5 November 2018

Screen pregnant women for hep C, stop vitamin D

General Practice O&G Women

Test for hepatitis C, forget checking vitamin D levels and get comfortable with weight conversations, the new guidelines for doctors managing pregnant Australian suggest.

Asking about family violence was also important for GPs to include in their assessment of their pregnant patients, given the tragic link between this time in a woman’s life and the beginning or worsening of abuse, experts say.

“It’s important, given the challenge around family violence at the moment in Australia, that we make sure that women are in a situation with an antenatal provider where they ask, ‘Are you safe? Can you go home?’ and doing it in a routine way as though we do this for all women,”  Professor Caroline Homer, co-program director of maternal and child health at the Burnet Institute, said.

Professor Homer and her colleagues published a summary of the clinical guidelines, which combine and update the 2012 and 2014 editions, in the MJA this week.

They urged doctors to visit the “living document” online and give feedback on other sections currently under consultation, which include screening for chlamydia, syphilis, diabetes and others.

The new guidelines come down against vitamin D testing unless there is a specific indication, saying routine screening and supplementing was not supported by evidence “and should cease as the benefits and harms of vitamin D supplementation remain unclear”.

“Over the last five to 10 years we’ve become very enthusiastic about screening everyone for vitamin D deficiency, despite the fact that we live in a country with a lot of sunshine,” Professor Homer said.

“But there’s no good evidence that supplementing women with vitamin D gives any benefit.”

It is also expensive for the healthcare system and for the women involved.

“If testing is performed, only recommend vitamin D supplementation for women with levels lower than 50 nmol/L,” the guidelines, which were developed in collaboration with professional bodies for GPs, obstetricians and gynaecologists and midwives, said.

Weight management was another important change, with the guidelines recommending doctors proactively ask pregnant women if they might like to have their weight monitored at each antenatal visit.

While there wasn’t necessarily strong evidence for or against weighing, Professor Homer said that clinicians were enthusiastic about it being included in the guidelines because it was “an entrée into the discussion”.

“It gives you permission to talk about weight and see how she’s going with it,” she said.

Around half of all Australian women having babies are overweight or obese, which increases the risks of negative outcomes for the child. The guidelines recommend the doctor discusses weight changes, physical activity and diet with all pregnant women and encourages women to self-monitor weight gain.

“Aerobic exercise, such as walking 30-60 minutes, three to seven times a week, may help to reduce the risk of early birth in women with singleton pregnancies who are overweight or obese without any contraindications to physical activity,” they said.

The recommendation to test for hepatitis C at the first antenatal visit comes in the wake of cures for the disease now being widely and cheaply available. The aim is to help identify women who could start treatment after giving birth, preventing issues with future pregnancies.

Knowing a woman has hepatitis C early in the pregnancy might also alert clinicians to the need to try and avoid invasive procedures that would increase the risk of the foetus becoming infected.

To see the full document, which includes advice on lifestyle, social and emotional screening, chromosomal anomalies and other conditions, visit: https://beta.health.gov.au/resources/publications/pregnancy-care-guidelines-and-related-documents

MJA 2018; online 5 November