High Risk Pregnancy

High Risk Pregnancy

Definition

High Risk Pregnancy is a pregnancy complicated by a disease or a disorder that may endanger the life or affect the health of the mother, the fetus or the newborn

Maternal Death Incidence

A maternal death is death of a Woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration and the site of the pregnancy, from any course related to or aggravated by the pregnancy or in management but not from accidental or incidental causes. - WHO

·  20-25% deaths occur during pregnancy.

·  40-50% deaths occur during labour and delivery.

·  25-40% deaths occur after childbirth (More during the first seven days)

·  Annually, 585,000 women die of pregnancy related complications

High risk mothers are

·  Women below 18 years, over 35 years in primigravida

·  Women who had four or more pregnancies

·  Short Structure (height <145 cm and below)

·  Twins

·  Aneamia

·  Previous Abortion, Intra uterine death.

·  Malnutrition mother.

1. Placenta Praevia

DEFINITION: Placenta Praevia is a condition where the placenta is implanted completely or partially in the lower part of the uterus.

Cause: Unknown

Risk factors: Multiparity, multiple gestations, previous uterine surgery

Manifestations: Painless, bright red bleeding >  20th week; episodic, starts without warning, stops & starts again.

Vaginal examination is contra - indicated.

Types of Placenta Praevia

·  First degree (Type I): Low lying Placenta the lower edge of the placenta reaches the lower uterine segment but not the internal cervical os.

·  Second degree (Type II): Marginal the lower edge of the placenta reaches the margin of the internal os but does not cover it.

·  Third degree (Type III): Incomplete or partial the placenta covers the internal os partially.

·  Fourth degree (Type IV): Total placenta covers the internal os completely.

Management

Management depends upon gestational age, amount of bleeding and fetal condition.

·  Monitor Fetal Heart Rate, maternal Vital signs

·  Intra Venus Fluid administration

·  O₂ administration

·  Assess intake and output, amount of bleeding

·  Do complete Blood count and Rh factor test (CBC), Type and cross match for transfusion.

·  Ultrasound

·  No pelvic exams

·  No vaginal delivery- may lead to haemorrhage

·  Prepare for caesarean section

Prognosis: depends on amount of bleeding & gestational age

2. Abruptio Placenta

Abruptio Placenta: Premature separation of normally situated placenta.

Cause: Unknown

Types of Abruptio placenta:

Concealed - The blood collects behind the separated placenta or collected in between the membranes and decidua. (Blood is not visible outside) Rare type.

 Revealed - Following separation of the placenta, the blood comes out of the cervical canal to be visible externally (commenest type)

Risk factors

·  Smoking

·  Short umbilical cord

·  Advanced maternal age

·  HTN

·  PIH

·  Cocaine use

·  Trauma to or near abdomen.

Manifestations: Tenderness mild to severe constant pain; mild to moderate bleeding depending on degree of separation.

Management

·  Monitor Fetal Heart Rate, maternal Vital signs

·  Intra Venous Fluid administration

·  O₂ administration

·  Assess intake and output, amount of bleeding

·  Do complete Blood count and RH factor test (CBC), Type and cross match for transfusion.

·  Ultrasound

·  No pelvic exams

·  No vaginal delivery- may lead to haemorrhage

·  Prepare for caesarean section

3. Amniotic Fluid

DEFINITION: Amniotic fluid is a clear, slightly yellowish liquids surround and protects the fetus during pregnancy. Normal Amniotic fluid is around 800 ml

Amniotic fluid is made up of fetal urine & fluid that is transported through placenta from maternal circulation.

Polyhydramnios

Polyhydramnios is defined as a state where amniotic fluid exceeds more than 2000 ml.

Risk factors

·  Multiple pregnancy.

·  Fetal abnormalities.

·  Fetal skeletal malformations.

·  Obstruction of GI tract- prevents normal ingestion of amniotic fluid.

·  Rh Iso immunization

·  Maternal Diabetes Mellitus.

·  Spinabifida; Anencephaly, Hydrocephaly. Diagnosis: Sonography-To detect Amniotic Fluid Index (AFI) is more than 20 cm. (Normal AFI is 8-18 cm).

Management

·  Bed rest.

·  Monitor weight gain.

·  Remove excess amniotic fluid every 1-2 weeks through amniocentesis.

·  Most women with mild polyhydramnios deliver healthy baby.

Oligohydramnios

It is a condition where the amniotic fluid is less than 500 ml in the amniotic sac.

Causes

·  Failure of fetal kidney development

·  Obstruction in urinary tract

·  Intra Uterine Growth Restriction (IUGR)

·  Post-term pregnancy

·  Premature rupture of membrane

·  Fetal anomalies

·  Poor placental function.

Diagnosis

·  AFI < 5-6 cm

·  Small uterine size.

·  Less fetal movements

·  Prominent fetal parts on palpations

·  Small for date uterine size.

·  Fetal demise.

·  Ultrasonogram

Prognosis: Depends on severity of disease.

Management

·  Careful assessment of mother/fetus

·  Frequent ante-partum testing

·  Determine optimal time for delivery (early)

·  Antibiotics/corticosteroids with PROM (Premature Rupture Of Membranes)

4.  Ectopic Pregnancy

The fertilized ovum is implanted and develops outside the normal uterine cavity usually in fallopian tubes, rare on ovary, cervix or abdominal cavity.

Incidence

·  Leading cause of death from hemorrhage in pregnancy

·  Reduces fertility

·  1 in 100 pregnancies

Causes

·  Scarring of fallopian tubes (Chlamydia/ Gonorrhea).

·  More common with infection of fallopian tubes or surgery to reverse Tubale Ligation.

·  Previous ectopic

·  Multiple induced abortions

·  Diethylstilbestrol (DES) exposure

Symptoms

·  Colicky, cramping pain in lower abdomen on affected side

·  Tubal rupture: sudden/sharp/steady pain before diffusing throughout pelvic region

·  Heavy bleeding causes shoulder pain, rectal pressure

·  Dizziness/weakness - If tube ruptures, weak pulse, clammy skin, fainting. Assess for s/s shock.

Diagnosis

Estimation of Beta hCG (more than 1500 IU/L

·  Ultrasonogram

Treatment

·  Immediate surgery to remove/repair tube.

·  If no rupture, Methotrexate - stops cellular division in fetus; causes cell death. Conceptus expelled with bleeding.

5. Hypertension In Pregnancy

Global cause of maternal/fetal morbidity mortality. Responsible for 76,000 deaths/ year. Normotensive patient may become hypertensive in late pregnancy, during labor, or 24 hours postpartum.

Pre-Eclampsia

Defined As

Pre-Eclamsia is characterised by hyper tention protrinuria and oedema.

Dangers of Pregnancy Induced Hyper tention (PIH)

·  BP ≥ 140/90 mmHg

·  Systolic ↑ of 30mm Hg > pre-pregnancy. levels

·  Diastolic ↑ of 15mm Hg > pre pregnancy. levels.

·  Presents with HTN (Hypertension), proteinuria, edema of face, hands, ankles.

·  Can occur anytime > 20th week of pregnancy.

·  Usually occurs closer to due date. Will not resolve until birth.

General Signs of PRE-ECLAMPSIA

·  Rapid weight gain; swelling of arms/face

·  Headache; vision changes (blurred vision, seeing double, seeing spots)

·  Dizziness/faintness/ringing in ears/ confusion; seizures

·  Abdominal pain, ↓ production of urine; nausea, vomiting.

·  Alarming signs:

U - Urinary output dimished S - Sleep disturbance

H - Headache

E - Epigastric pain and eye symptoms.

Eclampsia

Seizures or coma due to hypertensive encephalopathy

Incidence

·  Most serious complication.

·  Affects ~ 0.2% pregnancy.

·  Major cause of maternal death due to intracranial hemorrhage.

·  Maternal mortality rate is 8-36%.

Risk factors

·  < Age 20 years or > 40 years

·  Twins, triplets

·  Primigravida

·  Molar pregnancy

·  Preexisting HTN, Diabetes mellitus

·  Renal or vascular disease

·  Previous history of preeclampsia/eclampsia Causes: Unknown.

Management: Usually only cure is termination of pregnancy. It depends upon symptoms.

Mild preeclampsia

·  Bedrest

·  Monitor at home or hospital.

·  Deliver close to EDD

·  Frequent Blood Pressure, 24 hours urine, liver enzymes

·  Fetal Heart Rate

·  Ultrasounds.

Severe preeclampsia: BP = 160/110 mmHg, epigastric pain, 2-4+ proteinuria, ^ liver enzymes, thrombocytopenia [↓ 100,000].

Goal: prevent convulsions & control BP. Magnesium sulphate is the drug of choice

Magnesium Toxicity based on clinical signs: such as sharp drop in BP, respiratory paralysis and disappearance of patellar reflex.

·  STOP infusion

·  O₂ administration

·  Calcium gluconate if magnesium sulphate toxicity present

6. Gestational Diabetes Mellitus

Glucose intolerance beginning in pregnancy.ussually present in the second or during the third trimester. Fasting blood sugar exceeds 90 mg/dl and post prandial value is greater than 120 mg/dl

Pathophysiology

Pregnancy hormones estrogen, HPL, prolactin, cortisol, progesterone, blocks insulin receptors > 20 weeks pregnancy.

·  Results in increased circulating glucose

·  More insulin released to attempt to maintain glucose homeostasis

·  Patient feels “hungry” due to increased insulin

·  vicious cycle of increased appetite & weight gain results

Diagnosis

·  Oral Glucose Challenge Test (OGCT)

·  Screen all women at 24-28 weeks.

·  HIGHER Risk patient to be screened in 1st trimester/1st prenatal visit and at 24-28 weeks.

Determining High Risk Clients

·  Family history DM; Previous GDM

·  Marked obesity; Glycosuria

·  Maternal Age > 30

·  Previous infant > 4000g

·  Member of high-risk racial/ethnic group

·  Hispanic, Native American, South or East Asian, African American, Pacific Islander.

·  If results negative, repeat during 24-28wks.

Interventions

Antepartum Goal: strict glucose control.

·  Provide immediate education to patient. and family members

·  Standard diabetic diet [2000-2500 cal/day].

·  Total calories – 30Kcal/Kg for normal weight women

Distribution of calories: 40-50% carbs, 20% protein, 30-40% fat,

Recommend: 3 meals & 3 snacks evenly spaced to avoid swings in blood glucose. Snack at bedtime.1200 mg/day calcium, 30 mg/day iron, 400 mcg/day folate.

Intrapartum: monitor glucose levels and titrate with insulin

Postpartum: Mostly return to normal after delivery.

·  50% patients. with GDM develop type II later in life.

·  After 6 wk. PP (Postprandial) serum glucose estimation to be done

·  Children of GDM (Gestational Diabetes Mellitus) patients. ^ risk for obesity/ diabetes in childhood/adolescence

Pre-Conception Planning:

·  Begin during reproductive years

·  Maintain normal HbA1c 3-6 months before conception & during organogenesis (6-8weeks) –minimize risk of spontaneous AB & congenital anomalies.

·  HbA1c level > 7: increased risk for congenital anomalies & miscarriage. (Normal HbA1c = 4-6 %. )

·  Multidisciplinary team: nutritionist, endocrinologist, high risk OBG nurse.

·  Educate patient.- managing diet, activity, insulin Excercise

Daily food diary to assess compliance.