Ant natal &postnatal care notes essays

Obesity in Pregnancy

Definitions

 Body mass index = weight / height2

 The healthy range for BMI is between 18.5 and 25 kg/m2
 Underweight: BMI < 18.5
 Overweight: BMI 25 – 29.9
 Obese I: BMI 30 – 34.9
 Obese II: BMI 35 – 39.9
 Obese III or Morbidly obese: BMI 40 and over

Waist circumference is also used as a measure of obesity, allowing muscle

mass to be distinguished from fat. Raised waist circumference is > 88cm for
women and > 102cm for men.

NICE guidelines on prevention, identification, assessment and management of

overweight and obesity uses both BMI and waist circumference to categorise risk for
developing long-term health problems.

BMI Classification Waist Circumference

Male <94cm 94-102cm >102cm

Female <80cm 80-88cm > 88cm

Normal   No increased No increased Increased risk

risk risk

25-29.9   No increased Increased risk High risk

risk

30-34.9   Increased risk High risk Very high risk

 Scale of the problem
England:

 2007: 37 per cent of adults were overweight (BMI 25 and over) and a further
24 per cent were obese (BMI 30 and over). 14% children were overweight
and 19 per cent were obese. 41% of women and 33 % of men had a waist
circumference above the healthy range.
 The proportion of adults with a healthy body weight has decreased from 41%
to 34% in men and from 49% to 42% in women between 1993 and 2007.
 The per cent with a waist circumference above the healthy range rose from
20 to 33% for men and from 26 to 41% for women between 1993 and 2007.
 It is estimated that rates of obesity will rise even further to 36 per cent in men
and 28 per cent in women by 2015 and 47 per cent and 36 per cent
respectively by 2025.
Global perspective
2007 - % of adults Overweight / obese

Nauru                           78.5%              Tonga                           56.0%

USA                              64%                  New Zealand                62.6%

United Kingdom         61.0%              Iceland                         60.2%

Luxembourg                54.8%              Ireland                          51.0%

Finland                         48.9%              Canada                        46.8%

Italy                              45.5%              Netherlands                  45.5%

Sweden                        44.0%              Switzerland                   37.3%

Japan                           3.2%                South Korea                 3.2%

 WHO projects that by 2015, 2.3 billion adults will be overweight and more
than 700 million will be obese. Overweight and obesity are now dramatically
increasing in low- and middle-income countries, particularly in urban settings.

Health consequences of obesity

 Relative risk of specific diseases in obese people by gender; England

  Men Women

Type II diabetes 5.2 12.7

Hypertension 2.6 4.2

Myocardial infarction 1.5 3.2

Colon cancer 3.0 2.7

Ovarian cancer   1.7

Stroke 1.3 1.3

Obesity and Pregnancy

 BMI over 30 at booking

 Affects ~20% of women in the UK

Antenatal Risks
  Gestational diabetes
 Hypertensive disorders
 Macrosomia
 Venous thrombo-embolism (throughout pregnancy)
 Vitamin deficiencies:

a) Women with BMI ≥ 27 have been shown to have lower serum folate levels, receive
folate through their diet or take nutritional supplements compared to women with BMI
< 27).

b)  Serum vitamin D levels fall with increasing pre-pregnancy BMI. Obese women are
at increased risk of vitamin D deficiency and their babies have lower cord serum
vitamin D levels.

Intra-partum / post-partum risks

 Slower progress in labour

 Need for caesarean section
 Post-partum haemorrhage
 Shoulder dystocia
 Wound infection
 Anaesthetic complications
 Difficulties with intra-partum fetal monitoring

Fetal, neonatal and childhood risks

 Miscarriage
 Congenital anomalies including neural tube defects – risk increases with
increasing category of obesity
 Poor ultrasound visualisation of the fetus and difficulties with surveillance
 Macrosomia and Birth trauma
 Stillbirth and neonatal death
 Admission to SCBU
 Less likely to initiate and maintain breastfeeding
 Prematurity
 Obesity in childhood

Pre-pregnancy management of the obese woman

 Provide information on risks of obesity in pregnancy and potential benefits of

optimising weight. Provide support to lose weight before conception
 Provide information on weight and lifestyle during family planning
consultations
 Women wishing to become pregnant should be advised to take 5mg folic acid
daily beginning at least 1 month before conception until the end of the first
trimester

Antenatal care
Organisation:

 The management of obesity in pregnancy should be integrated into all

antenatal clinics as specialist clinics for obese women are not feasible. All
clinicians should be aware of the risks associated with obesity and
interventions to minimise risk.
  Maternity units should have accessible multi-disciplinary guidelines on the
management of obese pregnant women
 Nutritional supplementation: Women should be administered 5mg folic acid
daily during the first trimester and 10 micrograms vitamin D daily during
pregnancy and breastfeeding

Referral

 All women with BMI ≥ 30 should be referred to a consultant obstetrician

 All women with BMI ≥ 40 should have antenatal consultation by an obstetric
anaesthetist. A management plan should be discussed and documented
 All women with BMI ≥ 40 should be have an assessment by a qualified
professional in the third trimester to determine manual handling requirements
and tissue viability issues

Antenatal counselling

 All women with BMI ≥ 30 should be given information on the risks associated
with obesity and how these can be minimised. Discuss importance of healthy
eating and exercise. Provide information in a sensitive manner to empower
the woman to engage with the services available.
 Information should include:

1. The increased risk of hypertensive disorders, gestational diabetes and fetal

macrosomia requiring an increased level of maternal and fetal monitoring
2. The potential for poor ultrasound visualisation of the baby and consequent
difficulties in fetal surveillance and screening for anomalies
3. The increased risk of induction of labour
4. The potential for intrapartum complications, including difficulty with fetal
monitoring, anaesthesia and caesarean section which would require senior
obstetric and anaesthetic involvement and an antenatal anaesthetic
assessment, and potential for emergency caesarean section
5. The need to prioritise the safety of the mother at all times
6. The importance of healthy eating and appropriate exercise during pregnancy
for the management of weight gain
7. The importance of breastfeeding and opportunities to receive additional
breastfeeding support.
8. Nutritional advice by an appropriately trained professional may be useful early
in the pregnancy.

Clinical Assessment
a)      BMI – weight and height for all women at booking, recorded in hand-held notes
and electronic patient records. Use appropriate equipment and do not use self-
reported weight and height. If BMI > 30, reassess in the third trimester

b)      VTE – assess risk of VTE and provide thromboprophylaxis. BMI ≥ 30 plus 2
additional risk factors = antenatal + post-natal thromboprophylaxis

c)      BP measurement – use appropriate cuff size and document size in notes. Too
small a cuff and BP is artificially high with error up to 50mmHg. Too large a cuff
results in BP that is artificially low although the error is smaller. Use standard cuff
(13x23cm) for an arm circumference of up to 33cm, a large size (33 x 15 cm) for an
arm circumference between 33 and 41cm) and a thigh cuff (18x36cm) for an arm
circumference of 41cm or more. There is less error introduced by using too large a
cuff than by too small a cuff.

Antenatal screening

a)  Pre-eclampsia – women with BMI ≥ 35 are at increased risk of pre-eclampsia

and should be screened according to PRECOG guidelines. These women should be
referred early for specialist antenatal care if they have additional risk factors
including:
Multiple pregnancy
Underlying medical conditions like
i)  Pre-existing hypertension or booking diastolic BP ≥ 90 mmHg
ii) Pre-existing renal disease or booking proteinuria (≥ 1+ on more than one occasion
or quantified at ≥ 0.3g/ 24 hour)
iii)  Pre-existing diabetes
iv)  Antiphospholipid antibodies
Pre-eclampsia in any previous pregnancy

Any two of the following: first pregnancy, age 40 years or more, family history,
booking diastolic BP ≥ 80 mmHg < 90mmHg
 
Women with BMI ≥ 35 but no additional risk factors can have community BP
monitoring at least every 3 weeks between 24 and 32 weeks then every 2 weeks
from 32 weeks till delivery

b)  Gestational diabetes

All women with BMI ≥ 30 should be screened using a 2 hour 75g oral GTT at 24 – 28
weeks gestation.

Planning labour and delivery

 Women with BMI ≥ 35 should give birth in a consultant-led obstetric unit.

Women with BMI 30-34 should have an individualised plan for place of birth
 Discuss intra-partum risks and strategies to minimise risks. Document
management plan
 Women with a previous CS should have an individualised plan for planned
vaginal delivery following informed discussion and consideration of all the
clinical issues. Successful vaginal delivery rates are lower in obese women
and those with morbid obesity have a higher risk of uterine rupture.

Intra-partum care

Staffing & training

a)  Anaesthetics: The duty anaesthetist should be informed when a woman with BMI
≥ 40 is admitted. An anaesthetist at ST6 and above or equivalent experience should
be available
b)  Obstetrics – a trainee at ST6 level or above should be available and should have
been assessed as competent to perform CS on women with BMI ≥ 40 otherwise the
consultant should attend CS or be immediately available

c)  Midwifery – women with BMI ≥ 40 should receive continuous midwifery care

d)  Operating theatre – staff should be informed if a woman weighing > 120kg
requires operative intervention.

e)  All clinicians should be educated on the impact of maternal nutrition on maternal,
fetal and child health.

f) All clinicians should be trained on manual handling techniques and the use of
specialist equipment which may be required for women with obesity.

Clinical interventions

 All women with BMI ≥ 30 should have active management of the third stage of
labour and this should be documented in the notes
 All women with BMI ≥ 30 should be given prophylactic antibiotics at the time
of caesarean section
 All women undergoing CS should have the sub-cutaneous tissue closed if
there is more than 2cm of fat to reduce the risk of wound infection and
dehiscence
 Women with BMI ≥ 40 should have venous access established early in labour

Postnatal care

a)      Thromboprophylaxis

 All women receiving antenatal LMWH should have postnatal risk assessment
and LMWH continued for 6 weeks
 All women with BMI ≥ 30 requiring prophylactic LMWH should be
administered a dose appropriate for maternal weight
 All women with BMI ≥ 30 should be encouraged to mobilise early after
delivery
 All women with BMI ≥ 30 and one or more additional persisting risk factors for
VTE should be given LMWH for 7 days after delivery. Those with two or more
risk factors should also be given TED stockings
 All women with BMI ≥ 40 should be offered postnatal LMWH regardless of
mode of delivery for a minimum of 1 week

b)      Breastfeeding

 All women with BMI ≥ 30 should receive specialist advice and support
antenatally and post-partum to support initiation and maintenance of
breastfeeding

Diabetes mellitus

 All women with BMI ≥ 30 should continue to be given nutritional and lifestyle
advice after delivery with a view to weight reduction
 All women with BMI ≥ 30 and gestational diabetes but a normal GTT after
delivery should have regular follow-up by their GP to screen for the
development of type II diabetes
 All women with BMI ≥ 30 and gestational diabetes should have annual
screening for cardio-metabolic risk factors and be offered lifestyle and weight
management advice
Facilities and Equipment

Maternity units should have documented risk assessment on the availability of

facilities to care for obese women including:

a)      Circulation space

b)      Accessibility and doorway widths
c)      Safe working loads of equipment and floors (up to 250kg)
d)      Appropriate theatre gowns
e)      Transportation
f)        Staffing
g)      Availability of specific equipment including:

(i) Assessment equipment: large BP cuffs, sit-on weighing scales, ultrasound scan

couches

(ii) Transportation: large wheelchairs, theatre trolleys, lifting and lateral transfer

equipment.

(iii Ward equipment: large chairs without arms, ward and delivery beds, ultrasound
machine on delivery suite

(iv) Operating theatre equipment: operating theatre tables, extra long spinal and
epidural needles

There should be a central list of equipment with details of dimensions, working loads
and location.

Llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

Antenatal assessment of fetal growth and well-being: NICE guidelines

• Symphysis-fundal height should be measured and recorded at each antenatal
appointment from 24 weeks.

• Ultrasound estimation of fetal size for suspected large for gestational age fetus
should not be undertaken in a low risk population.

• Routine Doppler ultrasound should not be used in low risk pregnancies.

• Fetal presentation should be assessed by abdominal palpation at 36 weeks or later,

when presentation is likely to influence the plans for the birth. Routine assessment of
presentation by abdominal palpation should not be offered before 36 weeks because
it is not always accurate and may be uncomfortable.

• Suspected fetal malpresentation should be confirmed by an ultrasound

assessment.

• Routine formal fetal-movement counting should not be offered.

• Auscultation of the fetal heart may confirm that the fetus is alive but is unlikely to
have any predictive value and routine listening is therefore not recommended.
However, when requested by the mother, auscultation of the fetal heart may provide
reassurance.

• The evidence does not support the routine use of antenatal electronic fetal heart
rate monitoring for fetal assessment in women with an uncomplicated pregnancy and
therefore it should not be offered.

• The evidence does not support the routine use of ultrasound scanning after 24
weeks of gestation and therefore it should not be offered.

………………………………………………………………………………………………………………………………………………

Nutritional supplements in pregnancy - NICE guidelines

• Pregnant women (and those intending to become pregnant) should be informed
that dietary supplementation with folic acid, before conception and throughout the
first 12 weeks, reduces the risk of having a baby with a neural tube defect. The
recommended dose is 400 micrograms per day.

• Iron supplementation should not be offered routinely to all pregnant women. It does
not benefit the mother’s or the baby’s health and may have unpleasant maternal side
effects.

• Pregnant women should be informed that vitamin A supplementation (intake above

700 micrograms) might be teratogenic and should therefore be avoided. Pregnant
women should be informed that liver and liver products may also contain high levels
of vitamin A, and therefore consumption of these products should also be avoided.

• All women should be informed at the booking appointment about the importance for
their own and their baby•s health of maintaining adequate vitamin D stores during
pregnancy and whilst breastfeeding. In order to achieve this, women may choose to
take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin
supplement. Particular care should be taken to enquire as to whether women at
greatest risk are following advice to take this daily supplement. These include:

1) women of South Asian, African, Caribbean or Middle Eastern family origin

2) women who have limited exposure to sunlight, such as women who are
predominantly housebound, or usually remain covered when outdoors

3) women who eat a diet particularly low in vitamin D, such as women who consume
no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal

4) women with a pre-pregnancy body mass index above 30 kg/m2.

Fffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff

PROLONGED PREGNANCY
Definition
• Pregnancy that has progressed beyond 42 weeks or 294 days from LMP.

Incidence
• 3-10% dependent on the use of early pregnancy dating by ultrasound scan. There
is evidence that early pregnancy dating reduces the need for labour induction for
prolonged pregnancy. Recurrence risk is 30% after one pregnancy and 40% after
two prolonged pregnancies.

Fetal risks
• Progression of pregnancy beyond 42 weeks gestation is associated with:
1) Increased perinatal mortality - ante-partum, intra-partum and neonatal
2) Increased incidence of meconium stained liquor and meconium aspiration
3) Increased risk of emergency caesarean section for fetal distress (or failure to
progress)
4) Increased risk of dystocia
• Intra-uterine death of a term fetus in an otherwise normal pregnancy is particularly
distressing for parents and staff
• Placental insufficiency is thought to be the cause of fetal compromise

Maternal risks
• Increased risk of operative delivery - caesarean section and vaginal operative
delivery with their complications
• Maternal anxiety

MANAGEMENT OPTIONS

Women should be assessed at 41 weeks, with induction of labour if any high

risk features are identified (history of antepartum haemorrhage, hypertension,
previous stillbirth)

Induction of labour

• Should be recommended if pregnancy progresses beyond 42 weeks

• Associated with lower caesarean section rate and operative vaginal delivery rate,
lower risk of meconium stained liquor and lower perinatal mortality rate compared to
expectant management

• Cost-effective intervention

• This, however, is a medical intervention which may be resented by some women

Membrane sweeping
• Sweeping of the membranes, performed as a general policy in women at term,
was associated with reduced duration of pregnancy and reduced frequency of
pregnancy continuing beyond 41 weeks (RR 0.62, 95% CI 0.49 to 0.79) and 42
weeks (RR 0.28, 95% CI 0.15 to 0.50).

• To avoid one formal induction of labour, sweeping of membranes must be

performed in seven women (NNT = 7). There was no evidence of a difference in the
risk of maternal or neonatal infection.

• Discomfort during vaginal examination and other adverse effects (bleeding,

irregular contractions) were more frequently reported by women allocated to
sweeping.

Expectant management

• This is also likely to result in a favourable outcome, and may be undertaken in

women who decline labour induction.

• Programme of fetal surveillance needs to be instituted and may include twice

weekly CTG, Dopplers of the umbilical arteries, assessment of liquor volume, BPP

• The role of these investigations in preventing perinatal mortality have not been
proven

• 40-50% of women will deliver 4-5 days after 42 weeks

Labour

• Labour in prolonged pregnancy is ‘high risk’ and continuous electronic fetal

monitoring should be recommended especially in the presence of meconium stained
liquor or no liquor at membrane rupture

• Hypoxia and acidosis are particularly undesirable in the presence of meconium

stained liquor

NICE Guidelines: Prolonged pregnancy

• Prior to formal induction of labour, women should be offered a vaginal examination

for membrane sweeping.

• Women with uncomplicated pregnancies should be offered induction of labour

beyond 41 weeks.

• From 42 weeks, women who decline induction of labour should be offered

increased antenatal monitoring consisting of at least twice weekly cardiotocography
and ultrasound estimation of maximum amniotic pool depth.

Uuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu

DRUG INTERACTIONS
DRUG INTERACTIONS

Anti-muscarinic agents (oxybutynin, tolterodine)

Antibiotics - avoid use of erythromycin and clarithromycin with tolterodine

Ketoconazole / itraconazole - absorption reduced by tolterodine

Anti-histamines and anti-psychotics increase anti-muscarinic side-effects

Antiviral agents - avoid concomitant use of tolterodine with indinavir, nelfinavir,

rotnavir and saquinavir

Bisphosphonates.
Reduced absorption with antacids, calcium salts and iron
Increased risk of hypocalcaemia with aminoglycoside antibiotics.

Bromocriptine and carbegoline.

Alcohol - reduces tolerance to bromocriptine
Microglide antibiotics such as erythromycin - increase plasma concentration and
toxicity
Octreotide - increases concentration of bromocriptine
Metoclopramide and domperidone - antagonise hypo-prolactinaemic effect
Sympathetic agonists like phenylpropanolamine increase risk of toxicity with
bromocriptine.

Clopidogrel.
Anti-platelet agent
Increased risk of bleeding with NSAIDs
Enhances effect of anticoagulants

Danazol

Enhance effect of anticoagulants like warfarin by inhibiting metabolism

Increase plasma concentration of carbamazepine by inhibiting its metabolism

Increase plasma concentration of cyclosporin by inhibiting metabolism

Plasma concentration of tacrolimus possibly increased

Combine oral contraceptive

ACE- inhibitors and Angiotensin II antagonists - antagonise hypotensive effect

Antibiotics - rifampicin accelerates metabolism and reduces contraceptive efficacy

(progesterone-only pill also). Broad spectrum antibiotics also reduce contraceptive
efficacy

Antagonise anti-coagulant effect of oral anticoagulants

Antagonise oral hypoglycaemic agents

Anti-epileptics - phenytoin, carbamazepine, primidone, Phenobarbital - increase

metabolism and reduce efficacy of COCP and progesterone-only pill

Anti-fungal agents particularly griseofulvine - increase metabolism and reduce

efficacy

Anti-viral agents - nelfinavir, nevirapine and ritonavir increase COCP metabolism

and reduce efficacy

Cyclosporine - COCP increases plasma cyclosporine concentration

COCP increase plasma corticosteroid concentration

Modafinil - increase COCP metabolism and reduce efficacy

Tretinoin - reduce efficacy of progesterone-only pill and possibly COCP

Tacrolimus - efficacy of COCP possibly reduced

Theophylline - COCP delays excretion and increases plasma concentration

Flutamide

Enhances anti-coagulant effect of warfarin

Gestrinone

Rifampicin and anti-epileptics enhance metabolism

Heparin

ACE inhibitors and angiotensin II antagonists increase risk of hyperkalaemia

NSAIDs and anti-platelet agents enhance anti-coagulant effects

GTN infusion increases heparin excretion and reduces anti-coagulant effects

Hydralazine

Other anti-hypertensive agents - enhance hypotensive effect

Anaesthetic agents - enhance hypotensive effect

NSAIDs - antagonise hypotensive effect

Anti-depressants - enhance hypotensive effect

Anti-psychotic and anxiolytic agents - enhance hypotensive effect

Corticosteroids - antagonise hypotensive effect

COCP - antagonise hypotensive effect

Magnesium sulphate

Profound hypotension with nifedipine

Methotrexate.

NSAIDs reduce excretion and increase toxicity.

Penicillins and probenecid - reduce excretion and increase risk of toxicity

Anti-folate agents such as phenytoin, trimethoprim increase anti-folate effects.

Toxicity increased by sulphonamides

Increased plasma concentration and risk of toxicity with retinoids such as acitretin

Methyldopa

NSAIDs - antagonise hypotensive effect

Anaesthetic agents and anti-depressants - enhance hypotensive effect

Lithium - neurotoxicity may occur without increased plasma lithium concentration

Other anti-hypertensives - enhance hypotensive effects

Oxytocin

Inhalation anaesthetics possibly reduce oxytocic effect and enhance hypotensive

effect and risk of arrhythmias

Prostaglandins potentiate uterotonic effect

Progestogens

Rifampicin - increases metabolism of progestogens and reduce efficacy

Nevirapine - accelerate metabolism and reduce efficacy

Cyclosporine - progestogens inhibit metabolism and increase cyclosporine levels

Aminoglutethamide - reduces plasma concentration of medroxyprogesterone

Raloxifene

Anion exchange resins like cholestyramine - reduce absorption of raloxifene

Raloxifene reduces anti-coagulant effect of warfarin

Tamoxifen

Enhances effects of oral anticoagulants like warfarin

Aminoglutethimide reduces plasma tamoxifen concentrations

Testosterone

Enhances anticoagulant effects of warfarin

Enhances hypoglycaemic effects of oral hypoglycaemic agents

Tibolone

Rifampicin enhances metabolism and reduces plasma concentration

Anti-epileptics increase metabolism and reduce plasma concentration

Lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

Antenatal information for women - NICE Guidelines

Antenatal information should be given to pregnant women according to the

following schedule.

• At the first contact with a healthcare professional

1) folic acid supplementation

2) food hygiene, including how to reduce the risk of a food acquired infection

3) lifestyle advice, including smoking cessation, and the implications of recreational

drug use and alcohol consumption in pregnancy

4) all antenatal screening, including screening for haemoglobinopathies, the

anomaly scan and screening for Downs syndrome, as well as risks and benefits of
the screening tests.

• At booking (ideally by 10 weeks)

1) how the baby develops during pregnancy

2) nutrition and diet, including vitamin D supplementation for women at risk of

vitamin D deficiency, and details of the ?Healthy Start? programme

3) exercise, including pelvic floor exercises

4) place of birth

5) pregnancy care pathway

6) breastfeeding, including workshops

7) participant-led antenatal classes

8) further discussion of all antenatal screening

9) discussion of mental health issues.

• Before or at 36 weeks

1) breastfeeding information, including technique and good management practices

that would help a woman succeed, such as detailed in the UNICEF 'Baby Friendly
Initiative'

2) preparation for labour and birth, including information about coping with pain in
labour and the birth plan

3) recognition of active labour

4) care of the new baby

5) vitamin K prophylaxis

6) newborn screening tests

7) postnatal self-care

8) awareness of 'baby blues' and postnatal depression.

• At 38 weeks

options for management of prolonged pregnancy.

This can be supported by information such as 'The pregnancy book' (Department of

Health 2007) and the use of other relevant resources such as UK National
Screening Committee publications and the Midwives Information and Resource
Service (MIDIRS) information leaflets.

• Information should be given in a form that is easy to understand and accessible to

pregnant women with additional needs, such as physical, sensory or learning
disabilities, and to pregnant women who do not speak or read English.

• Information can also be given in other forms such as audiovisual or touch screen
technology; this should be supported by written information.

• Pregnant women should be offered information based on the current available

evidence together with support to enable them to make informed decisions about
their care. This information should include where they will be seen and who will
undertake their care.

• At each antenatal appointment, healthcare professionals should offer consistent

information and clear explanations, and should provide pregnant women with an
opportunity to discuss issues and ask questions.

• Pregnant women should be offered opportunities to attend participant-led

antenatal classes, including breastfeeding workshops.

• Women's decisions should be respected, even when this is contrary to the views
of the healthcare professional.

• Pregnant women should be informed about the purpose of any test before it is
performed. The healthcare professional should ensure the woman has understood
this information and has sufficient time to make an informed decision. The right of a
woman to accept or decline a test should be made clear.

• Information about antenatal screening should be provided in a setting where

discussion can take place; this may be in a group setting or on a one-to-one basis.
This should be done before the booking appointment.

• Information about antenatal screening should include balanced and accurate

information about the condition being screened for.
Ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo

THROMBOPROPHYLAXIS

 Pulmonary thrombo-embolism (PTE) is the commonest cause of direct

maternal deaths in the UK and the second commonest cause of maternal
deaths.
 Most recent Confidential Enquiry: 8/13 fatal antenatal PTE occurred in the
first trimester. 10/14 post-partum deaths followed vaginal delivery
 Most VTE occurs antenatally but the risk per day is greatest in the weeks
immediately following delivery. The threshold for recommending
thromboprophylaxis is lower in the postpartum period compared to the
 antenatal period because the risk per day is higher and the duration of risk is
shorter
 Caesarean section is an important risk factor for VTE but 55% of post-partum
maternal deaths from VTE in the UK in 1997 – 205 occurred following vaginal
delivery.
 Thrombotic risk exists from the beginning of the first trimester and antenatal
booking is usually at the end of the first trimester
 There is evidence that low molecular weight heparin (LMWH) reduces the risk
of VTE in medical and surgical patients by 60-70%. LMWH is recommended
for use in pregnancy as it is as effective as unfractionated heparin with fewer
side-effects.
 All women should undergo an assessment of risk factors for VTE pre-
pregnancy or in early pregnancy and should be repeated if the woman is
admitted or develops intercurrent problems

RISK FACTORS FOR VTE

Pre-existing

 Previous VTE
 Inherited thrombophilia – found in 20-50% of VTE in pregnancy
 Acquired thrombophilia (lupus anticoagulant, anti-cardiolipin antibodies, beta-
2 glycoprotein 1 antibodies
 Medical co-morbidities
 Age > 35 years
 Parity > 3
 Obesity (BMI > 30)
 Smoking
 Gross varicose veins
 Immobility

Obstetric

 Multiple pregnancy and assisted reproduction

 Pre-eclampsia
 Caesarean section
 PPH > 1L
 Prolonged labour, rotational operative delivery

Transient

 Surgical intervention
 Dehydration
 OHSS
 Systemic sepsis
 Post-partum wound infection
 Long distance travel (> 4h).

PRE-PREGNANCY / EARLY CARE

 All women should have documented assessment of risk factors for VTE in
early pregnancy or pre-pregnancy.
 Women at high risk of VTE should be offered pre-pregnancy counselling with
a prospective management plan. Take detailed history to identify risk factors.
Screen for inherited and acquired thrombophilia in women with a non-
 oestrogen-related VTE provoked by a minor risk factor. Women should be
counselled about the implications of a positive result for themselves and their
family. Testing for thrombophilia not recommended in women with a prior
unprovoked or oestrogen-related VTE as this will not alter management.
 High risk women who are pregnant without prior counselling should be
referred for expert assessment as soon as possible
 Women with a previous non-oestrogen related VTE provoked by a minor risk
factor should undergo testing for thrombophilia as this will influence antenatal
thromboprophylaxis
 Women with a previous single provoked VTE (excluding oestrogen-related)
and no other risk factors should undergo close surveillance and antenatal
LMWH is not routinely recommended
 Risk assessment should be repeated if women are admitted to hospital or
develop additional problems
 Antenatal thromboprophylaxis should begin as early in pregnancy as possible

ANTENATAL LMWH THROMBOPROPHYLAXIs

Antenatal LMWH thromboprophylaxis is recommended in the following:

a) Women with a history of recurrent VTE

b) Women with a history of unprovoked VTE
c) Women with a history of oestrogen-related VTE
d) Women with a history of pregnancy-related VTE
e) Women with a previous VTE and a history of VTE in a first degree relative
f) Women with a previous VTE and a documented thrombophilia
g) Women with three or more risk factors (other than previous VTE or thrombophilia)

 Women receiving antenatal LMWH thromboprophylaxis should be treated for

6 weeks post-partum with a post-partum risk assessment
 Women with 2 or more risk factors (other than previous VTE or thrombophilia)
should be considered for post-partum prophylactic LMWH for at least 7 days
 Ensure anaesthetic review and discuss implications of LMWH therapy for
labour analgesia and CS

MANAGEMENT OF WOMAN AT HIGH RISK OF VT

Previous VTE: Recurrence risk 10.9% during pregnancy and 3.7% outside
pregnancy

a) Recurrent VTE – high risk of recurrence during pregnancy and women are likely to
be on warfarin pre-pregnancy. Stop warfarin as soon as pregnancy confirmed (within
2 weeks of missed period) and convert to LMWH. If not on warfarin, start LMWH as
soon as pregnancy test is positive. Women should be managed by a clinician with
expertise in haemostasis and pregnancy

 b) Single unprovoked VTE – higher risk of recurrence compared to women with a

provoked VTE

 c) Single oestrogen-provoked VTE  (pregnancy, COCP) – higher risk of recurrence

in pregnancy compared to women with a non-oestrogen provoked VTE

 d) Previous VTE plus inherited thrombophilia – inherited thrombophilia thought to be

a weak risk factor for recurrent VTE in pregnancy, with a relative risk of 1.9 (0.5 –
6.6). Women with antithrombin deficiency are at higher risk and higher doses of
LMWH may be required. A therapeutic or intermediate dose should be used and
continued for at least 6 weeks or until converted to warfarin. Management should be
with haematologist

 e) Previous VTE plus acquired thrombophilia – increased risk of recurrence in

pregnancy. Manage with antenatal LMWH plus post-partum prophylaxis for at least 6
weeks. Women on warfarin should be converted to LMWH before 6 weeks gestation
and continued in the post-natal period until converted to warfarin. Women not on
warfarin should start LMWH as soon as pregnancy is diagnosed. Single previous
VTE – use high (12 hourly) prophylactic dose. Women with recurrent VTE may
require a therapeutic dose. Low dose aspirin is also recommended in women with
anti-phospholipid syndrome.

 f) Previous VTE associated with temporary risk factor – recurrent risk is low if DVT
was associated with a transient major risk factor that is no longer present (surgery,
trauma, intravenous drug abuse). In the absence of other risk factors, antenatal
LMWH not recommended. Post-natal prophylaxis recommended for 6 weeks.

Women with a previous VTE can therefore be classified into three groups:

1) Very high risk – recurrent VTE associated with antithrombin deficiency or the
anti-phospholipid antibody syndrome. Usually on warfarin pre-pregnancy. Require
high prophylactic dose (12 hourly) or weight adjusted (75% therapeutic dose)
antenatally and for 6 weeks post-partum / until converted to warfarin. Manage with
haematologist

 2) High risk – previous unprovoked or idiopathic VTE, oestrogen-related VTE,

family history of VTE in first degree relative, thrombophilia or other risk factors.
Require antenatal LMWH prophylaxis and for 6 weeks post-partum

 3) Intermediate risk – VTE provoked by a transient major risk factor that is no

longer present and no other risk factors present. No antenatal treatment. Close
surveillance to identify risk factors. Post-partum LMWH for 6 weeks.

INHERITED THROMBOPHILIA BUT NO PREVIOUS VTE

 Identified through screening - risk varies depending on defect - antithrombin

deficiency carries 30% risk of VTE in pregnancy. Homozygotes for Factor V
Leiden mutation have a relative risk of 41.3. Heterozygotes for Factor V
Leiden carry a lower risk (relative risk 9.2)
 Stratify according to risk, taking account of nature of defect and family history
including number of family members affected, age at which VTE developed
and presence of additional risk factors in family members
 Antenatal and post-partum thromboprophylaxis recommended for women with
antithrombin deficiency, those who are homozygous for defects, those with
multiple defects and those with additional risk factors
 Otherwise close antenatal surveillance to detect any new risk factors and
post-partum prophylaxis for at least 7 days is recommended
 If LMWH is used in the antenatal period, it should be continued for 6 weeks
post-partum
 No evidence that homozygosity for a thermolabile variant of the gene for
methylene tetrahydrofolate reductase is associated with VTE in pregnancy

ACQUIRED THROMBOPHILIA AND NO PREVIOUS VTE

  Anti-phospholipid syndrome (APS): the presence of lupus anticoagulant or
anticardiolipin antibodies of medium - high titre on 2 occasions 8 weeks apart
in association with a history of thrombosis or adverse pregnancy outcome
(recurrent first trimester miscarriage, fetal death after 10 weeks or preterm
delivery <35 weeks due to severe PET or IUGR
 Risk of VTE in women with APS is >70%.
 Pregnant women with APS and previous thrombosis - antenatal prophylaxis +
post-natal thromboprophylaxis for 6 weeks or until converted back to warfarin
 Women on warfarin should be converted to heparin before 6 weeks and those
not on warfarin should start LMWH as soon as possible after pregnancy is
diagnosed.
 Women with antiphospholipid antibodies but no thrombosis or adverse
pregnancy event – antenatal prophylaxis not required and close surveillance
to detect new risk factors is recommended. Post-partum LMWH
recommended for 7 days

WOMEN WITHOUT VTE OR THROMBOPHILIA

 Three or more risk factors (excluding thrombophilia or previous VTE as

above) - consider antenatal prophylaxis
 Two risk factors - consider antenatal prophylaxis if admitted to hospital
 Ensure mobilisation and avoid dehydration

INTRA-PARTUM THROMBOPROPHYLAXIS

 Women should be advised not to inject further doses of heparin if they think
they are in labour or have vaginal bleeding
 Pro-thrombotic changes of pregnancy are maximal just after delivery
 Reduce therapeutic dose to prophylactic dose on the day before IOL or C/S
and continue prophylactic dose during labour
 Discuss analgesia with senior anaesthetist and discuss implications with the
woman
 Regional techniques should not be used until 12h after prophylactic or 24h
after therapeutic dose of LMW heparin. Catheter should not be removed
within 10-12h of the most recent injection
 Delivery by C/S - prophylactic dose LMW heparin day before surgery, omit
morning dose on day of surgery and administer prophylactic dose by 3 hours
post-op or 4h after insertion or removal of catheter
 Use unfractionated heparin if risk of haemorrhage - shorter half life and
experience with use of protamine sulphate

POST-PARTUM THROMBOPROPHYLAXIS

 Thromboprophylaxis should continue for at least 6 weeks in high risk women

and 7 days for intermediate risk women
 Women with 2 or more risk factors should receive prophylactic LMWH for 7
days. If there are persisting risk factors or three or more risk factors, the
duration of LMWH prophylaxis may be extended beyond 7 days and may be
used for up to 6 weeks or until additional risk factors are no longer present
 Women with BMI > 40 should receive LMWH for 7 days even if there are no
additional risk factors
 Additional post-partum risk factors include prolonged labour, immobility,
infection, haemorrhage, blood transfusion
 All women should receive LMWH for 7 days after emergency CS
  All women who have an elective CS plus one or more additional risk factors
should receive LMWH for 7 days
 Administer dose as soon as possible after delivery if there is no PPH; 4 hours
after insertion or removal of epidural catheter. First dose can be given after
insertion but before removal.
 COCP should not be prescribed in the first 3 months for women with other
risk factors for VTE

LMWH

 Drug of choice for antenatal prophylaxis - as effective as, and safer than
unfractionated heparin. Lower risk of thrombocytopaenia and osteoporosis
 Monitoring with anti-Xa levels not required provided renal function is normal.
Lower dose of enoxaparin and deltaparin should be used if renal impairment
(creatinine clearance < 30ml / min). Tinzaparin dose should be reduced if
creatinine clearance is < 20ml / min
  However, monitoring is required in antithrombin deficiency. Check platelet
count 1 week after starting treatment

GRADUATED ELASTIC COMPRESSION STOCKINGS

Should be used by:

1) All women with a previous VTE or a thrombophilia - throughout pregnancy and for
6-12 weeks after delivery

2) Hospitalised women in whom LMWH is contraindicated

3) Post-CS
4) Long distance travel > 4h

Contraindications to LMWH

 Active bleeding
 Women at increased risk of major haemorrhage (placenta previa)
 Bleeding disorder
 Low platelet count (< 75 x 10 9
 Stroke in the previous 4 weeks
 Severe renal impairment
 Severe liver disease
 Uncontrolled hypertension (systolic BP > 200 mmHg or diastolic > 120
mmHg).

Ppppppppppppppppppppppppppppppppppppppppppppppppppppppp

A 30 year old pregnant woman seeks your advice regarding the risk
and prevention of venous thrombo-embolism during air travel. How
would you advise her?

RISK

• Long distance air travel is associated with 2-3 fold increase in risk of VTE thought
to be related to immobility, low oxygen tension, low cabin pressure and dehydration
secondary to excessive consumption of coffee and alcohol.

• Risk of symptomatic DVT ~ 1:10,000, though robust data do not exist. Risk of
asymptomatic DVT likely to be higher.

• Pregnancy associated with increased risk of VTE from first trimester. No data on
travel related risk of VTE in pregnancy.

• Risk likely to be greater in women with previous VTE and thrombophilia as well as
other risk factors such as obesity and severe varicose veins, multiple pregnancy,
medical disorders associated with increased risk of VTE.

PREVENTION

• General measures such as isometric calf exercises, preventing dehydration by

drinking water / soft drinks and avoiding alcohol and coffee

• Compression stockings - evidence from pilot study shows reduction in risk of DVT
in travellers over the age of 50 during long-haul flights (>17h duration). Therefore
advise well fitting below-knee compression stockings for long-haul flights (>4 hours)
or for any flight if additional risk factors

• Pharmacological thrombo-prophylaxis - heparin or aspirin. Efficacy of aspirin in

preventing VTE inferior to low molecular weight heparin and heparin does not cross
placenta. However, self-administration of heparin not practicable in most women
and therefore aspirin remains an alternative (75mg per day for three days before
travel and on day of journey)

• No available evidence from pregnant women to base advice

• Prophylaxis required at all gestations up to 6 weeks post-partum

Advice on preventing deep vein thrombosis for pregnant women travelling by air
RCOG Scientific Advisory Committee Opinion Paper 1. RCOG

HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH

A 30 year old pregnant woman seeks your advice

regarding the risk and prevention of venous
Show Answer 2010-11-02 46 views
thrombo-embolism during air travel. How would
you advise her?

A 20 year old primigravida is found to have a

haemoglobin concentration of 8g/dl at 14 weeks Show Answer 2010-11-02 44 views
gestation. Justify your management.

A 25 year old woman seeks your advice regarding

mode of delivery 36 weeks into her second
pregnancy. Her first baby was delivered by Show Answer 2010-11-02 39 views
Neville Barnes forceps and she suffered a third
degree tear. How would

A 34 year old woman at 36 weeks gestation in her

first pregnancy requests delivery by caesarean
section at 39 weeks gestation for personal Show Answer 2010-11-02 30 views
reasons. How would you counsel her given that
her pregnancy is

Critically appraise the impact of antenatal care in

Show Answer 2010-11-02 32 views
reducing perinatal mortality and morbidity.
A 42 years old woman is referred for antenatal
care at 15 weeks into her 7th pregnancy. Justify
Show Answer 2010-11-02 30 views
your antenatal, intra-partum and post-partum
care.

A 35 year old woman is referred for hospital

antenatal care at 24 weeks in her second
pregnancy. Her first pregnancy and delivery were Show Answer 2010-11-02 32 views
uncomplicated but the baby weighed 4700g.
Justify your management.

A 24 year old woman is referred to you by her

community midwife because the fetus is large- Show Answer 2010-11-02 27 views
for-dates. Justify your initial assessment.

A 30 year old primigravida has been found to

have a fetus with a breech presentation at 37
Show Answer 2010-11-02 33 views
weeks gestation. How would you advise her with
regards to mode of delivery?

A 30 year old lady seeks your advice 20 weeks

into her second pregnancy. Her first baby was
Show Answer 2010-11-02 29 views
delivered by caesarean section. How would you
advise her regarding mode of delivery?

Debate the need for antenatal beds in an

Show Answer 2010-11-02 32 views
obstetric unit.

Debate the need for obstetric day assessment

Show Answer 2010-11-02 32 views
units.

A 20 year old woman attends the antenatal clinic

7 days after her due date. Her pregnancy has
been uncomplicated. Justify your advice to her Show Answer 2010-11-02 31 views
regarding the timing and method of induction of
labour.

A 30 year old woman with three previous vaginal

deliveries complains of severe simphysis pubis
Show Answer 2010-11-02 29 views
pain at 38 weeks gestation. Critically appraise her
management options.

A 30 year old woman is referred for antenatal

care at 10 weeks gestation. She weighs 120kg
with a body mass index of 38 but has no other Show Answer 2010-11-02 32 views
risk factors. Justify your antenatal and intra-
partum care with

A 30 year old woman with a renal transplant is

planning a pregnancy. How would you counsel Show Answer 2010-11-02 22 views
her?

Critically appraise the impact of maternal

nutrition and nutritional supplementation on Show Answer 2010-11-02 29 views
pregnancy outcome

A 34 year old primigravida is referred to the

antenatal clinic at 8 weeks gestation. She has a
BMI of 40 but is otherwise well. (a) What will you Show Answer 2010-11-02 33 views
tell her about the antenatal risks associated with
obesity?

Perinatal mortality from Rhesus iso-immunisation

is increasingly uncommon. (a) Evaluate the
factors that have resulted in this fall in perinatal Show Answer 2010-11-02 31 views
mortality. [9 marks].(b) Evaluate the factors
contribute