Clinical FeaturesWomen’s Health

Maternal Medicine; Where Teamwork Makes the Dream Work

We are all familiar with older generations saying “It wasn’t like that in my day!”. Indeed, when it comes to Obstetrics, never a truer word was said.

Women are now embarking on childbearing later in life due to a variety of socio-economic factors. The Irish CSO figures show that the average age at first childbirth in 1980 was 24.9 years. In 2018 this had risen to 31.1 years. The National Maternity Hospital’s Annual Report in 2022 demonstrated that 11.6% of all births in that year were to women aged over 40. Older mothers are more likely to have comorbidities than younger counterparts. Added to this, developments in medical and surgical therapies over the last 20-30 years have meant that more women with complex medical and surgical conditions in early life are now surviving & reaching childbearing years. All of these facts, coupled with a frameshift in societal expectation of what is now possible, has led to the development of Maternal Medicine as a distinct subspecialty of Obstetrics.

There are two key questions which the Maternal Medicine team must consider when meeting a woman with a complex medical condition who is now pregnant. How does the disease affect the pregnancy? And how does the pregnancy affect the disease? For example, the woman with epilepsy will have an increased risk of seizures in pregnancy due to the physiological plasma expansion and lowered serum levels of antiepileptic drugs that occurs in pregnancy and also the effects of pregnancy hormones on lowering the seizure threshold. Nausea and vomiting in pregnancy can affect medication compliance and sleep deprivation in late pregnancy can be a trigger for seizure activity also. Medication safety will be of critical importance to these women. Understanding the risk/benefit profile of the various anti-epileptic drugs will help get the best outcome for mother and baby. A second example of this could be a woman with active Lupus and hypertension. She will have a significant risk of pre-eclampsia, fetal growth restriction and iatrogenic preterm delivery due to her disease and so a care plan will need to be devised to mitigate against and offer surveillance for this. In turn, should she develop severe pre-eclampsia this may cause her renal function to deteriorate in the long term also and so the pregnancy may impact on her disease trajectory. Medication safety and optimisation will be a critical focus of the team here too.

Maternal Medicine is a team sport! Owing to the highly complex nature of the care provided at the Maternal Medicine Clinic, it is necessary to have a wide range of health care professionals working together on any given pregnancy. Obstetricians, Specialist Midwives and Advanced Nurse Practitioners, Maternal Medicine Pharmacists, Anaesthetics, Renal, Haematology, GI, Endocrinology and Neurology physicians among many others will frequent input to the care of any one women.

So what makes a Maternal Medicine team effective? The most critical skill in Maternal Medicine is good communication. Pregnancy is dynamic and deteriorations or changes in a patient’s status can happen quickly. Added to this, the unpredictability of obstetrics means that timely and effective communication between members is essential. The MultiDisciplinary Team (MDT) meeting is the lynchpin of the service where members are updated weekly and careplans are made. Shared decision making with the patient is an important part of any effective service and of course the Maternal Medicine team has a critical role in clinical teaching and improving the care of women with complex medical needs. Flexibility in delivery planning means that the Maternal Medicine team will often have developed 2 or 3 different delivery plans with one woman to account for the unpredictability of childbirth.

Increasingly, Preconceptual Counselling has come to the fore in recent years as an opportunity and a challenge in Maternal Medicine. Pregnancy outcomes in many conditions are improved following preconceptual planning. Medications can be optimised, potential risks & complications can be explored and a pregnancy care plan can be devised. In very rare situations, pregnancy may not be advised due to serious risks to the health of the mother and alternatives can be explored.

Maternal Medicine as a subspecialty is both challenging and incredibly rewarding due to the variety and the complexity each day brings. Seeing a mother and her baby safely through pregnancy and supporting them through any complications means that no two days are the same. Working in a diverse and highly effective team with this shared goal is hugely fulfilling. The future is bright here.

Written by Dr. Siobhán Corcoran, Consultant Obstetrician & Gynaecologist, The National Maternity Hospital

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