O&G · Intrapartum care — medical comorbidity
Intrapartum care for women with existing medical conditions
Also known as Medical disorders in pregnancy · Cardiac disease in labour · Diabetes in labour · Epilepsy in labour · Obesity in labour · Anticoagulation in pregnancy
Exam-exhaustive FRANZCOG reference on intrapartum care for women with existing medical conditions — the modified WHO cardiac classification and CARPREG II risk, the diabetes intrapartum glucose target and CONCEPTT, epilepsy in labour, the obesity class III thresholds and difficult-airway implications, and the anticoagulation-to-neuraxial timing rules. Anchored to the ESC and ASH guidelines, RANZCOG-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- A woman whose written intrapartum plan exists but the night team has never read it — the most common failure in this topic
- Ergometrine given reflexively to a cardiac or hypertensive woman — reach for oxytocin, slow and dilute
- Antiseizure medication withheld because the woman is nil by mouth — give it by another route, never skip it
- An epidural sited too close to a heparin dose — the spinal epidural haematoma that never needed to happen
- Fluid loaded into a fixed-output lesion before a spinal — the decompensation you caused
- Every seizure in labour labelled eclampsia — a woman with epilepsy is allowed to have epilepsy
She is 34, she has bicuspid aortic stenosis, and she is 6 cm in labour. The plan is in the notes — written by you, signed by cardiology and anaesthesia three weeks ago. The whole of this topic turns on whether you wrote it, whether you can find it at 03:00, and whether it anticipates the moment that goes wrong. Indirect maternal deaths — those from medical conditions worsened by pregnancy — now outnumber direct obstetric deaths in high-income settings, and the European Society of Cardiology guideline exists precisely because cardiac disease is the leading of these, with most deaths preventable by an intrapartum plan that actually reached the labour ward.[4]
Overview and definition
An "existing medical condition" in this topic is one the woman walked into pregnancy with — cardiac disease, pre-existing or gestational diabetes, epilepsy, obesity, a thrombophilia or a current anticoagulant, and the rarer autoimmune, renal, haematological and neuromuscular disorders.[4]
The unifying principle is simple and the failures are always the same: the plan must be written antenatally, agreed by every specialty involved, and findable on labour ward. A plan that lives in a clinic letter nobody opens is no plan at all.[4]
References13ShowHide
- [1]Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation, 2001.PMID 11479246
- [2]Silversides CK, Grewal J, Mason J, et al. Pregnancy Outcomes in Women With Heart Disease: The CARPREG II Study. J Am Coll Cardiol, 2018.PMID 29793631
- [3]Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J, 2010.PMID 20584777
- [4]Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J, 2018.PMID 30165544
- [5]Ruys TP, Roos-Hesselink JW, Pijuan-Domènech A, et al. Is a planned caesarean section in women with cardiac disease beneficial? Heart, 2015.PMID 25539946
- [6]Feig DS, Donovan LE, Corcoy R, et al. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. Lancet, 2017.PMID 28923465
- [7]Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip. Am J Obstet Gynecol, 2006.PMID 16893507
- [8]Bates SM, Rajasekhar A, Middeldorp S, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv, 2018.PMID 30482767
- [9]Leffert LR, Dubois HM, Butwick AJ, Carvalho B, Houle TT, Landau R Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis With Unfractionated or Low-Molecular-Weight Heparin: A Systematic Review and Meta-analysis. Anesth Analg, 2017.PMID 28628578
- [10]Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med, 2018.PMID 29561531
- [11]Harden CL, Hopp J, Ting TY, Pennell PB, French JA, Allen Hauser W, Wiebe S, Gronseth GS, Thurman D, Meador KJ, Koppel BS Management issues for women with epilepsy-Focus on pregnancy (an evidence-based review): I. Obstetrical complications and change in seizure frequency: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Epilepsia, 2009.PMID 19496807
- [12]Tähtinen RM, Cartwright R, Tsui JF, et al. Long-term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis. Eur Urol, 2016.PMID 26874810
- [13]Kominiarek MA, Espinal M, Cassimatis IR, Peace JM, Premkumar A, Toledo P, Shramuk M, Wafford EQ Peripartum interventions for people with class III obesity: a systematic review and meta-analysis. Am J Obstet Gynecol MFM, 2024.PMID 38494155