GP Maternity Share Care Education Alignment Maternity 1

In partnership with Brisbane South Primary Health Network and Mater Mothers’ Hospital Metro South Health and Hospital Service Redland Hospital – Maternity Shared Care (Alignment 1) Saturday 22nd May 2021

Acknowledgments • Metro South Health and Hospital Service • Brisbane South PHN • Maternity Services at Logan/Beaudesert/Redland Hospitals for their clinical input and support • The Alignment team at MMH • The > 1600 GPs who’ve been through the MMH Alignment process and given us their feedback • Dr Wendy Burton • Yourselves Introducing today's team …..

• Facilitator: Dr Kim Nolan , GP - GPLO Maternity Share Care • Kate Tillack, BSPHN Program Officer Child, Youth and Family • BSPHN Education – Susan Cederblad From Redland Hospital Maternity Teams

• Dr Wendy Dutton • Jane Rundle - Clinical Midwife Consultant • Dr Phillipa Sexton • Samantha Shepherd, Clinical • Naomi Scolari, Dietitian Midwife • Ellodie Ruffin, Physiotherapist • Tracey Button, Child Health, Bayside & Jeanelle Gibson – • Erica Holder, Perinatal Well- Child Health Being Service • Andy Walker – Nurse • Melanie Mackenzie, Harrison’s Navigator BIG GAP + Little Wings Dr Chee Tang, VMO Redland Hospital House keeping

• Raise your hand if you want to contribute to the discussion or to ask any questions. • Phones on silent please. Session 1 Time Session name Presenter Delivery

9:00 am Welcome Dr Kim Nolan GP Facilitator

9:15 am Housekeeping, learning objectives. Dr Kim Nolan GP Facilitator

9:20 am The Antenatal Referral – the good, the Dr Kim Nolan GP Facilitator bad & the ugly. The importance of the right information. 9:30 am Maternity services and models of care Samantha Shepherd, Midwifery Presentation – Clinical Midwife Midwifery Teams – ANC & MGP – Redland Hospital 9:45 am Booking investigations, scans and early Dr Kim Nolan GP Facilitator pregnancy clinical assessment Obstetrician

9:55 am Covid and Covid Vaccination in Dr Kim Nolan GP Facilitator Pregnancy and Breastfeeding Obstetrician

10:00 am – Anomaly screening, Dr Glenn Gardener Webinar 10:30 am carrier screening, scans Group Discussion – all Session 2 Time Session Presenter Delivery 10.50 am Case 1 Breakout group. Breakout Facilitated groups

11:05 am Presentations - Groups 1-4 Dr Kim Nolan Facilitated groups 11:05 am Management of routine & abnormal test Dr Kim Nolan Case Discussion – ALL results, CALD patients, anaemia (Case 1) PowerPoint presentation 11:20 am Syphilis in Pregnancy Dr Kim Nolan + Obstetrician Case Discussion – ALL Obesity in Pregnancy (Case 2) PowerPoint presentation 11.35 pm Perinatal Wellbeing Service Erica Holder, Nurse Practitioner PowerPoint presentation +/- Presentation/Video Video 11:45 am Care of the Psychosocially Complex Woman Dr Kim Nolan Case Discussion – ALL in pregnancy/TOP (Case 3) + Midwife PowerPoint presentation

12:10 pm Early Pregnancy Bleeding/PUL/EPAU (Case Dr Kim Nolan + Obstetrician Case Discussion – ALL 4) PowerPoint presentation 12:30 pm BIG GAP Project Presentation Andy Walker – Nurse Navigator PowerPoint presentation Lunch Break BIG GAP + Dr Chee Tang, VMO Redland Hospital Session 3 Time Session Presenter Delivery 1:15 pm Quick Quiz and the next 2 hours Dr Kim Nolan 1:25 pm Physiotherapy Services Ellodie Ruffin PowerPoint presentation 1:35am Cases 1-4 Breakout Facilitated groups

1:50 am Thyroid Disease and Obesity in Dr Kim Nolan + Obstetrician Case Discussion – ALL pregnancy (Case 1) Naomi Scolari – Dietitian PowerPoint presentation Dietitian Presentation 2:10 pm Gestational Diabetes (Case 2) Dr Kim Nolan + Dr Wendy Dutton Case Discussion – ALL PowerPoint presentation; VOPP 2:30 pm Pharmacology in Pregnancy Dr Treasure McGuire, VOPP Pharmacologist 2:40 pm Hypertension and MAC (Case 3) Dr Kim Nolan + Obstetrician Case Discussion – ALL PowerPoint presentation 2:55 pm Safer Baby Bundle and the Dr Kim Nolan + Jane Rundle – Case Discussion – ALL importance of managing DFM and Clinical Midwife PowerPoint presentation suspected IUGR (Case 4) Session 3 - The End Time Session Presenter Delivery method 3:10pm Community Midwifery Service Jane Rundle – Clinical Midwife PowerPoint presentation Consultant

3:20 pm Child Health Services Tracey Button, CNC Child Health PowerPoint presentation Bayside

3.20 –3:30pm Close – Alignment requirements and Dr Kim Nolan certification Questions ? Complete quiz online + Evaluation Online resources • Metro South Health GP Maternity Share Care Clinical Guidelines – in Draft • Clinical Practice Guidelines – Pregnancy Care (Australian Govt) • Queensland Clinical Guidelines - Maternity • Metro South Health Refer Your Patient • Mater Mothers’ Hospital GP Maternity Shared Care Guidelines – 2021 version • RANZCOG education resources • Australian Society of Infectious Diseases – Management of Perinatal Infections • GP Learning (RACGP) • Australasian Diabetes in Pregnancy Society • Brisbane South PHN Maternity Share Care website and resources • Safer Baby Bundle Online education and resources • Syphilis in Pregnancy Clinical Guidelines and resources • Healthy Pregnancy Healthy Baby • Metro South Health Maternity Services website Today's aim

• Educate • Update • Equip • Empower We aim to increase your familiarity with • The new GP Maternity Share Care Clinical Guideline for GP Maternity Share Care (in draft) • Referrals for AN care • The lines of communication for all things maternity • AN and PN services available in Metro South Health • AN screening • Managing common Antenatal presentations and complications • Online resources and learning opportunities that are relevant to our community cohort • Maternity Models of Care How are we going to achieve this?

• By utilising the existing skill base within General Practice and the Maternity Team • Highlighting the existing resources at Queensland Health, Mater Mothers’ Hospital and Brisbane South PHN • Improving communication channels between primary, secondary and tertiary level care • Managing expectations!

And ultimately….. Improve the health outcomes for women, their babies and their children Pregnancy Care Guidelines 2019

https://www.health.gov.au/resources/public ations/pregnancy-care-guidelines Queensland Health Guidelines

Please read the 4 pages of actual information within this 11-page document and incorporate the principals (play nice and communicate well) into your everyday practice https://www.health.qld.gov.au/__data/ assets/pdf_file/0018/143505/g- sharedcare.pdf Queensland Health Clinical Guidelines

QHealth Maternity Guidelines has evidence-based guidelines, consumer and education resources https://www.health.qld.gov.au/qcg Brisbane South PHN https://bsphn.org.au/support/ for-your-practice/ MSHHS Maternity Services page

https://metrosouth.health.qld.gov.au/maternity-services MSHHS Maternity Services page

https://metrosouth.health.qld.gov.au/maternity- services/pregnancy/public-hospital-care-options Choices in Maternity models of care Page 2 Choices in Maternity Models of care The first appointment. Women's choices in pregnancy Helen is a 27-year-old healthy G1P0 who presents for advice with a LNMP 5 weeks ago and three positive home pregnancy tests! She has private health insurance, but thinks it is only singles cover. She has done some online research, checked out the blogs and is a bit confused. Some mothers prefer a private obstetrician (should she simply self-insure if she’s not covered and how much will that cost?) others swear by midwifery care (but she’s read she needs to ask for the continuity of care model, can she be sure she’ll get it and what does it mean?) and she found you on the site for Aligned GPs – you are nice and close to where she lives and what is the difference between GP, midwife and obstetrician care anyway?

You have 15 minutes, what do you tell her? What resources can you recommend? The antenatal referral • The quality and completeness of the antenatal referral is an important component to the start of the women’s pregnancy care journey. • The content of the referral assists our maternity team partners with the information required to triage the referral in a timely manner, and dependent upon a woman’s individual personal and clinical needs, allocate a woman to the right maternity model of care. • Referrals are required to include blood reports and scan reports as per recommended best practice for booking pregnancy care (Queensland Health 2016). • All women should be referred to the local hospital. When should you send the referral to the Central Referral Hub? The antenatal referral journey • Your referrals (about 600/month) for antenatal care come into the Central Referral Hub (CRH). Hub sits within the Primary Care Partnership Unit , Metro South Health.

• Once they reach the “inbox”, the referral goes straight to the requested Maternity Services (Redland, Logan, Beaudesert)

• In AN clinic, the admin officer checks the referral for bloods and scans , and then logs for triage by the Obstetrician or midwife.

• The women then receives an appointment for a booking appointment with a midwife. Audit 1. Results. 75 referrals

Type of data per referral

ethn 35 phone 94 address 100 Pt named ref 98 dob 99 MOC 43 hops 87 scan 82 b bloods 91 meds 75 psychos 41

Named Named data screen 60 obst 70 med 67 g+p 82 gest 76 edd 74 lmp 44 named ref Dr 75 0 20 40 60 80 100 120 % data per referral What does the data say…. 30 referrals audited Refer Your Patient, standard and essential referral criteria unique page view – a comparison Refer Your Patient - standard and essential referral criteria https://metrosouth.health.qld.gov.au/referrals/antenata l Routine blood tests, tests and scans Booking investigations:

These are part of the essential referral information for ALL Antenatal referrals https://metrosouth.health.qld.gov.au/referrals /antenatal/all-antenatal-conditions Dating Scans …yes or no? Pregnancy Care Guidelines recommends GPs should provide information and offer pregnant women who are unsure of their conception date an ultrasound scan between 8 weeks 0 days & 13 weeks 6 days to determine gestational age, detect multiple pregnancies and accurately time fetal anomaly screening (Grade B evidence).

• Always if unsure of LMP • Women planning to undergo NIPT testing • Irregular Menstrual Cycle • Women with pre-existing hypertension, • Abdominal pain or bleeding in early diabetes or other medical condition that pregnancy may influence pregnancy risks (including high BMI) • Conception within 3/12 of a miscarriage • Conception while breastfeeding or within • Women with previous GDM /high GDM 3/12 of breastfeeding cessation risk • Conception while taking OCP or within • Previous ectopic pregnancy 3/12 of cessation • Conception as a result of assisted • Conception within 9/12 of Depo-Provera reproduction injection • Woman’s choice Please cc ANC on all pathology and radiology

Practice Point: If you order pathology electronically i.e. not handwritten request, and CC ANC in on that form, results will be uploaded to patient’s my HR record and can then be accessed at hospital via their “Viewer”. Not yet available for Radiology reports. Management of abnormal test results • When you order a test or scan, you are responsible for sending a copy to the hospital AN clinic regardless of the result • The clinician who orders the test is responsible for follow up and prompt referral when appropriate • What to do with what you have found can be guided by the MSH GP Maternity Shared Care Guideline (in draft) or phone the GPLO Maternity Midwife/GP or Obstetrician/Registrar on call • An abnormal result may prompt you to contact the booking hospital to discuss further management or arrange review • Document your actions in the Pregnancy Health Record (or print the visit note from your software Obstetric tab) Where are you recording your antenatal visits?

Use the obstetric tabs in your software! • easy to enter data • print a copy for PHR • ready for "Smart maternity referrals" - COMING! GPSR is coming , but at this time Please use “Refer Your Patient - Antenatal and Maternity” to • Keep up to date with changes to clinical guidelines e.g. COVID 19, Obesity and Pregnancy (including post bariatric surgery) and GDM screening. • Know about Maternity Services in Metro South Health • Access downloadable referral templates – with in-built prompts to assist you providing the right information • Assists MSH Maternity Teams with triage of referrals into the right Maternity Models of care • Of particular importance is ethnicity and language spoken, and choice of model of care. Tips to referring in a timely manner • Identify medical and social • Women with chronic medical risks and any other indications, conditions should be referred for to optimise planning for safe AN care as soon as possible and appropriate care after the pregnancy is diagnosed • Ongoing referrals can then be • Allows time for the maternity made for specialist care if team to liaise with other required specialists if required. • Make any important • PRE-PREGNANCY Assessment information easy to find in the Clinic available if these referral women present preconception. • Include BMI in referral please Tips for referrals • Remember to attach all scan • Complete all sections reports & all blood results of the template (and cc in when make • All referrals are to come via request). the Central Referral Hub • Electronic requests will • Please indicate what ensure pathology is maternity model of care uploaded to my HR the woman would like • Indicate if you are an “aligned GP” and the women’s choice of model is GP Maternity Share Care Where to find Referral Templates? https://metrosouth.health.qld.gov.au/referrals/antenatal https://bsphn.org.au/support/for-your-practice/forms- and-referrals/ Referral Example For women who are over 40 years of age

Aim to have an early obstetric appointment. Preferably before 14 weeks. Send the referral BEFORE the FTCS/NT Women age 40 and over will see the Obstetrician at 36 weeks to discuss and plan IOL at 39 weeks Women identified as suitable for MGP can be directed to these services early if the appropriate information is in the referral. Most women will be seen initially for a booking in visit with a hospital midwife, before Obstetrician review at about 20 weeks, and the MOC confirmed.​

GPs should then receive correspondence confirming the woman's model of care​ Pregnancy Management Plan (Logan Hospital -completed by the Obstetrician)

Referrals beyond the local maternity hospitals e.g. patients with complex medical issues/ specialist care at other hospitals e.g. at MNH/RBWH, or to MMH may be accepted out of catchment, but usually only after discussion with or on the recommendation of the local Obstetrician. Pre-pregnancy Assessment Clinic (Logan Hospital) ➢ Women with high medical or obstetric risk can now be referred to a Preconception Clinic at Logan Hospital when planning a pregnancy – Tuesday PM (Ambulatory Building 2). ➢ Purpose of this clinic is to provide comprehensive assessment, counselling and optimisation of conditions prior to future pregnancies. ➢ Patients may be referred from 6-8/52 post a pregnancy to discuss planning for a subsequent pregnancy. ➢ The clinic is not intended for examinations or procedures.

Patients with the following conditions meet the criteria for referral to the Clinic. The conditions may be pre- existing or new onset during a recent pregnancy: ➢ Poorly controlled GDM patients on Metformin (>2.5grams/day) - internal referral. ➢ Type 1 or 2 Diabetes ➢ Thyroid conditions and other endocrine disorders ➢ Haematological/Respiratory/Cardiology/Renal/Hepatic and Gastrointestinal/Connective tissue/Neurological Disorders ➢ Infectious diseases ➢ Genetic conditions ➢ Previous poor Obstetric outcomes Please ensure that appropriate investigations are completed prior to review in the clinic. For example, if the patient has a renal condition it is expected that FBC, E/LFT's, Urine M/C/S and Cytology +/- renal ultrasound would have been organised and results ready to be discussed at the review appointment. Maternity Models of Care at Redland Hospital Presented by Samantha Shepherd, Clinical Midwife Maternity Models of Care at Redland Hospital

Model: Philosophy: Criteria to participate:

Live on the Bay Islands Continuity of Care to all risk women (not Twins). 18 years and under within RH Providing antenatal, intrapartum and post geographical boundaries Midwifery Group Practice partum care up to 6 weeks- (care provided in Live within RH geographical boundaries the community or at the woman’s home) and would benefit from continuity of care model: ie previous poor outcome Continuity of Care to all risk women (except twins). Providing antenatal, intrapartum and post Aboriginal and Torres Strait Islander BIOC midwifery Group family Practice partum care up to 6 weeks- (care provided in the community or at the woman’s home.) Wrap around service for indigenous families in partnership with YBB and IUIH Maternity Models of Care at Redland Hospital

Model: Philosophy: Criteria to participate: Continuity of care to low risk women planning for normal and active birthing Live in RH geographical boundary Midwifery Care Care provided at Redland and Wynnum Plan active birth ANC Provide close supervision and support for women with complex pregnancy. High Risk Obstetric – Care provided at Redland and Wynnum Live in MSHHS led Clinics ANC

Low risk women, live in or Continuity of care to low risk women by GP share care outside RH geographical boundary. their GP Other Midwifery Services at Redland Hospital

Service: Purpose: How to contact:

Antenatal Classes (Saturday only) Preparation and information for Antenatal Clinic Reception labour, birth, breastfeeding and early Phone 3488 3434 Antenatal facility tours (Sunday) parenting Tours 3488 4075 Support women antenatally and postnatally with preparation for and Lactation Consultant Lactation Service establishment of breastfeeding Ph 3488 3409 (inpatient/outpatient service) Provide care to women in community for 3 to 5 days following birth for continuation of care from postnatal Phone number 3488 3444/ Postnatal Midwifery Home Visiting ward. 3488 3759 Service Home visit to women in geographical boundary. Phone call to women outside geographical boundary. Other Services Service: How to contact:

Antenatal Clinic Reception Women & Birthing Social Work Service

Maternity Assessment Unit- Mon – Fri 0930 – 1800hrs Phone Midwife direct Outside of these hours contact Birth suite 3488 4169/ 3488 4075

Healthy Hearing- Universal screening for all babies, Phone: 3488 3444 inpatient and outpatient service

[email protected] Perinatal Mental Wellbeing Service Phone: 3825 6214 Midwifery Models of Care- Redland Hospital • Midwives, Obstetricians and GPs work together to provide shared antenatal care and education for women preparing to birth at Redland • The current Models of Care available at Redland are – Consultant-led care (Women with complex needs) – Shared care with O&G and Midwives (Low – Medium complexity) – Shared care with O&G and GPs (Low – Medium complexity) • Midwives work regular clinic days so they can build a rapport and provide some continuity for women. • A Consultant is available to liaise with if necessary, as a Consultant led clinic is run alongside the Midwives' clinic • Midwives also see some of the women under consultant-led care for midwifery input with regards to education, birth planning etc Current Redland Midwifery Care Information • Antenatal Midwife Clinics are held Monday to Friday- Monday, Tuesday, Thursday and Friday at Cleveland. Wednesday at Gundu Pa, Wynnum. • Midwife review appointments are also available to women on Tuesday evenings. • Appointment availability is 08.00 – 16.00 for daytime clinics, and 17:00 – 21.00 for the evening clinics • Contact Antenatal Clinic on 3488 3434 to change appointment times during office hours. • Any other queries can be directed either to the Team Leader on 3488 3065, or the MUM on 3488 3451. • SMS reminders are sent out to women 10 days and 2 days prior to their appointments to remind them of date and time. Antenatal education classes -Redland

Antenatal Group At the moment we have not recommenced Antenatal classes, but hope to do so in the near future.

These 4 hour group sessions will be held on both Saturday morning and afternoon, they are quite informal and interactive, but get fully booked quite quickly. Booking is essential, and should be in the 3rd trimester.

We encourage our clients to bring one support person with them to the group. What maternity models of care are available and where? Questions? https://metrosouth.health.q ld.gov.au/loganexpansion/ maternity Midwife Navigator Services- Logan Midwife Navigator service is available at Logan Hospital to support women diagnosed with GDM and for vulnerable women with complex needs . The Midwife Navigators assist women in engaging with services and navigating the health system for any extra care required.

The aim of the roles are to:

• Increase access to continuity of care and to work in partnership with the woman, her lead care provider (including GP), specialist and allied health professionals involved with the woman and her care.

• Improve perinatal outcomes for vulnerable women and their families. Midwife Navigator Services- Eligibility Criteria • Gestational Diabetes Mellitus:- GDM and another complexity i.e. poor engagement • Complex Care:- ➢ substance misuse ➢ significant mental health issues ➢ child safety ➢ homelessness ➢ significant DFV Midwife Navigator team at Logan Hospital • Midwife Navigator for Complex Care is Nicky Taylor- Edwards Email [email protected] Mob. 0436 850 016

• Midwife Navigator: GDM is Amanda Wolski. Email [email protected] Mob. 0436 850 028 You will meet both midwives later !

Beaudesert Hospital Maternity Care Lower complexity clients • May be cared for by any model with antenatal & postnatal care conducted locally, and birthing at Beaudesert Hospital​ • Flexible clinical pathway to accommodate clinical needs • MGP for local women only (all risk model) - 50% of women birthing at Beaudesert in 2019/2020 were cared for by MGP​ • Antenatal care can be provided to all women by hospital RGO’s/Midwives or in the GP Shared Care arrangement • Medical care is provided by Rural Generalist Obstetricians (RGO) or shared with GPs​ • An Obstetric Consultant from Logan Hospital performs case reviews if requested by the RGO Beaudesert Hospital Maternity Care Higher complexity clients • If complexity increases, the women may be referred to a higher-level hospital for birthing according to criteria, with antenatal care shared with BDH if appropriate • MGP women are cared for by their midwife at both BDH and LGH for antenatal and birthing along with postnatal home visiting • Postnatally, mother and baby may be transferred back to BDH if medically fit and postnatal home visiting will be carried out by BDH midwives • If women are referred to a hospital other than Logan, the BDH midwife will not be involved in care, but the women can be transferred back to BDH postnatally and MAY qualify for postnatal home visiting COVID 19 and pregnancy • Current evidence that pregnant women are not more at risk of severe COVID disease than other women of the same age BUT • approximately 3 x risk ICU admission • approximately 3 x risk of needing invasive ventilation • 1.3 x risk of preterm birth (<37/40) ? in part – iatrogenic • X 3 risk of NICU admission • No evidence that COVID +ve will affect the baby or cause miscarriage • To-date, insufficient evidence of mother-to-child transmission (https://www.birmingham.ac.uk/research/who-collaborating-centre/pregcov/about/mother-to-child- transmission.aspx– 7/10/2020) • International reports suggest women in the 3rd trimester, women for Black, Asian and minority ethnic groups , those over 35 and those with pre-existing medical issues (BMI > 30, Pre-existing hypertension, Pre-existing diabetes (type 1 or 2)) may be at more risk of becoming unwell and requiring hospital admission • No evidence that CS or IOL are required for COVID +ve women • Breastfeeding post birth encouraged as risk of transmission does not outweigh benefits. Additional hygiene measures recommended - handwashing before and after touching baby, pumps, bottles; wearing mask while feeding; follow sterilization recommendations for bottles and pumps. https://www.health.gov.au/resources/publications/covid-19-vaccination-covid-19-vaccination-decision-guide-for- women-who-are-pregnant-breastfeeding-or-planning-pregnancy https://www.birmingham.ac.uk/research/who- https://www.birmingham.ac.uk/research/who- collaborating-centre/pregcov/about/mother- collaborating-centre/pregcov/about/mother-to-child- outcomes.aspx (Version 5 Nov 2020) transmission.aspx (Version 4: Nov 2020) What do we know about COVID-19 vaccines in pregnancy? • No clinical trials yet on COVID-19 vaccines in pregnant women - planned or underway, but ? many months before results known. • In Comirnaty trial, 23 women became pregnant during trial, with 11 women received Comirnaty. As of 14 November 2020, their pregnancies are ongoing, and their pregnancies are being closely monitored. • More safety information to come in pregnant women who have chosen to have COVID-19 vaccine in countries, like the USA or UK. • No available information yet on other mRNA vaccines in pregnant women

Possible benefits of COVID-19 vaccination during pregnancy • Likely protection against Covid-19 and serious complications, with significantly reduced risk of severe illness/hospitalisation

May be less effective in pregnant women and may not protect their babies from COVID-19 • Could be less effective than in non-pregnant women, however not seen this with other vaccines used in pregnant women. Other vaccines routinely given during pregnancy (such as flu or whooping cough vaccine) are equally effective in pregnant women compared to non-pregnant women. • It is unknown if receiving Comirnaty during pregnancy will provide protection for the baby against COVID-19, because this has not been studied. https://www.health.gov.au/resources/publications/covid-19-vaccination-covid-19-vaccination- decision-guide-for-women-who-are-pregnant-breastfeeding-or-planning-pregnancy https://www.health.gov.au/sites/default/files/documents/2021/02/covid -19-vaccination-covid-19-vaccination-decision-guide-for-women-who- are-pregnant-breastfeeding-or-planning-pregnancy.pdf COVID Vaccination for Pregnant and Breastfeeding Women - RANZCOG

Watch the recording RANZCOG's COVID Vaccination for Pregnant and Breastfeeding Women webinar. What can we do.....inform and educate! • Advise re social distancing; avoid those with respiratory symptoms • Hand hygiene /Don’t touch hands and mouth • Early reporting of symptoms and investigation • Stay home if sick • Prompt access to care • Referral by phone for review by obstetric team of the booking hospital. Additional surveillance may be required for women with COVID • Routine Influenza and Pertussis vaccinations should still be given • Routine antenatal care should continue with some modifications, and consider extra fetal growth and wellbeing scans (especially if less F2F Consultations) • Limit support person to 1 • Resource: Maternity care for mothers and babies during the COVID-19 pandemic – Queensland Clinical Guideline QHealth Covid resources

Maternity care for mothers and babies during the COVID-19 pandemic Qld Clinical Guideline Resources • https://ranzcog.edu.au/statements-guidelines/covid-19-statement/information-for- pregnant-women • https://ranzcog.edu.au/statements-guidelines/covid-19-statement/covid-19- vaccination-information • https://www.health.qld.gov.au/__data/assets/pdf_file/0039/949683/c-covid-preg.pdf • https://www.health.qld.gov.au/__data/assets/pdf_file/0033/947148/g-covid-19.pdf • https://www.health.gov.au/resources/publications/covid-19-vaccination-covid-19- vaccination-decision-guide-for-women-who-are-pregnant-breastfeeding-or-planning- pregnancy • https://www.pregnancybirthbaby.org.au/coronavirus-covid-19-and-pregnancy • https://www.breastfeeding.asn.au/classes • https://www.birmingham.ac.uk/research/who-collaborating-centre/pregcov/index.aspx • https://www.health.qld.gov.au/news-events/news/sars-cov-2-covid-19-queensland- vaccines-rollout-safety-testing-approval-allergies-pregnancy-priority-phases • https://www.qld.gov.au/__data/assets/pdf_file/0024/155049/qld-covax-pt-info.pdf Task 1 - 1st trimester pregnancy Angie is a healthy 24 year old whose LNMP was 6 weeks ago and whose uHCG is positive. This is her first pregnancy; she has no private health insurance and she wants to know what comes next. She has been nauseated and vomited twice this week. She has a 15 min appointment. Outline your approach. PUQE Score – SOMANZ Guidelines

https://www.somanz.org/downloads/NVPGUIDELINEFinal.pdf https://spotonhealth.communityhealthpathways.org/25368.htm Iodine supplementation in pregnancy Iodine. Why is supplementation required? • Increased thyroid function during pregnancy increases iodine requirements. • Supplementation with Iodine of a dose of 150mcg per day is recommended at least one month prior to pregnancy, and during pregnancy. • Caution in women with known thyrotoxicosis, have Grave’s disease or a multinodular goitre

Resource: RANZCOG Clinical Practice guidelines: Pregnancy Care. 2018 Edition, Chapter 11.3.2 p76 Healthy eating and weight gain during pregnancy

What’s in this handout? • Healthy eating for pregnancy – essential nutrients I need and how I get them • A sample meal plan to show you how this all fits together • Managing healthy weight gain in pregnancy • Food safety, including Listeria and safe Eating fish during pregnancy • Managing food related side effects, like constipation, heartburn, and morning sickness • Being active during pregnancy • Breastfeeding

Other Resources: • Healthy eating during your pregnancy – Australian Dietary Guidelines • Pregnancy and exercise – Better Health Channel https://www.health.qld.gov.au/__data/assets/p (Victoria Govt) df_file/0028/154792/antenatal-heatwtgain.pdf STI’s – Chlamydia • http://www.sti.guidelines.org.au/ -Australian STI Management Guidelines • https://www.health.gov.au/resources/pregnancy-care- guidelines/part-g-targeted-maternal-health- tests/chlamydia (Pregnancy Care Guidelines) PREGNANCY CHECKLIST Available at: https://bsphn.org.au/wp- content/uploads/2020/07/ Pregnancy-Checklist-June- 2020.pdf Antenatal care Communication is a two way street ….. • Once the woman has been booked at the hospital, she will be seen for a Booking Visit with the ANC midwives (unless diverted directly to the MGP model) – • •At Redland Hospital, usually after 20 weeks, she will have an Obstetric review • •If a woman is considered suitable for GP Shared Care, a letter informing the GP, will be forwarded back to the GP. • In a low risk pregnancy, care remains with GP until around 36 weeks as per the Antenatal Schedule. Logan Hospital Pregnancy Management Plan – EXAMPLE

Name Ms TH Antenatal risk assessment and management UR: 0000000 # Antenatal bloods at 26 weeks: GTT, FBC, Grouping and DOB :17-Sep-1988 Antibody test, Ferritin, Syphilis Serology - GP to organise and Consultant Name : HASTHIKA ELLEPOLA verify results please Sign Date : 01-OCT-2020 15:19 # Antenatal bloods at 36 weeks: FBC, Grouping and Antibody test- GP to organise and verify results please Age: 32 Years EDD: 18/02/21 Delivery management plan G1 P0 # Keen on a vaginal birth Booking at K20 weeks + 0 days Previous births: nil Post-natal BMI: 22 Blood group: A-positive # Education on breastfeeding by the Midwifery team Antibodies: Negative # CST- To be organise by GP 6-12 Weeks postnatal # Education on Mental health USS: EDD 18/02/21 (USS at 9 weeks and 5 days) # High risk for Postnatal depression USS: FTCS, aneuploidy not detected USS: Morphology - pending, Tue 6 Oct 2020- GP to check on results Follow up plan 1. Modified shared care with GP Pre-pregnancy risk assessment and management # Past Medical – migraine , Depression ANC DR - 36, 40 – Schedule by Logan hospital ANC # Past Surgical - Nil CR - 22Weeks Morphology US; 28 Weeks GTT # Medication - Nil GP - 24, 28, 30, 32, 34,38 # Systemic review CVS, RS, ABDOMEN, BREAST , THYROID , SKIN - Normal The initial plan has been discussed and agreed by the patient Practice Under 12 weeks NTS Morphology ($51.80 rebate) ($60.40 rebate) ($86.30 rebate)

City Scan $121 HCC BB viability, dating $220 $181 Exact BB viability, dating scans $180 (available at Sunnybank, Inala, $175 ($210 for multiples, Rebate $127.50) Radiology Chapel Hill, Ipswich Riverlink and Follow up scan post morphology $140 Underwood) (rebate $85) I-MED $116.80 unless too soon for $190.40 for all $216.30 for morphology Radiology dating, will BB follow up scan if & all 3rd TM scans required Qld Xray $171.77 $235 for all $230 for morphology (all) HCC BB viability, dating $190.40 3rd TM scans (BB HCC holders) Qscan $111* $250* $276* for morphology & *BB Meadowbrook 3rd TM scans QDI BB $220.40 not available at all sites (book $196.30* for morphology (prefer 20-22/40) well in advance (prefer 12/40) & 3rd TM scans So + Gi $190 $360 ($575 for NIPT + dating scan, $360 ($90-$120 rebate) (4D) $94 rebate, $870 NIPT + NTS rebate $350 3rd TM scans ($90-$100) $102) Eligibility MEDICARE REQUIREMENTS • Eligibility for Obstetric USS has changed - Medicare Rules for rebates changed (June 2020) recognising that all pregnancies are at risk of fetal anomaly & miscarriage.

• If ordered by a GP, a Medicare rebate is payable for an ultrasound of the pelvis related to pregnancy or a complication thereof, for a gestational age of less than 16 weeks (as determined by ultrasound).

• GPs limited to one pregnancy ultrasound request for services performed from 17 to 22 weeks gestation + one request for scans performed on patients > 22 weeks gestation.

• To attract a Medicare rebate, any additional scans required must be referred by DRANZCOG holders or RANZCOG Fellows/Members (as clinically indicated – Item Number 55721). Morphology scan at 18- 20 weeks gestation- a refresher

Also known as a morphology scan , the scan also looks at placental location and the structural and developmental growth of the fetus. This scan is not a screening test for chromosomal anomalies.

Areas examined during morphology USS Fetal anomaly detection at 18-20 weeks The head Neural tube defect >90% The spine Cardiac anomaly 20%-75% The abdominal wall Cleft lip >75% The heart Trisomy 21 20-50% The stomach Trisomy 13 >90% Kidneys and bladder Trisomy 18 >90% Arms, legs, hands and feet Placental position Umbilical cord examination The amniotic fluid ( AFL) Antenatal testing ​for fetal abnormality

Dr Glenn Gardener​

Director ​ Mater Centre for Maternal Fetal Medicine​ Mater Mothers Hospital​ Ph. 3163 8844 Antenatal testing for fetal abnormality | Dr Glenn Gardener, Maternal Fetal Medicine | Mater Mothers - YouTube Take home messages about Anomaly Screening • Inform and offer screening and diagnostic tests for chromosomal abnormality to ALL pregnant women

• NIPT is the best screening test for Down syndrome but $$

• FTCS offers additional information to NIPT

• Triple test remains a valid option for late presentation

• NIPT, FTCS or triple test are better screening tests for Down syndrome than using maternal age risk alone or 18-20 week morphology scan

• Morphology scan has poor screening performance for Down syndrome but good

for trisomy's 18 and 13. In a nutshell ……

• If ordering NIPT from 10 weeks request FTCS but discard the T21, 18 and 13 result (risk assessment for trisomy's 21,18,13 not required after NIPT)

• Papp-A <0.4 MoM - risk of pre-eclampsia, growth restriction, stillbirth - refer to Mater MFM (they will do fetal growth scan and uterine artery Dopplers at 24 weeks)

• Triple test - needs EDB by dating scan, maternal weight, ethnicity, smoking status, diabetes, parity for improved risk evaluation For high risk FTCS or NIPT result • If after discussion, women wish to have further testing, refer ASAP either to Mater Centre for Maternal Fetal Medicine OR back to hospital providing the results to the booking facility. • Redland/Logan Hospitals currently have no Maternal Fetal Medicine (MFM) Specialist capacity to offer Amniocentesis or CVS, so referral to MMH Maternal Fetal Medicine Centre is likely, but ideally discuss with local Obstetric team also. • Tertiary USS services are expected to be available at Logan Hospital soon. • Phone “On Call” Obstetrician if you wish to obtain further advice and then forward a referral as consultant advises. • Redland Hospital - Obstetrician on Call - Telephone: 3411 3111 or via Switchboard • Logan Hospital – Obstetrician on Call - Telephone: 3089 6963 or via Switchboard • Beaudesert Hospital - GP Obstetrician/Rural Generalist on Call - Telephone: 5541 9174 or via Switchboard • NIPT result takes 2-3 weeks to come back and the earliest diagnostic testing via a CVS can only be done between 11- and 14-weeks gestation. And consider • There is variable understanding within the community of congenital abnormalities and their risks in pregnancy • Much less known about trisomy's 18 (Edward syndrome) and 13 (Patau syndrome) – both life limiting conditions • Cultural and language barriers are evident and should be considered in your approach to communication • Provide verbal and written information… in the right languages • Document the giving of information * • Document offer of test/s * • Document response * * Use Q Health referral templates to facilitate this Resources

Perinatal Testing Information Brochure https://www.downsyndrome.org.au/qld/ - Genetic Health Queensland Resources

Mater Brochures

http://brochures.mater.org.au/brochures/ mater-mothers-hospital/the-mater- centre-for-maternal-fetal-medicine Genetic Carrier Screening

• Screening preconception BEST (gives more options) or in early pregnancy. • Determines carrier status for many genetic conditions including Fragile X syndrome, Spinal Muscular Atrophy (SMA), cystic fibrosis • Autosomal recessive and X- linked conditions – parents are well and often no family history or known ethnicity risk • Society increasingly multicultural • Private funding - 3 gene test – $400; 400+ gene test – $600+ • RANZCOG & RACGP both recommended "should be offered to all women/couples" https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp- guidelines/genomics/reproductive-carrier-screening Centre for Genetics Education: REPRODUCTIVE GENETIC CARRIER SCREENING Fact Sheet for patients https://www.genetics.edu.au/publications-and-resources/facts- sheets/FS65REPRODUCTIVECARRIERSCREENING.pdf "Mackenzie’s Mission" - Australian Reproductive Genetic Carrier Screening Project • Mackenzie diagnosed with SMA at 10/52 & died aged 7/12 • Her parents were not aware of Genetic carrier screening as option - campaign established to raise awareness of genetic conditions & to lobby government to fund GCS for all. • Research study - offering reproductive genetic carrier screening to 10,000 Australian couples planning or in early pregnancy (up to 10 weeks) - approx. 750 genes tested. • Will give couples information about likelihood of having a child with a severely debilitating and/or life-limiting genetic condition occurring in childhood with o Significant impact on lifespan and/or quality of life o Frequent and/or burdensome medical treatment o May be treatable after birth • Couples recruited by selected healthcare providers (GPs, O & Gs, fertility specialists) - demographically & geographically widespread, with 1200 in Qld. https://www.australiangenomics.org.au/our-research/disease-flagships/mackenzies-mission/ Support organisation for families Morning Tea Task 2 – Break out groups

• Yellow – Amina – Vit D/CALD/Low Hb • Blue – Meghan – Syphilis in pregnancy/ high BMI/Perinatal Mental Health concerns • Green – Jade – TOP/Complex Psychosocial/ Substance Use/DFV • Red – Anne - Early Pregnancy Bleeding/Pregnancy of Unknown Location/ EPAU Role of facilitator Each group will have a facilitator • To observe • To assist GPs to stay on task • To assist GPs to tease out the cases

These cases are deliberately short on detail. Focus on the process not the particulars. Consider, as GPs do, the probable outcome but also the possible, more risky ones. Task 2

➢ You need a scribe ➢ You need to identify a presenter ➢ You have 15 minutes

GOOD LUCK! Yellow Group: Task 2 - Amina

• Amina is a 22-year-old who presents with an unplanned pregnancy. • You have known the family for a year. Her home pregnancy test was positive. • Amina and her family are Somalian. Amina wears a Hijab. • Her FBC from last year shows a HB of 104 and a low MCV

She has a 15 min appointment - Outline your approach . Redland LGA demographics

• 27.5% born overseas, and 9.4% speak alanguage other than English at home • 2.3% people in Redland identify as Aboriginal and Torres Strait Islander • Most common countries of birth were England 6.7%, New Zealand 5.4%, South Africa 1.7%, Scotland 0.9% and Philippines 0.5%. (ABS Statistics 2016 Census – LATEST ISSUE Released 23/10/2017)

• Some of Bay Island residents ranked in most disadvantaged Quintiles, but overall Redland City LGA population in higher Quintiles. • Do have unique needs in covering geographically isolated communities of the North Stradbroke Island and islands of the southern Moreton Bay (Russell, Macleay, Lamb and Karragarra Islands) Logan area demographics

• 30% were born overseas, and 21% from a NES background • 50% of population in the most disadvantaged socio- economic quintile (QLD is 20%) • Brisbane south is the area of highest refugee settlement in Queensland. • 2.8% people in Logan identify as Aboriginal and Torres strait Islander • 15% are Maori (Brisbane south is home to > 42 000 people of Pasifika and Māori decent) Amina – discussion Increased risk to women who are born outside of Australia of not accessing antenatal care due to particular social determinants: • education and other social inequalities, • traditional beliefs, • language barriers, • poor knowledge about availability of services , • unemployment and • financial hardship. What services could you use to refer Amina to for pregnancy and postnatal support? Communicating the concept of Antenatal care • Be culturally sensitive - culturally responsive healthcare to meet needs of at-risk populations • Preferably use an onsite interpreter (can take 2/52 to organise) • TIS Ph. 13 14 50 • Talk about the maternity models of care and what that means • Clear communication • Traditional beliefs ? • Check Medicare access – Refugees usually have full access, but don’t assume screening investigations e.g. for infectious diseases have been undertaken • Asylum seekers may have limited health and financial support. Communication

• Offer interpreter services actively • Engage local women early in pregnancy • Despite advanced pregnancy and childbirth care, the rate of stillbirth is high among ethnic groups and migrant populations living in HICs https://journals.plos.org/plosmedicine/article?id=10.1371/j ournal.pmed.1003061 Assessment of Specific Risk Factors: Obstetric History Diseases • Multiple spontaneous or elective • Vitamin D Deficiency (dark-skin, Hijab) abortions • Anaemia: Thalassaemia, sickle-cell • Previous stillbirth • Pelvic infections (previous sexual • Female Genital Cutting (FGM) assault, FGM) • Recurrent UTIs (FGM) • Multigravida • Infectious Diseases: • Short spacing intervals between o Latent TB pregnancies o Hepatitis B &C • Cephalopelvic disproportion (higher o HIV incidence in women from Africa) o Parasites (e.g. Schistosomiasis) • Neonatal death o Rubella Refugee Health • Refugee Health Connect- 3864 7580- one point of call for all aspects of refugee health • Partnership between BSPHN, BNPHN, Mater Health, and Metro South HHS aimed to support primary care in working with people of refugee backgrounds. • Can assist Primary Care navigating the refugee health space & linking people from refugee backgrounds to appropriate providers (to improve health access & engagement) • By providing education & support, builds the skills and capabilities of primary care to manage the care of refugee families in a culturally and clinically appropriate manner • South-East QLD Refugee Health Contact list (2018) – Refugee Health Network

• Australian Refugee Health Practice Guide -a resource to support doctors, nurses and other primary care providers to deliver comprehensive, evidence informed health care for people from refugee backgrounds including people seeking asylum.

• Working with patients when there are language barriers – a guide to accessing and using the Translating and Interpreting Service (TIS) National for primary care health professionals working in private practice (BSPHN) Access Gateway Hub – MGP for Women in Logan Hospital Catchment

https://www.accesscommunity.org.au/ Vitamin D and pregnancy Prevalence of Vitamin D levels <50nmol/L in Australia

• Lower levels seen in the summer by 14% vs winter at 36% (Australia wide) • Relatively low across all states in the winter • Particularly higher in southern states in winter compared to Qld/NT • 26.5% of Aboriginal and Torres strait islanders had levels lower than 50nmol/L, and prevalence was higher in remote areas • Levels lower than 75nmol/L were more common in refugee women Vitamin D: Who and why?

Increased frequency of Vitamin D deficiency is seen in some Australian communities. Women at increased risk of Vitamin D deficiency include • those with reduced sunlight skin exposure e.g. veiled women • those who use sunscreen on a regular basis • dark-skinned women • mothers of infants with rickets • women with a BMI >30. • post bariatric surgery

Demographic predictors are poor for Vitamin D levels Vitamin D - Two schools of thought....

If risk factors are identified, consider testing (and advise supplementation if levels lower than 50 nmol/L)

OR simply supplement all with oral Vitamin D in order to prevent neonatal / infant increased incidence of hypocalcaemic seizures and impaired skeletal development.​

Approved by NHMRC in October 2017 – Pregnancy Care Guidelines – Vitamin D Status RANZCOG statement - Vitamin & Mineral supplementation in pregnancy. November 2019 • Does not recommend Vitamin D testing as routine test in pregnancy regardless of maternal risk • Do not retest regardless of previous result • Advise all women to take minimum 400IU vitamin D daily during pregnancy • Talk about safe sun exposure • Fully breastfed infants should be supplemented with 400IU of vitamin D for first 6 months of life • Supplementation increases a woman's vitamin D levels but the clinical significance of this with respect to pregnancy outcomes is unclear.

RANZCOG Statement: https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Vitamin-and- mineral-supplementation-in-pregnancy-(C-Obs-25).pdf?ext=.pdf Anaemia in pregnancy Global prevalence of sickle cell anaemia and thalassaemia Ethnicities at an increased risk of thalassaemia

Alpha thalassaemia Beta thalassaemia • Middle Eastern • Italian • Southern European • Greek • Indian subcontinent • Arabian Peninsula • Central and southeast Asian • Iranian • African • South-East Asian • Maori/Pacific Islanders • Africa Southern China • Aboriginal and Torres strait islanders for NT and far north WA Best Practice • Ideally testing should occur preconception • Offer testing as early as possible in pregnancy • Routinely provide information about Haemoglobin disorders • Offer testing (FBC) • Consider offering ferritin testing and haemoglobin electrophoresis for women from high-risk groups, remembering society is becoming increasingly multicultural. • Further testing is recommended for women with a family history of SC and thalassaemia's, and from high-risk countries • Consider DNA analysis • Provide women with sufficient information about haemoglobinopathies to enable decision making and informed consent about testing • Early referral and results to ANC, including partner testing if undertaken • https://www.health.gov.au/resources/pregnancy-care-guidelines/part-f- routine-maternal-health-tests/haemoglobin-disorders Interpretation of results

https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp- guidelines/view-all-racgp-guidelines/genomics/haemoglobinopathies Iron deficiency True prevalence of IDA in pregnancy within Australia – approx. 18-20% in several studies (50% worldwide) Risk factors for developing anaemia in pregnancy • younger age (<18 years) • past bariatric surgery • multiparity (>3) • Aboriginal and Torres Strait Islander women • previous iron deficiency • non-white ethnic origin • shortened interval between pregnancies • haemoglobinopathy • disadvantaged socioeconomic status • chronic blood loss • poor nutrition • parasitic disease • vegetarian or vegan diet Consider women at increased risk from the effects of anaemia • women at risk of haemorrhage at birth • who have bleeding disorders • are on anticoagulation therapy • who, for religious or cultural reasons, might decline blood products Definitions

Definitions Anaemia Hb≤ 110 g/L

Iron deficiency without anaemia x 3 incidence of iron deficiency anaemia ? 60 -70% Ferritin ≤ 30 mcg/L

Iron deficiency anaemia From: Maternity Blood Management - Low ferritin and low Hb National Blood Authority Haemoblobin Assessment and Optimisation in Maternity

Flow Charts available for each trimester + postpartum management Consequences of iron deficiency anaemia in pregnancy and postnatal period Maternal Fetal / Neonatal Fatigue Impaired placental growth/placental inefficiency Reduced mental and physical performance Low birth weight

Poor gestational weight gain Preterm birth

IUGR secondary to poor placental perfusion Neurological impairment- cognitive disorders , behavioural problems Increased risk of birth complications- haemorrhage, need for Increased mortality transfusion, infection, hospitalisation

Depression Associated with retinopathy of prematurity

Inhibited lactation Iron deficiency/ childhood anaemia

Higher incidence of thyroid autoimmunity Inadequate iron stores at birth mean higher risk of iron Restless leg syndrome deficiency throughout early childhood and in to the preschool years Increased mortality Oral iron choices

https://transfusion.com.au/node/2359 Remember …… • NB NOT all microcytic anaemias are due to iron deficiency. • Consider Haemoglobinopathy • Perform haemoglobinopathy screening if risk factors – women with a family history of anaemia, thalassaemia or other abnormal haemoglobin variant RACGP Guidelines for preventive activities – any woman from a high-risk ethnic background who in General Practice - 9th edition has not previously been tested – or the booking FBC shows a MCV ≤ 80 fL and/or MCH < 27 pg • If haemoglobinopathy detected – arrange partner screening ASAP • With Australia's mixed population - identifying underlying haemoglobinopathies is a potential concern

AJGP - March 2019 - Anaemia in pregnancy Blue Group: Task 2– Meghan

• Meghan presents as a 32-year-old lady. Married. She is currently 9 weeks pregnant and has returned to you for her blood results organised by another GP. She has had a positive syphilis screen. • She is extremely distressed at this news and had no idea she has had it. She cannot recall ever having symptoms in the past. • You also note she has a BMI of 34.

What are your next steps? Syphilis across Australia

SYPHILIS OUTBREAK SURVEILLANCE REPORT: February 2021 @ https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp- infectious-syphilis-outbreak.htm Syphilis screening in Metro South Health • Over the last 2 years steady increase of notifications throughout Queensland, including in SEQ, including several cases of congenital syphilis

• Steady increase in notifications - both indigenous and non-indigenous women.

• Logan/Beaudesert women now being routinely screened with initial antenatal bloods, AND again at 26-28 weeks, not routine at Redland Hospital

• Women considered to be of HIGH Risk may be screened repeatedly throughout pregnancy as per the Syphilis in pregnancy: Antenatal care (Flowchart)

• Testing and treating during first two TM’s of pregnancy results in 2.2 times more chance of a healthy baby than those receiving syphilis treatment during 3 rd TM

• Refer back as urgent to AN clinic with the test results if positive

Syphilis in Pregnancy Queensland Clinical Guidelines (updated Feb 2021) Syphilis in pregnancy – Clinical Guidelines

• https://www.health.qld.gov.au/__data /assets/pdf_file/0035/736883/g- sip.pdf • https://www.health.gov.au/resources/ pregnancy-care-guidelines/part-f- routine-maternal-health-tests/syphilis Syphilis in SE Queensland Metro North Infectious 323 Late 53 + 1 CS Metro South Infectious 213 Late 64 Gold Coast Infectious 96 Late 30 Darling Downs Infectious 36 Late 12 Sunshine Coast Infectious 30 Late 5 West Moreton Infectious 50 Late 13 + 1CS Wide Bay Infectious 13 Late 5 Cairns/Hinterland Infectious 45 Late 25

Queensland Health - Notifiable Conditions Surveillance Report - as at 16.03.2021

Notifications of bloodborne viruses and sexually transmissible infections (BBVSTIs) in Queensland: 1 January–30 September 2020 SEQ Queensland Syphilis Surveillance Service

• Two cases of Congenital Syphilis in Qld in 2020- 21 (Jan 2020 – 8th Mar 2021 data – Metro North and West Moreton) • ? 1 in Metro South on recent review of Qld Health Notifiable Conditions webpage (viewed 18.05.2021) • In Queensland, 17 cases since 2011/ 8 IUFD or died soon after delivery KEEP SCREENING KEEP PROMOTING AWARENESS

* Resource for Syphilis Positive Patient Parent information: Syphilis in pregnancy (health.qld.gov.au) STI Contact Tracing:

https://www.health.qld. gov.au/clinical- practice/guidelines- procedures/sex- health/contact-tracing https://letthemknow.org.au/index.html “Let Them Know” https://letthemknow.org.au/DocInfo.html https://www.true.org.au/Education/Course -Catalogue/course?eventtemplate=62- antenatal-sexual-health-kit-ask-course What is the BMI of pregnant women that triggers additional care and planning needs?

BMI of >30 What additional tests would be indicated for a woman with BMI>30?

• E/LFTs • Early GDM screening ( HbA1c or OGTT) • Urine Protein / Creatinine ratio

.. and remember FOLATE 5mg (Obese women have lower serum concentrations of folate than non-obese women) and higher risk Vitamin D deficiency. Early GDM Screening indications If high risk, please request HBA1C if <12 weeks (first trimester), or arrange early OGTT Risk factors for GDM are: • BMI >30 (pre-pregnancy or on entry to care) • Ethnicity (Aboriginal and Torres Strait Islander, Pacific or South Sea Islander, Indian subcontinent, South-East Asia, Middle Eastern or African) • Previous GDM • Previous elevated BGL • Maternal age > 40 years • Family history DM (1st degree relative or sister with GDM) • Previous macrosomia (birth weight >4500g or > 90th percentile) • Previous perinatal loss • Polycystic ovarian syndrome • Medications (corticosteroids, antipsychotics) • Multiple pregnancy Queensland Clinical Guideline: Gestational Diabetes Mellitus, August 2015 www.health.qld.gov.au/qcg

Queensland Clinical Guideline: Gestational Diabetes - Notice of update during COVID-19 pandemic - 29 June 2020) Prophylactic Aspirin use in pregnancy to reduce PE and IUGR High Risk Factors o Women with any of the following: Hypertension Renal disease Auto-immune diseases e.g. SLE or anti-phospholipid syndrome Diabetes (Type 1 or Type 2) Past history of pre-eclampsia Moderate Risk Factors o Women with more than one of the following: Primiparous BMI > 35 Age > 40 Multiple pregnancy 150 mg aspirin nocte Family history of pre-eclampsia (mother or sister) More than 10 years since last pregnancy BEFORE 16 weeks gestation Ideally from 12 weeks until birth What about calcium? o Calcium has been shown to reduce BP, relax smooth muscle, lower resistance in uterine and umbilical arteries. If a woman has deficient intake, 1.5 g/day is recommended. Reintroducing Meghan ……. • Now seen at age 34yrs, two years after her marriage failed following the syphilis diagnosis. She was treated appropriately with Penicillin but decided to terminate the pregnancy as her marriage fell apart. • Treated for depression since soon after and remains on a SSRI. • Is now in a new relationship and hoping to fall pregnant in the next few months. • Very worried about further miscarriage risk, but also worried about the effect of the antidepressant in pregnancy.

She has a 15 min appointment - Outline your approach . Preconception Medication: Choices to consider

• Stop medication before & during pregnancy • Stop medication & reintroduce if symptoms recur • Reduce dose • Change to alternate medication / Rx • Continue current medication Perinatal Depression

Prevalence of Perinatal Depression Recurrences of major depressive - Antenatal Depression: (new cases) disorders occur rapidly

• 1st Trimester - 7.5% • 50% 1st Trimester • 2nd Trimester - 13% • 90% 2nd Trimester • 3rd Trimester - 12%

Practice Point: Important to warn women/discuss mental health risks associated with pregnancy early, so that symptoms are not hidden, denied or not acknowledged until they become overwhelming. Resources to help Meghan decide what to do:

https://www.cope.org.au/health-professionals/health-professionals- 3/decision-making-making-management/pharmacological-treatment/ During Pregnancy • NO DRUG “SAFE” • Need clear indication for medication • “Dance with the one that brung you” • Medication considerations ✓ Dose (lowest effective, evidence based) ✓ Time ✓ Interactions ✓ Complicating factors

✓ Prior Use/Efficacy/Reason discontinued. ✓ Tolerability Medication in Pregnancy -General principles • Avoid 1st trimester if possible • Lowest effective dose for shortest time • Chose best evidence-based medication – usually SSRIs such as Sertraline or Escitalopram (large body of comparative safety evidence) • Discuss reason for choice and goals of treatment with women • Avoid polypharmacy • Use an effective medication in an effective dose, treat to remission and continue treatment past vulnerable times Online Mater resources Antidepressant medication in pregnancy – MMH Resources • PANDA (Perinatal Anxiety & Depression Australia)- Online resources & Helpline: 1300 726 306 • Beyond Blue- phone & online help, resources/ factsheets. Ph: 1300 22 4636 • Black Dog Institute • COPE – Centre of Perinatal Excellence • “What Were We Thinking” website - whatwerewethinking.org.au • The Women's Pregnancy and Breastfeeding Medicines Guide – RWH Melbourne - www.thewomenspbmg.org.au • Headspace: 12yr to 25 yrs, ph: 1800 650 890 • Lifeline Australia: 1311 14 • Kids Helpline: 1800 55 1800 • Mensline Australia: 1300 78 99 78 COPE – Centre of Perinatal Excellence Ready to cope https://peachtree.org.au/ Suicide • One of leading causes of maternal death in the postpartum period • Often violent • Highest risk period 6 weeks - 12 months post diagnosis • 73% victims have serious mental illness • High incidence of perinatal complications • 59 deaths by suicide between 2004-2017 – 53% post-natal – 36% following a termination of pregnancy (ToP) – remainder either during pregnancy or following a miscarriage or ectopic pregnancy

Queensland Mothers and Babies Report 2016 & 2017 Report of the Queensland Maternal and Perinatal Quality Council 2019 (published May 2020) Screening for Perinatal Mental Health Issues • Edinburgh Postnatal Depression Scale (EPDS) should be used to SCREEN all women for symptoms of depression and/or anxiety during the perinatal period. • EPDS - validated for use in both pregnancy and the postnatal period to assess for possible depression and anxiety • Alternatives - Antenatal (Psychosocial) Risk Questionnaire (ANRQ), DASS, K10 • ANRQ – includes items to identify specific risk factors that independently put the woman at greater psychosocial risk (past history of trauma or significant mental health condition). • EPDS developed in various languages and for diverse backgrounds but not necessarily validated for these groups

Mental Health Care in the Perinatal Period - Australian Guidelines - COPE Initial assessment to plan appropriate treatment Health professionals can ASSESS risk more broadly and to identify ways in which different kinds of services (not all of them clinical) can be activated to support the woman and her family through pregnancy and after birth Assessment includes • Psychosocial risk assessment including comorbid issues incl family violence; lifestyle factors including nutrition, physical activity, substance use and smoking; availability of social supports in family or externally • Past mental health history (esp. of Bipolar Disorder/Psychosis) and family history • ? difficulties in the mother-infant relationship • ? risk of harm to the infant or other children in woman’s care • Suicide risk assessment Assessment is required to be culturally and linguistically suitable Mental Health Care in the Perinatal Period - Australian Guidelines - COPE Management of mental illness in the perinatal period

Consider all options including lifestyle & facilitating appropriate supports Options include: • Pregnancy support counselling—no Mental Health Plan required, 3 Medicare funded visits Search for eligible psychologists at www.psychology.org.au • Mental health assessment and plan if required and manage/refer as appropriate • Medication/GP Support and counselling • Private Psychologist under “Better Access” • Psychiatrist – Assessment and Planning Item (291) or ongoing care • Metro South Health Mental Health Services Perinatal Well-Being Service

Erica Holder - Clinical Nurse Consultant Credentialed Mental Health Nurse Perinatal Wellbeing Service

Video https://vimeo.com/35 1322500/ee92ff319c Perinatal Mental Health Perinatal Wellbeing Service • A specialist perinatal mental health assessment and brief intervention community service up to 6 appointments (Qld Health) • For women ≥18 years who are pregnant or have a baby up to 1 year and their families, living in Logan, Beaudesert or Redland suburbs • Services provided by a Nurse Practitioner and Clinical Nurse Consultants who work closely with referrers, GPs, and other health providers • Primary target group: women with adjustment disorders, anxiety and depressive disorders • Do not provide services to women with psychotic illnesses, Bipolar disorder, needing urgent or case management services – refer these to MH CALL • Psychological based treatments and prescribing and reviewing medications (NP) • Provide information, advice and education about perinatal mental illness and advice around treatment Perinatal Wellbeing Service Keeping Well - During Referral process Pregnancy and Beyond • A woman can self-referral by contacting the service directly • GPs, midwives, community health and other health providers can make referrals on the behalf of a woman with consent. • GPs & Non-Q Health referrers - Fax to: 3089 2722 • The service can assist with GP management and suggest other services that may assist the woman or her family. • More information available on: Website: https://metrosouth.health.qld.gov.au/logan- beaudesert-wellbeing-service/perinatal Perinatal Wellbeing Referral Form For urgent assistance or advice

• Lifeline: ph. 131114 • MH CALL – ph. 1300 64 22 55 - Metro South Wide, 24/7 – provide public urgent and after-hours triage assessment and advice for service providers – for patients assessed at high risk of harm to self or others – can also provide expert advice on management and advice around medications. • PANDA: (Perinatal and Anxiety Depression Australia) National Perinatal Mental Health Helpline ph. 1300 726 306 Green Group: Task 2 - Jade. • 32 year old. Multiparity G5 P3 at 10 weeks pregnant. • History of Postnatal depression treated sporadically with an SSRI. • Unplanned pregnancy and considering a termination of pregnancy. • Department of Child Safety involvement in the past, but you are unsure of the current situation • Large bruise on her arm noted when you check her BP

Set out your initial assessment and referrals. Termination of pregnancy Termination of Pregnancy Act 2018

• Lawful termination may be performed by registered medical practitioners • Up to gestational limit of 22 + 0, for any reason • Gestation upward of 22+1; 2 x medical practitioner agreement that termination can be performed Termination of Pregnancy services available in the region • Local hospital and health services provide a limited service for TOP • Most TOP referrals should be via private services • Local hospital services prioritise appointments ONLY for women with complex healthcare needs or significant social disadvantage • Is your patient under 16 years of age? – Consider independent counselling & ensure there is a support person who is available and engaged – Paediatric/adolescent patients: refer to The Queensland Statewide Paediatric and Adolescent Gynaecology Service https://www.childrens.health.qld.gov.au/service- paediatric-adolescent-gynaecology/ • For Redland Hospital, please phone the Consultant on Call for advice/consideration prior to sending a written referral • Logan Hospital TOP service – contact nursing case manager – Ph: 2891 5578 (M–F 9-4) • Beaudesert Hospital does NOT have a TOP service. • Referrals need to be complete and have all relevant investigations attached as per Termination of Pregnancy Clinical Guidelines https://www.health.qld.gov.au/qcg/publications#top Essential referral information • Medical, surgical and obstetric history • Menstrual history and last menstrual period (LMP) date • Results of a physical examination as indicated by patient history + vital signs, and BMI • MUST have confirmation of pregnancy (βhCG) and gestation with USS proven live intrauterine pregnancy "Refer Your Patient" - Gynaecology - Termination of Pregnancy

Where a health practitioner conscientiously objects to TOP care, they must disclose their objection and they have a professional responsibility and legal requirement to ensure transfer of care without delay to a health practitioner or service who they believe can provide the requested service Additional referral information: • Blood group, Rh status and antibody screen • Routine AN bloods: FBC, Rubella antibody, Hep B/C serology , HIV serology, Ferritin, and syphilis serology • HPV vaccination history & CST result if done • STI screen - endocervical swab for chlamydia +/- gonorrhoea, T vaginalis • History of smoking/ substance use and alcohol • History of DFV or sexual violence • Mental Health Status BE TIMELY Follow up after TOP Follow-up is recommended 2-3/52 after termination of pregnancy (TOP). • Enquire re - symptoms suggestive of ongoing pregnancy (failed termination) - signs of infection or retained products of conception (RPOC) – any abnormal vaginal bleeding or discharge, pain, or fever. • Note that if a patient starts hormonal contraception immediately after a miscarriage or termination, they may experience prolonged abnormal bleeding. • If concerns re possible infection, retained products of conception, or abnormal bleeding: - perform examination – Temp/BP/Pulse, Uterine tenderness/? Involution, ? Clots at os -arrange investigations – swabs incl STI screen, ? βhCG test, ? FBC, ? TVUS • For medical termination of pregnancy (MTOP), arrange a 2 to 3 week post-TOP βhCG test to confirm that TOP is complete - 2% failure rate with MTOP. • Contraception and future pregnancy planning • Ask about patient's feelings about her experience - significant mental health risk Spot On Health Pathways - Follow Up after TOP Resources available in MSH region

• 13 HEALTH – 13 43 25 84 provides health information, referral and services to the public

• Children by Choice – 1800 177 725 offers free all-options pregnancy counselling, information and referrals Qld wide

• Women’s Health Qld – 1800 017 676 offers health promotion, information and education services for women and health professionals

• True Relationships and Reproductive Health provides expert reproduction and sexual healthcare • Termination of Pregnancy Clinical Guidelines https://www.health.qld.gov.au/qcg/publications#top – provides patient information + Flowcharts/ Education for Health Professionals • Key facts about the Termination of Pregnancy Act https://clinicalexcellence.qld.gov.au/sites/default/files/docs/priority-area/termination- pregnancy/termination-pregnancy-act-facts.PDF Practice Points - Women with Psychosocial Concerns or Substance Use Issues:

• Illicit drug use has high association with mental health issues, and many substance using women are polysubstance users. Coexisting mental health disorders may contribute to substance use or the effects of substance use in pregnancy and include anxiety, schizophrenia, PTSD, BPD, and personality disorders. Perinatal Substance Use: Maternal – Queensland Clinical Guidelines • Later pregnancy recognition & 50% unintended pregnancies increases risks/harmful effects of substance use.

• Refer as per usual pathways, but please identify in the referral as much information as you have available to assist in suitable triage to wrap around and support services: • EDB (by USS determined dates if possible) • Substance used (as specific as can), amount and frequency • Brief History of past + DV, Child Protection Service/ Dept of Child Safety history, if known • STI Screen , Cervical Screening Test result, Screening for blood borne viruses • If non-attendance & information re substance use/complex needs included in referral, ANC staff can follow up appropriately. Substance Using Women:

• Try to retain attendance of women who use illicit substances or alcohol during pregnancy to antenatal appointments. • Try to foster a non-judgemental environment, to build a trusted relationship, in a positive environment supporting the individual woman’s needs. • Promoting engagement in a partnership with support services that aim to improve outcomes for mother and infant. • Minimise harm by undertaking comprehensive assessment and recommendations for care around continued substance use & associated risks for mother and infant. • Planning for a safe birth, care planning for medication requirements, and reducing risks of presentation with acute maternal withdrawal and fetal distress, and/or effects of substance abuse. SCN tour prenatally can be arranged if considered that may be needed. • Consider comorbidities and necessary referrals for further management e.g. STD management, postnatal Hepatitis C treatment. Nicole Mackin Linking with other services

• Maternity Team may liaise with internal/external support networks prn – GP, Community-based Addiction (Alcohol and Drug) Service, MH Team, Quitline, Social Worker, Dietitian, Women's Legal Service, Family and Child Connect, Centre for Women and Co, Home visiting Midwifery Program, Right@home

• Communication is imperative to best support the client during the pregnancy and postpartum.

Nicole Mackin Quit for You…Quit for Baby REFERRAL FORM https://www.health.qld.gov.au/__data/assets/pdf_file/0027 /737316/quitline-hp-referral-pregnancy.pdf Smoking Cessation Information Quit & Alfred Health, RWH (Melbourne) have developed an evidence-informed clinical guideline, including an algorithm for prescribing NRT: Supporting smoking cessation during pregnancy – nicotine replacement therapy (NRT). TWO versions available - for clinicians providing care to pregnant women in •General practice •Health services Recognised as Accepted Clinical Resource by RACGP & endorsed by RANZCOG, the Stillbirth CRE and the Australian College of Midwives.

https://www.quit.org.au/resources/maternity-health- professionals/training-and-resources-maternity-health-professionals/ Women want to know campaign Information for health professionals on pregnancy and alcohol How do you ask women about DV? • Every woman – are you safe at home? “In addition to the blood tests and ultrasound scans we recommend in pregnancy; we ask every woman questions about how she is feeling and if she is safe. Anxiety, depression and domestic violence are common conditions and they may occur for the first time or get worse in pregnancy. “Are you safe?” • DV screening for ALL at 28/40 visit (to claim 16591 Item Number) Resources • Domestic Violence Hotline 1800 811 811 • 1800Respect 1800 737 732 • REFERRAL TO DFV LOCAL LINK/Centre for Women and Co. (See next slide)

Facilitate early referral to hospital • Flag concerns/suspicions • Enable social worker support New service in Logan/Beaudesert and Redland region (and now Brisbane) provided​ by the BSPHN - Domestic and Family violence specialist service - Centre for Women & Co. https://bsphn.org.au/support/for-your-patients-clients/domestic-and-family-violence/ Recognise, Respond, Refer program: Offers one-point of referral for patients affected by domestic and​ family violence, as well as advice and support for general practices​ to enable better identification & response to domestic and family​ violence.

REFERRALS TO DFV LOCAL LINK​ - Eligible for referral to DFV Local Link if:​ ➢ affected by domestic & family violence, including​ perpetrators seeking behavior change support​ ➢ a patient of a general practice in the Brisbane South region.​ Can provide the following for referred patients via​ telephone or face-to-face (at a general practice or at The Centre for​ Women and Co.) ➢ undertake a risk assessment​ ➢ provide initial support and advice on next steps​ ➢ connection with appropriate supports/services​ ➢ safely and securely provide feedback to referrer on outcomes​ of referral.​ Grace Tuaoi DFV Local Link Coordinator, Redlands 0482 811 980 or GENERAL PRACTICE DFV SUPPORT AND ADVICE [email protected]

DFV Local Link can also provide the following to general Mikaela Martyn practice​ staff over the phone or via practice visits:​​ DFV Local Link Coordinator, Logan ➢ confidential advice on managing patients affected by DFV​​ 0460 626 502 or ➢ information sessions re primary care role in responding​ to DFV​​ [email protected] ➢ connection to RACGP accredited DFV training opportunities​​ Beaudesert/Jimboomba Service - ➢ support to implement practice-level measures to enable operated by Youth & Family Services (YFS) safe​ and supportive responses to DFV in the general practice​​ Phone: 07 38261500, Mobile: 0417 078 108 Email: [email protected] DFV Local Link service is for General Practices only, but midwives and other medical staff can contact the DFV services directly on the Brisbane Service: contact information provided. Brisbane DFV Local Link Coordinator Phone: 3013 6035 For secure referrals: find “The Centre for Women & Co.” on Mobile: 0488 180 590 (Hannah) or 0419 757 Medical Objects. 257 (Summer) Available : Mon|Tue|Wed|Fri -9.00am - 4.00pm, Email: [email protected] Thurs 1.30pm - 4.00pm Closed Saturday, Sunday and Public Hols. FREE DOMESTIC AND FAMILY VIOLENCE TRAINING FOR GENERAL PRACTICES IN THE REDLANDS

The Centre for Women and Co. are delivering free domestic and family violence training for general practice staff next Tuesday evening

When: Tuesday 25 May

Time: 6.00pm – 7.30pm

Where: Men and Co. Services Unit 2 24 Steel Street Capalaba QLD 4157

This RACGP accredited training explores practical measures to support patients affected by DFV, including how to recognise signs of DFV, respond to disclosures, and information about referral options available.

For more information and to register talk to the Redlands DFV Local Link Grace: [email protected] or 0482 811 980

Recognise Respond Refer Red Group: Task 2 - Anne • 26-year-old female presents with vomiting and pinky PV bleed at 8 weeks of pregnancy • Pale pink coloured ? PV discharge for 1/7 with lower abdominal pain since the weekend • BP 90/60, PR 104. • Known Rh neg blood group Early pregnancy bleeding

Dr Wendy Dutton Director | Obstetrics & Gynaecology | Women’s and Children’s Division Redland Hospital | Metro South Health • 20 to 40% of women experience vaginal bleeding in the 1st TM of pregnancy • Most common diagnoses are threatened miscarriage and ectopic pregnancy • Often not the case that a diagnosis can be made at onset of the symptoms … singular or serial scans and /or bloods may be required

Alternative diagnosis of vaginal bleeding in early pregnancy • Endometrial implantation ( very early gestational bleeding) • Cervical , vaginal lesions- polyps, ectropion, malignancy • Uterine infection • Gestational trophoblastic disease in the setting of unusually high bHCG and USS findings • Ectopic pregnancy - diagnosis is vital as it can be life threatening condition GP assessment • History: o expected gestation o blood loss/pain assessment, o contraceptive use o assisted reproduction status o pelvic infections/STD’s o previous ectopic • Serious clinical symptoms of syncope, chest pain, shortness of breath • ? Shoulder tip pain i.e. rupturing or ruptured ectopic • Cervical screening history • Rh negative blood group • Any condition that may increase risk of miscarriage GP assessment

• Abdominal examination for rigidity, rebound, guarding, distension • Fundal height • Consider Speculum examination and inspection of vagina and cervix • Bimanual examination for uterine size, dilatation of cervical os, pelvic tenderness, cervical motion tenderness, presence of tissue in open cervix • Send for TVS/ USS or to EPAU service and/or ED if unstable and suspicion of ectopic (rising bHCG in serial testing can still be seen in an ectopic in 21% of cases) • Counselling/ refer for support if suspected miscarriage Haemodynamic instability • Initial clinical assessment is vital to establish existing haemodynamic instability, and anaemia • Immediate transfer to ED via QAS for significant vaginal blood loss and/or abdominal pain as haemodynamically instability may not be clinically evident in young women even after significant blood loss • Look for – Hypotension – Tachycardia or arrythmia – Peripheral cyanosis – Confusion Threatened miscarriage • Is defined as bleeding that occurs before the 20th week of pregnancy, usually with no pain. Cervix remains closed, and pregnancy continues • No specific treatment for a threatened miscarriage • Abstain from sexual intercourse • "take it easy"

Patient information re Miscarriage – https://www.health.qld.gov.au/__data/assets/pdf_file/0026/621197/ed-miscarriage.pdf Incomplete miscarriage Inevitable miscarriage • Some but not all the • Cervix will be open products of conception • Increased bleeding have passed • Increased pain • Risk of infection • Risk of increased bleeding

https://www.health.qld.gov.au/__data/assets/pdf_file/0026/621197/ed-miscarriage.pdf Complete miscarriage

• Pregnancy is diagnosed as having ended • USS will confirm an empty uterus • Dropping bHCG levels

https://www.health.qld.gov.au/__data/assets/pdf_file/0026/621197/ed-miscarriage.pdf Ectopic pregnancy - Qld Clinical Guideline: Early Pregnancy Loss Classic ectopic symptoms include: • Amenorrhea 6-8 weeks post LNMP • Shoulder tip pain and or rectal pain • Abdominal pain • PV bleeding • hCG >2000 IU/L and TVS with no IUP, complex adnexal mass and/or free fluid- High probability of ectopic pregnancy (stable women only) Risk factors: • Previous ectopic • Past PID/endometriosis/tubal surgery/IUD use > 2 yrs • Infertility (increased risk with length of) • Age 40 yrs + • Smokers Pregnancy of unknown location (PUL)

• An intrauterine pregnancy (IUP) is one where a yolk sac is seen • No yolk sac = a PUL • If you have no yolk sac, especially if HCG is> 800-1000, be cautious • Consider referral as a potential for ectopic pregnancy Pregnancy of unknown location (PUL) • An Intrauterine pregnancy (IUP) is one where a yolk sac is seen • NO yolk sac = a PUL • If you have no yolk sac, especially if the HCG is > 800-1000, be VERY CAUTIOUS • IUP can usually be seen with B-HCG levels above 800

• Threshold of 1500 will detect 98% of IUPs (Pitfall: multiple pregnancy)

• B-HCG >10 000, should be a fetal heartbeat

• An IUP almost always excludes ectopic (heterotopic awareness when risk factors) Diagnosing an early pregnancy loss

Don’t just read USS scan reports, get used to looking at the measurements on the scan pictures: • Once crown rump length (CRL) is 7mm, there should be a heartbeat, if there is not, then it is a miscarriage • If CRL is < 7mm (even if report says it is a missed miscarriage) it is too early to call, repeat USS in a week • If there is no CRL yet, then go by sac size • Once sac size is 25mm, there should be a fetal pole, if there is not then this is an anembryonic pregnancy (old term blighted ovum) • If the mean sac diameter (MSD) < 25mm, repeat scan in a week Diagnosing an early pregnancy loss

• If CRL or MSD grows over a week then repeat scan in a week, even if it has only grown by 1mm, any growth is growth, and you can't diagnose an early pregnancy loss while there is growth • If CRL or MSD gets smaller over 2 scans a week apart or fails to grow at all, then you can diagnose a missed miscarriage • If CRL or MSD growing slowly, then a drop in HCG level (done at same lab) is enough to diagnose a missed miscarriage

• B-HCG usually doubles every 48hrs between 5-10 weeks gestation in a viable IUP • If B-HCG is slowly rising by < 50%, usually non-viable IUP, or ectopic (99% accuracy) • Rapidly rising levels - consider multiple or molar pregnancy • Single isolated level is less useful for uncertain clinical scenarios Early Pregnancy Review Clinic – Redland Hospital

Women with early pregnancy complications seeing their GP and living in the Redland Hospital catchment may be directed to the next Early Pregnancy Review Clinic if clinically stable, but • ONLY after discussion between the GP and the Obstetrician/Registrar. • This clinic does not accept direct GP referrals.

Redland Hospital contact details: • Phone On-Call Registrar 3488 3758 or Obstetrician 3488 3111 • Or refer to the Emergency Department Early Pregnancy Assessment – other MSHHS Services

Logan Hospital EPAU – Early Pregnancy Assessment Unit Specialist area in Logan Hospital - deals specifically with problems in early (< 20/40) pregnancy. Open on weekdays from 8am – 4pm, by appointment only. Contact EPAU Nurse/Midwife or Obstetric Registrar to arrange review Phone: 3299 8456 / FAX – 3089 2016

Beaudesert Hospital

Does not have a dedicated EPAU Phone On-Call GP Obstetrician 5541 9174 OR refer to the Emergency Department Early Pregnancy Service can: • Assist GPs with management of threatened/ incomplete miscarriages & investigate causes of pain. • Assist GPs with management of non-viable pregnancies that have opted for conservative/medical management. • Manage confirmed stable ectopic pregnancies that are to be medically/conservatively treated or pregnancies of unknown location that are stable but require follow up. • Assist in management of women with high risk combined first trimester screen or NIPT – referral for follow up may be directed to MMH Materno-Fetal Medicine Service or alternatively be seen in ANC or an early pregnancy clinic dependent on the abnormality. (Consider contacting the on-call Obstetrician to discuss the next step if uncertain, and please copy hospital into obtain results of any tests ordered). • Does NOT look after women with Hyperemesis requiring IV fluids (send to ED), or if narcotic pain relief is required. • Women with clinically suspected unstable ectopic (shoulder tip pain, rebound tenderness, abdominal rigidity, tachycardia, unstable BP) should be directed urgently to ED (via QAS prn)

Most common problems are vaginal bleeding or pain. Hemodynamically unstable women should be directed to ED. Early Pregnancy Assessment Services:

All referrals made initially by phone should be followed up with: • a detailed referral stating reason for referral and indicate current gestation/LMP, EDD, Past Obstetric (and Medical History if relevant), and clinical findings. • Please include results of antenatal bloods (especially blood group and antibody screen), any quantitative HCG levels and ultrasound reports, if available. • Referrals are to be faxed to the hospital directly (as directed by the Obstetrician or Registrar), not to the Central Referral Hub. So, remember ……..

• 7mm – CRL at which should be a heartbeat on TVUS • 25mm – Should be a fetal pole within the uterus • 1500 U/l – HCG level at which intrauterine pregnancy should be detectable on TVUS • X 2 every 48/24 – HCG level should rise in viable pregnancy (at 5-10/40) Incomplete miscarriage treatment options Type Treatment Expectant Follow up USS if still presents with PV bleeding after 2 weeks OR if painful, heavy bleeding. May be managed by GP, with specialist input if required - Phone On call Consultant O&G/Registrar for advice.

Medical Initiated by the hospital or by approved GP prescribers – (Training management available at www.ms2step.com.au) Surgical Available at Logan, Redland and Beaudesert Hospital. management

All women should be counselled and offered all options from the time of early pregnancy loss diagnosis, with all options being valid choices, guided by the woman's preference and any acute clinical considerations. Early Pregnancy Loss Queensland Clinical Guideline Medical management • Misoprostol has proven effective in 80-85% of incomplete miscarriages at a gestation of <13/40 • X2 doses. S/L administration on consecutive days as an outpatient • Bleeding and pain occur 2-4 hours after the first dose and lasts up to 24-72 hours before miscarriage is completed • Period like bleeding can be expected over the next week • 10% of women may have excessive pain or bleeding – advice is to refer for medical review as D&C may be required • Hospitalisation for heavy bleeding or infection occurs in < 1% of women • Not TGA registered for use in pregnancy. Use is supported by QH and RANZCOG • HCG levels should be followed up until undetectable. Anti-D administration in pregnancy • Give within 72 hours • Dose: 250 IU before, 625 IU after 12 weeks • Routine Anti D (625 IU) at 28 and 34-36 weeks • Can be ordered for women and stocks held in general practice • If sending women into the hospital for Anti D, please send with a letter with a copy of the result confirming their blood group. • Appointments preferred/phone ahead • Parent Information re Rh Neg Blood Type https://www.health.qld.gov.au/__data/assets/pdf_file/0017/140 804/c-epl-rhdnegative.pdf Rhesus D negative women

Anti D for: • completed miscarriage at any gestation • threatened miscarriage after 12 weeks (unless worried about compliance), but required if miscarriage completes • antepartum hemorrhage • abdominal trauma sufficient to cause bleeding • interventions such as ECV, amniocentesis, CVS • postpartum if baby Rh positive Administration of Anti- D • Rh D immunoglobulin should be given by slow, deep IMI • Document in the Pregnancy Health Record • Rh D immunoglobulin can be obtained from QML and Mater upon receipt of a signed and completed request form. It will be delivered by their routine courier service. • Mater Blood Bank Fax 07 3163 8179 • QML Blood Bank Fax 07 3371 9029

• You may choose to order and keep a small supply in your immunization fridge. Where can a women get her Anti-D? • If you don’t have access to anti–D - can be referred via ED if <20/40 • OR contact the Maternity Assessment Unit to book an appointment – Telephone: 3488 4075 (Mon-Fri 0930-1800) or by Fax: 3488 4432 • If it is for routine prophylaxis, can be given in ANC if woman has an appointment • For bleeding later in pregnancy send to the Maternity Assessment Unit/Birth suite – open 24 hours • If she is bleeding or it is her 28-week injection, send with a copy of her recent blood group and antibody result • No blood group and antibody test is required for the 34-week injection if it has been done at 28 weeks Other red cell antibodies… • ALL women – test for blood group antibodies at the first antenatal visit, and at 28 weeks • Rh negative women with no Rh (D) antibodies in early pregnancy – test AGAIN for the presence of antibodies before administration of Anti-D at K28 • Antibody testing should be performed EVEN if the woman is Rh (D) positive as other red cell antibodies can be of clinical significance (Netherlands study * - positive antibody screen incidence 1:80, with 1:300 incidence of antibodies other than anti-D) Risks to the fetus Risks to the mother

Fetal anaemia Haemolytic transfusion reactions

Haemolytic disease of the newborn/ hyperbilirubinemia HDFN risk is greatest with anti D, anti C, anti kell Hydrops fetalis

Premature birth

Premature death On the PHR 2 ……routine anti D prophylaxis Please record the routine administration on page 7 of the clinician’s section of the PHR. Bayside Integrated GP Greater Access Program

Monday to Friday 8.00am – 4.00pm  MBChB (UK) and FRACP  Staff specialist in Endocrinology and General Medicine  VMO Redland Specialist Centre and Mater Private Hospital Redland  Current role as Nurse Navigator Big Gap since August 2020

 Previously worked at The Prince Charles Hospital as the Nurse Navigator for the Frail Older Person, Metro South ACAT, Community Health Interface Program PAH and Emergency at Mater and PAH AVOID Emergency

For appropriate medical patients !  Iron deficiency anaemia HB <100 Ferritin <30  Urinary Tract Infections/acute pyelonephritis  Exacerbation of COPD  Heart Failure  Hypertension  Diabetes Stabilization  Infection requiring IV A’B eg cellulitis, UTI, pneumonia  DVT upper limb and above knee  Stable PE Are you considering to send your patient to ED?

 Is the patient over 18 years of age?  Is it a general medical problem?  Do you have a working diagnosis?  Is your patient haemodynamically stable?  Do they need immediate specialist assessment? ➢ Patient under 18 years of age

➢ Client in a Residential Aged Care Facility

➢ Pregnant and requiring an iron infusion

➢ Chest Pain Without Big GAP With Big GAP

1. Patient with uncomplicated cellulitis attends GP 1. Patient with uncomplicated cellulitis and assessed to require IV A’B attends GP and assessed to require IV A’B

2. GP refers patient to Redland Hospital Emergency Department 2. GP calls BIG GAP

3. Patient waits in ED for 6 hours before being 3. Within 20 minutes, a same day admitted to SSU for HITH review mane appointment is made for the patient to see Senior Medical officerin HITH Clinic

4. Patient assessed & IV A’B required and accepted for HITH 4. Patient directly admitted to HITH, and discharged home with IV A’B

5. Patient is discharged from hospital with HITH

Improved 1 bed Reduced patient Timely days burden on experienc coordinatio saved ED n of MDT e When clinically appropriate Big Gap can -

➢ Facilitate direct, same day or next day admission ➢ Facilitate Hospital in the Home admission ➢ Facilitate iron and blood transfusion ➢ Arrange ongoing Nurse Navigator or community support ➢ Arrange a Rapid Access OPD clinic appointment Ring First 0419146630 Then fax 34884168 Once faxed referral received we aim to ring you with a plan within 20mins Have you used Big Gap ?

Have you got any feedback ?

Would you use the service again ? Lunch break Session 3 Time Session Presenter Delivery 1:15 pm Quick Quiz and the next 2 hours Dr Kim Nolan 1:25 pm Physiotherapy Services Ellodie Ruffin PowerPoint presentation 1:35am Cases 1-4 Breakout Facilitated groups

1:50 am Thyroid Disease and Obesity in Dr Kim Nolan Case Discussion – ALL pregnancy (Case 1) Naomi Scolari – Dietitian PowerPoint presentation Dietitian Presentation 2:10 pm Gestational Diabetes (Case 2) Dr Wendy Dutton – Obstetrician Case Discussion – ALL PowerPoint presentation; VOPP 2:30 pm Pharmacology in Pregnancy Dr Treasure McGuire, VOPP Pharmacologist 2:40 pm Hypertension and MAC (Case 3) Dr Kim Nolan Case Discussion – ALL PowerPoint presentation 2:55 pm Safer Baby Bundle and the Dr Kim Nolan + Jane Rundle – Case Discussion – ALL importance of managing DFM and Clinical Midwife PowerPoint presentation suspected IUGR (Case 4) Session 3 - The End

Time Session Presenter Delivery method 3:10pm Community Midwifery Service Jane Rundle – Clinical Midwife PowerPoint presentation Consultant

3:20 pm Child Health Services Tracey Button, CNC Child Health, PowerPoint presentation Bayside

3.20 –3:30pm Close – Alignment requirements and Dr Kim Nolan certification Questions ? Complete quiz online + Evaluation What is the BMI of pregnant women that triggers additional care and planning needs?

BMI of >30 What additional tests would be indicated for a woman with BMI>30?

• E/LFTs • Early GDM screening ( HbA1c or OGTT) • Urine Protein / Creatinine ratio Which of these results would require referral back for review by the booking hospital? High risk CFTS or NIPT • Referral for follow up may be required to MFM or ANC dependent on the abnormality • Consider contacting the on-call Obstetrician to discuss the next step, or refer direct to MMH Materno-Fetal Medicine Service • Regardless of the abnormality ALL results should be sent with correspondence to the ANC

• If not already booked in at Maternity hospital, separate antenatal referral needs to be completed (forwarded to the Central Referral Hub) Anaemia and/or low iron study results • GP responsibility to follow up and treat. • Very low results (Haemoglobin < 110g/l) may need hospital review if iron infusion or haematology opinion is needed. • Details of the results should be provided to the Obstetric team via written correspondence and results to the ANC Positive GDM screen Urgently send results and written correspondence to ANC. Mark as URGENT

Forward to the booking hospital as directed (not via the Central referral Hub) Low rubella titre Follow up in the Postnatal period - with MMR vaccination by GP/in hospital Positive Syphilis screen Phone the obstetrician on-call AND send the result with written correspondence Varicella Exposure (sharing home/face to face > 5 minutes) Serology will not help in an immunised woman. • Clear history of varicella/immunisation or known IgG positive – no action required • Poor clinical history or no history of varicella and no history of immunisation – check IgG levels • If positive, no action required • If negative, notify the obstetric team, ZIG if within 96 hours of exposure, Acyclovir after 96 hours and/or ASAP after the rash has emerged if the woman is >20 weeks, a smoker or asthmatic • Discuss with Obstetrician if symptoms, but liaise by phone before referral in Any morphology scan abnormality that identifies increased maternal and or fetal risk • Referral may be required to MFM or ANC dependent on the abnormality. • Consider contacting the on-call Obstetrician to discuss the next step, or refer direct to MMH Materno-Fetal Medicine Service • Regardless of the abnormality ALL results should be sent with correspondence to the ANC Physiotherapy Services

Prepared by Tracey Anderson (Physiotherapist - Advanced) & Dr Tanja Miokovic (Senior Physiotherapist) Presented by Ellodie Ruffin Women’s, Men’s and Pelvic Health Physiotherapy Redland Hospital and Wynnum-Manly Community Health Centre Ph 3488-3222 Outpatient Antenatal Physiotherapy Service

Referrals accepted (via Central Referral Hub) for perinatal conditions including: • Lower back pain (LBP)/Pelvic girdle pain (PGP) • Antenatal DRAM (diastasis of the rectus abdominis muscle) • Carpal tunnel syndrome (CTS) /Dequervains Tenosynovitis • Incontinence

*Comprehensive referrals are appreciated to facilitate triage

Referral management and triage: • Antenatal (AN) musculoskeletal pain (e.g. LBP, PGP/CTS) referrals: – Offered early appointment in fortnightly AN or PGP class then individual if symptoms not resolving. Recent consumer engagement demonstrated positive feedback from those attending a class • Antenatal continence issues: seen individually if triaged as urgent. If routine (e.g. stress incontinence) – may attend antenatal class Antenatal and Pelvic Girdle Pain classes

• LBP and PGP referrals triaged into PGP class initially • Antenatal class content: – Anatomy of the abdominal wall and pelvic floor – Pelvic floor and core stability exercise – Optimal bladder and bowel habits – Self management strategies for common

pregnancy discomforts including exercise, https://www.alphasport.com.au stretches, activity modification, maternity belt advice/fitting – Back care and ergonomic advice – General exercise in pregnancy Management of common perinatal presentations

Pelvic girdle pain/LBP

‒ Fitting of maternity belts (self purchase) – Mobility aid prescription (if required) – Gentle exercises – Lifestyle advice (bed mobility, avoid heavy lifting etc.) – Functional bracing on movement (core muscles) – Pelvic floor muscle training – Posture, comfort positions, diaphragmatic breathing

The Amazing Female Pelvis, Designed for Giving Birth, Vaginal Birth (pregnancy-and-giving-birth.com) Carpal tunnel syndrome – Gentle ROM/stretches – Activity modification – Night splints (self purchase) – Elevation where possible – Cold packs – Self retrograde massage

Dequervains Tenosynovitis ‒ Taping ‒ Thumb splints ‒ Icing ‒ Activity modification

Myfamilyphysio.com.au Incontinence

– Pelvic floor muscle function and coordination training – Optimal bladder and bowel habits (including constipation management) – Fluid/fibre education – Voiding dynamics/double void as required – Optimal defaecation position and pattern Exercise in pregnancy

Recommendations: • Walking • low impact or water aerobics • pregnancy exercise classes (e.g. Yoga, pilates) • cycling (stationary) • swimming • light weight training Avoid: • high impact exercise • sit ups • heavy weights • asymmetrical weight bearing/twisting • contact sports If pregnancy is deemed high risk by GP/Obstetrician, exercise programs will be modified accordingly in consultation with Doctor as required Maternity Ward

Physiotherapy services 2 hours each weekday – referrals accepted from Dr/Midwife

• Prioritisation – OASI – Instrumental delivery/prolonged 2nd stage/>4kg – Respiratory infection – Acute MSK injury/difficulty mobilising – Incontinence – Reduced bladder sensation – Diastasis Rectus (DRAM) – LSCS

• Education brochure provided to every postnatal woman outlining essential recovery information and access to physiotherapy services and/or postnatal classes Maternity ward (cont)

Assessment and treatment according to presentation

Routine education may include: • Pelvic floor muscle exercises • Perineal oedema and pain management (as required) • Bed mobility • Optimal bladder/bowel habits • Graduated return to activity/ADL’s • Screening for incontinence or voiding dysfunction • Back care (optimise posture, movement, safe lifting) • Diastasis rectus assessment and treatment • Postnatal follow up or individual if required OASI

Reviewed by ward physio and provided Telephone review at Individual 3rd/4th degree tear with essential physiotherapy identified and 2/52 and arrange information and early review if appointment at O&G review at 3/12 repaired by O&G referred for physio OPD follow up at required 6-8/52 2/52 and 6-8/52 Postnatal class

• Review and progression of pelvic floor and core muscle exercises • Posture and movement optimisation • Re-assessment of DRAM • Optimal bladder/bowel habits • Management of postnatal discomforts • Baby massage and handling • General return to pelvic floor safe exercises. (www.pelvicfloorfirst.org.au) - focus on PF/core strength initially and gradual return to higher intensity after 3 months (modify if required) • Individual appointments made from class if necessary. Outpatient individual postnatal Physiotherapy

• Urinary/faecal/flatus Incontinence • Dyspareunia • Pelvic organ prolapse • Ongoing LBP/PGP • Diastasis rectus (DRAM) • Pelvic floor muscle rehabilitation post 3/4th deg tear • Perineal pain How to refer? https://metrosouth.health.qld.gov.au/referral-hub Contact details: Central Referral Hub: Fax 1300 364 248

Redland Hospital Further enquiries to:​ • Tracey Anderson – Advanced Physiotherapist • Dr Tanja Miokovic – Senior Physiotherapist Telephone: 3488-3222; Fax: 3488-3223

Logan and Beaudesert Hospitals Further enquiries: Melanie Walkenhorst - Clinical Lead Physiotherapist Telephone: 3299 8858​; Fax: 3299 8280 High prevalence medical Conditions in pregnancy MSH Metro South Demographic: High prevalence conditions

• Iron deficiency ( with or without anaemia) • Gestational Diabetes Mellitus • Hypertensive disorders of pregnancy • Prenatal weight excess/ Excess weight gain antenatal • Perinatal substance use incl smoking Task 3 – Break out groups

• Green – Kate - Thyroid disease/ Obesity • Blue – Moana - GDM • Yellow – Amina - Hypertension incl MAC info • Red – Anne - Reduced FM/IUGR/Safer Baby Bundle

You are SUPER clinicians this afternoon – 10 minutes only! Green group: Task 3 - Kate • Kate is 28 year old. G6P4 (+1) at 14 weeks gestation • Identifies as an Aboriginal and Torres Strait islander woman. • She has been stable on 100 mcg of thyroxine o.d. for several years and is taking no other medication. • Her BMI is 40. What are the next steps? What changes if her BMI is now 32 after having undergone bariatric surgery last year? Thyroid disease and pregnancy Why is thyroid disease important? Hyperthyroidism Hypothyroidism

Fetal / neonatal hyperthyroidism Infertility Increased perinatal mortality Risk miscarriage Pulmonary Hypertension (uncontrolled) Reduced IQ children Preeclampsia Increased risk of hypertensive disorders of Miscarriage pregnancy Premature labour Placental abruption Placental abruption Preterm delivery Infection Perinatal morbidity and mortality PPH Routine testing NOT recommended in pregnancy unless: • Symptomatic • > 30 years old • Family history of thyroid disease • Morbid Obesity • Coeliac disease/Type 1 Diabetes Tips • 10% of women have suppressed TSH in the 1st trimester due to hCG mediated hyperthyroidism • Occasionally Free T4 and T3 are mildly elevated • Differentiate from Grave’s disease by the presence of TSH receptor antibody and increased colour flow doppler sonography • Don’t treat- will resolve 2nd trimester Hypothyroidism • If Borderline/Subclinical ….. • If overt – increase thyroxine dose by 30% at conception (extra dose 24% of Australian women are positive twice/week) for thyroid antibodies Studies regarding treatment of euthyroid • TSH > 10? Commence or increase anti-TPO antibody women with thyroxine thyroxine and refer as urgent are inconclusive with respect to reduction in miscarriage and adverse • Measure TSH at first visit, 6/52 later, pregnancy outcomes. then 2nd and 3rd trimester adjusting thyroxine dose as required. Subclinical Hypothyroidism – TSH > 2.5 • Aim for TSH - <2.5 1st trimester • Check T3/T4 and thyroid Abs (TPO) • Be guided by Flow Chart if antibody nd <3 2 trimester positive <3.5 3rd trimester • Drop dose postnatally/check at 6/52 Hyperthyroidism • Graves disease is the most common cause throughout pregnancy • Rx with propylthiouracil 1st trimester; carbimazole 2nd and 3rd trimester • ~ 60 % women able to have medications weaned by end 2nd trimester – need to watch for postpartum flare • Check TFTs every 4-6 weeks • TSH receptor antibody titre predicts risk fetal / neonatal thyrotoxicosis • Our Obstetric Medicine/Endocrinology colleagues will sort this out! • Refer early any woman who is thyrotoxic or who has a PHX Thyrotoxicosis (? Could still be TRAB positive and affect the pregnancy/infant). Obesity in pregnancy Redland maternity population: • ? 50+ % of people in Redland area are obese • (68% in Logan Catchment) • Around 30% of women who are pregnant are obese (across Qld) • Past bariatric surgery - growing incidence (0.5% in Qld 2014-19 - from new QCG) • “BMI greater than 25 kg/m2 or excessive Gestational Weight Gain (GWG) is implicated in up to 30 % of pregnancy complications” (Qld Clinical Guidelines – Obesity in Pregnancy – under review) The first GP visit …… • Early referral - Maternity Services including relevant information - Dietitian (if available)

• And initiate the following ➢ HbA1c (if K<12)/early OGTT

➢ 5mg folic acid daily (preconception/first TM) - increased congenital anomaly risk (esp neural tube defects) and higher incidence folate deficiency ➢ Baseline Urinary protein: Creatine ratio ➢ Dating scan - Early USS best for calculating EDB. Ongoing clinical assessment can be difficult! ➢ Arrange detailed anomaly scan - increased congenital anomaly risk ➢ Commence discussion re appropriate weight gain in pregnancy for BMI (chart if possible on weight tracker) The first GP visit should……

Consider the following • Aspirin 150mg OD - if also has the additional risk factor of hypertension • Antenatal thromboprophylaxis - if has additional risk factor for DVT And throughout antenatal care visits • Weight at each (counsel woman and chart on weight tracker for BMI) • Urinary protein (if hypertension/pre-eclampsia risk) • BP (with the right size cuff) • OGTT repeat at 26-28/40 if first one was negative With the obstetrician…. • Anaesthetic referral if BMI >40 if available • Serial scans if BMI>50 for fetal growth • If weight could impact transfer of care or birth decisions, recalculate BMI at approximately 36/40 or earlier (e.g. at 32/40) • Discussion about timing of birth Quick look information:

Flowchart: Obesity in pregnancy- including post bariatric surgery Queensland Clinical Guidelines (currently under review) https://www.health.qld.gov.au/__data/as sets/pdf_file/0022/141727/f-obesity.pdf Target gestational weight gain

Useful tools • See page 6 of the PHR or use a weight tracker for BMI Weight Tracker for BMI

• Use pre-pregnancy BMI if known as baseline or BMI at first Antenatal visit (or assume gain of 0.5-2kg in first TM) • New table coming with GWG recommendations including variations added for women of Asian ethnicity. Queensland Clinical Guidelines: Obesity in Pregnancy (currently under review) From “Obesity in pregnancy-including post bariatric surgery Queensland Clinical Guidelines” (currently under review) Available to download BMI < 25 Kg/m2 ; BMI > 25 kg/m2 Maternal obesity is associated with a range of complications which can have a negative health impact on both the mother and her baby

Consider initiation of the following Aspirin 150mg mg/day, • if obese and additional risk factor for hypertension Antenatal thromboprophylaxis • if obese and additional risk factor for DVT Maternal Obesity: Risks for the mother • Increased rate of subfertility • Type 2 diabetes and it’s associated sequelae • Hypertensive related disorders • Thromboembolism • Obstructive sleep apnoea • Higher incidence induction of labour and Caesarean section • Complications in labour resulting in birth trauma/ instrumental birth • Anaesthetic complications • Post operative complications • Higher PPH incidence • Postnatal complications i.e. Delayed lactogenesis/breastfeeding difficulties, thromboembolism, postnatal depression • Maternal death rate higher The frequency of adverse outcomes with increasing BMI The following charts are based on analysis of 75,432 women birthing at Mater Mothers Hospital Brisbane 1998-2009

McIntyre HD, Gibbons KS, Flenady VJ, Callaway LK. Overweight and obesity in Australian mothers: epidemic or endemic? Med J Aust. 2012; 196(3):184-8. The frequency of adverse outcomes with increasing BMI The following charts are based on analysis of 75,432 women birthing at Mater Mothers Hospital Brisbane 1998-2009

McIntyre HD, Gibbons KS, Flenady VJ, Callaway LK. Overweight and obesity in Australian mothers: epidemic or endemic? Med J Aust. 2012; 196(3):184-8. Maternal Obesity - Risks for the baby • Increased risk of miscarriage/recurrent miscarriage/foetal anomaly • Reduced reliability of cfDNA testing (NIPT). • Limitations on clinical assessment and ultrasound screening for fetal anomaly and growth – higher risk missed IUGR/anomalies • Increased risk pregnancy complications e.g. Macrosomia, shoulder dystocia, birth trauma, stillbirth • Increased risk perinatal complications e.g. respiratory distress, jaundice, hypoglycaemia and increased perinatal death. • Delayed lactogenesis, reduced breastfeeding initiation & continuation • Childhood obesity and diabetes risk ongoing The frequency of adverse outcome increases with increasing BMI The following charts are based on analysis of 75,432 women birthing at Mater Mothers Hospital Brisbane 1998-2009

McIntyre HD, Gibbons KS, Flenady VJ, Callaway LK. Overweight and obesity in Australian mothers: epidemic or endemic? Med J Aust. 2012; 196(3):184-8. The frequency of adverse outcome increases with increasing BMI.

The following charts are based on analysis of 75,432 women birthing at Mater Mothers Hospital Brisbane 1998-2009

McIntyre HD, Gibbons KS, Flenady VJ, Callaway LK. Overweight and obesity in Australian mothers: epidemic or endemic? Med J Aust. 2012; 196(3):184-8. In an ideal world….. The provision of preconception/inter-conception care would be gold standard because • ↑ chances of conception by reducing BMI to <30 (5-10% reduction if obese) • prepregnant weight excess may be more of a risk than excess weight gain in pregnancy • Women gaining one to two BMI units from one pregnancy to the next increase their risk of gestational hypertension, GDM or LGA birth by 20–40%. Why is this such an issue?

https://www.beginbeforebirth.org/ Get Healthy Queensland • Free confidential telephone service providing a health coach who will help with: Eating healthy Getting active Gain or maintain a healthy amount of weight in pregnancy Alcohol abstinence Return to pre pregnancy weight • It includes personal health coach for pregnancy and postnatal period 10 coaching calls over 6 months options to re enrol or get 6 months free coaching texts https://www.gethealthyqld.com.au/ So back to Kate…..

If she has undergone bariatric surgery and BMI is now 32 – what changes to our management and that at the hospital? Queensland Clinical Guidelines

Obesity in pregnancy https://www.health.qld.gov.au/__dat a/assets/pdf_file/0019/142309/g- obesity.pdf (currently under review) Prenatal advice

CONSIDER: • Bariatric surgery • Metformin • Inter-pregnancy weight reduction

Behold the benefits of seeing an enthusiastic dietitian…. Dietitian – Redland Hospital

Naomi Scolari Dietitian – Redland Hospital Antenatal Dietitian • GPs are advised to make clear in the antenatal referral if Dietitian review is considered likely in the pregnancy. • Early referral will assist in ensure the Dietitian in Antenatal Clinic is involved in a timely manner.

• Consider in: ➢Women with previous weight loss surgery ➢Women with poor gestational weight gain ➢Women with nutrition related co-morbidity e.g. Colitis. ➢Women below a healthy weight (BMI < 18.5kg/m2) ➢Women following restrictive diet (ie vegan diet) Healthy pregnancy weight gain. Education from the start!

• Advocate for health/lifestyle changes - generally very motivated

• Recommend weekly/fortnightly weight tracking; encourage women to self

monitor. Especially important from early pregnancy – “avoid eating for 2”

• Where to access: https://www.health.qld.gov.au/nutrition/patients# or Get

Healthy NSW Pregnancy Weight Calculator

• Encourage to set small achievable goals • Consider referral to Get Health in Pregnancy (as previously mentioned). Bariatric Surgery

• 80% of bariatric surgery recipients are women of childbearing age. – Contraception recommended for minimum 12 -24 months post surgery – however, this doesn’t always happen!

• Lifelong micronutrient supplementation & monitoring is recommended for all surgery recipients to prevent deficiency. – 1-2 multivitamins (iron, folate, thiamine) – Calcium supplementation dependant on oral intake – Vitamin D titrated to serum levels

Summary on Table 91 Pregnancy after bariatric surgery In pregnancy, literature has significant gaps: Analysing different surgery types Correctly reporting biochemistry & potential confounders Considering oral intake, supplement use & compliance

Currently, literature suggests increased risk of: ??? role of • SGA, IUGR & pre-term birth2 dietary intake & • Vitamin A, B12, D, calcium & iron deficiency healthy • Up to 90% of pregnancies3 gestational weight gain Every Trimester + every 3 months if First Trimester 4 breastfeeding1,4 LEVEL 4 EVIDENCE: LEVEL 2- EVIDENCE: Suggested Serum vitamin E FBC + Iron studies supplementation in Serum zinc & copper Serum Folate clinical practice: Selenium Serum Vitamin B12 Serum Vitamin A (include CRP & retinol binding protein) 1-2 adult multivitamins5-7

LEVEL 4 EVIDENCE: -Centrum Advanced multivitamin Serum Vitamin D + Calcium BD -BN Multi (capsule or chewable) Phosphate BD Magnesium -Nutri Chew Multivitamin BD

+ prothrombin time, PTH, INR, vitamin K1 Folic acid Calcium & Vitamin D Dietary management

➢ Managing weight expectations – fear of weight General dietary recommendations in pregnancy gain Grains 8.5 serves ➢ Nutritional adequacy with focus on meeting Meat and Alternatives 3.5 serves Vegetables 5 serves protein and calorie requirements Fruit 2 serves ➢ Ensuring intake is nutrient dense, not just Dairy and Alternatives 2.5 serves calorie dense Discretionary foods Limited to 0-2.5 serves ➢ Managing symptoms: ➢ Constipation, reflux, early satiety How is a patient with previous bariatric surgery ➢ Use of supplement drinks e.g. able to consume this? Ensure/Sustagen as required. Although this is case by case basis References

1 Mechanick, J. I., et al. (2019). "Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, the Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists - Executive Summary." Endocr Pract 25(12): 1346-1359. 2 Kwong, W., et al. (2018). "Maternal and neonatal outcomes after bariatric surgery; a systematic review and meta-analysis: do the benefits outweigh the risks?" American Journal of Obstetrics and Gynecology 218(6): 573-580 3 Rottenstreich, A., et al. (2017). "Maternal nutritional status and related pregnancy outcomes following bariatric surgery: A systematic review." Surgery for obesity and related diseases. 4 Shawe, J., et al. (2019). "Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care." Bariatric Surgery / Pregnancy. 5 Rothman, K. J., et al. (1995). "Teratogenicity of high vitamin A intake." Journal of Medicine 333(21). 6 Azais-Braesco, V. and G. Pascal (2000). "Vitamin A in pregnancy: requirements and safety limits." American Journal of Clinical Nutrition 71: 1325S-1333S. 7 Dolk, H. M., et al. (1999). "Dietary vitamin A and teratogenic risk: European teratology society discussion paper." European Journal of Obestetrics and Gynaecology 83: 31-36. https://metronorth.health.qld.gov.au/health-professionals/healthy-pregnancy-healthy-baby Dietary needs and considerations Blue Group: Task 3 - Moana

• Moana is 38 and happy to be pregnant again with her second baby (new partner) • Positive pregnancy test at home yesterday • Did a pregnancy test 3/52 ago, but this was negative. She is not sure when she fell pregnant though, as her periods have been irregular with the last one 9 weeks ago. • First baby was 4.7kg at birth – 15 years ago • Her BMI is now just over 33 - she never lost the weight she gained in her first pregnancy. No personal or family history of GDM.

Outline your assessment, considerations and next steps Gestational Diabetes Mellitus

Dr Wendy Dutton Director of Obstetrics and Gynaecology, Redland Hospital Gestational Diabetes Testing for Diabetes in Pregnancy

GDM Definition: Glucose intolerance of variable severity with onset, or first recognition, during pregnancy

There are two main issues: 1. Does a woman have undiagnosed diabetes? Preconception or first trimester testing is particularly important if high risk e.g. BMI > 30, past history of gestational diabetes (GDM), PCOS or previous macrosomic baby 2. How best to test for GDM? GDM Diagnosis – Oral Glucose Tolerance Test (75g)

• Time Plasma glucose level (one or more) • Fasting ≥ 5.1 mmol/L • 1 hour ≥ 10.0 mmol/L • 2 hour ≥ 8.5 mmol/L • Hb1Ac > 5.9% (> 41 mmol/mol) https://www.health.qld.gov.au/__data/assets/pdf_file/0022/950503/g-gdm.pdf https://www.health.qld.gov.au/__data/assets/pdf_file/0024/140874/ed-gdm.pdf Screening and diagnosis of GDM: Queensland Clinical Guidelines.

Qld Clinical Guidelines https://www.health.qld.gov.au/__data/assets /pdf_file/0023/950504/f-gdm-diagnosis.pdf https://www.health.qld.gov.au/__data/asset s/pdf_file/0031/951457/o-gdm-covid-faq.pdf

Testing for Diabetes during Pregnancy

• First trimester HbA1c (or early OGTT if k>12) for women at high risk of GDM • No random or fasting BSLs • No glucose challenge testing • Routine OGTT (24 – 28 weeks) for all women not previously noted as abnormal (HbA1c NOT suitable) • OGTT diagnostic criteria changed in 2015 Risk factors for GDM*

• BMI >30 (pre-pregnancy or on entry to care) • Ethnicity (Aboriginal and Torres Strait Islander, Pacific or South Sea Islander, Indian subcontinent, South East Asia, Middle Eastern or African) • Previous GDM • Previous elevated BGL • Maternal age > 40 years • Family history DM (1st degree relative or sister with GDM) • Previous macrosomia (birth weight >4500g or > 90th percentile) • Previous perinatal loss • Polycystic ovarian syndrome • Medications (corticosteroids, antipsychotics) • Multiple pregnancy

*Queensland Clinical Guideline: Gestational Diabetes Mellitus, February 2021 https://www.health.qld.gov.au/__data/assets/pdf_file/0022/950503/g-gdm.pdf HbA1c

• HbA1c can be used as a diagnostic test for diabetes in first trimester • HbA1c of ≥5.9% (41mmol/mol) required for a diagnosis of GDM * • >6.5% (48mmol/mol) to diagnose type 2 diabetes • This DOES NOT replace the OGTT for women after first trimester, or in the 6-8 weeks postpartum • HbA1c can be used for long term follow up of women with a past history of GDM, for early pregnancy or preconception testing in a high-risk woman.

https://www.health.qld.gov.au/__data/assets/pdf_file/0024/140874/ed-gdm.pdf Previous Bariatric Surgery – GDM Diagnosis If previous bariatric surgery, OGTT not suitable • 1st trimester - fasting BGL and HbA1c • 2nd trimester - 24–28 weeks ◦ If 4.6–5 mmol/L, fasting and postprandial self-monitoring BGL for 1–2 weeks • 3rd trimester - If clinical suspicion or evidence of fetal hyperinsulinaemia on USS, commence BGL testing Practice Points • Approx. 15% of women birthing at Redland are diagnosed with GDM (28% incidence in last 12/12 at Logan Hospital) • Logan Hospital patients approx.14.2% Pacific Islander and New Zealander • Samoans have 7x higher hospitalisation rates for diabetes complications than the rest of Queenslanders • A&TSI women are 10x more incidenceT2D in pregnancy and 1.5x more likely to have GDM • There were 7779 registered cases of gestational diabetes in Queensland in 2018— 11-12% of women who gave birth and of these, about 25% required insulin. Key Facts - Diabetes in Queensland - Chief Health Officer Report 2018 • "Women diagnosed with GDM were over 20 X more likely to develop type 2 diabetes, had almost twice the risk of developing hypertension and were 2.5 X more likely to develop ischaemic heart disease following delivery compared with control women." Diabetes Queensland - Diabetes in the News - January 2018 Logan Hospital GDM incidence compared to peer services - 2019-2020 1200 women a year diagnosed with GDM​ Why are we testing? Fetal and neonatal considerations, Major malformations/ Spontaneous miscarriages

No major malformation Major malformation Spontaneous miscarriage

100%

0% 7.7 < 9.3 - 7.7 11 - 9.4 12.7 - 11.1 14.4 - 12.8 14.4 > First Trimester HbA1c (%) Potential adverse pregnancy outcomes Maternal • Trauma related to macrosomia • Increased caesarean section rate • Pre term delivery • Pre eclampsia • Polyhydramnios Fetal • Congenital Malformations Respiratory distress • Spontaneous miscarriage Hypoglycaemia • Macrosomia Stillbirth • Shoulder dystocia Polycythaemia • Preterm birth and ongoing health issues Hyperbilirubinemia • Cardiomyopathy What if ….. • Moana has been undertaking GP Shared Care with you, and has been progressing well • Her initial screening for was negative, but at 26 weeks the repeat OGTT confirms GDM.

What is your next step, and how do you counsel Moana about what happens from here? GDM – Redland Hospital Model of Care

• Notify ANC ASAP once a diagnosis is made - send a referral to the obstetrician at ANC noting (in big, bold letters) “New diagnosis of GDM” and include a copy of the OGTT (or HBA1C) • Send back to ANC directly (not the HUB) – FAX: 3488 3436 Telephone: 3488 3434 • Please note if women need an interpreter or would not be suitable for a group presentation • Women attend a single group session with a nurse practitioner (NP) in diabetes within a week or so of the referral coming in • As woman is no longer low risk, her care will transfer back to the hospital obstetric team for care, with multidisciplinary input. • Endocrinologist input may be sought to advise the antenatal clinic team, so a separate referral is not required GDM - Redland Hospital Model of Care • Women are advised to use a glucometer and to measure their BSLs regularly and dietary control is commenced • They will be seen by an obstetrician the following week for review of their BSL readings/Pregnancy assessment • Further review of readings will be undertaken via the M THer app or hospital appointments as required • At present, women with GDM are transferred to an obstetric MOC where they are reviewed every 2/52 • Dietitian input is available where required (one day/week at present) • Lifestyle modifications are the primary therapy, with Metformin used prn. If insulin is required, women will be managed with physician input, and the Diabetes NP helps adjust insulin dosing • NDSS referral by GP or hospital team M THer-APP video: https://metrosouth.health.qld.gov.au/ news/redland-hospital-mother-app- takes-out-the-gold Gestational Diabetes Mellitus Tight sugar control is recommended – TARGET BSL’s

• Fasting BSL’s of <5.1 • 1 hour post prandial of <7.5 • 2 hour post prandial of <6.8

Be aware that Glycaemic targets are different than the RACGP targets. Targets are consistent with the ADIPS (Australian Diabetes in Pregnancy Society) Consensus Guideline and Queensland Health guideline (viewed at https://www.health.qld.gov.au/__data/assets/pdf_file/0024/140874/ed-gdm.pdf) Key points for GDM screening and management • Early identification of risk of GDM and screen as per Queensland Health Guidelines for GDM (& alternative COVID 19 recommendations and risk stratification advice). • Early referral to Antenatal clinic if at risk and has an abnormal OGTT or HbA1c • GDM education within first week of diagnosis • Dietetic review • Smoking cessation as required Recommended Antenatal Schedule of Care for GDM – Queensland Health https://www.health.qld.gov.au/__data/ assets/pdf_file/0029/146549/o-gdm- antenatal.pdf Resources For Patients: Booklets /Pamphlets/Webpages Useful websites • Diabetes Australia - Gestational Diabetes • NDSS – National Diabetes Services Scheme – Fact Sheets/Patient Videos • Diabetes Queensland – information and support service For Clinicians: • Australian Diabetes Educators Association • Australasian Diabetes in Pregnancy Society • Queensland Clinical Guidelines Videoconference • GDM Queensland guidelines: presentation https://www.health.qld.gov.au/__data/assets/pdf_file/0024/ 140874/ed-gdm.pdf https://www.health.qld.gov.au/news-events/news/what- Gestational diabetes mellitus is-gestational-diabetes-diagnosis-risk-factors-treatment- booklet (health.qld.gov.au) pregnancy-glucose-tolerance-test Postnatal follow up – GP

Women with GDM have a very high risk of developing Type 2 DM in the next 10 years, hence • OGTT 6-12/52 postpartum • HbA1c every 1-3 years • Repeat HbA1c prior to or early in next pregnancy • NDSS reminder once registered • Follow up other risk factors for macrovascular disease • Patient Resource : Gestational diabetes mellitus - Important postnatal information (health.qld.gov.au) Pharmacology and pregnancy

Dr Treasure McGuire, Pharmacologist Medication in pregnancy and breastfeeding Q&A General Principles, Organogenesis, ADEC Medication Categories - Interview with Dr Treasure McGuire Yellow Group: Task 3 - Amina • Amina is now 28/40 after a fairly uneventful pregnancy – has been seeing MGP midwife but presents with her husband today for both to have their Pertussis vaccination. • She has a mild headache and a blood pressure of 138/88. • Her BP was previously noted at 105/65. • Quite stressed on arrival as she has a meeting at work and is worried she will be late back. Outline your approach What is different if her BP was 152/97? Hypertensive disorders in pregnancy Hypertension in pregnancy Adverse perinatal outcomes with hypertension

• Cerebral injury; haemorrhage, encephalopathies • Placental abruption • Pre eclampsia/ eclampsia : 64% maternal mortality attributed to cerebral event • Premature birth, SGA, admission to NICU • Perinatal death Queensland Clinical Guidelines – Hypertension in Pregnancy Guidelines – February 2021 Hypertension in pregnancy

Management of hypertension in pregnancy – Flowchart (Qld Clinical Guidelines) When should you seek further advice and assessment? • BP> 140/90 and/or • persistent and/or severe headache • visual abnormalities (scotomata, photophobia, blurred vision, or temporary blindness) • upper abdominal or epigastric pain • nausea, vomiting • dyspnoea, retrosternal chest pain • altered mental status • hyper-reflexia. Pre-eclampsia Pre-eclampsia (PE) is the most common serious medical disorder of human pregnancy. • Most common in primiparous women • Family and personal history of pre-eclampsia is important

Signs and symptoms include • Hypertension • Renal dysfunction • Proteinuria • Oedema – hands, feet, face • in severe cases dizziness, headaches and visual disturbances. Untreated, it can lead to convulsions/other life-threatening problems for both mother and baby.

Pre-eclampsia occurs when a woman is pregnant, and currently, the only cure for it is to end the pregnancy, even if the baby premature. Some at risk women may develop, or have worsening symptoms in the immediate post- natal period – careful monitoring must extend into this period. Pre-eclampsia In Australia • mild pre-eclampsia occurs in 5-10% of pregnancies • severe pre-eclampsia in 1-2% of pregnancies • pre-eclampsia and complications associated with this condition account for 15% of direct maternal mortality and 10% of perinatal mortality • Pre-eclampsia is the indication for 20% of labour inductions and 15% of Caesarean sections. • It accounts for 5-10% of preterm deliveries. Worldwide, pre-eclampsia and its complications kill many tens of thousands of women and their babies each year​ Source: The Women's Hospital Long Term Consequences…. • “Analysis of health data from almost 90,000 women (Nurses’ Health Study II) 1989 - 2017 suggests effects are long-lasting. • Researchers found that one in seven women developed gestational hypertension or preeclampsia in one or more of their pregnancies. • In the three-decade follow up, found those who developed gestational hypertension or preeclampsia during pregnancy had a 42% greater risk of dying before age 70 than those who didn’t. • In particular, these women were more than 2 X as likely to die of cardiovascular disease than those who didn’t develop hypertensive disorders during pregnancy. • Links remained, even if women did not report persistent hypertension after birth. Hypertensive Disorders of Pregnancy and Subsequent Risk of Premature Mortality, Journal of the American College of Cardiology – March 2021 https://doi.org/10.1016/j.jacc.2021.01.018 Pre-eclampsia –​​ a multisystem ​disease Prophylactic Aspirin use in pregnancy to reduce PE and IUGR

High Risk Factors - Women with Moderate Risk Factors - Women any of the following: with more than one of the following: 150 mg aspirin nocte BEFORE 16 weeks gestation •Hypertension •Primiparous Ideally from 12 weeks until birth •Renal disease •BMI > 35 •Auto-immune diseases such as •Age > 40 SLE or anti-phospholipid •Multiple pregnancy syndrome •Family history of pre- •Diabetes (Type 1 or Type 2) eclampsia (mother or sister) •Past history of pre-eclampsia •More than 10 years since last pregnancy

What about calcium? Calcium has been shown to reduce BP, relax smooth muscle, lower resistance in uterine and umbilical arteries. If a woman has deficient intake, 1.5 g/day is recommended. Medical condition or complication develops after referral/booking FAX a new referral/letter to ANC with results attached, and problem clearly identified If advice required or URGENT - PHONE first:

• Redland – Phone (On-call Obstetric Registrar) – 3488 3758, FAX 3488 3436 • Logan - Phone: 32998811(Triage Midwife) or 3299 8027 (Obstetric Registrar on-call), FAX: 3299 8082 • Beaudesert – Phone:Triage Midwife – 5541 9144 or GP Obstetrician on-call – 5541 9174, FAX: 5541 9132

DO NOT REFER BACK THROUGH THE CENTRAL REFERRAL HUB. CONTACT IS TO THE MATERNITY TEAM DIRECTLY Just a reminder….

BP ≥ s BP 140 and/or d BP ≥ 90

1. URGENT review is required in the Maternity Hospital 2. Call the obstetrician/registrar on call 3. Document and provide a handover via phone and via written documentation Maternity Assessment Clinic (MAC) - Logan and Redland Hospital

• For pregnancy related Most common presentations: conditions > 20 weeks • Suspected preterm labour gestation • Uncertainty about or • You should contact the assessment for premature MAC before you send a rupture of membranes woman for review • Change in fetal movements • How serious is the woman’s • Review of hypertension condition? Consider QAS • Bleeding after 20 weeks transfer gestation

For Beaudesert Hospital: Contact Triage Midwife – 5541 9144 or GP Obstetrician on Call – 5541 9174 Red group: Task 3- Anne

• Anne is now 32 weeks pregnant. Small for dates? Everyone is telling her she looks too small. • Her symphysis-fundal height today is 29cms. The last SFH (@30weeks) was 29cms. • Her hairdresser has been super helpful with advice and told her something is very wrong, and the baby might die!!!

Outline your assessment, considerations and next steps Standardised Fetal Growth Chart – in next version of PHR (and hospital Antenatal Record)

https://metronorth.health. qld.gov.au/wp- content/uploads/2021/01 /mn274.pdf A quick tip... • Assessment of fetal growth and well-being by USS in the third trimester should be considered if fundal height is 3cm above or below expected for gestational age (or difficult to monitor because of maternal BMI). • Consider assessment of amniotic fluid volume (deepest vertical pocket) & Doppler umbilical artery flow measurements • If IUGR confirmed, refer back to the Maternity Service (Fax to ANC and recommended to phone Obstetrician or Registrar). Decreased fetal movements (DFM)

• Early reporting of DFM and or changed fetal movements is vital. • Good antenatal education has been shown to reduce the time a woman waits to show health seeking behaviour after noting a change to fetal movements which is why we are talking about this today as a potential primary care provider during pregnancy Risk factors for stillbirth

• > age 35 years • Congenital abnormality • Obesity • IUGR • Smoking, drugs, alcohol • Pre eclampsia • GDM • Congenitally acquired • Hypertension infections • Placenta or cord issues • Multiple pregnancy • Medical conditions How to observe for DFM Out In Kick charts Watch for change in pattern, frequency or strength of movement Cold water/ sweet drinks Third trimester - encourage to start every sleep lying on side Reassurance without review Monitoring with an app BUT not linked to “ amount per day” URGENT assessment required for DFM or change to movements > 24 weeks gestation Stillbirth rates – UNICEF 2020 Rate of stillbirth in Australia is higher than other top performing countries.

Australia's stillbirth rate (28 weeks' gestation and beyond) is 35% higher than the six best performing countries What can you do to assist with reducing preventable stillbirth rates?

Implementation of the care bundle has been reported to reduce stillbirth rates by 20% in England and Scotland. In many cases stillbirth is preventable, and research shows 20-30% of stillbirths could be avoided with better care.

The Safer Baby Bundle Handbook and Resource Guide has been created to assist maternity healthcare professionals with implementation of the bundle.

Free and accredited CPD training for healthcare professionals is available via e-learning modules Safer Baby Bundle - Handbook and Resource Guide

Resources- brochures, posters, learning modules

• Safer Baby Bundle https://www.stillbirthcre.org.au/safer- baby-bundle/ • Stillbirth – Centre of Research Excellence • Perinatal Society of ANZ - Stillbirth and Neonatal Death Alliance (PSANZ-SANDA) Stretch your legs – on the home run……

Guest presenters for this section: • Postnatal Midwifery Service – Jane Rundle, Clinical Midwife • Child Health Service – Tracey Button, CNC, Child Health Bayside Session 3 - The End

Time Session Presenter Delivery method 3:10 pm Postnatal Midwifery Home Visiting Jane Rundle – Clinical PowerPoint presentation Service Midwife Consultant

3:15 pm Child Health Services Tracey Button, CNC, Child Health PowerPoint presentation Bayside

3:25 –3:30pm Close – Alignment requirements Dr Kim Nolan and certification Questions ? Complete quiz online + Evaluation Postnatal care Reintroducing Kate….. • Kate has gone on to have a healthy pregnancy and baby born by spontaneous vertex delivery. Placenta and membranes delivered complete with second degree tear repaired according to the discharge summary. She is breast feeding her baby. • Presented today with sudden increased heavy PV bleeding, clots and low cramping pain. She is apyrexial but reports waking in the night sweating. Her BP is 105/67 and pulse 102. She looks pale and in pain • What is your assessment and plan for Kate? Postnatal Information Brochure - provided to all women at Logan at time of hospital discharge.

Brochure for post Caesarean birth also.

Postnatal care by GP- Why is the GP so important? • A most vulnerable time for women and their families • The ability to provide regular review and collaborative care with specialist services • Review at 5-10 days • An opportunity for the woman and her baby to reconnect with the GP if maternity care has been provided elsewhere • Ongoing care for medical issues such as hypertension, diabetes and anaemia Postnatal care by the GP • Breastfeeding support and referral to lactation services • Immunisations • Well baby checks and 6-week check • Long term education and care to maximize achievement of long-term health goals • Contraception and pregnancy spacing • Pre pregnancy counselling and referral • Re-engaging those in low socio-economic regions https://www.racgp.org.au/afp/2012/may/the-6-week-check/ Postpartum lochia Secondary PPH = excessive bleeding occurring 24/24 postpartum and up to 6/52 postnatal

• More than 500mls • Deterioration in clinical presentation • Regression to bright red lochia, heavy, clots • Increase in pain to low abdomen or pelvic region • May have rigors or pyrexia In the GP surgery.....a presentation with abnormal bleeding postnatally • Observations esp temp, PR, BP (?postural drop) • Clinical assessment of blood loss, check fundal height ? tenderness • ? Other discharge ? Malodour, – consider PVE/swabs • Review birth history • Consider sepsis …… Call QAS immediately for clinically instability and/or deteriorating clinical condition. Conditions that mimic sepsis in pregnancy (and postpartum)

SOMANZ guidelines for the investigation and management sepsis in pregnancy SOMANZ (Society of Obstetric Medicine Australia and New Zealand) 5–7-day check mum and baby check by GP • Think ahead..... women need to be advised to make a double appointment and register the baby with the Medicare too! They may be shocked to find that as baby has no medicare yet, they may be privately billed. • Remind to bring any records and the Child Health (red) book • When they leave, ask them to book the 6-week check • See your patients in response to individual need • Refer to/or provide information about Child Health Services • MMR required?– if non-immune and missed in hospital • Pertussis booster required? - if missed during pregnancy Systems based approach to Post-Partum Care Post-Partum check at 6/52 History: Examination: Adacel/Boostrix Abdomen Bladder, bowels, breasts Breasts, BP Calves, contraception Consider Cervical Screening Delivery debrief prn Test, inspect perineum if EPDS tear/episiotomy Feeding Gestational Diabetes follow up prn Hypertension follow up prn The 6-week postnatal check- not just physicality • Part of the lifelong journey of health • Promoting and enhancing the family to GP partnership in health • Looking at parental strengths to establish any emerging health deficits in the childhood years • Identifying parental issues that may be of detriment to childhood development • Understanding the social determinants within the family and the context of their family lives https://www.racgp.org.au/download/documents/AFP/2012/May/201205fasher.pdf Breastfeeding • The cornerstone to child health, survival , nutrition and development (WHO 2017) • Considerable evidence about the benefits of breastfeeding for both baby and mum • 10 steps to breastfeeding • https://www.evidentlycochrane.net/new-baby-new- parents/:quick look at some research around the most common breastfeeding/ breast complaints and preventative measures/treatment Breastfeeding http://www.tensteps.org/ Referring to breastfeeding support services is one of the ten steps Resources for the new parent

• 13 HEALTH (13 43 25 84). Ask for the Child Health Nurse • Child Health Services- https://www.childrens.health.qld.gov.au/chq/our- services/community-health-services/child-health-service/ • Pregnancy Birth and Baby website - https://www.pregnancybirthbaby.org.au/ • Postnatal Midwifery Service – Redland Hospital – Phone: 3488 3444/3488 3759 • Community Midwifery Service for vulnerable women in Logan/Beaudesert Catchment Lactation Support: face to face or telephone services • Redland Hospital Lactation Consultant - Phone: 3488 3409

• ABA – Ph: 1800 686 268 www.breastfeeding.asn.au • Lactation consultants: LCANZ - Find a Lactation Consultant

• Mater Breastfeeding Support Centre Ph: 31638200 • Possums Clinic Ph: 3036 4081 or Website - www.possumsonline.com/ Postnatal Midwifery Service – Redland Hospital

Jane Rundle – Clinical Midwife Consultant Postnatal Midwifery Home Visiting Service – Redland Hospital • Provide care to women in community for 3 to 5 days following birth for continuation of care from postnatal ward. • Home visit to women in geographical boundary. • Phone call to women outside geographical boundary. • CONTACT: Phone number 3488 3444/3488 3759

• MGP Model - care up to 6 weeks- (care provided in the community or at the woman’s home)

• Do not see unwell babies/mothers – refer newborns that GP concerned about back to ED/dedicated Paediatric ED at Redland Hospital/Lamb Ward Community Midwifery Service- Logan only • Support for vulnerable women and their babies up to twenty-eight days after birth • For women who have birthed Logan/Beaudesert and reside in this catchment • Women and babies must be medically stable to be eligible for referral • Don’t forget the additional service of Child Health • Other women may access the service dependent upon discretion and service capacity Eligibility criteria Women and or neonates who require additional support that they are unable to access via mainstream services. This may include: • Complex feeding support • Psycho-social support • Birth counselling and debriefing • Jaundice assessment • Wound assessment • Newborn check and weight assessment • Safe relationship education and review Ineligibility criteria

• Women under the MGP model of care • Women under the care of a Private Practicing Midwife • Women or babies who are acutely unwell- GP need to refer as appropriate to meet clinical need • Women who are known to have been identified as an “at risk ” by the safe home visiting criteria • Women who are out of catchment How to refer Logan Community Midwifery Service • Via Central Referral Hub – details as per “Refer Your Patient” website. • State your referral is for CMS • Phone 3089 2814. 8am-3pm. Mon to Sunday

Beaudesert Midwifery Service • Phone 5541 9144 Child Health Services

Tracey Button, CNC, Child Health Bayside Child Health Services Overview

• Our team, clients and services

• Supporting children’s development

• Who and how to refer

• Our feedback to you

• Questions? Child Health Services

• Universal service for all children (0-5yrs) and their parents/carers. • Targeted services (0-8yrs) and their parents/carers • Free for all, including those who are ineligible for Medicare rebates. • Interpreter services available. Our Services

• Self weigh facilities Our Multidisciplinary Team • Drop-in clinics for early feeding support (0-12 weeks) • Day stay for feeding and parent support (0-6 months) • Child Health Nurses • Clinic appointments • Social Workers and Psychologists for • Nurse home visiting parenting support • Key age child health checks • Advanced Health Workers • Parenting groups • Early referral to dental care (0-4 years) Supporting children’s development

• Child Health Nurses use the opportunity of completing key child health checks to provide specialist advice and build parents’ capacity as a carer and an educator. ✓ 0-4 weeks

✓ 6 months

✓ 12 months

✓ 18 months

✓ 2.5 - 3.5 years

✓ 4 - 5 years Supporting children’s development

30

25.9 25 22.7 21.7

20

15 13.9 12.1 11 10

5

0 % Vulnerable on 1+ Developmental Domains Vulnerable on 2+ Developmental Domains Australia Queensland Redland community Supporting children’s development

45 41.2 40 35.2 35 29.8 30 25.9 27 25 23.5 20 20 16.8 16.9 15 13.9

10

5

0 % Vulnerable on 1+ Developmental Domains Vulnerable on 2+ Developmental Domains

Queensland Alexandra Hills Birkdale Capalaba Macleay Island and surrounds Who to refer

• New babies, toddlers, and beyond! Specialist Child • The Child Health Service is universal and free Health Nurse for everyone.

• We’re part of the care team, with you as the lifelong carer. GP Midwives • Families with more need or who are experiencing vulnerability can be provided more intensive and sustained support. Early Childhood Educators How to refer Families can also self refer t: 1300 366 039

Dedicated phone line for Southern Moreton Bay Islands (free call) t: 07 3488 4350 Our feedback

• For your consideration and referral to secondary services.

• Concerns re: children’s growth and development or anomalies noted during the assessment.

• Concerns noted re: parental wellbeing.

• Developmental concerns raised by the parent/carer. More information Child Health Services https://youtu.be/R5bHvphAKNE

Metro South Health Spot On Health Pathways

https://metrosouth.health.qld.gov.au /spotonhealth-healthpathways https://bsphn.org.au/support /for-your-practice/maternity- shared-care/ https://metrosouth.health.qld.gov.au/referrals/antenatal Summary of routine investigations • Routine first trimester Antenatal Screen = FBC, Blood group and antibodies, Ferritin, Rubella, Hep B, Hep C, HIV, Syphilis and MSU m/c/s (+ CST if due) • Women with BMI > 30 to have first trimester HbA1c or early OGTT if K>12 , E/LFTs urinary protein/creatinine ratio as well as the above • 26-28 week bloods = FBC, Ferritin, OGTT and Blood group and antibodies • 36 week bloods = FBC, consider repeat Ferritin (if previously low) Brisbane South Antenatal Share Care Summary – April 2021

Available at Metro South Health – “Refer Your Patient” and the BSPHN “Maternity Shared Care” webpage Who can you call? If you are uncertain about the best approach to take in caring for or referring a woman, phone the: • On-call Obstetrician • Registrar • Dedicated MATERNITY GP Liaison Midwife Manager • & Dr Kim Nolan –GPLO General Practitioner – Maternity – Primary Care Partnerships Unit | Metro South Health 2404 Logan Road Eight Mile Plains – PHONE: 07 3156 4336 – Email: [email protected] If woman requires urgent review, call the On-call Obstetrician/Registrar (or Maternity Assessment Unit at Logan Hospital) Who can you call at Redland Hospital?

• Antenatal Clinic Reception (8 am- 4 pm Mon to Fri) Telephone: 3488 3434 Fax: 3488 3436 • Triage Midwife Telephone: 3488 3044 • Maternity Assessment Unit – Telephone: 3488 4075 (Mon-Fri 0930-1800) or by Fax: 3488 4432 • Women’s, Men’s and Pelvic Health Physiotherapy - Telephone: 3488 3222 Fax: 3488 3223 • O & G Registrar – Telephone: 3488 3758 or via Switchboard • Obstetrician on Call – Telephone: 3488 3111 or via Switchboard • Pregnancy Complications: Contact On-Call Obstetrician – 3488 3111 • Perinatal Mental Health Service: 3825 6214 Who can you call at Logan Hospital?

• Antenatal Clinic Reception (8 am- 4 pm Mon to Fri) Telephone: 3299 8527 Fax: 3299 8202 • Triage Midwife Telephone: 3299 8811 • Women’s, Men’s and Pelvic Health Physiotherapy Logan and Beaudesert Hospitals - Telephone: 3299 8858 Fax: 3299 8280 • O & G Registrar – Telephone: 3299 8027 or via Switchboard • Obstetrician on Call – Telephone: 3089 6963 or via Switchboard • Early Pregnancy Assessment Unit (K<20): Telephone: 3299 8456 • Maternity Assessment Clinic (Complications K>20): Telephone: 3299 8811 • Postnatal Community Midwifery Service: Telephone: 07 3089 2814 Who can you call at Beaudesert Hospital?

• Antenatal Clinic Reception (8 am- 4 pm Mon to Fri) Telephone: 5541 9144, FAX: 5541 9132 • Triage Midwife Telephone: 5541 9144 • Women’s, Men’s and Pelvic Health Physiotherapy Logan and Beaudesert Hospitals • Telephone: 3299 8858 Fax: 3299 8280 • GP Obstetrician/Rural Generalist on Call – Telephone: 5541 9174 Item numbers for MSC 16500 Rebate $40.10 Antenatal Attendance 91853 (video) 91858 (telephone) equivalent of 16500 16591 Rebate $121.30 “Planning and management, by a practitioner, of a pregnancy if: (a) the pregnancy has progressed beyond 28 weeks gestation; and (b) the service includes a mental health assessment (including screening for drug and alcohol use and domestic violence) of the patient; and (c) a service to which item 16590* applies is not provided in relation to the same pregnancy Payable once only for a pregnancy” (*16590 = planning to undertake delivery for a privately admitted patient) Postnatal item numbers 16407 Postnatal professional attendance (other than a service to which any other item applies) if the attendance: (a) is by an obstetrician or general practitioner; and (b) is in hospital or at consulting rooms; and (c) is between 4 and 8 weeks after the birth; and (d) lasts at least 20 minutes; and (e) includes a mental health assessment (including screening for drug and alcohol use and domestic violence) of the patient; and (f) is for a pregnancy in relation to which a service to which item 82140 applies is not provided (participating RM)

Payable once only for a pregnancy Fee: $71.70 Benefit: 75% = $53.80 85% = $60.95

16408 Home visit for woman who was admitted privately for the birth. Midwife (on behalf of and under the supervision of the medical practitioner who attended the birth) Obstetrician or GP can claim. 1-4 weeks post partum, at least 20 min duration Fee: $53.40 Benefit: 85% = $45.40 To apply the best practice share care models in antenatal and postnatal care, we all need to be Clinically competent Up to date Following the Guidelines Thinking Communicating How to be aligned with MSHHS • Ensure have sent in evidence that completed RACGP ALM – Certificate of Completion/ Dashboard Screenshot • ? Flowcharts • Undertake Knowledge Assessment – link to be sent from BSPHN by email in next few days (80% pass mark)

• Undertake Evaluation/Feedback – link to be forwarded – please let us know what we did well and what we could do better!

• RACGP CPD points are only allocated and MSHHS Alignment confirmed if all completed. • Alignment will need to be undertaken (or an alternative) every 3 years. https://bsphn.org.au/wp-content/uploads/2021/05/Metro-South-Health-Maternity-Shared-Care-Alignment-and-Realignment-Options.pdf Maintaining Alignment To maintain your alignment after the next 3 years, you must either: • repeat an Alignment Seminar - you can repeat a MSHHS Alignment OR an affiliated Alignment (MMH/RBWH/Nambour/? soon to be Ipswich) + complete an online bridge including Q&A. OR • attend three relevant antenatal or postnatal/neonatal CPD events & complete online bridge including Q & A. CPD events DO NOT need to be with the Metro South Health Services OR • Complete a RANZCOG Diploma or Certificate in Women’s Health + complete the online bridge

Hoping to commence an Alignment 2 (and then 3) in next 12-18/12 for MSHHS. MSH Maternity Shared Care Online Bridging Program

• Program is delivered via an interactive online learning module including an exam/quiz to complete • Available to GPs who are currently aligned to Shared Care at MMH and wish to align with MSH. • Takes approximately 1- 1 ½ hours to complete. • Once complete, GPs will receive notice of completion which can be claimed as Continuing Professional Development (CPD), logged through the RACGP member portal or other associations. • To access the MSH GP Maternity Shared Care Online Bridging Program, please complete the expression of interest form on the BSPHN Maternity Shared Care webpage. MMH Alignment • To become aligned with MMH you can participate in an Alignment event run by MMH (AM1/AM2/AM3 and soon to be AM4 + Online Realignment option) OR • after a MSHHS Alignment GPs will need to complete MMH’s online bridge including Q&A – accessed by contacting the MMH Alignment team and forwarding a copy of your certificate from completion of this event. • MMH GP Liaison Midwife - Telephone 07 3163 1861, mobile 0466 205 710 or email [email protected] • . Thank you …. and three more things... • Let us know if you would be happy to have your contact information available for pregnant women who don’t have a regular GP • MSHHS will hold your contact details as well as BSPHN – Alignment stays with the doctor, not the practice, but let us know if you move practice. • Provide an updated email address that we will be able to contact/update you on in the future [email protected] Good afternoon and thank you!