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At the heart of general practice since 1960

'Warn GPs on risk of falls'

Miss Maggie Blott outlines the five latest developments in her field

1. Transformation of antenatal care

For the first time since its inception, antenatal care is undergoing a major transformation. The familiar pattern of antenatal care originated in the early 20th century and changed little despite evidence that a less intensive visiting schedule is not associated with a failure to detect problems such as pre-eclampsia.

The majority of women will confirm their pregnancy at home and then visit their GP for referral to the obstetric unit. An appointment is made currently for between 12 and 16 weeks.

The NICE guideline suggests that antenatal care should start much earlier in pregnancy with one or two visits by the midwife prior to 12 weeks to allow the woman time to assimilate all the information about the multitude of screening tests now available.

Following this initial contact there is a recommendation that the frequency of visits is reduced from the current level of 14 to 10 for a primigravid woman to seven for a multiparous woman.

The reduced visiting schedule will free up midwives, allowing them to spend more time as appropriate with women and so improve the overall quality of antenatal care.

Maggie Blott is consultant in obstetrics and gynaecology at Royal Victoria Infirmary, Newcastle

2. New thinking on infertility

The latest NICE guidelines on the management of infertility offer general evidence-based advice for couples having difficulty conceiving. Within a year 84 per cent of sexually active couples not using contraception will achieve a pregnancy. Of those not pregnant after one year, 50 per cent will be pregnant within the second year.

Sexual intercourse should occur every two to three days to maximise chances of conception without increasing the psychological stress associated with fertility problems. There is a link between alcohol and nicotine consumption and reduced fertility in both men and women.

Women with a BMI over 29 who are not ovulating regularly will improve their conception rate if they lose weight.

Women menstruating regularly are likely to be ovulating and tests for ovulation induction are only now recommended if they have failed to conceive after one year.

Measuring basal body temperature does not reliably predict ovulation and is not recommended. As women with fertility problems are no more likely than the general population to have thyroid disease and high prolactin levels, measurement of these hormones should be reserved for when symptoms suggest thyroid disease or hyperprolactinaemia.

The link between ovarian cancer and the drugs used for ovulation induction is unclear and it is therefore recommended that women on these drugs are closely monitored to ensure that they have the lowest possible effective dose and that treatment is not carried on unnecessarily if they are not responding.

All women between 23 and 39 with an identifiable cause for their infertility or a history of three years of unexplained infertility are now to be offered up to three cycles of IVF.

3. Management of a missed abortion

The diagnosis of a missed abortion is very distressing, more so as it is often unsuspected, being frequently diagnosed at a routine first trimester scan.

Women need reassurance that miscarriages occur because of problems intrinsic to the pregnancy and not as a result of actions by her.

Many women will now be offered a choice about further management. Options include expectant management ­ allowing the woman to miscarry at home. The main disadvantage of this is its unpredictability. It may take some time, often weeks, for the bleeding to start and the miscarriage to occur.

The woman also has the option of a surgical evacuation of the uterus. This requires hospital admission and an anaesthetic and complications include perforation of the uterus, bleeding and infection.

The third option is a medically induced miscarriage. Most early pregnancy units now offer this, which has the advantage of avoiding the hazards of surgery.

At diagnosis of the miscarriage and after counselling, mifepristone is given to the woman who is then allowed home, to return 48 hours later for administration of misoprostol. Studies have confirmed that the medical management of a missed abortion is a safe, cost-effective alternative to surgical evacuation of the uterus.

4. Down's Syndrome screening for all women

Until recently the type of test and whether it was offered varied depending on the unit where the woman was receiving antenatal care.

There is now a recommendation that all women, regardless of age, be offered screening for Down's syndrome. The test should have at least a 60 per cent detection rate with a less than 5 per cent false positive rate.

In practice this is achieved with either a nuchal translucency test at 11 to 13 weeks, with or without first trimester biochemical screening, or a second trimester (14-20 weeks) biochemical screening test.

By 2007 it is recommended that all units offer a test with a 75 per cent detection rate, which means a nuchal translucency scan at 11-13 weeks in addition to biochemical first trimester screening or the quadruple biochemical test at 14 to 20 weeks.

While all women should be offered this test, what is crucial is that women have sufficient information and time to make an informed decision, and are then supported in their choice.

5. New pregnancy hope for polycystic ovarian syndrome sufferers

PCOS is characterised by obesity, menstrual irregularity, infertility and hyperandrogenic problems such as hirsutism and acne and insulin resistance. These are in combination with a characteristic polycystic appearance of the ovary on ultrasound.

It affects up to 5 to 10 per cent of all women. PCOS is also the commonest cause of anovulation. PCOS is linked to type 2 diabetes and atherosclerosis.

Treatment will be determined by the fertility wishes of the woman. In those women who do not wish to conceive, type 2 diabetes should be excluded and lifestyle advice given. It has long been known that oligomenorrhoea in the presence of normal oestrogen levels is associated with an excess of endometrial hyperplasia and endometrial cancer.

Women with PCOS who do not wish to become pregnant should be offered three monthly cyclical progestogens to induce a withdrawal bleed and to protect the endometrium.

In those women who wish to conceive there is evidence that metformin, by reducing hepatic gluconeogenesis and reducing ovarian hyperandrogenaemia thereby restoring normal ovarian steroid production, is associated with a restoration of ovulation and menstruation.

There is as yet no convincing evidence that used alone this drug improves live birth rates. However, used in conjunction with clomifene, pregnancy rates in obese women with PCOS were improved.

In women who failed to respond to clomifene, the addition of metformin was also associated with improved pregnancy rates. Metformin should be stopped as soon as pregnancy is confirmed.

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