Multidisciplinary Obstetric Simulation Training: Experience at KK Women's and Children's Hospital (KKH), Singapore, a Tertiary Referral Centre.

Background Multidisciplinary simulation training in the management of acute obstetric emergencies has the potential to reduce both maternal and perinatal morbidity. It is a valuable tool that can be adapted for targeted audiences of different specialities at all experience levels from medical students to senior consultants. Methods In this study, pre- and post-course questionnaires of learners with varying levels of clinical experience from Obstetrics and Gynaecology (O&G), Anaesthesia, Neonatology, Emergency Medicine, midwifery, and nursing who undertook two simulation courses (namely the Combined Obstetrics Resuscitation Training course, CORE, and the CORE Lite), which comprised lectures and simulation drills with manikins and standardized patients, between 2015 and 2023 were compared. This also included a period when training was affected by the coronavirus disease 2019 (COVID-19) pandemic.  Results The results showed that both simulation courses increased confidence levels among all learners in the management of obstetric emergencies.  Pre-course, participants were most confident in the management of neonatal resuscitation and severe pre-eclampsia, followed by postpartum haemorrhage. They were least confident in the management of vaginal breech delivery, uterine inversion, and twin delivery. Post-course, participants were most confident in the management of neonatal resuscitation and shoulder dystocia, followed by postpartum haemorrhage. They were least confident in the management of uterine inversion and maternal sepsis, followed by vaginal breech delivery and twin delivery. Whilst we saw a huge improvement in confidence levels for all obstetric emergencies, the greatest improvement in confidence levels was noted in vaginal breech delivery, twin delivery, and uterine inversion. Conclusion The simulation courses were effective in improving the confidence in the management of obstetric emergencies. While it may be difficult to measure the improvement in clinical outcomes as a result of simulation courses alone, the increase in confidence levels of clinicians can be used as a surrogate in measuring their preparedness in facing these emergency scenarios.

Continuous Glucose Monitoring Feedback in the Subsequent Development of Gestational Diabetes: A Pilot, Randomized, Controlled Trial in Pregnant Women.

OBJECTIVE: This study evaluated the effects of receiving glucose feedback from continuous glucose monitoring (CGM) by intermittent scanning (unblinded group), and CGM with masked feedback (blinded group) in the subsequent development of gestational diabetes mellitus (GDM). STUDY DESIGN: This was a prospective, single-center, pilot, randomized controlled trial including n = 206 pregnant women in the first trimester of pregnancy with no prior diagnosis of type 1 or type 2 diabetes. The participants were randomized into the unblinded group or blinded group and wore the CGM in the first trimester of pregnancy (9-13 weeks), the second trimester of pregnancy (18-23 weeks), and late-second to early-third trimester (24-31 weeks). The primary outcome was GDM rate as diagnosed by the 75-g oral glucose tolerance test (OGTT) at 24 to 28 weeks. RESULTS: Over 47 months, 206 pregnant women were enrolled at 9 to 13 weeks. The unblinded group had a higher prevalence of women who developed GDM (21.5 vs. 14.9%; p > 0.05), compared to the blinded group. In the unblinded group compared to the blinded group, plasma glucose values were higher at 1 hour (median 7.7 [interquartile range {IQR}: 6.3-9.2] vs. 7.5 [6.3-8.7]) and 2 hours (6.3 [5.8-7.7] vs. 6.2 [5.3-7.2]), but lower at 0 hour (4.2 [4.0-4.5] vs. 4.3 [4.1-4.6]; p > 0.05). All these differences were not statistically significant. CONCLUSION: Glucose feedback from CGM wear in the first to the third trimester of pregnancy without personalized patient education failed to alter GDM rate. KEY POINTS: · Continuous glucose monitoring (CGM) is feasible for use in pregnant women.. · No significant difference in gestational diabetes rates with or without CGM feedback.. · Future clinical trials should incorporate CGM education and personalized guidance to enhance study outcomes..

Knowledge, Attitude and Perceptions Around Perinatal Mental Health Among Doctors in an Obstetrics and Gynaecology Academic Department in Singapore.

Background Frontline healthcare professionals who provide regular care to women in the antenatal and postnatal period play a critical role in the early detection and management of maternal perinatal mental health (PMH). This study aimed to assess the knowledge, attitudes, and perceptions of doctors around perinatal mental health in an obstetrics and gynaecology (O&G) department in Singapore. Methods Using an online survey, data was collected from 55 doctors who participated in the Doctor's Knowledge, Attitudes and Perceptions of Perinatal Mental Health (I-DOC) study. The survey questions assessed the knowledge, attitudes, perceptions and practices in relation to PMH among doctors in the O&G specialty. Descriptive data was presented as means and standard deviations (SDs), or frequency and percentages. Results Out of the 55 doctors, more than half (60.0%) were not aware of the adverse impacts of poor PMH; 83.7% of doctors were not confident in providing PMH advice and 65.5% did not routinely screen patients for PMH disorders. There was a lower percentage of doctors (10.9% vs. 34.5%, p<0.001) who discussed PMH issues in the antenatal period compared to the postnatal period and this was statistically significant. Majority of doctors (98.2%) agreed that having standardised PMH guidelines will be useful. All doctors agreed on the benefits of having PMH guidelines, education and routine screening for patients. Conclusion There is inadequate PMH literacy among O&G doctors and lack of emphasis on antenatal PMH disorder. The findings highlighted the need for increased education and development of perinatal mental health guidelines.

Attitudes and practices of exercise among pregnant mothers in Singapore.

Introduction: There is increasing evidence demonstrating the safety and benefits of physical activity (PA) in uncomplicated pregnancies. Literature has shown that pregnant women around the world do not engage in adequate exercise. This study aims to assess the current practices of exercise among pregnant women in Singapore, determine the proportion of women meeting different PA targets and evaluate the factors influencing the practice of exercise. Methods: In this cross-sectional study, pregnant women in different trimesters of pregnancy from KK Women's and Children's Hospital and Singapore General Hospital were surveyed. Information regarding patient demographics, attitudes and perceptions of exercise, and practice of exercise was collected. The International Physical Activity Questionnaire (IPAQ) was used to determine the amount of PA. Results: A total of 201 pregnant women aged 20-44 years were surveyed. Almost all (99.0%) participants thought that exercise was beneficial in pregnancy. Only 31.6% of them engaged in any moderate or vigorous leisure-time PA (LTPA) and they were active for a median of 120 min/week. Only 12.6% of the pregnant women met the national recommendations of at least 150 min of moderate exercise per week. The amount of total PA performed was lower among women in later trimesters of pregnancy and higher among working mothers. Conclusion: Although most Singaporean pregnant women perceived exercise as beneficial, the majority did not engage in PA. Most of the participants did not meet the international PA targets and recently published national guidelines. More can be done to promote the uptake of exercise in pregnancy and optimise metabolic management of pregnant women in Singapore.

Unexpected case of postnatal pancreatitis: first presentation of autoimmune diabetes.

Gestational diabetes mellitus (GDM) is defined as the first onset of glucose intolerance in pregnancy without prior known diabetes. While it is commonly associated with metabolic risk factors such as obesity and hypertension, a small percentage of women with GDM have underlying autoimmune causes, with presence of islet-cell antibodies resulting in autoimmune-mediated destruction of the pancreas. We present a case of idiopathic postpartum pancreatitis precipitating fulminant diabetic ketoacidosis in a patient with otherwise well-controlled GDM during pregnancy, and subsequent findings of positive anti-glutamic acid decarboxylase antibody. This is the first presentation of autoimmune diabetes diagnosed postnatally in a woman who has no previous medical or family history.

Glycemic Variability in Early Pregnancy May Predict a Subsequent Diagnosis of Gestational Diabetes.

Purpose: This study examined the prospective association between CGM-derived glycemic variability (GV) and glycemic control (GC) parameters in the first and second trimester, with subsequent diagnosis of GDM in the early third trimester. Methods: In a longitudinal observational study, 60 study participants in the first trimester (9-13 weeks' gestation), and 53 participants (18-23 weeks' gestation) in the second trimester of pregnancy had CGM data extracted after a minimum of 8 days' wear time (up to 14 days). At 24-31 weeks' gestation, participants underwent a 75 g, 2-hour oral glucose-tolerance test as per IADPSG criteria to diagnose GDM. GV parameters examined in both first and second trimesters were mean amplitude of glycemic excursion (MAGE), standard deviation (SD), mean glucose, and coefficient of variation (CV). GC parameters measured were J-Index and percentage of time spent in glucose target ranges. Results: The first trimester SD and MAGE were significantly higher in participants subsequently diagnosed with GDM (SD adjusted median 1.31 [interquartile range 1.2-1.3] mmol/L; MAGE 3.26 [3.2-3.3] mmol/L) than those who were not (SD 1.01 [0.9-1.0] mmol/L, MAGE 2.59 [2.4-2.6] mmol/L; p<0.05). Similarly, second trimester SD and MAGE were also significantly higher in participants subsequently diagnosed with GDM (SD 1.35 [1.3-1.4] mmol/L; MAGE 3.32 (3.31-3.41) mmol/L) than those who were not (SD 0.99 [0.98-1.01] mmol/L, MAGE 2.42 [2.42-2.55] mmol/L; p<0.05). Associations between SD and MAGE with GDM outcomes were adjusted for prepregnancy BMI and ethnicity. There were nonsignificant trends of higher J-Index scores in the first and second trimester, higher CV in the first trimester only, and higher mean in the second trimester only in participants diagnosed with GDM. Other study parameters measured were not significantly different between groups (p>0.003). Conclusion: Our study suggests the potential value of CGM-derived SD and MAGE in early pregnancy as potential predictors of subsequent GDM diagnosis.

Asia-Pacific consensus on physical activity and exercise in pregnancy and the postpartum period.

Physical activity and exercise in pregnancy are generally beneficial and enhance the physical and mental health of women. These benefits also prevent excessive weight gain and reduce risks of obesity in pregnancy, such as gestational diabetes, hypertensive disorders, higher rates of caesarean delivery, macrosomia and stillbirth. Thus, there is a need to optimise perinatal exercise and physical activity globally. There is currently no consensus recommendation on the role of physical activity and exercise in pregnancy and the postpartum period in the Asia-Pacific region. In this paper, we present seven key consensus recommendations on physical activity and exercise in pregnancy and the postpartum period by 18 key members representing 10 countries in Asia-Pacific regions during an international workshop of the Asia Diabetes in Pregnancy Conference in Singapore on 11-12 January 2020. Through these consensus recommendations, we hope to improve the metabolic health of pregnant women living in Asia-Pacific regions by educating the public and guiding healthcare professionals on the safety and importance of physical exercise and activity to benefit pregnant women and after childbirth.

Epidemiology of pregnancy-associated pulmonary embolism in South Asian multi-ethnic country: Mortality trends over the last four decades.

OBJECTIVE: To determine the cumulative incidence, time of occurrence and risk factors of pregnancy-associated pulmonary embolism (PE) in Singapore, and to review the maternal mortality ratio of PE over the last four decades. STUDY DESIGN AND SETTING: In this retrospective epidemiology review, women with pregnancy-associated PE were identified via International Classification of Diseases codes and included if they had been objectively diagnosed on imaging with PE during pregnancy or within 6 weeks postpartum from 2004 to 2016 at KK Women's and Children's Hospital (KKH) and Singapore General Hospital (SGH) in Singapore. The medical records were reviewed and the time of occurrence of confirmed PE cases and risk factors for PE were noted. RESULTS: There were 18 PE cases out of 174 708 deliveries, of which two were fatal, giving a cumulative incidence of PE at 1.03 per 10 000 deliveries and a mortality rate of 11.1%. The maternal mortality ratio is 1.14 per 100 000 deliveries, the lowest compared to that of the previous three decades (2.5-4.9 per 100 000 deliveries). Majority of PE (66.7%) occurred during the first 2 weeks postpartum. Cumulative incidence of postpartum PE was four times more in caesarean section compared to vaginal delivery at 1.58 per 10 000 deliveries and 0.40 per 10 000 deliveries, respectively. CONCLUSION: Although the cumulative incidence of pregnancy-associated PE in Singapore is low, it is comparable to the United Kingdom (UK) and United States (US). Risk assessment and thromboprophylaxis have decreased PE mortality significantly during this period.

Risk factors for pregnancy-associated venous thromboembolism in Singapore.

OBJECTIVES: Pregnancy-associated venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with increased risk of maternal mortality and morbidity. This study aimed to assess potential risk factors for pregnancy-associated VTE. METHODS: In this case-control study, women with pregnancy-associated VTE were identified via International Classification of Diseases codes and included if they had been objectively diagnosed with VTE during pregnancy or within six weeks postpartum, from 2004 to 2016, at KK Women's and Children's Hospital or Singapore General Hospital in Singapore. Controls, i.e. pregnant women without VTE, were selected from a prospective longitudinal study. The odds ratio (OR) for VTE was computed for a range of maternal and obstetric factors. RESULTS AND CONCLUSIONS: From 2004 to 2016, 89 cases of pregnancy-associated VTE and 926 controls were identifed and analysed using logistic regression. The most significant risk factors for pregnancy-associated VTE were smoking (OR 5.44, p=0.0002) and preterm delivery (OR 5.06, p=0.023). Malay race, multiparity, non-O blood group and caesarean section, were also identified to be of higher risk. These risk factors should be useful in the development of thromboprophylaxis strategies for pregnancy and the postpartum period, especially in Singapore.

Pregnancy Outcomes in COVID-19: A Prospective Cohort Study in Singapore.

INTRODUCTION: Pregnant women are reported to be at increased risk of severe coronavirus disease 2019 (COVID-19) due to underlying immunosuppression during pregnancy. However, the clinical course of COVID-19 in pregnancy and risk of vertical and horizontal transmission remain relatively unknown. We aim to describe and evaluate outcomes in pregnant women with COVID-19 in Singapore. METHODS: Prospective observational study of 16 pregnant patients admitted for COVID-19 to 4 tertiary hospitals in Singapore. Outcomes included severe disease, pregnancy loss, and vertical and horizontal transmission. RESULTS: Of the 16 patients, 37.5%, 43.8% and 18.7% were infected in the first, second and third trimesters, respectively. Two gravidas aged ≥35 years (12.5%) developed severe pneumonia; one patient (body mass index 32.9kg/m2) required transfer to intensive care. The median duration of acute infection was 19 days; one patient remained reverse transcription polymerase chain reaction (RT-PCR) positive >11 weeks from diagnosis. There were no maternal mortalities. Five pregnancies produced term live-births while 2 spontaneous miscarriages occurred at 11 and 23 weeks. RT-PCR of breast milk and maternal and neonatal samples taken at birth were negative; placenta and cord histology showed non-specific inflammation; and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific immunoglobulins were elevated in paired maternal and umbilical cord blood (n=5). CONCLUSION: The majority of COVID-19 infected pregnant women had mild disease and only 2 women with risk factors (obesity, older age) had severe infection; this represents a slightly higher incidence than observed in age-matched non-pregnant women. Among the women who delivered, there was no definitive evidence of mother-to-child transmission via breast milk or placenta.

Attitudes and precaution practices towards COVID-19 among pregnant women in Singapore: a cross-sectional survey.

BACKGROUND: COVID-19 may predispose pregnant women to higher risks of severe disease and poorer neonatal outcome. Psychological sequalae of this pandemic may pose a greater conundrum than its clinical aspects. It is currently unknown that how pregnant women cope with this global pandemic and its ramifications. The aims of the study are to understand the attitudes and precaution practices of non-infected pregnant women towards the COVID-19 outbreak in Singapore. METHODS: An online cross-sectional survey of COVID-19 awareness among pregnant women attending antenatal clinics in Singapore was conducted. An internet link was provided to complete an online electronic survey on Google platform using a quick response (QR) code on mobile devices. The online survey consists of 34 questions that were categorized into 4 main sections, namely 1) social demographics 2) attitude on safe distancing measures 3) precaution practices and 4) perceptions of COVID-19. Multiple linear regression analysis was performed to examine women's precaution practices among six independent socio-demographic variables, including age, ethnicity, education, front-line jobs, history of miscarriage and type of antenatal clinic (general, high risk). RESULTS: A total of 167 survey responses were obtained over 8 weeks from April to June 2020. The majority of women were aged ≤35 years (76%, n = 127), were of Chinese ethnicity (55%, n = 91), attained tertiary education (62%, n = 104) and were not working as frontline staff (70%). Using multiple linear regression models, Malay ethnicity (vs. Chinese, ß 0.24; 95% CI 0.04, 0.44) was associated with higher frequency of practicing social distancing. Malay women (ß 0.48; 95% CI 0.16, 0.80) and those who worked as frontline staff (ß 0.28; 95% CI 0.01, 0.56) sanitized their hands at higher frequencies. Age of ≥36 years (vs. ≤30 years, ß 0.24; 95% CI 0.01, 0.46), Malay (vs. Chinese, ß 0.27; 95% CI 0.06, 0.48) and Indian ethnicity (vs. Chinese, ß 0.41; 95% CI 0.02, 0.80), and attendance at high-risk clinic (vs. general clinic, ß 0.20; 95% CI 0.01, 0.39) were associated with higher frequency of staying-at-home. CONCLUSION: Social demographical factors including age > 36 years old, Malay ethnicity, employment in front line jobs and attendance at high-risk clinics are likely to influence the attitudes and precaution practices among pregnant women towards COVID-19 in Singapore. Knowledge gained from our cross-sectional online survey can better guide clinicians to communicate better with pregnant women. Hence, it is important for clinicians to render appropriate counselling and focused clarification on the effect of COVID-19 among pregnant women for psychological support and mental well being.

Maternal and Fetal Outcomes in Systemic Lupus Erythematosus Pregnancies.

INTRODUCTION: To describe the maternal and fetal outcomes in systemic lupus erythematosus (SLE) pregnancies followed-up in a single tertiary referral centre. METHODS: We performed a retrospective cohort study of 75 SLE pregnancies who were followed up in Singapore General Hospital over a 16-year period from 2000 to 2016. Adverse fetal and maternal outcomes including preterm delivery, miscarriages, fetal growth restriction, congenital heart block, neonatal lupus, pre-eclampsia and SLE flares were obtained from the medical records. RESULTS: The mean age at conception was 32 years old (SD 3.8). The mean SLE disease duration was 5.9 years (SD 5.2). The majority (88%) had quiescent SLE disease activity at baseline. Most pregnancies resulted in a live birth (74.7%). The mean gestational age at birth was 37.4 weeks (SD 3.4). Adverse fetal outcomes occurred in 53.3%. Preterm delivery (33.9%), miscarriages (20%) and fetal growth restriction (17.3%) were the most frequent adverse fetal outcomes. There was 1 neonatal death and SLE flares occurred in a third (33%). In the subgroup of SLE pregnancies with antiphospholipid syndrome, there were higher SLE flare rates (40%) and adverse fetal outcomes occurred in 8 pregnancies (80%). There were no predictive factors identified for all adverse fetal and maternal outcomes. In the subgroup analysis of preterm delivery, anti-Ro (SS-A) antibody positivity and hydroxychloroquine treatment were associated with a lower risk of preterm delivery. CONCLUSION: Although the majority had quiescent SLE disease activity at baseline, SLE pregnancies were associated with high rates of adverse fetal and maternal outcomes.

Coverage and determinants of influenza vaccine among pregnant women: a cross-sectional study.

BACKGROUND: Pregnant women are at increased risk of influenza-related complications. The World Health Organisation recommends influenza vaccination to this high-risk population as highest priority. However, achieving high influenza vaccine coverage among pregnant women remains challenging. We conducted a cross-sectional survey to estimate the coverage and determinants of influenza vaccination among pregnant women in Singapore. METHODS: Between September and November 2017, pregnant women aged ≥21 years were recruited at two public hospitals in Singapore. Participants completed an anonymous, self-administered online questionnaire assessing participants' influenza vaccination uptake, knowledge of and attitudes towards influenza and the influenza vaccine, vaccination history, willingness to pay for the influenza vaccine, and external cues to vaccination. We estimated vaccine coverage and used multivariable Poisson models to identify factors associated with vaccine uptake. RESULTS: Response rate was 61% (500/814). Only 49 women (9.8, 95% Confidence Interval (CI): 7.3-12.7%) reported receiving the vaccine during their current pregnancy. A few misconceptions were identified among participants, such as the belief that influenza can be treated with antibiotics. The most frequent reason for not being vaccinated was lack of recommendation. Women who were personally advised to get vaccinated against influenza during pregnancy were 7 times more likely to be vaccinated (prevalence ratio (PR) = 7.11; 95% CI: 3.92-12.90). However, only 12% of women were personally advised to get vaccinated. Other factors associated with vaccine uptake were vaccination during a previous pregnancy (PR = 2.51; 95% CI: 1.54-4.11), having insurance to cover the cost of the vaccine (PR = 2.32; 95% CI: 1.43-3.76), and higher vaccine confidence (PR = 1.62; 95% CI: 1.30-2.01). CONCLUSIONS: Influenza vaccination uptake among pregnant women in Singapore is low. There is considerable scope for improving vaccination coverage in this high-risk population through vaccination recommendations from healthcare professionals, and public communication targeting common misconceptions about influenza and influenza vaccines.

Comparison of Caesarean sections and instrumental deliveries at full cervical dilatation: a retrospective review.

INTRODUCTION: This study aimed to compare instrumental vaginal deliveries (IDs) and Caesarean sections (CSs) performed at full cervical dilatation, including factors influencing delivery and differences in maternal and neonatal outcomes. METHODS: A retrospective review was conducted of patients who experienced a prolonged second stage of labour at Singapore General Hospital from 2010 to 2012. A comparison between CS and ID was made through analysis of maternal/neonatal characteristics and peripartum outcomes. RESULTS: Of 253 patients who required intervention for a prolonged second stage of labour, 71 (28.1%) underwent CS and 182 (71.9%) underwent ID. 5 (2.0%) of the patients who underwent CS had failed ID. Of the maternal characteristics considered, ethnicity was significantly different. Induction of labour and intrapartum epidural did not influence delivery type. 70.4% of CSs occurred outside office hours, compared with 52.7% of IDs (p = 0.011). CS patients experienced a longer second stage of labour (p < 0.001). Babies born via CS were heavier (p < 0.001), while the ID group had a higher proportion of occipitoanterior presentations (p < 0.001). Estimated maternal blood loss was higher with CSs (p < 0.001), but neonatal outcomes were similar. CONCLUSION: More than one in four parturients requiring intervention for a prolonged second stage of labour underwent emergency CS. Low failed instrumentation rates and larger babies in the CS group suggest accurate diagnoses of cephalopelvic disproportion. The higher incidence of CS after hours suggests trainee reluctance to attempt ID. There were no clinically significant differences in maternal and neonatal morbidity.

Altered Placental Chorionic Arterial Biomechanical Properties During Intrauterine Growth Restriction.

Intrauterine growth restriction (IUGR) is a pregnancy complication due to placental dysfunction that prevents the fetus from obtaining enough oxygen and nutrients, leading to serious mortality and morbidity risks. There is no treatment for IUGR despite having a prevalence of 3% in developed countries, giving rise to an urgency to improve our understanding of the disease. Applying biomechanics investigation on IUGR placental tissues can give important new insights. We performed pressure-diameter mechanical testing of placental chorionic arteries and found that in severe IUGR cases (RI > 90th centile) but not in IUGR cases (RI < 90th centile), vascular distensibility was significantly increased from normal. Constitutive modeling demonstrated that a simplified Fung-type hyperelastic model was able to describe the mechanical properties well, and histology showed that severe IUGR had the lowest collagen to elastin ratio. To demonstrate that the increased distensibility in the severe IUGR group was related to their elevated umbilical resistance and pulsatility indices, we modelled the placental circulation using a Windkessel model, and demonstrated that vascular compliance (and not just vascular resistance) directly affected blood flow pulsatility, suggesting that it is an important parameter for the disease. Our study showed that biomechanics study on placenta could extend our understanding on placenta physiology.

Multiple pregnancy in a primigravida with uncorrected Pentalogy of Fallot.

Pentalogy of Fallot is a cyanotic congenital heart disease that has guarded prognosis without surgical intervention in infancy. Women with uncorrected defects rarely survive into childbearing age and pregnancy in this group is associated with a high rate of perinatal loss. Physiological cardiovascular changes in pregnancy can lead to maternal haemodynamic instability with subsequent adverse cardiac sequelae with or without fetal decompensation. Optimum management and pregnancy outcomes in mother with uncorrected Pentalogy of Fallot and twin pregnancy have not been described in the literature. We describe a successful case of monochorionic diamniotic twin pregnancy in an affected woman who has not undergone surgical repair. Her pregnancy progressed without any adverse cardiopulmonary complications. Her caesarean delivery and postpartum recovery were favourable, with successful birth of two healthy babies at 35.7 weeks. This case emphasises the importance of a multidisciplinary team, especially of obstetricians with expertise in high-risk pregnancies, adult congenital heart disease cardiologists and anaesthesiologist.