Obstetric History Taking in Patients with Prior Pregnancy Complications (MIDAS Framework)
A comprehensive obstetric history documenting prior Malformations, Infections, Deformations, Associations, and Syndromes is essential for risk stratification and should trigger continuous reassessment throughout pregnancy, with specific attention to cardiovascular disease risk, recurrent pregnancy complications, and mental health screening. 1, 2
Critical Components to Document
Prior Pregnancy Outcomes and Complications
Document each pregnancy using standardized scoring: term births, preterm births, spontaneous abortions, therapeutic abortions, and living children, with gestational age at delivery for each. 2 History of preterm birth increases risk of recurrent preterm delivery and stroke. 2 Prior cesarean deliveries carry dose-dependent risks—as the number increases, so do rates of hysterectomy, blood transfusion, adhesive disease, and surgical injury. 1
Pregnancy-specific complications require detailed documentation:
- Hypertensive disorders (preeclampsia, gestational hypertension) increase stroke risk and predict early cardiovascular disease within 5 years postpartum (42% greater risk). 1, 2
- Gestational diabetes increases stroke risk and necessitates early glucose screening in subsequent pregnancies. 2
- Placental complications (previa, abruption, retained placenta) are associated with increased placenta accreta risk, particularly with prior cesarean delivery. 2
- Stillbirth history increases subsequent cardiovascular disease risk. 1
Fetal Anomalies and Congenital Conditions
Prior infant birth weight and congenital malformations indicate predisposition to vascular, hypertensive, or diabetic illness in the mother. 3 Women with pregnancies complicated by fetal anomalies demonstrate significantly higher anxiety (mean state anxiety score 43.6 vs 29.1 in uncomplicated pregnancies), particularly with pre-existing mental health disorders. 1
Mental health screening is mandatory: 5.5% of women with fetal anomaly history are at high risk of traumatic stress and 35.9% at elevated risk of major depression in the immediate postpartum period. 1
Infectious Disease History
Microbiological evaluation is relevant for recurrent pregnancy loss: Toxoplasmosis associates with complete abortion (38%), stillbirths (6%), premature delivery (16%), and congenital anomalies (6%). 4 Cytomegalovirus infection associates with complete abortion (41.66%), preterm delivery (33.33%), and congenital anomalies (8.33%). 4 Ureaplasma infection results in preterm delivery with premature rupture of membranes (45%) and complete abortion (35%). 4
Risk Stratification Framework
Risk assessment must be continuous, not a single timepoint evaluation. 1, 5 The Society for Maternal-Fetal Medicine recommends evaluating five areas at each assessment: healthcare system's ability to manage the condition, fetal/neonatal prognosis, patient's ability to manage the condition, woman's desire to continue pregnancy, and expertise of available practitioners. 5
High-Risk Indicators Requiring Subspecialty Referral
Immediate maternal-fetal medicine consultation is indicated for:
- Suspected placenta accreta/percreta with prior cesarean and anterior previa 1
- Severe heart disease (complex cardiac malformations, pulmonary hypertension, coronary artery disease, cardiomyopathy) 1
- Severe preeclampsia with uncontrollable hypertension 1
- Preterm HELLP syndrome 1
- History of open fetal surgery (9.6% uterine rupture rate in subsequent pregnancies, comparable to classical cesarean) 1
Quantifying Recurrence Risk
Women with prior hypertensive disorders develop persistent postpartum hypertension and metabolic syndrome within the first year after delivery. 1 Preeclampsia history confers 42% greater cardiovascular disease risk within 5 years, even after adjusting for demographic and socioeconomic factors. 1
Short interpregnancy intervals (<18 months) increase morbidity and mortality, particularly for women >35 years. 1
Contextual and Psychosocial Factors
Document non-medical risk modifiers that impact outcomes:
- Exposure to racism (Black women have 1.44 times higher severe maternal morbidity risk after adjusting for all other factors) 1
- Socioeconomic status and healthcare access 1, 5
- Exposure to interpersonal violence 1
- Substance use (tobacco, alcohol—alcohol increases abruption risk; cocaine carries increased placental abruption risk) 2, 6
- Family structure and support systems 2
Mental health history is critical: Depression and anxiety associate with adverse childhood experiences and early-onset depression, which link to hypertension. 2 Untreated psychiatric illness is a leading cause of maternal mortality and contributes to fetal demise risk. 6
Communication and Care Coordination
Establish early communication between obstetricians, anesthesiologists, and subspecialists when risk factors are identified. 1, 2 Recognition of significant anesthetic or obstetric risk factors should trigger consultation between providers. 1
Plan multidisciplinary care with early involvement of maternal-fetal medicine, cardiology, or other specialists as needed. 2 Women with conditions like lupus or diabetes require coordination between non-obstetrical specialists and MFM subspecialists throughout pregnancy. 1
Common Pitfalls to Avoid
Never perform single-timepoint risk assessment—risk evolves dynamically throughout pregnancy and requires continuous reassessment. 1, 5
Do not overlook contextual factors including socioeconomic status, geographic location, healthcare access, and implicit bias, which significantly contribute to maternal outcomes. 5
Avoid bed rest for preterm birth prevention—it increases risk of preterm delivery (adjusted OR 2.37 for delivery before 37 weeks). 6
Do not delay mental health intervention—untreated psychiatric illness results in poor prenatal care adherence, inadequate nutrition, substance exposure, and increased fetal demise risk. 6