The growing importance of medical problems in pregnancy

Internal medicine and its subspecialties will become an even more integral part of the care of pregnant patients as the obstetric population ages and has an increase in comorbid conditions, such as diabetes, heart disease, hypertension and obesity. In the United States, there are 62 million women of childbearing age, most of whom will have given birth by the age of 44, translating to 4 million births annually. Over 25% of these women will enter pregnancy with a chronic medical condition, and nearly half will be overweight or obese, further increasing risk. The metabolic syndrome has been associated with hypertension, preeclampsia and increased risk for thromboembolic disease. A recent review of maternal morbidity during obstetric hospitalizations in the US has shown a 26% increase in overall medical complications, and an even higher rate for pulmonary embolism, respiratory and renal failure. Complications rise with increase in age and with caesarean delivery, and this was especially true for pulmonary embolism and acute respiratory distress syndrome, but all of the increase cannot be accounted for by age or mode of delivery. There is little doubt that internal medicine will need to step up and fill the void that exists in treating this complex patient group. Obstetric medicine specialists must act as mediators between women with complex medical illnesses and their obstetrical care team.

An equally critical role for internists caring for women with chronic medical conditions is in preconception counselling. Diabetes affects 1.85 million US women of reproductive age and preconception management could reduce risk for 113,000 births per year. One million women are on anti-epileptic drugs, affecting 75,000 pregnancies, and 7 million women are frequent drinkers, potentially affecting 577,000 births/year.

In a 2004 survey of women age 18–44, it was found that most women of childbearing age will not have obtained preventive health services in the year preceding childbirth and over half of pregnancies are unplanned or unintended. By the time patients are seen by their obstetricians, most major morphologic abnormalities will have occurred and a window of opportunity to enter pregnancy in a quiescent disease state, on the safest possible medication profile, may have passed:

At some point, the public health approach to improving birth outcomes … must recognize that the only way to reach this goal is by addressing the requirements of women's health regardless of pregnancy status. The only way to provide preconception care for that large group of women not expecting to become pregnant but who do is by providing high-quality health care to all preconceptional women, namely, all those of reproductive age.¹

In this issue of the journal, maternal heart disease, a major cause of indirect maternal mortality in the developed world, and the leading cause of maternal death in the UK, is discussed both in the excellent review on maternal cardiac arrhythmias and in the journal watch prepared by Claire McClintock. She reviews with great clarity the recent series of articles on the use of therapeutic low molecular weight heparin for mechanical heart valves, and the complex issues surrounding therapeutic decisions. The editors are pleased to have been part of the First International Congress on Cardiac Problems in Pregnancy, held in Valencia in February 2010 (http://www.cpp2010.com/) which was an opportunity to hear further from international experts in the field.