Risk factors that might determine an 'at risk' pregnancy

There are multiple factors that inform an 'at risk pregnancy' and these can include age and ethnicity, but in this article we will examine obesity, diabetes, and hypertension.

Women with health conditions require increased monitoring and specialised care during pregnancy to ensure that stillbirths and complications during birth are avoided. It is the duty of the midwife or consultant responsible for the mother's care to ensure that adequate monitoring and risk assessments are carried out from the initial antenatal booking appointment up until the birth of the child. A Failure to do so may amount to a breach of duty of care worthy of compensation.

Obesity

Women with a high BMI are at greater risk of gestational diabetes, high blood pressure, pre-eclampsia and still birth. Women who are classed as obese should be offered a test for gestational diabetes during their pregnancy. BMI should be calculated at the antenatal booking visit.

Women with high BMI have a pre-existing risk factor for developing VTE (Venous thromboembolism) during pregnancy. Risk assessments should be undertaken at the antenatal booking, throughout the pregnancy, and the post-natal period to ensure that the VTE is monitored throughout the pregnancy.

Symptoms of VTE may include leg pain, swelling, abdominal pain, chest pain, collapse, and pyrexia.

Diabetes

Women with either type 1 or 2 diabetes have a higher risk of experiencing complications during pregnancy as they tend to have large babies, often resulting in a difficult birth that requires induction or a caesarean section. There is also a greater risk of stillbirth if appropriate monitoring is not carried out. Stillbirth is due to diabetes related changes in the placenta leading to placental insufficiency.

A glucose tolerance test is used to measure a person's tolerance to sugar. The amount of sugar in the urine (glycosuria) should be within an acceptable range.

Some women develop diabetes during their pregnancy, this is known as gestational diabetes.

At the initial review the NICE Guidelines NG3 Diabetes in Pregnancy , September 2020 ,indicate the following explanations should be given:

• the implications (both short and long term) of the diagnosis for her and her baby (including UK government advice on driving with diabetes).

• that good blood glucose control throughout pregnancy will reduce the risk of fetal macrosomia, trauma during birth (for her and her baby), induction of labour and/or caesarean section, neonatal hypoglycaemia, and perinatal death.

• that treatment includes changes in diet and exercise and could involve medicines.

It is essential that diabetic women control their diabetes throughout the pregnancy and a clear management plan is engaged. Dietary advice and blood glucose parameters must be correctly explained. The risks mentioned above should be explained.

Some women are able to control this through diet and exercise, but for others, this may involve them taking medication such as insulin or metformin, as well as ensuring that blood glucose measurements are monitored multiple times per day throughout the pregnancy. These results will then be monitored by the antenatal team to ensure that blood sugar levels are controlled. Metformin should be offered if blood glucose levels are not normalised within 2 weeks.

The NICE guidelines acknowledge that ' most women with gestational diabetes will need oral blood glucose -lowering agents or insulin'

Any assessment that relies on the Patient to interpret whether results are within an acceptable range , and where tests have been missed and blood glucose readings not available for review, are inadequate. Sadly, I have dealt with cases where the onus has been placed on the woman to monitor, without adequate review.

Diabetic women require closer monitoring and will be offered additional appointments to monitor the baby's size and check for abnormalities. An ultrasound scan will be offered at 18-20 weeks, and at week 28, 32 and 36 to monitor the baby's size. Appointments will become more regular from week 38, as the ideal time for a diabetic woman to give birth is from 38 - 40 weeks due to concerns that the baby's size will cause complications during birth. There will be induction of labour after 40 weeks. Delivery may be induced earlier if there are concerns relating to blood glucose levels or the baby's health.

During childbirth and labour, clinicians must monitor the blood glucose levels hourly.

Women with diabetes are also at greater risk of developing pre-eclampsia.

The Local protocol of the hospital and the NICE guidelines should be looked at to determine the correct course of action.

The NICE guidelines state that the 36 week review should;

• Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

• Provide information and advice about:

  • timing, mode, and management of birth

  • analgesia and anaesthesia

  • changes to blood glucose-lowering therapy during and after birth

  • care of the baby after birth

  • starting to breastfeed and the effect of breastfeeding on blood glucose control

  • contraception and follow-up.

There should be a holistic approach and review with the obstetric and diabetes team. There should be referral to the Joint Clinic for obstetric review at 36 weeks.

In relation to delivery the NICE Guidelines indicate:

• Advise women with gestational diabetes to give birth no later than 40 +6 weeks. Offer elective birth by induced labour or (if indicated) by caesarean section to women who have not given birth by this time.

• Consider elective birth before 40 +6 weeks for women with gestational diabetes who have maternal or fetal complications.

A clear and adequate management plan can prevent against the delivery risks and ultimately the death of a baby.

Hypertension

Women who suffer from high blood pressure during pregnancy are at risk of intrauterine growth restriction (poor fetal growth), stillbirth, and pre-eclampsia. These women require increased levels of monitoring during their pregnancy to ensure that their high blood pressure is not affecting the growth of the baby.

A sustained raised blood pressure should result in antihypertensive treatment and admission for observation. Any high blood pressure reading would prompt a cardiotocograph (CTG) to assess fetal wellbeing.

Women with hypertension should have their blood pressure monitored every 15 - 30 mins during labour and are more likely to have a c-section or forceps delivery.

Pre-eclampsia

The mother will also be checked for signs of pre-eclampsia, a condition that causes the blood pressure to rise. This will involve testing the mother's urine for protein. Urine tests should be completed at every antenatal appointment.

Women who have suffered from high blood pressure before becoming pregnant, have had pre-eclampsia in a previous pregnancy, or have a family history of pre-eclampsia, will be identified as at high risk of developing pre-eclampsia. They must be monitored for signs of pre-eclampsia such as high blood pressure and protein in the urine at each antenatal appointment.

Symptoms of pre-eclampsia may include raised blood pressure, protein in the urine, headaches, abdominal pain, reduced fetal movements, as well as swelling in the hands, face and feet.

There is evidence that taking a low dose of aspirin daily throughout the pregnancy may reduce the risk of pre-eclampsia. Some women may be advised to take aspirin by their consultant.

Issues on presentation to hospital

A common problem that I have encountered in cases where women have presented in the emergency department is that clinicians in this setting are not aware of the guidelines for the management of pregnant or postnatal women attending the emergency department or non maternity ward. I have learnt that information sharing is essential, and staff must be properly trained. One common error is a failure to use Modified Obstetric Early Warning Score (MEOWS) , rather than the NEWS. In my experience this has led in a delay and failure to escalate appropriately.

A failure to adequately monitor pregnant women for issues such as pre-eclampsia, high blood pressure, and gestational diabetes can lead to devastating consequences during childbirth. As a lawyer I have to consider, often with the assistance of expert opinion, what would the outcome have been had the correct approach been taken. The loss is the difference to the outcome that it made.

There are so many factors that impact a pregnancy and the outcome. If you or your family member have suffered from any pregnancy complications and feel that there has been a breach of duty of care by your midwife or consultant, please contact a member of our clinical negligence team to discuss your concerns.