High-risk pregnancy

Ob&Gy Department ,First Hospital, Xian Jiaotong University

WANG SHU

General consideration

mother ,fetus,or newborn during,or after delivery

before, at

increased risk of morbidity or

mortality

 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

Leading

cause of maternal death

Thromboembolic disease
Hypertensive disease

Hemorrhage
Infection Ectopic pregnancy

General consideration

Risk factors related to specific pregnancy problems

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

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

General consideration

Risk factors related to specific pregnancy problems

polyhydramnios

oligohydramnios
renal agenesis Rolonged rupture of membranes

diabetes mellitus

Moutiple gestation Fetal congenital

abnormalities
Isoimmunization(Rh or ABO) Nonimmune hydrops Abnormal fetal presentation

Intrauterine growth
restriction Intrauterine fetal

demise

General consideration

In the chapter we will discuss the

indications and justifications for

Antepartum care

Intrapartum management Postpartum follow-up

General consideration

Maternal assessment for potential fetal or perinatal risk

Initial

screening
oMaternal age oModality of conception oPast medical history oFamily history

History :

oEthic background
oPast obstetric history

History
Past medical history
Chronic hypertension Renal disease pulmonary disease(eg.tuberculosis,sarcio dosis, asthma) Gastrointestinal and liver disease Epilepsy Blood disorders(eg,anemia,coagulo pathy) The others

Diabetes mellitus
Heart disease Previous endocrine

ablation(eg.thyroidectomy)
Maternal cancer Sickle cell trait and disease

Substance use or abuse

Thyroid disorders

Initial screening

Past obstetric history

Habitual abortion
oKaryotype of abortus oParental karyotype

History
Previous preterm delivery Rh isoimmunization or ABO incompatibility Previous preeclampsiaeclampsia Previous infant with genetic disorder or congenital aomaly Teratogen exposure o drugs oInfectious agents oradiation

oCervical and uterien anomalies

oConnective tissue disease oHormonal abnormalities

oAcquired and inherited

thrombophilias oInfectious disease of the genital

tract
Previous stillbirth or neonatal death

Initial screening

Antepartum course
Prenatal

visits
o Fever(>100.4,even >103 )
o Urinary ,pulmonary ,hematological

Vital signs
A

sources;chorioamnionitis o Preterm labor;adverse effect on fetus and mother o Amniocentesis for microscopy and culture o Antipyretics;delivery

Prenatal visits
Pulse B
oTachycardia(>100bpm even <120bpm) oInfection,anemia,heart disease,et. oMild:follow-up; Severe: ECG , hemogram ketonuria o anbiotics o >140/90mmHg >30/15mmHg oPIH,chronic hypertention,

Blood pressue C

urinalysis

o Protein,glucose,leukocyte,blood,

Antepartum course

Screening Tests
A oSonography oFirst and trimester oAneuploidy,malformation B

Faster trail

Maternal serum analyte testing

o Triple screen(msAFP,-hCG, estriol)

o 15-19 weeks

o Trisomy 21,open neural tube defect

Antepartum course

Screening Tests
C oTransvaginal sonography oFirst and trimester oAneuploidy,malformation o RH(-) or/and type-O mother with RH(+) or/and typeA,B,AB father; o First visit,24-28 weeks again,repeat per 4 weeks if necessary o Fetal or newborn hemolysis Antepartum course

Diabetic screen

D Isoimmunization

Fetal Assessment
1.Ultrasound o Basic:fetal numbers,pesentation,fetal viability,placental location,gestational age

A Assessment of prenatal diagnosis

o Limited:for suspected problem o Comprehensive:fetalanomalies , growth, physiologic complication 2.Aneuploid screening o sonography marks: . Echogenic intracardiac focus

. Pyelectasis
. Echogenic bowel

Antepartum course

. Shorter femur

Fetal Assessment
Assessment of prenatal diagnosis A
3.Amniocentesis o Use of this amniotic fluid: . Cytology for infection . Alpha-fetoprotein for neural tube defect . L/S for fetal lung maturity . Cytogenetic analysis o 15-20 weeks 4.Chorionic villus sampling(CVS) o Cytogenetic analysis o 10-12 weeks 5.fetal blood sampling (cordocentesis or PUBS) o Chromosomal or metablic analysis o second ans third trimester

Antepartum course

Fetal Assessment
1. Fetal monitoring techniques o External fetal monitoring

B Assessment of Fetal well-bing

o Internal fetal monitoring o sonographic fetal monitoring

2.fetal heart rate interpretation

o NST . Baseline:120-160bpm . acceleration of 15bpm for 15s at least o in risk pregnancy of possible fetal demise

Antepartum course

Fetal Assessment
1. Vibroacoustic stimulation o burst of sound to stimulate fetus o when NST is nonreactive

C Ancillary tests

o anoxia
2.fetal scalp stimulation o stimulate fetal vertex

o anoxia
3.Oxytocin challenge test (OCT) o induce effective uterine contraction artificially o positive results:late deceleration after each of three consecutive contraction

Antepartum course

o fetal distress

Fetal Maturity Tests

Indications for assessing fetal lung maturity:
>37 weeks
according following criteria: oLecithin:Sphingomyelin Ratio(L/S) oPhosphatidylglycerol(PG) oFoam Stability Index(FSI) risk of respiratory distress syndrome Antepartum course

Fetal Maturity Tests

Fetal maturity tests
Test Positive discriminating value Positive predictive value Relative cost Pros and Cons

L:S ratio

>2.0

95~100%

High

Large laboratory variation

PG

present

95~100%

High

Not affected by blood,meconium.C an use vaginal pooled sample

FSI

Stable ring of foam

95%

Low

affected by blood,meconium.

Antepartum course

Intrapartum Fetal Surveillance

Ancillary

tests

A:fetal scalp blood sampling

o PH<7.2
o Serious fetal distress;low Apgar scores B:Fetal lactate levels o A higher value Marker of neurologic disability

Fetal

heart rate patterns

Reassuring fetal heart rate seldom relate to acidosis patterns or hypoxia

o Baseline:120-160bpm & Periodic changes o Accelerations and variable deceleration o Early decelerations and bradycardia of 100~119bpm o Certain arrhythmia . persistent tachyarrythmia . Persistent bradyarrythmia

Normal autonomic nervous system Fetal head compression Well tolerated

Fetal heart disease

Intrapartum Fetal Surveillance

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 .Moderate fetal hypoxemia .No adverse outcome . Mild cord compressin . benign Fetal Ph falls

o Late deceleration o sinusoidal heart rate o variable deceleration . No late component . Late recovery Intrapartum Fetal Surveillance

Fetal heart rate patterns

fetal distress patterns

likely to cause fetal or neonatal death or damage

. Alternating tachycardia and bradycardia . Wide range . FHR <100bpm . >10min

o undulating baseline
o severe bradycardia

o tachycardia with diminished variability

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

Intrapartum Fetal Surveillance

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