High Risk Pregnancies

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High Risk Pregnancies

• Anna Mae Smith, MPAS, PA-C

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DEFINITION

• A pregnancy in which the mother, fetus, or
  newborn is or will be in a state of increased
  jeopardy
• 75 of obstetric deaths are preventable most
  are a result of
• HEMORRHAGE
• INFECTION
• HYPERTENSIVE states

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Perinatal death

• Those not caused by congenital anomalies
• Breech
• Placental separation
• Pre-eclampsia/eclampsia
• Twinning
• Pyelonephritis
• Placenta previa/abruptio
• Hydramnios

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INITIAL SCREENING HISTORY

• Maternal Age - young or old
• Reproductive history
• Medical complications
• Physical Exam

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TWINS

• Dyzogotic twins - (fraternal)
• originate from two zygotes!
• Account for about 2/3 of twins
• rate increases with age
• same or different sex
• hereditary tendency
• genotype of the mom
• one set of dyzotic twins twice as likely as
  general population of doing it again!!

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TWINS

• Monozygotic - (identical)
• form from one zygote
• If the division of the inner cell mass occurs
  after the amniotic cavity occurs (8days) the
  identical twins will be in the same amniotic
  chorionic sac
• this accounts for only 1 of monozygotic twins

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Monozygotic twins cond

• 70 of monozygotic twins will have a separate
  amniotic sac, single chorion, a common placenta
• 29 develop from early separation of the
  blastomeres (first 3 days)
• each embryo has its own amnionic chorionic sac
• The placentas may be separate or fused

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Maternal Complications

• The physiologic changes occurring in the mother
  with a twin gestation are an exaggeration of what
  occurs in a singleton pregnancy.
• She has a greater increase in blood volume,
  pulse, cardiac output, and weight gain.

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Increased Risk for...

• Preterm labor
• Hypertension
• Abruption
• Anemia
• Hydramnios
• Urinary tract infection
• Postpartum hemorrhage
• Cesarean section

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INFANT Complications

• Prematurity
• small infants weighing less than 2500 g from a
  twin pregnancy fare better in the nursery and
  have lower mortality rates than comparable-weight
  infants from singleton pregnancies.

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INFANT Complications

• congenital anomalies is increased two to three
  times in twins, and this increase is mostly
  confined monozygotic infants
• Discordance - unequal weights
• altered surface area of placenta
• twin to twin transfusion

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Twin complications

• Vanishing fetus
• Locking Twins
• Dead fetus syndrome
• Delayed delivery of one twin
• Cord clamping
• Abruption

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Epilepsy
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Seizure Activity

• Maternal injury
• miscarriage
• fetal hypoxia
• Status epilepticus increases the mortality rate
  for both mom fetus!!

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Seizures

• May be related to hormone levels in some women
• 90 will have a good outcome with adequate
  planning
• 25will have fewer seizures when pregnant
• 25will have more
• 50 no change in seizure activity

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Increased risk of

• Pre-eclampsia
• anemia
• vaginal bleeding
• C-section
• abruption
• hyperemesis gravidarum

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AED anticonvulsant drugs

• Many are anti-folate, therefore critical to begin
  folate replacement prior to conception
• Most are secreted in breast milk
• High teratogenicity (neural tube defects) seen
  with
• phenobarbital
• valproic acid
• carbamazepine

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Risk of Congenital Problems

• MAJOR 4-6 ( general population - 2-4)
• MINOR 6-20
• Most common abnormality - Cleft Lip palate
  congenital heart disease
• Vit K deficiency in the newborn from AEDs

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THROMBOEMBOLIC DISEASE
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• More estrogen
• May occur at any stage but more common later
• DVT!!!
• VIRDOWs TRIAD
• hypercoagulable state
• venous stasis
• endothelial injury

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Hypercoagulation

• Protective for delivery
• Liver produces more clotting factors!