Every woman hopes for an uneventful pregnancy. However, in a small proportion of pregnant women who present for antenatal care – generally 10 to 20 per cent – their pregnancy and/or delivery is considered “high risk” due to their medical or obstetric history, or conditions relating to the pregnancy or fetus.

A high-risk pregnancy or delivery is defined as any condition which increases the likelihood of an adverse outcome for the expectant mother, fetus, or both. Such conditions are often complex, requiring detailed multidisciplinary planning, preparation and coordination leading up to, during and even after delivery.

As the largest tertiary referral hospital specialising in healthcare for women and children in Singapore, KK Women’s and Children’s Hospital (KKH) manages about 12,000 deliveries each year, of which approximately five per cent are patients with high-risk pregnancies who have been referred from other healthcare centres.

Management for high-risk pregnancies at KKH is coordinated by the Obstetric High Risk Clinic (OHRC), also known as the Complicated Pregnancy Clinic. In recent years, the number of patients attending the OHRC has risen from around 300 in 2014 to more than 1,000 in 2017.

Led by experienced obstetricians from the Department of Maternal Fetal Medicine at KKH, the OHRC coordinates multidisciplinary care with teams comprising obstetric physicians, neonatologists, anaesthetists, radiologists, geneticists, paediatric cardiologists and surgeons, and operating theatre staff to provide holistic management for the wide range of conditions and critical considerations associated with the high-risk pregnancy. An overview of conditions seen at the OHRC is as follows:

The Obstetric High Risk Clinic (OHRC) provides:

1. Pre-pregnancy counselling

A vital aspect of favourable pregnancy outcomes for women with severe medical conditions is pre-conception / pre-pregnancy counselling and care, which aims to optimally control their conditions in conjunction with the medical team. These include patients with diabetes mellitus, epilepsy and thyroid diseases.

2. Postnatal counselling

Postnatal counselling often involves debriefing following a poor obstetric outcome – such as intra-uterine fetal death, stillbirth or an extremely premature delivery. These consultations enable discussion of perinatal events and results of investigations, follow-up of maternal conditions and the facilitation of transfer of care to relevant care teams. They are also an opportunity to make care plans for future pregnancy, if appropriate.

Criteria for referral to OHRC:

For a number of reasons, high-risk pregnancies require careful planning and are ideally managed in the setting of an obstetric high risk clinic. Early recognition and referral allows adequate time for optimising care and planning delivery. Decisions regarding the timing and mode of delivery are usually made during weekly multidisciplinary team meetings involving neonatologists and other specialists. Continuing surveillance of high-risk antenatal women is provided in the Obstetrics Day Assessment Centre and the Obstetric Monitoring Unit.

Patients may be directly referred to the OHRC from a number of sources including community healthcare practitioners such as family medicine clinics, polyclinics and general practitioners, or obstetricians and specialists from other disciplines whose patient is pregnant.

The criteria for referral to OHRC are as follows:

Case study: Early management of cervical incompetence results in successful delivery

Twenty-nine-year-old Madam A had a history of cervical incompetence, causing her to experience miscarriages in her second trimester and having to place a cervical cerclage during previous pregnancies.

When she fell pregnant once more, Madam A presented to the Obstetrics High Risk Clinic at KKH at 15 weeks' gestation, and was offered cervical surveillance to manage her condition. During her antenatal checkup at 17 weeks, Madam A’s cervical length was measured and found to be within the normal range.

However, in view of her past history, she opted for a cervical cerclage to be placed electively at 18 weeks of gestation, which was subsequently removed at 34 weeks. After the removal, Madam A developed some irregular tightening and, in the following week, she went into labour and delivered a healthy boy.

A cervical cerclage is a purse string suture, commonly placed at the cervico-vaginal junction to keep the cervix occluded. In selected groups of patients, cervical cerclage has shown to reduce the risk of mid-trimester pregnancy losses and early or extremely premature deliveries.

Madam A’s case demonstrated the benefits of managing cervical incompetence at an early stage of pregnancy. Community healthcare practitioners and obstetricians can take note of the following signs in patients with cervical incompetence, which prompt for an early referral to a tertiary institution for follow up and management:

	​Dr Lional Karuna Mary, Staff Physician, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital As lead for the Obstetric Monitoring Unit at KKH, Dr Lional Karuna Mary has been providing care to mothers with high-risk pregnancy or delivery in the Obstetrics High Risk Clinic since 2012. Dr Karuna Mary is a passionate member of the team at the Department of Maternal Fetal Medicine.
	​Dr Shephali Tagore, Head and Senior Consultant, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital Dr Shephali Tagore leads in high-risk obstetrics and operative obstetrics, and implements risk reduction strategies towards safer clinical care. Dr Tagore is also Director of the O&G International Medical Programme at KKH, and is actively involved in teaching, training and research activities. She has a passion for organising overseas training in obstetrics emergencies within Southeast Asia, and leads teams in teaching simple and safe obstetric practices to improve perinatal outcomes.
	Dr Ann Wright, Consultant, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital Dr Ann Wright underwent training in the United Kingdom and has been a member of the Department of Maternal Fetal Medicine at KKH since 2014. Dr Wright has an interest in high-risk pregnancy and labour ward management.