When not to travel….

This Christmas break has highlighted to what extent some people will go to fulfill the need to travel.

Examples of note

A 60-year old man leaves home with the hint of an impending UTI. Pre-emptively he started a course of antibiotics from a repeat left over from a previous successfully treated UTI. He travels across Australia gradually getting worse such that he stops for advise at a mainland country hospital. There he is given the diagnosis of pyelonephritis treated with oral antibiotics and analgesia. I am not certain what my colleague was thinking but the man continued on his way to KI. Vomiting can be expected on the ferry but not fever and vomiting along the highway even before Cape Jervois. Shortly after arriving on KI he presented to the local hospital quite unwell, febrile, tachycardic and dehydrated with marked left abdominal pain. My working diagnosis was diverticulitis and I admitted him, hoping that he would settle with IV antibiotics and not requiring a journey with the flying doctor to Adelaide.

A 50 something year old man arrives to check his warfarin dose. Two days earlier his implanted defibrillator has fired off, not once, twice but three times. Felt like a horse kicked me in the chest her explained. Oh he went to hospital and got cleared to continue travel. He was restarted on amiodarone and ask to check his INR given the interaction. The local doctor did have a conversation with his cardiologist. Good and did he think it was a good idea to continue to travel to a remote (but stunningly beautiful :- ) part of Australia? Sure he said. The look on his wife’s face suggested maybe subtly different advise.

A family of four had booked a Christmas holiday on KI to spend time with his cousins including a new born baby. A two year who developed a red rash, fever and stopped eating was not enough to deter the holiday. Thankfully a viral exanthem rather than meningitis. A few days latter the local family brought in one of the children with something similar. Thanks for the Christmas present.

I wont tell you how many times I have had to write prescriptions for people who travel with their medication still in the bathroom cupboard back at home.

No we don’t have a CT, MRI or half reasonable ultrasound machine here.

Apart from an istat, bloods and other pathology get sent to Adelaide once  day and we get the results the next day.

Oh and we drive on the left…….

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How to have a healthy pregnancy

Chappell L et al Exploration and confirmation of factors associated with uncomplicated pregnancy in nulliparous women: prospective cohort study BMJ 2013;347:f 6398

This multi-centre prospective study of was of 5628 healthy women in their first pregnancy recruited from  Australia, New Zealand, UK and Ireland.

The authors attempted to identify at 15 and 20 weeks gestation variables that were associated with a uncomplicated pregnancy, and to highlight those factors amenable to modification before pregnancy. Thus allowing interventions to be made which may increase the likelihood of a healthy pregnancy.

Firstly, 2/3 of the women had an uncomplicated pregnancy delivering after 37 weeks a healthy baby.

Beneficial factors identified were

  • pre-pregnancy fruit intake at least three times daily (relative risk of an uncomplicated pregnancy =  1.09, 5% confidence intervals 1.01 to 1.18)
  • being in paid employment at 15 weeks (per eight hours’ increase 1.02, 1.01 to 1.04)

Admitted these numbers are not massive, eating fruiting may give you an almost 10% chance of having an uncomplicated pregnancy.

Some of the potentially modifiable variables identified are already known to contribute to poor outcome on a pregnancy. These included,

  • body mass index over 30 kg/m2 (relative risk of an uncomplicated pregnancy =  0.74, 95% confidence intervals 0.65 to 0.84
  • misuse of drugs (including binge drinking) in the first trimester (0.90, 0.84 to 0.97)
  • mean diastolic blood pressure (for each 5 mm Hg increase 0.92, 0.91 to 0.94), and mean systolic blood pressure (for each 5 mm Hg increase 0.95, 0.94 to 0.96

Detrimental factors not amenable to alteration were a history of hypertension while using oral contraception, socioeconomic index, family history of any hypertensive complications in pregnancy, vaginal bleeding during pregnancy, and increasing uterine artery resistance index on morphology scan.

Smoking in pregnancy was noted to be a detrimental factor in the initial data but did not remain in their final model. Increased maternal age was not found to be detrimental factor. Despite this, these two factors have been identified in previous studies as detrimental to a pregnancy outcome.

So how does this paper change what I do?

I suspect I am not alone here but as a rural GP, I see few women who come in asking “I would like to get pregnant, how will I ensure I will have a healthy pregnancy and baby?”

Generally by the time I see someone, egg and sperm have already met and a fetus is being nurtured in the womb. However, the results of this study does allow some predictions about outcome and helps select women who I would watch more closely (check PAPP-A and uterine artery dopplers) and possibly refer on for obstetrician’s opinion.

For my pregnant patient with spotting at 8 weeks, who had high blood pressure,  smokes tobacco,  cannabis mixed with meth, drinks a carton of beer a week and live in house with a dirt floor have no flushing toilet and has never been employed, with a BMI of 40 ….. well I don’t think this study add to my thoughts that this pregnancy is going to be a disaster!