1. Immunisations and Infections Helen Toyne, GP Toby Angstmann, O&G Ashley Watson, Infectious Diseases

2. Case 1: Mrs A: Planning her first pregnancy 29 years of age Never been pregnant Works as primary school teacher Thinks she had childhood immunisations, no physical record No known history of varicella infection Several tattoos acquired in Bali 5 years previously

3. Case 1 Mrs A: Routine care, individualised care Syphillis, Rubella, Hep B Antigen, HIV, varicella IgG, UMCS Other possibilities: – Hep B sAntibody (if immune, no more tests!) – Hep C – chlamydia – Parvovirus B19 ?? Not routinely screened – Measles antibody – may be relevant in some people, outbreak at present – Bacterial vaginosis HVS – not antenatal, not first preg.

4. Parvovirus B19: Also known as fifth disease, slapped cheek syndrome, erythema infectiousum 50% women immune pre-pregnancy If infected during pregnancy, less than 5% have miscarriage/anaemia Serology availability and indications? When/ if to stay away from work (kids infectious 48 hours before symptoms)

5. Toby’s video here Severe consequences possible 4 cases TCH past 12 months

6. Pre-pregnancy immunisations Influenza MMR (live virus) DTPa Varicella (live virus) What about early pregnancy – fever??

7. Whooping cough outbreak from 2009

8. Influenza in the ACT – per CHO Influenza in neonates: ACT Data In 2012, there were 17 cases of influenza in infants aged 12 months or less. Of those, 6 were aged 3 months or less, one was aged 4 weeks

9. National FluCan data – pregnant women Between 4 April to 12 October 2012, – 39 pregnant women hospitalised with influenza, accounting for – 3.5% of all hospitalisations due to influenza. – 2 were in ICU.

10. Case 2 - Antenatal Mrs H, 26 weeks pregnant, 2 nd baby Immunised 3 year old son has mild varicella illness She does not recall having chicken pox or immunisation – Which test – How to get ZIG What if child 18months with vaccine associated varicella?

11. Case 3 - Antenatal Mrs C, 36 weeks pregnant Copious white vaginal discharge, perineal itch History of recurrent candida – Swab – Treat ?? – Oral fluconazole?? – GBS – current practice

12. Case 4 Antenatal Mrs D 16 weeks pregnant Nasal congestion, coloured nasal discharge, frontal headache, 5 days. Temp 37.9 aural 2 year old has streaming nose and moist cough Mrs D desperate, can’t sleep, miserable +++

13. Options – limited guidelines “Safe” remedies: saline Unclassified but low risk remedies, eg topical decongestants (xymetolazone) Nasal steroids –mometasone, fluticasone lowest systemic bioavailability, listed as B3, budesonide cat A Antibiotics – amoxycillin, erythromycin cat A

14. A, B, C, D, X – NOT hierarchical Human data are lacking or inadequate for drugs in the B1, B2 and B3 categories Subcategorisation of the B category is based on animal data The allocation of a B category does not imply greater safety than a C category Medicines in category D are not absolutely contraindicated during pregnancy (e.g.anticonvulsants)

15. Case 5: Post partum Nikki, with 3 day old Arthur calls from home NVD, early discharge Increasing “period pain” feeling hot and cold, moderate PV bleeding, light headed and tired Midwife already visited for the day Issues for GP: – ?how urgent – How to fit in to schedule – Who to call and how if concerned

16. Cont. Nikki attends the surgery as an urgent “fit in.” Delivery record indicates placenta complete O/E temp 38.2, uterus 3cm above pubic bone, mildly tender. BP normal, HR 85 – Empirical treatment – Investigation – swab – When to US? – When to send back to hospital?

17. Summary - Immunisation Immunise prepregnancy where possible Live vaccines given in pregnancy are unlikely to be harmful Influenza vaccine is routinely recommended for all pregnant women dTpa is recommended pre-pregnancy, elsewhere used during pregnancy. – WATCH THIS SPACE Hep B Consider measles

18. Summary - screening New guidelines – HIV, hep B, syphillis, rubella, bacteriuria, chlamydia in <25s, Hep C if high risk, varicella if no history Effective interventions available for all except Hep C Parvovirus - case by case GBS ???

19. Summary - infections Diagnosis and treatment of non pregnancy related illness generally similar to non pregnant Symptomatic treatments often safe and highly significant to women Antibiotics category A first line if required

20. Referral pathways Pre-conception or early pregnancy Antenatal Post partum Infectious diseases

21. THANK YOU