Dr Rachel Mackey reviews antenatal/postnatal care in the primary care setting

Pregnancy, to coin a phrase used by many, is a condition and not an illness. The care provided by a woman’s doctor at primary care level differs from other interactions the patient may have had in the past. The patient more often than not feels and looks well. However, the involvement of a woman’s GP in her pregnancy from preconceptual care right through to her six week postnatal check and beyond is crucial in the process of making a woman’s pregnancy both safe and well informed.

Periconceptual care

Thanks to increased awareness, women are increasingly more likely to consult their doctor when considering pregnancy.

This consultation is particularly important in the presence of a pre-existing medical condition, such as epilepsy or depression, where the patient may be on medication. A discussion may be required as to whether it is safe to remain on the medication.

The patient should start to take folic acid, preferably several months prior to conception. If the patient is a smoker, she should be advised to stop now. Alcohol can be continued in moderation.

Immunity to rubella should be checked. If the patient is not immune she should be vaccinated and good contraception provided for a further three months.

A cervical smear should be done if it has not been checked in the previous two years. Diet should be optimized and a regular exercise regime should be established.

Diagnosis of pregnancy

The patient will often choose to consult her doctor for a pregnancy test. Once pregnancy has been confirmed it is important to try to establish the gestation as accurately as possible. If this is left until attending hospital, the details of last menstrual period etc, may be forgotten.

A list of foods that should be avoided can be discussed at this stage, including unpasteurized products, soft cheeses, pate, uncooked shellfish, and food containing raw egg etc. These foods have a higher risk of containing bacteria such as campylobacter, listeria and salmonella.

These can all cross the placenta and cause infection in the foetus, which can potentially lead to stillbirth and premature labour.

With the exceptions of folic acid and iron supplements where necessary, vitamin and mineral supplementation in pregnancy is not recommended. A well-balanced diet is a sufficient source of all nutrients required in pregnancy.

The diet should include fruit and vegetables; wholegrain breads and cereals; moderate amounts of low-fat dairy foods and lean meat; small amounts of food high in fat, sugar and salt; lean meat, chicken and fish; dried beans and lentils; nuts and seeds; low-fat milk, cheese and yoghurt; and green leafy vegetables.

Referral to hospital-based services

If this is the patient’s first pregnancy, it is likely that she has no knowledge of the various forms of antenatal care available to her. It is important to inform her of all her choices and the approximate cost associated with each form.

Due to the unprecedented strain on the maternity services in recent years, it is important to stress to the patient that she should decide sooner rather than later on her choice of antenatal care, as some of the options have limited availability.

If the woman chooses to opt for combined care with her GP, an application form for the Mother and Infant Scheme should be completed at this stage.

During a typical antenatal visit, the GP should check the general wellbeing of the mother and infant, including foetal movements, blood pressure, urinalysis, fundal height check, presentation and lie of the foetus and foetal heart rate.

Common problems in pregnancy

Nausea

Morning sickness can occur at any time of the day. It usually starts at six or seven weeks gestation and lasts until 12 to 14 weeks. In its more severe form, the patient may require hospitalization for rehydration.

Normally a woman can cope with the unpleasant nausea by limiting herself to bland snacks and avoiding large meals.

Urinary tract infections

There is an 8 per cent increased risk of developing urinary tract infections (UTI) during pregnancy.

This is thought to be due to decreased ureteral tone caused by increased progesterone levels and the presence of glycosuria, which encourages bacterial growth in the urine. UTIs can manifest as asymptomatic bacteriuria, symptomatic cystitis and pyelonephritis. All pregnant women should be treated when bacteriuria is identified.

Constipation

Constipation is common for several reasons. Progesterone slows the passage of food through the gastrointestinal tract, while the growing uterus can put pressure on the rectum.

Iron supplements can also make constipation worse. Drinking at least six to eight glasses of water a day, in conjunction with a diet rich in fruit and whole grain foods, can prevent or relieve constipation.

Backache

This is due to several factors, including the increasing size of the womb and breasts, and also relaxin, the pregnancy-specific hormone that causes relaxation of muscles and tendons, particularly in the sacro-iliac joints.

Rest, local application of heat and massage can relieve backache. If severe enough, the patient may need analgesia.

Leg cramps

The exact cause of these is unknown, but it may be related to changes in peripheral circulation, and also the extra weight being carried by the mother.

The condition occurs most frequently in the second and third trimesters of pregnancy and can be relieved by stretching, walking, warm baths and massage.

Haemorrhoids

Haemorrhoids may first appear or worsen during pregnancy. They are caused by several factors, including reduced venous return and constipation. They may also develop de novo during the pushing stage of labour.

The treatment of haemorrhoids is firstly prevention, by adhering to a high-fibre diet with adequate hydration. Symptoms can be improved with topical creams. Most haemorrhoids resolve spontaneously following delivery, but occasionally surgery is required.

Pre-eclampsia

Pre-eclampsia occurs in 5 to 8 per cent of all pregnancies. It is a rapidly progressive condition characterized by hypertension and proteinuria. Typically it presents after 20 weeks and symptoms include generalized swelling, sudden weight gain, headaches and changes in vision.

However, some women with rapidly advancing disease report few symptoms. Clinically, the signs are:

  • 1. Elevated BP — a rise in BP of more than or equal 15mmhg diastolic or more than or equal to 30mmhg systolic from early pregnancy; and
  • 2. Proteinuria — more than or equal to +1 proteinuria.

Peripheral oedema is often seen in pre-eclampsia but is not a necessary finding for its diagnosis. A finding of pre-eclampsia requires referral to the patient’s maternity unit. If the pre-eclampsia were mild, a referral to the day care unit the following day would be appropriate. If the condition is more advanced, the patient should be referred immediately to hospital for admission.

Gestational diabetes

Gestational diabetes occurs in one in 400 pregnancies. It is usually asymptomatic and first detected on routine urinalysis, by the presence of persistent glycosuria. The diagnosis is then made by a glucose tolerance test.

High-risk groups, such as obese women, or women with a strong family history of diabetes are screened at 28 weeks’ gestation. Management includes dietary advice and insulin if required.

Deep vein thrombosis

Pregnancy increases the risk of deep vein thrombosis (DVT) by 5- to10-fold. Other additional risk factors include maternal age over 35 years, obesity, Caesarean section or immobility.

Diagnosis of DVT and pulmonary embolism in pregnancy is challenging because of the physiological changes, which normally occur in pregnancy.

Many of the classical symptoms such as tachypnoea, tachycardia, dyspnoea and leg swelling can also be associated with a normal pregnancy. In up to a quarter of cases, untreated DVT will progress to a pulmonary embolus. Identification of DVT is important as it involves prolonged antenatal therapy, prophylaxis during future pregnancies and avoidance of the oral contraceptive pill.

The diagnostic test of choice is Doppler ultrasound of the leg veins and ventilation/perfusion lung scanning. However, in the presence of high levels of clinical suspicion but inconclusive investigations, anticoagulation is advisable.

Anaemia

The definition of anaemia in pregnancy differs somewhat from that of anaemia in the non-pregnant population. It is defined as haemoglobin (Hb) less than 11g/dl, but a physiological anaemia occurs due to a blood volume increase to a greater extent than red cell mass, thus leading to a reduction in blood viscosity and resulting in a dilutional anaemia.

It is more common in patients with multiple pregnancies, poor diet and with haemoglobinopathies. Symptoms include dyspnoea, pallor, excessive tiredness and palpitations, but these are often confused with normal pregnancy.

Treatment is dependent on the cause and severity of the anaemia. It is recommended that iron deficiency anaemia with an MCV less than 84fl should be treated with low- dose iron supplements such as ferrous sulphate 200mg daily to maintain Hb above 10g/dl.

Support in the immediate postnatal period.

After discharge from hospital, particularly on her first pregnancy, the prospect of caring for a newborn infant can seem daunting. During this period, the role of the GP is important.

Some of the common problems encountered include maternal exhaustion, tearfulness or low mood, backache, haemorrhoids and/or constipation, perineal pain and feeding issues such as mastitis, cracked or painful nipples, and concerns regarding the baby’s milk consumption, weight gain etc.

A commonsense approach to the new mother’s concerns and practical suggestions will often relieve her anxiety. It is also important to watch out for any signs that she is not coping well, as this may be an early warning sign for ensuing postpartum depression.

The postnatal visit

At six weeks postpartum, the mother is asked to attend a healthcare professional for a health check. The patient’s doctor routinely does this once they have received a report from the maternity hospital with the labour and delivery details outlined. The following topics are usually covered.

General well-being

Any evidence of poor coping skills or mood depression at this point should be examined further to rule out postnatal depression.

Blood pressure

For any mothers with antenatal hypertension, it is important to confirm that it is fully resolved, as a small proportion of those women affected in pregnancy will continue to have essential hypertension postnatally.

Anaemia

Most mothers with low Hb postnatally are discharged on iron supplements. However, due to the often poor tolerability of these, they are not always taken. A repeat Hb may be indicated if the patient is symptomatic.

Breasts

If the mother is breastfeeding, examination may detect mastitis.

Perineum

This is not always thought to be necessary, unless the patient is complaining of dyspareunia or ongoing perineal pain.

Pelvic floor function

It is important to ask about urinary and faecal continence to establish early on if there is a problem. This is a good opportunity to re-establish the importance of pelvic floor exercises. Ongoing severe incontinence requires referral to the gynaecology services.

Contraception

Contraception is an essential part of the visit. If the mother is still breastfeeding her options are limited. It is important to explain that lactational amenorrhoea is not 100 per cent protective. Barrier methods and the progesterone-only contraception are the common forms used.

For the formula-feeding mothers, a full range of appropriate contraception should be offered.

Dr Rachel Mackey,
LRCP&SI, MB BCh NUI, MRCOG,
Women’s Health Clinic,
81 Upper Georges Street,
Dun Laoghaire,
Co Dublin

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We are delighted to announce that Dr Suzanne Kelleher consultant paediatrician has recently started at the Womens Health Clinic.

  

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