What is the hospital policy for managing high-risk pregnancies?

Hospital Policy for High-Risk Pregnancy Management

All pregnant women with identified high-risk factors require multidisciplinary care coordination, preferably in a tertiary care center, with systematic risk assessment across the entire reproductive spectrum from preconception through postpartum. 1, 2

Definition and Risk Identification

High-risk pregnancy is defined as any pregnancy where the woman, fetus, or infant faces increased risk of death or residual injury, requiring additional resources, procedures, or specialized care to optimize outcomes. 1, 2

Major Risk Categories Requiring Enhanced Surveillance:

Cardiovascular Conditions:

• Rheumatic heart valve disease, Marfan syndrome, Ehlers-Danlos syndrome 1, 2
• Pulmonary hypertension, Eisenmenger syndrome, cyanotic heart disease 1
• Fontan circulation, dilated aortic roots, aortic dissection 1

Hypertensive Disorders:

• Chronic hypertension and preeclampsia 1, 2
• Previous history of preeclampsia 1, 3

Medical Comorbidities:

• Pregestational and gestational diabetes 2
• Advanced cirrhosis or liver transplant 1
• Complex inflammatory bowel disease 1
• Known coagulopathy 1

Obstetric Risk Factors:

• Previous adverse pregnancy outcomes 2
• Multiple gestation 2
• Short birth spacing (<18 months) 4
• Previous cesarean delivery 4

Socioeconomic and Lifestyle Factors:

• Substance use 2
• Geographic isolation from tertiary care 2
• Lack of education and poverty 4

Preconception Management Protocol

All women of reproductive age with chronic medical conditions must receive preconception counseling addressing reproductive plans, contraception options, disease optimization, and pregnancy timing. 1, 2

Preconception Interventions:

Risk Stratification:

• Conduct comprehensive assessment of medical and surgical history 1
• Perform genetic testing when indicated (e.g., Marfan syndrome) 1, 2
• Optimize management of underlying diseases before conception 1, 2

Cardiovascular-Specific Preconception Care:

• Obtain baseline echocardiogram for all women with structural heart disease 1, 2
• Consider elective aortic root replacement prior to pregnancy if aortic root diameter >45mm in Marfan syndrome 2
• Classify patients as low-risk (few symptoms, good ventricular function, no severe obstruction) versus high-risk (requiring specialized cardiac center management) 1

Contraception Counseling:

• Discuss adequate birth spacing to reduce high-risk pregnancy complications 1, 2
• Provide immediate postpartum contraception for women at high risk in future pregnancies 2

Antenatal Management Protocol

Continuous risk assessment throughout pregnancy is mandatory, as maternal and fetal conditions evolve and new risks may emerge. 1, 2

Care Coordination Requirements:

Multidisciplinary Team Composition:

• Maternal-fetal medicine subspecialist 1
• Relevant medical subspecialists (cardiology, gastroenterology, hepatology) 1
• Obstetric anesthesiology 1
• Neonatology consultation when indicated 1

Location of Care:

• Low-risk patients: Managed locally with established links to tertiary cardiac/obstetric center 1
• Higher-risk patients: Managed within or from tertiary cardiac center 1
• Highest-risk patients: Admission from approximately 20 weeks gestation 1
• Complex inflammatory bowel disease, advanced cirrhosis, or liver transplant: Tertiary care center throughout pregnancy 1

Monitoring and Surveillance:

Cardiovascular Monitoring:

• Regular echocardiograms for women with aortic aneurysm risk 2
• Close monitoring of hypertension and arrhythmias 2
• Continue beta-blocker therapy throughout pregnancy when indicated 2

Hypertension Management:

• For severe hypertension: Use oral nifedipine, IV labetalol, or IV hydralazine in monitored setting 2
• Avoid ACE inhibitors during second and third trimesters due to risk of fetal renal dysgenesis 2

Preeclampsia Prevention and Management:

• Initiate low-dose aspirin (100mg daily) before 20 weeks gestation in high-risk women 2, 3
• Evidence shows 100mg aspirin reduces preeclampsia risk by approximately 38% in high-risk patients 3
• Magnesium sulfate for seizure prophylaxis when preeclampsia develops 2, 5
• Monitor patellar reflexes before each magnesium dose; absence indicates withholding additional doses 5
• Maintain serum magnesium levels between 3-6 mg/100mL (2.5-5 mEq/L) for seizure control 5
• Limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema 2
• Delivery is the only definitive treatment for preeclampsia 1, 2
• Administer steroids for 48 hours to accelerate fetal lung maturation if gestation <34 weeks 1

Fetal Surveillance:

• Doppler velocimetry of umbilical and fetal arteries in high-risk pregnancies reduces perinatal mortality by 29% 6
• Maternal BMI screening, symphysial-fundal height measurement, and targeted ultrasound for intrauterine growth restriction detection 6
• Detection and management of IUGR can reduce antepartum and intrapartum stillbirth by 20% 6

Medication Management:

General Principles:

• Procedures, medications, and interventions to optimize maternal health should NOT be withheld solely because a patient is pregnant 1
• Assess risks and benefits for each intervention individually 1
• Most interventions, including CT scans or ERCP, should not be withheld if deemed necessary 1

Specific Medication Considerations:

• Continue beta-blockers throughout pregnancy when indicated 2
• Avoid ACE inhibitors in second and third trimesters 2
• Low molecular weight heparin use in patients with coagulopathy or previous preeclampsia remains controversial 1

Activity Restriction Policy:

Activity restriction should NOT be routinely prescribed for high-risk pregnancies. 1

Evidence Against Routine Activity Restriction:

• No definitive data demonstrating improved perinatal outcomes 1
• Associated with increased risk of venous thromboembolism (15.6 vs 0.8 cases per 1000 women) 1
• Increased rate of gestational diabetes (4% increase per day of inpatient restriction) 1
• Trabecular bone loss increases by 3.1% compared to ambulatory women 1
• Significant psychological distress, anxiety, and depression 1
• Family disruption and financial strain 1

Recommendation:

• Activity restriction should not routinely be prescribed for preterm labor symptoms, arrested preterm labor, or shortened cervix 1
• Routine inpatient hospitalization for activity restriction is not recommended 1

Delivery Planning Protocol

Determine optimal timing and mode of delivery well in advance through collaborative multidisciplinary discussion. 1, 2

Mode of Delivery Decision Algorithm:

Vaginal Delivery Preferred For:

• Most high-risk pregnancies unless specific contraindications exist 1, 2

Cesarean Delivery Indicated For:

• Dilated Marfan aortic roots or aortic dissections 1, 2
• Uncorrected coarctation 1
• Pulmonary vascular disease including Eisenmenger syndrome 1
• Cyanotic heart disease 1
• Mechanical valve prostheses (to minimize heparin withdrawal period) 1

Anesthesia Management:

Epidural Anesthesia:

• Favored for most high-risk deliveries 1, 2
• Avoid vasodilatation in patients with cyanosis or compromised stroke output 1, 2
• Adequate fluid volume loading is important but should not be excessive in left ventricular obstruction or severe hypertrophic cardiomyopathy 1
• Invasive monitoring rarely justified by inherent risks 1

Antibiotic Prophylaxis:

Endocarditis Prophylaxis:

• Discretionary for anticipated normal delivery 1
• Risk of endocarditis is very low and benefits not proven 1
• Recommended for: 1
  • Surgical deliveries
  • Patients with intracardiac prostheses
  • Patients with previous endocarditis
• Gynaecologists routinely advise prophylaxis to prevent post-abortal endometritis (occurs in 5-20% without antibiotics) 1

Special Delivery Considerations:

Ehlers-Danlos Syndrome:

• Anticipate increased bruising, hernias, varicosities, or rupture of large blood vessels 2
• Prepare for severe postpartum hemorrhage 2
• Use retention sutures for incisions 2

Marfan Syndrome:

• Newborns require careful physical, echocardiographic, and ophthalmic examination 2
• Genetic testing options: chorionic villus biopsy at 13 weeks, amniocentesis, or postnatal testing 2

Postpartum Management Protocol

Continue close monitoring in the postpartum period, as this represents the highest-risk period for certain conditions. 1, 2

Cardiovascular Monitoring:

Pulmonary Hypertension:

• Postpartum monitoring should continue for up to one week 1
• Conduct monitoring in CCU for high-risk patients 1
• Use continuous pulse oximetry 1
• This is the period of highest risk when increased pulmonary vascular resistance must be combated most aggressively 1

Postpartum Assessment:

Physical and Mental Health Evaluation:

• Assess physical and mental health risks to identify women needing interventions 2
• Screen for postpartum depression and anxiety, which are elevated in women with high-risk pregnancies 1

Contraception and Future Pregnancy Planning:

• Provide immediate postpartum contraception for women at high risk in future pregnancies 2
• Discuss reproductive plans and optimal birth spacing 2

Follow-up Care:

• Schedule follow-up visits to ensure transition to appropriate ongoing care 2
• Coordinate with primary care and subspecialists for continued management of chronic conditions 1

Pregnancy Termination Protocol (When Indicated)

Pregnancy termination should be discussed with women in whom gestation represents major maternal or fetal risk. 1

Timing and Location:

• First trimester is safest time for elective termination 1
• Perform in hospital rather than outpatient facility for emergency support services 1
• High-risk patients managed in experienced center with on-site cardiac surgery 1

Method Selection:

First and Second Trimester:

• Dilatation and evacuation is safest procedure 1

Second Trimester (if surgical evacuation not feasible):

• Prostaglandins E1 or E2, or misoprostol can be administered 1
• Monitor systemic arterial oxygen saturation with pulse oximeter 1
• Infuse norepinephrine to support diastolic blood pressure 1
• Avoid prostaglandin F compounds (can significantly increase pulmonary artery pressure and decrease coronary perfusion) 1

Up to 7 Weeks Gestation:

• Mifepristone is alternative to surgery 1

Contraindicated Methods:

• Avoid saline abortion (can cause intravascular volume expansion, heart failure, and clotting abnormalities) 1

Antibiotic Prophylaxis:

• Not consistently recommended by cardiologists but should be individualized 1
• Gynaecologists routinely advise prophylaxis to prevent post-abortal endometritis 1

Quality Assurance and Documentation

All high-risk pregnancies require comprehensive documentation of:

• Initial risk assessment and stratification 1, 2
• Multidisciplinary team discussions and delivery planning 1, 2
• Medication management decisions with risk-benefit analysis 1
• Delivery mode rationale and anesthesia plan 1
• Postpartum monitoring plan and follow-up arrangements 2