|
At the Singapore General Hospital, the high-risk obstetric clinic specialises in managing mothers with a wide variety of conditions. Management of some medical conditions requires a multidisciplinary team of doctors and nurses to optimise the underlying medical or surgical condition while the growing foetus is being monitored. Coordination of care is facilitated by the various medical specialties at the Singapore General Hospital, managing in tandem with the obstetrician and neonatologist. These complicated cases are discussed at regular perinatal meetings attended by obstetricians and neonatologists to enable a comprehensive plan for management to be formulated.
 During a high-risk consultation early in the first trimester, parents may require information on how the underlying medical/surgical condition affects the unborn foetus and, conversely, how pregnancy impacts on the medical/surgical condition. The obstetrician will need to discuss with parents the advantages and disadvantages of normal birth, or instrumental / Caesarean delivery (see following article) if normal birth is impossible or ill-advised. Mothers who have had bad obstetric histories (for example, delivery of repeated stillbirths) would naturally be extremely anxious about the outcome of the pregnancy, so early discussion alleviates anxiety and prepares the couple psychologically for delivery outcomes.
At the time of delivery, a team of trained, experienced neonatologists must be present to provide appropriate resuscitation. Following resuscitation, the neonate may require intensive care because of severe prematurity, severe intra-uterine growth restriction, emergency management of a birth defect or difficulty in adaptation to extrauterine life. The neonatal intensive care environment provides the best chance for a critically ill neonate to receive optimal care while recovering.
When the mother has fluctuating blood sugar levels from uncontrolled diabetes mellitus, the infant’s blood sugar levels must be closely monitored for hypoglycaemia.
Where mothers are known to have Graves’ disease, there are risks of miscarriage, pregnancy -induced hypertension, congestive heart failure and thyroid storm. The foetus of a mother with Graves’ disease will be at risk for intra-uterine growth restriction and thyrotoxicosis arising from placental transfer of thyroid receptor antibodies. The newborn may then require anti-thyroid medication, since raised thyroid hormone levels can result in poor weight gain, heart failure and premature fusion of the skull sutures.
The mother who suddenly discovers the presence of a tumour mid-way in pregnancy may be depressed, have concerns for the well-being of the foetus and show anxiety over the side-effects of chemotherapy treatment on the developing foetus. In such cases, the mother is best managed by a team consisting of the oncologist, radiation therapist, gastro-enterologist, pharmacist and obstetrician, so that she receives appropriate advice on the best options for early yet safe delivery, in order that she can begin chemotherapy treatment immediately after the delivery.
Regardless of the medical condition involved, we believe the key to successful management of these pregnancies is to involve the different relevant disciplines early in the course of the pregnancy. Apart from ad hoc consultations, a number of joint clinics are also in place which enable members of different medical specialities to see these patients together. Examples of such clinics in SGH are the gestational diabetes joint clinic and the cardiac disease in pregnancy clinic.
From The Uterus To The Newborn (Intensive) Care Environment
The baby of a high-risk pregnancy is often born earlier than the expected date because of maternal obstetric complications (such as pre-eclampsia), maternal medical conditions (such as heart failure, SLE), severe intra-uterine growth restriction or non-reassuring foetal status. Placental complications (such as placenta accreta, increta and percreta) may preclude normal vaginal birth and require the collaboration of a team of specialists such as the interventional radiologist, haematologist, obstetrician and neonatologist. Assisted reproduction techniques are associated with an increased risk of multiple (twin or higher order) pregnancies, many of which may develop preterm labour. The increasing age of the Singapore obstetric population may be associated with an increasing risk of birth defects.
The preterm baby requires the expertise of a tertiary care neonatal team, such as the SGH Neonatal team, for optimal care. The immature lung of the preterm baby is deficient in surfactant, preventing adequate alveolar expansion and leading to respiratory failure. The ductus arteriosus is oftentimes patent with left to right flow, resulting in pulmonary oedema and heart failure. The immature gastrointestinal tract will not be ready for digestion and absorption. The relatively immature kidneys face challenges in filtration and excretion of waste. The immature brain is prone to intraventricular bleeding. The neonatal intensive care unit is thus an important environment to assist the vulnerable preterm neonate to effect the transition to extra-uterine life while promoting growth and homeostasis. In babies with a birth defect, an accurate diagnosis must be made early so that parents can understand the implications of the defect on the child’s health, growth and development.
|
|
 Before the discharge of a high-risk baby from SGH, some parents naturally feel anxious about their parenting skills. It is not uncommon for parents to express uncertainty over how to recognise the type of baby’s cries. Thus parents of high-risk infants about to be discharged will be taught basic parenting skills, like infant bathing, breastfeeding, massage therapy and basic resuscitation. Routine screening is undertaken to ensure that treatable conditions such as jaundice secondary to G6PD deficiency, congenital hypothyroidism, hearing impairment and metabolic diseases are detected and anaged ppropriately. Babies who are born with very low birth weight (below 1500 gram) automatically qualify to join the “Light Weight Club” where they can receive guidance, advice and emotional support in coping with and caring for the formerly ‘lightweight’ family member.
As outpatients, the high-risk baby has access to the full range of ambulatory care, including follow-up of growth, tracking of developmental milestones, provision of vaccinations, advice on age-appropriate diets and management of medical conditions. In particular, the baby born with very low birth weight will be seen till schoolgoing age to detect developmental and learning difficulties early through multi-disciplinary follow-up.
With the highly coordinated, holistic care of the high-risk baby, favourable outcomes can now be achieved for both parents and baby, offering much hope for the future.
|