Women’s health in pregnancy and post-partumMichelle Wise BSc MD FRCSC MSc

Senior Lecturer, Department of Obstetrics & Gynaecology, U of AConsultant Obstetrician & Gynaecologist, National Women’s Health, ADHB

Outline

• Iodine supplements in pregnancy• Nausea and vomiting of pregnancy• First trimester screening• Gestational weight gain• Planning a VBAC• Postnatal contraception

Iodine supplement

• Essential for normal brain development• Moderate iodine deficiency and goitre found in

12/170 pregnant women nationwide (Pettigrew et al. 2006)

• Iodine levels of breast-fed infants < half that of formula-fed infants (Skeaff 2005)

• Choose iodised table salt at home

Nausea and vomiting of pregnancy

• Don’t forget vitamin B6 (pyridoxine)

First Trimester Screening (FTS)

• Offered routinely to all pregnant women regardless of age

• Combines: – Maternal age– Nuchal translucency at 11 - 13+6 weeks– PAPP-A and free βhCG at 9 – 13+6 weeks

Maternal Serum Screening, by age

Ontario Women’s Health Equity Report 2010

FTS

• 85-90% of Down syndrome pregnancies are detected using FTS, compared to:– 50% with age alone– 75% with MSS

• 5% of screening results will be “↑ risk”– To be followed by discussion of options for diagnostic

testing and clinical management

• 98% of “↑ risk” babies will be unaffected

RANZCOG “A Decision Aid: Testing in pregnancy for fetal abnormalities”

FTS

• If twins, need to know chorionicity to correct MoM values of blood tests

• Additional factors that modify aneuploidy risk assessment:– Previous pregnancy w T21 or T18– Assisted reproduction– Maternal weight

Obesity in Pregnancy

Obesity in pregnancy– Set goals for gestational weight gain– Early diabetes testing

• add HbA1c and fasting 2h OGTT to booking bloods to exclude T2DM

– Measure weight at each visit– Monitor for maternal and fetal complications

• GDM, HTN, stillbirth, C/S, PPH)– Timely referral

Centre for Maternal and Child Enquiries 2010: Guideline on management of women with obesity in pregnancy

Gestational weight gain

BMI Institute of Medicine 2009 guidelines

Normal 11-16 kg

25-29 7-11 kg

30 or more < 9 kg

Limited or no weight gain in obese women is associated with improved pregnancy

outcomes

Planning a VBAC

• What is the risk of uterine rupture in women having attempt at Vaginal Birth After Caesarean (VBAC)

Risk of uterine rupture with VBAC attempt

• Bujold et al. 2002 – 1,527 women w 1 prev C/S having TOL– Cohort study with chart review

• Bujold et al. 2010– 1,768 women w 1 prev C/S having TOL– Cohort study with chart review

Inter-delivery interval, months

Inter-delivery interval, months

Planning VBAC

• 2o analyses from two large multicentre studies further support ↑ risk for rupture with shorter inter-pregnancy intervals

• Conclusion: important to counsel and provide effective contraception post-caesarean

Lactational Amenorrhea Method (LAM)

• 98% effective during first 6 months if all 3 criteria met:– Menses have not returned– Exclusive breastfeeding– Baby feeding during the night (< 6 hrs)

• When to start COC

LAM Interagency Working Group www.irh.org

Planning VBAC

For more information:

• www.ranzcog.edu.au• www.rcog.org.uk• www.healthed.govt.nz• www.consensus.nih.gov/2010/vbac.htm• www.nationalwomenshealth.adhb.govt.nz• Or contact me m.wise@auckland.ac.nz• Or attend:

– Update in Women’s Health for Primary Care (12 November 2011)

– Postgraduate diploma in Obstetrics and MedicalGynaecology