Transcript gp obstetric shared care sa

Lets refresh 2015!
Dr Dragica Sosa
Learning Objectives
You will be able to:
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Describe accreditation requirements of the SA OSC program
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Manage a low risk pregnancy using the SA OSC protocols and SA
PPGs
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Identify and manage key risk factors encountered in low risk
pregnancies
Accreditation Requirements
To maintain accreditation with GP OSC SA,
GPs must attend in every triennium:
• three GP OSC evening CPD events, or
• one GP OSC Update Day
or may contact us regarding other options….
OSC Visit Schedule
1st visit
2nd visit
3rd visit
GESTATION
Diagnosis
10-12 weeks
22 weeks
LOCATION
GP
GP or Hospital
GP
4th visit
5th visit
6th visit
7th visit
8th visit
9th visit
28 weeks
32 weeks
34 weeks
36 weeks
38 weeks
40 weeks
GP
GP
GP
Hospital
GP
Hospital
Antenatal Booking Process
• All metro patients need a ‘booking reference number’
from Pregnancy SA Info line: 1300 368 820.
• Arrange hospital booking visit ASAP
(before 20 weeks)
• Women requiring specialist perinatal care can be
referred directly to the relevant hospital.
• Rural locations: follow usual booking processes
• The SA Pregnancy Record (orange book) must be used
to document all care of OSC patients.
Version 6 Order forms available on GP OSC website.
Routine Supplements
The following supplements are recommended:
 Folic Acid: 500 ųg/day from at least one month prior to
conception* until 12 weeks gestation.
 5 mg/day if at increased risk of neural tube defect: taking
certain antiepileptic medications, diabetic, family history
NTD, multiple pregnancy, haemolytic anaemia, known MTHFR
mutation
 Iodine:150ųg/day should be taken during pregnancy and for the
duration of breastfeeding
Routine Supplements
Antenatal Protocols
• Developed 2002, recent update 2014
• Protocols must be followed to meet indemnity
requirements & provide ‘best practice care’
 Including non Medicare insured women
 Unless have procedural insurance
• Protocols recently been updated
• National Antenatal Care Guidelines
 Module 1 Dec 2012; Module 2 Oct 2014
Routine Antenatal Booking Tests
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CBP
Blood group and antibody screen
Rubella titre
Syphilis
Hepatitis B
Hepatitis C
HIV
MSSU for M,C&S
 Pap smear if this has not been done within the last 18 months
Additional 1st Trimester Tests
for Women at Risk
• Vitamin D screening for patients at risk of deficiencymeet new Medicare rebate guidelines
has deeply pigmented skin or has chronic and severe lack of sun
exposure for cultural, occupational, medical or residential reasons
• OGTT at 12-16 weeks for patients at high risk of
gestational diabetes
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LMHS/MH patients: test ferritin but red blood cell folate has
been removed since medicare rebate changes
• Other
OGTT at 12-16 weeks for patients
at high risk of gestational diabetes
High risk factors (need only 1):
PH Gestational Diabetes, age >40, FH, obesity (BMI >35), previous
macrosomic baby BW > 4.5kg or 90th centile, PCOS,
medication including corticosteroids or antipsychotics
Moderate risk factors (need 2, if only 1, do random or fasting
serum BGL & proceed to GTT if indicated) :
Ethnicity- Asian, Indian subcontinent, Aboriginal, Torres Strait &
Pacific Islanders, Middle East, non-white African, BMI >25-35.
Interpret GTT results (path lab interpretation may vary):
Diagnosis fasting ≥5.5 &/or ≥ 7.8 at 2hrs (SA PPG)
If normal, repeat GTT at 26-28 weeks.
Vitamin D Deficiency
 If level is <60 nmol/L, commence vitamin D 1000IU
 Use 1000IU tablets, not larger dose sachets or oils
 Test is repeated at 28 weeks
 If 2nd level is <60 nmol/L, increase dose 2000IU
 If 2nd level is >60 nmol/L, continue 1000IU
 Continue therapy postpartum and retest at 6 months
 Breastfed infants require 400IU (0.45ml) Pentavite
until at least 12 months of age
http://www.mja.com.au/public/issues/194_07_040411/lau11085_fm.html
Bariatric Guidelines
Standards for the Management of the Obese Obstetric Woman in
South Australia
• Calculate BMI, if > 35 apply Bariatric Guidelines
• High BMI - liaise with hospital re special requirements.
• Consider:
 Counselling - risks, exercise and nutrition
 Appropriate booking hospital/anaesthetic referral
 Early OGTT
 Morphology scan may need to be repeated a week later
 Close monitoring of BP (using appropriate cuff)
Further Routine Tests
 Maternal Serum Screening
 Routine morphology scan 19-20/40
 Booked with private radiology firms
 26-28 weeks gestation:
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CBP
OGCT (50gm glucose)
Blood group/antibodies (Rh negative women) prior to anti D
Vitamin D if low at booking visit
• 36 weeks gestation
 Low vaginal swab for Group B streptococcus
Routine Visit Essentials
Document in SAPR:
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Gestation (completed week)
Progress
BP – right arm, seated, correct cuff
Fundal height in cm and plot on graph
Foetal heart
Fetal movements
Investigation results
Presentation and descent from 30 weeks
Routine Anti-D Prophylaxis
 Hospital staff issue GP with 2 doses of Anti-D for
prophylaxis of Rh negative OSC patients. Please use only
for allocated patient.
 All Rh negative women need antibody screen at 28/40,
before giving Anti-D.
 All Rh negative women without preformed Anti-D
antibodies receive 625 IU Rh-D Ig at 28/40 and 34/40.
 If patient misses Anti-D at 28/40 give at next visit with
2nd injection 6 weeks later.
Need help?
http://www.gppaustralia.org.au/
• Program information and news
• Updated OSC Protocols, resources, order forms and links
• Upcoming CPD events
• Accredited OSC GP Registry – update your contact details!
• OSC Program Coordinator: ph. 8112 1100
Need help?
SA GP Obstetric Shared Care Protocols 2014
SA Perinatal Practice Guidelines
• www.health.sa.gov.au/ppg
OSC Midwife Coordinators
• contact details in brochure
GP Medical Advisors
• contact via GP OSC Program SA