1. Women’s health in pregnancy and post- partum Michelle Wise BSc MD FRCSC MSc Senior Lecturer, Department of Obstetrics & Gynaecology, U of A Consultant Obstetrician & Gynaecologist, National Women’s Health, ADHB

2. Outline Iodine supplements in pregnancy Nausea and vomiting of pregnancy First trimester screening Gestational weight gain Planning a VBAC Postnatal contraception

3. Iodine supplement Essential for normal brain development Moderate iodine deficiency and goitre found in 12/170 pregnant women nationwide (Pettigrew et al. 2006) Iodine levels of breast-fed infants < half that of formula-fed infants (Skeaff 2005) Choose iodised table salt at home

5. Nausea and vomiting of pregnancy Don’t forget vitamin B6 (pyridoxine)

6. First Trimester Screening (FTS) Offered routinely to all pregnant women regardless of age Combines: –Maternal age –Nuchal translucency at 11 - 13+6 weeks –PAPP-A and free βhCG at 9 – 13+6 weeks

7. Maternal Serum Screening, by age Ontario Women’s Health Equity Report 2010

8. FTS 85-90% of Down syndrome pregnancies are detected using FTS, compared to: –50% with age alone –75% with MSS 5% of screening results will be “ ↑ risk” –To be followed by discussion of options for diagnostic testing and clinical management 98% of “ ↑ risk” babies will be unaffected

9. RANZCOG “A Decision Aid: Testing in pregnancy for fetal abnormalities”

10. FTS If twins, need to know chorionicity to correct MoM values of blood tests Additional factors that modify aneuploidy risk assessment: –Previous pregnancy w T21 or T18 –Assisted reproduction –Maternal weight

11. Obesity in Pregnancy

12. Obesity in pregnancy –Set goals for gestational weight gain –Early diabetes testing add HbA1c and fasting 2h OGTT to booking bloods to exclude T2DM –Measure weight at each visit –Monitor for maternal and fetal complications GDM, HTN, stillbirth, C/S, PPH) –Timely referral Centre for Maternal and Child Enquiries 2010: Guideline on management of women with obesity in pregnancy

13. Gestational weight gain BMIInstitute of Medicine 2009 guidelines Normal11-16 kg 25-297-11 kg 30 or more< 9 kg Limited or no weight gain in obese women is associated with improved pregnancy outcomes

16. Planning a VBAC What is the risk of uterine rupture in women having attempt at Vaginal Birth After Caesarean (VBAC)

17. Risk of uterine rupture with VBAC attempt Bujold et al. 2002 –1,527 women w 1 prev C/S having TOL –Cohort study with chart review Bujold et al. 2010 –1,768 women w 1 prev C/S having TOL –Cohort study with chart review

18. Inter-delivery interval, months

20. Planning VBAC 2 o analyses from two large multicentre studies further support ↑ risk for rupture with shorter inter-pregnancy intervals Conclusion: important to counsel and provide effective contraception post-caesarean

21. Lactational Amenorrhea Method (LAM) 98% effective during first 6 months if all 3 criteria met: –Menses have not returned –Exclusive breastfeeding –Baby feeding during the night (< 6 hrs) When to start COC LAM Interagency Working Group www.irh.org

22. Planning VBAC

23. For more information: www.ranzcog.edu.au www.rcog.org.uk www.healthed.govt.nz www.consensus.nih.gov/2010/vbac.htm www.nationalwomenshealth.adhb.govt.nz Or contact me m.wise@auckland.ac.nzm.wise@auckland.ac.nz Or attend: –Update in Women’s Health for Primary Care (12 November 2011) –Postgraduate diploma in Obstetrics and Medical Gynaecology