High-Risk Obstetric Patients – More Needs to Be Done! 2023

High-risk pregnancy involves any condition or situation that leads to increased risk of morbidity and mortality for the mother or her offspring. With such a broad definition, it is not surprising that the qualifying criteria for high-risk pregnancy differs greatly between studies (Obstet Gynecol 1987;69:951-64; CURRENT Diagnosis & Treatment: Obstetrics & Gynecology. 2013). Pregnancies complicated by preeclampsia, diabetes, premature labor, multiple pregnancy, intrauterine growth retardation, oligohydramnios, and breech presentation are unanimously considered high-risk. The same applies to pregnant patients with any underlying preexisting cardiovascular, renal, endocrine, hematologic, respiratory, neural, oncologic, or infectious disease. Some studies include any case in which emergency cesarean section was necessary, e.g., cases of fetal distress, prolapse of the umbilical cord, or uterine rupture (J Int Med Res 2019;47:4365-73). The Centers for Disease Control and Prevention (CDC) reports that pregnancy-related mortality has risen from 7.2 deaths per 100,000 live births in 1987 to 17.3 deaths per 100,000 live births in 2018. Disappointingly, more than 80% of those pregnancy-related deaths were determined to be preventable (asamonitor.pub/3KQTwl7; asamonitor.pub/3KQxXRR; asamonitor.pub/3FzKZy8; Sci Rep 2022;12:18626; Lancet Glob Health 2018;6:e18-9).

The Table provides information on the incidence of the common comorbidities associated with high-risk pregnancies. Some of these conditions have a greater impact on the development of maternal and/or neonatal complications. In the presence of several risk factors, each comorbidity will independently contribute to the increased risk of an unfavorable clinical outcome. Postpartum hemorrhage (PPH) remains overall a worldwide leading cause of maternal morbidity and mortality (Lancet Glob Health 2018;6:e18-9; Int J Gynaecol Obstet 2020;148:290-9; Clin Obstet Gynecol 2017;60:384-93). Moreover, PPH is one of the high-risk conditions where early detection and adequate management can significantly impact outcomes. A retrospective questionnaire covering three administrative regions of France reported that 24% of those who developed severe PPH received totally inadequate care (BJOG: Int J Obstet Gynaecol 2001;108:898-903). In their cohort review evaluating the quality of care for severe PPH, Bouvier-Colle et al. found that after adjusting for sociodemographic, antenatal care, and organizational factors, the lack of a 24/7 on-site anesthesiologist at the hospital and a low volume of deliveries (<500 births/year) were responsible for substandard care (BJOG: Int J Obstet Gynaecol 2001;108:898-903). Similar results have been reported by others, including Saucedo et al., who found that after controlling for other risk factors, the risk of maternal death from PPH was higher in hospitals without a 24/7 on-site anesthesiologist, in level 1 hospitals, and in for-profit hospitals (Sci Rep 2022;12:18626; Anesth Analg 2020;130:52-62).

Institutional requirements:

For high-risk patients, ACOG recommends the following to improve outcomes (Obstet Gynecol 2019;134:883):

• Obstetric facilities must have a higher level of resources that need to be readily available
• Standardization of a regionalized system of perinatal care and risk-appropriate care
• This requires uniform definitions:
  • A standardized description of maternity facility capabilities and personnel (anesthesiologists, obstetric staff, neonatologists)
  • A framework for integrated systems that address maternal health needs.

Established levels of maternal care include basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). Patients with complex medical conditions should receive care in level II to level IV centers that have more facility capabilities and specialized medical staff available when needed. Risk-assessment systems should be utilized to ensure that patients are at a facility with an appropriate level of care. There should be transportation available in case transfer to a higher level of care is needed.

Anesthesiologist availability and anesthetic care:

While standardized, comprehensive, multidisciplinary programs have demonstrated significant reductions in morbidity of the obstetric population, the variety of comorbidities reported in high-risk pregnant women makes it difficult to create one single plan to fit all patients. All high-risk patients require a thorough individualized plan that should be carefully tailored to the patient’s needs. This requires input from an obstetrician and an anesthesiologist, and often close follow-up by large multidisciplinary teams. Early referral of high-risk OB patients to preoperative anesthesia clinics facilitates the creation of a delivery plan in a timely manner. This allows the patient and other members of the multidisciplinary team to be involved in the decision-making process.

At M Health Fairview (UMMC), a significant volume of high-risk pregnancies leads to the implementation of a protocol to identify those high-risk patients early and promptly refer them to the UMMC preoperative assessment center. For the development of this protocol, we adopted the criteria for consultation suggested by the Society for Obstetric Anesthesia and Perinatology (SOAP) and reviewed it with our colleagues from obstetrics and maternal-fetal medicine. Our final protocol lists the high-risk conditions that require evaluation by the anesthesia team and recommends preoperative assessment center referrals earlier than 30 weeks of gestation to ensure timely consultations. As has been suggested, the preoperative assessment center evaluation needs to be completed by 32 weeks of gestation or earlier if premature delivery is anticipated (asamonitor.pub/3y6abtn). More recently, telehealth resources have allowed us to offer an alternative virtual preoperative assessment evaluation, thus increasing accessibility to vulnerable populations and those with barriers to health care such as poor access to transportation. After completion of preoperative assessment evaluation and obtaining pertinent additional studies and/or referrals, detailed recommendations for an anesthetic plan are discussed with the patient and clearly documented in electronic medical records. We have developed a high-risk OB-anesthesia team that communicates anesthesia concerns of high-risk obstetric patients with all members of the care team. We believe this will have a positive impact on clinical outcomes. Currently, this multidisciplinary approach and the early development of an anesthetic birth plan have significantly reduced the anxiety of our high-risk patients and resulted in an overall improvement in patient satisfaction. We will be conducting surveys to demonstrate statistically significant improvements in our patients’ perceived quality of care during delivery. We will also collect and evaluate more longitudinal data to demonstrate the clinically significant benefits of this approach.

Institutional commitment is important for the proper care of high-risk obstetric patients. This must include the availability of a dedicated anesthesiologist to facilitate the antenatal evaluation and coordination of multidisciplinary care often required for these patients. The 24/7 availability of anesthesiologists, along with institutional commitment, will result in optimal elective and emergency care for high-risk obstetric patients.