Providing Integrated, One-Stop Multidisciplinary Care for Mothers-to-Be
CHiRP is a one-stop multidisciplinary tertiary integrated care centre for high-risk pregnancies. By optimising pre-pregnancy care and counselling for prospective mothers with risk factors, it aims to ensure the best possible outcomes for both mothers and babies.
The Department of Obstetrics & Gynaecology (O&G) at Singapore General Hospital has built a strong reputation for managing high-risk pregnancies, in particular mothers with medical disorders and complications. Drawing on the strengths and depth of expertise available in a tertiary teaching hospital and an academic medical centre, the department has now established a one-stop centre for joint multidisciplinary clinics and services between obstetrics and a growing pool of medical specialties. A close working relationship with the departments of Neonatology and Anaesthesia has also been forged to ensure the best possible outcomes for both mothers and babies.
These services are operated by the Maternal Fetal Medicine section of the department. Given the increasing complexity of cases seen and the growing number of joint clinics, CHiRP will also optimise and streamline the coordination and operations of these services together with the other perinatal services of prenatal diagnosis under one centre.
Currently the centre is a virtual one, but we hope to be able to have a well-sited physical space to house these services under one roof in the near future.
WHO TO REFER / SERVICES
• Patients with bad obstetric history • Patients at risk of preterm labour • Placenta praevia • Placenta accreta • Two or more previous caesarean sections • VBAC • Hyperemesis gravidarum
Gestational Diabetes Joint Clinic
• Type 1 diabetes • Type 2 diabetes • Gestational diabetes
Cardiology Joint Clinic
Pre-existing cardiac conditions, such as: • Congenital heart disease • Valvular disease • Aortopathies • Ischaemic heart disease • Arrhythmias • Cardiomyopathy • Heart failure • New onset cardiac issues
Rheumatology Obstetric Clinic
All rheumatological conditions, such as: • Systemic lupus erythematous (SLE) • Scleroderma • Rheumatoid arthritis • Vasculitides • Mixed connective tissue disease
Obstetrics & Gynaecology Haematology Clinic
Complex anaemias (e.g., thalassaemias) • Platelet disorders (e.g., immune thrombocytopaenia (ITP)) • Thrombosis • Thrombophilias • Patients requiring long-term anticoagulation
Obstetric Kidney Clinic
• All pre-existing kidney disorders • Renal transplant patients • Dialysis patients
Obstetric Medicine Clinic
General medical disorders including: • Hypertension • Thyroid disorders • Neurological conditions • Epilepsy • Dermatology • Complex multiple medical co-morbidities
Fetal Medicine Clinic
• Counselling for prenatal screening and diagnosis (including NIPT & CMA) • Diagnosis and management of fetal anomalies including echocardiography and neurosonography, and intrauterine growth restriction • Management of monochorionic twins and higher-order multiple pregnancy • Rhesus iso-immunisation, fetal infections and intrauterine fetal therapy
CASES SEEN AT OUR HIGH-RISK CLINICS CHiRP’s range of joint clinics were thoughtfully developed to care for patients and the specific needs they may have. The case studies below illustrate the scale and spectrum of complicated cases that these clinics are equipped to manage.
Mdm L. is a 30-year-old with a complex medical background of type 1 diabetes mellitus, rheumatoid arthritis, Hashimoto’s hypothyroidism and depression. She was receiving long-term care from various medical specialties.
When she became pregnant for a second time, her antenatal care was undertaken at the Gestational Diabetes Joint Clinic (GDJC) where she would see the consultant endocrinologist, consultant obstetrician, dietitian and diabetic nurse in a one-stop joint service. She was placed on a basal-bolus insulin regimen with close obstetric monitoring for fetal anomalies and growth. She was reassured about the safety of and rationale for continuing the thyroxine for hypothyroidism, as well as the hydroxychloroquine for her rheumatoid arthritis. Subsequently, she developed obstetric cholestasis.
She had a successful induction of labour and delivered a healthy appropriately-grown baby boy.
Mdm T. is a 35-year-old who has systemic lupus erythematous (SLE) complicated by immune thrombocytopaenia (ITP) and Raynaud’s phenomenon. Her previous pregnancy was complicated by severe earlyonset pre-eclampsia requiring caesarean delivery which in turn was complicated by a deep vein thrombosis.
For the second pregnancy, she was managed by our Rheumatology Obstetric Clinic, a one-stop clinic where she saw both the consultant rheumatologist and consultant obstetrician. Clearly a very high-risk pregnancy, she was placed on low-dose aspirin and her medications were reviewed, reassuring her that hydroxychloroquine, prednisolone, and low molecular weight heparin were safe and important to maintain the SLE in remission for the benefit of the pregnancy, and also to prevent the formation of thrombosis.
She had close monitoring of both her condition and her baby’s development, and required a course of intravenous immunoglobulin during the pregnancy, before having a healthy term baby delivered by a planned caesarean section at 37 weeks.
Mdm N. is a 20-year-old with compound heterozygosity for sickle cell anaemia and beta thalassaemia. Transfusion-dependent, she had an unplanned pregnancy which was referred early to the Obstetrics & Gynaecology Haematology Clinic, where her antenatal care was undertaken jointly by a consultant haematologist and consultant obstetrician.
The complexity of her medical issues, superimposed on the physiological changes of pregnancy, required a coordinated multidisciplinary effort with other disciplines including cardiology, anaesthesia and neonatology. The risks of sickling crisis and thrombosis with potentially adverse consequences to pregnancy, including fetal growth restriction, were closely anticipated, and she was placed on prophylactic anticoagulation.
The team managed to bring her pregnancy till 37 weeks when she was delivered by elective caesarean section.
Mdm L. is a 27-year-old in her second pregnancy, with a significant medical history of a surgically corrected tetralogy of Fallot. She was managed by the Cardiology Joint Clinic, where she was seen jointly by a consultant cardiologist and a consultant obstetrician at every session. This facilitated timely serial echocardiographic assessments of her cardiac function, as well as simultaneous monitoring of her obstetric and baby’s wellbeing.
She was counselled and monitored for cardiac complications such as heart failure, arrhythmias, cyanosis and syncope, and a multidisciplinary delivery plan was carried to fruition with a term normal vaginal delivery at 39 weeks.
Mdm C. is a 36-year-old with diabetic nephrosclerosis with impaired renal function (serum creatinine 100 μmol/L) and significant proteinuria, hypertension, anaemia and depression. This being her first pregnancy, she was managed by the Obstetric Kidney Clinic where she was seen jointly by a consultant nephrologist and a consultant obstetrician. She was counselled on the high-risk nature of the pregnancy, and was closely monitored for the progression of her renal function while controlling her hypertension and anaemia. She was also tracked for fetal growth restriction and possible development of pre-eclampsia.
Despite the increased risk of preterm birth, the team managed to bring her pregnancy to 37 weeks when she had a successful induction of labour and gave birth to a healthy 2.4kg baby.
The Centre welcomes GP referrals for patients with any of the aforementioned conditions. To refer a patient to any of these clinics, please contact CHiRP at:
Tel: 6321 4516Fax: 6321 4837Email: email@example.com
Assoc Prof Tan Lay Kok Director & Maternal Medicine Lead; Senior Consultant
Assoc Prof Devendra Kanagalingam Peripartum Lead; Senior Consultant
Dr Tan Eng Loy Education and Training Lead; Senior Consultant
Dr Tan Wei Ching Fetal Medicine Lead; Senior Consultant
Dr Yang Liying Research Lead; Consultant
Francine Tu Chen Chen Coordinator and Nursing Lead
Latifah Nur Binte Mohamed Taufik Senior Staff Nurse
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