LU 4.4 High Risk Pregnancy

What is high risk pregnancy ?

• the mother and fetus is or might at increased risk of morbidity or mortality before, during or after delivery

What are the general risk factors of high risk pregnancy :?

• age : women <18y, >40y

• lifestyle : smoking, obesity, alcoholism

• chronic medical conditions : hypertension, diabetes mellitus

• infectious disease : HIV, active TB, Hep B

• social history : domestic violence

Explain the identification of high risk pregnancy

• When : at first AN visit, subsequent visit or intrapartum if patient is first seen in labour

• How : by careful history taking, interview and physical examination

• Why : To reduce maternal and perinatal mortality and morbidity

• By Whom : Health personnel

• Where : Any place where antenatal care is given (eg : district hospital)

What is the low risk and high risk for these factors of high risk pregnancy ?

• Age

• Gravida, Parity

• Personal history

• Social history

• Height

• Age : 20-35 (low risk), <20, >35 (high risk)

• Gravida, Parity : 2-4 (low risk), Primigravida, Grandmultips, Elderly primi (high risk)

• Personal history : educated (low risk), illiterate, smoking, drinking, drug addiction (high risk)

• Social history : High/Middle class (low risk), low class (high risk)

• Height : >5ft (150cm) (low risk), <4’10ft & bony abnormality (high risk)

What are the general management of high risk pregnancy ?

• early detection of high risk factors

• pre pregnancy counseling

• regular frequent AN care

• correct any maternal + fetal ill health with available facilities

• close monitoring of maternal & fetal growth and well being

What are the type of high risk pregnancy ?

• Antepartum haemorrhage

• Cardiac disease

• Hypertensive disorders of pregnancy

• Diabetes

• Anaemia

• Twins

• Syphilis

• Infections

What is antepartum haemorrhage (APH) ?

• bleeding after 20th week of pregnancy before the birth of the baby

• causes : placenta previa, abdominal trauma, miscarriage

What are the management for APH ?

• identify the cause of APH (blood for group & hold, FBC, assessment of fetal movement CTG)

• caesarean section (if unstoppable labour, fetal distress or life threatening)

• expectant management if preterm, no fetal distress, not life threatening)

What are the class description for patient with cardiac disease ?

• Class I: unrestricted physical activity. No symptoms of cardiac insufficiency.

• Class II: slight limitation physical activity.

• Class III: moderate limitation physical activity.

• Class IV: No physical activity

What are the management for mother with cardiac disease ?

• pre-conceptual counselling

• continuous oxygen via facial mask to ensure good o2 saturation

• unfractionated heparin (UH), low-molecular weight heparin (LMWH) and warfarin throughout pregnancy

• vaginal birth (preferable)

What are the types of hypertensive disorders in pregnancy ?

• Chronic Hypertension • Hypertension existed before pregnancy or present before 20 weeks of gestation

• Pregnancy induced hypertension (PIH) • Hypertension after 20 weeks of pregnancy

• Pre-eclampsia (PE) • May present with any symptoms of headache, blurring of vision, epigastric pain or oliguria and oedema • When the blood pressure is >=140/90, with proteinuria trace, 1+ or 2+

• Eclampsia • generalized convulsion(s) associated with background of pre-eclampsia during pregnancy, labour or within seven days of delivery

What is Pre-Eclampsia (PE) ?

• BP ≥ 140/90

• Systolic increase of 20mm Hg > prepregnancy levels.

• Diastolic increase of 15mm Hg > prepregnancy levels.

• Presents with HPT, proteinuria, edema of face,hands, ankles.

• Occur after 20th wks of pregnancy.

• Usually occurs closer to the due date & may not resolved after delivery

What are the general signs of Pre Eclampsia ?

• Rapid weight gain; swelling of arms and face.

• Headache; blurred vision, seeing double, seeing spots.

• Dizziness, fainting, ringing in ears, confusion; seizures.

• Abdominal pain, decrease urine output; nausea, vomiting, blood in vomit or urine

What are the severity / type of Pre Eclampsia ?

• Mild : mild HPT; no end-organ damage; minimal proteinuria.

• Severe : significant HPT; severe proteinuria (>5.0 g/d); end-organ damage due to systemic vaso-constriction.

What are the risk factors for Pre- Eclampsia ?

• < age 20 or > 40 • Twins, triplets; primagravida

• Molar pregnancy

• Preexisting: HTN, Diabetes mellitus

• Renal or vascular disease

• Prior hx of PIH, pre-eclampsia/eclampsia

What are the management for preeclampsia ?

• the only cure is delivery.

• Mild preeclampsia: Bed rest. Monitor @ home or hospital. Deliver close to EDD. Close monitoring of FHR & BP, 24 hrs urine for protein, liver enzymes & ultrasounds.

• Severe pre eclampsia: Goal: prevent convulsions & control maternal BP.

What are the medical management for Preeclampsia ?

• Tab methyldopa 250 mg BD/TDS

• Tab Nifedipine 10-20 mg orally bd/tds (the second line of treatment after methyldopa).

• Tab Labetalol 100 mg twice daily is equally effective

• 1 gm /day of calcium in pregnancy after 1st trimester reduces risk of Pre-eclampsia by 50%.

• Magnesium Sulfate (MgSO4) : prevent seizures; lowers BP, Contraindicated with renal impairment.

What to monitor when giving patient with preeclampsia MgSO4 ?

• Infusion pump – IV before/during labor & 24 hrs > delivery. Infuse slowly.

• Patellar reflex, place foley, RR, fetal status q hr

• If sharp drop in BP, respiratory paralysis, disappearance of patellar reflex : STOP infusion, give O2 & Calcium gluconate ASAP.

What is Gestational Diabetes (GDM) ?

• Glucose intolerance begins in pregnancy

• occurs after 20th week

What are the maternal and infant risk for GDM ?

• Maternal Risks: HPT disorders, polyhydramnios, macrosomia (^ LSCS rate).

• Infant Risks: Birth trauma, shoulder dystocia, hypoglycemia, thrombocytopenia, hypocalcemia, fetal death

What are the management for GDM ?

• Refer to Dietician

• Provide immediate education to pt./family ❖ Standard diabetic diet [2000-2500 cal/day].

• Exercise [walking, swimming] 30 min.3-4 x/wk

• Teach daily glucose self-monitoring & urine testing.

• Teach monitoring of fasting & postprandial levels

What is anemia in pregnancy ?

• Anemia is defined as Hb level < 11g/dl in pregnancy or immediate post partum period

• Anemia is grouped as mild (10-10.9g/dl), moderate (7-9.9 g/dl), severe (< 7 g/dl)

• Iron deficiency anemia is the commonest

What are the maternal and fetal risk for anemia in pregnancy ?

• Maternal : cardiac failure, preterm labour, Postpartum hemorrhage (PPH)

• Fetal : Intrauterine Growth Restriction (IUGR), anemia of newborn, prematurity

What are the diagnosis done for anemia ?

• History of weakness, giddiness or breathlessness

• Assess for pallor

• Investigations i) Hb estimation ii) Complete blood count iii) Urine for blood and stool for occult blood/ova/cyst

What are the management for anemia in pregnancy

• for prophylaxis

• mild to moderate anemia

• moderate to severe anemia

• For prophylaxis: haematinics supplements (with 100 mg ferrous fumerate and 0.5 mg folic acid)

• Mild to moderate anemias: i) Treated by iron and folic acid tablets twice daily and to be continued during postpartum period ii) Hb level to be assessed monthly

• Moderate to severe anemia: i) For Hb between 7-8 gm%, IM iron therapy with oral folic acid daily ii) repeat Hb after 8 weeks

What are the complications for the maternal if twins pregnancy ?

• hypertension

• gestational diabetes

• anemia

• postpartum hemorrhage

What are the complications for the fetal if twins pregnancy ?

• premature

• intrauterine growth restriction (IUGR)

• birth defects

• Twin-to-Twin Transfusion Syndrome (TTTS) : identical twins who share a placenta, where one twin receives too much blood and the other receives too little.

• Cord Entanglement

What are the management for twins pregnancies ?

• More frequent prenatal visits to closely monitor maternal & fetals health and development.

• Increased ultrasound for monitoring fetal positions, growth, and signs of complications like TTTS.

• Hospital delivery recommended due to the higher likelihood of needing intervention (LSCS) or specialized care (NICU)

• Nutritional support: need a higher intake of calories and nutrients, particularly iron and folic acid

What are the infections that can happen during pregnancy ?

• Urinary Tract Infections (UTI)

• Monilial Vaginal Infection

• Sexually Transmitted Disease (Chlamydia)

What are the treatment for syphilis ?

• <1 yr - benzathine penicillin x 1 dose

• >1 yr SAME MED 1x/wk x 3 wks.

• Sexual partners screened & treated together.