Abstract
Although the natural process of pregnancy and childbirth do not change, the specialty of obstetrics (‘to stand by’ in Latin) is forever changing. There is no time to ‘stand by’ with ever busier maternity units and pressures on appointments, beds and resources. As techniques, pathways, tests and guidelines become more advanced and detailed we must not lose sight of basic skills, thorough clinical assessment, and the need for more joined-up thinking between obstetrics as a specialty and general practice. This article does not focus on intrapartum care or on the high-risk pregnancy issues managed within maternity units, rather it considers some of the areas where shared care of the expectant mother between obstetricians, midwives and those working within general practice matter most. It also highlights some of the common issues that arise during pregnancy and present to a primary care setting.
The GP curriculum and care of the pregnant woman
Be familiar with and implement key national guidelines that influence healthcare provision for pregnant women Demonstrate knowledge of normal pregnancy and recognise common pregnancy symptoms, common conditions and complications that may occur in pregnancy and the puerperium Involve other members of the healthcare team where appropriate, with timely, accurate and clear communication Be able to advise on prevention strategies and antenatal screening programmes relevant to pregnant women
Learning from confidential enquiries into maternal mortality
During the middle of the last century, maternal mortality rates dramatically decreased in the UK. There were many suggested reasons for this phenomenon, including better training of midwives and doctors, antibiotics, antiseptic products, hand-washing, improved maternity care, ergotamine, blood transfusion, better post-war standards of living and safer anaesthesia.
Continued regular national confidential enquiries into maternal mortality help us to continue this downward trend. Understanding why women die and implementing strategies to reduce mortality and morbidity are essential to hospital obstetrics and general practice. Such reports make chilling reading as we see how all too often lack of communication, lack of integrated thinking, failure to escalate concerns, failure to recognise key signs and symptoms, and failure of basic skills such as thorough history taking, lead to such devastating outcomes.
Maternal-fetal assessment units are using more advanced techniques for fetal monitoring, scanning, detecting membrane rupture and attempting to predict premature labour, and yet, the findings and messages from the recent MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) report are not concerned with advanced technology or fancy tests, but rather they are about clear communication, simple clinical skills performed well, and coordination between obstetrics and primary care.
An overview of the physiology of pregnancy
Physiological changes during pregnancy.
Of course, this is not to say, for example, that dyspnoea in pregnancy is always a normal finding. However, when an expectant mother presents with a feeling of breathlessness and careful history, examination and consideration excludes conditions such as asthma, pulmonary embolus and infection, it may be helpful to provide the explanation in terms of the normal physiological changes many women experience in pregnancy. Table 1 also includes some key messages about how some physiological changes increase the risk of adverse events, such as venous thromboembolism and pulmonary oedema.
Pre-conception care
Family planning issues commonly present to primary care and discussion regarding contraception is a routine part of the postnatal visit. Despite this, many pregnancies are unplanned.
Findings from the latest confidential enquiry of maternal mortality and morbidity (MBRRACE-UK) highlighted the need for a more multidisciplinary approach to pregnancy planning and preparation for women with certain risk factors and complex medical problems.
Optimising body mass index, smoking cessation, verifying rubella immunity and pre-conception folic acid are standard requisites for pregnancy planning. However, as treatment strategies for medical conditions such as cystic fibrosis, epilepsy, type-1 diabetes, cardiac events, and renal conditions improve, so more women with these conditions are reaching a point at which they can consider starting a family.
Complex medical problems
The National Institute for Health and Care Excellence (NICE) antenatal care guideline makes recommendations regarding which pregnant women will require additional care and therefore referral (usually initiated at the booking visit) by the community midwife to the consultant-led antenatal clinic. These include women who have had problems in a previous pregnancy (such as severe pre-eclampsia, premature birth or Caesarean delivery), women with pre-existing medical conditions or risk factors (such as obesity) and women with complex social factors.
It is not possible in the scope of this article to provide disease-specific advice for every condition; however, the following general points are important for all pre-existing diseases:
Pre-pregnancy advice, liaising with the specialist team and obstetric team to aid optimisation of the medical condition Referral for combined specialist and maternity care early in pregnancy Consideration of the effect of disease on pregnancy for mother and fetus, and the effect of pregnancy on the severity and progression of the medical condition To review medication, changing agents if required to aim to control the disease with single agents that are considered safe in pregnancy wherever possible. For example, a woman with essential hypertension using a diuretic or an angiotensin converting enzyme inhibitor should be changed to a medication considered safe in pregnancy, such as methyl dopa (which has been used for many years without any serious side effects on the fetus or newborn) Ensure understanding of risks and provide contraception (long term if required or short-term contraception while stabilising the disease), optimising medications, or awaiting tests prior to trying for a pregnancy Consider referral to the clinical genetics team if appropriate for the condition. This may be obvious for a condition such as cystic fibrosis; however, there are many other medical conditions for which this may be relevant. Ideally this should be discussed before conception
Diabetes
The Diabetes in Pregnancy Pathway published by NICE in 2015 emphasises the importance of pre-conception care for women with pre-existing type-1 diabetes, aiming for a pre-pregnancy glycosylated haemoglobin (HbA1c) of 48 mmol/mol and strongly advising against pregnancy if the HbA1c is greater than 86 mmol/mol. Folic acid at a dose of 5 mg daily is recommended for 3 months prior to conception in all diabetic women.
Careful counselling about the risks of pregnancy for a woman with diabetes includes consideration of the effects of the pregnancy on the disease and the effects of the diabetes on the pregnancy for both the mother and fetus. This counselling is particularly important, as the risks are reduced with tighter diabetic control.
There is an increased progression of nephropathy and retinopathy for diabetic women in pregnancy. Therefore, renal function tests and retinal screening are important in the pre-conception period and during pregnancy. Episodes of hypoglycaemia are more common in pregnancy, and the woman may have a decreased awareness of these events (this is the leading cause of maternal death in pregnant women with diabetes).
Maternal diabetes also causes an increased risk of miscarriage, congenital abnormalities, pre-eclampsia, infections, sudden intrauterine fetal demise, macrosomia and intrauterine growth restriction. There is an increased chance of Caesarean delivery and intrapartum problems such as shoulder dystocia.
Epilepsy
The recent MBRRACE-UK report recognised epilepsy as a high-risk condition in pregnancy. It noted that pre-conception counselling for women with epilepsy is not always provided effectively and should be robustly delivered in all care settings and on an opportunistic basis.
Phenytoin, primidone, phenobarbitone, carbamazepine and sodium valproate all cross the placenta and are teratogenic. The major malformations are neural tube defects, orofacial clefts and heart defects. The average risk of fetal malformation with one anti-epileptic agent is 3.7%; however, it increases with use of multiple agents.
The aims of epilepsy management are to avoid seizures that are harmful for both mother and child while minimising the risks of anti-epilepsy medications. All women should be prescribed 5 mg of folic acid daily, ideally pre-conception. Their pregnancy should be considered as high risk (even if they have had a long period free from seizures) and they should be referred for combined specialist care early in pregnancy.
Most women with epilepsy and of child-bearing age are currently prescribed lamotrigine. The dose may need to be increased two to three fold during pregnancy.
Although up to one-third of women experience an increased frequency of seizures during pregnancy, for most women, pregnancy does not affect the frequency of seizures. Women who have been free from seizures for many years are unlikely to experience seizures in pregnancy, provided that their medication is continued. The risk of seizures is highest around the time of labour and delivery.
Sudden unexplained death in epilepsy remains the predominant cause of death from epilepsy during pregnancy. Fourteen women died from epilepsy during pregnancy in the UK between 2009 and 2012 and this is now higher than maternal deaths from hypertensive disease. The MBRRACE-UK report included two entirely preventable cases of death due to drowning of epilepsy sufferers, and it recommends that strong advice is given against bathing/washing over a bath of water to all women with epilepsy who are of child-bearing age.
Headaches
GPs are familiar with the assessment of headaches and ‘red flag’ features. Headaches in pregnancy and the postnatal period are common, and 90% are primary headaches due to migraine or tension headache and are troublesome but benign. However, there are several key messages for this group of patients.
In the last MMRRACE-UK report, neurological conditions were one of the leading causes of maternal death and potentially devastating morbidity. It is imperative to recognise life-threatening secondary headaches such as in severe pre-eclampsia, cerebral venous thrombosis and subarachnoid haemorrhage, which can occur during pregnancy or in the peurperium. A detailed history usually distinguishes the nature of the headache and a full neurological examination including fundoscopy is essential.
Headache is the most common prodromal symptom for an eclamptic seizure. Therefore, blood pressure and assessment for urinary protein are also an essential part of the examination.
Headache is also the most frequently occurring symptom in the rare, catastrophic event of cerebral venous thrombosis (CVT) and is often the first symptom patients experience. Pregnancy is a risk factor for CVT. Caesarean section, systemic infection, vomiting and anaemia further increase the risk.
Itching in pregnancy
Itching is a common symptom of pregnancy. Only a small number will have obstetric cholestasis (also called intrahepatic cholestasis of pregnancy), however, this is still a relatively common obstetric condition. There is intrahepatic reduction of bile excretion from the liver, causing an accumulation of serum bile acids, and this usually develops in the third trimester. The itching can be widespread, often affects the palms and soles and can be very distressing. There is no associated rash. Liver function and bile acids should be checked if obstetric cholestasis is suspected.
Liver function is abnormal and both liver function and the itching resolve after birth. (Alkaline phosphatase is increased in normal pregnancy as it is made by the placenta, so this does not indicate disease).
Other causes of itching and liver dysfunction such as drugs, hepatitis, autoimmune conditions and gallstones need to be excluded. Other pregnancy-specific conditions to be considered in any woman with abnormal liver function are pre-eclampsia and acute fatty liver during pregnancy.
Women with obstetric cholestasis should then be referred to an obstetric team and will have weekly liver function tests and consideration of timing of delivery. Over the years, obstetric cholestasis has caused much maternal anxiety and iatrogenic prematurity, due to its association with still birth. The current additional risk of stillbirth above that of the general pregnant population has not been determined, however, it is likely to be small.
Once the woman has delivered, symptoms and liver function should return to normal. Checking liver function tests can be deferred until the postnatal check. She can be reassured about the lack of long-term sequelae for herself and her baby, although the recurrence rate of obstetric cholestasis in a future pregnancy is high. Oestrogen-containing contraceptives should be avoided.
Screening during pregnancy
There are currently four main national screening programmes offered in the UK during pregnancy:
Trisomies 21 (Down's syndrome), 13 and 18 ideally at 12 weeks gestation Detailed fetal anomaly ultrasound scan usually at 20 weeks gestation Maternal sickle cell and thalassaemia offered at booking visit Infectious diseases (syphillis, hepatitis B, human immunodeficiency virus, and rubella susceptibility) offered at booking visit
Figure 1 shows the UK screening programmes for antenatal patients as a timeline (NICE, 2015). These screening tests are accepted by most pregnant women and the appropriate counselling and advice is given by the community midwife and the maternity unit team. The scan performed at the first trimester screening appointment also assesses pregnancy viability, accurately dates the pregnancy and identifies multiple pregnancy, establishing chorionicity if this is the case.
National screening for antenatal patients.
Screening for Down's syndrome and other common aneuploidies is now possible using free fetal DNA from a maternal blood test. Further research and evaluation is necessary before these tests are introduced by the NHS, although they are already available in the private sector and many women are choosing this option. It is more than 98% accurate, however, it is still considered a screening test and therefore women receiving a positive test result are offered invasive testing (chorionic-villus sampling or amniocentesis) to confirm the result.
In addition to the official national screening programmes offered under the NHS, there are several other ways pregnant women are screened for conditions during their antenatal course. These include:
Questionnaires are used by community midwifery teams at the booking visit to establish women at risk of domestic violence, female genital mutilation and mental health issues Body mass index (BMI) is calculated in the first trimester to screen women who may develop risks associated with obesity during their pregnancy At each point of contact with a midwife, blood pressure is checked and urine tested for the presence of protein, thus screening for pre-eclampsia Certain groups of patients are targeted for gestational diabetes (usually by an oral glucose tolerance test during the second trimester) and these include women who have had gestational diabetes before, women with a BMI greater than 30, women with a history of polycystic ovarian syndrome and women from certain ethnic backgrounds Fetal growth assessment by measurement of symphysis fundal height at each midwife appointment and referral for ultrasound growth assessment if indicated Full blood count and antibody screen at booking and at 28 weeks of pregnancy to check for anaemia and red cell antibodies.
Although the benefits of screening are widely understood, each screening opportunity also risks unnecessary anxiety. An understanding of the antenatal screening processes and options for definitive testing and management for each is therefore important for the GP as some anxieties, concerns and questions will inevitably present to primary care, despite attempts to provide clear information, counselling, advice and support by midwives and obstetricians.
Pre-eclampsia prevention
Pre-eclampsia is a common pregnancy-specific condition with potentially significant complications for mothers and the fetus.
Screening for pre-eclampsia (blood pressure, symptoms, urine) is addressed at each point of contact with the community midwife or GP. There are clear referral criteria for further evaluation in the maternity unit if required.
Women for whom low-dose aspirin is recommended for the prevention of pre-eclampsia.
Significant infections in pregnancy and the postnatal period
A quarter of the women who died in the UK between 2009 and 2012 during pregnancy or the puerperium had sepsis; however, rates of genital tract sepsis had fallen since the previous triennial report. One-third of the women who died from sepsis presented initially to primary care, so the over-riding message is to think of sepsis, rapidly give antibiotics and refer early.
Signs and symptoms of sepsis in pregnancy may be less distinctive than in non-pregnant women and signs may not necessarily correlate with the severity of sepsis. Thus, a high index of suspicion is necessary. Progression of sepsis may be far more rapid than in the non-pregnant patient.
Bacterial infection
The pathogen most commonly leading to maternal death in the early postnatal period is group A beta-haemolytic streptococcus (GAS). The most common site is the genital tract resulting in endometritis.
Doctors in primary care should be aware of the importance of early referral to hospital of recently delivered women who feel unwell and have pyrexia. The ‘red flag’ signs and symptoms for sepsis include a pyrexia (greater than 38oC), sustained tachycardia, breathlessness, abdominal or chest pain, diarrhoea, vomiting, uterine or renal angle pain and tenderness, and a woman who is generally unwell or seems unduly anxious or distressed. Genital tract sepsis may present with constant severe abdominal pain and tenderness that is not relieved by oral analgesia, and this should prompt urgent review. Non-steroidal anti-inflammatory drugs, which are commonly used in the postnatal period, should be stopped as they are detrimental to polymorphs fighting GAS infection.
Mastitis is easily overlooked. Immediate referral to hospital is indicated if a woman with mastitis is systemically unwell or if there is no response to oral antibiotics within 48 hours, as mastitis may lead to abscesses, necrotising fasciitis or toxic shock syndrome.
Other important sites for pregnancy-related sepsis are the urinary tract, pneumonia, soft tissues, gastroenteritis and pharyngitis. Infections secondary to regional anaesthesia around the time of labour are very rare but the relevant questions should always be posed.
Prevention of neonatal infection
Sometimes confusion and anxiety arises about the significance of Group B streptococcus during pregnancy. Group B streptococcus (GBS) is recognised as the most frequent cause of severe infection in newborn infants in the first 7 days. There is still controversy about prevention of neonatal GBS infection and UK practice differs from that in the USA where there is routine screening for GBS in pregnancy. The National Screening Committee does not recommend screening for GBS in the UK, as there is insufficient evidence that antenatal screening does more good than harm and that the benefits are cost-effective. Antibiotic treatment during the antenatal period if GBS is detected incidentally is also not recommended.
Vaginal swabs should not be taken during pregnancy without clear clinical indication. Intrapartum intravenous antibiotics are offered to women who have been identified with GBS bacteriuria or on a vaginal swab during the current pregnancy or to women who have had a previous baby with GBS disease.
Influenza and pregnancy
Increasing the uptake of seasonal flu vaccination was strongly encouraged in the MBRRACE-UK report. Between 2009 and 2012, one in every 11 maternal deaths was from flu (the epidemic was during this timeframe) and more than half of those deaths could have been prevented by flu vaccination in pregnancy.
Viral infections
Three viruses that can be transmitted to the fetus and cause birth defects are varicella zoster, rubella and cytomegalovirus. Most women in the UK are immune to rubella from past vaccination. This is confirmed on blood tests early in pregnancy, a measles, mumps and rubella vaccination is given postnatal and prior to discharge if the woman is found to be non-immune. Cytomegalovirus (CMV) is an uncommon diagnosis: maternal infection is subclinical; 50–60% of UK women are already immune; and there is only a small risk of fetal damage if infection occurs during pregnancy. CMV is usually picked up due to a fetal defect being identified. However, chickenpox is an important issue in primary care.
A common scenario in pregnancy is an expectant mother worried about chickenpox exposure. More than 90% of women born in the UK are immune to varicella zoster and this can be elicited either by a history of having had chickenpox, chickenpox scarring or being seropositive (can be tested on the first trimester blood samples). Significant exposure is classified as face-to-face contact or being in the same room for more than 15 minutes.
Contracting varicella zoster is not known to increase the risk of miscarriage; however, it carries a small risk of fetal varicella syndrome for the time period less than 28 weeks of gestation. In the last 4 weeks of pregnancy there is significant risk of varicella infection in the newborn.
Varicella immunoglobulin can be given to non-immune women up to 10 days after exposure. This is not only for fetal effects of varicella zoster infection, but also because chickenpox during pregnancy presents greater risks to the pregnant women than in the non-pregnant state. If chickenpox develops then treatment is with acyclovir. Seronegative women can be offered immunisation outside of pregnancy.
Parvovirus (also called PVB19, slapped cheek or fifth disease) is a common infection in children. Fifty percent of women of child-bearing age are immune to PVB19 infection. Maternal infection causes a rash, arthralgia and fever, however, the main effect of parvovirus infection is fetal anaemia. If maternal parvovirus infection occurs in the first 20 weeks of gestation then ultrasound scans are performed from 4 weeks after the onset of symptoms or estimated seroconversion, to look for fetal hydrops. The most important role for the GP is in establishing the likelihood of parvovirus exposure and whether the woman has immunity. A careful history and consideration of serological tests (perhaps on blood taken at the booking visit) are essential in this regard.
Primary episodes of genital herpes simplex virus infection are important in pregnancy, as although neonatal herpes is a rare, it is a serious viral infection with high morbidity and mortality. Most cases of neonatal herpes occur from direct contact with infected maternal secretions. The risks are greatest when a woman acquires a new infection in the third trimester, particularly within 6 weeks of delivery, as viral shedding may persist and the baby is likely to be born before the development of protective maternal antibodies. Management of the woman should be in-line with her clinical condition and usually involves the use of oral acyclovir. Caesarean section should be considered for all women developing their first episode of genital herpes in the third trimester.
Women with recurrent genital herpes should be informed that the risk of neonatal herpes is low, even if lesions are present at the time of delivery. In such cases, vaginal delivery should be anticipated in the absence of other indications for Caesarean section.
Management of blood pressure in the postnatal period
All women should have their blood pressure checked within 6 hours of delivery.
For women with a diagnosis of pre-eclampsia, the guidance is to remain as a postnatal inpatient until day 3 after delivery. This is difficult to achieve, especially with women who feel clinically well and ever-increasing pressures on beds and midwifery staff.
A clear discharge plan should be sent straight to the GP, outlining the plan for managing blood pressure in the postnatal period. A specific proforma is helpful for this task.
All women should be aware of symptoms such as headache, nausea, vomiting, visual disturbance and epigastric pain. The blood pressure should be checked by the community midwife on alternate days for 2 weeks after discharge for women with hypertension during pregnancy and/or labour. Any woman with a diastolic blood pressure greater than 90 mmHg with symptoms or sustained over 4 hours or a systolic blood pressure greater than 150 mmHg should be reviewed and have blood taken for full blood count, renal and liver function tests.
Most women with antenatal hypertension will need antihypertensive medication for 2 weeks following delivery. Blood pressure medication can be reduced when the blood pressure is consistently 130–140/80–90 mmHg.
If medication is still required at 6 weeks post-delivery, then review regarding other causes should occur, as 13% of women thought to have gestational hypertension or pre-eclampsia have underlying disease. Urine should be checked at the 6 week postnatal check and if proteinuria still exists this should be further investigated from a renal point of view.
The advice given to women at their postnatal GP visit who have had hypertension/pre-eclampsia in pregnancy should include the fact that this has an association with hypertension and complications in later life. Severe early onset (requiring delivery before 34 weeks) pre-eclampsia has a recurrence rate of 40% in future pregnancies, although this usually occurs 2 to 3 weeks later and is less severe. Mild pre-eclampsia at term has a recurrence risk of 10%. (Smith, Waugh, & Nelson-Piercy, 2013)
Postnatal care for women who have developed gestational diabetes
Blood glucose-lowering therapy is discontinued immediately after birth for women who have developed gestational diabetes. They have a significant risk of developing gestational diabetes in future pregnancies. They should be given lifestyle advice and encouragement to normalise their BMI if overweight.
A fasting glucose test should be offered at 6–13 weeks postnatal to exclude diabetes. If this is below 6.0 mmol/L they will need an annual HbA1c test to check their blood glucose level is normal and they should be told they have a moderate risk of developing type-2 diabetes in the future, with appropriate advice and guidance (NICE, 2015)
Women with a fasting glucose of 6.0–6.9 mmol/L should be told that they have a high risk of developing type-2 diabetes. Women with a fasting level glucose value greater than 7.0 mmol/L are highly likely to have type-2 diabetes and therefore need confirmatory tests.
Postnatal advice for women with pre-existing diabetes
Insulin is reduced as soon as the woman delivers and blood glucose levels should be monitored closely in the immediate postnatal period, due to the increased risk of hypoglycaemia, especially if breastfeeding. Women with pre-existing type-2 diabetes who are breastfeeding can resume or continue to take metformin and glibenclamide immediately after delivery; however, they should avoid other oral blood glucose-lowering agents.
Key points
GPs have an important part to play in the delivery of high-quality antenatal and postnatal care Prepare women with pre-existing medical conditions for a healthy pregnancy using appropriate medication and advice Consider checking all medications given to women of child-bearing age for safety profile in pregnancy since unplanned pregnancies are common Refer early if necessary and liaise appropriately with specialist teams Use postnatal appointment to give accurate advice relating to pregnancy-specific conditions Recommended reading includes the key recommendations from national confidential enquiries