Information for GP’s

NICE 2017 define anaemia in pregnancy as:

First trimester and up to 27 weeks and 6 days gestation	< 110 g/L
28 weeks and above	< 105 g/L
Postpartum	< 100 g/L

Click here for our antenatal and postnatal management of anaemia pathways.

Aspirin is frequently used in pregnancy as prophylaxis for pre-eclampsia and placental disease. Women are risk assessed at their booking appointment to determine if it is required. Those at high risk of pre-eclampsia are advised to take 150mg Aspirin nightly, for the duration of pregnancy:

Click here for our eligibility criteria for aspirin in pregnancy.

You may find the following information useful in supporting your prescribing:

Video summary

Full article of of the RCT ‘Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia’ (Dr Rolnik et al, 2017).

For our guideline on managing asthma in pregnancy click here.

We recommend that contamination on MSU is not treated (e.g. if the culture suggests mixed growth or coliforms BUT microscopy shows no significant pyuria (wbc <10 x10*6/L) this does not require antibiotic treatment (or a repeat sample) – doctors and midwives can regard these results as normal).

The BCG immunisation is recommended for all infants (aged 0 – 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater:

Tuberculosis (TB) by country: rates per 100,000 people.

https://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people

Babies born under the care of Saint Mary’s Hospital will be assessed for eligibility to receive the BCG vaccination. In cases where the immunisation needs to be deferred, and the baby will be >12months, the GP will be responsible for administering the vaccination.

At the booking appointment women are issued with the pregnancy hand held notes. We use this booking to risk assess each woman individually. You can view the booking proforma here.

Cardiac disease is the leading cause of maternal death (MBRRACE, 2016).

Saint Mary’s Hospital offer a Joint Obstetric Cardiology service. For more information on how to refer to the service and regarding pre-pregnancy counselling and support click here.

We also have an information leaflet, Contraception for women with cardiac disease, which you can find here.

Anticoagulation and metallic valves in pregnancy

Recent case reviews at Saint Mary’s Hospital, have highlighted some learning regarding the management of women with metallic valves in pregnancy, especially with regard to the importance of early referral into specialist services.  A recent UKOSS study has demonstrated that these women have high rates of poor fetal and maternal outcomes, with a 9% risk of maternal mortality and a 47% incidence of serious maternal morbidity.  In particular, the management of anticoagulation can be challenging and lead to complications. (Vause S, Clarke B, Tower CL, et al (on behalf of UKOSS)). Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG 2017;124:1411–1419.)

Women on long term warfarin therapy for their metallic valves should be assessed for transfer onto low molecular weight heparin as early as possible after pregnancy is diagnosed.  Low molecular weight heparin dosing should be guided by anti Xa level monitoring.  We can facilitate supervised transfer onto Tinzaparin at Saint Mary’s Hospital, and a direct referral can be made for this via the haematology specialist midwives on (0161) 276 8793/or 0782 796 9104.  An early referral should also be made in writing to Dr Sarah Vause or Dr Anna Roberts, Consultant Obstetricians in the Obstetric Cardiology service.  Telephone contact can be made with the team secretary Robyn Eccleston on (0161) 276 6426 if needed.

The team are keen to see any woman considering a pregnancy for preconception counselling, please make a referral in writing as above.

The Rainbow Clinic is a specialist service for women and their families in a subsequent pregnancy following a stillbirth or perinatal death. We care for families from the time of the postnatal appointment to discuss investigations onwards and into a subsequent pregnancy. The clinic provides additional scans to identify placental dysfunction and detect complications early in a subsequent pregnancy, continuity of care and psychological support.

Watch the short video below for more information on The Rainbow Clinic.

Women should be advised not to attend antenatal services (community or hospital based) until they have discussed any potential exposure to chicken pox or shingles with a midwife. Advise women to call their booking hospital’s antenatal clinic by telephone at the earliest possible opportunity:

Saint Mary’s Hospital (0161) 276 6423

Saint Mary’s at Wythenshawe (0161) 291 2951

During out of hours times, they can contact triage for advice:

Saint Mary’s Hospital (0161) 276 6567

Saint Mary’s at Wythenshawe (0161) 291 2724

For more information about chicken pox and shingles click here.

Preconception care and referrals for women with pre-existing diabetes

The importance of avoiding unplanned pregnancy should be part of diabetes education from adolescence for women with diabetes. The NICE guidelines for diabetes in pregnancy state that women with diabetes should aim to achieve an HbA1c result of 48mmol/mol (6.5%) or lower if this is achievable without causing problematic hypoglycaemia. GP’s should strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant due to risks of miscarriage, congenital malformation, stillbirth and neonatal death and to use contraception until good blood glucose control has been established.

All women with diabetes who are contemplating pregnancy should be commenced on high dose folic acid (5mg OD). Those wishing to book at Saint Mary’s Hospital should also be referred to the diabetes in pregnancy service.  To make a referral contact (0161) 276 6408.

Early referrals in pregnancy for women with pre-existing diabetes

As soon as pregnancy is confirmed, we recommend that diabetic women are referred urgently to the specialist consultant obstetrician or the diabetes specialist midwife. This can be done by telephone on (0161) 276 6408 and women should be seen in clinic within a week. Angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists and statins should be discontinued. Alternative antihypertensive agents suitable for use during pregnancy should be substituted.

We also recommend that women with type one or type two diabetes should be prescribed 150mg of aspirin at night for the duration of the pregnancy.

Gestational diabetes screening criteria

An oral glucose tolerance test (OGTT) is offered at 26 weeks for women with any ONE of the following risk factors:

• BMI 30 kg/m2 or higher
• Previous large baby (>4.5kg or >95th centile on customised chart)
• Previous gestational diabetes (see above section 2.2)
• Parent, brother or sister with diabetes
• Women with a family origin with a high prevalence of diabetes which includes South Asian (specifically from India, Pakistan and Bangladesh), Black Caribbean and Middle Eastern (specifically from Saudi Arabia, United Emirates, Jordon, Oman, Kuwait, Lebanon and Egypt)
• Taking anti-psychotic medication in pregnancy

Gestational Diabetes

Women with gestational diabetes undertake home blood glucose monitoring 6-7 times a day throughout their pregnancy and will require a prescription for 100 blood glucose testing strips and lancets every two weeks.

For women who were diagnosed with gestational diabetes and whose blood glucose levels returned to normal after birth, the GP should offer a fasting plasma glucose test 6-13 weeks after birth to exclude diabetes. Offer an annual HbA1c test to women who were diagnosed with gestational diabetes due to their moderate risk of developing type 2 diabetes.

For up to date advice about fetal movements refer to the patient information leaflets available via the links below –

Royal College of Obstetricians and Gynaecologists :

https://www.rcog.org.uk/en/patients/patient-leaflets/your-babys-movements-in-pregnancy/

Tommy’s:

https://www.tommys.org/pregnancy-information/health-professionals/free-pregnancy-resources/leaflet-feeling-your-baby-move-sign-they-are-well

Please note, this leaflet is available in a number of different languages

All women are asked at booking if they have a history of recurrent genital herpes and an appropriate management plan is developed.

Click here for more information about referring pregnant women who present with their first episode of genital herpes.

Women should be informed that no antenatal antibiotic treatment is required when GBS has been isolated on a LVS/HVS. However, women with a GBS bacteriuria (Positive Mid-stream Sample Urine (MSU) result) will need antenatal treatment (as per the sensitivities) even if asymptomatic.

All women with a positive Group B Strep result on MSU, vaginal swab or rectal swab in this pregnancy will be offered intrapartum antibiotics. If the test has been taken locally please ensure you inform her midwife in order that the necessary plan can be put into place.

GBS patient information and resources are available at:

https://gbss.org.uk/

https://www.rcog.org.uk/en/patients/patient-leaflets/group-b-streptococcus-gbs-infection-pregnancy-newborn-babies/

There is also a patient information leaflet that can be found here.

The Department of Health recommends that women should take a daily supplement of 400 micrograms of folic acid while they are trying to conceive, and should continue taking this dose for the first 12 weeks of pregnancy, when the baby’s spine is developing.

Patients requiring a higher dose of 5 milligrams (mg) of folic acid include those with:

• Epilepsy
• BMI ≥30
• Diabetes
• Sickle Cell Disease
• Thalassaemia
• Previous pregnancy affected by a neural tube defect or family history of neural tube defect
• Conditions that cause malabsorption including:
  • Coeliac disease
  • Inflammatory bowel disease (Crohns/Ulcerative colitis)
  • Women on folate antagonist drugs
  • Women with a history of excessive alcohol consumption

Click here for more information about HIV in Pregnancy and the Puerperium.

Saint Mary’s Hospital run a tertiary referral service for women with hypertension and kidney disease in pregnancy led by Dr Jenny Myers. All women with a diagnosis of hypertension and/or chronic kidney disease prior to pregnancy can be referred to the service for pre-pregnancy advice and pregnancy planning (contacts below).

• Before pregnancy women should be advised to take folic acid supplementation (400μg) daily.
• Chronic hypertension in the context of pregnancy is defined as a blood pressure >140/90mmHg recorded before 20 weeks gestation and/or a woman requiring antihypertensive medication before pregnancy.
• Women with chronic hypertension should be referred to Saint Mary’s as soon as they are pregnant, subsequent care will be tailored to individual needs and should be shared between hospital and community appointments where appropriate.
• Once a pregnancy is confirmed, women with hypertension should be prescribed aspirin 150mg daily (unless there are contraindications).
• Blood pressure should be optimised to a target of <140/90 mmHg in women with chronic hypertension.
• In women with blood pressure consistently above 150/100mmHg, anti-hypertensive medication should be increased or anti-hypertensive medication commenced.
• Medications suitable for continuation in pregnancy include:
  • Labetalol – minimum of three times per day, usual starting dose 100-200mg tds (upto 2.4g/day).
  • Nifedipine modified release (12 hourly preparations) or
  • Amlodipine (5-10mg od).
  • Doxazosin (2-4mg bd).
  • Methyldopa (500-750mg tds).
• In women with blood pressure >160/110mmHg, after 20 weeks gestation, should be referred to Saint Mary’s Hospital for a same day review.
• Home monitoring of blood pressure should be encouraged in women motivated to do so, but all home BP monitors should be checked against a machine validated for use in pregnancy.

 

• The following medications are not recommended to be continued during pregnancy:
  • ACE inhibitors (can be continued until confirmation of positive pregnancy test)
  • Statins
  • Angiotensin receptor blockers
  • Atenolol

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After pregnancy

• Blood pressure should be maintained <140/90mmHg after birth and should be checked daily if >150/100mmHg and weekly until normalised up to 6 weeks post delivery.
• Hypertension can usually be managed in the community setting in the postnatal period with oral anti-hypertensives – acute or severe hypertension (>160/110mmHg) should be discussed with a Consultant Obstetrician.
• Medications considered safe in breastfeeding include:
  • Calcium channel blockers (amlodipine/nifedipine)
  • Doxazosin
  • Enalapril
  • Beta blockers

Methyldopa should not be used in the post natal period due to the risk of depression.

Labetalol should be avoided for long term use (>2 weeks) after pregnancy as it is short acting and compliance is poor with more than once daily regimes.

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Contacts

Hypertension specialist midwife	(0161) 701 4871
Manchester Antenatal Vascular Service (MAViS) Clinic Team	(0161) 701 6980
Dr Jenny Myers Secretary – Lynne Nicholson lynne.nicholson@mft.nhs.uk jenny.myers@mft.nhs.uk	(0161) 276 6116

Women who are on long term warfarin therapy need to be seen by the obstetric haematology team as soon as possible after a positive pregnancy test.  This is particularly important for those women with metallic valves, who will be evaluated for transfer over to low molecular weight heparin (please see cardiac disease in pregnancy).

Please make a direct telephone referral to the haematology specialist midwives on (0161) 276 8793/or 0782 796 9104.

As of the 1^st April 2016, Public Health England no longer recommends routine screening for rubella status in pregnancy.

Nausea and vomiting affects up to 80% of women in pregnancy and the majority of women are managed with reassurance and advice. If further support in the community is required oral/buccal/rectal anti-emetics may be required.

Hyperemesis gravidarum is a severe form of Nausea and Vomiting in pregnancy and affects only 0.3%-3.6% of pregnant women.

Anti-emetics may include (RCOG Green top guideline 69, June 2016):

• 1^st line:
  • Cyclizine 50mg PO, IM or IV 8 hourly
  • Prochlorperazine PO 5-10 mg 6-8 hourly; 12.5mg 8 hourly IM/IV; 25mg PR daily
  • Promethazine 12.5-25 mg 4-8 hourly PO, IM, IV or PR
  • Chlorpromazine 10-25 mg 4-6 hourly PO, IV or IM; or 50-100mg 6-8 hourly PR
• 2^nd line:
  • Metoclopramide 5-10 mg 8 hourly PO/IV/IM (Maximum 5 days duration)
  • Domperidone 10 mg 8 hourly PO; 30-60mg 8 hourly PR
  • Ondansetron 4-8 mg 6-8 hourly PO

Referrals would be indicated if:

• Continued nausea and vomiting and inability to keep down oral anti-emtics
• Continued nausea and vomiting associated with ketonuria and/or weight loss (>5% body weight), despite oral anti-emetics
• Confirmed or suspected co-morbidity (E.g. UTI and inability to tolerate oral antibiotics)

Women booked in at Saint Mary’s Hospital presenting with symptoms of obstetric cholestasis should be advised to see their midwife or self-refer to triage by telephoning (0161) 276 6567.

Although Pruritus and LFTs should resolve postnatally, we ask that GPs repeat LFTs and bile acids at the 6 week postnatal check and follow local protocol if these are raised beyond normal levels.

Women should be advised to avoid oestrogen containing oral contraceptives where possible. For women that use oestrogen-containing contraception such as the combined oral contraceptive (COC) pill this may result in recurrence of cholestasis. The use of COC with a history of obstetric cholestasis is a UK medical eligibility criteria category 2.

Women with a history of obstetric cholestasis have a higher risk of hepatobiliary disease in later life.

Read our clinical guideline to learn more about obstetric cholestasis.

Click here for more information regarding perinatal mental health and Specialist Services provided at Saint Mary’s Hospital including information on medications in mental health.

The Royal College of General Practitioners also offer a great resource for GPs which can be found at:

http://www.rcgp.org.uk/clinical-and-research/resources/toolkits/perinatal-mental-health-toolkit.aspx

Conditions suitable for obstetric physiotherapy referral include:

• Pelvic girdle pain
• Hip pain
• Low back pain
• Rib pain
• Separated abdominal muscles
• Urinary or faecal incontinence
• Vaginal prolapse
• Vaginal varicosities

(This list is not exhaustive and professional judgement should be used).

Referrals to obstetric physiotherapy differ depending on the patient’s address click here for further details.

After 3 months postnatal women must be referred to their local physiotherapy service.

The physiotherapy department also have a video link including information that might be helpful as first line advice.

Perineal wound infection:

• Exclude systemic infection, if systemically unwell refer to triage.
• Swab perineum.
• If clinical infection, commence 5 day course of oral Co-Amoxiclav.
• Advice regarding perineal hygiene – change pads regularly, clean with water only and avoid use of products in the bath.

Perineal wound dehiscence:

• Swab +/- antibiotics if clinically infected.
• Granulation tissue often appears very erythematous and may be confused with signs of infection.
• Are not re-sutured unless very early dehiscence (within 48-72 hours) and no infection.
• Usually associated with profuse vaginal discharge as healing.
• Manage conservatively and allow to heal by secondary intention. Do not need prolonged courses of antibiotics in the absence of infection.
• May experience over granulation tissue, but this usually settles with time.

If there are concerns about poor healing or other perineal issues, a rapid access perineal clinic for women within 8 weeks of delivery runs every other week at Saint Mary’s Hospital Oxford Road Campus.

Contact Perineal Midwife for advice and support on 0161 701 7539 Mobile 07813406073 or email glenys.fell@mft.nhs.uk

For urgent queries call (0161) 276 6426, Robyn Eccleston, Dr Roberts secretary.

Click here for more information regarding specific antenatal care and advice for all pregnant women with a raised BMI (≥30).

Recent immigrants who have not had a full medical examination before their pregnancy booking appointment will be referred back to their GP to have this performed. For women who have not yet registered with a GP, a member of the obstetric team will be asked to review the woman and undertake the examination.

Lifestyle advice regarding alcohol consumption and the use of recreational drugs should be given prior to conception to both prospective parents or as soon as the pregnancy is known.

Please be aware that women should not be advised to give up drugs or alcohol abruptly if their intake is heavy or they are having problems in reducing intake.

Please refer women to the Specialist Midwives for Drugs, Alcohol and Mental Health for additional advice and support:

Email: substancemh.specialistmw@mft.nhs.uk

Tel: (0161) 701 3522.

Although there is no advice which can guarantee the prevention of Sudden Unexplained Death of an Infant (SUDI); it is important that parents are informed that the risk can be considerably reduced if they follow relevant advice.

A guide for health professionals and other useful patient resources can be found:

Within the Personal Child Health Record (the red book)

UNICEF

The Department of Health

Lullaby Trust

The Joint Obstetric Haematology Clinic (JOHC) at Saint Mary’s Hospital provides multidisciplinary, tertiary level care for pregnant women with risk factors for VTE and/or a previous history of VTE. Any woman with antenatal risk factors for a VTE should be referred to JOHC via the specialist haematology midwife (0161) 276 8793/or 0782 796 9104. For referral criteria click here.

The use of appropriately sized and properly applied below knee anti-embolic stockings (BKAS) is recommended in pregnancy and the puerperium for the following women:

• Women in hospital who would normally be offered low molecular weight heparin (LMWH) due to risk factors but cannot take it due to contraindications.
• Women travelling for long distances more than four hours.

If a clinical decision is made to recommend antenatal BKAS, a letter of recommendation will be given to the women to present to her GP, advising her to request a prescription.

All women should be signposted to the online information leaflet Pregnancy and Thrombosis – Am I at Risk?.

All women have a postnatal re-assessment of VTE risk and a management plan is documented in their medical records prior to leaving Saint Mary’s Hospital. Women requiring postnatal LMWH should leave hospital with their entire supply to ensure continuous therapy.  A sharps bin should always be provided.

For our usual prescribing guidelines for Tinzaparin and Dalteparin and VTE risk assessments click here.

If a woman has had a previous VTE, required antenatal LMWH, is at high risk of thrombophilia or low risk thrombophilia with a family history of VTE it will be recommended that she has at least 6 weeks of prophylaxis. For all other women treatment is usually for 7 days only. Women requiring treatment for 7 days only do not require monitoring of anti Xa levels. Monitoring (if required) is usually done at the JOHC.

Hypothyroidism:

In women with pre-existing hypothyroidism, TFTs should be checked as early as possible in pregnancy and should aim for a TSH <2.5 mU/L. Pregnant women who are obstetrically low risk but have a background of hypothyroidism (medicated or not) need to be seen by their GP in order to optimise their thyroid control. As minimum TFTs should be checked by the primary care provider in each trimester of pregnancy and then 6 weeks postnatally.

Hyperthyroidism:

Women with hyperthyroidism are managed in the joint obstetric endocrinology antenatal clinic and early referral is essential to enable timely planning of antenatal care. TFTs including T3 should be checked as early as possible during pregnancy.

Anti-thyroid medication (Carbimazole or Propylthiouracyl) is generally safe in pregnancy and should not be stopped at the time of conception.

For early referrals contact Dr Sorin Juverdeanu’s secretary on (0161) 276 6116 or email Lynne.Nicholson@mft.nhs.uk.

All pregnant women must be advised of the importance of vitamin D and be offered supplementation of 400 units or 10 micrograms of vitamin D per day.

Women with a high risk of vitamin D deficiency (listed below) should be offered a supplementation of 800 units vitamin D daily in combination with calcium:

• Women with a BMI of 30 or more
• Women with increased skin pigmentation including women of Asian, African and Afro-Caribbean descent
• Women who keep their skin covered the majority of the time

Women and their GP’s are given a copy of this letter advising them of suitable preparations to purchase or have prescribed.

It is recommended that all babies receive an intramuscular dose of Vitamin K shortly after birth to prevent haemorrhagic disease of the newborn. Women who choose for their baby to have oral supplementation of Vitamin K are informed that irrespective of their feeding method, their baby should have a second dose of 2mg Vitamin K at 7 days of age.

Subsequently:

• Bottle fed babies – no further routine supplements.
• Breast fed babies – will need a third dose at day 28 (the community midwife/health visitor will give the 2nd and 3rd doses).

Whilst the infant remains more than 50% breast fed, then the GP and health visitor will arrange further doses every month until 6 months of age.

If a young person is 18 & under at approximate estimated date of delivery they can be referred directly to the Young Parent’s specialist midwife either by phone (0161) 276 4245 or email ypg.specialistmidwife@mft.nhs.uk.