In our 110th edition, Rachel has some seasonal advice, Tina loves LocumDeck, Claire has some warming paintings for us, Judith unmasks a ruthless dictator, Louise gives a comprehensive rundown of hypertension in pregnancy and Liz has some great tips if you're in the process of making babies.
The Sessional GP
Supporting sessional GPs to improve patient care
Preview attachment 8385 BMJ Live NASGP Avdert AW (3).pdf 8385 BMJ Live NASGP Avdert AW (3).pdf 117 KB
image © Claire de Mortimer
December 2019
have yourself a merry risk-free christmas
With seasonal cheer building and the countdown to the holidays drawing near, it is important that sessional GPs are well-prepared for possible challenges during Christmas and New Year. Dr Rachel Birch, Medicolegal Consultant at Medical Protection, offers practical advice on how to make this year as safe and enjoyable as possible. “Let it snow! Let it snow! Let snow!......” You may all be dreaming of a White Christmas, but this can present a challenge for sessional GPs. Snow and ice on the roads can cause significant travel disruption and, in the worst scenario, may prevent you from getting to work. When driving to an unfamiliar practice, ensure that you know where you are going and plan any alternative routes in advance. Leave plenty of time for travel. Ensure that you have the practice direct dial number, so that you can let them know if you are going to be late. Always keep your mobile phone fully charged. Keep a snow shovel in the car. “We three kings of Orient are.....” You may not be expecting gold, frankincense and myrrh, but boxes of chocolates, fruit baskets and wine are sometimes gifted to doctors by appreciative patients. It is important that you know, in advance, what to do if you are given a festive token of their gratitude. Ensure that you keep your own personal register of all gifts received. Familiarise yourself with the practice’s gift policy and always let the practice manager know if you have received a gift. Inform NHS England if you receive any presents over the value of £100. Do not leave wine bottles in doctors’ rooms- this could give patients the wrong impression. The GMC advises doctors that they “must not ask for or accept – from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients.” Doctors should always be mindful of this guidance and ensure that accepting a gift could not be misinterpreted by others. “I wish it could be Christmas every day......” Whilst time spent with family and friends is precious over the Christmas and New Year bank holidays, general practice can be a busy place in the days following these long breaks, with many patients saving up their concerns for their own GP practice, rather than attending OOH. Between Christmas and New Year many NHS services may be reduced, including outpatient clinics, laboratory services and pharmacies. Clarify these arrangements with practices in advance, as well as what will be expected of you, as a locum, as there may be fewer staff than at other times. Will you be responsible for triage telephone appointments or repeat prescriptions? Ensure you are clear with what is being asked of you. Consider coming in a few minutes earlier than you usually would, to ensure that you start the day running to time. Check the OOH contact sheets early, so that home visits and review appointments are pencilled in early in the day. Request essential tests urgently, so that results come back in a timely manner. Bring a packed lunch and ensure you have time for coffee. Be understanding and try not to get frustrated! It is a busy time of year for everyone. “I’ll be home for Christmas….” Vulnerable patients, such as the elderly, housebound and homeless populations, may feel isolated during the festivities. With winter bringing its own set of illnesses, coupled with the possibility of inclement weather, there may be more requests than usual for home visits. Ensure you have adequate time for home visits. Liaise with district nurses, social services or crisis teams if you are concerned about a patient- these services may be restricted, but will still be available over the festive period. The holiday season is also a time when signs and symptoms may be dismissed as harmless typical festive ailments, such as those caused by alcohol and food excess. These issues can get more complicated if patients attend as temporary residents, without access to their medical records, for example if they are visiting from abroad or out of area. Always remain vigilant to the possibility of serious illnesses, such as heart attacks, and avoid the potential pitfall of assuming a patient is suffering from festive excess. “Have yourself a merry little Christmas.....” Everyone working in primary care tends to work extra hard in the run up to Christmas and New Year. This, coupled with seasonal social events, can place extra demands on health and resilience. If you have not already done so, consider arranging to have an influenza vaccination- remember you are in the front line and need to keep healthy! Try not to organise late nights prior to a working day so that you don’t look or feel tired the next day. Ensure that you act professionally at all times, even when out with friends locally. Make time for some emotional “down time” over the long holiday period when you are not working. If you become unwell, remember to visit your own GP- you cannot help other people if you are unwell yourself. Beware the inevitable chocolate boxes at reception… You may or may not feel that it is the most wonderful time of the year, but with a little planning and awareness of what to expect, you can make a success of working over this festive season. Rachel Birch rachel.birch@medicalprotection.org
By Rachel Birch @MPSdoctors
It's time to put your stockings up, but don't let your guard down
"Do not leave wine bottles in doctors’ rooms- this could give patients the wrong impression."
One locum's career journey
my path to LocumDeck
By NASGP member Tina Sumner
Like many highly skilled professions, a career in general practice can be a journey with obstacles to overcome, barriers to navigate and choices to make. NASGP member Tina Sumner describes how she came to be working as a GP locum and how NASGP has helped her in that journey. Like most GPs, I entered medical school 'wanting to help people'. I was the first of our family to go to university, so there was no-one in the background advising me on what to really expect throughout training and whilst a fledgling in hospital. I entered general practice after my junior house officer jobs, as I loved every department I had encountered, but wanted continuity, and something of everything. I have never regretted my decision. As my GP VTS training entered its final months, and with my first baby on the way, I was asked to join the partnership of the course organiser. The surgery was close to my home, in a practice with 2 excellent doctors, so I jumped at the chance and became a partner at the stroke of midnight as we entered a new millennium in January 2000. The practice was in a deprived urban setting, with many socially challenged patients, but the work was rewarding, and with plenty of chronic health issues to get my teeth into. My partners were great, we worked well together, with an ethos of equality, democracy, workload and list sizes. Despite all this, I needed some months off after several years due to the spectre of depression, my second episode, this time moderately severe. None of us had seen it coming and my colleagues felt guilty for not recognising the signs, but how could they? When my stress became burnout, and then depression, and all the time I was fooling myself that I was fine. After recovering, I was able to return to work, reducing my workload from seven to five clinical sessions a week. The practice was expanding rapidly, and we had a new and much larger building built, and after moving took on another and then another partner, making us a five partner team. The practice started training, so I became a mentor to one of our nurses whilst she did the nurse prescribing course. I took on the challenges of an ever evolving primary care role with relish, and slowly found the amount of time spent on administrative tasks and meetings increased enormously. I had also become senior partner. The negative thinking returned, but of course, I said, 'I'm fine'. I wasn't, and hadn't learned from my previous episode, and so perhaps inevitably, depression overcame me again, this time severely, and I ended up requiring hospital admission. As I recovered it was clear to me that I needed to take action to protect my health in the future. Work was my biggest stressor; initially I was not sure I even wanted to be a doctor anymore. After much pondering, and after compiling a pros and cons list, with admin, meeting and staffing issues being strong negatives, and my love of direct patient care shining a light through the darkness, I resigned from the partnership. Locum life beckoned. But having recovered from depression, my confidence wasn't quite there, and so I joined a locum chambers. Through the administrative team I got as much work as I wanted, and was protected from all the bookkeeping of a self-employed freelance worker. In addition, each area covered by the chambers had monthly clinical governance meetings with other members, where we could share learning, gossip, and offer and receive support as needed. I'd found my career mojo once more. Without fail, the practices I worked at were welcoming, friendly and helpful. I could do a good job as a clinician, do direct patient administrative tasks then walk away. (Often to return shortly, as many practices made frequent re-bookings). After almost four years with the chambers I was on top form, had the confidence to 'go it alone', and decided to leave them and become freelance in order to save the 14% administrative fee that that particular chambers was charging. Then I found NASGP and LocumDeck. I can't remember how, possibly intrigued by an online advert whilst reading an article link sent from the local postgraduate centre. I now pay £12 a month to use LocumDeck’s excellent platform for all my bookings and allow all of the practices in my area to 'Instant Book', so I don't have to constantly monitor and reply to enquiring practices. Some practices do still email, and a couple who have not heard or used LocumDeck have signed up and love it. For some I have popped in to show them the site and the benefits for us both. Win- win! There's no need for negotiations, my terms are set out clearly and easy to use. I can choose what types of self-formatted session I offer to individual practices, and could choose if I wish to charge differing amounts too. Practices can see my availability instantly, book me and be assured with confirmation in a few clicks. I have set up my own non-principals group, so have not lost out on peer support and learning. My mental health remains good, I feel resilient, have plenty of work and enjoy many repeat short and longer term bookings. Despite several offers of permanent positions, I will remain a locum for the foreseeable future. Tina Sumner NASGP member dr.tina@ntlworld.com
"I'd found my career mojo once more. Without fail, the practices I worked at were welcoming, friendly and helpful."
One less thing to loose sleep over
parental benefits
"SMP starts when you take your maternity leave, or automatically if you are off work with a pregnancy related illness in the 4 weeks before due date."
By Liz Densley @honey_barrett
Christmas seems an appropriate time to think about new babies, so here we consider some money matters you might need to think about. Statutory maternity pay v maternity allowance Eligibility for statutory maternity pay (SMP): Earning at least £118 a week Give appropriate notice to employer with proof of pregnancy Have worked for your employer continuously for at least 26 weeks continuing into the ‘qualifying week’ (15th week before the expected due date) So, this will apply to most salaried GPs. You will get 90% of your average weekly earnings before tax for the first 6 weeks and £148.68 per week (or 90% of earnings if that would be a lower figure) for the next 33 weeks. If you are not the mother, you might be entitled to Shared Parental Leave pay (ShPP) – this is payable at £148.68 (or 90% of average earnings if lower). Effectively this means if you are both working, then after the first 6 weeks you can get the same benefit whichever of you stays at home with the baby. SMP starts when you take your maternity leave, or automatically if you are off work with a pregnancy related illness in the 4 weeks before due date. Eligibility for maternity allowance (MA - full rate £148.68/week or 90% of your average earnings if less, for 39 weeks): If you are employed but not entitled to SMP If you are self employed and pay Class 2 NIC If you’ve recently stopped working In the 66 weeks before your baby is due you must have been: Employed or self employed for at least 26 weeks Earning £30 a week or more in at least 13 weeks To get full maternity allowance you must have paid at least 13 weeks Class 2 NIC during that 66 week period – if not enough you only get a reduced amount of allowance (£27 per week for 39 weeks) If you have not been working then you can still claim, if for at least 26 weeks in the last 66 weeks before your due date: You are married/civil partnership Not employed or self employed Take part in your spouse’s business but unpaid Your partner is self employed and paying Class 2 NIC You are not otherwise entitled to SMP or MA In this situation you will only get 14 weeks of allowance Child benefit You will be able to register for child benefit when your baby arrives. Doing this gets them set up in the system so they get their national insurance number when they are of age. This also protects your State Pension if you do not have sufficient National Insurance contributions because of time out of work looking after a child under 12. If either you or your partner (whether married, or civil partnership or living together) earn over £50k some of your child benefit will be recouped via the tax system. If either of you earn over £60k the whole amount will be recouped. Where you know that one of your incomes will always exceed £60k you can disclaim the benefit if you prefer that to having to pay it back. Note that this can get complicated! If, for example, you are a single parent, but someone moves in with you, with whom you live as a married couple (but not necessarily the parent of the child), and they earn over £60k, then they can get taxed on your child benefit even if you do not share finances in any way. Tax and children Children are individuals for tax purposes from the moment they arrive, so they are entitled to a personal allowance just like anyone else. This might tempt you to put money in the baby’s name so that the interest isn’t taxable. That won’t work if parents make gifts to children – it will still be taxed as the parents’ income if it exceeds £100. However, if grandparents want to make gifts to children, that’s fine – the income will be deemed to be that of the child. Often grandparents want to set up a fund to help children with university costs once they reach 18 – and this can be a tax efficient way of doing it. Inheritances If your parents are likely to leave you funds, consider if it may be more tax efficient to leave them to the next generation. Or perhaps a trust for a set period from which the child can benefit (perhaps to age 26 to cover further education) and then the capital can be distributed to either parent or child depending on the needs at that time? Depending on what is in the trust, this may give rise to a need for tax returns – so take advice first to make sure it is cost effective. Your own tax position If you are employed then the PAYE system should cope fine with your tax. Depending on the time of the year you stop working, you may get reduced tax or refunds of tax with your SMP. If, however, you are on a ‘non cumulative’ code, you will need to check carefully to make sure that not too much tax has been deducted by the end of the year. Be careful if you have an underpayment of tax for an earlier year that HMRC ‘coded out’ for a tax year when you are not working. This amount that would otherwise have been taken out of your salary will fall due for payment. For example, an underpayment for 2018-19 would normally, if it is small enough, be adjusted from April 20 – so if you were expecting to not be working in 2020-21, you would have to pay the tax separately. If you are self-employed, you will need to consider your payments on account. So, if you have completed your 2018-19 tax return, when you were fully self-employed, you’ll most likely have some substantial payments on account due for 19-20. If you have stopped work part way through 19-20, your taxable income is likely to be less, and therefore you may need to reduce your payments on account. Note that if you reduce them too much, you will get charged interest when the actual amount is known. Some prefer to pay the January figure, then deal with the next return early enough to know the total due before the July payment on account is due. Talk to your accountant about this. You will still need to complete a tax return and a pension certificate each year if you are normally doing them (unless you time your leave for a precise tax year), so make sure you are up to date with your finances before baby arrives – you won’t want your accountant nagging you for information when you have a newborn to look after! Liz Densley is medical specialist Director with Sussex Chartered Accountants, Honey Barrett and secretary of aisma (the association of independent specialist medical accountants). Contact her on 01424 730345 or at liz.densley@honeybarrett.co.uk
© Claire de Mortimer, GP locum, acrylic
In 2011, Hamza was a young Syrian doctor learning German in the hope of going abroad for specialist training. Then the civil war broke out and he opted to stay in Aleppo, operating in makeshift hospitals on the people wounded by collapsing buildings, by barrel bombs, by snipers. Five years later government forces, backed up by the Russians, were one street away. Reluctantly, he and his team accepted last-minute deal brokered by Turkey and Russia to permit them to leave, and so to live. We know how normal life choices shrank to survival in rebel-held East Aleppo because Waad al-Kateab, a young journalist who became Hamza’s wife, was there with her camera. She gave birth in besieged Aleppo and the film is for her daughter, Sama. So she will be able to understand why her parents made the choices they did. And so that we too can understand. Hospitals are protected under international humanitarian law. Yet, the Syrian regime targets anywhere that people may congregate. We see the dust clouds arising from bombing throughout the city. Rudimentary hospitals are created underground where they may not be detected. People are safer from the bombs there, but not from the chlorine gas which is heavier than air and seeps into the cellars where they operate in cramped space with limited medical supplies. They are short of water. There are weevils in their meager stock of rice. We hear the airstrikes getting nearer and nearer. The power fails and someone holding a switched-on camera stumbles down dark stairways. For Waad, filming is a poignant way to remember friends and colleagues who were to become casualties of the war. Filming is a way of remembering some of the thousands of patients, the tragedy of those who died and the joy when some survived against all the odds. Filming was a reason for staying and providing evidence of the regime’s atrocities. Filming will give Sama a memory of the city where she was born. How moving to see her innocent face as her father cradles her while the bombs fall. Hamza was not the only Syrian doctor to stay on in Aleppo. And British vascular surgeon David Nott, who has worked in a dozen of the world’s most unpleasant conflict zones, kept returning there. His love for the people he worked with impelled him to take huge risks to negotiate a cease-fire so those still alive could escape when East Aleppo fell in December 2016. It isn’t just doctors who lay their lives on the line to help others in Syria. When the civil war put paid to Alaa Aljaleel’s electrical business he used his van as an ambulance, rescuing god’s creatures. Not just humans. Alaa loves cats. When homes, schools and playgrounds are reduced to rubble, Alaa’s cat sanctuary is a respite from horror where children can play. In an inhumane world they learn to care for the cats, and Alaa has found funding for food, for a kindergarten and clinics, and community development projects. So his cats give life and hope. Aeham Ahmad also put his life at risk to raise the morale of his besieged community. He’s from the Palestinian refugee district of Yarmouk near Damascus. Son of a blind violinist, he was a music student when his future was destroyed by the uprising. He took his piano out into the rubble of the streets and played. But the regime believes that raising the morale of innocent and apolitical people is tantamount to being a terrorist. When a child in the group singing around his piano was killed by a sniper, Aeham had to accept that he was a danger not just to himself but to his family and friends, so he made the dangerous journey to Europe. He now makes music for his fellow countrymen from his home in Germany. The regime targets anyone who may bear witness. Journalist Marie Colvin felt so committed to the people she knew in Homs that, against all advice, she went back. She was killed in a cellar by a nail bomb. The regime had tracked her satellite phone signal. The regime has doctor apologists. And it is President Bashar al Assad M.D. who has taken the decision to cross moral line after moral line and starve, torture, bomb and gas his fellow-Syrians. What turned a mild-mannered ophthalmologist into a monster? A question his medical school classmate asks himself: “One of us is bombing hospitals. And one of us is treating the victims of the bombing.” But having seen the BBC’s A Dangerous Dynasty: House of Assad, the surprise is that someone from that family, with those parents, ever showed compassion, even briefly, for ordinary people. Which of us could do what Hamza and the other people who stayed on in Aleppo, risking their lives to help their fellow citizens, have done? We can’t know for certain unless we find ourselves having to make the choices they faced. There will be other conflicts, where the worst and the best of humanity will be on display. “Sama, will you remember Aleppo?” asks her mother. Sama will have her mother’s film, as we do, to help us comprehend the horrors of living in a besieged city in the 21st century. For Sama, Waad al-Kateab and Edward Watts, Channel 4 2019 War Doctor: Surgery on the Front Line David Nott, Picador 2019 The Last Sanctuary in Aleppo, Alaa Aljaleel with Diana Darke, Headline 2019 The Pianist of Yarmouk Aeham Ahmad, Michael Joseph 2019 Under the Wire: Marie Colvin, Storyville BBC4 2018 A Dangerous Dynasty: House of Assad, BBC2 2018 Judith Harvey judithharvey12@gmail.com
By Judith Harvey @judithharvey12
doctors under siege
For Sama is a film that brings tears to the eyes.
"What turned a mild-mannered ophthalmologist into a monster?"
This is an updated guideline from NICE on managing hypertension in pregnancy. It was first published in 2010 and has been updated in June 19. I will do a summary of the bits of the guideline that are relevant to us, but the following are some of the key changes: Choice of medications. This has been tightened up. Now they advice labetolol first line, nifedipine second line and methyldopa third line. Target BP level. This has been lowered. For both chronic and gestational hypertension, the target BP is now 135/85. Risk of recurrence. There is a 1 in 5 chance of recurrence in future pregnancies. Future risks. There is a small increased risk of cardiovascular disease in later life in people who have had hypertensive problems in pregnancy. Aspirin should be used from 12/40 until birth at a dose of 75 - 150mg (there is no clear evidence about the best dose). This is unlicensed. This isn't new advice, but I thought it worth highlighting as often we may need to initiate it. Women need it who have chronic hypertension or have risk factors for pre-eclampsia as advised below. Patients who had pre-eclampsia should have their urine dipped at 6-8/52. If they still have 1+ or more of protein, they need a further review at 3m. Definitions Chronic hypertension. This is pre-existing hypertension that was present at the time of booking, or where it presents before 20/40. Gestational hypertension. This is new hypertension without proteinuria that presents after 20/40. Pre-eclampsia. This is new hypertension of over 140/90 that presents after 20/40 with at least 1 of: Significant proteinuria (PCR > 30 mg/mmol , ACR > 8 mg/mmol or 2+ on dipstix). Maternal organ insufficiency (eg renal dysfunction, liver involvement, neurological complications or haematological complications). Uteroplacental dysfunction (eg IUGR, stillbirth or abnormal dopplers). How should we test for proteinuria? If dipstix 1+ or more, then do PCR or ACR. Don't use a first void of the morning. PCR. Use a cut off of 30 mg/mmol or over to determine significant proteinuria. ACR. Use a cut off of 8 mg/mmol or over to determine significant proteinuria. Obviously interpret the results in the clinical context. If pre-eclampsia is still suspected, then repeat the test and review the patient. How should we manage women at risk of pre-eclampsia? Advise women of the symptoms of pre-eclampsia. Antiplatelet treatment Some women at risk will need to take aspirin at 75 - 150mg a day from 12/40 until birth. This is unlicensed and informed consent must be sought. High risk patients should take aspirin if they have 1 of the following risk factors: Hypertension in a previous pregnancy. CKD. Autoimmune disease (eg SLE or antiphospholipid syndrome). Diabetes (type 1 or 2). Chronic hypertension. Moderate risk patients should take aspirin if they have 2 or more of the following risk factors: First pregnancy. Age over 40. Pregnancy interval > 10 yrs. BMI > 35 at first visit. Family history of pre-eclampsia. Multiple pregnancy. How should we manage women with chronic (pre-existing) hypertension? Pre-pregnancy advice. Offer referral to a specialist clinic if planning a pregnancy. What medications should we use in women planning a pregnancy? ACEi / ARB (angiotension receptor blockers). There is an increased risk of congenital malformations. Consider alternatives if women are planning a pregnancy. If they become pregnant, they should be stopped within 2d and an alternative started. Chlorothiazides. There may be an increased risk of congenital malformations and neonatal complications. Consider alternative if planning a pregnancy. Other medications. No evidence of harm during pregnancy. You would obviously want to double check this in the BNF for the patient in front of you. What medications should be used to treat chronic hypertension in pregnancy? First line - labetolol. Second line - nifedipine. Third line - methyldopa. Medication should be started if there is a sustained rise in BP to 140/90 or more. Target BP is 135/85 (this is lower than previous targets as new evidence suggests better outcomes with lower target BPs). Continue medications unless there is a sustained drop in BP to less than 110/70 or there is symptomatic hypotension. How often should patients be monitored? Anywhere between 1 - 4 weeks, depending on the severity. Should antiplatelets be used? Offer aspirin at 75 - 150mg OD from 12/40 to birth. This is unlicensed. PIGF (Placental growth factor) testing. Offer PIGF testing once from 20 - 35/40 to rule out pre-eclampsia if it is suspected. How do we manage women post-natally? Target BP - 140/90. Monitor on day 1 and day 2 then at least 3-5d after birth, then as indicated. Methyldopa. If using this antenatally, then stop it within 2d and start an alternative. If breast-feeding, ensure the safety of any medications used (see below). The baby should be checked daily for 2d. Review at 2/52 and 6/52 with the GP or specialist. How should we manage patients with gestational hypertension? Firstly, patients should be fully assessed in secondary care, so hopefully we will have a good care plan to work from if we need to get involved in management here. How do we manage ladies with moderate gestational hypertension (BP 140/90 - 159/109)? Treat patients if they have a sustained BP over 140/90. Aim for a target BP of 135/85. Measure BP once or twice a week until this target is reached. Dipstix urine once or twice a week. Measure FBC, LFT and UE at presentation then weekly. Carry out PIGF testing on one occasion between 20 and 35/40 if pre-eclampsia is suspected. Use the NICE guideline on PIGF testing when deciding when to measure it. You can read my blog post on PIGF testing for a quick reminder. The fetal heart should be auscultated at each visit. USS should be done at presentation and then every 2-4/52 thereafter if clinically indicated. Birth shouldn't be planned before 37/40 unless there are other indications to do so. How should patients with severe gestational hypertension (BP 160/110 or more) be managed? Women should be admitted until their BP falls back to the moderate level. Otherwise management is the same as it would be for women with moderate gestational hypertension. The only difference is that USS should be done every 2/52 as long as severe hypertension persists. What medications should be used in gestational hypertension? The same as for chronic hypertension (labetolol first line, then nifedipine, then methyldopa. How do we manage women with gestational hypertension post-delivery? If no treatment has been needed so far, only start treatment if the BP is 150/100 or more. Measure the BP daily for 2d, then once between 3-5d then as indicated. If methyldopa has been used, it should be stopped within 2d of delivery. If BP < 130/80, then reduce the medication. Patients should be reviewed 2/52 after delivery then at the 6/52 check. Advise women that the duration of post-natal treatment is likely to be equal to that of the duration of their antenatal treatment. How should patients with pre-eclampsia be managed? Patients will be managed in secondary care, so I'm not going to go into too much detail here. I'll just cover the bits that are most relevant to us. Among other fairly obvious warning signs, there are certain blood markers that would give rise to concern in a patient with pre-eclampsia. These include new and persistent changes in: Creatinine - rise of 90 micromol/L or 1mg/100ml or more. ALT - a rise to over 70 IU/L, or twice the upper limit of normal. Platelets - a fall in platelets to under 150,000/microlitre. How should patients with pre-eclampsia be managed postnatally? If methyldopa has been used, it should be stopped within 2d. Patients can be transferred to the community if their BP is less than 150/100, there are no symptoms of pre-eclampsia and their bloods are either stable or improving. If they didn't take medication during pregnancy, then their BP should be checked at 3-5d postnatally, then every 2d for 2/52. They should be asked about headaches and epigastric pain at every visit. Medication should be started if their BP is > 150/100. If they did take medication during pregnancy, then their BP should be measured every 1-2d until they are off medications and their BP is normal. Consider reducing medications once their BP is < 140/90. Do reduce their medications if their BP is < 130/80. Bloods should be done at 48-72 hrs post delivery or step down from critical care. Once they are normal, don't remeasure them. Repeat them at 'clinically indicated' intervals. Proteinuria. Dipstix at 6-8/52. If they still have 1+ protein or more, then offer further review with a GP or specialist at 3m to recheck renal function. At that point, consider referring as you would any other patient with chronic kidney disease. What advice should we give women regarding medications and breast-feeding? Explain that the drugs used can pass into milk, but that they are only present in small amounts and they are unlikely to have any effect on the baby. Consider monitoring the baby's BP for the first few weeks, especially if they were born premature. Watch out for signs of hypotension in the baby (drowsiness, lethargy, pallor, cold peripheries or poor feeding). What drugs should be used? Offer enalapril first line. If the patient is of Black African or Caribbean descent, then consider either nifedipine or amlodipine first line. Generally amlodipine would be used if it has been used successfully in the past. If 2 medications are needed then: Enalapril + Nifedipine or amlodipine If this combination is not tolerated then: Add atenolol or labetolol or Swap one of the medications already used for one of the above. Where possible avoid angiotensin receptor blockers and diuretics whilst breast-feeding. What advice should be given to patients who have had hypertension in pregnancy? The pre-eclampsia recurrence risk rises if the pregnancy interval is over 10 yrs. If there has been pre-eclampsia, then keeping your BMI between 18.5 and 24.9 lowers the risk of recurrence. Renal risks. If the patient had pre-eclampsia and at 6/52 follow up they have normal BP and no proteinuria, then they have a raised relative risk of end stage renal failure. However, the absolute risk is low, so the patient needs no specific follow-up. If the patient delivered before 34/40, then consider pre-pregnancy counselling to discuss their risk factors and how to lower them. Louise Hudman louisehudman@gmail.com
By Louise Hudman
Louise runs through a summary of the latest NICE guidelines published this summer
Hypertension in pregnancy
"Patients under 60 with a 10 yr CV risk of < 10% may well actually have a higher lifetime CV risk. You should consider treatment in these patients."
www.nasgp.org.uk
Promises, promises
This magazine is supported by an educational grant from the Medical Protection Society.