The role of obstetric medicine in holistic care.

Abstract

Comprehensive care of the pregnant woman involves a number of health professionals with a significant input from the woman and her family. The family physician, midwife and/or obstetrician may provide antenatal care through a variety of settings from hospital-based outpatient clinics or private surgeries to community centres or even the home. When pregnancy is complicated by a medical condition, either de novo or pre-existing, the number of interested parties may multiply exponentially. Who should be providing this additional care remains controversial. The history of obstetric medicine as practiced by physicians or internists is relatively brief. Many physicians are forced to care for pregnant patients as an extension of their care of adults, but without any specific training or expertise. Often this is accompanied by a high level of anxiety as the physician may be inexperienced in, or not familiar with, aspects of normal pregnancy, let alone abnormal pregnancy. In the case of pre-existing conditions, how is the underlying disease going to influence the pregnancy; is the current therapy suitable in pregnancy; and how is the pregnancy likely to effect the maternal condition? What about delivery, breastfeeding, the effects of poor sleep and postnatal mood disturbance? From this dilemma has evolved the role of the obstetric physician, a subspecialty dedicated to the prepregnancy, antenatal and postnatal care of women with medical disorders of pregnancy. Not surprisingly, as a new subspecialty evolves there may be new borders to be established. In the past, the obstetrician-gynaecologist was responsible for all aspects of obstetric care from diagnosing and managing infertility to resuscitating the neonate after a difficult delivery for shoulder dystocia. With improving knowledge and technology a number of subspecialties have evolved, including assisted conception, fetomaternal medicine, fetal surgery and perinatology. In many units, high-risk midwives play an active role in the monitoring, counselling and management of pregnant women with medical disorders. In addition, the general anaesthetist has been replaced by the obstetric anaesthetist, the intensivist and the neonatal anaesthetist. Each of these subspecialists may form part of a multidisciplinary team caring for a woman with a medical complication in pregnancy. So, to whom does obstetric medicine belong? The correct answer must be whoever has the expertise, experience and ability to work in a multidisciplinary team to provide the most appropriate care for that particular woman. This may involve a number of health professionals, the only prerequisite being that a model of care is established taking into account local resources and abilities. What is clear is that optimal care requires a continual updating of knowledge and skills. As we are all aware, it is very difficult to keep up to date in all fields of medicine. Given its complexities, we need to acknowledge the potential contribution of all of the specialists with an interest in the medical disorders of pregnancy. There is no place for ego or isolationism when caring for this special population of patients, and every reason to cooperate and learn from each other. In Obstetric Medicine: the Medicine of Pregnancy, we hope to stimulate and satisfy the interests of all those clinicians working with women with medical complications of pregnancy. In this issue we review the fascinating and unique physiology of calcium in pregnancy and lactation, highlighting the important role of parathyroid hormone-related protein (PTHrP) in this complex system. In contrast, mitral valve disease is an old disease revisited in the context of current practice. We examine two very different aspects of liver disease in pregnancy. Individual case reports remain an important mechanism for highlighting the diversity and difficulties of practice in the area of obstetric medicine, and the importance of multidisciplinary input and advice. We look forward to original contributions from all those committed to improving the care of women with medical disorders in pregnancy.