Updated Advice for the Care ofPregnant Women
Dear Obstetric Shared Care GPs,
CONNECTING YOU WITH THE NEWS YOU NEED FOR
GP OBSTETRIC SHARED CARE
Welcome to the first Spring edition of the GP Obstetric Shared Care Program’s enews.
After all that 2020 and 2021 brought, we have found staying connected to one another has been so important. What is also important is to check in with yourself, to acknowldege how you are feeing and to reach out if you need.
This R U OK? Day, we encourage you to reach out and check in with the people in your life!
R U OK? DAY
9 September 2021
Every news headline. Conversations with friends. The global SARS-CoV-2 pandemic and management of COVID-19 continues to dominate our world, and the pipeline of research to testing to practice has never been as visible to the public and professionals alike.
Stay up to date with the latest information by clicking on the links below
COVID-19 Vaccination for Pregnant Women
From Monday 6th September 2021 pregnant women who are patients of WCHN can access the COVID 19 Pfizer vaccine by presenting to Boylan Ward, WCH or Enfield Clinic as a walk-in (no appointment necessary).
The Clinical Guidance on use of COVID-19 Vaccine in Australia (ATAGI) deem pregnant women as a priority group for vaccination and recommend they are routinely offered the Pfizer vaccine at any stage of pregnancy.
All antenatal outpatient areas are encouraged to
- provide the women with a COVID-19 Vaccine Consent and Screening Form to complete (see below)
- direct them to Boylan Ward, WCH or the Enfield Clinic
- advise they may need to wait prior to being vaccinated as they do not have booked appointments.
Level 1, Good Friday Building, WCH
Opening hours are 8 to 4.30pm 7 days per week.
55 Watson Avenue (CAMHS Building), Enfield
Opening hours are as follows:
Mon, Tue and Wed 9.00 to 16.15hrs
Thur 12.00 to 18.15hrs
Fri and Sat 9.00 to 16.15hrs
I have attached:
- COVID-19 Vaccine Consent and Screening Form
- COVID-19 vaccination decision guide for people who are pregnant, breastfeeding or planning pregnancy
- Information on COVID-19 Pfizer (Comirnaty) vaccine
Pregnant women are a priority group for COVID-19 vaccination, and should be routinely offered Pfizer mRNA vaccine (Cominarty) or Spikevax (Moderna) at any stage of pregnancy.
Talking COVID-19 Vaccines Information For Women
Many of you have asked for links to COVID-19 Vaccination in pregnancy videos:
Links to download PDFs of slides can also be found here.
Password for all videos – Twilight
Talking Vaccination: Information for Women
Pregnant women have a higher risk of severe illness from COVID-19. In this webinar, experts will discuss COVID vaccination in pregnancy, breastfeeding, and those planning to be pregnant. They will dispel myths and highlight the global evidence, which has shown that vaccines are safe for women and their babies. The event is open to both the general public as well as medical practitioners and specialists.
Date: Wednesday 15 September 2021
Time: 6PM AEST
Duration: 1 hour
Continuing Professional Development
Facts and Fertility
Presented by the GP Obstetric Shared Care Program
Date: Thursday 23rd September 2021
Time: 6.00pm – 9.15pm
Venue: The Healthy Living Precinct, Welland
Complimentary dinner provided. Free parking.
6 CPD Program points allocated in the RACGP CPD Program for the 2020-2022 triennium
6 CPD Program points allocated in the GP OSC Program for the 2020-2022 triennium
GPPA/OSC CPD points can be claimed for these learning modules. Please email Leanne for allocation of your points.
This newsletter presents a number of publications authored by Aussies – papers that have aired in the most prestigious journals in the world.
The first is a review of pre-eclampsia published in The Lancet. Two of the four authors are from the Mercy Perinatal stable. The other authors are Lucy Chappell (Kings College London; an absolute superstar in the field) and the mega legend John Kingdom (Mount Sinai, Toronto).
Two other papers reviewed come from teams at Monash in Melbourne. One examines educational outcomes for infants that were born from pregnancies that were induced for suspected fetal growth restriction. It makes for provocative reading. The second provides some reassurance that a wholesale switch to Telehealth during the COVID era by their centre doesn’t seem to alter the detection of pregnancies at risk of adverse outcomes (the first author is Kirsten Palmer, a MFM academic at Monash.)
Here we also describe a paper published in JAMA that reports the efficacy of the vaccination in reducing the risk of catching COVID-19 among pregnant women. It works.
We hope you find this all interesting reading!
Paper 1: A Pre-eclampsia update.
Pre-eclampsia. Lucy Chappell, Catherine A Cluver et al. The Lancet. May 2021.
A comprehensive update on all aspects of pre-eclampsia from the world’s leaders.
The expert authorship team walks through:
- Pre-eclampsia diagnosis and consensus across international guidelines
- The different ways to screen for pre-eclampsia, including first trimester screening
- Disease pathogenesis
- Prevention, including a close look at aspirin (dose, risk, who to give it to) and the evidence underlying other options.
- The use of PIGF and the sFlt/PIGF ratio in clinical management
- Clinical management including medications and the monitoring of mother and fetus
- What long-term health for women after preeclampsia looks like
- Where we need to be focusing our efforts to continue reducing the morbidity and mortality of pre-eclampsia.
This review is THE ultimate one stop shop for the most recent updates in pre-eclampsia.
Paper 2: Delivery for suspected fetal growth restriction and offspring outcomes.
Association Between Iatrogenic Delivery for Suspected Fetal Growth Restriction and Childhood School Outcomes. Selvaratnam et al JAMA. 2021
(This review is also authored by Dr Natasha Pritchard, Mercy Hospital for Women)
This Victorian retrospective, population-based cohort study used routine birth data from 2003-2013, and aimed to answer the question: When obstetricians induce pregnancies for suspected FGR (to reduce stillbirth risk), are there impacts on developmental and educational outcomes for the offspring?
- Early childhood developmental outcomes were assessed from data obtained from The Australian Early Developmental Census (AEDC), which assesses children at school entry (ages 4 – 6) across 5 developmental domains. Children were deemed developmentally vulnerable if they were in the bottom 10th percentile across two or more domains.
- Educational outcomes were obtained from The National Assessment Program – Numeracy and Literacy (NAPLAN). Developmental vulnerability was defined as below minimum standard in 2 or more of the 5 domains.
The <3rd percentile infants
In the main analysis only looking at fetuses severely growth restricted (<3rd centile) who were suspected of being small (and delivered at a mean 37.9 weeks gestation) vs those <3rd centile and were not suspected of being born small (and delivered at a mean 39.4 weeks gestation):
- Compared with those <3rd centile but were not suspected of having FGR, those severely growth restricted and delivered early (n=181,902) were significantly more likely to score poorly in childhood developmental outcomes (AEDC) assessed at school entry (16.2% vs 12.7%; adjusted odds ratio, 1.36 [95% CI, 1.07-1.74]; absolute difference 3.5% [95% CI, 0.5-6.5]).
- Compared with those <3rd centile but were not suspected of having FGR, those severely growth restricted and delivered early (n=425,717) were also more likely to score poorly in childhood educational outcomes (NAPLAN) assessed at grades 3, 5 and 7 (grade 7: 4% vs 10.5%; aOR, 1.33 [95%CI, 1.04-1.70]; absolute difference 2.9% [95% CI, 0.4%-5.5%])
The >10th centile infants
- Compared with infants >10th centile not suspected of having FGR, babies >10th centile that were delivered for suspected FGR had no differences in the odds of scoring poorly on childhood outcomes (AEDC: 8.6% vs 8.1; aOR, 1.17 [95%CI, 0.95-1.45];
The authors conclude that iatrogenic delivery for suspected FGR in severely growth restricted infants was associated with poorer school outcomes, but iatrogenic delivery for suspected FGR in infants with normal growth was not associated with poorer school outcomes.
The authors published an earlier report showing severely growth restricted infants delivered early for suspected FGR had a 3-fold increase in the odds of NICU admissions but incurred an almost 20-fold reduction in stillbirth (0.8 per 1000 compared to 16.4 per 1000) and a 4.6-fold reduction in total perinatal death (Selvaratnam et al. J. Paediatrics & Childhealth, 2020).
The second point to note is that those in the early delivery group birthed at a significantly earlier gestation and this is likely to account for the differences seen in educational outcomes.
In putting all this together it is suggested induction for suspected fetal growth restriction is still absolutely warranted to reduce the stillbirth risk. This study suggests we might reconsider when we book inductions for suspected FGR and there is now a reason to avoid going too early (e.g. 37 weeks vs close monitoring and delivering well into the 38th week. Or even 39 weeks).
Paper 3: Does Pfizer vaccination reduce COVID-19 infection among pregnant women?
Association Between BNT162b2 Vaccination and Incidence of SARS-CoV-2 Infection in Pregnant Women. Goldshtein et al. JAMA. July 2021
(Review also authored by Dr Hannah Gordon, Mercy Hospital for Women)
In Australia, women at any stage of pregnant are now eligible for the BNT162b2 (Pfizer-BioNTech) vaccine. However, pregnant women were originally excluded from RCTs assessing the safety and efficacy of COVID-19 trials. Thus, until now it has not been clear whether pregnancy women benefit from vaccination in the same way as the general population.
- This retrospective cohort study from Israel included 7530 Pfizer-vaccinated pregnant women, matched with 7530 unvaccinated pregnant women, and investigated COVID-19 infection at 28 days or more following first dose of vaccine.
- During the median follow up of 37 days (range 0 – 70 days), there were 118 (1.6%) COVID-19 infections within the vaccinated group vs 202 (2.7%) in the unvaccinated group.
- A greater benefit of vaccination was found 28 days post vaccination (primary outcome), with 10 COVID-19 infections within the vaccinated group and 46 in the unvaccinated group after this time (28 – 70 days post). This gave an adjusted hazard ratio of 0.22 (95% CI, 0.11-0.43) and a vaccine efficacy of 78%.
- Most Covid-affected participants were symptomatic (89%), irrespective of vaccination status, and 0.2% of vaccinated, and 0.3% of unvaccinated women required hospitalisation.
- Vaccination-related side-effects were reported by 68 women, and none were considered severe, with the most reported including headache, general weakness, non-specified pain and stomach pain.
- During the study period 2,814 women gave birth. Importantly, there were no significant differences in pregnancy outcomes between the two groups, including rates of preeclampsia, intrauterine growth restriction, infant birth weight, miscarriage and stillbirth.
Because testing was done on an as-need basis, the study may have overlooked participants with asymptomatic illness. Additionally, participants were followed from their first dose, thus it is likely efficacy would increase after the second.
Despite some limitations, and being an observational study, this paper evidences the effectiveness of the Pfizer vaccine for pregnant women, during a period where the delta variant was present in Israel, and should provide reassurance for those considering vaccination during pregnancy.
Paper 4: Telehealth for antenatal care, is it comparable to in-person care?
Widespread implementation of a low-cost telehealth service in the delivery of antenatal care during the COVID-19 pandemic: an interrupted time-series analysis. Palmer et al. Lancet. July 2021.
This retrospective observational study examined routine birth data from Monash Health. It compared the detection of adverse obstetric outcomes between two time periods – the first, a pre-COVID ‘conventional antenatal care period’ (1 Jan 2018 – 20 March 2020) and the second, a post-COVID 19 ‘integrated care period’ including telehealth (April 20 – July 26 2020). For clarity we will present ‘integrated care period’ as the ‘COVID era’.
- Primary outcomes included detection of fetal growth restriction, pre-eclampsia, and gestational diabetes. Secondary outcomes were stillbirth, NICU admission and preterm birth (<37 weeks).
- During the conventional care period (prior to COVID), 20,031 women gave birth with 2,292 giving birth during the ‘COVID era’.
- More than half the consultations (53%) during the ‘COVID era’ were by telehealth (voice or video call).
- No differences were found between the care periods, for low or high-risk models of care, with regards to:
- Fetal growth restriction (babies <3rd percentile: 2% in low-risk care during both periods, p=0.72; 5% in high-risk care during both periods, p=0.50).
- Stillbirths (1% during both periods for low-risk care, p=79; 2% during both periods for high-risk care, p=0.70)
- Pre-eclampsia (3% during both periods for low-risk care, p=0.70; 9% for integrated care and 7% for conventional care for high-risk care, p=0.15)
- Gestational diabetes (22% during both periods for low-risk care, p=0.89; 30% for integrated care and 26% for conventional care for high-risk p=0.06)
- The authors conclude that antenatal care during the COVID era where telehealth was commonly used was not associated with a change in adverse pregnancy outcomes or complications, compared with conventional care. Telehealth seems safe and should be considered as part of routine antenatal care in the future.
In this report more women failed to attend their scheduled consultations during COVID era care than during conventional care (8% vs 5%, p<0.001). While the data is reassuring, it may have been underpowered to detect differences for some important adverse outcomes, especially stillbirth. Hence, ongoing surveillance of the performance of Telehealth is warranted.
Australian Preterm Birth Prevention Alliance
The Australian Preterm Birth Prevention Alliance was
born on 7 June 2018. This Alliance is the world’s first
national program aiming to safely lower the rate of
early birth across its population.
CLICK HERE to read the latest from the AUSTRALIAN Preterm Birth Prevention ALLIANCE.
Please remember to ensure that your antenatal women have booked into ‘Shared Care’, and that you have received a letter of confirmation stating your patient has been accepted into ‘Shared Care’ at the relevant public hospital.
If you have not received a confirmation letter from the relevant birthing hospital please follow-up with the hospital’s Midwife Coordinators.
Can you help us find out the ideal amount of iodine needed in pregnancy for baby’s brain development?
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