Outline the indications for referral of the high-risk pregnant woman to more specialized centres of obstetric care

What are the broad categories

1. Pre-existing medical problems and AGE

2. Prior obstetric complications

3. Medical problems that occur during pregnancy

4. Conditions that may complicate anaesthesia

5. OTHERS

1. Pre-existing medical problems and AGE

• AMA - this may mean the pt presents with diseases of later life - IHD, CVA, HTN, and T2DM etc

• CVS – congenital heart disease, arrhythmias, valvular heart disease, ischaemic heart disease, HTN

• Resp – asthma, OSA, pulmonary hypertension, restrictive lung disease

• Neuro – epilepsy, MS, muscular dystrophy, myopathies (myasthenia, myotonia)

• Endocrine – Diabetes, long-standing steroid therapy, acromegaly, addisons, phaeo

• Renal disease

• Haematological disorders – thrombocytopenia, anticoagulant therapy, haemoglobinopathies (thalassaemia, sickle cell), porphyria, history of VTE before or during pregnancy, hypercoagulability (e.g. protein C/S/AT3 deficiency) and congenital coagulopathies (e.g. von willebrand)

• Connective tissue disorders – rheumatoid, scleroderma, SLE, antiphospholipid syndrome

• Transplant recipients

• Infectious disease e.g. HIV, hepatitis

2. Prior obstetric complications

• Disorders of the plcenta

• PPH

• PET

3. Medical problems that occur during pregnancy

- GDM – poorly controlled

- More than 3 previous LUSCS

- Placenta praevia, percreta

- Hypertension / PET / eclampsia

4. Conditions that may complicate anaesthesia

Neuraxial

• Abnormalities of the spine including spina bifida occulta, previous spinal surgery, longstanding back

pain, intervertebral disc prolapse

• Thrombocytopenia

• Sepsis

• Diseases that may lead to coning

GA

• Known difficult airway

• Sux apnoea

• MH

• Previous Hx of failed intubation

• Previous head and neck and major thoraco-abdominal surgeries

• Morbid obesity – BMI >40 or BMI >45 with other comorbidities

• Previous anaesthetic complications / known difficult airway

OTHERS

• JW

• Needle phobia

• Substance abuse

• Previous bad anaesthetic experience

How should high risk pregnancies be managed?

High risk obstetric patients with severe disease should have

• multi-disciplinary management care with midwifery, obstetric, specialist medical/surgical, anaesthetic and neonatology input

• ideally pregnancy should be planned

• these patients are best cared for in specialist obstetric centres