Women’s health in
pregnancy and postpartum
Michelle Wise BSc MD FRCSC MSc
Senior Lecturer, Department of Obstetrics
& Gynaecology, U of A
Consultant Obstetrician & Gynaecologist,
National Women’s Health, ADHB
Outline
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Iodine supplements in pregnancy
Nausea and vomiting of pregnancy
First trimester screening
Gestational weight gain
Planning a VBAC
Postnatal contraception
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
Nausea and vomiting of
pregnancy
• Don’t forget vitamin B6 (pyridoxine)
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
Maternal Serum Screening,
by age
Ontario Women’s Health
Equity Report 2010
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
RANZCOG
“A Decision Aid:
Testing in
pregnancy for
fetal
abnormalities”
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
Obesity in Pregnancy
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
Gestational weight gain
BMI
Institute of Medicine 2009
guidelines
Normal
11-16 kg
25-29
7-11 kg
30 or more
< 9 kg
Limited or no weight gain in obese women is
associated with improved pregnancy outcomes
Planning a VBAC
• What is the risk of uterine rupture in women
having attempt at Vaginal Birth After
Caesarean (VBAC)
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
Inter-delivery interval, months
Inter-delivery interval, months
Planning VBAC
• 2o 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
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
Planning VBAC
For more information:
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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.nz
Or attend:
– Update in Women’s Health for Primary Care (12
November 2011)
– Postgraduate diploma in Obstetrics and Medical
Gynaecology