The ITIJ team have been reporting live from ITIC Global in Barcelona this week (November 2023) sharing the discussions that took place at the conference. Read all reports
Dr Bettina Vadera, Auditor at EURAMI and Chief Medical Advisor for AMREF Flying Doctors, introduced the session with some background about why it was decided to cover high-risk pregnancy away from home, and how the three case studies were chosen, highlighting the opportunities for educational value, especially since one-third of pregnant women travel intercontinental distances away from home.
Dr Solenn Coz, Medical Director at Airlec Air Ambulance
Coz presented a case study of a 28-year-old woman in her third pregnancy who had not carried the previous two pregnancies to viable gestational age. In-vitro fertilisation had been performed for the pregnancy as well as a cervical cerclage to help prevent a cervical insufficiency from causing a preterm birth. The patient then suffered from preterm premature rupture of membranes (PPROM) at 16+3 weeks of gestation while in Western Africa where there were no local facilities to remove the cerclage, no specialists in pregnancy disease and no neonatal intensive care unit (ICU). The patient had to be flown to France, where she was transferred to an obstetrics unit for continued care.
Coz explained that the initial assessment by the local medical team established that the patient had no fever, no hyper-/hypotension, no biological sign for infection and no pregnancy disease, and the fetus had normal cardiac activity, active movements and oligohydramnios.
As the patient suffered from a PPROM with a cervical cerclage in an area without the facilities or staff for the required removal the cerclage before delivery of the fetus, an urgent medevac was determined as the course of action. The considerations required for the medevac included an ultrasound – for review of the placenta, fetus and the quantity of amniotic fluid – and to handover to a suitable obstetric team in France. However, a neonatal specialist was not needed onboard as the fetus was not carried a term compatible with survival.
Coz discussed the causes and effects of PPROM, indicating that it is a major cause of morbidity and mortality, and that intra-uterine infection is both a causal factor in PPROM but also a resulting consequence.
Coz also detailed statistics for fetal outcome, showing that earlier intervention and later delivery leads to better outcomes. Coz then talked through the guidelines for care of patients with PPROM from French and Canadian recommendations.
Discussing the best outcomes for the mother and fetus, Coz said they need a ‘high level of care, obstetric pathology specialists and neonatologists; close monitoring and antibiotic management; and immediate cerclage removal in case of intra-uterine infection.’
When asked by the audience how rapidly this case was resolved and whether there was a possibility of any other local help to perform a cerclage removal, Coz stated that they were engaged after an assistance company had failed to find a local solution. The complexity of the procedure needed required facilities and specialists only available elsewhere, and the medical transfer took place within 24 hours.
Dr Susana de la Fuente, Medical Director, Iris Global
The second case study was presented by de la Fuente and involved a 38-year-old woman in the 29th week of her first pregnancy. The patient complained of mild abdominal (belly and back) pain, discomfort and tenderness, and light vaginal bleeding. When the patient was admitted to the local hospital, the medical assessment concluded that her vitals were stable, but that her placenta was partially separated from the wall of her uterus, and she was diagnosed with mild premature placental abruption.
Due to this diagnosis, the patient would require close monitoring of herself and the fetus in the event that the abruption could get worse, with the development of life-threatening complications, and changes in the fetus’ vitals. It was agreed that the patient would benefit from a specialist neonatal unit, especially in the event of a preterm birth.
As this facility did not have a specialist maternity and neonatal ward, it was determined that she would have to be moved to a tertiary care facility that does – either to a French tertiary hospital, or back to her home hospital in Spain. As the two options were of a similar distance, repatriation to her home was the course chosen.
De la Fuente discussed the presentation and background of placenta abruption, identifying symptoms such as bleeding, pain, and uterine hypertonia – where the bleeding is scant, dark in colour and occurs in 80 per cent of cases, and the pain is usually sudden and lancinating.
De la Fueta said: “The condition is not fully understood yet, but is dependent on many factors.” Occurring in about one per cent of pregnancies, and with 10 per cent of premature births, de la Fuente also listed the risk factors associated with placenta abruption, including previous abruption – which carries a greater than 10 per cent chance of recurrence – high blood pressure, smoking, abdominal trauma, age of more than 35 years old, uterine infection, carrying twins, triplets or more, and uterus or umbilical cord conditions.
De la Fuente closed her presentation describing the complications of placenta abruption, and detailed the treatment and care for patients suffering from it.
Asked why it was decided to use ground transport for this medical transport, rather than by air, she responded: “The patient was stable, as assessed by attending physicians, and the time would only take 3.5 hours [by ground to either hospital], so ground transport was most feasible.” Vadera posed the question that if the patient was closer to a hospital that wasn’t the patient’s home hospital, would the decision have been different, and de la Fuenta confirmed that, yes, the patient would then have been transferred to the closer suitable facility.
Dr Joseph Lelo, Medical Director at AMREF Flying Doctors
Lelo began the third case study by describing pre-eclampsia – a multisystem progressive disorder characterised by the new onset of hypertension and proteinuria, or the new onset of hypertension plus significant end-organ dysfunction with or without proteinuria, typically presenting after 20 weeks of gestation or postpartum. He explained that it can affect up to eight per cent of pregnancies globally, and that 16 per cent of maternal deaths are associated with hypertensive disorders.
Lelo presented a case of a 38-year-old woman in western Kenya who was on her third pregnancy at 29 weeks’ gestation after losing two previous pregnancies. She developed very high blood pressure and a headache. On examination, it was found through ultrasound that there was fetal growth retardation. It was decided that an immediate medevac was required to transfer her to a specialist tertiary hospital in Nairobi. At the hospital, she was diagnosed with severe pre-eclampsia, intrauterine growth restriction (IUGR) and haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.
Lelo noted the immediate care that was provided and the constant monitoring, but when the IUGR worsened and there was non-reassuring fetal heart rate and hemodynamic instability, the patient was taken for emergency caesarean section. The baby was delivered and treated at the neonatal intensive care unit, where they remained for ‘turbulent’ 95 days due to multiple complications before being successfully treated and discharged.
The mother developed severe postpartum hypertension and was treated by a multidisciplinary team of an obstetrician, a physician and a clinical pharmacist before discharge 10 days later.
Lelo explained that the relationship between HELLP syndrome and pre-eclampsia is controversial, and identified that a difference in disorders can be seen in up to 20 per cent of patients with HELLP who do not present with antecedent hypertension or proteinuria.
Lelo highlighted that hypertensive disorders during pregnancy are a leading cause of morbidity and mortality, especially in poorer parts of the world, and also iterated: “Prompt quality care improves outcomes.”
Asked by the audience whether the flight crew could have delivered a viable baby, Lelo said: “Yes, our crew has obstetric training and carry a delivery kit but the problem, in this case, would have been the immediate care of the baby after it was born.”
Vadera opened up the discussion to the audience. A question was asked if anyone had delivered a baby in the air, and if anyone had planned for delivery during transit. Veldman pointed out the risk associated with trying to deliver a child without the proper facilities and staff during transit is fraught with danger, and stated: “Planning for a birth in flight is risky and you would be planning for disaster.”
A member of the audience stated that these situations call for robust and protracted shared decision making with the family, deeply outlining all the risks and benefits of a transfer or remaining in place.
It was also highlighted that with these cases, and in general, that a good history is explored to help with medical decisions.
A question was asked whether carrying an ultrasound would be worthwhile for these cases. The panel agreed that it is helpful, but that adequate training and staffing to use the equipment is important. Another audience member stated that regulations in India would severely limit this option as they are not allowed to carry ultrasound machines onboard aircraft, and they are heavily restricted even in hospitals.
When asked what the considerations were regarding neonatal transfer, Veldman stated that the best incubator and transport is in utero.
Dr Alex Veldman, Medical Director at Unicair
Veldman started the final talk by explaining that ‘high-risk’ pregnancies are any pregnancy that carries and increased health risk to a pregnant person, their fetus or both. Veldman went on to describe the factors that associated with high-risk pregnancies, such as pre-existing diabetes, organ transplant, chronic hypertonus, aged less than 17 years old or more than 35 years old, autoimmune disease, thrombophilia, HIV, tuberculosis, heart disease and cancer for the mother; birth defects, chromosome problems, genetic syndromes, fetal growth restriction and fetal anaemia for the fetus; and a history of multiple miscarriages, stillbirth or pregnancy losses, pre-eclampsia and HELLP syndrome, placental abruption, abnormal placentation, PPROM, too much or too little amniotic fluid, infections, and multi-fetal gestation for both.
Veldman warned that although many of the factors associated with high-risk pregnancies can be screened for, occasional significant maternal and fetal morbidity and mortality occurs spontaneously, and will require acute or sub-acute management.
Veldman illustrated the disparity in maternal and fetal mortality between high-income and low-income countries, where low-income countries experience much poorer outcomes. Veldman continues to list the leading causes of maternal and neonatal mortality, further emphasising that the statistics for mortality are much worse in low-income countries. Veldman said: “You can see why many mothers might want to be transported back and would expect to be transported back.”
Identifying that pre-term birth is the primary cause of fetal morbidity in high-risk pregnancies, Veldman notes that the likelihood of delivery in 24 hours can be well predicted and that tocolysis can be used to delay delivery by up to 48 hours in the hope of reducing the chances of associated fetal morbidity.
Veldman concludes that, although fetal viability is judged at 23 weeks of gestation, there can still be high levels of morbidity up to a gestational period of 28 weeks. Veldman advises that, depending on available local care, one should avoid moving very pre-term babies in the first – and likely the second – week of life.