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The WHO definition of obesity is an abnormal or excessive accumulation of body fat that may impair health. The outstanding cause of weight gain in exogenous obesity is excessive calorie intake coupled with lack of exercise. Useful measuring instruments include:

• body mass index (BMI): ‘healthy’ range is between 20 and 25 (BMI = weight (kg) ÷ height (m²))

• abdominal fatness—defined as a waist:hip circumference ratio (W/H ratio) of >0.85 in women and >0.95 in men—which is a better predictor of cardiovascular risk and other complications of obesity than BMI

• waist circumference: risk of comorbidity ♂ >94 cm; ♀ >80 cm

• single skin-fold thickness (>25 mm suggests increased body fat)

Management principles

1. Reduction in energy intake

2. Change in diet composition

3. Increased physical activity, (e.g. walking 30 min/d or 10 000 steps/d (use pedometer))

4. Behavioural therapy

Rules

• Need a close supportive relationship.

• Promote realistic goals—lose weight slowly.

• Follow a low-fat, high-fibre, reduced calorie intake diet.

• Allow normal foods with reduced quantity and frequency (e.g. eat ⅓ less than usual).

• Supportive counselling (never judgmental).

• Provide a list of ‘tips’ for coping.

• Advise keep a food, exercise and behaviour diary.

• Strict follow-up (e.g. fortnightly, then monthly) until goal weight achieved, then 3 mthly reviews.

Pharmacotherapy (adjunct therapy)

Adverse effects can be problematic. Consider for those with BMI >30 and failed well-supervised lifestyle measures.

The agents are:

• local, acting on GIT:

  • bulking agents (e.g. methylcellulose)

  • lipase inhibitors—orlistat (Xenical) 120 mg (o) tds ac (used with a low-fat eating program)

• centrally acting agents:

  • amphetamine derivatives (reduce hunger)

  • phentermine 15–40 mg (o)/d (limited use)

• serotonin analogues (enhances satiety)

  • fluoxetine 20–40 mg (o)/d

  • sibutramine 10–15 mg (o)/d (monitor BP)

  • sertraline 50–100 mg (o)/d

Bariatric surgery

Consider surgical intervention (e.g. Lap Band, sleeve gastrectomy and Roux-en-Y bypass)—perhaps the most effective treatment for obesity. It is recommended in those with a BMI >40 or >35 with severe comorbidities, especially diabetes.

• Psychological intervention, esp. cognitive behaviour therapy

• Refer for group therapy

• Any SSRI antidepressant (e.g. fluoxetine 20 mg (o)/d) is first-line pharmacological treatment

• Second line: clomipramine 50–75 mg (o) nocte, increasing every 2–3 d to 100–250 mg orally (o) nocte

Basic antenatal care

Antenatal care presents preventive medicine opportunities par excellence and is the ideal time to develop an optimal therapeutic relationship with the expectant mother.

Preconceptual care

• General nutritional or lifestyle advice

• Discourage smoking, alcohol, drugs (note: fetal alcohol syndrome is a leading cause of mental retardation)

• Check rubella immune status

• Consider genetic issues—family and personal issues

• Folic acid—about 3 mths prior to conception 0.5 mg (o)/d, those at risk of neural tube defect 5 mg (o)/d; continue in first 3 mths of pregnancy

The initial visit

• Careful history, physical examination

• Establish date of confinement

• Investigations (Table O2)

Visits during pregnancy

Average is 12 but some recommend as few as 6 or 8.

• Initial in first trimester: 8–10 wks

• Up to 28 wks: every 4–6 wks

• Up to 36 wks: every 2 wks

• 36 wks–delivery: wkly

For each visit record:

• weight gain

• blood pressure

• urinalysis (protein and sugar)

• uterine size/fundal height

• fetal heart (usually audible with stethoscope at 25 wks and definitely by 28 wks)

• fetal movements (if present) patients to record date of first

• presentation and position of fetus (third trimester)

• presence of any oedema

The first trimester maternal serum screening test (MSST)

(to identify risk for Down syndrome and other fetal abnormalities)

• serology tests (9–13 wks, 11 is ideal)

  • free β-HCG

  • PAPP-A

• nuchal translucency ultrasound (12–13 wks)

A new test, the free fetal DNA test (for chromosomal and genetic abnormalities), done on a maternal blood sample at about 10–12 wks, is now available but expensive.

The second trimester MSST

This is a blood test done at 15–16 wks: it is a triple or quadruple test. It is less useful for chromosomal abnormalities but the 2 fetoprotein assessment defines the risk of a neural tube defect.

Management of specific issues

Pregnancy sickness

• Invariably disappears by end of first trimester

• Explanation and reassurance

• Simple measures:

  • small frequent meals including ginger daily

  • fizzy soft drinks, esp. ginger drinks

  • ensure adequate hydration inc. sucking ice chips

  • avoid stimuli such as cooking smells

  • avoid oral iron

  • be careful cleaning teeth

Medication (for severe cases): pyridoxine 25–50 mg bd or tds

If still ineffective add: metoclopramide 10 mg tds

Cramps

• Place pillow at foot of bed to dorsiflex feet. Exercises.

Varicose veins

Wear supportive pantyhose (not elastic bandages). Keep to ideal weight.

Mineral supplements in pregnancy

Iron is not routinely recommended for pregnant women who are healthy, following an optimal diet and have a normal blood test. Those at risk (e.g. with poor nutrition) will require supplementation—at least 150 mcg. Aim to keep vitamin D levels >70 nmol/L. Increase iodine intake, e.g. iodised salt.

Pregnancy–induced hypotension

Due to increased peripheral circulation and venous pooling. Advise avoiding standing suddenly and hot baths. This may cause syncope. Fainting may occur with lying on back in latter half of pregnancy (supine hypotension), so encourage to lie on left side.

Pregnancy–induced hypertension

Commonly used medications:

• Beta–blockers, e.g. labetalol, oxprenolol and atenolol (used under close supervision and after 20 wks gestation)

• Methyldopa: good for sustained BP control

Diuretics and ACE inhibitors contraindicated.

Physiological breathlessness of pregnancy

Consider with unexplained dyspnoea which is constant and aggravated by exercise, in 2nd trimester. No special treatment is needed or helpful.

Acute cystitis

• Cephalexin 250 mg (o) 6 hrly for 10–14 d or

• Amoxycillin clavulanate (250/125 mg) (o) 8 hrly

Transmissible infections in pregnancy

Rubella

In utero infection causes fetal clinical disorders up to 19 wks. Screening for rubella IgG positivity. If –ve, at risk.

Diagnosis: 4-fold rise in IgG or +ve IgM (recent infection)

Vaccination: routine vaccination → 95% protection. Do not vaccinate during pregnancy. If inadvertent vacc'n in early pregnancy—negligible risk to fetus. Offer vacc'n to IgG –ve women in puerperium.

Varicella (chickenpox)

Greatest risk to fetus is <20 wks gestation and very late pregnancy.

Diagnosis: +ve IgG antibody test

Contacts: if –ve IgG give varicella zoster immunoglobulin (VZ-Ig) within 3–4 d.

• Maternal infection (early pregnancy): give course of antiviral, (e.g. valaci-clovir) esp. <20 wks.

• Maternal infection (late pregnancy): greatest risk is 5 days before and up to 4 wks after delivery—30% fetal mortality if infected.

• Consider VZ-Ig for baby if <7d before and up to 4 wks after delivery.

• Isolate mother from baby until not contagious.

Parvovirus B-19

Non-immune are at risk. Miscarriage rate is 4% <20 wks.

Fetal parvovirus syndrome is anaemia—hydrops fetalis and possible death.

If infection during pregnancy (IgM +ve) refer for fetal monitoring by US.

If hydrops consider early blood transfusion.

Cytomegalovirus

CMV is the most common viral cause of birth defects. 1% infection usu. asymptomatic. The fetal effects are variable—mild to severe (up to 30% have mental retardation). There is no therapy or preventive strategy. Consider referral and amniocentesis if fetal infection likely or suspected.

Hepatitis B

For infected mother vertical transmission during labour is the concern, esp. if HBeAg +ve. Infected infants have a 90% risk of becoming carriers with liver disease.

At delivery or ASAP give newborn babies of carrier mothers both Hepatitis B vaccine and immunoglobulin (HBV Ig). This gives ∼90–95% efficacy.

Hepatitis C

Screen those at risk at first antenatal visit. If +ve transmission rate to fetus is 5% and much higher if maternal infection during pregnancy. Breastfeeding transmission is unclear. Screen infants at risk at 12 mths and treat +ve cases under specialist care.

HIV

The infection rate from an HIV mother is ∼15–25%. If screening detects HIV and both mother and newborn infant require antiretroviral therapy, refer early. Risk of transmission is reduced by treatment for mother antenatally and during labour and to the neonate for first 6 mths, by elective CS and avoiding breastfeeding.

Genital herpes

Both 1° genital herpes (in particular) and recurrent herpes pose a major risk to the neonate. The risk from 1° infection is greatest >28 wks. Main problem is vertical transmission during labour.

Management

• Perform cervical swabs for HSV infection in patients with previous infection and those with apparent infection in pregnancy.

• Consider prophylactice antiviral, e.g. aciclovir, for mother from 38 wks until delivery—to try to prevent recurrent herpes in late pregnancy.

• Arrange caesarean section if:

  • active lesions present (cervix/vulva) at time of delivery or within preceding 4 d

  • membranes ruptured <4 h

• If vaginal delivery, give aciclovir to the neonate (check with neonatal paediatrician).

Genital warts

Although high community carriage rate of HPV, risk of transmission to fetus is very low and no intervention required.

Syphilis

If infected, usu. transmitted in 2nd trimester—may cause fetal death or congenital infection with mental handicap. Treat mother with IM benzathine penicillin.

Chlamydia/gonorrhoea

The concern is neonatal conjunctivitis and chlamydia neonatal pneumonia (usu. 2–3 mths). PCR testing of maternal urine as appropriate and eye swabs from the neonate are advisable with appropriate treatment as necessary.

Postnatal care

After pains

These are lower abdominal cramps in 1st 2 wks esp. with breastfeeding. Suspect endometritis if offensive lochia, fever and poor involution of uterus. If not, give paracetamol 1 g 4 hrly prn.

Oral contraception

Delay to after 21 d.

• The mini pill (progestogen only)

  • norethisterone 350 mcg/d or

  • levonorgestrel 30 mcg/d taken every night

• Transfer to combined OC when breastfeeding completed. Oestrogens can potentially suppress lactation.

(IUCD: if used, fit ≥6 wks)

Lactation amenorrhoea method (LAM)

LAM is an effective contraception method in the first 6 mths but only in the presence of amenorrhoea. If concerned about pregnancy use an additional method (e.g. condoms).

Insufficient milk supply

Due mainly to lactation mismanagement such as poorly timed feeds, infrequent feeds and poor attachment. The milk ejection reflex is essential to establish supply—affected by pain, stress, shyness, lack of confidence.

Important factors are positioning and attachment to breast and getting the baby to feed often (according to supply and demand).

Engorged breasts

Regular feeding and demand feeding is the best treatment.

Advice to mother

• Feed your baby on demand from day 1 until baby has had enough.

• Finish the first breast completely; maybe use one side per feed rather than some from each breast. Offer the second breast if the baby appears hungry.

• Soften the breasts before feeds or express with a warm washer or shower, which will help to get the milk flowing.

• Avoid giving the baby other fluids.

• Express a little milk before putting the baby to your breast (a must if the baby has trouble latching on) and express a little after feeding from the other side if it is too uncomfortable.

• Massage any breast lumps gently towards the nipple while feeding.

• Apply cold packs after feeding or cool washed cabbage leaves (left in the refrigerator/between feeds).

• Use a good, comfortable brassiere. Remove your bra completely before feeding.

• Take paracetamol or ibuprofen regularly for severe discomfort.

Lactation suppression

• Avoid nipple stimulation.

• Refrain from expressing milk.

• Use well-fitting brassiere.

• Use cold packs and analgesics.

Engorgement settles over 2–3 wks.

Hormonal suppression (for severe engorgement)

• Cabergoline (Dostinex) 1 mg (o) single dose day 1 post partum

• Avoid oestrogens

Nipples: cracked

• Get baby to latch onto breast fully and properly.

• Do not feed from the affected breast—rest the nipple for 1–2 feeds.

• Express the milk from that breast by hand.

• Start feeding gradually with short feeds.

• Take paracetamol 1 g just before feeding to relieve the pain.

• Avoid drying agents such as spirits, creams and ointments.

Nipples: sore

• Use a relaxed feeding technique.

• Try to use the ‘chest to chest, chin on breast’ feeding position.

• Start feeding from the less painful side first if one nipple is very sore.

• Express some milk first to soften and ‘lubricate’ the nipple.

• Never pull the baby off the nipple: gently break the suction with your finger.

• Apply covered ice to the nipple to relieve pain.

• Keep the nipples dry (exposure to air or to hair dryer).

• Do not wear a bra at night.

• If wearing a bra by day, try Cannon breast shields.

Postnatal depressive disorders

1. Postnatal blues

• Occurs in 80% of women

• Days 3–10 (lasts 4–14 d)

• Feeling flat or depressed

• Emotional—tearfulness

• Mood swings, mainly flat

Treatment

• Support and reassurance

• Help from relatives and friends

2. Postnatal adjustment disorder

• Occurs in first 6 mths

• Similar symptoms to ‘blues’

• Anxiety with handling baby

• Psychosomatic complaints

• Fearful of criticism

Treatment

• Support and reassurance

• Cognitive therapy

• Parentcraft support

• Settles with time

3. Postnatal depression

Use the Edinburgh Postnatal Depression Scale. A score of ≥12 is significant.

• Occurs in 10–30% of women

• In first 6–12 mths (usually first 6)

• Anxiety and agitation common

• Marked mood swings

• Poor memory and concentration

• Typical depressive features

Treatment

• Support, reassurance, counselling

• Group psychotherapy

• Couple therapy

• Postnatal depression support group

• Hospitalisation may be nec.

• Medication (e.g. SSRIs (sertraline, paroxetine are agents of choice), amitriptyline, dothiepin)

  Note: Beware of puerperal psychosis with onset usually within first 4 wks. Symptoms include irrational behaviour, agitation, delusions, hallucinations, mania and suicidal ideations. Requires urgent inpatient psychiatric care. Check thyroid function.

Postpartum thyroid dysfunction

Postpartum thyroiditis may be misdiagnosed as postpartum depression and should always be considered in the tired apparently depressed woman in the first 6 mths after delivery. It must be differentiated from new onset or relapsing Graves disease indicated by antibody studies.

Hair loss

Hair shedding (telogen effluvium) is common 4–6 mths post delivery. Large clumps of hair with white bulbs come out easily with combing and shampooing. Reassure that it reverts to normal in 3–6 mths. See also Telogen effluvium.

• Shampoo daily with a ‘shampoo for oily hair’.

• Massage the scalp during the shampoo process.

• Leave the shampoo on for at least 5 mins.

• Avoid hair conditioners.

• Avoid overbrushing.

• Attend to lifestyle factors: relaxation and balanced diet are important.

A known overdose patient should be treated initially with a double dose of naloxone:

• naloxone 0.8 mg IM or SC (repeat as nec.) or

• 0.2–0.4 mg IV boluses, titrated to clinical effect

Orf is due to a pox virus and presents as a single papule or group of papules on the hands of sheep-handlers after handling lambs with contagious pustular dermatitis.

• Spontaneously remits in 3–4 wks.

• For rapid resolution inject triamcinolone or other LA steroid, diluted 50:50 in N saline.

Refers to the increased bone fragility that accompanies ageing and many illnesses. It literally means porous bone and is actually reduced bone mass per unit volume. Densitometry can predict an increased risk of osteoporosis. Osteopenia is low bone density. DEXA, which is the current gold standard, assesses bone mass density (BMD). The BMD ‘T score’ is the number of SDs away from the mean BMD of a 30-year-old adult while the ‘Z score’ is the number of SDs away from the age- and sex-matched BMD.

Treatment

The following medication may be valuable in preventing further bone loss, possibly reversing the osteoporosis process and preventing further fractures.

• HRT (not currently recommended for long-term use) or

• Bisphosphonates (decrease bone absorption)

  • alendronate 10 mg (o) daily or 70 mg (o) once weekly (take care with potential side-effect of oesophagitis)

  • etidronate 400 mg (o) daily for 14 d, then 76 d of calcium (e.g. 1.25 g CaCO₃)

  • risedronate 5 mg (o) daily or 35 mg (o) once weekly or 150 mg (o) once monthly

  • zoledronic acid, single annual IV injection or

• Raloxifene—a selective oestrogen receptor modulator 60 mg (o) daily or

• Strontium ranelate 2 g (o) as powder in water, daily or

• Teriparatide (synthetic parathyroid hormone) 2 mg SC daily

• Denosumab (a monoclonal antibody) 60 mg SC once every 6 mths once Ca intake and vitamin D levels are optimal

Anabolic agents such as nandrolone deconate may reduce further loss but the side-effects are problematic.

Recommendations for prevention—includes regular intake of calcium and vitamin D

• Adequate dietary intake of calcium:

  • 1200–1300 mg/d in both men and women

  Note: 500 mL calcium-enriched milk contains 1000 mg calcium.

• Exercise (e.g. brisk walk for 30 mins 4 times/wk).

• Lifestyle factors: stop smoking and limit alcohol and caffeine intake.

• Exposure to sunlight: face, arms and hands, (e.g. 5–15 mins/d in warm–hot climate; 25–50 mins/d in winter in temperate climate (check regional recommendations))

• Vitamin D supplementation based on s Vitamin D (keep ≥75 mmol/L)

• Adequate nutrition: keep BMI >19

• Attention to falls prevention inc. avoiding sedatives