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Antenatal

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


First Trimester 

  • Suspected or proven ectopic pregnancy 
  • Heavy bleeding/severe pain (haemodynamically unstable) +/- fever (suspicion of sepsis)
  • Threatened or incomplete miscarriage if haemodynamically unstable
  • Intractable vomiting

Post first trimester 

  • Heavy bleeding/severe pain (haemodynamically unstable) +/- fever (suspicion of sepsis)
  • Threatened or incomplete miscarriage  
  • Threatened preterm labour
  • Pre-term rupture of membranes
  • Evidence of cervical incompetence
  • Intractable vomiting
  • Hypertension equal to or greater than 140/90 mm Hg
  • Severe headaches or visual disturbances
  • Suspected pre-eclampsia presenting with  hypertension systolic blood pressure equal to or greater than 140 mmHg and/or diastolic blood pressure equal to or greater than 90 mmHg and
    • one or more of the following organ/system features related to the mother and/or fetus:
      • Renal
        • random urine protein to creatinine ratio greater than or equal to 30mg/mmol from an uncontaminated specimen (proteinuria)
        • Serum or plasma creatinine greater than or equal to 90 micromol/L or 
        • oliguria (less than 80 mL/4hours or 500 mL/24 hours)
      • Haematological
        • thrombocytopenia (platelets under 150 x 109/L)
        • haemolysis (schistocytes or red cell fragments on blood film, raised bilirubin, raised lactate dehydrogenase (LDH), decreased haptoglobin)
        • disseminated intravascular coagulation (DIC)
      • Liver
        • new onset of raised transaminases (over 40 IU/L) with or without epigastric or right upper quadrant pain
      • Neurological
        • headache
        • persistent visual disturbances (photopsia, scotomata, cortical blindness, retinal vasospasm)
        • hyperreflexia with sustained clonus
        • convulsions (eclampsia)
        • stroke
      • Pulmonary
        • pulmonary oedema
      • Uteroplacental
        • fetal growth restriction (FGR)
        • suspected fetal compromise
        • abnormal umbilical artery Doppler wave form analysis
        • stillbirth
    • If gestational age is 23-32 weeks or fetal weight is less than 1500grams then contact local service as referral for emergency treatment may be directed to a level 6 maternity service for obstetric assessment
  • Seizures or unexplained syncope
  • Acute mental health concern needing to be seen by acute mental health service or psychiatric emergency centre.  
  • Abdominal trauma – GP check with maternity booking hospital level of care required
  • Any concern regarding fetal growth requires confirmation with ultrasound (if available) and referral to maternity service as indicated.  
  • Change in fetal movement pattern
  • Suspected or confirmed fetal death in utero 
  • Any other significant concern

Gestational Diabetes Mellitus

  • Diabetic ketoacidosis 
  • Diabetes and severe vomiting
  • Acute severe hyperglycaemia
  • Acute severe hypoglycaemia

 

  • Refer to local Healthpathways or local guidelines
  • Expect the first hospital visit to be offered between 16-20 weeks unless there are issues requiring more urgent review
  • GP will be responsible for the care until review by maternity service
  • Discuss the Maternity model of care options available across Queensland, these are site specific.
  • Document woman’s preferred model of care – if known or provide information and time for woman to consider options
  • Advise earlier referral if woman requesting midwifery group practice model of care 
  • Advise if woman requesting GP Shared Care Model
    • Advise if GP prepared to participate in the GP shared care model (GP’s wanting to participate in a shared care model will need to meet local training and CPD requirements).
  • Advise antenatal, lactation and parenting education preparation and support
  • Recommend routine vaccinations for pertussis and influenza 
  • Physiotherapy – indications for referral, consider community referrals or local health pathways
    • Urinary/faecal incontinence
    • Pelvic organ prolapse
    • Significant pelvic joint pain
    • Significant back pain
    • Carpal tunnel syndrome/de Quervain’s Syndrome
    • Inpatient on prolonged bed rest referred by medical team
    • Varicosities 
  • Dietitian – indications for referral – consider community referrals or local health pathways 
    • Gestational diabetes mellitus [no additional referral once referred to diabetic clinic].
    • Hyperemesis gravidarum (in-patient only) See: Pregnancy induced vomiting and hyperemesis gravidarum
    • History of Bariatric surgery
    • Body mass index (BMI) <18
    • BMI ≥ 35 (pre-pregnancy BMI >30)
    • Excessive weight gain during pregnancy (10 kg or more at 20 weeks)
    • Young women aged < 17 years
    • Nutrient deficiencies
    • Multiple Pregnancy
    • History of eating disorders
    • History of previous or current alcohol and/or drug abuse
  • Social Work – indications for referral consider community referrals or local health pathways
    • Domestic and family violence 
    • Child Protection involvement (current and relevant past history)
    • Substance abuse / drug & alcohol issue 
    • Unwanted pregnancy (refer to Termination of Pregnancy CPC)
    • Consistent poor attendance for pregnancy care
    • Multiple social concerns (i.e. a combination of poor social supports, housing and financial issues, significant relationship concerns)
    • New serious health diagnosis for mother or baby during pregnancy
    • Anticipated significant difficulties coping with the baby

Clinician resources

 

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Antenatal care requiring review within 30 days
  • Category 2
    (appointment within 90 calendar days)
    • Antenatal care requiring review within 90 days
  • Category 3
    (appointment within 365 calendar days)
    • No category 3 [6] criteria

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention not otherwise accessible to the patient
  • For advice regarding management
  • To engage in an ongoing shared care approach between primary and secondary care
  • Reassurance for GP/second opinion
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)

2. Essential referral information Referral will be returned without this

  • Current pregnancy (*ensure early referral if risk factors identified, all referrals preferred by twelve weeks where possible)
    • Gravidity, Parity 
    • LNMP (Last normal menstrual period), 
    • EDB (Estimated Date of Birth)
    • Single or multiple pregnancy
    • Confirmation of pregnancy (positive urine or serum B-HCG)
    • BMI 
    • BP 
  • Past Obstetric history (if known) - for each previous pregnancy please provide details of outcome:
    • Date of birth, gestation, mode of birth, birth weight, place of birth
    • Any pregnancy complications e.g. GDM (Gestational Diabetes Mellitus), fetal growth restriction, pre-eclampsia, APH (antepartum haemorrhage)
    • Any birth complications e.g. PPH (Postpartum Haemorrhage), preterm birth, stillbirth, pre-existing birth trauma 
    • Previous neonatal admission to SCN/NICU and reason
    • Miscarriage
    • Ectopic pregnancy
    • Termination of pregnancy
  • Summary of relevant medical, surgical, and psychosocial history including details of any risk factors/co-morbidities (e.g. diabetes, obesity, bariatric surgery, asthma, cardiac, renal or liver disease, hypertension, eating disorders, mental health concerns etc) 
  • Current medications including psychotropic drugs such as Sodium Valproate, Lithium and other medication with recognised fetal implications
  • Indigenous status, Ethnicity and language spoken (identify if interpreter is required)
  • Drug, alcohol, and smoking history 
  • Routine antenatal bloods: FBC, blood group and antibody screen, rubella antibody screen, hepatitis B serology, hepatitis C serology, HIV serology, syphilis serology, Mid-Stream Urine for MCS

 

3. Additional referral information Useful for processing the referral

  • Method of conception (either spontaneous or assisted)
  • First trimester early OGTT (preferred) or HbA1c – if risk factors for gestational diabetes 
    • BMI > 30 kg/m2 (pre-pregnancy or on entry to care) 
    • Ethnicity (Asian, Indian subcontinent, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non-white African) 
    • Previous GDM 
    • Previous elevated Blood Glucose Level (BGL) 
    • Maternal age ≥ 40y 
    • 1st degree relative with DM or sister with GDM 
    • Previous macrosomia (birth weight > 4500 g or > 90th percentile) 
    • Previous perinatal loss
    • Polycystic Ovarian Syndrome 
    • Medications (corticosteroids, antipsychotics) 
    • Multiple pregnancy
  • Advise if new partner with this pregnancy
  • Prenatal screening and diagnostic testing for fetal chromosome and genetic conditions e.g. combined first trimester screen, NIPT, CVS, amniocentesis, genetic carrier screening
  • Ferritin
  • TSH – if > 30y or other thyroid risk factors (family history, autoimmune disease including coeliac disease, T1DM etc)
  • ELFT’s and Urine protein/creatinine ratio if indicated e.g. women with BMI >30, pre-existing hypertension, diabetes 
  • Chlamydia investigation for women ≤30y or if risk factors
  • STI screen result as indicated
  • Cervical screening reports if >25y or indicated
  • Include pathology relevant to any medical history i.e. known cardiac renal or liver disease
  • Dating, Nuchal Translucency and Morphology Ultrasound scans
  • Include imaging relevant to any medical history i.e. known cardiac, renal or liver disease

Other considerations

  • Refugee status
  • Social history including domestic violence, living situation, drug and alcohol use 
  • Identification of Gillick competence and intellectual capacity (where appropriate)
  • Recognition of sexual orientation i.e. Lesbian, Gay, and Bisexual (LGB)
  • Preferred model of care

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.