Abstract
Medical disorders are complicating pregnancy with increasing frequency for many reasons. Women are deferring pregnancy to later years when they more frequently suffer from medical conditions such as hypertension, diabetes or obesity and its associated complications. In addition, childhood illness such as congenital heart disease is increasingly well managed such that these women are surviving to adulthood and wish to have children.
It is now well recognised that medical disorders complicating pregnancy are a major cause of maternal morbidity and mortality, worldwide. Globally, indirect causes are responsible for 27% of the mothers who die. 1 In the UK, indirect causes of maternal death now outstrip direct causes, overall and at every stage of pregnancy and postpartum. In the latest Confidential Enquiry into Maternal Death and Morbidity in the UK and Ireland (2010–2012), 2 two-thirds (i.e., 168/257) of women who died did so from an indirect cause (either medical or mental health), and ∼75% (i.e., 163/215) of those women had a pre-existing medical condition. This was after excluding obesity (present in 26.0%) which is an independent risk factor for direct maternal death. 3 Also, medical co-morbidities increase the risk of direct maternal death from the most common obstetric complications. In a UK study of risk factors for the five leading causes of direct maternal death (i.e., eclampsia, pulmonary embolism, severe sepsis, amniotic fluid embolism, and peripartum haemorrhage), medical co-morbidities were the strongest risk factor for direct maternal death in multivariable modelling. 3
There is growing recognition that pregnancy is a ‘stress test’ that reveals underlying subclinical risk and which may be predictive of future long-term health conditions such as diabetes mellitus following gestational diabetes 4 or frank cardiovascular disease and/or stroke following pre-eclampsia, independent of traditional cardiovascular risk markers. 5 Thus, these medical complications in pregnancy warrant ongoing management and screening to potentially optimize long-term health.
Calls have been made to improve the care of women with medical problems before, during, and after pregnancy. 2 This should include readily available, expert, multidisciplinary preconception counselling services; patient-centred multidisciplinary pregnancy management and models of postpartum management that recognise pregnancy complications as risk factors for future health problems.
How that can be accomplished is likely to be different even within well-resourced environments and potentially more difficult in under-resourced settings. In this edition of Obstetric Medicine, we present the first in a series describing the organisation of obstetric medical services in Canada where there is strong interest in the delivery of these services within medical and obstetric communities.
In this quarter's issue Andy Shennan reviews the role of oxidative stress in reproduction. At the time of writing National Institute of Health and Care Excellence (NICE) in the UK has just approved both PlGF (placental growth factor) and soluble FMS-like tyrosine kinase-1 (sFlt-1)/PlGF ratio to help rule out pre-eclampsia between the 20th and 35th week of pregnancy. So it is timely to publish Kane's review on screening for pre-eclampsia in the first trimester. You may not all agree with the use of retrievable inferior vena caval filters or current guidelines for management of thyroid disease in pregnancy and will therefore be interested to read the articles by Du Plessis et al. and Robinson et al. discussing these issues. We have our usual pot pourri of case reports describing the weird and rare conditions complicating pregnancy including a peritoneal pseudocyst causing acute kidney injury, a ruptured pudendal artery aneurysm and cytomegalovirus infection in an immunosuppressed woman causing hepatitis, respiratory failure, oesophagitis and ultimately death.