Michael Peek - The Australian National University

1. Planning and counselling for high risk pregnancies:
Best to start early!
Professor Michael Peek
michael.peek@anu.edu.au

2. 2
Conflicts of interest

3. Does planning pregnancy improve
outcomes?
• Not a lot of data
Aust N Z J Obstet Gynaecol. 2014 Dec;54(6):510-4.
Does preconception care work?
Beckmann MM1, Widmer T, Bolton E.
Evaluated whether women who receive preconception care through a
structured approach will be more likely to be healthy around the time of
conception compared with women who plan their pregnancy but have not
been exposed to preconception care.
Suggested some optimism that a comprehensive preconception care service
may positively influence maternal and neonatal outcomes.
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4. Meta-analysis of preconception care in Type
1 Diabetes
Pooled rates of major congenital anomalies
•Preconception care 2.1%
•No Preconception care 6.5%
•RR 0.36 95% CI 0.22-0.59
Ray JG et al. QJ Med 2001; 94:435-44

5. Reality
• Perinatal mortality rate
• Maternal mortality rate
• Induction rate
• Caesarean section rate
• Episiotomy/tear rate
• Pre-eclampsia, twins, PPH………….
• Models of care and place of birth
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6. High risk pregnancy???
• Definition
• Before, during, after
• Maternal problems
– Coexisting medical disorders, obesity,
previous poor obstetric outcomes, placenta
praevia……….
• Fetal problems
– Anomaly, multiple pregnancy, growth
restriction………
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7. Basics
• Effects of pregnancy on the disease
• Effects of the disease on the pregnancy
• Effects of treatment
• Know what’s coming!
• Don’t forget normal pregnancy care
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8. General issues in counselling for high
risk pregnancies
and what can you do about them?
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9. Risk
• Means different things to different people
• Comparing risk
• How we counsel will change a person’s
perspective of risk
• Qualitative studies
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10. Multidisciplinary Approach
• Does not just mean seeing a lot of people
from different disciplines
• Multidisciplinary plan with everyone
coming to a consensus on the plan
• Understanding maternal physiology
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11. Don’t forget the baby
• Many conditions often lead to preterm
delivery
• Need to explain the implications of preterm
delivery
• Counselling by neonatologist
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12. What is the child’s prognosis
• Understanding the realities of the condition
is difficult
• Referral to paediatric surgeons,
specialised clinics, families with the same
problem
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13. Termination of pregnancy
• Legal aspects
• Difficulties and dangers of raising the
option
• No right answer
• Wanted children
• Medical v Surgical TOP
• Fetocide
• Staff
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14. Planning a loss
• ? Monitoring in labour
• ? Caesarean section
• ? Resuscitation
• ? Palliation
• Keeping the baby with the family
• An agreed, documented plan is needed
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15. Practicalities of care and delivery
• Difficulties of those living rurally
• Increased number of visits
• Effects on family
• Costs
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16. Making sure the plan is followed
• Written documentation to the woman,
general practitioner, hospital……
• Tell the woman who to contact if there is
an issue
• Hospital Meetings with documentation
• Hospital guidelines and protocols
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17. Dealing with an adverse or unexpected
outcome
• Immediate accurate information
• Debriefing
• Staff
• Post mortem and other tests
• Hospital processes
• Follow up
• Risk of recurrence
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18. Coordination
• For all aspects of care
– Information
– Visits
– Management
– Follow up
• Need someone to lead this
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