Postpartum follow-up of medical conditions

  • Follow-up medical conditions as early as possible and at 6–8 week postnatal check

Do

  • Check discharge letters for any changes to pre-existing conditions and for follow-up actions
  • Update medical conditions list in electronic medical record
  • Advise women with chronic medical conditions or risk factors for pregnancy induced problems, to plan future pregnancies carefully
  • Talk about contraception and coming to clinic early when pregnant for antenatal and specialist medical care

Anaemia

  • See — Anaemia (weak blood) in adults
  • Medical follow up if any
    • Anaemia during pregnancy
    • Hb less than 110g/L at first check after birth
    • Any other abnormal blood results
    • Postpartum haemorrhage (heavy vaginal bleeding during or after birth)
    • Caesarean section birth

Rheumatic heart disease

  • Medical consult if any RHD or other cardiac condition at every visit
    • Urgent medical consult for specialist consultation and echocardiogram if any shortness of breath or worsening fatigue in women with RHD or at high risk of RHD (includes all Aboriginal and Torres Strait Islander women in rural/remote areas)
  • Check woman is on regular recall  
  • Make sure prophylactic Bicillin L-A (benzathine benzylpencillin) injections are up-to-date. If not — administer
  • Bicillin L-A, oral penicillin and erythromycin are safe while breastfeeding and should be continued
  • Encourage breastfeeding and review safety of any other heart medications with breastfeeding
  • See —  Acute rheumatic fever (ARF) and rheumatic heart disease (RHD)

Hypertension (high BP) or preeclampsia

  • High BP may have been pre-existing and continue postpartum
  • High BP and preeclampsia/eclampsia can occur in the immediate postpartum period — see High BP in pregnancy
  • BP usually stabilises in the first 2 months post pregnancy
  • Medicine to manage high BP may need the type or dose changed, or slow withdrawal

Medical consult

  • If continuing or worsening high BP (over 140/90mmHg or over 130/90mmHg if diabetes and protein in urine)
  • Any other abnormalities (eg proteinuria, headaches, abdominal pain)
  • Early in postnatal period if
    • Recurrent preeclampsia — had it in previous pregnancies
    • High BP was detected before 20 weeks gestation
    • Had kidney, liver, neurological or haematological abnormalities during pregnancy

Follow-up

  • See woman every week for 6 weeks, then at 6-8 week postnatal check — needs medical consult
    • Check BP, weight,  U/A for protein
  • Review 3 months after birth. Check BP, weight, U/A for protein
    • If BP still high — manage as chronic high BP
    • If U/A still shows protein (1+ or more) — investigate cause

Sexually Transmitted Infections (STIs)

Gonorrhoea, chlamydia, trichomonas

If positive tests for gonorrhoea, chlamydia or trichomonas in pregnancy

  • Check if treatment given. Special considerations, trichomonas may not have been treated in pregnancy
  • Check that contact tracing done and partner/s treated
  • If mother not treated during pregnancy
    • Baby needs medical consult
    • Develop treatment plan for mother and contacts

Syphilis

Active syphilis should be promptly treated during pregnancy. It can cause significant pregnancy complications and congenital syphilis in baby

  • Check results of syphilis tests taken during pregnancy or at birth
    • If unsure whether treated — talk with sexual health unit
  • If mother has positive syphilis serology — check baby's risk of congenital syphilis was assessed
  • If baby was not born in hospital — always do urgent medical/ sexual health consult about baby's risk and any treatment plan

Diabetes

  • Any diabetes in pregnancy needs careful follow-up after birth
  • Document maternal diabetes in pregnancy in the baby’s medical record as it is a risk factor for future obesity and diabetes, and other adult conditions

Pre-existing diabetes

  • See — Diabetes for general advice on management
  • Medical consult and refer to diabetes educator
  • Monitor BGL regularly and adjust treatment accordingly — Table 4.1
  • Less medication is usually needed after birth to maintain target blood glucose levels (BGLs)
  • If woman did not birth in hospital, medical consult — for advice from endocrinology regarding diabetes medications
  • Encourage breastfeeding
    • Breastfeeding is beneficial for both mother and baby
    • Women with pre-existing diabetes are less likely to breastfeed than women without diabetes. Offer support and consider referral to lactation consultant if needed
    • Only use metformin and/or insulin if breastfeeding — Do not use other glucose-lowering medicines
  • Women using insulin may be at risk of hypoglycaemia (low BGL) especially when breastfeeding — see Hypoglycaemia (low blood glucose)
  • Ensure routine diabetes follow-up is in place. If BGL’s are not within the target range, consider more frequent review (eg every 1-2 weeks) initially
  • Repeat HbA1c after 4 months — inaccurate earlier

Gestational diabetes

  • See Table 4.1 for postpartum management and BGL monitoring
  • All women with GDM, who are able to stop treatment postpartum, should be screened for pre-existing diabetes using
    • Fasting 75g OGTT at 6-8 weeks postpartum
    • If OGTT not possible, do HbA1c at 4 months postpartum — inaccurate earlier
    • See Diabetes to interpret results
  • If postpartum screening normal, note high risk of developing type 2 diabetes (more than 1 in 5 Aboriginal and/or Torres Strait Islander women with GDM have type 2 within 3 years post-partum)
  • Talk about
    • Early check in next pregnancy — testing for diabetes, may have gestational diabetes in future pregnancies
    • Breastfeeding — may help reduce future risk of obesity and diabetes for both mother and baby
    • Healthy food, drink and physical activity
    • Maintaining a healthy weight may prevent future gestational diabetes. Consider referral to dietitian

Table 4.1 Postpartum monitoring and management according to type of diabetes

Obesity

  • See — Healthy weight in pregnancy for classifications of BMI and recommended gestational weight gain
  • Excessive weight gain during pregnancy and retention of weight after birth can increase risk of complications in future pregnancies
  • Healthy eating, physical activity and breastfeeding should be discussed as strategies for a return to pre-pregnancy weight
  • Breastfeeding may help women lose weight and reduce the risk of obesity in the baby
  • Women with obesity are less likely to initiate or maintain breastfeeding. Appropriate support should be provided including consideration of referral to lactation consultant
  • Consider referral to dietitian