Pregnancy for Women with Complex Medical Needs Homerton

Pregnancy for Women with Complex Medical Needs Homerton University Hospital London Maryam Parisaei Consultant Obstetrician and Gynaecologist Jane Bekoe Midwifery Manager for Antenatal Clinic

Increasingly Common Conditions • Obesity • Advanced Maternal Age • IVF/Ovum donation

Body Mass Index ≥ 30 Independent Risk Factor • Folic Acid 5 mg Pre conception • 3 x more likely to develop GDM • 4 x more likely to develop pre-eclampsia • Stillbirths 1 in every 100 births • 50% chance of caesarean section

Age : Independent Risk Factor for Perinatal Outcomes • Advance Maternal Age: >35 years • With increasing age – Pre eclampsia X 2 ↑ – Fetal Growth Restriction ↑ – Placental Abruption X 1. 5 ↑ – Stillbirth rates x 2 ↑ • Advanced Paternal Age: >45 ↑stillbirth rates by 50% • Placental development, structure and function alters with age Advanced Maternal Age and Adverse Pregnancy Outcomes: 44 Million births A Systemic Review and Meta-analysis Lean et al 2017

Advanced Maternal Age UKOSS Publication • • Multiple pregnancy 18% Gestational Hypertensive disorder 15% Gestational Diabetes 18% Pre term Birth 22% Caesarean section 78% Post partum haemorrhage 26% Maternal Mortality 22 : 100 000

IVF/ICSI Independent Risk Factor • Increased Rates of – – – – Antepartum haemorrhage Hypertensive disorders Gestational Diabetes Pre labour Premature Rupture of Membranes Caesarean section Low birth weight baby Increased admission to Neonatal Intensive Care Postpartum haemorrhage

Ovum Donation Additional Risk Factor • Hypertensive disease – most common complication – higher than spontaneous and autologous IVF – Twins X 3 more likely • Caesarean section – Increased elective and emergency • Post partum haemorrhage – Increased rates of blood transfusion and hysterectomy

Before Embryo Transfer • Preconception Counselling please – BMI <30 – Control diabetes – BP <135/80 – Cervical Screening – Breast Screening – Mental Health – Co morbidities: Disease in Remission – Advise and inform women of risks

Obstetric Medicine Clinics Homerton MDT Approach • • Cardiology Hypertension Endocrine Gastroenterology Rheumatology Haematology Neurology Women with Previous Poor Outcome

Better Birth 2020 Personalised Care Continuity of Carer Safer Care Better postnatal and perinatal mental health care • Multi-professional working • Working across boundaries • Better payment system • •

The Multi-Disciplinary Team • • • Midwives Maternity Support Workers Obstetricians Specialist Physicians Anaesthetists Specialist Midwives Administrative Staff Specialist Nurses Dieticians

First Pilot Team- ELM • City & Hackney CQUIN commission • Collaborative working for women with complex medical needs • Model of care is designed and approved for 25 women with pre-existing diabetes • Booked & case-loaded until post delivery inpatient • Pilot began April 1 st 2019 & exceeds 25 clients • Bespoke Antenatal Education Classes • Meet the ELM Team Sessions (last Wednesday of every month)

Queries huh-tr. obstetricquery@nhs. net or Maternity Helpline 020 8510 5955 Self Referral via Homerton Website

Thank you for all your referrals and helping us care for the women and their babies.