9.8 Cervical incompetence

CONTENTS Foreword

i

Introduction

ii

Guidelines Development Group

iii

CHAPTER

TOPIC

1. Haematological Disorders in Pregnancy 1.1 Anaemia in pregnancy 1.2 Thalassaemia carrier in pregnancy 1.3 Asymptomatic thrombocytopenia in pregnancy 1.4 Rhesus isoimmunisation in pregnancy 2. Hypertensive Disorders in Pregnancy 2.1 Gestational Hypertension / Pre-eclampsia ( PE ) 2.2

Chronic Hypertension in pregnancy

3. Diabetes in Pregnancy 3.1

Gestational Diabetes Mellitus

3.2

Pre-existing diabetes in pregnancy

4. Thyroid Disorders in Pregnancy 4.1 4.2

Hyperthyroidism complicating pregnancy Hypothyroidism complicating pregnancy

5. Bronchial asthma in Pregnancy

6. Cardiac Diseases in Pregnancy 6.1 6.2 6.3

Heart disease in pregnancy Peripartum Cardiomyopathy (PPCM) Chronic rheumatic heart disease in pregnancy

7. Infectious Diseases in Pregnancy 7.1 7.2

HIV in pregnancy HIV in Serodiscordant Couple (HIV-positive Male, HIV-negative female)

7.3 7.4 7.5

Syphilis in pregnancy Viral hepatitis B in pregnancy Tuberculosis in pregnancy

8. Kidney Disorders in Pregnancy 8.1 8.2

Urinary Tract Infection Chronic Kidney Disease

9. Obstetrics Problems 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8

Multiple Pregnancy Breech/ Malpresentation Previous Scar(s) (LSCS, Classical CS, Myomectomy) Placenta Praevia Risk for Macrosomia/ Shoulder dystocia Obesity in Pregnancy Recurrent Miscarriages Cervical incompetence

10. Connective Tissue Disease in Pregnancy 10.1 10.2

Rheumatoid Arthritis Systemic Lupus Erythematosus

11. Neurological Problem in Pregnancy 11.1

Epilepsy

12. Mental Disorders in Pregnancy

13. Thromboembolism 13.1

Venous thromboembolism (VTE) in pregnancy

14. Teenage Pregnancy/ Single Expectant Mother

15. Antenatal Care 15.1 15.2 15.3 15.4 15.5

Down Syndrome Screening Smoking in pregnancy Alcohol abuse in pregnancy Substance Abuse in Pregnancy Group B Streptococcal Infection (GBS)

15.6 15.7 15.8

Chicken Pox in pregnancy Aspirin and calcium supplements Pre-eclampsia screening

16. The Obstetric Emergency Retrieval

17. Pre-Pregnancy Care 17.1 17.2 17.3 17.4 17.5 17.6 17.7 17.8

Obesity Advanced maternal age (>37 years) Recurrent miscarriage Previous preterm labour (less than 34 weeks) Previous Intrauterine Death (IUD) Previous pre-eclampsia (delivery less than 34 weeks) Previous post-partum haemorrhage (PPH) Medical 17.8.1 Diabetes mellitus 17.8.2 Hypertension 17.8.3 Renal impairment 17.8.4 Cardiac disease 17.8.5 Epilepsy 17.8.6 Systemic lupus erythematosus 17.8.7 Hyperthyroidism 17.8.8 Previous venous thromboembolism (VTE)

18. WHO Medical Eligibility Criteria For Contraceptive Use 2017

19. Appendix

GUIDELINES DEVELOPMENT GROUP

CHAIRPERSON

CO - CHAIRPERSON

Dr. George G. Mathew Family Medicine Consultant Tamparuli Health Clinic Tuaran

Dr. Shari bin Nor Consultant Obstetrics & Gynaecology Sabah Women & Children’s Hospital Kota Kinabalu

MEMBERS ( in alphabetical order ) Dr. Aini binti Simon Sumeh Family Medicine Specialist Penampang Health Clinic Penampang

Dr. Amory S. Chong Obstetrics & Gynaecology Specialist Lahad Datu Hospital Lahad Datu

Dr. Anita Delilah Salahuddin Family Medicine Specialist Nabawan Health Clinic Keningau

Dr. Chan Kok Seong Consultant Obstetrics & Gynaecology Sabah Women & Children’s Hospital Kota Kinabalu

Dr. Christine Shamala Selvaraj Family Medicine Specialist Sandakan Health Clinic Sandakan

Dr. Eleza Nazefah binti Rosli Family Medicine Specialist Telipok Health Clinic, Kota Kinabalu

Dr. Farah Aishah binti Hamdan Family Medicine Specialist Tandek Health Clinic Kota Marudu

Dr. Farah Waheeda binti Ghulam Khan Family Medicine Specialist Kinarut Health Clinic Papar

Dr. Fazilawati @ Azmira binti Ab. Latif Family Medicine Specialist Lahad Datu Health Clinic Lahad Datu

Dr. Haryati binti Hamzah Family Medicine Specialist Tawau Health Clinic Tawau

Dr. Hazwanim binti Md Hashim Family Medicine Specialist Penampang Health Clinic Penampang

Dr. Hii Ling Yien Obstetrics & Gynaecology Specialist Sabah Women & Children’s Hospital Kota Kinabalu

Dr. Hoong Fam Weng Michael Consultant Obstetrics & Gynaecology Sabah Women & Children’s Hospital Kota Kinabalu

Dr. Juliana Idora binti Abdul Jalal Family Medicine Specialist Manggatal Health Clinic Kota Kinabalu

Dr. Khairunnisa bt Mohd Kathri Family Medicine Specialist Putatan Health Clinic Putatan

Dr. Lee Cathy Family Medicine Specialist Tamparuli Health Clinic Tuaran

Dr. Lee Wai Khew Family Medicine Consultant Luyang Health Clinic Kota Kinabalu

Dr. Maherah Kamarudin Obstetrics & Gynaecology Specialist Sabah Women & Children’s Hospital Kota Kinabalu

Dr. Mohd Nazri Mohd Daud Family Medicine Specialist Manggatal Health Clinic Kota Kinabalu

Dr. Mohd Suzuki Abdul Rahman Family Medicine Consultant Nabawan Health Clinic Keningau

Dr. Noor Diana binti Ismail Family Medicine Specialist Manggatal Health Clinic Kota Kinabalu

Dr. Nor Asyikin Yahya Family Medicine Specialist Membakut Health Clinic Beaufort

Dr. Norfaridah binti Masiran Family Medicine Specialist Kundasang Health Clinic Ranau

Dr. Norhayaty Sharman binti Khamis @ Roslee Family Medicine Specialist Sindumin Health Clinic Sipitang

Dr. Norlaily binti Hassan Family Medicine Specialist Lahad Datu Health Clinic Lahad Datu

Dr. Nur Syariza Radzi Family Medicine Specialist Sg Manila Health Clinic Sandakan

Dr. Nurzaitil Aswani binti Zainuddin Family Medicine Specialist Membakut Health Clinic Beaufort

Dr. Rasina Nilofer binti Jabarulla Khan Family Medicine Specialist Tawau Health Clinic Tawau

Dr. Rumihati Abdul Hamid Family Medicine Specialist Putatan Health Clinic Putatan

Dr. Ruqaiah Busu Rerah Obstetrics & Gynaecology Specialist Tawau Hospital Tawau

Dr. Samantha Veronica Teh Poh Suan Family Medicine Specialist Luyang Health Clinic Kota Kinabalu

Dr. Saodah binti Hashim Family Medicine Specialist Bongawan Health Clinic Papar

Dr. Sathya Rao Jogulu Family Medicine Specialist Tamparuli Health Clinic Tuaran

Dr. Shakiroh bt Abdul Mokti Family Medicine Specialist Luyang Health Clinic Kota Kinabalu

Dr. Siti Aishah Tajuddin Obstetrics & Gynaecology Specialist Keningau Hospital Keningau

Dr. Teoh Soo Huat Family Medicine Specialist Bingkor Health Clinic Keningau

Dr. Yew Cheng Boon Obstetrics & Gynaecology Specialist Sandakan Hospital Sandakan

Dr. Zaiton binti Yahaya Family Medicine Consultant Sandakan Health Clinic Sandakan

1.

HAEMATOLOGICAL DISORDERS IN PREGNANCY

1.1

Anaemia in Pregnancy

1

Phase

Plan of Action

At diagnosis

•

Asymptomatic ➢ Hb 8 - ≤ 11 g/dl, irrespective of gestational age ▪

Follow-up at health clinic

➢ Hb < 8 g/dl, POA < 36 weeks ▪

Follow-up at health clinic

➢ Hb < 8 g/dl, POA > 36 weeks

•

▪

Hospital admission

▪

Refer O&G team for management plan

Symptomatic anaemia, irrespective of gestational age & Hb level ➢ Refer to O&G for hospital admission

•

Do relevant investigations: ➢ FBC (if only Hb was done previously) ➢ PBF ➢ Iron study - Serum Ferritin is preferred test ➢ Hb analysis if indicated ➢ BSMP / BFMP ➢ Urine FEME ➢ Stool for ova & cyst

•

Start treatment dose of haematinics

•

Repeat Hb after 2 weeks

•

Consider parenteral iron in confirmed iron deficiency anaemia where: ➢ Unable to tolerate iron orally ➢ Poor response to oral iron therapy ➢ Rapid iron replenishment is required

•

After completed parenteral iron, repeat Hb at 1-2 weeks and resume oral iron therapy after 1 week.

2

3

4

5

6

Subsequent antenatal follow-up

•

Monitor Hb level at health clinic

•

Monthly foetal growth monitoring by health clinic

Delivery plan

•

Keep Hb > 11.0 g/dl

•

Generally may allow postdates, unless specified otherwise

•

Hospital delivery

•

PPH prophylaxis

•

Discuss options of contraception with patient / couple

•

Continue haematinics for 3 months postpartum

•

Routine discharge procedure

Delivery

Postpartum

Upon discharge from hospital

REMARKS:

•

Definition of anaemia: ➢ Hb < 11.0 g/dl in the first and last trimester ➢ Hb < 10.5 g/dl in the second trimester

Classification

Hb level (g/dl)

Severe

≤ 7.0

Moderate

7.1 – 8.9

Mild

9.0 – 11.0

•

If confirmed thalassaemia carrier, screen husband as well

•

If husband confirmed thalassaemia carrier, see SOSCG guideline “Thalassaemia Carrier in Pregnancy”

•

Recommended prophylaxis oral iron dose: ➢ T. Ferrous Fumarate 200mg OD

•

Recommended therapeutic oral iron dose: ➢ Elemental iron 100 – 200 mg daily ➢ T. Ferrous Fumarate 400 mg OD ➢ Various iron-combinations are widely available with various dosage

Iron salt

Dose per tablet

Elemental iron

Ferrous fumarate

200 mg

65 mg

Ferrous gluconate

300 mg

35 mg

Ferrous sulphate (dried)

200 mg

65 mg

Ferrous sulphate

300 mg

60 mg

Iron polymaltose

370 mg

100 mg

•

Parenteral iron preference (depends on availability): ➢ Iron Dextran – Can be given IM but risk of hypersensitivity ➢ Iron Sucrose – Must be given IV, less side effects, preferably hospital admission. Can be given in outpatient setting with emergency & resuscitation facilities ➢ Expected Hb increment after parenteral iron: 1 – 2 g/dl in 2 weeks ➢ Repeat Hb after reassessment in 2 weeks

•

Contraindications for parenteral iron: ➢ Non-IDA ➢ Thalassaemia (relative contraindication) ➢ Known allergy to iron

Reference(s): 1. National Thalassaemia Screening Programme, Malaysian Ministry of Health, 2007 2. Perinatal Care Manual (Third Edition) 2013 3. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 (WHO/NMH/NHD/MNM/11.1) 4. UK guidelines on the management of iron deficiency in pregnancy. British Journal of Haematology, 2012, 156, 588–600. doi:10.1111/j.13652141.2011.09012.

1.2

Thalassaemia Carrier in Pregnancy

Phase 1

2

Pre-pregnancy

At diagnosis

Plan of Action •

If couple is thalassaemia carriers, refer to FMS / O&G (Prepregnancy clinic) for counselling, including information regarding prenatal diagnosis

•

Advice for contraception

•

Advice for early booking before 12 weeks gestation

•

All antenatal women should be offered screening if they fall into these categories:

➢ Past history of unexplained anaemia ➢ Family history of anaemia (unknown cause) or haemoglobinopathy ➢ Belonging to an ‘at risk’ ethnic background for haemoglobinopathies •

Request for diagnosis confirmation (Hb analysis) if: ➢ Women who have no risk factors for haemoglobinopathies but blood results show a MCV ≤ 80fL and MCH ≤ 27pg and a normal ferritin level (e.g. > 30ug/L)

•

Pregnancy confirmed

➢ Arrange for dating scan ➢ Screen partner for thalassaemia status (if not done yet) ➢ Refer to O&G / MFM Clinic immediately for couple requesting prenatal diagnosis or agreed for prenatal diagnosis** ▪

To be seen at 11 weeks gestation

▪

CVS preferably before 13 weeks 6 days gestation and amniocentesis at 15 weeks gestation

▪

If opted for termination of pregnancy need to be done before 20 weeks gestation

➢ Detailed scan appointment at 24 weeks POG if couple are αthalassaemia carrier

3


•

Monitor Hb level

•

Check serum ferritin & TIBC before giving iron supplement

➢ Serum ferritin 20 weeks gestation

•

Gestational hypertension: ➢ BP ≥140/90 mmHg ➢ no proteinuria

•

Grading for gestational hypertension: ➢ Mild: 140-149/90-99 ➢ Mod: 150—159/100-109 ➢ Severe: SBP≥ 160 and/or DBP ≥ 110

•

Pre-eclampsia: ➢ SBP 140-169 mmHg ➢ DBP 90-109 mmHg ➢ with proteinuria ≥ 1+ ▪ Urine dipstick testing ▪ 1+ = 0.3g/l ▪ 2+ = 1g/l ▪ 3+ = 3g/l

•

Severe Pre-eclampsia: ➢ BP ≥ 160/110 with proteinuria ≥ 2+ or end-organ involvement

•

Eclampsia: ➢ HPT + seizure

Subsequent antenatal follow-up •

Symptoms of impending eclampsia: ➢ severe headache ➢ visual disturbance (blurring, flashing) ➢ vomiting ➢ severe pain just below epigastric ➢ Sudden swelling of face, hands or feet.

•

PE profile: ➢ Creatinine level: < 100 ➢ Uric acid level (according to trimester) ➢ To do clotting studies if PLT < 100 ➢ AST /ALT < 2x ( 20 weeks: Either T. Methyldopa or Labetalol. Nifedipine can be used if still not controlled. Target BP control: ➢ < 150/100 mmHg in uncomplicated chronic HPT ➢ < 140/90 mmHg if target organ damage is present (e.g. chronic kidney disease) Do the following: ➢ BP, weight, urine protein ➢ Baseline PE profile (FBC, RFT, SUA, LFT) ➢ Educate and advise mother to return immediately if symptoms of impending eclampsia ➢ Refer to Combined Clinic for shared care if difficult to control HPT or secondary cause for HPT identified Ask for symptoms of impending eclampsia at every visit Maternal surveillance with BP, weight, urine protein (frequency depends on severity) Criteria of admission: ➢ Severe hypertension, SBP≥ 160 and/or DBP ≥ 110 ➢ Moderate HPT on 1st diagnosis, BP: 150—159/100-109 Reason for admission is to assess organ complications ➢ District health clinic case to be admitted at nearest district hospital, ➢ Health clinics in Kota Kinabalu to refer O&G and if need admission, to be admitted at HWKKS, Tuaran or Papar Hospital. PE profile: ➢ Monitor FBC, RFT, SUA, LFT at every trimester. If abnormal refer O&G. ➢ 24-hour urinary protein if suspected PE Foetal surveillance with SFH, FKC, foetal growth monitoring by serial ultrasound, starting at 28 weeks, at 4-weekly interval Educate and advise mother to return immediately if symptoms of impending eclampsia Refer at 34-36 weeks gestation for plan of delivery If PE / foetal compromise is detected at any time: ➢ Refer to hospital Outlined by O&G Specialist at about 36 weeks

5

Delivery

•

Hospital delivery

6

Postpartum

•

Continue antenatal anti-HPT after delivery ➢ aim for BP 35 years Glycosuria ≥2+ on two occasions Booking BMI > 27kg/m2 First degree relative with diabetes Previous macrosomic baby (≥4kg) Previous unexplained intrauterine death, recurrent miscarriages, congenital anomalies, previous history of shoulder dystocia • Previous history of Gestational Diabetes Mellitus • Current obstetric problems (suspicious macrosomia, polyhydramnios, essential hypertension, pregnancy- induced hypertension, current use of steroids) Screening test: •

Initial screening of high risk women (multiple risk factors/previous GDM) should be done at booking using any of the following: 1. 75g MOGTT or 2. FPG (fasting plasma glucose) if patient unable to tolerate MOGTT (minimal role of MOGTT after 32 weeks)

¥

Definition of GDM using 75 gm OGTT:

GDM is diagnosed in the presence of any one of these results: ➢ FPG ≥5.1 mmol/L ➢ 2-hour postprandial (2-HPP) ≥7.8 mmol/L Definition of Overt DM •

•

Is diagnosed in the presence of at least two of the following criteria at different time: ➢ FPG ≥7.0 mmol/L ➢ 2-HPP ≥11.1 mmol/L ➢ RPG ≥11.1 mmol/L with symptoms Offer immediate treatment with insulin with or without metformin ➢ if FBS≥7mmol/l at diagnosis or ➢ if FBS 6.0-6.9mmo/l with complications such as macrosomia or polyhydroamnios

*BSP targets (mmol/L): The blood glucose targets should be as the following: (new guideline) •

Fasting or preprandial/pre bed: ≤5.3 mmol/L 1-hour postprandial: ≤7.8 mmol/L 2-hour postprandial: ≤6.7 mmol/L

•

Post-prandial glucose level monitoring should be encouraged, especially for patients practising Home Blood Glucose Monitoring (HBGM)

∞Refer appendix on “Medical Eligibility Criteria for Contraceptive Use”

References: 1. National Institute for Health and Care Excellence (NICE) guideline, Diabetes in Pregnancy: management from preconception to the postnatal period, 25 February 2015. 2. Malaysian Ministry of Health Clinical Practice Guidelines on Management of Type 2 Diabetes Mellitus (5th edition), December 2015. 3. Perinatal Care Manual, Malaysian Ministry of Health, 2013 (3rd edition) 4. CPG on Management of Diabetes in Pregnancy, Ministry of Health Malaysia 2018

3.2 Pre-Existing Diabetes In Pregnancy Phase 1

Prepregnancy

Plan of Action • •

•

2

At booking

• • • • •

3


• • • •

•

Refer to FMS / O&G for preconception care (Pre-pregnancy clinic) Assessment ➢ Disease severity ➢ Complications ➢ Co-morbidities ➢ Glycaemic control & optimization. ➢ Review medications. Acceptable antidiabetic medication: Metformin, Insulin (Human/ Analog) Counselling ➢ Maternal and foetal complications ➢ Symptoms and signs of hypoglycaemia. ➢ Importance of blood glucose optimization prior to pregnancy ➢ Planned pregnancy for contraception advice according to Medical Eligibility criteria. ➢ Weight reduction if overweight or obese ➢ For Folic acid 5 mg per day should be given at least three months prior to conception and continue until 12 weeks of gestation Consult FMS (outpatient) / O&G Department (inpatient) for initiation / adjustment of insulin Dating scan Get combined clinic appointment Get detailed scan appointment (24 weeks) Do the following: 1. RP 2. HbA1c (baseline to determine risk of pregnancy, if not done in the last 3 months) 3. Retinal assessment 4. Dietary counseling by dietician 5. Women with T1DM/T2DM are at high risk of developing PE/ eclampsia – start on Tab Aspirin 75mg OD from 12 weeks (before 20 weeks) until delivery, unless contraindicated BSP (2-weekly, more frequently if not controlled) ^ ➢ Basal bolus insulin regime is preferred during pregnancy Monthly growth scan and AFI from 24 weeks Refer Diabetes Educator / Medication Therapy Adherence Clinic (MTAC) for poorly controlled DM if available Retinal assessment ➢ Retinal assessment at booking and repeat at least once throughout the pregnancy ➢ If retinopathy is present, refer ophthalmology Renal assessment ➢ Renal profile ➢ Urine dipstick- if protein present to proceed with 24-hour urine protein or urinary albumin-to-creatinine ratio ➢ If creatinine >125mmol/l or 24-hour urine protein >0.5g/day, to refer Nephrologist ➢ Consider thromboprophylaxis if 24-hour urine protein >5g/day

4

Delivery plan

In pregnant women with pre-existing diabetes: • •

With no complications, delivery should be planned between 37+0 and 38+6 weeks Who develop maternal or foetal complications, elective delivery before 37+0 weeks should be considered Hospital delivery

5

Delivery

•

6

Postpartum

• Pre-existing T1DM ➢ Lower insulin dosage • Pre-existing T2DM (for breastfeeding) ➢ Continue insulin at lower dosage or resume pre-pregnancy metformin ➢ Avoid other types of Oral Antidiabetic Drugs • Discuss options of contraception with couple∞ • Encourage breastfeeding

7


• •

•

Notification of high risk case discharge to Health clinic as per guideline Health clinic / Medical to continue with follow up care ➢ For pre-existing T1DM and T2DM, to refer back to their routine diabetes care arrangements (Health clinic / Medical clinic) ➢ Newly diagnosed T2DM should be referred and be followed up in Health clinic / Medical clinic Pre-pregnancy clinic for pre-existing DM at 3 months postpartum

REMARKS:

^Antenatal target blood glucose control:

BSP: • • • •

Pre-breakfast /fasting(following an 8-hour of overnight fast): ≤5.3 mmol/L Pre-prandial/pre-bed: ≤5.3 mmol/L 1-hour post-prandial: ≤7.8 mmol/L 2-hours post-prandial: ≤6.7mmol/L

HbA1c: 450mg/day) ➢ Non-adherence or uncontrolled hyperthyroidism. ➢ The optimal timing of surgery is in the second trimester. • • •

Refer Appendix “Medical Eligibility Criteria for Contraceptive Use” Women with history of Post-partum Thyroiditis (PPT) have a markedly increased risk of developing permanent primary hypothyroidism in the five-to-ten year period after the episode of PPT. An annual TSH level should be performed in these women.

Reference(s): 1. The American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum, Stagnaro-Green, A., Abalovich, M., Alexander, E., Azizi, F., Mestman, J. Wiersinga, W. (2011). Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum. Thyroid, 21(10), 1081–1125. http://doi.org/10.1089/thy.2011.0087 2. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Erik K. Alexander, Elizabeth N. Pearce, Gregory A. Brent, Rosalind S. Brown, Herbert Chen, Chrysoula Dosiou, William A. Grobman, Peter Laurberg,John H. Lazarus, Susan J. Mandel, Robin P. Peeters,11 and Scott Sullivan. THYROID, Volume 27, Number 3, 2017 ª American Thyroid Association ª Mary Ann Liebert, Inc. DOI: 10.1089/thy.2016.0457 3. 2015 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Bryan R. Haugen,,* Erik K. Alexander, Keith C. Bible, et al. The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer.

4.2

Hypothyroidism Complicating Pregnancy

Phase 1

Pre-pregnancy

Plan of Action • • • • •

2

At diagnosis in pregnancy

• • •

3


• • • • • • •

Refer for counselling by FMS / O&G (Pre-pregnancy Clinic) Thyroid sonography and survey of cervical lymph nodes should be performed in all patients with thyroid nodule(s) Women with thyroid nodule(s) should be referred for FNAC (SOPD) if ultrasound features reveal complex thyroid nodule Thyroid nodule diagnostic FNAC is not required if nodule(s) is purely cystic or no sonographic suspicion. Maintain TSH < 2.5 mIU/L Overt hypothyroidism (OH) and subclinical hypothyroidism should be treated. In woman with hypothyroidism, the dose of L-Thyroxine should be increased by 25%-30% once UPT is positive. Serum TSH should be obtained early in women with: ➢ History of thyroid dysfunction or thyroid surgery ➢ Symptoms of thyroid dysfunction or presence of goitre ➢ History of head or neck radiation ➢ Use of amiodarone or lithium, or recent administration of iodinated radiologic contrast. Refer to FMS/combined clinic. Rapid normalizing of TSH level is advised.

•

Shared care between FMS and Combined Clinic team. Detail scan in MFM Clinic at 18-22 weeks. Combined Clinic follow-up once per trimester. L-Thyroxine should be given and titrated up to the optimal TSH level (according to trimester): ➢ 1st trimester: 0.1-2.5 mIU/L ➢ 2nd trimester: 0.2-3.0 mIU/L ➢ 3rd trimester: 0.3-3.0 mIU/L TFT should be measured every 4- 6 weeks.

4

Delivery plan

•


5

Delivery

•

Hospital delivery

6

Postpartum

•

After delivery, most hypothyroid women may need to decrease the LThyroxine dose to the pre-pregnancy levels. L-thyroxine should be continued in lactating women Serum TSH should be done at 6 weeks post-partum Refer all babies born to mother with hypothyroidism to the Paediatric team

• • • 7


• • •

FMS/MO appointment to review TSH result at 2 months Endocrinology appointment, if indicated Pre-pregnancy Clinic appointment at 3/12 postpartum (if future pregnancy possible)

REMARKS: • • • • •

There is an association between maternal hypothyroidism and child’s developmental delay. Overt Hypothyroid: ➢ An elevated TSH (>2.5 mIU/L) in conjunction with a decreased FT4 concentration or ➢ Women with TSH level >10 mIU/L, irrespective with their FT4 level Subclinical Hypothyroid (in pregnancy): ➢ Serum TSH above the upper limit of the trimester-specific reference range with a normal Free T4. The thyroxine dose usually needs to be increased by 4-6 weeks of gestation and may require 30-50% increase in dosage. Complications of hypothyroidism during pregnancy Mother Child • • • • • • • • •

• • •

Pre-eclampsia Need for Caesarean Gestational diabetes Placental abruptions Infertility Miscarriage anaemia Postpartum haemorrhage Goitre

• • • • • • • •

Malformations Respiratory problems Anaemia Sepsis Need for ICU treatment Large or small for gestational age Pre-term delivery Neurocognitive defects

TRab crosses the placenta and can cause foetal hyperthyroidism. Women with thyroid autoimmunity who are euthyroid in early pregnancy are at risk of hypothyroidism. Refer Appendix “Medical Eligibility Criteria for Contraceptive Use” References: 1. The American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum, Stagnaro-Green, A., Abalovich, M., Alexander, E., Azizi, F., Mestman, J. Wiersinga, W. (2011). Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum. Thyroid, 21(10), 1081–1125. http://doi.org/10.1089/thy.2011.0087. 2. Lazarus J, Brown R, S, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B, 2014 European Thyroid Association Guidelines for the Management of Subclinical Hypothyroidism in Pregnancy and in Children. Eur Thyroid J 2014;3:76-94. 3. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Erik K. Alexander, Elizabeth N. Pearce, Gregory A. Brent, Rosalind S. Brown, Herbert Chen, Chrysoula Dosiou, William A. Grobman, Peter Laurberg,John H. Lazarus, Susan J. Mandel, Robin P. Peeters,11 and Scott Sullivan. THYROID, Volume 27, Number 3, 2017 ª American Thyroid Association ª Mary Ann Liebert, Inc. DOI: 10.1089/thy.2016.0457 4. 2015 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Bryan R. Haugen,,* Erik K. Alexander, Keith C. Bible, et al. The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

5.

Bronchial Asthma In Pregnancy

Phase

Plan of Action

1

Prepregnancy

• • • • •

2


•

•

Assess level of asthma control as per GINA guideline Optimize asthma control before embarking on pregnancy Continue treatment if stable Do not step down controller therapy Those with poorly controlled asthma to advise defer pregnancy and use appropriate contraception method till optimum control achieved Adjust asthma treatment in a continuous cycle: assess, adjust treatment and review response Check diagnosis, inhaler technique and adherence before considering any treatment step-up If asthma is controlled ➢ follow-up by M&HO If asthma is partly controlled or uncontrolled ➢ step up treatment as per GINA guideline and reassess after 2 weeks Continue treatment if asthma is controlled after stepping up treatment Refer FMS / nearest district hospital (for non-FMS areas) if asthma remains partly controlled or uncontrolled Any patient partly controlled on Step 3 treatment MUST be referred to Combined Clinic for re-assessment and management Acute exacerbations require acute management and admission*

• • • • • •

3


• • •

Assess level of asthma control and manage accordingly Monitor PEFR every visit 2-4 weekly review depending on level of asthma control

4

Delivery plan

•


5

Delivery

•

Hospital delivery

6

Postpartum

• • •

Continue asthma medications until review in own clinic Discuss options of contraception with patient / couple Step-down treatment to pre-pregnant doses or using stepwise approach (Box 3)

7


•

Notification of high risk cases discharge as per guideline for uncontrolled asthma

* Refer appendix

REMARKS:

DEFINITION:

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.

INCIDENCE:

It affects 1–18% of the population in different countries. Asthma control often changes during pregnancy: • one-third of women asthma symptoms worsen • one-third of women improve • one-third remain unchanged Exacerbations are common in pregnancy, particularly in the second trimester. Exacerbations and poor asthma control during pregnancy may be due to: • • •

mechanical changes or hormonal changes, or cessation or reduction of asthma medications due to concerns by the mother and/or the health care provider

DIAGNOSIS IN PREGNANCY

Box 1:Diagnostic flowchart for clinical practice – initial presentation Patient with respiratory symptoms Are the symptoms typical of asthma?

No Yes

Detailed history/examination for asthma History/examination supports asthma diagnosis?

Further history and tests

Yes

Perform spirometry/PEF with reversibility test Results support asthma diagnosis?

Yes

Consider alternative diagnosis Refer FMS/ visiting physician

Treat for ASTHMA

Diagnostic criteria for asthma in adults

1. History of variable respiratory symptoms (increased probability of asthma diagnosis) • Wheeze, shortness of breath, chest tightness and cough (generally more than one respiratory symptoms) • Symptoms occur variably over time and vary in intensity; often worse at night or on waking • Symptoms are often triggered by exercise, laughter, allergens and cold air; worsen with viral infections 2. Confirmed presence of airflow limitation or variable expiratory airflow limitation: • Reduced FEV1/FVC • Excessive variability (> 10%) in twice daily PEF over 2 weeks • Positive bronchodilator reversibility test- increase in FEV1 of > 12% and 200ml from baseline ASSESSING ASTHMA CONTROL AND SEVERITY IN PREGNANCY

Box 2: GINA assessment of asthma control in adults 1. Symptoms control Asthma symptoms

PEFR value:

In the past 4 weeks, has the patient had: Level of asthma control Well controlled

Partly controlled

Uncontrolled

None

1-2 of these

3-4 of these

Daytime asthma symptoms more than twice/week o Yes o No Any night waking due to asthma o Yes o No Reliever needed for symptoms more than twice/week o Yes o No Any activity limitation due to asthma o o

Yes No

2. Risk factors for poor asthma outcomes. Having one or more of these risk factors increases the risk of exacerbations even if symptoms are well controlled: • Uncontrolled asthma symptoms • High SABA use (> 1 canister 200 doses/month)

• • • • • •

Inadequate ICS, not prescribed ICS, poor adherence, incorrect inhaler technique Low FEV1 especially if 200-400

>400

Budesonide

200-400

>400-800

>800

Fluticasone propionate

100-250

>250-500

>500

Reference(s): Global Strategy for Asthma Management and Prevention (2017 update) by Global Initiative for Asthma (GINA)

MANAGEMENT OF ACUTE EXACERBATIONS OF ASTHMA IN PREGNANCY Box 4. Management of asthma exacerbations in primary care PRIMARY CARE Patient present with asthma exacerbation

ASSESS THE PATIENT Is it asthma? Risk factors for asthma related death? Severity of exacerbation?

MILD or MODERATE Talk in phrases, prefers sitting than lying, not agitated, respiratory rate increased 50% predicted or best

SEVERE Talks in words, sits hunched forward, agitated, respiratory rate >30/min, use accessory muscle, pulse rate >120 bpm, O2 saturation on air < 90%, PEFR 60-80% of personal best or predicted, oxygen saturation > 95% at room air, resources at home adequate

ARRANGE AT DISCHARGE Reliever: continue as needed Controller: start or step up, check inhaler technique and adherence Prednisolone: continue 5-7 days. Follow up: within 2-7 days

LIFE THREATENING Drowsy, confused or silent chest

FOLLOW UP Reliever: reduce to as needed Controller: continue at higher dose for short term or long term depends on exacerbation history. Risk factors: check and correct modifiable risk factors Asthma action plan

TRANSFER TO HOSPITAL Give neb Salbutamol/Combivent, high flow oxygen and stat dose IV Hydrocortisone. Secure IV access Refer O&G and medical team

6.

CARDIAC DISEASES IN PREGNANCY

6.1

Heart Disease in Pregnancy Phase

Plan of Action

1

Pre-pregnancy

•

2

At diagnosis

• • •

All women in the reproductive age group and plan to conceive should be referred to the Pre-Pregnancy Clinic upon diagnosis Suspected of heart disease: Refer for ECHO / O&G Clinic appointment within 1 to 2 weeks For women with pre pregnancy plans – refer to combined clinic. Urge husbands/partners to attend visits.

*Modified WHO classification of maternal Cardiovascular risk: WHO Class I and II: Health clinic with FMS WHO Class II-III,III-IV: Refer to Tertiary Centre, advise TOP if indicated 3

Subsequent antenatal follow up

• • •

Shared care between FMS and Combined Clinic team Anomaly scan in MFM Clinic at 24 weeks for patients with Congenital Heart Disease (a detailed fetal echocardiogram should be offered) Further follow-up plan will be made on case-to-case basis ➢ WHO/NYHA I&II: at least 2 visits at week 22 – 28 & weekly visit from 36 weeks onwards ➢ WHO/NYHA III&IV: once in 2 weeks visit at week 22 – 28, followed by weekly visit afterwards & consider admission at 36 weeks (with anaesthetic review) Correct anaemia if any Outlined by O&G Department by 36 weeks

4

Delivery plan

• •

5

Delivery

•

Hospital delivery

6

Postpartum

• •

Individualised plan Follow perinatal care manual (postnatal section) and watch out signs and symptoms of heart failure Importance of contraception and planned pregnancy reinforced (Refer Appendix “Medical Eligibility Criteria for Contraceptive Use”)

• 7


• • • • •

Notification of high risk cases discharge as per guideline (Refer Appendix “Notification of High Risk Cases Discharge”) Emphasize the importance of early report to health clinic and review by medical officer at 1 week FMS appointment within 1 month Cardiology appointment Pre pregnancy clinic appointment at 3 months postnatal (if future pregnancy possible)

REMARKS

Cardiovascular disease affects approximately 0.2% to 4% of pregnant women

Characteristics Symptoms of Heart Failure: • • •

Shortness of breath (dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea) Reduced effort tolerance Ankle swelling (may be absent)

Signs of Heart Failure: • • • • • •

Elevated jugular-venous pressure (JVP) Third heart sound Laterally displaced apical impulse in the presence of cardiac murmur Peripheral oedema Tachycardia Narrow pulse pressure

Modified WHO Classification of Maternal Cardiovascular Risk(s):

Conditions in which pregnancy risk is WHO I • Uncomplicated, small or mild - pulmonary stenosis - patent ductus arteriosus - mitral valve prolapse • Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage). • Atrial or ventricular ectopic beats, isolated

Conditions in which pregnancy risk is WHO II or III WHO II (if otherwise well and uncomplicated) • Unoperated atrial or ventricular septal defect • Repaired tetralogy of Fallot • Most arrhythmias

WHO II–III (depending on individual) • Mild left ventricular impairment • Hypertrophic cardiomyopathy • Native or tissue valvular heart disease not considered WHO I or IV • Marfan syndrome without aortic dilatation • Aorta 50 mm in aortic disease associated with bicuspid aortic valve • Native severe coarctation

Indication for TOP:

• • • • • • •

Severe pulmonary hypertension Eisenmenger syndrome Marfan syndrome with aortic root dilatation > 45 cm Previous peripartum cardiomyopathy with residual impairment of left ventricular function LVEF < 30 %, NYHA III-IV Severe mitral stenosis (MVA < 1.0 cm2) Severe symptomatic aortic stenosis (AVA < 1.0 cm2)

References: o o

ESC Guidelines on the management of cardiovascular disease in pregnancy 2011 Heart Disease in Pregnancy, 2nd Edition, 2016

6.2 Peripartum Cardiomyopathy (PPCM) Phase 1

Diagnosis (Antenatalpostpartum)

Plan of Action • • • •

2


• • • •

3

Postnatal Care

• • •

Identify women at risk for PPCM and monitor presence signs and symptoms of heart failure during pregnancy or postnatal period. Women with previous history of PPCM need to be referred to FMS/Combined Clinic/Cardiologist. If presence of symptoms and signs of heart failure, refer hospital immediately Tertiary hospital management. Notification of high risk cases discharge as per guideline (Refer Appendix “Notification of High Risk Cases Discharge”) Contraception before discharge (Implanon) Emphasize the importance of early report to health clinic and review by medical officer at 1 week: Ensure contraception/ Implanon and thromboprophylaxis in place FMS appointment within 1 month Cardiology/ECHO appointment as planned (if not given need to take appointment within 3 to 6 months) To refer to Cardiologist if: - presence of signs/symptoms of heart failure, or arrhythmias - For women with persistently reduced EF.

•

4

Risk of subsequent pregnancy

5

Future • pregnancy plan •

Refer Pre Pregnancy Care Clinic in Specialist Clinic -hospital/FMS (if not on any contraception)

Require Cardiologist assessment prior next pregnancy. To ensure patient follow up with Cardiologist and Feedback.

REMARKS Definition : • • •

Heart failure develops in the last month of pregnancy or within 5 months of delivery with EF less than 45% and not attributed by other causes. The incidence varies from 1:300 to 1:4000 pregnancies. Incidence is low ( 250 cells/µL

• •

Preferred choice of ART is Tenofovir + Emtricitabine + Efavirenz If late diagnosis of HIV(> 28 weeks), should consult ID Physician as patient must be commenced on ART without delay and regimen may include Raltegravir to achieve more rapid viral load suppression Strict adherence to ART must be stressed throughout the pregnancy

• •

PCP prophylaxis can be initiated regardless of stage of pregnancy and continue throughout the pregnancy

•

Refer to BF guideline in Mother with HIV

•

Contraception choice - refer to MEC in view of interaction with ART

Reference(s): 1. Management of HIV Infection in pregnant women, February 2008 2. Malaysian Consensus Guidelines on Antiretroviral Therapy 2017 3. Circular on breastfeeding 2017 (by KKM)

7.2

HIV in Serodiscordant Couple (HIV-positive Male, HIV-negative Female)

Phase Pre pregnancy

Plan of Action Pre-conception counselling Pregnancy must be well planned Assess husband and wife for any fertility issues • Husband –Semen analysis is recommended before conception is attempted to rule out low sperm count • Wife – if irregular menses, need further investigations HIV-positive husband is strongly recommended to be on ARTand is virologically suppressed before attempting conception Advise for early antenatal booking Stress on compliance to ART and condom use (if not virologically suppressed) Plan for timed unprotected intercourse during fertile period [sexual intercourse limited to the 2-3 days before and the day of ovulation (peak fertility)] Repeat husband’s VL after 6 months. Recommend PrEP for HIV-negative female if • Husband not on treatment/non-compliance/VL not known • Husband’s VL not suppressed • If husband VL suppressed • PrEP is not required but mother must be well counseled and closely monitored

2.

At booking / diagnosis

• • • •

3.

Subsequent antenatal follow-up Delivery Postpartum

1.

4. 5.

Early booking if UPT positive To do HIV screening each trimester Emphasize on safe sex or abstinence Condom use should be encouraged in pregnancy because of increased risk of HIV acquisition during pregnancy • Mother must be closely monitored • If HIV screening is reactive, refer to FMS • Advise BTL if completed family Vaginal delivery unless otherwise indicated. Referral to pre-pregnancy care clinic To be advised on dual protection contraception PrEP to be continued for the duration of breastfeeding if husband not on treatment/non-compliance/VL not known/VL not suppressed

REMARKS: ‘Virologically suppressed’ - undetectable viral load in 2 consecutive viral load readings. References: 1. Malaysian Consensus Guidelines on Antiretroviral Therapy, 2017.

7.3 Syphilis in Pregnancy Phase 1


Plan of Action • • • • • • •

Routine screening of RPR/TPPA for all mothers at booking For known cases trace previous RPR titre Screen partner and to treat if indicated Screen for other STIs (i.e. Hep B, Hep C) if there is risk Advice for protective sex using condom Notification for new cases Advice high risk behaviour

Indications for treatment: • • • • • 2


• • •

Newly diagnosed syphilis at any stage Unclear history of syphilis treated prior to this pregnancy Titre during current pregnancy is ≥ 1:8 Serological cure (a four-fold drop in RPR titre, e.g. from 16 to 4) did not occur Increased titre from titre before pregnancy

• • • • •

Referral to FMS for assessment and counselling Referral for anomaly scan at 24 weeks Look up for signs of foetal infection i.e. polyhydramnios, preterm labour, hydrops, IUGR, hepatosplenomegaly Repeat RPR titre monthly Should have repeat serological titres at 28 weeks of gestation To repeat treatment if there is an increase of titre/ new infection To refer MFM team if resistance suspected (no fourfold RPR reduction) Refer O&G at 34-36 weeks gestation for further assessment

3

Delivery plan

•

May allow postdate, unless specified otherwise

4

Delivery

• •

Advise hospital delivery Refer baby to Paediatrics team

5

Postpartum

• •

Contraception (refer to MEC) Advise patient on importance of early booking in next pregnancy

6


•

Refer mother and partner to continue follow up titre as outpatient in health clinic Refer to pre-pregnancy clinic

•

REMARKS:

• • • • • •

Treatment with IM Benzathine penicillin 2.4 MU weekly x3 doses Doxycycline and Tetracycline are contraindicated in pregnancy Erythromycin should not be used as first line unless patient is allergic to penicillin Need to do test dose for penicillin allergy Look for Jarisch-Herxheimer reaction within 24 hours after penicillin especially in 2nd half of pregnancy Refer Appendix Medical Eligibility Criteria for Contraceptive Use

References: 1. Malaysian Guidelines in the treatment of Sexually Transmitted Infection Fourth Edition

2015 2. UK National Guidelines on the Management of Syphilis 2015, December 31, 2015 3. WHO Guideline on syphilis screening and treatment for pregnant women, 20

7.4 Viral Hepatitis B in Pregnancy Phase

Plan of Action

1


• • •

Screen for Hep C co-infections if not done previously Screen husband and family Counsel on risk-taking behaviours

2


• •

•

To do HBe antigen, HBe antibody, LFT To do LFT monitoring (every trimester) and monitor closely for hepatic flares Referral to Gastroenterology clinic to initiate treatment if HBe antigen reactive or deranged liver enzymes If HBe antigen non-reactive, to follow up in health care clinic

•

3

Delivery plan

•

Timing & mode of delivery as per obstetric indication

4

Delivery

• • •

Hospital delivery Standard precaution Refer infant to Paediatrics ➢ Hep B vaccine given as per national policy ➢ Hep B immunoglobulin given at birth within 12 hours post-delivery Allow breastfeeding

• 5

6

Postpartum


• • •

Offer contraception (refer MEC) Refer mother with HBe antigen reactive to follow up in Gastroenterology clinic Advice patient on importance of early booking in next pregnancy

•

Pre-pregnancy care FMS clinic appointment within 3/12

Remarks:

Reference(s): 1. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update 2. Management of Hepatitis B in Pregnancy: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists July 2016 3. South Australian Perinatal Practice Guidelines: Hepatitis B in pregnancy 4. Chronic Hepatitis B in Pregnancy A Workshop Consensus Statement on Screening, Evaluation, and Management 5. Sabah Obstetric Shared Care Guideline 2012

7.5 Tuberculosis in Pregnancy Phase

Plan of Action

1

Prepregnancy

•

Women with TB on treatment must be advised for contraception until completed treatment

2


• •

To screen all pregnant mothers according to checklist Patient suspected for tuberculosis based on history and physical examination, do investigations such as: ➢ Sputum AFB direct smear X 3 (Induced sputum if unable to produce sputum)

•

• •

➢ CXR with abdominal shield (preferably after 12 weeks gestation) ➢ Biopsy if indicated (extrapulmonary tuberculosis) If diagnosed tuberculosis: ➢ Refer Pusat Rawatan 1 (PR 1) and FMS once diagnosed for follow up ➢ Notify and contact tracing ➢ Baseline investigations (FBC, RBS, BUSE, creatinine, LFT, sputum MTB C&S, HIV rapid test) ➢ Refer combined clinic/ visiting O&G specialist in district For relapsed PTB: ➢ Order GenXpert test (discuss with respiratory team) Treatment regime: ➢ For pulmonary tuberculosis - 2 EHRZ / 4HR (Pyridoxine 30 mg OD to be given with Isoniazid) ➢ For extrapulmonary tuberculosis – refer to respective team ➢ For DR-TB – refer to chest physician

3


• • • •

Check on DOTS Continue anti-TB treatment Monitor patient as per guidelines. Ultrasound monthly after 24 weeks to look for IUGR

4

Delivery

•

Hospital delivery

5

Postpartum

• • • •

Refer baby to Paediatrics team to initiate isoniazid prophylaxis Defer giving BCG if baby symptomatic Inform health clinic upon discharge to ensure continuity of TB treatment Allow breastfeeding

REMARKS:

• • • • • •

Diagnosing TB in pregnancy can be difficult as it is masked by pregnancy changes Arrange for TB workout among pregnant women with symptoms suggestive of TB Mantoux test is considered safe and valid for use in pregnancy Streptomycin cause foetal ototoxicity and should not be used during pregnancy Children below 5 years will need Isoniazid prophylaxis. Trace contacts for latent TB

•

Rifamycin drugs such as rifampicin and rifabutin reduce the contraceptive efficacy of both OCP & POP Alternative method should be used (refer to MEC)

•

Reference(s): 6. Malaysia CPG Management of Tuberculosis 2012 7. South Australia Guideline 2014 8. Obstetrics, Gynaecology and Reproductive Medicine Journal 9. CPG Management of Drug Resistant Tuberculosis, Malaysia 2017 10. Centres for Disease Control and Prevention

8.

KIDNEY DISORDERS IN PREGNANCY

8.1

URINARY TRACT INFECTION

(Asymptomatic Bacteriuria, Acute Cystitis and Acute Pyelonephritis)

Phase 1

Pre-Pregnancy

Plan of Action •

Advise on lifestyle such as: ➢ avoid delayed voiding habits ➢ avoid douching ➢ avoid tight clothing ➢ Other non-pharmacological measures: increase fluid intake ➢ empty the bladder after sexual intercourse double voiding to ensure no residual urine) ➢ clean perineum from front to back after defecation

2 •

3 2


Asymptomatic Bacteriuria •

Proceed with multi-reagent dipstick if routine dipstick shows proteinuria or glycosuria If multi-reagent dipstick is positive for WBC, RBC or Nitrite, do urine C&S If positive urine culture treat with short course antibiotics (3 days)

• •

Acute Cystitis •

Symptoms of acute cystitis include dysuria, frequency and urgency Perform urine analysis and urine C&S if patient is symptomatic Treat patient empirically with antibiotics for 5 days Choice of antibiotics

• • •

Antibiotics o o o o

Amoxycillin Cephalexin Cefuroxime Nitrofurantoin*

Recommended dose 500mg TDS 500mg BD 250mg BD 100mg BD

*Avoid in G6PD deficiency *Avoid in 3rd trimester: risk of haemolysis if foetus is G6PD-deficient;

• •

Trace urine C&S result & manage accordingly Repeat urine C&S 1-2 weeks after completing antibiotics to ensure eradication of the UTI

Recurrent UTI • •

Perform ultrasound KUB and renal profile Consider prophylaxis for pregnant women at risk of recurrent UTI as follows: ➢ ➢ ➢ ➢

Pre-pregnancy history of recurrent UTl Persistent symptomatic UTI Asymptomatic bacteriuria after 2 antibiotic therapies After only one UTI, if has other conditions that potentially increase the risk of urinary complications (e.g. DM) ➢ Abnormality of the urinary tract (e.g. renal calculi, urinary tract malformations)

•

Choice of antibiotics: Antibiotics o o o

•

Cephalexin Cefuroxime Nitrofurantoin

Recommended dose 250mg OD 250mg OD 50mg OD

Patient on prophylaxis should be continued till 36 weeks

3

Delivery plan

Acute Pyelonephritis • If patient is suspected to have Acute Pyelonephritis, admit to start IV antibiotics • Assess patient for: ➢ dehydration ➢ maternal or foetal complications • Ultrasound KUB is required for further assessment • Timing & mode of delivery as per obstetric indication

4

Delivery

•

Hospital delivery

5

Postpartum

• •

To discuss options of contraception with patient/couple Pre-pregnancy Clinic appointment

Remarks Prevalence of UTI: • •

Symptomatic bacteriuria occurs in 17–20% of pregnancies Asymptomatic bacteriuria occurs in 2-10% of pregnancies

Definition of significant Bacteriuria: • In asymptomatic woman: 2 consecutive voided urine specimens grow 105 cfu/ml of the same bacterial species on quantitative culture; or a single catheterized specimen grows 105 cfu/ml of a uropathogen • In symptomatic woman: a voided or catheterized urine specimen grows 103 cfu/ml of a uropathogen • The gold standard for detecting bacteriuria in pregnancy is urine culture of MSU Complications of UTI include: Maternal  • • • • Foetal • • •

Acute pyelonephritis Premature labour PPROM Chorioamnionitis IUGR Low birth weight  Prematurity

Reference:

1. Management of suspected bacterial urinary tract infection in adults- 2012. 2. SIGN Guideline 3. Malaysian Antibiotics Guidelines 2014 4. Malaysia Family Physician 2007; volume 2, number 2; Urinary Tract Infections in Pregnancy;54-56.

5. The Cochrane Library 2009-2011; Duration of treatment for asymptomatic bacteriuria during pregnancy; Antibiotics for asymptomatic bacteriuria In pregnancy; Treatment for symptomatic urinary tract infections during pregnancy.

6. The Society of Obstetricians and Gynaecologists of Canada (SOGC); Clinical Practice Guideline; Recurrent Urinary Tract Infection; November 2010.

7. European Association of Urology; Guidelines on Urological Infections 2010. 8. Vazquez JC, Abalos E. Treatments for symptomatic urinary tract infections during pregnancy (Cochrane Review). Cochrane Database of Systematic Reviews 2011, Issue

9. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis, 2005. 40(5): p. 643-54.

10. Pfau A, Sacks TG. Effective prophylaxis for recurrent urinary tract infections during pregnancy. Clin Infect Dis 1992;14:810–4.

11. Widmer M, Gülmezoglu AM, Mignini L, Roganti A. Duration of treatment for asymptomatic bacteriuria during pregnancy (Cochrane Review). Cochrane Database of Systematic Reviews 2011, Issue 12 12. Antimicrobial therapy for obstetric patients. ACOG educational bulletin no. 245. Washington, D.C.: American College of Obstetricians and Gynaecologists, March 1998;245:8–10.

8.2 CHRONIC KIDNEY DISEASE Phase

1

PREPREGNANCY

Plan of Action

• • • •

• 2

ANTENATAL

• • • • • • • •

All women in the reproductive age group with renal impairment should be referred to pre-pregnancy clinic in O&G department Pregnancy may be considered in women having mild renal impairment (serum creatinine < 124µmol/L) and well controlled blood pressure Women with moderate to severe renal impairment should be counselled to avoid pregnancy due to greater adverse maternal and foetal outcome Rule out relative contraindication to pregnancy: ➢ ESRF ➢ Haemodialysis ➢ Recent transplant < 1-2 years ➢ Transplant with recent rejection Baseline investigations ordered: Pre-eclampsia profile Shared care between Health Clinic and O&G team First trimester dating scan For Aspirin 75mg OD and Calcium Carbonate 1gm BD at booking At every visit, women should be screen for complications, hypertension, proteinuria and pre-eclampsia UTI screening for asymptomatic bacteriuria at each visit Renal function checked at each trimester or more frequent if needed. Anomaly scan at 24 weeks (Indication: drug exposure in pregnancy) Ultrasound for fetal growth every 4 weeks starting from 24 weeks POA till delivery

3

DELIVERY

•

Hospital delivery

4

POSTPARTUM

•

Refer appendix on “Medical Eligibility Criteria for Contraceptive Use, 5th edition PPH prophylaxis (for over-distended uterus) Encourage breastfeeding Pre-pregnancy clinic in O&G for future pregnancy

• •

REMARKS

Severity grading in chronic kidney disease follows serum Creatinine level.

Severity

Serum Creatinine Level

Mild

90-124

Moderate

125-225

Severe

>225

•

Pregnancy in women with moderate to severe renal impairment (serum creatinine>124µmol/L) results in increased risk of adverse maternal and foetal outcomes

•

Common maternal complications include accelerated decline in renal function, hypertension, proteinuria and pre-eclampsia Common foetal complications include spontaneous abortion/ neonatal death, prematurity, low birth weight/ SGA baby

•

Reference(s):

1. Clinical Practice Guidelines on Management of Chronic Kidney Disease in Adults, June 2011

9.

OBSTETRICS PROBLEMS

9.1 Multiple Pregnancy Phase 1


Plan of Action • • • • •

2


• • •

First trimester ultrasound is recommended, (best at 14 weeks) difficult to determine chorionicity after 14 weeks. When to refer: ➢ KD to refer immediately to KK ➢ KK: to be seen by MO/FMS Refer O&G within 1 week to determine chorionicity, counselling and outline of antenatal follow-up plan Refer MFM as soon as chorionicity is determined for further antenatal care plan URGENT REFERRAL if: ➢ Monoamniocity ➢ Suspected Twin-twin Transfusion Syndrome (TTTS) ➢ Foetal structural abnormality ➢ Suspected discordance in weight >18% (weight) ➢ Higher order or multiple gestation (>3) ➢ Single foetal demise If Monochorionic (MC) twins or higher order multiple pregnancy (≥3): to follow up MFM Clinic/general O&G Clinic of hospital (high risk pregnancy) If Dichorionic (DC) twins, patient will be followed-up both at health clinic and hospital (general O&G clinic) All multiple pregnancies require monthly growth scan

3

Delivery plan

•

Outlined by O&G: ➢ Higher order multiple pregnancy: soon after diagnosis is confirmed ➢ Twins: depend on chorionicity, presentation and any other associated factors, by 3rd trimester ➢ Uncomplicated Monochorionic: to deliver by 36 weeks ➢ Uncomplicated dichorionic – deliver by 38 weeks

4

Delivery

•

Hospital delivery

5

Postpartum

•

Discuss option of contraception with patient/couple

6


•


REMARK:

•

Incidence: ➢ 1/3 of twin is monochorionic twin pregnancy ➢ 10-15% monochorionic has TTTS(twin to twin transfusion) ➢ 3% of livebirth (NICE 2011) ➢ Risk of stillbirth 2.5 times higher than singleton

•

Multiple pregnancy patients are at higher risk of: ➢ Anaemia ➢ PIH ➢ Preterm labour

•

Mode of delivery: Individualized (based on gestational age, co-morbidity, availability of expertise in management of vaginal twin birth and women preference)

•

CS summary is attached with patient’s home based card for all post-LSCS patients

Reference(s): 11. RCOG Green-top Guidelines No. 51 (2008). 12. NICE Guidelines on Multiple Pregnancies (twin and triplet) (2011)

9.2 Breech / Malpresentation Phase 1

2

Plan of Action

At diagnosis (>36 weeks)

•

Delivery plan

•

• • •

Refer O&G if > 36w and to be seen within a week (37-38 weeks) for assessment, counselling and delivery plan If patient has underlying previous scar, to get date for ELLSCS If transverse lie, refer to O&G specialist Advise patient to come to Patient Assessment Centre (PAC) immediately if she has symptoms of labour or PPROM / PROM Outlined by O&G: Breech ► Refer O&G team for counselling and assessment ► For External Cephalic Version (ECV) if suitable and agreeable All malpresentation ► Rule out placenta praevia, foetal anomaly, pelvic tumour and other causes of malpresentation Unstable lie

• •

► Observe in hospital If for elective LSCS, book operation date at the same clinic review Routine antenatal follow-up at health clinic if no other complication

3

Delivery

•

Hospital delivery

4

Postpartum

•

Discuss options of contraception with patient / couple

5


• •

Routine discharge procedure CS summary is attached with patient’s home based card for all postLSCS patients

9.3 Previous Scar(s) (LSCS, Classical CS, Myomectomy) Phase

Plan of Action

1

At booking

• •

Look at patient’s previous home-based card If previous CS Summary is not available, please provide as much information* as possible at the time of referral, so that previous LSCS / myomectomy case notes can be retrieved in time for review during appointment

2


• • •

Scan for placental site is essential To distribute VBAC brochures by 24 weeks. Refer to O&G team: − as soon as placenta praevia is suspected − Inter-pregnancy (Poor spacing) (< 18 months)

3

Delivery plan

•

For 1 previous scar: - To do VBAC counselling 32 - 34 weeks by MO/ FMS at health clinic (refer to VBAC counselling form in appendix) - To give option regarding mode of delivery - If opt for repeat CS, to call O&G team at 36 weeks to get elective CS date - If opt for vaginal delivery, to go to hospital if in labour 2 previous scars with normally sited placenta: − To call O&G team at 32 – 34 weeks to get elective CS date − Patient may then be followed-up at health clinic if no other risk factor / complication

•

4

Delivery

• •

Delivery at tertiary hospital for any previous history of scar VBAC is contraindicated in women with previous uterine rupture or classical scar and in women who have absolute contraindication to vaginal delivery such as PP.

5

Postpartum

•

Ensure compliance to thromboprophylaxis treatment if underwent Caesar Discuss options of contraception with patient / couple if concurrent BTL was not done Routine discharge procedure Contraception as per “Medical Eligibility Criteria”

• 6


• •

REMARKS:

• •

VBAC is appropriate for and may be offered to the majority women with singleton pregnancy of cephalic presentation at 37 weeks or beyond who had single previous caesarean with or without previous vaginal delivery Success rate of VBAC is 72-75%

•

Refer Appendix for o Caesarean section summary o Counselling for vaginal birth after caesarean section and consent (English version) o Counselling for vaginal birth after caesarean section and consent (Malay version)

•

Risk of morbidly adherent placenta must be considered in anterior placenta praevia major with previous LSCS *information: ➢ Patient name ➢ IC ➢ Contact number ➢ Date of surgery / discharge ➢ Intraoperative findings including complications

•

•

Attach copy of VBAC counselling form by O&G Department in antenatal book

•

Absolute contraindication for trial of vaginal delivery after caesarean ➢ Previous uterine rupture ➢ Previous upper segment uterine incision (hysterotomy, classical uterine incision) ➢ Previous cornual pregnancy ➢ Previous complex myomectomy

Reference: 1. Perinatal Care Manual, 3rd Edition (2013) 2. Birth After Previous Caesarean Birth Green-top Guideline No 45, 2015

9.4 Placenta Praevia Phase 1


Plan of Action •

Asymptomatic PP ► refer to O&G at 30-32 weeks, however, requires earlier admission in cases of logistics problem(s), poor compliance to advice, etc. (to discuss with O&G)

•

Asymptomatic PP with previous scar ► refer to O&G immediately, to be seen within 1 week Symptomatic PP ► refer to hospital immediately PP major without APH: ► admit at 34 weeks till delivery

• •

2

Subsequent antenatal followup

Once confirmed to be PP major, general follow-up plan will be outlined by O&G - inpatient/outpatient care, timing of admission, etc

3

Delivery plan

• •

Outlined by O&G at about 34-36 weeks; addressing timing, mode, place of delivery, etc If placenta leading edge > 2cm from internal os: may allow vaginal delivery

4

Delivery

•

Hospital delivery

5

Postpartum

•

Discuss options of contraception with patient / couple if concurrent BTL was not done

6


•


REMARKS: • ➢ ➢ ➢

Definition: Placenta wholly or partially inserted into the lower uterine segment Major : placenta overlies the cervical os Minor : leading edge does not cover the cervical os

• Incidence: ➢ 0.3-0.5% of all pregnancies • •

Risk of morbidly adherent placenta must be considered in anterior placenta praevia major with previous LSCS Special consideration must be given to patient with previous classical CS/myomectomy even with a normally sited placenta in current pregnancy

•

CS summary is attached with patient’s home based card for all LSCS patients.

References: 1. RCOG Green-top Guideline No. 27 (2011) 2. Canterbury DHB : Protocol Development : Maternity Guidelines Group 2015

9.5 Risk for Macrosomia / Shoulder Dystocia Phase

Plan of Action

1


• •

Have high index of suspicion if *risk factors present History of macrosomia / LGA baby is an indication to rule out GDM

2


• • •

Monthly foetal growth assessment 28 weeks onwards If AC on USS>90th centile, to refer O&G clinic To continue antenatal follow-up at health clinic

3

Delivery plan

•

Timing & mode of delivery as per obstetric indication

4

Delivery

•

Hospital delivery

5

Postpartum

• •

Discuss options of contraception with patient / couple Advice patient on importance of early booking in next pregnancy

6


• •

Routine discharge procedure Diabetic screening after post-partum period

REMARK:

• Definition of Large for gestational age: Excessive growth beyond specific threshold regardless of gestational age AC/ EFWt >90th centile/ BW>4kg

•

Incidence: ➢ 5.58% macrosomic babies in DM, 2.98% in non-DM ➢ Mothers with previous shoulder dystocia has 10x higher risk of recurrence (1-25%)

•

*Antepartum risk factors for shoulder dystocia include: ➢ Genetic predisposition ➢ Maternal pre-pregnancy obesity (BMI>30kg/m2) ➢ Excessive maternal weight gain >15kg (2.5x higher risk of macrosomia) ➢ Multiparity ➢ Advanced maternal age ➢ Post date ➢ Male infant ➢ Previous shoulder dystocia ➢ Previous macrosomia (birth weight >4kg) ➢ Previous LGA baby ➢ Diabetic pregnancy If there was previous shoulder dystocia, ask for pre-pregnancy care plan if patient was seen in pre-pregnancy Clinic

•

•

Decision on mode of delivery for suspected macrosomia / at risk for shoulder dystocia in index pregnancy would be made after assessment at 34-36 weeks, including: ➢ Previous shoulder dystocia ➢ Previous pregnancy outcome ➢ Presence / absence of DM/GDM in index pregnancy ➢ Clinical estimation of estimated birth weight ➢ Ultrasound parameters (AC, EFW)

•

CS summary is attached with patient’s home-based card for all post-LSCS patients

Reference(s): 13. American College of Obstetrics and Gynaecologists (ACOG) guidelines on Foetal Macrosomia (2014). 14. Malaysian National Health Morbidity Survey 2006 15. RCOG, Green-top Guidelines No. 42 (2012) 16. Perinatal Care Manual (3rd edition)

9.6

Obesity in Pregnancy

Phase

Plan of Action

1

Pre-pregnancy

• • • • • •

2

Booking

• • • •

3

Subsequent antenatal followup

• • • • •

Monitor maternal weight gain throughout pregnancy* (Table II) Monthly foetal growth scan Screen for GDM Continue exercises and diet control (under dietician review) Reassess VTE risk throughout pregnancy

4

Delivery Plan

•

Refer O&G team for delivery plan including anaesthetist assessment, to be seen at 34 – 36 weeks

5

Delivery

•

Tertiary hospital delivery if BMI >35 kg/m2

6

Postpartum

• • •

Contraception as per “Medical Eligibility Criteria for Contraceptive Use” Advice and support breast feeding Thromboembolism prophylaxis

7

Lactation

• •

Pre-pregnancy clinic appointment Continuance of lifestyle and dietary modification

Identify co morbidities Counsel regarding weight loss Advice life style modification Advice Tablet folic acid 5mg daily (at least 1 month prior to conception) Counsel regarding *complications of obesity in pregnancy (Table I) Contraception until ready for conception

Ideally BMI should be calculated using pre-pregnancy weight (Table II) Measure BP with appropriate cuff Refer MO once obesity identified To do STOP-BANG Score TRO OSA during booking (If score 3 and more, to get appointment in High Risk Pregnancy Clinic) • If booking BMI >35, to get detail scan at 24 weeks • Early scan for confirmation of EDD • Refer dietician • Assess VTE risk If risks are identified for preeclampsia refer to O&G clinic

REMARKS:

•

Obesity during pregnancy defined as BMI > 30kg/m2 measured at 1st antenatal visit.

•

Incidence: 50% pregnant women either overweight or obese.

Table I: Complications of obesity Complications of obesity Antenatal

Intrapartum

Anaesthetic risk

Post-partum

Neonates

• •

•

•

•

•

Macrocosmic baby

•

Neonatal obesity and metabolic syndrome

• • • • • • • •

Miscarriage Gestational Diabetes Foetal Congenital Abnormality Stillbirth Pre-eclampsia Thromboemb olism Abnormalities foetal growth Obstructive sleep apnoea Preterm birth Maternal death

• • • • • • •

IOL/prolong labour/ failure to progress Instrumental delivery Failure of instrumental delivery Shoulder dystocia Caesarean section Difficult foetal heart monitoring Postpartum haemorrhage Peripartum death

• • •

Difficulty with labour analgesia Use of GA Failed intubation Increase risk ICU care postop

• •

•

Delayed wound healing Thromboembolic disease Need support for breastfeeding initiation and continuation Postnatal depression

Table II: Weight gain during pregnancy (Manual Perkhidmatan Kesihatan Ibu & Anak 2016) Classification

2

BMI (kg/m )

Total weight gain range (kg)

0-20 weeks

20-40 weeks

Ideal weight increment

Underweight

refer medical / rheumatology AND combine clinic MOGTT for patients on Prednisolone Foetal detail scan

•

3

Delivery

•

As per obstetric indications

4

Postpartum

•

Monitor for flares². Refer rheumatologist for follow-up at the rheumatology clinic

5

Lactation

•

Safe to continue: NSAIDS (but aspirin should be avoided), Corticosteroids, HCQ, SSZ³, TNF inhibitors, AZA Inadequate data: JAK inhibitors (tofacitinib) Contraindicated: Methotrexate, Leflunomide, cyclosporine, cyclophosphamide, chlorambucil and other biologics

• •

REMARKS:

Hydroxychloroquine (HCQ), Sulfasalazine (SSZ), Azathioprine (AZA) and Corticosteroids in doses up to 15 mg/day (prednisolone equivalent) are compatible with pregnancy

¹Clinical evaluation based on 2010 ACR/EULAR classification criteria

²A flare is associated with functional disability, intense fatigue, more swelling, more pain, more stiffness, flu like symptoms

³SSZ: use with caution in setting of prematurity, hyperbilirubinaemia, G6PD deficiency

Reference(s): 1. EULAR textbook on Rheumatic Diseases 2012 2. Up to date: Patient information: Rheumatoid arthritis and pregnancy (Beyond the Basics).

10.2 Systemic Lupus Erythematosus Phase 1

Pre-pregnancy

Plan of Action • • •

Refer to pre – pregnancy clinic (FMS/O+G) Avoid unplanned pregnancy Should defer pregnancy until disease is under good control on medications compatible with pregnancy, whenever possible • If planning to conceive, refer rheumatologist for assessment • Folic acid 5mg daily • Disease increase likelihood of flare in pregnancy • Assess disease activity, major organ involvement, hypercoagulability and concurrent medical conditions • Pregnancy is allowed if: ➢ Disease in remission for ≥6 months ➢ BP well-controlled ➢ eGFR >60ml/min ➢ Proteinuria