ANSC July 2022 Update: Royal Hospital for Women

Contact details for RHW

Email address for GP enquiries at RHW: SESLHD-RHWGPSCEnquiries@health.nsw.gov.au

ANSC Liaison Midwife Chantelle du Boisee work days are Monday and Tuesday 8.00am-5.30pm (please note these days have changed). Email – Chantelle.duBoisee@health.nsw.gov.au

For Clinical GP Advice call 0417 995 153 (Monday – Friday 8.00am-4.30pm). The mobile phone will be answered by the liaison midwife or the senior in charge midwife.

If you need to speak directly to the Obstetric doctors, please call 9382 6111 and ask the operator to page the on-call Obstetric Registrar.

For more urgent 7 day/24hr advice, contact Delivery Suite on 0439 869 035  or 9382 6100 (from 20 weeks pregnancy).

General Reminders

The Obstetric Medicine Physician Registrar can be contacted for advice Monday-Friday during business hours by calling 9382 6111 and asking the operator to page the Registrar.

Delivery Suite can accept referrals from GPs and women, with urgent obstetric medical concerns in the immediate 14 days following the birth. Contact Delivery suite on 0439 869 035 or 9382 6100.

Antenatal Blood tests must be attended at the confirmation of the pregnancy. Any pre-conception bloods cannot be accepted.

Please refer to specialised obstetric ultrasound practices for all pregnancy ultrasounds. RHW ultrasound department accepts referrals for third trimester ultrasounds.

If a woman’s GP is not available for a routine antenatal visit, please ensure the woman sees another RHW accredited GP at the practice. If an accredited GP is not available, telephone the Liaison Midwife to organise a hospital appointment on 0417 995 153.

The Safer Baby Bundle (SBB)

The Australian Safer Baby Bundle (the Bundle) is primarily designed to reduce stillbirth rates after 28 weeks gestation by at least 20percent by 2023. The Bundle addresses commonly reported care factors that can be moderated including maternal smoking, detection and management of fetal growth restriction (FGR) and for women with decreased fetal movements (DFM), maternal sleep position (a recently reported avoidable risk factor for stillbirth) and an increasing clinical concern regarding decision-making about the timing of birth for women with risk factors for stillbirth.

The Safer Baby Bundle has been developed primarily for midwives, doctors, health service managers, nurses, and other health care providers (e.g. Aboriginal health care providers) providing maternity care and for women accessing maternity care in Australia

Information for the SBB can be found on the Clinical Excellence Commission webpage or via the SBB SharePoint (for public health service clinicians only).  You can request access via this link Safer Baby Bundle (sharepoint.com)

Further information:

• The national website is The Safer Baby Bundle | The Centre of Research Excellence in Stillbirth (stillbirthcre.org.au)
• NSW has a specific Fetal safety risk assessment pathway for fetal growth restriction screening
• YouTube video on the Safer Baby Bundle for GPs
• Information on how GPs can order SBB resources can be accessed

Updated GP Shared Care Protocol Summary and ANSC Guidelines

 The RHW Antenatal Share Care Guidelines and RHW GP Shared Antenatal Care Protocol Summary have been updated

The updated guidelines are available on the RHW website, CESPHN website and South Eastern Sydney HealthPathways.

Please ensure you are referring to the most up to date versions by clearing your browser history.

The Ironwoman Study – Update

The Royal Hospital for Women (RHW) and St George Hospital, under Dr Antonia Shand, MFM specialist’s direction, have been conducting a double-blinded RCT Oral and IV iron treatments and their effect on a pregnant woman’s quality of life for the last year. Further information about the study is available in the information brochure for clinicians.

We are recruiting women that have Iron Deficiency Anaemia at 26 – 32+6 weeks gestation. A large proportion of pregnant women at RHW are in the GP Shared Care model and you can assist us greatly in identifying women who meet our recruitment criteria:

+ 26 – 32+6 weeks gestation

+ Ferritin < 30

+ Hb 104

Recruitment has been a little slow moving and we believe GPs could hold the key to accelerating our recruitment. If you meet women booked at one of the two above sites, please email the woman’s details to Jennifer.goth@health.nsw.gov.au. Please also reach out if you would like further information about this and other studies we are running at the Royal Hospital for Women.

Booking in visit

Please advise women to book online via the RHW website at ~ 6 weeks gestation. The booking in visit will generally be attended between 14-16 weeks gestation.

If your patient needs a more urgent Obstetric/and or Obstetric Medicine Physician review, please fax the referral to 9382 6118.

Please note these Important changes with the booking process during COVID-19:

• Booking visits are via telehealth video appointment.
• The GP is NOT required to complete the yellow card as this will be completed by the booking in midwife. The card will be mailed directly to the woman after the booking is completed.
• The GP needs to complete the entire RHW antenatal referral form. Please fax, together with antenatal pathology, ultrasound results and any other relevant results to RHW Outpatients Department prior to the booking visit. Fax: 9382 6118.
• Documents for the booking visit can be emailed to SESLHD-RHWOPDRESULTS@health.nsw.gov.au (please send as one document).

NB: Following on from the booking visit all ongoing results must be given to the woman to bring to their next hospital visit. Please do not fax, mail or CC in any results unless you have urgent clinical concerns.

If your patient has not been contacted within two weeks of lodging their online booking submission, please ask them to follow up on 9382 6206.

Preterm birth prevention clinic

RHW has commenced a weekly preterm birth prevention clinic under the care of Dr Daniel Challis and Dr Laura Gerhardy (MFM Fellow). Please see the attached information on the clinic.

Royal Applause

This column provides recognition of the excellent work performed by RHW ANSC GPs.

This month RHW would like to recognise Dr Sandra Badawi from My Health Zetland. Dr Badawi  always provides clear and detailed referrals for her patients. This helps facilitate optimal care for women and enhances the collaboration across the RHW ANSC Program. Dr Badawi should be commended for her thorough clinical and communication skills.

Ask the Royal – Hyperemesis Gravidarum

The information contained in this column is written by Obstetricians, Medical Specialists and other Health Clinicians and is drawn from regular questions asked by GPs via the ANSC advice line. Joanna Pinder CMC for the Hyperemesis Gravidarum Initiative has outlined below information on Hyperemesis Gravidarum (HG) including information on the NSW HG initiative at SESLHD.

Hyperemesis Gravidarum is the leading cause of hospitalisation during early pregnancy, and second to premature labour as the leading cause overall during pregnancy. HG usually extends beyond the first trimester and may resolve by 21 weeks; however, it can last the entire pregnancy.

Severe HG is often associated with:

• loss of greater than 5 percent of pre-pregnancy body weight (usually over 10%)
• dehydration
• nutritional deficiencies
• metabolic imbalances
• severe fatigue and debility
• depression/anxiety and trauma
• premature labour/delivery and
• adverse fetal complications.

Emerging evidence has found a genetic association predisposing women to HG and children born to mothers diagnosed with HG, are more predisposed to autism spectrum disorder, learning difficulty, depression, anxiety and processing disorders.

May is HG awareness month, NSW Health used the awareness day on Sunday 15 May to highlight awareness of HG on their Facebook page and launched a dedicated webpage to educate professionals and the public about HG.

The NSW Health Guideline Identification and Management of Nausea & Vomiting in Pregnancy and Hyperemesis Gravidarum is due to be published and will ensure clear management and treatment pathways. SESLHD aim to develop models of care that integrate hospital, community and primary care pathways to optimise treatment that suits the needs of the community and hospital service.

SESLHD project lead Joanna Pinder can be contacted with any questions regarding care of women with HG.  Joanna  Pinder can be contacted via email at joanna.pinder@health.nsw.gov.au

For further information see link to the NSW Health – Hyperemesis Gravidarum Fact Sheet.

Gestational Diabetes Mellitus (GDM)

The Diabetes in Pregnancy team at RHW have a provided an ANSC Diabetes in Pregnancy update. There is also a new patient educational letter for woman, explaining why screening for gestational diabetes is recommended.

Please be mindful that some pathology labs use different reference ranges for diagnosing GDM. The RHW criteria for diagnosing GDM is as follows:

FASTING >5.1 mmol/L

1 HOUR >10 mmol/L

2 HOUR >8.5 mmol/L

If the following tests are incidentally performed at any stage in pregnancy PRIOR to OGTT and show the following results, do NOT perform OGTT, but refer as diagnostic of GDM or DM.

Fasting BGL:   (< 13 weeks gestation) ≥ 6.1mmol/L* OR

                         (≥ 13 weeks gestation) ≥ 5.1mmol/L

Random BGL ≥ 11.1mmol/L (i.e. beyond 2 hours postprandial)

* if OGTT or fasting BGL is performed < 13 weeks gestation and fasting BGL 5.1-6.0 mmol/L, this may be physiological and may require further evaluation. Discuss with, or refer to, DE/Diabetes Team for further advice

For further information you can review this helpful flowchart for screening, diagnosing and referring GDM and the GDM Screening and Management Policy

Referral Process after a diagnosis of GDM

If you have a patient diagnosed with GDM, please contact the Diabetes Educator within one week of the GDM diagnosis on (02) 9382 6010 or at SESLHD-RoyalHospitalforWomen-DiabetesServices@Health.nsw.gov.au

Please address the referral to Prof. S Lowe/Dr S M Lau/Dr A Beech/Dr H Barrett and attach the pathology results. Fax the referral and results to 9382 6118.

Perinatal Loss Service at RHW

The Perinatal Loss Service at the Royal Hospital for Women is a service that supports families experiencing pregnancy loss from 18 weeks gestation. This loss may be a miscarriage, stillbirth, a termination of pregnancy for abnormality or a neonatal death.

The Perinatal Loss team comprises a specialist obstetrician, a bereavement midwife and a named social worker, who coordinate care with genetic counsellors, neonatologists, perinatal mental health, chaplains as required.

The Perinatal Loss Service offers individualised care to these women and families through practical, emotional support and will offer ongoing contact in the early loss period and then follow up in Perinatal Loss Clinic to review results of autopsy, or other investigations and plan subsequent pregnancy management.

The “Living with Loss” program is an online support program offered to parents following a perinatal loss. This evidence based program has been co-designed by parents and the Stillbirth CRE (Centre of Research Excellence) and aims to assist parents in navigating their grief and find coping strategies to help bereaved parents manage the future without their baby.

For further information about the Perinatal Loss Service please contact the bereavement midwife at SESLHD-BereavementRHW@health.nsw.gov.au or by calling 9382 6007

Medical Disorders in Pregnancy Clinic

Referrals to Obstetric Medicine Physicians at the Medical Disorders in Pregnancy Clinic must be addressed to Professor Sandra Lowe/Dr Amanda Beech. The patient will be contacted directly to arrange an appointment only after the referral has been received. Please fax referrals to 9382 6118.

Local Operating Procedures (LOP’s)

You can access useful clinical policies, procedures and guidelines at RHW here.

Recently reviewed Local Operating Procedures:

• Fetal Movements – Identification and Management of Reduced Patterns

The RHW fetal movement patient brochure (Fetal movement: what is normal) has also been updated. It is important to discuss and educate women about fetal movement at all antenatal visits

• Sepsis in pregnancy and postpartum
• Next Birth after Caesarean Section

Important and helpful policy reminder:

• Thyroid disease in pregnancy: management of women with subclinical or overt thyroid disease in pregnancy

Important Reminder: Please refer to the above policy prior to screening for thyroid disease in pregnancy. Use pregnancy trimester specific ranges for each pathology laboratory. If laboratory does not have trimester specific ranges, then use the following (as per RANZCOG policy statement) If pathology results fall out of the normal range for pregnancy, please refer to the policy above or make contact with the ANSC Liaison midwife for further advice.

Genetic counselling

Please ensure that you are familiar with the RHW Genetic Counselling policy. A flowchart at the end of the Genetic Counselling Policy is helpful with navigating the correct referral pathway.

Important reminder: Women referred for a NIPT (from 10 weeks gestation) must also be referred for a Structural NT Ultrasound at 12-14 weeks gestation.

Any woman who receives an increased risk aneuploidy screening result (cFTS or NIPT) or has a structural anomaly detected on ultrasound can be referred to the Maternal Fetal Medicine Department at RHW. They  will be offered genetic counselling, a repeat ultrasound, a consultation with a maternal fetal medicine specialist and prenatal diagnostic testing (such as amniocentesis or chorionic villus sampling), if appropriate. All these consultations will be covered by Medicare.

For GPs to arrange or discuss a referral please call the  ‘Fetus Phone’  on 0437 537 448  (Mon-Fri 9.00am- 4.00pm). For patient enquiries the number is 9382 6098

Ferinject infusion at RHW – changes to booking procedure

There has been a recent sharp rise in requests from GPs for RHW to administer Ferinject infusions for pregnant women who have a low ferritin but normal Hb.

RHW protocol recommends that for these women a trial of oral iron is the first line therapy. If oral iron has failed or is contraindicated then an IV iron infusion may be considered. See the link to the relevant policy.

How to book an iron infusion at RHW for a pregnant patient over 20 weeks gestation:

Check the levels meet strict criteria of Hb 105 or less and Ferritin <30. 

The GP can discuss and organise and Iron infusion by phoning the Pregnancy Day Stay Unit (PDSU) on 9382 6417. Please note bookings will not be accepted by the patient directly.

Fax the  referral, FBC and ferritin result to PDSU fax 9382 6404.

Give the patient a prescription for the Ferinject and remind her to bring the medication to her PDSU appointment.

Give the patient the IV iron infusion information sheet (found in Appendix 2 in the policy.)

If a patient does not meet criteria but the GP believes that iron infusion is warranted, then the GP can phone RHW and ask to speak to Dr Fay or Dr Lee to discuss the case; or arrange the infusion elsewhere.