Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Mm. Ok, so hi everyone. Thank you for joining us again on Tuesday evening. So we have Doctor Alice Bradfield here with us today to give us a talk on Antenatal care. So, um I'll pass it over to her so please make sure to go back home at the end and enjoy. Um So hi, everyone is, I'm Alice. Um I'll just get the slides up and I'll go through um what we're gonna be doing this evening. Um Just bear with me so I have to share the whole screen. So. Ok. Um So yes, today we're gonna be doing a talk on Antenatal care. So it'll be a little sort of with stop tour through the whole antenatal schedule and a few key um Antenatal conditions. Um Just a little bit about who I am. So, um I don't know if anyone here did the OB and Gyne placements in Nool, but I'm the Op and Gyne undergraduate clinical teaching fellow at Norfolk Park. Um So I organized the year five placements there. Um I'm actually currently in F four, so I'm not um in O ND training, but I've done have and Gyne work. Um I Yeah, graduated from Liverpool Medical School in 2021 did my foundation training in Northwest London. So Chelsea North Wick and I think soon going to be entering GP training as AP um, and if anyone wants to contact me about anything, my email address is there and then yeah, so things we're gonna be covering today. So a little bit about antenatal schedule, we'll go through each of the appointments. Um, we'll talk about the different screenings that you do including down screening um routine ultrasounds. We'll talk a little bit about um some other antenatal conditions. So GDM UTI S recess disease, preeclampsia, and we'll also touch a little bit on induction of labor as well and I won't go through all of these, but I just had a look, look at your curriculum learning and these are the ones we should be covering today. So we are covering quite a lot. But um hopefully, yeah, a good revision topic for your exams. So we'll go through each of the appointments essentially. So, um so off with this is your standard underneath your schedule. So this is for a low risk um low risk pregnancies. So for Neller woman, she would have 10 appointments and for a multiparous woman that would be seven appointments. And again, this is just a low risk patient. So anyone who has other other pathology going on, it might be different. So we're talking about about the booking visit to start off with. So this takes place at 8 to 12 weeks. Um The main purpose of this er, visit is essentially just to take a really thorough in depth history for the patient and essentially dictate how the rest of their pregnancy is gonna be managed. So, we're gonna be identifying which patients need to have additional care. So essentially who are the high risk pregnancies um because they may, they'll need onward referrals and essentially obstetrician led care instead of a mid midwife led antenatal care, we're going to offer them all their, all their initial um screening and screening blood tests. So we're going to arrange their booking, um their dating ultrasound. I'll talk about a little bit later, arrange the down screening and then screening for other other things. So checking if they're anemic, um what their blood group is, red cell allo antibodies. So considering, you know, are they, are they at risk of recess disease? Um any hemoglobinopathies and also any blood borne viruses which might be transmitted to the baby. Um We will arrange gestational diabetes testing at this point for someone who, who has GDM risk factors, but it takes place at a later point in the pregnancy, but we'll again identify those at risk at their booking visit. Um We'll also identify those who at risk of preeclampsia, which we'll talk about that a little bit later. And then in terms of things we're also gonna do. So, pregnant women at any point we're gonna be offering them the flu vaccine um if it is winter. So anytime between October to January, um we do advise Vitamin D also um to be taken during the pregnancy. So essentially reduces your chance of miscarriage. Um and we're going to take our baseline examination. So height weight BMI I um because that helps us essentially monitor baby's growth as well later on. Um and at every single appointment, obviously, at the first appointment, we're gonna be doing BP and protein urea. So we're checking for preeclampsia at every single appointment. Um We're gonna do some other conservative things. So we're gonna be giving them basic lifestyle advice. Um So that can be, you know, talking to them about food, diet, dietary changes into it during pregnancy. So staying away from, you know, soft and RPE and cheeses, um you can't have liver pate, you know, raw fish, et cetera. So you can give all that basic um conservative antenatal advice then. Um we want to highlight which patients are, you know, at risk of mental health problems as well. So, um people who have preexisting mental health problems are at much higher risk of any of these postnatal, you know, depression, um postpartum psychosis, et cetera. So these patients may need extra support. So we need to identify that during the booking appointment and we also give them other basic advice about breastfeeding, um maternity benefits, pelvic floor, et cetera. A little bit of planning about that as well. Um Oh yeah, and patients will also get their handheld maternity notes at this point. So thinking about what makes pregnancies high risk. So, um high risk pregnancies will need to be managed by an obstetrician instead of a midwife essentially. So we've got different categories of um factors. So first thing we have are medical indicators. So they can be things like essentially if mum's got any, any major preexisting medical conditions. So if she's got epilepsy, um a malignancy, any, you know, positive blood borne viruses. So HIV syphilis, et cetera. Um again, history of any major psychiatric illness, um many, many, many options essentially. So these are all things that are gonna make sure that she needs to be seen by an obstetrician instead, we then have obstetric indicators. So, is there anything high risk with the actual pregnancy itself? So if essentially, if they've had any major issue with a previous pregnancy, they're probably going to need to be, they're going to be considered a high risk obstetric case for this one. So, you know, a previous PPH uh a previous retained placenta, previous stillbirth, um previous 3rd, 4th degree care. These are all reasons they need it. Um obviously, if they have, if they develop any sort of major pregnancy related conditions. So, if they develop preeclampsia, um that's a reason why they need to be managed by an obstetrician in some of, you know, recurrent miscarriages. Um grand M parities. So, you know, more than four deliveries, more than six pregnancies. And if you are at an old age, so if you're aged over 40 you would be considered high risk. And then in addition to these me, medical and obstetric indicators, you do also have some social indicators. So that tends to be reserved for um patients. So any teenage pregnancies, anyone under the age of 18 and of course, any safeguarding issues is gonna need a larger sort of approach essentially. Ok, we'll talk a little bit about GDM now and about uh anti nasal testing for GDM. So I'm sure you guys are familiar with it, but essentially, this is the glucose intolerance that can develop during pregnancy. Um So it is quite common. So it affects one in five pregnancies and this uh rate is actually rising, um most likely related to essentially rising obesity rates. Um So naturally your insulin resistance does actually increase during pregnancy. Um but it won't always be pathological for some people, but that is a natural thing to happen. Um What we find in GDM, obviously, um normally this will actually remit after they've delivered, but for some patients, it may not. So some of these patients may go on to develop type two diabetes. Um most patients will be asymptomatic. So it's very rare for a patient to have GDM and actually be symptomatic. So this is why we have to pick it up on screening. Um And as I said before, so complications of a patient having G DMS. So for, for the mother, she's at much higher risk of type two diabetes in the future. So 25% will develop it within five years. She's likely to have GDM in a future pregnancy as well. And again, face the same complications and it can also um increase the risk of prenatal death for or for the, for the baby. Um and also macrosomia as well. I think I did to write that on there. But um so can have be risk for mum and risk for baby essentially. So how do we manage it? So essentially, if a woman is diagnosed with GDM, we'll talk about the diagnosis just after this. We're aiming for all their preprandial BMS to potential to be less than six. So all these women will need to, they'll all need to have dietary modifications and exercise, obviously, and they'll be sent home with a home, BP monitor, uh not BP, blood sugar monitor. Um We have different options for managing it. So we're gonna be completely conservative and just manage, manage it with diet exercise or we can consider doing Metformin or as a last resort per se as we do insulin. Um So in general, we'd work our way up that um as like a, you know, step wise ladder approach. However, if a woman's fasting BMS are greater than seven at diagnosis or at any point, essentially, it's unlikely that is that her blood sugar is ever going to be controlled with just Metformin and diet, diet and exercise. So, if the fasting BMS are ever greater than seven, we will start insulin therapy. Essentially. If you imagine we don't really have as much time within a pregnancy to be able to tailor things and work our way up. So essentially, if it's greater than seven, we're really concerned that she will, she won't be very well controlled. So we need to just start in them. And because of the risk of macrosomia, um they will need additional growth scans as well and in general for gestational diabetes. Um So this isn't a hard and fast rule, but I said if they're on treatment, we generally aim to deliver by 37 to 38 weeks. So once they've reached term, it's safe for baby and we can avoid some of those other complications. Um if they're only managed conservatively, so just the diet and exercise, then we can actually aim to deliver them a bit later. So essentially 41 weeks, well before, before 41 weeks. Ok. And then in terms of diagnosing GDM, uh we do that through the oral glucose tolerance test. So as I said, at booking, we'll identify patients who have risk factors for GDM and then we will offer them 75 g, two hour OGTT test. So essentially I'll drink this glucose drink. Um And yeah, we'll arrange that for 24 to 28 weeks. The reason why we don't, the reason why we do it at 24 to 28 weeks is essentially that, as I said before, your insulin resistance actually rises during pregnancy. So it will, it will be higher in that second trimester, second or third trimester, I guess. Um So if you actually try to diagnose it earlier in the pregnancy, you may, it may come back.