Obstetrics | Bits & Bumps

Niacin for prevention of birth defects – is it all it’s cracked up to B ?

August 20, 2017 · by Penny Wilson

On this episode of the podcast, Penny looks at a recent study published in the NEJM looking at the genetic basis for certain congenital defects and the possible role of niacin (vitamin B3) in their prevention. In particular, how does this paper stack up to the claims in the media, and what does it mean for clinicians?

In other news, there is a new Australian O&G podcast on the block. Check out Conversations in Obstetrics and Gynaecology here.

And, you can catch up with Penny at the RANZCOG ASM in Auckland in October 2017 where she will be presenting a masterclass in Social Media. Come along!

References & Resources

The paper:

Shi et al. NAD Deficiency, Congenital Malformations, and Niacin Supplementation N Engl J Med 2017; 377:544-552

The press release:

Historic Discover Promises to Prevent Miscarriages and Birth Defects Globally

The responses:

From The Conversation

From The Science Media Centre

From RANZCOG

From NHS Choices

The response to the responses:

Statement Regarding Pregnancy Discovery

Dr Fiona McKinnon: On the Path to GP Obstetrics

October 13, 2016 · by Penny Wilson

On this episode of the podcast we are joined by Dr Fiona McKinnon, a soon-to-be-fully-fledged GP obstetrician from Ipswich in Queensland.

We chat about:

The process for training in GP obstetrics through the DRANZCOG (basic and advanced)
Tips and tricks on getting through the program
Gaining confidence after qualification
The highs and lows of the job and why we do it!

Resources:

About diploma and womens health certificate training through the RANZCOG

Rural Health West GP obstetrics mentoring program

Also, be aware there is Commonwealth funding available to support GPs to undertake DRANZCOG advanced training via the GP Procedural Training Support Program

Travel Medicine for the Pregnant Patient

October 3, 2016 · by Penny Wilson

On this episode of the podcast we are joined by Dr Wendy Sexton to talk about travel medicine for the pregnant patient.

Take home messages:

The best time to travel is in the second trimester, but be sure to advise patients about the clinical and financial risks in case of pre-term birth while overseas.
For flights longer than 4 hours, compression stockings, hydration and mobilisation is recommended. If additional risk factors are present, consider low molecular weight heparin.
Pregnant women should be aware of the local health services available in their travel destination, and be prepared with medications to treat common symptoms or conditions of pregnancy.
Water and food safety, and hand hygeine advice is important.
Mosquito bite avoidance is crucial. Measures include DEET, long sleeves and mosquito nets.
Malaria prophylaxis options include chloroquine and mefloquine. Malarone is sometimes used off-label –> consult a travel med specialist.
Yellow fever is a live vaccine and is not recommended, but consider individual risks and consult a travel med specialst.
Influenza and DTP vaccines are routinely recommended in pregnancy.

References & resources:

Pregnancy and Travel patient information sheet

Airline fitness to fly forms: Qantas and Virgin

CDC Travelers’ Health information online

NHS Fit For Travel

The Travel Doctor information sheets: Special Considerations for Pregnant Travellers, Zika and Travellers, Zika in Bali

ACOG statement on Travel During Pregnancy

RCOG patient information sheet on Air Travel and Pregnancy

And thanks to Dr Minh Le Cong for drawing these references to our attention:

Air travel and pregnancy – with reference to obstetric and perinatal aeromedical retrieval

CDC press release – Are flight Attendants at Higher Risk for Miscarriage?

Pregnancy Dating – Getting it Right the First Time!

August 9, 2016 · by Penny Wilson

In this episode of the podcast, Penny has a rant about one of her pet peeves – the ever changing due date – and gives lots of tips on how to determine the estimated due date (EDD) with the greatest accuracy.

Take home messages:

The only way to know the exact EDD for certain is an IVF pregnancy with a known implantation date.
The next most accurate method is an ultrasound measurement of crown-rump length between ~7 and 13+6 weeks (or maybe even up to 23 weeks, if you believe the Canadians). Dates based on LMP are fraught with assumptions and risks of error.
Transabdominal measurements are just as good as transvaginal scans at determining the EDD.
The margin of error increases the later the scan is done – about 5 days in first trimester, 7-10 days up to 20 weeks, 2 weeks in late second trimester, and up to 3 weeks in third trimester.
International organisations agree that ultrasound should be offered universally between 8 and 13+6 weeks and an EDD based on first trimester crown-rump length should be the definitive date. Note, however, that in practice, some radiologists will leave the EDD as per the LMP if it’s within 5-7 days.
Offering universal early dating scan reduces the rate of interventions in the post-dates period.
Check for inaccurate dates written on request forms, or typos on reports.
Never use HCG to determine gestational age.
Don’t be fooled into adjusting the due dates based on growth parameters later in pregnancy!

Australasian Society of Ultrasound Medicine recommendations:

Earliest measurement of gestational age in pregnancy should be the definitive assessment
If the first scan is after the first trimester –> if the ultrasound measurements are within one week of EDD as determined by LMP date, the scan confirms the LMP date.
If the first scan is 14 – 20 weeks and differs from the LMP date by more than one week, a new EDD is assigned, if the different measurement parameters are in agreement.

References & Resources:

ASUM Statement on Normal Ultrasound Fetal Measurements (Australia)

ASUM Guidelines for the Performance of First Trimester Ultrasound (Australia)

ISUOG Practice Guideline: Performance of First Trimester Fetal Ultrasound (international)

SOGC Clinical Practice Guideline Determination of Gestational Age by Ultrasound (Canada)

ACOG Committee Opinion: Method for Estimating Due Date (USA)

NICE Guideline: Antenatal Care for Uncomplicated Pregnancies (UK)

Perinatal Mental Health with Dr Matthew Coates

October 1, 2015 · by Penny Wilson

Today on the podcast we pick the brain of Dr Matthew Coates, a psychiatrist with experience in perinatal mental health. We talk about the common dilemmas of antidepressant prescribing in pregnancy and how to pick the post-natal patient with genuine mental illness as well as breastfeeding and neonatal issues. We also take a look at the more serious end of the spectrum of psychosis and mania in pregnancy and the post-partum period.

Take home messages:

Pre-conception planning is important for patients on psychotropic medications.
The ideal choice of antidepressants in pregnancy is the one that works for the patient. SSRIs have been better studied than SNRIs. Dosages may need to be increased in the third trimester.
Use non-drug strategies such as psychological therapies.
Patients with bipolar 1 and psychosis should be jointly managed with a psychiatrist.
Consider the effects of psychotropic medications on the neonate when planning for delivery.
Post-partum psychosis is a psychiatric emergency. Engage perinatal psychiatric services urgently.

References & Resources

Massachuset’s General Hospital Center for Women’s Mental Health – womensmentalhealth.org

Perinatal Psychotropic Medications Information Service – ppmis.org.au

Drugs and lactation database – LactMed

Bergink et al, American Journal Of Psychiatry 2012 – Prevention of postpartum psychosis and mania in women at high risk

RCOG 2015 World Congress Wrap Up

April 20, 2015 · by Penny Wilson

We’re back on the podcasting bandwagon, and this episode Penny is joined by self-proclaimed twit and legendary Aussie GP obstetrician, Ewen McPhee (@Fly_texan), to discuss what they learned at the recent RCOG World Congress.

We cover a range of topical issues including:

An update of GDM diagnosis and management
NIPT for aneuploidy screening
The use of progesterone for threatened miscarriage
Pre-term labour – screening and treatment
Menopausal hormone therapy
Fertility, the place of AMH and the legal and ethical dilemmas of fertility preservation
Future therapies for pre-eclampsia

If this has whet your appetite, why not come along to RCOG World Congress 2016 in Birmingham, or RANZCOG 2016 Annual Scientific Meeting in Perth.

References & Resources

Official RCOG World Congress 2015 page, and Storify summaries for day 1, 2 & 3

Australian Diabetes in Pregnancy Society – Consensus Guidelines for Diagnosis of GDM (2014 Revision)

RACGP Clinical Guidelines for GDM (2014-215)

WHO Diagnostic Criteria for Hyperglycaemia in Pregnancy (2013)

International Society for the Study of Womens’ Sexual Health page

International Menopause Society page

Dr Alan Altman’s page – Menopause and Sexual Dysfunction

Cochrane Review – Hormone Therapy for Preventing Cardiovascular Disease in Post-menopausal Women – 2015

Climacteric 15(3) 2012 – The Women’s Health Initiative 10 years on

Your Fertility – Fertility information for professionals and patients

The Whole Nine Months – Western Australian pre-term birth initiative

Episiotomies and Perineal Protection – Practice Tips and Pitfalls

December 6, 2014 · by Penny Wilson

We have two special guests on the podcast this week: Paul Jones and Dan Finnigan are Canadian family doctors with extra training in emergency and obstetrics.

The guys have created a mobile obstetric app called “Simply Obstetrics”. Check it out here. In part one of the podcast we discuss the perils of rural and remote obstetrics and how the app can come in handy for those isolated or “occasional” birth attendants.

Part 1

In part two we get into the meaty clinical topic of episiotomies and protection of the perineum.

Part 2

Our top take home messages:

Episiotomies should be used selectively not routinely, as the use of routine episiotomy results in increased risk of major sphincter injury
The mediolateral approach is associated with less risk of sphincter injury compared to midline approach
The threshold for cutting an episiotomy should be much lower with instrumental deliveries, particularly forceps (NNT = 7)
We prefer the use of “hands on” technique for delivery, with controlled delivery of the fetal head and warm compresses to the perineum

References & Resources

Cochrane Review (2009) – Episiotomy for Vaginal Birth

Cochrane Review (2011) – Perineal Techniques During the Second Stage of Labour for Reducing Perineal Trauma

Dixon, O&G Magazine (Autumn 2014) – The Unkindest Cut?

Eogan et al, BJOG (Feb 2006) – Does the Angle of Episiotomy Affect the Incidence of Anal Sphincter Injury?

Jansova et al, International Urogynecology Journal (September 2014) – Modeling Manual Perineal Protection During Vaginal Delivery

Check out Paul’s Blog – A Life in the Woods and more info about the Simply Obstetrics app

Bleeding in Early Pregnancy: Diagnosing Miscarriage

November 10, 2014 · by drmarlenepearce

This week we discuss bleeding and pain in early pregnancy, and how to diagnose miscarriage.

Take Home Messages:

Miscarriage occurs in 1 in 5-6 confirmed pregnancies.
A pregnancy that has not yet been sighted on USS remains a ‘Pregnancy of Unknown Location’ and remains a possible ectopic pregnancy until proven otherwise.
Serial B-hCGs can be helpful in guiding your clinical decision making, however you cannot ‘locate’ a pregnancy with a blood test alone.
In the symptomatic patient, a falling, plateauing or rising B-hCG can ALL be associated with an ectopic pregnancy – these must be followed until an ectopic pregnancy can be diagnosed or excluded.
A rise of B-hCG in 48hrs of > 63% is relatively reassuring for an ongoing intrauterine pregnancy, make sure to confirm it with an USS as soon as you can.
The ultrasound diagnosis of both a blighted ovum and a missed miscarriage (with a foetal pole) have strict criteria – refer ASUM guidelines below.

References & Resources:

Early Pregnancy Ultrasound Rules and Report Card (LINK) – Ultrasound FOAM from The Sono Cave

First Trimester Bleeding Imaging Pathway (LINK) – Western Australia Health Department Flowchart

Clinical Guideline: Early Pregnancy Loss (PDF) – Queensland Health Guideline

First Trimester Bleeding Algorithm (PDF) – Reproductive Access Project, USA

ASUM Guidelines for Performance of First Trimester Ultrasound (PDF) – Australian Society for Ultrasound Medicine

NICE Guideline: Ectopic Pregnancy and Miscarriage (PDF) – UK Guidelines

How To Treat: Early Pregnancy Bleeding (PDF) – Australian Doctor Magazine, 2009

RANZCOG Guidelines – Anti-D use in Obstetrics (PDF) – Australia & New Zealand

Does speculum examination have a role in assessing bleeding in early pregnancy? (LINK) – Emergency Medicine Journal 2004

Vomiting in Pregnancy – More Than Just Morning Sickness

September 30, 2014 · by Penny Wilson

This week on the podcast we examine the common and very troublesome problem of vomiting in pregnancy, from mild morning sickness to the more severe hyperemesis gravidarum.

Take home messages:

Standard investigations include FBC, UEC, LFT, TFTs, urinalysis and obstetric ultrasound
In severe cases, consider secondary causes of vomiting such as urosepsis, GI or neurological pathology
Dietary advice, ginger and P6 acupressure have mixed evidence but are unlikely to do harm and useful for some patients
Pyridoxine (vitamin B6) and doxylamine have the best evidence for safety and efficacy and are recommended for first line
Second line options include metoclopramide, prochlorperazine and promethazine which are all considered safe in early pregnancy
If significant ketonuria, electrolyte imbalance or dehydration, refer for intravenous hydration, parenteral anti-emetics and thiamine

References & Resources:

Treatment of Nausea and Vomiting In Pregnancy – Australian Prescriber 2014

A Survey of Prescribing for Management of Nausea and Vomiting in Pregnancy in Australasia – ANZJOG 2013

Hyperemesis Gravidarum – O&G Magazine 2014

and Letter to the Editor: Nausea and Vomiting in Pregnancy – O&G Magazine 2014

Interventions for Treating Hyperemesis Gravidarum – Cochrane Library 2013

Antenatal Clinical Practice Guidelines (Australia)

ACOG guideline (USA)

SOGC guideline (Canada)

NICE guideline (UK – but appears to be geoblocked from elsewhere)

pregnancysicknesssupport.org.uk