When 30-year-old Filipina pregnant with twins presented at Aster Hospital Al Qusais’ Emergency due to reduced foetal movement and vaginal bleeding, the prognosis was poor. Diagnosed with placental abruption, where the placenta separates from the inner wall of the uterus, the babies were in danger of their oxygen supply being completely cut off and the mother was facing the prospect of heavy bleeding. To make matters worse Dr Fathima Safa, Specialist Obstetrics and Laparoscopic Gynaecology, could only detect one of the twins’ heartbeat. In a bid to save at least one of the babies, the patient was rushed to the operation theatre for a lower segment caesarean section. Even though one of the babies was delivered successfully, the other was limp. “But by God’s grace, we were able to resuscitate the second twin with the help of the paediatrician on call,” says Dr Safa who attributes the success to teamwork. “Timely intervention from all concerned, from the registrar to the paediatrician, helped save lives.”
Although placental abruption is an uncommon but serious complication – it occurs only in 0.4-1 per cent of pregnancies – there are other common complications that turn a pregnancy into a high-risk one, putting the life of the baby and mother in danger.
“Preterm deliveries, gestational diabetes and pregnancy-induced hypertension are among the commonest complications in a high-risk pregnancy,” explains Dr Shuchita Meherishi, Specialist Obstetrics and Laparoscopic Gynaecology at Aster Hospital, Al Qusais.
Preterm deliveries, gestational diabetes and pregnancy-induced hypertension are among the commonest complications in a high-risk pregnancy.
“More women are entering pregnancy with pre-existing high-risk factors such as previous surgeries like caesareans and fibroid removals; multiple pregnancies after assisted reproduction treatment; or age- and lifestyle-related conditions such as diabetes and hypertension. Consequently the baby may need to be delivered before its due date.”
Dr Meherishi adds that in the UAE she regularly comes across women who have undergone three to five caesarean sections. In other parts of the world it’s uncommon to see women with more than two C-sections. This of course increases the risk of complications during the next pregnancy, along with factors such as advanced age, obesity, epilepsy, thyroid disease, heart or blood disorders, and poorly controlled asthma.
So it pays to be more vigilant. Looking for early warning signs during routine check-ups, taking time to review reports in detail, listening closely to patient’s concerns, and educating the patient and her husband to watch out for red flags all go a long way in ensuring a healthy outcome for the mother and baby, says Dr Meherishi.
“Pregnancy is a dynamic nine months’ journey where things can at times go wrong,” she explains. “Skill and teamwork are essential. In Aster hospitals, our obstetrics and gynaecology team of specialists, labour room duty doctors and midwives are supported 24x7 by anaesthetist specialists for emergency surgeries and painless epidural labour, state-of-the-art operation theatre, a neonatal team for newborns and NICU. When required, the other specialists such as intensivists, endocrinologists, and cardiologists also give full support.”
While this support is crucial to ensure a successful delivery, the preparation for motherhood ought to begin much earlier than pregnancy, especially if there are risk factors. “Preconception counselling is the most effective way to identify and manage a high-risk pregnancy,” says Dr Jisha Pradeep, Specialist Obstetrics and Laparoscopic Gynaecology at Aster Hospital, Mankhool. “This helps us understand the risk factors and carry out the management option that is best suited for the patient. It is also an excellent opportunity to have an in-depth discussion regarding the over-the-counter medications the patient might be on. The importance of optimising weight in overweight and obese women, cessation of smoking, and planning pregnancy in the prime child-bearing age, etc. can be stressed upon during this consultation.”
Preconception counselling is the most effective way to identify and manage a high-risk pregnancy.
Beyond the preconception consultation, Aster offers antenatal packages that include all relevant investigations as per international standards to make sure the pregnancy proceeds smoothly. “We have different antenatal packages suitable for women who may travel out to their home country for delivery before 34 weeks, who come to the UAE before delivery after 28 weeks, or those looking for follow-up throughout their pregnancy and delivery,” explains Dr Susmita Das, Specialist Obstetrics and Laparoscopic Gynaecology at Aster Hospital, Mankhool. “They include antenatal consultations as well as post-delivery follow-up, but we clearly explain that certain high-risk patients with high blood pressure, diabetes and thyroid issues may need extra tests as per their condition that may be related to liver, kidney, etc.
“Usually three-four scans in the package are good enough but some patients with suspected growth disorders may require an extra scan or a Doppler. Some others with pre-existing conditions may require an additional consultation from a specialist, rheumatologist, cardiologist or nephrologist. Overall the package provides a substantial and economical care for patients who don’t have an insurance with maternity benefits.”
The maternity package provides a substantial and economical care for patients who don’t have an insurance with maternity benefits.
Dr Das believes women in the UAE are adequately aware about health issues that concern them thanks to the internet but at times the information overload can be confusing.
“So it is important on our part to guide patients to the right sources or provide them with correct links for information. They should also know that they have the freedom to go for a second or a third opinion if they are unsure.”
Managing rare complications
Aster hospitals are equipped with highly qualified specialists as well as the medical infrastructure to deal with the rarest of rare complications of pregnancy. Dr Caroline Alphine Jenitha, Specialist Obstetrics and Laparoscopic Gynaecology at Aster Hospital Mankhool, came across one such complication, haemoperitoneum, or intra-abdominal haemorrhage, following spontaneous rupture of the uterine vessel when a 29-year-old patient at 24 weeks pregnant was brought to the Emergency with upper abdomen pain and dizziness. With fewer than 150 cases reported, this life-threatening complication usually occurs in-vitro fertilisation pregnancy with a history of endometriosis.
Urgent ultrasound of the patient revealed a massive haemoperitoneum with foetal death. “Emergency laparotomy was done through midline vertical incision, with arrangements being made for blood and blood products,” explains Dr Jenitha. Experts were able to identify the ruptured vein that caused the internal bleeding in the peritoneal cavity – of about four litres with clots – and tie it up. A lower segment C-section was carried out to deliver the stillborn foetus.
Owing to recent advances in anaesthetic, resuscitative and operative technique, maternal mortality has been lowered from 50 per cent to 3 per cent.
“Owing to recent advances in anaesthetic, resuscitative and operative technique, maternal mortality has been lowered from 50 per cent to 3 per cent,” says Dr Jenitha. “But perinatal mortality remains high. Rapid diagnosis and aggressive fluid management together with prompt surgical intervention may be the only chance for a favourable outcome for both mother and child in such a rare, life-threatening complication.”
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