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Pregnancy Pathway Dr Akshaya Rajangam, MBBS iBSc (Hons) ST1 O&G, University Hospitals of Leicester NHS Trust 02/05/2023, 6.30pm-7.30pm @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS BRITISH INDIAN MEDICAL @BIMA ASSOCIATION BIMA Clinical and OSCE series The British Indian Medical Association (BIMA) - The British Indian Medical Association (BIMA) is a national non-profit organisation founded on developing a supportive network amongst students and doctors across the UK - Provides tutorial series, conference events, networking, careers talks, socials and more! - For more information follow us on social media and stay up to date with latest academic events by joining our mailing lists: BIMA Clinical and OSCE series: https://forms.gle/CidGvWAc9YY9WSSs8 BIMA Fundamentals of Medicine & Pathology series: https://forms.gle/KfAgeoX55GPAWqee8 BIMA Clinical and OSCE series Dr Akshaya Rajangam, originally from Singapore, now is an ST1 trainee in O&G in Leicester. She graduated from King's College London in 2020 and also holds a first class intercalated BSc (Hons) in Anatomy from King's College London. She undertook her academic foundation programme in East Midlands deanery focusing on medical education. She has published and presented nationally and internationally in robotics around Urology and Head & Neck surgery and was the former president of the KCL Surgical Society. She also won the Alfred Hughes Memorial Prize and the best dissertation prize during her intercalated degree. Outside of medicine, Akshaya was the former National vice- president of the National Hindu Students' Forum (Uk), the largest Hindu student movement engaging 10,000 students across the UK. She is also a part of the Vichaar Manthan Team and was a graduate of the first cohort of Vaani Speakers' Academy. Her passions include bharatanatyam, reading and painting. Dr Akshaya Rajangam MBBS, BSc Hons BIMA Clinical and OSCE seriesAims of session ● Journey of a pregnant woman in the NHS ○ Low risk pathway – role of bloods, scans and the GROW chart ○ Risk factors/issues that may alter pathway and subsequent pregnancy care ○ Management of various higher risk pregnant patients ○ Specialist midwife roles – pregnant woman beyond the clinical ○ Intrapartum care pathways and complications ○ Postpartum care ○ Bereavement – during and after ○ DISCLAIMER: Some of the services may not exist in all trusts/may have slightly different perspectives BIMA Clinical and OSCE seriesWhy do we care so much? ● 2,235,519 women who gave birth in 2016-18, 566 died of either direct or indirect causes of obstetric complications during or upto 1 year post-pregnancy (MBRRACE 2020 findings) ○ 217 are within the pregnancy/first 6 weeks of giving birthFetal Development in a nutshellBooking Time ● Bloods ○ FBC ○ HIV, Hep B, Syphilis ○ Screening tests – AFP, HCG, estriol (if patients consent) ● MSU ● History = medical, obstetric, gynaecology, family, social (including safeguarding, FGM, smoking & referral to cessation services)Screening tests ● If abnormal – counselled for amnioscentesis or chorionic villus sampling ○ CVS is suitable for 11+0 to 13+6/40. Amniocentesis is typically between 15 to 20 weeksAspirin in Pregnancy from 12 weeks: Risk of fetal growth restriction/pre-eclampsiaDetailed 20 week scanning ● Fetal anatomy ● Growth – Head circumference, abdominal circumference, femur length ● Dopplers – umbilical artery dopplers, uterine artery flow, middle cerebral artery flow, ductus venosus flowOral glucose tolerance test – testing for GDM ● Indications: ○ BMI 30 or more ○ Previous baby >4.5kg ○ Prev history of GDM ○ Family history of diabetes ○ Origin: South Asian, Chinese, African-Caribbean or middle-eastern ● 24-28 weeks: OGTT. Drink 50g of glucose in approx. 300ml of water and measure glucose levels before and 2 hours post. ○ Fasting -- <5.6mmol/L ○ 2 hour post --- <7.8mmol/LAn MDT approach ● Diabetes = diabetes clinics ● Hypertension/pre-eclampsia = hypertension clinics ● Sickle cell/beta thalassemia/haem conditions = haem-obs clinics ● Underlying medical conditions = maternal medicine clinics ● Previous recurrent miscarriages = prematurity prevention clinic ● Significant pre-pregnancy or intrapregnancy mental health = mental health clinics ● FGM = FGM clinics ● Fetal anomaly = maternal-fetal consultant-led scan and clinic And more!Common issues in pregnancy ● Reduced fetal movements ● Abdominal pain ● PV bleeding ● ?Premature rupture of membranes ● ?Clot ● Headaches/feeling unwell/vomiting ● NOTE: Issues that are non-pregnancy related can also occur in pregnancy!Pre-eclampsia ● Poor placental perfusion secondary to abnormal placental implantation ● Diagnosed AFTER 20 weeks of gestationWhy do we worry about pre-eclampsia? ● Eclampsia = new tonic- clonic seizure in the absence of any other neurological or metabolic causeIt’s time to deliver! ● Spontaneous labour, low risk ○ Labour on land ○ Labour in water +/- landInduction of Labour ○ Reasons: prolonged gestation, reduced fetal movements, pre-eclampsia, raised PCR, GDM, age, spontaneous rupture of membranes (SROM) without labour, fetal growth restriction ○ Step 1: Vaginal prostaglandins OR mechanical dilatation ○ Step 2: Amniotomy ○ Step 3: Augmentation of labourAnalgesia options, including epidural 1. Simple analgesia – Paracetamol and dihydrocodeine 2. Alternative pain measures – essential oils, pool, etc 3. Pethidine – weak opioid receptor agonist 4. EpiduralContinuous Fetal monitoringTime to deliver!Postnatal care ● Day 1, Day 4, Day 7, Day 14, Day 21 ● Access to maternal assessment units till 6 weeks’ post op ● Pre-eclampsia, proteinuria monitoring till resolution post-natally When things don’t go to plan… ● Miscarriage = Miscarriage is the spontaneous loss of a pregnancy before 24 weeks gestation. Miscarriage affects approximately 1 in 4 pregnancies. ● Stillbirth = Stillbirth is the birth of a baby after 24 weeks gestation who did not show any signs of life after delivery. In the UK, 1 in 200 babies are born dead. ● Neonatal death = liveborn baby but death within 28 days of lifeResources ● https://perinatal.org.uk/GAPguidance.pdf ● NICE Guidances https://www.nice.org.uk/guidance/ng201/chapter/Recommendatio ns#routine-antenatal-clinical-care ● https://www.nice.org.uk/guidance/ng207 ● RCOG Greentop guidelines ● https://teachmeobgyn.com/THANK YOU FOR LISTENING ANY QUESTIONS BIMA Clinical and OSCE series