children’s Services
Sue McBeath
Co-Director (Nursing & Midwifery)
Women’s & Children’s Services
Date: December 2007
REFERENCES
Best, J 2007 ‘Rubella', Seminars of Fetal & Neonatal Medicine, vol. 12, p. 182- 192.
De Jong, E, De Haan, T, Kroes, A, Beersma, M, Oepkes, D & Walther F 2006 ‘Parvovirus B19
infection in pregnancy' Journal of Clinical Virology, vol. 36 p. 1-7.
De Santis, M, Cavaliere, A, Straface, G & Caruso, A 2006 ‘Rubella infection in pregnancy',
Reproductive Toxicology, vol. 21, p. 390-398.
Enders, M, Schalasta, G, Baisch, C, Weidner, A, Pukkila, L, Kaikkonen, L, Lankinen, H, Hedman, L,
Soderlund-Venermo, M & Hedman, K 2006 ‘Human parvovirus B19 infection during pregnancy - Value
of modern molecular and serological diagnostics' Journal of Clinical Virology, vol.35, p.400-406.
Frydenberg, A & Starr, M 2003 ‘Slapped cheek disease: How it affects children and pregnant women'
Australian Family Physician, vol. 32, no. 8, p. 589-592.
Morgan-Capner, P & Crowcroft, NS 2002 ‘Guidelines on the management of, and exposure to, rash
illness in pregnancy (including consideration of relevant antibody screening programmes in pregnancy'
Communicable Disease and Public Health, vol. 5, no. 1, p. 59-71.
Servey, J, Reamy, B & Hodge, J 2007 ‘Clinical presentations of parvovirus B19 infection' American
Family Physician, vol. 75, no. 3, p. 373-376.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix G Pregnancy Assessment Clinic Referral
Next Appendix
WACSClinProc 1.20/08
Title:
Pregnancy Assessment Clinic Referral
Description: Criteria for referral to the Pregnancy Assessment Clinic and Early Pregnancy
Assessment
Purpose
The pregnancy assessment clinic (PAC) allows women with complications in pregnancy to
be assessed, monitored and treated on an outpatient basis reducing the need for admission
to hospital.
Pregnancy Assessment Clinic (PAC)
The pregnancy assessment clinic does not provide a triage service. Women should be
triaged (by Department of Emergency Medicine, general practitioner or Ward 4B) and if
appropriate then referred to the pregnancy assessment clinic. The pregnancy assessment
clinic is available on weekdays from 0900 to 1700 by appointment.
Women who are in labour, have pain or active bleeding after 14 weeks gestation or who
have preterm (<37 weeks) prelabour rupture of membranes should be assessed in 4B.
Pregnant women who have been involved in a motor vehicle accident with significant injury
or major trauma should be assessed in DEM. Fetal monitoring should be performed in DEM
as per Fetal Monitoring Following Trauma in Pregnancy WACSClinProc1.8.
Criteria for Early Pregnancy Assessment in PAC
Eligible women must have a diagnosed pregnancy and:
• are booked for confinement at the QV
• be referred by their general practitioner
• be referred by a private obstetrician
• be referred by the triage nurse or senior midwife in 4B.
Self-referral by women not booked for confinement will not be accepted. Women who do not
have a confirmed pregnancy by either: serum or documented urinary BHCG, ultrasound or
clinical means (>20 weeks), will not be seen in PAC.
Appropriate Indications for Early Pregnancy Assessment in PAC
Under 20 weeks gestation:
• Bleeding and or pain in early pregnancy (following appropriate triage)
• BHCG monitoring
• Non-viable pregnancy detected on USS
• Ectopic pregnancy being treated as an outpatient with methotrexate
• Women who have had a miscarriage and require non-surgical management
• Hyperemesis
• Suspected ectopic pregnancy
Exclusion Criteria:
• Non confirmed pregnancy
• Routine pregnancy dating scan or pregnancy confirmation
• Haemodynamically unstable/ heavy bleeding
• In significant pain and/or requiring narcotic administration
• Women categorised as triage categories 1 and 2
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix G Pregnancy Assessment Clinic Referral cont’d
Next Appendix
WACSClinProc 1.20/08
Appropriate Indications for PAC Referral Over 20 Weeks Gestation:
• Reduced fetal movement
• Fetal monitoring
• Fetal surveillance
• Monitoring of pregnancy induced hypertension
• Term spontaneous rupture of membranes not in labour
• Minor falls during pregnancy
• External cephalic version
• Iron transfusion > 36 weeks
Appointments
• The Pregnancy Assessment Clinic is available Monday to Friday from 0900 to 1700,
by appointment.
• Appointments for the Pregnancy Assessment Clinic can be made through the
antenatal clinic administration staff during office hours (6348 8980) or after hours a
message can be left on the answering machine (6348 8946).
• Written referrals can be faxed to the Antenatal Clinic (6348 7886).
Dr A Dennis
Co-Director (Medical)
Women’s & Children’s Services
Sue McBeath
Co-Director (Nursing & Midwifery)
Women’s & Children’s Services
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix H Rh D Immunoglobulin (Anti-D)
WACSClinProc 3.2/09
Title:
Rh D Immunoglobulin (Anti-D)
Description: The use of prophylactic Anti D in obstetrics. Rh negative, Rh D
Immunoglobulin, Anti-D
Purpose:
The administration of Rh D immunoglobulin (Anti-D) has been shown to result in a significant
reduction in the incidence of Rh isoimmunisation.
Summary of dosing recommendations for Rh D Immunoglobulin
Obstetric conditions
Sensitising events in the first trimester (singleton pregnancy)
Sensitising events in the first trimester (multiple pregnancy)
Sensitising events beyond the first trimester
250 IU (50µg)
625 IU (125µg)
625 IU (125µg)
Pregnancy
Antenatal prophylaxis (28 and 34 weeks gestation)
625 IU (125µg)
Postpartum
625 IU (125µg)
General
•
•
•
•
For successful immunoprophylaxis, Rh D immunoglobulin should be administered as soon as
possible after the sensitising event, but always within 72 hours.
If Rh D immunoglobulin has not been offered within 72 hours, a dose offered within 9 - 10
days may provide protection.
Blood for Kleihauer and antibody screening should be taken from the mother before
administration of the Rh D immunoglobulin to assess the magnitude of fetomaternal
haemorrhage (FMH). A single dose of Rh D immunoglobulin should not be withheld
based upon or pending these results.
Where FMH quantitation (Kleihauer) shows that FMH greater than that covered by the dose
already administered has occurred, administration of an additional dose/s sufficient to provide
immunoprophylaxis must be administered and preferable within 72 hours.
Sensitising Events in the First Trimester
•
•
•
A dose of 250 IU (50µg) Rh D immunoglobulin should be offered to every Rh D negative
woman with no preformed anti-D to ensure adequate protection against immunisation for the
following indications up to and including 12 weeks gestation:
o miscarriage
o termination of pregnancy
o ectopic pregnancy
o chorionic villus sampling.
A dose of 250 IU (50µg) Rh D is sufficient to prevent immunisation by a fetomaternal
haemorrhage of 2.5ml of fetal red blood cells (5ml of whole blood).
There is insufficient evidence to support the use of Rh D immunoglobulin in bleeding prior to
12 weeks gestation in an ongoing pregnancy, although if the pregnancy requires curettage Rh
D immunoglobulin should be given. If miscarriage or termination occurs after 12 weeks
gestation, 625 IU (125µg) Rh D immunoglobulin should be offered.
Sensitising Events Beyond the First Trimester
•
A dose of 625 IU (125µg) Rh D immunoglobulin should be offered to every Rh D negative
woman with no preformed anti-D to ensure adequate protection against immunisation for the
following indications after 12 weeks:
o genetic studies (chorionic villus sampling, amniocentesis and cordocentesis)
o abdominal trauma considered sufficient to cause fetomaternal haemorrhage
o each occasion of revealed or concealed antepartum haemorrhage (where the woman
suffers unexplained uterine pain the possibility of concealed antepartum haemorrhage
should be considered, with a view to immunoprophylaxis
o external cephalic version (performed or attempted)
o miscarriage or termination of pregnancy.
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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Appendix H Rh D Immunoglobulin (Anti-D) cont’d
WACSClinProc 3.2/09
Antenatal Prophylaxis
•
•
•
All women should have ABO and Rh D typing at their first antenatal visit to identify women
who may require the administration of prophylactic anti-D during pregnancy and after birth.
All Rh D negative women should have an antibody screen at 26 to 28 weeks gestation.
Universal prophylaxis with Rh D immunoglobulin 625 IU (125µg) to Rh D negative women at
28 and 34 weeks gestation is generally regarded as best practice.
Postpartum
•
•
•
•
Cord blood should be collected and sent to pathology for blood group and Coombs test. The
sample must be labelled with the newborn's UR, maternal surname and B/O maternal
Christian name, infants gender, date and time of birth and date and time of collection.
Maternal blood should be collected within 24 hours of birth to assess FMH (Kleihauer Test)
and the dose of Rh D immunoglobulin required.
Rh D immunoglobulin should be offered to every Rh D negative woman following delivery of
an Rh D positive baby.
Rh D immunoglobulin should not be given to women with preformed anti-D antibodies, except
where the preformed anti-D is due to the antenatal administration of Rh D immunoglobulin.
Kleihauer Test
The Kleihauer test is used to identify women with large FMH who may need additional anti-D
immunoglobulin to ensure clearance of all fetal red blood cells. A negative Kleihauer test
indicates that one dose of anti-D immunoglobulin is sufficient.
Administration and Documentation
•
•
•
•
•
The LGH Transfusion Medicine Request Form A/2500 is to be completed by a medical officer
to obtain the Rh D immunoglobulin from pathology.
The Human Anti-D Antibody Product Administration Form 17H should be commenced
antenatally and used to document all administrations of Anti-D.
Rh D immunoglobulin should be checked by two midwives prior to administration as per the
Statewide Policy for Transfusion of Blood & Blood Components.
Rh D immunoglobulin should be given as a deep intramuscular injection using a large bore
needle into the deltoid muscle or the anterolateral thigh.
If a dose of more than 5ml is required it is recommended to administer it in divided doses at
different sites.
Review Date: Annually verified for currency or as changes occur, and reviewed every 3
years via Policy and Procedure working group coordinated by the Clinical and Quality
improvement midwife. Nov. 12.
Dr A Dennis
Co-Director (Medical)
Women's & Children's Services
Sue McBeath
Co-Director (Nursing & Midwifery)
Women's & Children's Services
Date: March 2009
ATTACHMENT 1 - REFERENCES
Australian & New Zealand Society of Blood Transfusion Ltd 2007 ‘Guidelines for blood grouping and
antibody screening in the antenatal and perinatal setting', online:
http://www.anzsbt.org.au/publications/index.cfm
National Health & Medical Research Council 2003 ‘Guidelines on the prophylactic use of Rh
immunoglobulin (anti-D) in obstetrics', online:
http://www.nhmrc.gov.au/publications/synopses/wh33syn.htm
Royal Australian and New Zealand College of Obstetricians and Gynaecologist 2007 College
Statement ‘Guidelines for the use of Rh (D) Immunoglobulin (Anti-D) in Obstetrics in Australia', online:
http://ranzcog.edu.au/publications/collegestatements.shtml#CObs
Revised: 09/2012, 06/2012, 2010, 2009, 2007, 2005, 2003 - Developed 2002
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`