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Physicians Update


Physicians Update

Spring 2011

The Right Setting Is Necessary for Optimal Management of High-Risk Pregnancies


PU-Spring11-High Risk PregnanciesUCLA is seeing a growing number of high-risk pregnancies, according to Khalil Tabsh, M.D., vice chair of obstetrics and gynecology, due to several trends, including more women postponing childbirth until they are older, advances in infertility treatment and improvements in the medical management of diseases that were once incompatible with pregnancy. These patients are benefiting, among other things, from advances in prenatal technology and the ability to better detect — and in some cases intervene to treat — fetal abnormalities.

But Dr. Tabsh notes that optimal management of high-risk pregnancies involves more than stateof- the-art technology. “Patients need to be cared for in a setting in which any real or potential complications can be appropriately managed,” he says. At UCLA, that means not only highlevel diagnostic and treatment technology as well as access to the latest research, but also a comprehensive team approach. “It is important to have every specialty that might be needed accessible in a timely manner to assist in the management of these patients,” Dr. Tabsh says.

Unlike most facilities, UCLA has both an attending obstetrician and a dedicated OB anesthesiologist present in the hospital 24 hours a day, seven days a week. “For high-risk pregnancies we need to be prepared to take immediate action and have the entire team ready if there is a need for an emergency Cesarean section or other procedure,” says Jeannine Rahimian, M.D., an obstetrician at Ronald Reagan UCLA Medical Center. “At UCLA, if we decide an emergency C-section is indicated, we can have the patient in the OR and the baby out within a few minutes,” she adds. “For babies who will require admission to the Neonatal Intensive Care Unit (NICU), we can have them there without delay.”

Moreover, Dr. Tabsh, notes, UCLA’s perinatologists take on all of the obstetric care for high-risk patients. “This is rare,” Dr. Tabsh says. “Most maternal fetal medicine specialists and centers do only consultation, diagnosis and treatment, and perhaps co-management with an obstetrician, but not total care and delivery.”

Dr. Tabsh adds that pregnancies can be considered high risk for obstetric, medical or fetal issues. Fetal problems may include congenital defects such as cardiac, abdominal wall, brain/spinal or renal abnormalities; chromosome defects such as Down syndrome; or intrauterine growth retardation. These cases typically require immediate NICU admission following delivery.

Obstetric issues can range from patients who have had one or more previous Cesarean sections or those with multiple gestations to those with a history of premature labor, as well as cases of gestational diabetes, pregnancy-induced hypertension/preeclampsia and placenta previa. Medical problems that place pregnancies in the high-risk category include diabetes, hypertension, thyroid disease, autoimmune disease, asthma, clotting disorders, exposure to infectious disease and recurrent pregnancy loss. These conditions can be safely managed by achieving a stable state prior to pregnancy, Dr. Tabsh says.

These types of maternal risks demand early involvement of anesthesiologists to develop a plan of action. “We meet with the patient for an informal consultation well before the expected due date if there are maternal problems that complicate the pregnancy,” explains Richard Hong, M.D., chief of obstetrical anesthesia at UCLA. With 24/7 anesthesia coverage at UCLA, these consultations can occur following the patient’s visit to her regular obstetrician, he notes.

PU-Spring11-High Risk PregnancyAmong the factors Dr. Hong and his team must take into account when developing anesthetic plans for high-risk cases are bleeding disorders. For these patients, general anesthesia might be considered as an alternative to spinal or epidural anesthesia, despite the downside that the patient wouldn’t be awake during delivery. Similarly, placenta previa, in which the placenta develops so low in the uterus that it surrounds the cervical opening, can lead to increased maternal blood loss. “That’s the kind of condition we want to know about ahead of time, because we might manage those patients differently,” Dr. Hong says.

UCLA’s 24/7 in-house anesthesia coverage has also been a major factor in drawing certain types of high-risk patients. Among them are patients interested in attempting a vaginal birth after C-section (VBAC). “These patients are considered to be at increased risk of complications, including the uterus rupturing from the previous surgical incision, and as a result many obstetricians won’t see those patients in hospitals that don’t have 24/7 anesthesia coverage,” Dr. Hong explains.

Teamwork among the specialists is a key to successful management of high-risk pregnancies, Dr. Rahimian says. “When the obstetricians are seeing an issue, we alert the anesthesiologists ahead of time so that in an emergency, they have already assessed the patient and know there is a possibility that we might need an emergency procedure,” she explains. “This ensures that things run much more smoothly in the event of an emergency.” The high-risk team has also initiated a system in which a page goes out to the obstetrician, anesthesiologist and NICU team any time a patient is admitted for a C-section so that no time is lost and all parties are well prepared.

Ideally, high-risk pregnancy candidates should be referred for consultation prior to their pregnancy, Dr. Tabsh says.

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