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Are high-risk obstetric patients properly identified and managed?

Published:November 12, 2018DOI:https://doi.org/10.1016/j.ijoa.2018.11.001
      Maternal morbidity and mortality are epidemics that are on the rise world-wide, with maternal morbidity and pregnancy-related mortality rates more than doubling in the United States in the last 30 years. The causes are widespread and multivariant, however, before we can address the issue of preventable harm, we must firstly develop a valid measure of assessing and identifying those at risk. Once identified, appropriate triage to higher levels of care or resource allocation can be assessed, to appropriately prepare for potentially complicated deliveries or antepartum or postpartum management. In addition, coordinated care plans specifically designed to address risk, preventable harm and negative outcomes can then be developed and communicated with providers in the antepartum, intrapartum and postpartum periods.
      Our institution’s Division of Obstetric Anesthesia, in conjunction with the Department of Obstetrics and Gynecology, has established an innovative high-risk antenatal care coordination program. The goal of the program is to improve patient outcomes and satisfaction, while decreasing total hospital cost, length of stay and intensive care unit admissions. We’re in the process of analyzing our data and will be submitting for publication shortly, however, based on our experiences, the program has improved early identification and optimization of high-risk patients and collaboration of care amongst providers.
      In order to properly manage high-risk parturients, they first need to be accurately identified and triaged. The National Institute of Child Health and Human Development (NICHD) has defined high-risk as anyone with existing health conditions, overweight or obese, multiple gestations or young or old maternal age.

      “What Is a High-Risk Pregnancy?” National Institute of Child Health and Human Development, U.S. Department of Health and Human Services. Available at: www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/high-risk. Accessed October 1, 2018.

      The American Society of Anesthesiology (ASA) originally had six classifications to describe a patient’s physical status, but this was later modified in 1961 to the five classifications that are used today.
      • Saklad M.
      Grading of patients for surgical procedures.
      • Dripps R.D.
      • Lamont A.
      • Eckenhoff J.E.
      The role of anesthesia in surgical mortality.
      Pregnancy classifies one as an ASA II patient. The physiologic changes of pregnancy can complicate and exacerbate underlying disease states dramatically, changing risk stratification and anesthetic management. Both the NICHD definition and the ASA classification system provide a broad overview of the issue but neither stratifies risk according to the severity of disease in the pregnant state or takes into account how an underlying disease affects overall morbidity and mortality and the potential for adverse outcomes. It has been noted that being pregnant also results in more inconsistencies when it comes to assigning ASA status by physicians.
      • Owens W.D.
      • Felts J.A.
      • Spitznagel E.L.
      ASA physical status classifications: a study of consistency of ratings.
      • Barbeito A.
      • Schultz J.
      • Muir H.
      • et al.
      ASA physical status classification. A pregnant pause.
      In recent years, some anesthesiologists have proposed the idea of either adding ‘E’ or ‘P’ modifiers to pregnant patients.

      Pratt SD. “Clinical Forum Revisited: The “P” Value” (PDF). Spring 2003 newsletter. The Society for Obstetric Anesthesia and Perinatology (SOAP). pp. 9–11. Retrieved 2007-07-09.

      Segal S. Women presenting in labor should be classified as ASA E: Pro. Winter 2003 newsletter. The Society for Obstetric Anesthesia and Perinatology (SOAP). Available at: https://soap.org. Accessed October 2018.

      Goodman S. Women presenting in labor should be classified as ASA E: Con. Winter 2003 newsletter. The Society for Obstetric Anesthesia and Perinatology (SOAP). Available at: https://soap.org. Accessed October 2018.

      While this method identifies the patient as pregnant, it does not stratify risk and we have yet to reach a consensus in terms of classifying and stratifying risk based on the severity of disease and risk of adverse outcome in obstetric patients. Our system of risk classification will take into account not just the comorbidities present but their severity; and how they affect functional status throughout the peripartum period. With this method, a patient with corrected uncomplicated severe congenital heart disease may be classified as at lower risk than someone with asymptomatic aortic root dilation, a condition that, although asymptomatic, has the potential for significant harm. We believe that this new system of classification will aid obstetricians and anesthesiologists to properly triage high-risk patients and arrange for further resource allocations if needed.

      References

      1. “What Is a High-Risk Pregnancy?” National Institute of Child Health and Human Development, U.S. Department of Health and Human Services. Available at: www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/high-risk. Accessed October 1, 2018.

        • Saklad M.
        Grading of patients for surgical procedures.
        Anesthesiology. 1941; 2: 281-284
        • Dripps R.D.
        • Lamont A.
        • Eckenhoff J.E.
        The role of anesthesia in surgical mortality.
        JAMA. 1961; 178: 261
        • Owens W.D.
        • Felts J.A.
        • Spitznagel E.L.
        ASA physical status classifications: a study of consistency of ratings.
        Anesthesiology. 1978; 49: 239
        • Barbeito A.
        • Schultz J.
        • Muir H.
        • et al.
        ASA physical status classification. A pregnant pause.
        Anesthesiology. 2002; 96: 96
      2. Pratt SD. “Clinical Forum Revisited: The “P” Value” (PDF). Spring 2003 newsletter. The Society for Obstetric Anesthesia and Perinatology (SOAP). pp. 9–11. Retrieved 2007-07-09.

      3. Segal S. Women presenting in labor should be classified as ASA E: Pro. Winter 2003 newsletter. The Society for Obstetric Anesthesia and Perinatology (SOAP). Available at: https://soap.org. Accessed October 2018.

      4. Goodman S. Women presenting in labor should be classified as ASA E: Con. Winter 2003 newsletter. The Society for Obstetric Anesthesia and Perinatology (SOAP). Available at: https://soap.org. Accessed October 2018.