L13 Pregnancy Disorders and Obstetric Physicians

Question 1

How have women’s birth rates changed over the 2000’s?

Answer 1

• Continuous decline in almost all age groups except 35 -39 and 40 - 44
• Teenage pregnancy decreasing to very low levels
• 35 - 39 showing steady increase

Question 2

How has the prevalence of obesity changed in the UK population since 2000?

Answer 2

• Morbid obesity increasing prevalence (2.5% to 3.5% in women between 2000 and 2010)
• Overweight especially increasing
• More common in older age ranges

Question 3

How has the induction of ART added complexity to the maternal population?

Answer 3

• Facilitating higher volume of complex cases who would not be able to conceive naturally
• e.g. As the years go on, the proportion of older women pursuing IVF is increasing (20% of cycles in women over 40 in 2019)
• e.g. Used of donor eggs has had a marked impact -> women aged 45 - 50 are 10x more likely to conceive by using donor eggs (measured in birth rate per embryo transferred)

Question 4

What is the Ivacaftor drug? Effect on obstetrics:

Answer 4

• Allows CF patients to reproduce
• An example of medical advancements that are facilitating more complex maternity cases

Question 5

What was the purpose of the Ockenden report and what were its main findings?

Answer 5

• Investigating poor outcomes in Shrewsbury and Telford trust
• Found many cases of avoidable death
• Trust were not adequately investigating these cases, nor were they learning from them to address future care
• Amounted to ~200 deaths as well as ~100 permanent injuries to children

Question 6

What is the purpose of MBRRACE?

Answer 6

• Mothers and babies: Reducing risk through audits and confidential enquiries across the UK
• Annually investigating maternal deaths (split into fetal and maternal)
• Focusses on specific themes with each issue

Question 7

MBRRACE Theme: Multimorbidity (findings)

Answer 7

• Patchy multidisciplinary input with lots of gaps between services (lack of communication, often geographically disparate)
• Leading to teams feeling overwhelmed and patients finding it hard to engage with their care
• Highlights a need for physician’s comfortable handling multimorbidity
• Also highlights a need for obstetric guidelines around multibmorbidity
• Care should be coordinated and preplanned for these complex cases (including antenatal monitoring, labour, delivery and postnatal care)
• KEY: ‘Treat pregnant, recently pregnant, and breastfeeding women the same as a non-pregnant person unless there is a very clear reason not to do so’

Question 8

Top 6 causes of maternal death in UK 2020-22:

Answer 8

• Thrombosis/VTE
• Covid-19
• Cardiac disease
• Psychiatric
• Neurological
• Sepsis

Question 9

Types of maternal death:

Answer 9

• Direct: death due to disorder of pregnancy e.g. ectopic pregnancy
• Indirect: Pre-existing condition or disease developed during pregnancy that is not due to obstetric cause by aggravated by pregnancy e.g. epilepsy
• Coincidental/incidental/accidental: No link to pregnancy
• Late: between 42 days and 12 months after pregnancy

Question 10

Trends in maternal mortality: 2010 to 2021

Answer 10

• General decrease (both direct and indirect causes) up to ~2015
• Starting to increase again overall from ~2017
• Covid has accelerated indirect causes

Question 11

Between 2019 and 2021, the MBRRACE looked at quality of care surrounding maternal death; what proportion was good vs insufficient?

Answer 11

• 14% Good care
• 35% Improvements needed to care but would not have rescued outcomes
• 52% Improvements needed to care which would have made a difference to the outcome

Question 12

What types of neurological causes resulted in maternal death (MBRRACE report)?

Answer 12

• 42 women died 2020-22
• Mostly epilepsy
• Some stroke, some subarachnoid haemorrhage, some intracerebral bleeds and some ischaemic stroke

Question 13

Complications to epilepsy in pregnancy:

Answer 13

• Sudden unexpected death in epilepsy becomes more common in pregnancy
• Monitoring is crucial due to the effect of pregnancy on dosing of epilepsy drugs (need to make sure high enough levels are being sustained and adjust accordingly)

Question 14

What are maternal medicine networks and what are they for?

Answer 14

• Nationally mandated and regionally commissioned networks
• Aiming to improve maternal outcomes, particularly in cases with significant medical conditions
• Covering pre-pregnancy, antenatal and postnatal care for both acute and chronic conditions
• Key: Equity and services for all
• Note that an obstetric physician must be part of the MMN

Question 15

How are cases classified by MMNs?

Answer 15

• A: Somewhat complex but not referred (e.g. epilepsy); lack of clinical concern with sufficient local expertise or low severity disease
• B: Intermediate; care will be shared with MMC and local unit (e.g. routine scans done locally)
• C: Most complex cases where local care would be insufficient

Question 16

What is a big long-term worry about establishing centralised expertise via MMCs?

Answer 16

• Risk of deskilling other areas
• Local units losing capability to deal with complex cases