High-risk pregnancy

1
High-risk pregnancy

• ObGy Department ,First Hospital,
• Xian Jiaotong University
• WANG SHU

2
General consideration

• mother ,fetus,or newborn
• before, during,or after delivery
• at increased risk of morbidity or mortality

3

• Obstetric disorders can impose a higher toll on
  the mother and/or fetus
• Abruptia placentae
• Prematurity
• Postterm pregnancy
• Preeclampsia-eclampsia
• Polyhydramnios
• Oligohydramnios
• Growth restriction
• Chromosomal abnormalities

General consideration
4

• Leading cause of maternal death
• Thromboembolic disease
• Hypertensive disease
• Hemorrhage
• Infection
• Ectopic pregnancy

General consideration
5
Risk factors related to specific pregnancy
problems

• Drug addiction and alcohol abuse
• Pyelonephritis,pneumonia
• Multiple gestation
• Anemia
• Abnormal fetal presentation
• Preterm rupture of membranes
• Placental abnormalities
• infection

• Preterm labor
• age below 16 or over 35 years
• Low socioecomonic status
• Maternal weight below 50Kg
• Poor nutrition
• Previous preterm birth
• Incomplete cervix
• Uterine amonalies
• Smoking

General consideration
6
Risk factors related to specific pregnancy
problems

• polyhydramnios
• diabetes mellitus
• Moutiple gestation
• Fetal congenital abnormalities
• Isoimmunization(Rh or ABO)
• Nonimmune hydrops
• Abnormal fetal presentation

• oligohydramnios
• renal agenesis
• Rolonged rupture of membranes
• Intrauterine growth restriction
• Intrauterine fetal demise

General consideration
7

• In the chapter we will discuss the
  indications and justifications for
• Antepartum care
• Intrapartum management
• Postpartum follow-up

General consideration
8
Maternal assessment for potential fetal or
perinatal risk

• Initial screening
• History

• Maternal age
• Modality of conception
• Past medical history
• Family history
• Ethic background
• Past obstetric history

9
History

• Past medical history
• Chronic hypertension
• Renal disease
• Diabetes mellitus
• Heart disease
• Previous endocrine ablation(eg.thyroidectomy)
• Maternal cancer
• Sickle cell trait and disease
• Substance use or abuse
• Thyroid disorders

• pulmonary disease(eg.tuberculosis,sarciodosis,
  asthma)
• Gastrointestinal and liver disease
• Epilepsy
• Blood disorders(eg,anemia,coagulopathy)
• The others

Initial screening
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History

• Past obstetric history
• Habitual abortion
• Karyotype of abortus
• Parental karyotype
• Cervical and uterien anomalies
• Connective tissue disease
• Hormonal abnormalities
• Acquired and inherited thrombophilias
• Infectious disease of the genital tract
• Previous stillbirth or neonatal death

• Previous preterm delivery
• Rh isoimmunization or ABO incompatibility
• Previous preeclampsia-eclampsia
• Previous infant with genetic disorder or
  congenital aomaly
• Teratogen exposure
• drugs
• Infectious agents
• radiation

Initial screening
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Antepartum course

• Prenatal visits

• Fever(gt100.4?,even gt103 ?)
• Urinary ,pulmonary ,hematological
  sourceschorioamnionitis
• Preterm laboradverse effect on fetus and mother
• Amniocentesis for microscopy and culture
• Antipyreticsdelivery

Vital signs
A
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Prenatal visits

• Pulse

B
Blood pressue
C

• Tachycardia(gt100bpmeven lt120bpm)
• Infection,anemia,heart disease,et.
• Mildfollow-up
• Severe ECG , hemogram

• gt140/90mmHg
• ?gt30/15mmHg
• PIH,chronic hypertention,

urinalysis
D

• Protein,glucose,leukocyte,blood, ketonuria
• anbiotics

Antepartum course
13
Screening Tests
A

• Sonography
• First and trimester
• Aneuploidy,malformation

• Faster trail

• Triple screen(msAFP,ß-hCG, estriol)
• 15-19 weeks
• Trisomy 21,open neural tube defect

B
Maternal serum analyte testing
Antepartum course
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Screening Tests

• Transvaginal sonography
• First and trimester
• Aneuploidy,malformation

C

• Diabetic screen

• RH(-) or/and type-O mother with RH() or/and
  type-A,B,AB father
• First visit,24-28 weeks again,repeat per 4 weeks
  if necessary
• Fetal or newborn hemolysis

D
Isoimmunization
Antepartum course
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Fetal Assessment

• 1.Ultrasound
• Basicfetal numbers,pesentation,fetal
  viability,placental location,gestational age
• Limitedfor suspected problem
• Comprehensivefetalanomalies , growth,
  physiologic complication

A
Assessment of prenatal diagnosis

• 2.Aneuploid screening
• sonography marks
• . Echogenic intracardiac focus
• . Pyelectasis
• . Echogenic bowel
• . Shorter femur

Antepartum course
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Fetal Assessment

• 4.Chorionic villus sampling(CVS)
• Cytogenetic analysis
• 10-12 weeks

A

• 3.Amniocentesis
• Use of this amniotic fluid
• . Cytology for infection
• . Alpha-fetoprotein for neural tube defect
• . L/S for fetal lung maturity
• . Cytogenetic analysis
• 15-20 weeks

Assessment of prenatal diagnosis

• 5.fetal blood sampling (cordocentesis or PUBS)
• Chromosomal or metablic analysis
• second ans third trimester

Antepartum course
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Fetal Assessment

• 1. Fetal monitoring techniques
• External fetal monitoring
• Internal fetal monitoring
• sonographic fetal monitoring

B
Assessment of Fetal well-bing

• 2.fetal heart rate interpretation
• NST
• . Baseline120-160bpm
• . acceleration of 15bpm for 15s at least
• in risk pregnancy of possible fetal demise

Antepartum course
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Fetal Assessment

• 1. Vibroacoustic stimulation
• burst of sound to stimulate fetus
• when NST is nonreactive
• anoxia

C
Ancillary tests

• 2.fetal scalp stimulation
• stimulate fetal vertex
• anoxia

• 3.Oxytocin challenge test (OCT)
• induce effective uterine contraction artificially
• positive resultslate deceleration after each of
  three consecutive contraction
• fetal distress

Antepartum course
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Fetal Maturity Tests

• Indications for assessing fetal lung maturity
• gt37 weeks
• according following criteria
• LecithinSphingomyelin Ratio(L/S)
• Phosphatidylglycerol(PG)
• Foam Stability Index(FSI)
• risk of respiratory distress syndrome

Antepartum course
20
Fetal Maturity Tests
Fetal maturity tests
Antepartum course
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Intrapartum Fetal Surveillance

• Ancillary tests
• Afetal scalp blood sampling
• PHlt7.2
• Serious fetal distresslow Apgar scores
• BFetal lactate levels
• A higher value Marker of neurologic disability

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• Fetal heart rate patterns
• Reassuring fetal heart rate patterns
• Baseline120-160bpm Periodic changes
• Accelerations and variable deceleration
• Early decelerations and bradycardia of 100119bpm
  
• Certain arrhythmia
• . persistent tachyarrythmia
• . Persistent bradyarrythmia

seldom relate to acidosis or hypoxia
Normal autonomic nervous system
Fetal head compression
Well tolerated
Fetal heart disease
Intrapartum Fetal Surveillance
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• Fetal heart rate patterns

• Nonreassuring fetal heart rate patterns

if continuation or worsening, may result in
fetal distress
. Fall in fetal PH . Potential for perinatal
mortality and morbidity

• Late deceleration

.Moderate fetal hypoxemia .No adverse outcome

• sinusoidal heart rate

• variable deceleration
• . No late component
• . Late recovery

. Mild cord compressin . benign
Fetal Ph falls
Intrapartum Fetal Surveillance
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Fetal heart rate patterns
likely to cause fetal or neonatal death or damage

• fetal distress patterns

. Alternating tachycardia and bradycardia . Wide
range

• undulating baseline

. FHR lt100bpm . gt10min

• severe bradycardia

• tachycardia with diminished variability

• tachycardia associated with additional
  noreassuring periodic patterns, eg.
• . Late decelerations
• . variable decelerations with late
  recovery

Intrapartum Fetal Surveillance
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conclusion

• Aim at
• . recognize the risk beginning as early as
  possible.
• Just by
• . preconceptual counseling.
• . early and frequent prenatal care
• And try our best to
• . optimize outcome both of fetus and mother
• . maximize therapeutic treatment