NICE 121: Intrapartum Care for women with Medical Conditions — Part 1

Post #1
This blogpost is Post #1 of Summary of NICE guideline “NG 121: Intrapartum Care for Women with Existing Medical Conditions or Obstetric Complications and their Babies” released in March 2019. As this is an extensive and lengthy guideline, so I will be covering it in two posts. 

This post covers intrapartum care in Heart Disease, Asthma, Long-term Systemic Steroids, Bleeding Disorders, SAH / AV Malformation of Brain, Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD) and Obesity

I have extracted the main points only. You must read the original guideline to have complete understanding. Original guideline can be downloaded here: NG 121

This guideline should be read along with NICE intrapartum Care for Healthy Women CG190 (N.B: In this summary when it is written “to manage as low risk /like normal/follow routine intrapartum care” refers to CG 190)

Kindly let me know in comments below if anything needs to be modified in this post and suggestions to improve future posts are welcome.

Thanks

NICE 121: INTRAPARTUM CARE FOR WOMEN WITH EXISTING MEDICAL CONDITIONS

Information for women with existing medical conditions

• Clarify with women whether and how they would like their birth companions(s) involved in discussions about care during labour/birth
• Offer information about Intrapartum care including
• General information
• How medical condition affect care
• How labour & delivery affect medical condition 
• How medical condition and its management affect baby
• Offer this information in pre-conception consultations or as early as possible during pregnancy & Allow extra time to discuss
• Information delivered by a member of multidisciplinary team (MDT)

Planning for intrapartum care with women with existing medical conditions – involving a multidisciplinary team

• MDT led by named healthcare professional to prepare individualized plan involving woman
• Plan should be:
• Based on → shared decision making principles
• Reviewed with woman and her birth companions(s) → as soon as possible  throughout pregnancy & on admission for birth
• Updated → if change in medical condition
• Shared with → GP & teams providing Antenatal/ Intrapartum care
• MDT may include:
• Midwife, Obstetrician, Obstetric Anesthetist, Obstetric Physician or Clinician with Expertise in care of pregnant women with medical condition, Clinician with Expertise in Medical Condition, Speciality Surgeon, Critical Care Specialist, Neonatologist, woman’s GP, Allied Health Professionals 

HEART DISEASE

Risk Assessment

• Follow principles of MDT working
• Include a Cardiologist
• Heart disease diagnosed intrapartum→ urgent multidisciplinary discussions & take woman’s preferences into account
• Some women may be low risk→ follow routine intrapartum care 
• Reassess intrapartum risk regularly during pregnancy & during intrapartum period using ALL
• Comprehensive clinical assessment (Hx + Exam)
• Modified WHO classification of risk
• NYHA functional class
• Offer same investigations to pregnant as to women who are not pregnant
• Review results & act without delay

Management of anticoagulation for women with Mechanical Heart Valves

• When pregnancy confirmed
• Involve women in MDT discussions of plans for anticoagulation during intrapartum period
• Consider including Hematologist
• Explain to women→ need of individualized plan
• If taking Warfarin in 3rd trimester → switch to LWMH by 36+0 wks or 2 wks before planned birth. In hospitals consider:
• Stop warfarin → after 24 hrs→ start LMWH twice-daily based on most recent weight
• ↑ LMWH dose according to anti-Xa levels
• Check anti-Xa levels each day 3-4 hrs after dose of LMWH
• Aim for peak anti-Xa b/w 1.0 — 1.2 IU/ml
• Before dose of LMWH check it be >0.6 IU/ml
• Recheck anti-Xa→ weekly (once target level achieved) 
• Planned C/S→Stop therapeutic LMWH 24 hrs before C/S and CONSIDER
• Aim to do C/S as near to 24 hrs as possible & no later than 30 hrs after stopping OR
• Switch to I/V unfractionated heparin (aim aPTT twice of control). Stop I/V heparin 4-6 hrs before C/S
• IOL→ Involve a senior obstetrician to:
• Decide when to stop LMWH or I/V heparin to ↓ risk of maternal haemorrhage/valve thrombosis & to enable option of regional analgesia
• Review progress of labour and
• Need for LMWH every 12 hrs, aim for birth as close to 12hrs from last injection as possible or
• Need for unfractionated heparin, aim for birth as close to 4-6 hrs after stopping infusion
• Mechanical Heart Valves + taking Warfarin + Established Labour
• Check INR immediately & consult Haematologist
• No anticoagulation → till assessment by Obstetrician which should be within 2 hrs
• Senior Review→ to discuss mode of birth with least bleeding risk to woman/baby 
• Consider→ reversal of anticoagulation 
• Postpartum Review
• Within 3-4 hrs of birth
• Aim to restart LMWH/ unfractionated heparin within 4-6 hrs of birth
• High Risk of Peripartum Haemorrhage
• Consider prophylactic LMWH or no LMWH until hourly review indicates to re-start therapeutic anticoagulation
• Women with mechanical heart valves → consider delay starting warfarin until 7 days after birth

Mode of birth for women with heart diseases

• Individualized birth plan covering all 3 stages of labour following MDT discussion
• Consider including a cardiologist
• Manage pulmonary hypertension→ in consultation with a specialist pulmonary hypertension center
• Offer Planned Birth (IOL/C/S) to women with mechanical heart valves 
• Consider Planned C/S plus explain pros & cons
• High risk disease of aorta
• Pulmonary Arterial Hypertension 
• NYHA Class III or IV heart disease
• If pt refuses C/S→ explain pros/cons of assisted 2nd stage of labour
• Must have individualized emergency care plan (In case of early labour or new obstetrics complications) in women who have planed C/S

Fluid management for women with heart disease

• It should be planned during pregnancy in MDT & include
• Effect of condition on fluid balance
• Optimum fluid balance & how to achieve
• Risk assessment and monitoring plans

Women for whom fluid balance is critical 

1. Sever left-sided stenotic lesions (Mitral/Aortic)
2. Hypertrophic Cardiomyopathy 
3. Cardiomyopathy with Systolic Ventricular Dysfunction
4. Pulmonary Arterial Hypertension
5. Fontan & other Univentricular Circulations
6. NYHA Class IV Heart Disease

• Offer tailored monitoring and clinical review
• Hourly monitoring of fluid input/output, BP, Pulse, RR and O2 saturation 
• Continuous ECG & Pulse oximetry by trained staff
• Continuous intra-arterial BP monitoring
• Cardiac Output monitoring with non-invasive techniques or serial echocardiography by trained staff
• Intensive monitoring → may have to be carried out in an ICU

Standard fluid management

• Modified WHO 1 & NYHA class I → OFFER 
• Modified WHO 2-3 & NYHA class II-III → CONSIDER after MDT discussion

Diagnosis & Management of Heart Failure for ALL women in Intrapartum Period

• Take cardiac-specific history
• SUSPECT heart failure if no other likely cause of following symptoms
• Breathlessness when lying down or at rest
• Unexplained cough especially when lying down or which produces frothy pink sputum
• Paroxysmal nocturnal dyspnoea
• Palpitation
• CONSIDER heart failure if ANY of the signs
• Pale, sweaty, agitated with cool peripheries 
• Heart Rate persistently >110 beats per min at rest
• RR persistently >20 breaths per min at rest 
• Hypotension (systolic BP <100 mmHg) 
• O2 saturation <95% on air 
• Elevated JVP
• Added murmur or heart sound 
• ↓ air entry, basal crackles or wheeze, on listening to chest
• If ANY of above symptoms or signs → senior clinician should review woman without delay
• When clinical suspicion of heart failure in ANY woman → Peripheral I/V access; Urea & Electrolyte; FBC; ABGs; ECG; CXR
• If clinical suspicion cannot be ruled out by investigations
• Review by cardiologist
• Transthoracic echocardiogram 
• Measure NT-proBNP levels
• Consider → early birth in heart failure due to cardiomyopathy (acc to severity of condition)
• After delivery
• Optimise treatment of heart failure as soon as possible 
• If clinical suspicion persists → CONSIDER continued involvement of cardiologist

Anaesthesia and Analgesia for women with Heart Disease

• Discuss plan in MDT & consider involving a hematologist for women on anticoagulation during pregnancy
• Modified WHO 1/ 2 → Consider offering same information like low risk
• Modified WHO 3 /4
• Consider → Regional Anaesthesia (unless contraindicated)
• Collaborative working b/w obstetrics & cardiac anesthetist
• Offer intrapartum monitoring of heart/circulation to ALL woman (CVP + advanced monitoring)
• Offer → low-dose regional analgesia
• Consider regional analgesia→ woman on LMWH + no prophylactic dose for 12 hrs or no therapeutic dose for 24 hrs at least 
• Women on LMWH
• If dose given
• Prophylactic→ wait 12 hrs before siting or removing epidural
• Therapeutic→ wait 24 hrs before siting or removing epidural
• After siting epidural or removing catheter→ wait 4 hours before giving further dose of LMWH
• No therapeutic dose of LMWH if an epidural is in place

Management of 3rd stage of Labour for women with Heart Disease

• Prepare an individualized plan with MDT & woman. 
• Consider involving a cardiologist
• WHO 1 → treat as low risk
• Modified WHO 2 → active management of 3rd stage
• Modified WHO 3 / 4 → consider according to following table

Table 1: Management of 3rd stage of labour for women with modified WHO 3 or 4 heart disease
Condition	1st-line uterotonics	2nd-line uterotonics	Drugs to be avoided
Significant Aortopathy Marfan syndrome and Loeys–Dietz with aortic dilatation >40 mm Bicuspid aortopathy and aortic dilatation >45 mm Previous aortic dissection Turner syndrome and aortic size index >25 cm/ m Severe systemic ventricular dysfunction (ejection fraction <30%)	Oxytocin	Misoprostol Carboprost	Ergometrine
Limited or fixed low cardiac output, or preload-dependent circulation Severe valvular stenosis Hypertrophic cardiomyopathy with diastolic dysfunction or significant outflow tract obstruction Fontan circulation Cyanotic heart disease	Slow Oxytocin Infusion	Misoprostol Carboprost	Long-acting oxytocin analogues and ergometrine
Pulmonary Arterial HTN	Oxytocin	Misoprostol	Ergometrine, carboprost and long-acting oxytocin analogues
Coronary Artery Diesase	Oxytocin	Misoprostol	Ergometrine

ASTHMA

Analgesia for women with asthma

• Offer same options for pain relief during labour as woman without asthma
• Entonox (50% nitrous oxide plus 50% oxygen)
• I/V & I/M Opioids
• Epidural
• Combined spinal–epidural analgesia

Prostaglandins(PG) for women with asthma

• Do Not offer PG F2 alpha (risk of bronchospasm)
• IOL→ Consider PG E1 or E2 
• PPH → Consider PGE1

LONG-TERM SYSTEMIC STEROIDS

Steroid replacement regimens

• Do Not offer supplements hydrocortisone to women taking inhaled or topical steroids

Adrenal insufficiency or taking long-term oral steroids PLUS plan to have vaginal birth 

• Continue regular oral steroids AND
• Established 1st stage of labour → add I/V or I/M Hydrocortisone @ min dose of 50 mg every 6 hrs until 6 hrs after baby born

Adrenal insufficiency or taking long-term oral steroids PLUS having planned or emergency C/S

• Continue regular oral steroids AND
• Give I/V hydrocortisone when starting anaesthesia; dose depends on whether woman had hydrocortisone in labour 
• If Yes → Consider 50 mg
• If No → Consider 100 mg
• Further does of hydrocortisone 6 hrs after baby born

BLEEDING DISORDERS

Regional anaesthesia & analgesia for women with bleeding disorders

• Discuss → pros/cons with woman
• When considering regional → take into account
• Overall risk of bleeding & opportunity for corrective treatment
• Therapeutic & prophylactic anticoagulation 
• Risk of bleeding with used technique 
• Needle siting or insertion difficulty
• Comparative risk with no / non-regional analgesia and GA

Modifying birth plan according to platelet count or function

Women with known immune thrombocytopenia pupura 

Before admission

• Plan birth in an obstetric-led unit with NICU
• Plan as if baby will be at risk (regardless of mother platelet count)
• Consider → maternal platelet count weekly from 36wks if platelet count <50 ; discuss/agree plan with MDT including hematologist
• Consider → steroids or I/V immunoglobulin to ↑ platelet count

On Admission

• Measure platelet count
• Manage acc to table 2

Precautions to ↓ risk of bleeding for baby

• Inform neonatal team of imminent birth of at risk baby
• No → FBS / ventouse
• Use with Caution → fetal scalp electrodes ; mid-cavity or rotational forceps
• C/S may Not protect baby from bleeding
• Check platelet count at birth from umbilical cord

Gestational Thrombocytopenia / Uncertain Diagnosis

• Modify birth plan based on maternal platelet count for women
• Follow the table 2

Table 2: Modify Birth Plan Acc to Maternal Platelet Count
Maternal platelet count	Maternal care	Fetal and neonatal care
Above 80 × 10/l	Treat as healthy for considering regional analgesia/anaesthesia	ITP/Suspected→ assume baby at risk of bleeding & take precautions Gestational thrombocytopenia→ assume baby has normal risk of bleeding
50 - 80 x 10/l	Before considering regional, take into account Clinical history Woman’s preference Anaesthetic expertise
Below 50 x 10/l	Avoid regional under most circumstances

Management of 3rd stage of labour

• Be aware → these are at ↑ risk of primary/secondary PPH
• Offer → active management of 3rd stage
• Avoid → Uterotonics by I/M
• Postpartum Care
• Offer → individualized postpartum care as discussed with senior haematologist and include
• Blood loss measurement
• Monitoring → obstetric complications & haemotological parameters 
• Be aware → NSAIDs can add risk of bleeding
• Before discharge → inform risk of secondary bleeding & how to access care

SUBARACHNOID HAEMORRHAGE (SAH) OR ARTERIOVENOUS (AV) MALFORMATION OF BRAIN

Mode of birth & 2nd stage management

• Involve MDT in risk assessment 
• Include woman in care planning and expert neurovascular clinician 

Cerebrovascular Malformation

—At Low Risk of intracranial bleeding

• Classify as low risk if a woman has
• Fully treated cerebrovascular malformation OR
• Intracranial bleeding of unknown cause after investigation (occurred >2 yrs ago)
• Base decision of mode of birth / 2nd stage → on woman’s preference & obstetrics indications 

—At High Risk of Intracranial Bleeding 

• Classify as high risk if a woman has
• Untreated or partially treated cerebrovascular malformation that had bled previously
• Large aneurysm ≥7 mm or an aneurysm with other high-risk features as defined by a neuroradiologist
• Complex A/V malformation
• Cavernoma with high-risk features
• Intracranial bleeding within past 2 yrs
• Consider C/S after full discussion with pros & cons of all options
• For women who prefer to aim for vaginal birth or are in 2nd stage of labour
• Offer → regional analgesia and
• Explain → pros & cons of assisted 2nd stage of labour vs active pushing alone
• Manage as High Risk if
• Present first time in labour + Hx of CV malformation or intracranial bleeding  & unknown risk of intracranial bleeding
• Isolated CV malformation → Do not withhold regional unless genetic predisposition to multiple vascular malformations or unknown genetic Hx

ACUTE KIDNEY INJURY (AKI) or CHRONIC KIDNEY DISEASE (CKD)

Fluid management for women with kidney disease

• Involve → MDT in risk assessment & must include → Clinician with Expertise in managing renal conditions 
• For women with CKD stage 4/5 before pregnancy or with progressive or active kidney disease ENSURE
• to have intrapartum care by midwife, obstetrician & obstetric anesthetist
• input from a clinician with expertise in managing renal conditions in pregnant women and 
• Make sure his/her availability for consultation during intrapartum period
• Manage → AKI secondary to PET in line with NICE HTN in pregnancy
• No nephrotoxic drugs (like NSAIDS) in intrapartum to women with kidney disease
• Women with CKD with or without PET, monitor fluid balance in intrapartum period
• 1 Hourly → Heart rate
• At least every 4 hrs → BP, RR with chest auscultation, fluid intake/output, O2 Sat
• After each assessment→ develop an individualized plan for fluid management (may involve additional monitoring techniques). 
• Aim→ maintain normal fluid volume to ↓ risks of AKI & pulmonary 

• All women with CKD → assess RFT every 24 hrs during intrapartum period
• Women with AKI
• Identify & correct the cause of AKI
• 1 Hourly → Heart rate
• At least every 4 hrs → BP, RR with chest auscultation, fluid intake/output, O2 Sat
• After each assessment → develop an individualized plan for fluid management (may involve additional monitoring techniques). 
• Aim → maintain normal fluid volume to ↓ risks of AKI & pulmonary oedema
• If woman is dehydrated → consider giving single small fluid bolus (e.g. 250 ml) as crystalloid
• Review fluid status & urine output within 1 hr of first bolus & before considering giving a second
• Continue to monitor → fluid balance & RFT until AKI recovered

• For ALL women with kidney disease during pregnancy— Postpartum
• Monitor at least 4 hr for at least first 24 hrs after birth → HR, BP, RR & chest auscultation, fluid intake/output, O2 Sat
• Ensure→ postpartum assessment of renal function & follow-up for women with persistent kidney disease

Timing and mode of birth for women with kidney disease

• As early as possible during pregnancy → Plan Intrapartum care with woman & expert clinician in women with
• kidney disease due to lupus nephritis, vasculitits or glomerulonephritis
• kidney transplant
• Base decision for timing / mode of birth on woman’s preference & obstetric indications in 
• CKD stage 1 + stable renal function  
• Non-nephrotic-range proteinuria (urine protein:creatinine ratio <300 mg/mmol) 
• Kidney Transplant
• Consider planned birth by 40+0 wks in women with
• CKD stage 1 and nephrotic-range proteinuria (urine protein:creatinine ratio >300 mg/mmol)
• CKD stage 2 to 4 + stable renal function
• CKD stage 5 or deteriorating stage 3b / 4
• Before 34 wks → discuss option of dialysis with women & MDT / effort to prolong til at-least 34+0 wks
• After 34+0 wks → discuss option of planned birth & MDT / Consider birth no later than 38+0 wks

OBESITY

Assessing Fetal Position

• Consider → USG scanning at START of established labour if baby’s position uncertain in women with booking BMI >30 kg/m2 (esp in BMI >35)

Fetal Monitoring

• Fetal monitoring → base on woman’s preference & obstetric indications

Position in labour

• Booking BMI >30 → carry out risk assessment in 3rd trimester
• While developing birth plan → take into account
• Woman’s preference; her mobility; comorbidities; woman’s current/recent weight
• Booking BMI >30 + ↓ mobility→ consider lateral position in 2nd stage of labour
• Booking BMI >30 + adequate mobility→ provide care as per normal

Equipment needs for women in labour with a BMI >30

• All obstetric units should have ‘birthing beds’ → bearing upto 250 kg
• Carry out risk assessment → ensure essential equipment, in a size appropriate form available & included
• Surgical, obstetric & anaesthetic equipment ; BP cuffs; OT tables; lifting/lateral transfer equipment; antiembolism stockings; wheelchairs; monitoring & measuring equipment
• Women with BMI >50 kg/m2 at booking → offer referral to obstetric unit with suitable equipment & expertise as early as possible in pregnancy

** Keep watching this space for the next post which will cover the second half of this guideline

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