Clinical inertia – It is imperative to avoid delays in managing common conditions in pregnancy

It is my pleasure to co-author this editorial with Dr Anita Banerjee for the first issue of Clinical Medicine this year, focusing on maternal health. Despite comprising 51% of the population, across their life course, women face unique, gender-specific challenges. While women live longer than men, they spend a considerably greater proportion of their lives in poor health. Yet historically women-specific health issues have not been prioritised. The importance of good health is greater during pregnancy as it also involves the next generation. The Women’s Health Strategy, launched in England in 2022, aims to improve maternal and child health outcomes, ensuring that women’s health services are tailored to their individual needs throughout their lives – a welcome and promising step in the right direction.¹

Pregnancy is a crucial moment, especially in today’s rapidly changing obstetric landscape. Women now often enter pregnancy with advanced maternal age, with higher rates of obesity, cardiometabolic issues and mental health conditions. However, clinical inertia persists, leading to delays in investigations and treatment, risking the health of two lives – both the mother’s and the baby’s. MBRRACE reports have continued to identify huge health disparities in outcomes in the UK, including maternal death.² Black women are twice as likely to die compared to White women in pregnancy. In addition, women living in deprived areas and who are more than 35 years of age are two and three times more likely to die in pregnancy. Thromboembolism is the leading cause, closely followed by cardiac disease in pregnancy.³ The Ockenden national report highlighted ‘silo-working’ as a key issue for adverse outcomes in pregnancy and emphasised the importance of education, training and working together with other medical specialties in reducing these inequalities.⁴

This special issue addresses common clinical presentations in pregnancy with practical, evidence-based guidance for practicing clinicians.

Asthma: The most common chronic disease to affect pregnant women, asthma can significantly impact pregnancy outcomes. Jones and Jamil provide an important update and highlight that managing asthma in pregnancy should be the same as outside pregnancy. This includes all therapies, although the safety of biologics is still emerging.⁵

Palpitations: Saeed et al⁶ summarise a sound clinical approach for managing palpitations in pregnancy. They emphasise the need to involve the cardiac team early and safety of commonly used antiarrhythmic agents.

Proteinuria: Bertoni and Williams⁷ present a focused approach to investigating and managing proteinuria in pregnancy. They stress the importance of recognising rapidly progressive kidney dysfunction alongside increasing proteinuria and preeclampsia. Their article provides a simple, practical guide tailored to the stage of pregnancy.

Pulmonary embolism (PE): The article by Narayan⁸ provides a critical reminder that PE remains a significant cause of morbidity and mortality in pregnancy and the puerperium. As thrombosis and thromboembolism is the leading cause of maternal death in the UK, the article highlights the importance of avoiding delays in imaging for suspected PE, including computerised tomography pulmonary angiogram. It offers practical tips for risk stratification to guide monitoring and treatment of PE.

Acute confusion: Hill and Neuberger⁹ draw attention to the underappreciated and challenging presentation of acute confusion in pregnancy. Life-threatening diagnoses are discussed in more detail since these conditions have a significant risk of maternal mortality and morbidity, as well as poor fetal outcomes, if not recognised and treated early.

Bariatric surgery: With the rising incidence of obesity, bariatric surgery is an increasingly common and effective method of sustained weight loss for women of childbearing age. Morgan et al¹⁰ provide a streamlined approach to managing pregnancy after bariatric surgery. They also highlight the need for an optimal time interval between surgery and conception to minimise the potential adverse outcomes and call for further high-quality evidence in this ever-growing issue in pregnancy.

Eczema: The burden of eczema cannot be underestimated. Keeling et al¹¹ provide an excellent didactic review of the acute management of severe eczema in pregnancy, offering practical guidance.

Thyroid diseases: Singh and Boelaert¹² discuss the controversies in thyroid disease management in pregnancy. Yes, the controversies still exist, although significant progress has been made with better-quality evidence compared to a decade ago. Their article delivers an up-to-date summary of the latest evidence and management guidelines.

We welcome the recent NIHR award to establish nine consortia aimed at reducing maternal health inequalities in the UK and are optimistic about their potential to advance gender-specific care. In the meantime, clinicians can act now by avoiding inertia in diagnosing and managing common medical conditions in pregnancy. I hope that this comprehensive collection, guest edited by Dr Lucy Mackillop and Dr Nithya Sukumar with Dr Anita Banerjee, will provide practical tips for addressing these clinical challenges.

Declaration of competing interest

We declare that we have no conflicts of interest.