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Estimates of adherence to antihypertensive treatment in pregnancy are limited; identifying non-adherence could facilitate intervention and optimise blood pressure control. This study aimed to evaluate adherence to antihypertensive treatment amongst pregnant women with chronic hypertension using high-performance liquid chromatography-tandem mass spectrometry instrumentation. Spot urine samples collected from women who were randomised to labetalol or nifedipine were assessed. Samples from 74 women were included; documented prescribing and urine metabolite detection were concordant in 88% (n = 65). Evidence of self-administration of alternative treatment was observed in 8% (n = 6). Measurement of urinary antihypertensive metabolites in pregnancy provides insight into treatment adherence., (Copyright © 2019 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Background: Despite numerous publications stating the importance of multidisciplinary care for women with pre-existing medical conditions, there is a lack of evidence regarding structure or processes of multidisciplinary working, nor impact on maternal or infant outcomes. This study aimed to evaluate the implementation of guidelines for multidisciplinary team (MDT) management in pregnant women with pre-existing diabetes or cardiac conditions. These conditions were selected as exemplars of increasingly common medical conditions in pregnancy for which MDT management is recommended to prevent or reduce adverse maternal and fetal outcomes., Methods: National on-line survey sent to clinicians responsible for management or referral of women with pre-existing diabetes or cardiac conditions in UK National Health Service (NHS) maternity units. The survey comprised questions regarding the organisation of MDT management for women with pre-existing diabetes or cardiac conditions. Content was informed by national guidance., Results: One hundred seventy-nine responses were received, covering all health regions in England (162 responses) and 17 responses from Scotland, Wales and Northern Ireland. 132 (74%) related to women with diabetes and 123 (69%) to women with cardiac conditions. MDT referral was reportedly standard practice in most hospitals, particularly for women with pre-existing diabetes (88% of responses vs. 63% for cardiac) but there was wide variation in relation to MDT membership, timing of referral and working practices. These inconsistencies were evident within and between maternity units across the UK. Reported membership was medically dominated and often in the absence of midwifery/nursing and other allied health professionals. Less than half of MDTs for women with diabetes met the recommendations for membership in national guidance, and although two thirds of MDTs for women with cardiac disease met the core recommendations for membership, most did not report having the extended members: midwives, neonatologists or intensivists., Conclusions: The wide diversity of organisational management for women with pre-existing diabetes or cardiac conditions is of concern and merits more detailed inquiry. Evidence is also required to support and better define the recommendations for MDT care.

Background: Women with chronic kidney disease have an increased risk of maternal and fetal complications in pregnancy. Pre-pregnancy counselling is recommended but the format of the counselling process and the experience of the patient have never been assessed. This study examines the experience of women with chronic kidney disease attending pre-pregnancy counselling and evaluates their pregnancy outcomes., Methods: This is a cross-sectional assessment of 179 women with chronic kidney disease attending a pre-pregnancy counselling clinic (2003-2011) with retrospective evaluation of aetiology, comorbidity, treatment and adverse pregnancy outcome compared with 277 hospital controls. It includes an analysis of descriptive data and free text content from 72 questionnaire responders., Results: 65/72 (90%) of women found the clinic informative. 66 women (92%) felt that the consultation had helped them decide about pursuing pregnancy. 12 women (17%) found the multidisciplinary process intimidating. Free text comments supported the positive nature of the counselling experience, but also highlighted issues of access and emotional impact. Adverse pregnancy outcome rates were significantly higher in women with chronic kidney disease: 7/35 (20%) had pre-eclampsia (p < 0.001), 8/35 (23%) infants were small for gestational age (p < 0.001), 11/35 (31%) had preterm deliveries (<37 weeks) (p < 0.001) and 5/35 (14%) had a pregnancy loss compared with 4%, 10%, 8% and 3% of controls respectively., Conclusions: Women with a diverse range of renal disease severity and complexity attend pre-pregnancy counselling. Factors affecting pregnancy include hypertension, proteinuria and teratogenic medication. It is important to be able to inform women of the risks to them and their babies before pregnancy in order to facilitate informed-decision making. Most women with chronic kidney disease attending a pre-pregnancy counselling clinic report a positive experience.

A national U.K. workshop to discuss practical clinical management issues related to pregnancy in women with myasthenia gravis was held in May 2011. The purpose was to develop recommendations to guide general neurologists and obstetricians and facilitate best practice before, during and after pregnancy. The main conclusions were (1) planning should be instituted well in advance of any potential pregnancy to allow time for myasthenic status and drug optimisation; (2) multidisciplinary liaison through the involvement of relevant specialists should occur throughout pregnancy, during delivery and in the neonatal period; (3) provided that their myasthenia is under good control before pregnancy, the majority of women can be reassured that it will remain stable throughout pregnancy and the postpartum months; (4) spontaneous vaginal delivery should be the aim and actively encouraged; (5) those with severe myasthenic weakness need careful, multidisciplinary management with prompt access to specialist advice and facilities; (6) newborn babies born to myasthenic mothers are at risk of transient myasthenic weakness, even if the mother's myasthenia is well-controlled, and should have rapid access to neonatal high-dependency support.

The aims of critical care management are broad. Critical illness in pregnancy is especially pertinent as the patient is usually young and previously fit, and management decisions must also consider the fetus. Assessment must consider the normal physiological changes of pregnancy, which may complicate diagnosis of disease and scoring levels of severity. Pregnant women may present with any medical or surgical problem, as well as specific pathologies unique to pregnancy that may be life threatening, including pre-eclampsia and hypertension, thromboembolic disease and massive obstetric haemorrhage. There are also increasing numbers of pregnancies in those with high-risk medical conditions such as cardiac disease. As numbers are small and clinical trials in pregnancy are not practical, management in most cases relies on general intensive care principles extrapolated from the non-pregnant population. This chapter will outline the aims of management in an organ-system-based approach, focusing on important general principles of critical care management with considerations for the pregnant and puerperal patient.

Simultaneous pancreas and kidney (SPK) transplantation, in uremic women with insulin‐dependent diabetes, increases the chance of a successful pregnancy and minimizes the risk to infants. The aim of this study was to document pregnancy and explore the challenges in this cohort of women. Retrospective analysis of women who underwent pancreas transplantation between January 1, 1998 and 8 January, 2019 was conducted. Seventeen pregnancies were identified in 13 women. Mean transplant‐to‐pregnancy interval was 4.6 years (range, 1.1–10.2 years). Eleven pregnancies resulted in live birth (65%), and six (35%) ended in miscarriage/fetal loss at a median gestational age of 8.5 weeks. Mean gestational age at delivery was 34.9 weeks (SD ±3 weeks). Preeclampsia and C‐section rates were 77% and 67%, respectively. Adverse fetal and graft outcomes were observed in 100% of unplanned pregnancies, compared to 10% of planned pregnancies (P <.001). One kidney allograft was lost during pregnancy; one pancreas and two kidney allografts were lost within 3 years of pregnancy. This is a high‐risk group for grafts and offspring. Pre‐pregnancy planning is vital. A multidisciplinary approach by obstetric and transplant teams is important pre‐pregnancy, antenatally, and peripartum. This is the largest published series of pregnancies in SPK recipients from a single center. [ABSTRACT FROM AUTHOR]

Neurological disease encompasses a broad spectrum of conditions which may be affected by pregnancy, present de novo in pregnancy, or are caused by the pregnancy itself. In the UK, 9.8 women in 100,000 died during pregnancy or up to 42 days after delivery (Mothers and Babies Reducing Risk through Confidential Enquiry (MBRRACE) report 2018). Neurological diseases, including epilepsy and stroke, continues to be the second leading indirect cause of maternal mortality and the numbers have not changed since reporting began in 1985, despite the availability of easily accessible Green-top Guidelines on the management of epilepsy through the Royal College of Obstetricians and Gynaecologists (RCOG). It is important than any women of child-bearing age with a neurological condition receive appropriate pre-pregnancy counselling and that during pregnancy they are managed by an experienced multi-disciplinary team including a neurologist, specialist nurse or midwife, maternal medicine obstetrician or obstetric physician and obstetric anaesthetist. Additional benefits in care will come with improving awareness in the general public and community doctors so that appropriate support is provided to enable the safest possible pregnancy. [ABSTRACT FROM AUTHOR]

Key content: Postural tachycardia syndrome (PoTS) is a potentially debilitating autonomic disturbance that primarily affects females between the ages of 15 and 50 years, and may present for the first time during pregnancy. The typical signs and symptoms are vague and therefore the condition is often under‐ or misdiagnosed as pregnancy may induce similar symptoms. If correctly diagnosed and managed, patients have a good outcome; however, a delay in diagnosis may be disabling. PoTS is unfamiliar to most clinicians and its variable course during pregnancy requires a better understanding of the condition. PoTS management in pregnancy may be challenging and clinicians should be aware of common strategies that are suitable in pregnancy. A multidisciplinary approach is essential for correctly diagnosing and managing the condition and optimising pregnancy outcomes. Learning objectives: To understand: The common symptoms and signs of PoTS. How to diagnose and manage PoTS safely in pregnancy. The likely course of disease in pregnant women with PoTS. The effect of pregnancy on PoTS. Multidisciplinary antenatal, intrapartum and postnatal considerations required for patients with PoTS. Ethical issues: The impact of delayed diagnosis on individuals. The safety of commonly used pharmaceutical agents. The role of psychological support. [ABSTRACT FROM AUTHOR]

Indirect maternal deaths outnumber direct deaths due to obstetric causes in many high-income countries, and there has been a significant increase in the proportion of maternal deaths due to indirect medical causes in low- to middle-income countries. This review presents a detailed analysis of indirect maternal deaths in the UK and a perspective on the causes and trends in indirect maternal deaths and issues related to care in low- to middle-income countries. There has been no significant decrease in the rate of indirect maternal deaths in the UK since 2003. In 2011-2013, 68% of all maternal deaths were due to indirect causes, and cardiac disease was the single largest cause. The major issues identified in care of women who died from an indirect cause was a lack of clarity about which medical professional should take responsibility for care and overall management. Under-reporting and misclassification result in underestimation of the rate of indirect maternal deaths in low- to middle-income countries. Causes of indirect death include a range of communicable diseases, non-communicable diseases and nutritional disorders. There has been evidence of a shift in incidence from direct to indirect maternal deaths in many low- to middle-income countries due to an increase in non-communicable diseases among women in the reproductive age. The gaps in care identified include poor access to health services, lack of healthcare providers, delay in diagnosis or misdiagnosis and inadequate follow-up during the postnatal period. Irrespective of the significant gains made in reducing maternal mortality in many countries worldwide, there is evidence of a steady increase in the rate of indirect deaths due to pre-existing medical conditions. This heightens the need for research to generate evidence about the risk factors, management and outcomes of specific medical comorbidities during pregnancy in order to provide appropriate evidence-based multidisciplinary care across the entire pathway: pre-pregnancy, during pregnancy and delivery, and postpartum. [ABSTRACT FROM AUTHOR]

Death from venous thromboembolism (VTE) in pregnancy is potentially preventable. Guidelines from the Royal College of Obstetricians and Gynaecologists (2015) provide a framework to assist clinicians in risk- stratifying pregnant women and offer measures to reduce the possibility of developing VTE. The biggest challenge for clinicians is to remember to risk-stratify women while not over-medicalising a 'normal' pregnancy. [ABSTRACT FROM AUTHOR]

Key content Systemic lupus erythematosus (SLE) is an autoimmune condition that has multi-organ involvement., It is approximately ten times more common in women than in men and is often diagnosed during the childbearing years., SLE is known to increase the risk of spontaneous miscarriage; it can also cause fetal growth restriction and increased rates of sudden intrauterine death, pre-eclampsia and preterm delivery., Management of women with lupus nephritis can be difficult, as the disease may mimic and overlap significantly with pre-eclampsia., Multidisciplinary management of pregnant women with SLE ensures optimal surveillance of both mother and fetus., Learning objectives To understand how to manage pregnant women with SLE., To understand the importance of pre-pregnancy counselling for women with SLE., To understand the features and associated risk factors which increase the chance of adverse pregnancy outcome in women with SLE., To understand which therapies for SLE can be used safely in pregnancy and while breastfeeding., To understand the role of the multidisciplinary team in the care of women with SLE, particularly those with underlying organ impairment., Ethical issues When should women with SLE be advised against pregnancy?, At what point should termination of pregnancy be considered if there is deterioration in maternal health in early pregnancy? [ABSTRACT FROM AUTHOR]

Abstract: Obstetric critical illnesses represent a small but important proportion of all intensive care unit (ICU) admissions in the UK. They are challenging to the critical care team because of the unique physiology and specific medical disorders seen in this population. Maternal mortality is fortunately rare, but devastating when it occurs, with the commonest causes of death being cardiac disease and venous thromboembolism. Massive obstetric haemorrhage, pre-eclampsia and genital tract sepsis are also important causes, and these are reflected in the reasons for ICU admission in the obstetric population. Maternal mortality may be reduced by prompt recognition of critical illness in the pregnant woman, earlier initiation of intensive care, and increased input from senior clinicians. ICU management involves resuscitation, monitoring \and assessment of deranged physiology, and the provision of safe organ support. The overall aims are to ensure adequate oxygen delivery and tissue perfusion, and to stabilise the patient while awaiting investigations which may guide further disease-specific management. The normal physiological adaptations to pregnancy and the effects of any drugs or procedures on the fetus should be taken into account. [Copyright &y& Elsevier]

An introduction is presented in which the editors discuss various reports within the issue on topics including maternal deaths, the cost-effectiveness of 2009 thromboprophylaxis guidelines, and peripartum cardiomy.

The authors reflect on the role of obstetric medicine in holistic care. They state that obstetric physicians are specialized on pre-pregnancy, antennal, and postnatal care of women with medical disorder of pregnancy. They mention several subspecialties of obstetric medicine including assisted conception, fetal surgery, and perinatology. They relate that obstetric medicine involves several health professionals that work together to provide the appropriate care for the pregnant patients.

Objectives: To map the care provided to pregnant women with epilepsy in UK maternity units and identify future research priorities by conducting a nationwide survey of healthcare professionals.Study Design: A prospective cross-sectional electronic survey was conducted between 29 April and 30 October 2021. The survey included 23 questions developed and refined with relevant stakeholders, including a woman with lived experience of epilepsy and pregnancy. We used descriptive analyses to summarise responses and estimated proportions with medians and interquartile ranges.Results: 144 individual healthcare professionals from 94 hospitals, representing 77 NHS Trusts, participated in the survey. Obstetricians were the most common responders (45%, 65/144) and almost half (47%, 7/15) of regions had a survey response rate per NHS Trust greater than 50%. Six pregnant women with epilepsy, on average, were booked into antenatal care per hospital per month, and 49% (46/94) of hospitals saw women for specialist antenatal care in the first trimester. The care provided across healthcare systems varied, with multiple pathways for referral to specialist care within regions. Midwife referral was the most used care pathway (80%, 75/94). Less than a third of hospitals (31%, 29/94) ran joint obstetric/neurology clinics for pregnant women with epilepsy. Most survey respondents (81%, 117/144) were confident talking to pregnant women about their risk of seizures but only a minority (20%, 29/144) used validated calculators to assess this risk. There was broad agreement across healthcare professionals that the priorities for research should focus on how to improve communication and address pregnant women's concerns regarding epilepsy and pregnancy, and to develop further understanding on the optimal use and long-term effects of anti-seizure medication.Conclusion: Our UK nationwide survey of hospital-based maternity services for pregnant women with epilepsy identified wide variation in when, how and by whom these women are seen, with differences between and within the UK regions. This survey highlights areas for improvement in the care of pregnant women with epilepsy. [ABSTRACT FROM AUTHOR]