7 High risk pregnancy

Abstract

Summary An increasing number of women with significant medical disease are presenting to obstetricians for antenatal care. These pregnancies are recognized to be a major problem in obstetric practice, and the Confidential Enquiries into Maternal Deaths in the UK 1988–1990 ( HMSO, 1994 ) suggests that substandard care is provided in a high proportion of such pregnancies. The impact of pregnancy on pre-existing disease may be underestimated, and the relevant pathophysiology may be poorly understood. A multi-disciplinary approach to high risk pregnancy is strongly recommended. Our maternity unit has developed a system for identifying women with anaesthetic or medical risk factors at an early stage of pregnancy. The obstetric anaesthetist is then able to co-ordinate management with the obstetrician and relevant clinicians from other specialties. It is beyond the scope of this chapter to provide a comprehensive review of the management of all medical diseases in pregnancy. The topics discussed represent those most frequently presenting, and those in which management is controversial. The most commonly occurring high risk problems are obesity, asthma and diabetes. The management of diabetes in pregnancy has been well reviewed in recent literature ( Sibai, 1991 ; de Swiet, 1992 ; Ward and Douglas, 1993 ) and is not discussed in this chapter. Obesity is frequently not recognized as a risk factor in pregnancy, but was an associated factor in at least 12 reported deaths in the most recent Confidential Enquiries into Maternal Deaths in the UK ( HMSO, 1994 ). This chapter reviews the implications of obesity, asthma and cardiac disease in pregnancy. The management of musculoskeletal and neurological disorders in pregnancy are also discussed. It is hoped that an increased awareness of the impact of pre-existing medical disease on pregnancy will lead to a higher standard of antenatal and intrapartum care for these women.