As general practitioners are often the first point of contact, they are in a unique position to identify women who are potentially at risk during pregnancy, labour and birth. Find out more about the importance of prompt referral to a specialised antenatal clinic in order to optimise pregnancy outcomes.
Over the years, there has been a rising prevalence of medical problems in pregnancy due to a complex interplay between demographic and lifestyle factors, in addition to advances in medical care. This has resulted in a rising number of complex, high-risk obstetric patients.
Advances in medical care mean that women with medical problems who were previously unable to get pregnant can now do so. For example, in the past, women with kidney failure could not get pregnant due to kidney disease affecting their fertility. Now, with renal transplant, many of these women manage to get pregnant and achieve good outcomes. At the same time, more such pregnancies also correlate with an increase in medical problems in pregnancy.
An understanding of medical problems in pregnancy is essential for optimising outcomes, which involves:
Optimisation of medical therapy
Multidisciplinary management throughout pregnancy and the postnatal period
Specialised antenatal clinics are run by a team of obstetricians working together with specialist physicians (cardiologists, endocrinologists, rheumatologists, haematologists and nephrologists) and nurses who have expertise in the management of a range of medical conditions in pregnancy.
This unique service provides:
Specialised antenatal clinics utilise a multidisciplinary approach to ensure that the care provided is personalised and decisions about care are made using the best available evidence, in partnership with the woman and her partner.
General practitioners (GPs), often being the first point of contact, are in a unique position to identify women who have the potential for risks during pregnancy, labour and birth and refer them directly to the most appropriate specialised antenatal clinic as early as possible.
Ms P, a 35-year-old para 2 lady was referred from a polyclinic for her first antenatal booking visit. The referral letter stated that she was diagnosed with systemic lupus erythematosus (SLE) in 2017 and currently in remission.
Her active medications at time of referral were hydroxychloroquine, prednisolone, and mycophenolate mofetil (MMF). She is on biannual follow-up with her rheumatologist and her last follow-up visit was four months ago.
Presentation and diagnosis
She first presented to the polyclinic at around 11 weeks of amenorrhoea, and was subsequently seen at the general obstetric clinic for her first booking visit at 13 weeks of amenorrhoea.
At this booking visit, a viable singleton foetus with crown rump length corresponding to the 13th week of gestation was confirmed.
Ms P and her partner were counselled regarding the implications of MMF use during the first trimester, in particular the risk of major birth defects (e.g., defects of the distal limbs, heart, oesophagus and kidney). As her foetus was exposed to MMF throughout the organogenesis period in the first trimester, the risk of birth defects for her foetus has been reported to be as high as 31.6%.
She and her partner were not able to accept this risk and decided on termination of the pregnancy. Following termination, she was counselled on contraceptive choices as the couple does not wish to have more children. She opted for the levonorgestrel intrauterine system (Mirena) method.
Pregnancy in women with SLE should be considered high-risk, and the coexistence of pregnancy and SLE is by no means a rare event as the disease mainly occurs among fertile women.
Women with SLE were previously discouraged from pregnancy because of concerns regarding its potential effects on both mother and child. However, over the last decade, a better understanding of the disease, advancing medical technology and changes in the way we practice now mean that in many cases, a good pregnancy outcome is possible. This shift in practice applies not only to women with SLE but also to many other conditions, such as organ transplant recipients, complex cardiac disease and end-stage kidney disease, just to name a few.
This list of conditions will continue growing as medical advances have made good outcomes possible for women who were unable to get pregnant in the past, or were discouraged from pregnancy.
1. The Importance of Pre-pregnancy Counselling
For the best chance of a successful pregnancy, women with medical conditions that deem them at higher risk should receive pre-pregnancy counselling.
Counselling should be provided by obstetricians and physicians, ideally in a joint multidisciplinary clinic setting, who are adept in managing women with such medical conditions in pregnancy.
Counselling and recommendations
Pre-pregnancy counselling not only provides information on the impact of pregnancy on their existing medical condition and vice versa, but also allows for a plan to be put in place from pre-conception to delivery – which includes recommendations regarding changes to the treatment regime.
In any condition, pregnancy is usually advised when the disease has been quiescent for some time before conception (i.e., six months of ‘inactive’ period on stable therapy for SLE) or when disease control has been optimised (e.g., Hba1c < 6.5% for patients with type 1 or 2 diabetes mellitus).
An important aspect of planning pregnancy in women with pre-existing medical conditions is to ensure that any medications that they are taking are appropriate prior to conception and during pregnancy.
MMF, the medication taken by Ms P in the case study, is a purine synthesis inhibitor that is used as an immunosuppressant agent in the prophylaxis of organ rejection in patients receiving organ transplant and in patients with autoimmune conditions. MMF is a teratogen.
Its use in pregnancy is associated with spontaneous abortions (SABs) and major birth defects involving the external ear, facial anomalies, cleft lip/palate and defects of the distal limbs, heart, oesophagus and kidney.
Many organisations recommend discontinuing MMF at least six weeks prior to conception to take into account its wash-out period. Discontinuing MMF more than six weeks prior to pregnancy is associated with a birth defect rate of 5%, similar to that of the general population.
However, discontinuing MMF in first and second trimester is associated with birth defect rates of up to 8.5% and 31.6% respectively.
2. The Importance of Prompt Referral to Specialised Clinics
The case study also emphasises the importance of referring such cases urgently.
There was a two-week gap between Ms P’s first polyclinic visit and antenatal booking visit, during which the foetus continued to be exposed to MMF.
It would have been beneficial for her to be seen directly at the Rheumatology Obstetric Clinic, part of the Centre for High-Risk Pregnancies (CHiRP) at Singapore General Hospital (SGH), so that she could be counselled directly by both the high-risk maternal foetal medicine specialist and the rheumatologist, as well as for her medications to be switched to pregnancy-compatible agents.
The Centre for High-Risk Pregnancies (CHiRP) at the Department of Obstetrics & Gynaecology, SGH was created to provide a one-stop multidisciplinary tertiary integrated care service for high-risk pregnancy care and counselling for prospective mothers with risk factors.
These clinics under CHiRP are held at levels 1 and 2 at the Department of Obstetrics & Gynaecology, SGH, Block 5.
To refer a patient to any of the aforementioned CHiRP clinics, GPs can download the information letter here and submit it via:
Fax: 6321 4837
Please contact our nurses at 6321 4516 should an urgent appointment be required, or should advice be needed on which clinic is the most appropriate.
In special cases, we may initiate monitoring and treatment before the first clinic appointment, such as starting seven-point blood sugar profile monitoring and insulin in patients with suboptimally controlled diabetes in pregnancy.
The management of medical problems in pregnancy should begin before conception, with pre-pregnancy counselling and optimisation of medical therapy for women of reproductive age.
GPs can refer women with medical conditions who are considering pregnancy or currently pregnant directly to the most appropriate specialised antenatal clinic.
Dr Pamela Partana is an Associate Consultant Obstetrician and Gynaecologist at Singapore General Hospital. She graduated with Distinction from the King’s College London School of Medicine in 2013 and was nominated to represent King’s at the prestigious University of London Gold Medal Viva competition. She is currently pursuing her sub-specialty training in maternal foetal medicine and has a keen interest in the management of high-risk pregnancies.
GPs who would like more information about CHiRP, please contact Dr Partana at 6321 4675.
GP Appointment Hotline: 6326 6060
GPs can find out more information about the department here.
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