Welcome to Edition Four

2015 is well under way and we look forward to continuing to provide you and your patients with affordable obstetric and gynaecological care.

We continue to be able to provide timely access to consultations and please remember we are able to provide phone advice as required. If you would like your patients seen urgently please contact our rooms by phone, fax or email.

Iodine Supplementation in pregnancy

Iodine is required for the production of the thyroid hormones,T3 and T4.Thyroid hormones are required to promote brain and nervous system development starting from the first few weeks of embryonic life. Maternal thyroid hormone levels dictate thyroid levels for the first trimester. After the first trimester the fetal thyroid takes over, but still requires the transfer of iodine to make thyroid hormones.The concern with iodine deficiency in pregnancy is a negative impact on the nervous system development in the unborn child.

The World Health Organisation has declared Australia to be a mildly iodine deficient country (Tasmania has a history of iodine deficiency) and programs like fortification of bread with iodised salt have been implemented.

However, thyroid hormone production increases by 50% in pregnancy so to support this increased iodine requirement, the 2010 NHMRC guideline recommends pregnant and breastfeeding women take a daily iodine supplement of 150mcg. Note that the recommended dietary intake is 220 mcg for pregnant women and 270mcg of iodine for breastfeeding women so some iodine is still required from dietary sources. The best sources of iodine are fortified bread, dairy and seafood. Small amounts of iodine are stored in the thyroid gland and the excess intake is excreted.

Optimising maternal thyroid function is most important pre-conceptionally especially in high risk women, and advising all women considering pregnancy or who are pregnant or breastfeeding to add a daily iodine supplement is strongly recommended. A combination such as I-Folic or one of the specific preconception, pregnancy and breastfeeding multivitamins that contains iodine is the easiest way of meeting the need for both iodine and folate.

iodine – Folate – ? Vitamin D Supplementation in pregnancy

Vitamin D Deficiency has been linked with a range of pregnancy complications such as small for gestational age babies, pre-eclampsia and gestational diabetes. It is important to note however that there is very inconsistent evidence as to whether Vitamin D supplementation improves pregnancy outcomes and for whom to offer testing. Testing should definitely be considered in those at risk of very low levels such as those with dark skin or who cover their face and arms. It may also be indicated in women at risk of preeclampsia or gestational diabetes.Advice on the dose of Vitamin D supplementation in pregnancy is from international studies with an Australian guideline lacking. Levels <50 1000IU daily

Levels <30 2000IU daily

And remembering that 30 minutes in the sun daily with legs, arms and chest exposed (at the appropriate time of the day!) may provide more benefits than just Vitamin D.

Induction of labour and lSCS rates

We all agree that for most women a straight forward vaginal birth with minimal intervention is “the gold standard” and certainly our preference.

Induction of labour is considered when it is thought that the interests of the mother or the baby, or both, will be better served by ending the pregnancy. Accurate information about obstetric interventions such as induction is vital for women and their care givers, especially when induction has been linked negatively with adverse outcomes in the lay press.

Recently there have been several large studies showing that induction of labour does not increase caesarean rates but may actually lead to fewer caesarean deliveries. A meta-analysis of 157 randomised controlled trials involving 31,085 women published in 2014 showed that the overall risk of caesarean delivery was 12% lower with labour induction compared with expectant management. This was not influenced by whether the cervix was favourable, the indication for induction or the method of induction – in particular prostaglandin E2 which is the main method we use for inducing labour. Also of interest, induction without a medical indication was associated with a risk reduction of 19% in regards to caesarean delivery. The reduction was seen in term and post-term pregnancies but not in preterm pregnancies, and in both high and low risk pregnancies. As well as a reduction in caesarean deliveries there was a reduced risk of fetal death and also admissions to a neonatal intensive care unit.

This follows on from several studies showing no increase in caesarean section rates with induction for pregnancy induced hypertension from 37 weeks gestation. And a very large UK population based study of more than a million singleton pregnancies of 37 weeks or over, where women induced with no recognized medical indication were compared with expectant management which showed decreased perinatal mortality with no reduction in vaginal delivery rates.

Certainly women can be reassured that if they are induced they are not increasing their risk of requiring a caesarean section, but may in fact be reducing their chance of not only a caesarean but an adverse fetal outcome.

We certainly believe in individualizing the care of pregnant women, summarized beautifully in the quote below:

Our task as providers of care for pregnant women is to provide the most appropriate delivery mode for the individual woman and her fetus(es) that incorporates both the short- and long-term facets of their physical and psychological well-being.

Jan Dickinson editorial ANZJOG

Safety and Efficiency of HpV vaccination

Recent publications have shown the effectiveness of the Gardasil vaccination in Australia with the course of three injections usually administered to school age girls, reducing the chances of a high grade abnormality by half, and any abnormality by a third, compared with controls. There is also a reduction in future disease in women who have already been treated for CIN2 and CIN3 in the past, as well as a substantial reduction in presentations with genital warts. A study from Denmark and Sweden where nearly two million doses of the quadrivalent vaccine have been given to young women has confirmed the vaccine’s safety (in particular with respect to multiple sclerosis or other demyelinating diseases). This certainly encourages us to keep recommending the vaccine to our patients. We are now waiting for trials of a vaccine covering nine strains of HPV, which theoretically should reduce the burden of HPV related disease by up to 90%.

Full range of Diagnostic and Surgical Services

Within our group we are pleased to be able to provide our patients with an extensive range of both diagnostic and specialised surgical services. This includes amniocentesis and chorionic villus sampling for pregnancy, urodynamic testing for urinary incontinence, colposcopy for abnormal pap smears, total laparoscopic hysterectomies, advanced pelvic floor repairs, specialised hysteroscopic procedures such as fibroid resection and permanent tubal occlusion. Please feel free to contact us at Hobart OBGYN if you have a specific referral.