Managing High-Risk Pregnancy with Chronic Disease: Delivery Timing and Planning

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• Timing of Delivery in High-Risk Pregnancy
• Delivery Method Considerations and Anesthesia
• Choosing the Right Delivery Hospital
• Neonatal Care and Medication Planning
• Preconception Counseling Importance
• Multidisciplinary Care Coordination
• Managing Pregnancy Without Prior Planning

Timing of Delivery in High-Risk Pregnancy

Dr. Marc Dommergues, MD, emphasizes that determining when to deliver a baby is a pivotal decision for a mother with a chronic medical disease. He notes that delivery before the full nine-month term may be medically advisable in certain situations. For instance, if a pregnant woman has heart disease and her ventricular function shows signs of decreasing, an earlier delivery date can be a crucial intervention to protect both maternal and fetal health. This decision is based on continuous monitoring and careful risk assessment by the medical team.

Delivery Method Considerations and Anesthesia

The method of delivery is a complex question that involves both obstetricians and anesthetists, particularly regarding the impact of procedures like epidural anesthesia on maternal hemodynamics. Dr. Marc Dommergues, MD, explains that for a woman with a heart defect, the tolerability of pushing during labor and the potential risks from acute blood loss must be thoroughly discussed by her cardiologist and anesthetist beforehand. Despite these challenges, vaginal delivery is often still possible, sometimes facilitated by techniques to avoid strenuous pushing, ensuring a safer process for the mother.

Choosing the Right Delivery Hospital

Selecting where to deliver is directly influenced by the type of chronic disease a pregnant woman has. Dr. Dommergues advises that for conditions like Type 1 or Type 2 diabetes, delivery should occur in a hospital with immediate access to a diabetologist. Similarly, if there is a risk of a cardiac abnormality, the delivery hospital must have 24/7 availability of a qualified cardiologist. This strategic choice ensures that specialized care is on hand to manage any potential complications that may arise during labor and delivery.

Neonatal Care and Medication Planning

The quality of pediatric care at the delivery hospital is another critical factor. Dr. Marc Dommergues, MD, highlights that newborns may have medications in their bloodstream that were taken by the mother during pregnancy, which can affect neonatal health. This necessitates specialized medical attention immediately after birth. It is imperative that the pediatric team is fully informed about the mother's medication history and health status to provide appropriate and timely care for the newborn.

Preconception Counseling Importance

Dr. Dommergues addresses the profound question of whether pregnancy is advisable at all, given certain high-risk medical conditions. He describes the hospital's approach as one of transparently informing patients about all risks, including extreme cases where there might be a significant mortality risk, and supporting them in making their own decision. This process can be emotionally taxing for both the woman and her partner, often requiring psychological support to navigate the fears and realities of a high-risk pregnancy.

Multidisciplinary Care Coordination

Planning ahead is the most crucial element for a successful outcome. Dr. Marc Dommergues, MD, stresses the importance of a woman consulting with both a specialist for her specific disease and an experienced obstetrician before conception. Ideally, these specialists should be within the same hospital to facilitate seamless communication and coordinated care planning. This multidisciplinary team approach is fundamental to managing the complex interplay between a chronic disease and pregnancy.

Managing Pregnancy Without Prior Planning

For women who discover they are pregnant without the benefit of preconception counseling, Dr. Dommergues advises immediate action. He recommends scheduling consultations with the relevant disease specialist and an obstetrician as soon as possible to begin close and careful monitoring of all health issues. While not ideal, vigilant and coordinated care from the earliest possible moment can still help manage risks and guide the pregnancy towards the safest possible outcome for both mother and baby.

Full Transcript

Dr. Marc Dommergues, MD: An important question is when to deliver a baby if a mother has a medical disease. It may be wise to deliver a baby a little bit earlier than nine months. For example, if there's heart disease and the ventricular function is decreasing, then an earlier delivery date may be worthwhile.

Dr. Anton Titov, MD: There's a question of how we can perform delivery in a woman with a medical disease. This is an interesting question both for obstetricians and anesthetists.

For example, what will be the impact of performing epidural anesthesia on the hemodynamics of a pregnant woman? When a pregnant woman has a heart defect, that needs to be discussed by the cardiologist and the anesthetist.

How will pushing be tolerated by the pregnant woman? What is going to happen if she has an acute blood loss? Is there a particular risk for her health in that case? These things need to be discussed.

But in many instances, it is possible to have a vaginal delivery. It is possible to deliver vaginally without pushing, for example, if this is required.

Dr. Marc Dommergues, MD: We discussed when to deliver a baby and how to deliver a baby. Then the question is where to deliver a baby. This also relates to the type of disease a pregnant woman has.

If she has Type 1 diabetes or Type 2 diabetes before the pregnancy, it is best to have a delivery in a hospital where it is easy to find a diabetologist. If a pregnant woman is at risk of having a heart abnormality, it's best to have a baby delivered in a hospital where it's easy to get a good cardiologist 24 hours a day.

Dr. Anton Titov, MD: So this is something one has to consider when choosing labor and delivery options. It's important to consider the quality of pediatric care as well.

Many newborn kids may have the medications in their blood that their mother was taking. These drugs may affect neonatal health. This may require special medical care.

It's important that the pediatricians in charge know about what's happening and what drugs are being taken by the mother. Now we know how to manage the pregnancy, how to prepare for labor and delivery, and where to do it, and when to deliver a baby.

Dr. Anton Titov, MD: There's the last point. Is it desirable to have a pregnancy? This is a difficult point. Our choice in this hospital is to tell people about the risks and to let them make the decision.

Sometimes we are a bit worried. For example, if we believe that there is a 10% risk of dying during pregnancy, then we are going to tell the patient, and this may be very hard to manage for patients.

It may require psychological help for a woman and her partner. It's a big worry for a partner: "Am I going to kill my wife by letting her become pregnant?" This is really what men are asking, and this is also something that should be taken into account.

Overall, it's probably easier to plan things and make unrushed decisions before pregnancy.

Dr. Marc Dommergues, MD: Medical second opinion and to know in advance what to do as soon as you are pregnant. This is what I'm hearing. Planning ahead is the most important thing.

Talking to a disease domain specialist and to an obstetrician who has experience with that disease. Medical second opinion and preferably these specialists should be in the same hospital. They should be able to talk to each other.

But if they are not in the same hospital, one has to make sure that their work is somehow coordinated. Medical second opinion and if a woman finds that she is pregnant without having those preconception meetings, she has to have a meeting as soon as possible with a disease specialist as well as the obstetricians and follow all health issues very closely and carefully.