High-risk pregnancies in obstetrics today

Managing high-risk pregnancies in obstetrics today

By Dr Harini Narayan

Every year, across the world 287,000 women die in pregnancy and childbirth along with at least 2.6 million stillbirths, of which about 50% are intrapartum deaths. Among 133 million babies born alive each year, 2.8 million die in the first week of life. The latest MBRRACE reports of the UK show a maternal mortality rate of 10 per 100,000 women giving birth (December 2014) and an extended perinatal mortality rate of 6.0 per 1,000 total births, comprising 4.2 stillbirths per 1,000 total births and 1.8 neonatal deaths per 1,000 live births (June 2015).

While there have been significant clinical and technical advances in the care of high-risk pregnancies in the last few decades in economically advantaged countries, the complexity of patients has also changed quite dramatically. The challenges are numerous and varied with rising rates of obesity, diabetes, a host of co-morbidities, older mothers, immigration patterns, and social deprivation. Increasing numbers of women who were once unable to become pregnant or were advised not to due to underlying health problems are now able to have children. High-risk pregnancies form a significant and increasing proportion of any pregnant population. Improved outcomes also mean that patient expectations are at an all-time high.

Several generations of Confidential Enquiries into Maternal and Perinatal Mortality in the UK have focused on improvements needed in intrapartum care. The most recent MBRRACE report (2014) has, for the first time, highlighted the vital role of high standard pre-conceptual and antenatal care for women with underlying co-morbidities. Three quarters of all women who died had coexisting medical complications. Pre-existing medical or mental health problems were the main contributors to both direct and indirect causes of maternal death. Timely recognition and diagnosis of a high-risk condition complicating pregnancy, the involvement of appropriate senior staff from multiple disciplines, and prompt treatment or action can make the difference between life and death.

Most high-risk pregnancies belong to one or more of three categories:

1. Where there is a pre-existent medical/mental condition that could have a serious impact on the maternal/fetal outcome of any pregnancy and where specific management plans with multi-speciality input are essential.
2. Where the pregnancy itself could cause worsening of a pre-existent medical/mental disorder which had hitherto remained stable or in remission.
3. Where complications experienced during a previous pregnancy/ies are likely to recur or those that develop de novo in the present pregnancy could adversely affect maternal/fetal outcomes.

There is often much misunderstanding about the label “high-risk pregnancy” amongst health care professionals as well as in pregnant women and their families. It can result in patient anxiety to unwarranted, unnecessary, and sometimes potentially risky interventions undertaken without valid obstetric indications. It often leads to community midwives disengaging almost entirely from the ongoing routine antenatal care with the mistaken impression that their own input is unnecessary. This denies the normality that exists even in the most complex of pregnancies.

F.W. Peabody, a US physician (1881-1927), stated “The treatment of a disease may be entirely impersonal; the care of a patient must be entirely personal.” The corollary is equally true. Once deemed ‘high risk,’ there is often unnecessary duplication of appointments, sometimes within the same week or even the same day between the hospital antenatal clinics and primary care, creating significant disruption and inconvenience for patients. A lack of coordinated and integrated care planning in a patchy service wastes valuable resources. All maternity units are working under serious financial and manpower constraints in an increasingly litigious environment. There is more pressure than ever on the NHS to ensure every penny is spent in the most effective way for patients to improve standards of care while reducing costs. Every antenatal appointment needs a valid purpose, every investigation must be clinically justifiable, and every intervention must be medically indicated.

Challenging the status quo is bound to be difficult. The day-to day reality is that in most maternity units the antenatal care for women with high-risk pregnancy is of variable quality, often laced with conflicting advice. Trainees often find themselves in the dilemma of managing such patients depending on the consultant’s antenatal clinic in which they work. Individualized care pathways grounded in best practice, national guidelines, and centred on the woman with a specific high-risk condition are uncommon. Such care pathways should be designed to enable integrated and seamless care across primary, secondary, and, if indicated, in tertiary settings. Transforming structural and organisational norms is at the core of delivering a truly patient-centred service that starts from pre-pregnancy and continues to post-childbirth.

The crucial role of pre-pregnancy assessment and counselling services for women with pre-existing high-risk conditions is one that is often overlooked by commissioners and providers, quite apart from the woman herself. Does the obstetrician’s role end when the patient is discharged from the hospital? What about ‘after-sales customer care’? Does this extend to discussions about the most appropriate contraception suitable to her underlying medical condition? What about further multidisciplinary disease management and optimisation of health before the next pregnancy ‘just happens’? 

An informed patient who actively participates in the management of her pregnancy is one to be cherished. The keystone for this lies in providing clear and comprehensive information, thus starting the process of shared decision-making throughout pregnancy.

Dr. Harini Narayan has worked in the NHS for more than three decades, 21 years of which have been as Consultant Obstetrician and Gynaecologist and Lead Obstetrician. She is Lead Obstetrician at the Great Western Hospitals Foundation Trust in Swindon, UK (1997-to date), heading maternal medicine, high risk obstetrics and clinical risk management. She is also a preceptor/supervisor for the RCOG ATSMs in Maternal Medicine, Advanced antenatal and labour ward practice and Honorary Consultant in Feto-Maternal Medicine in Oxford. She is the author of Compendium for the Antenatal Care of High-Risk Pregnancies.