4 High risk preganancy and complications of child birth.pptx

a brief and to the point ppt about high risk pregnancies and the complications of child birth or delivery

1. High Risk pregnancy Complications of childbirth Dr. Mitali Srivastava, mbbs , md, sexual medicine consultant, shital womens hospital, Ahmedabad, the.besharam.doctor

2. High risk pregnancy [ hrp ] Refers to pregnancies in which the mother or the fetus has an increased risk of complications compared to uncomplicated pregnancies Maternal and medical risks increase pregnancy risk and complications during pregnancy and childbirth

3. Bad obstetric history 1 st or 2 nd trimester miscarriages Still birth Small weight baby Fetal anomalies IUGR- intrauterine growth restriction Prolonged labor Massive PPH IUD- intrauterine death Recurrent pregnancy loss

4. Heart disease

5. Severe anemia Who is at risk? Have two closely spaced pregnancies Are pregnant with more than one baby Are vomiting frequently due to morning sickness Don't consume enough iron-rich foods Have a heavy pre-pregnancy menstrual flow Have a history of anemia before your pregnancy

6. Severe anemia What are the signs and symptoms? Anemia: Fatigue Weakness Dizziness or lightheadedness Headache Pale or yellowish skin Shortness of breath Craving or chewing ice (pica) Severe anemia: A rapid heartbeat Low blood pressure Difficulty concentrating

7. Severe anemia Prevention : Iron RDA (required daily allowance): 30mg/day Iron rich diet Iron supplements: Should be taken with vit C (helps absorption) Should not be taken with calcium (reduces absorption) Can cause constipation, gastric disturbances, dark stools

8. Severe anemia Treatment : Iron injections ( eg. Revofer , IV iron bolus) Blood transfusions, Packed cell volume transfusions

9. Multiple pregnancy Why is it high risk? Preterm labor and birth Gestational hypertension Anemia Birth defects Miscarriage Postpartum hemorrhage Twin to twin transfusion syndrome Lower backache/ disc prolapse

10. Pre-eclampsia & eclampsia Preeclampsia is a pregnancy-specific disorder involving W idespread endothelial dysfunction and vasospasm O ccurs after 20 weeks of  gestation and can present as late as 4-6 weeks postpartum C linically defined by new-onset hypertension and proteinuria, with or without severe features In a previously normotensive patient: >140/90 mmHg, measured atleast twice, 4 hrs apart Or a one time reading >160/110 mmHg

11. Pre-eclampsia & eclampsia Severe features: Impaired hepatic function (elevated LFT) S evere persistent upper quadrant or epigastric pain that does not respond to pharmacotherapy and is not accounted for by alternative diagnoses Progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease) New-onset cerebral or visual disturbances Pulmonary edema Thrombocytopenia

12. Pre-eclampsia & eclampsia Who is at risk? Nulliparity Multifetal gestations Preeclampsia in a previous pregnancy Chronic hypertension Pregestational diabetes Gestational diabetes Thrombophilia Systemic Lupus Erythematoses [SLE] Pre-pregnancy BMI >30 Antiphospholipid antibody syndrome Maternal age 35 years or older Kidney disease ART: IVF etc

13. Pre-eclampsia & eclampsia What are the clinical features? Headache Visual disturbances: Blurred, scintillating scotomata Altered mental status Blindness: May be cortical  [ 3 ]  or retinal Dyspnea Edema: Sudden increase in edema or facial edema Epigastric or right upper quadrant abdominal pain Weakness or malaise: May be evidence of hemolytic anemia Clonus: May indicate an increased risk of convulsions

14. Pre-eclampsia & eclampsia HELLP syndrome Hemolysis Elevated liver enzymes Low platelets

15. Pre-eclampsia & eclampsia Management of Pre-eclampsia & eclampsia: Delivery is the only cure for preeclampsia Patients with preeclampsia without severe features  induced after 37 weeks <37 weeks  H ospitalized and monitored for development of worsening preeclampsia or complications of preeclampsia I mmature fetus is treated with corticosteroids to accelerate lung maturity in preparation for early delivery

16. Pre-eclampsia & eclampsia Management of active seizures: The basic principles of airway, breathing, and circulation (ABC) should always be followed Magnesium sulfate is the first-line treatment for primary and recurrent eclamptic seizures A loading dose of 4-6g is given by infusion pump over 5-10 minutes F ollowed by maintenance dose: infusion of 1g/ hr maintained for 24 hours after the last seizure

17. Pre-eclampsia & eclampsia R ecurrent seizures: Treated with an additional bolus of 2 g or an increase in the infusion rate to 1.5 or 2 g/ hr Prophylactic treatment with magnesium sulfate is indicated for all patients with preeclampsia with severe features Magnesium sulfate is discontinued 24 hrs after delivery Lorazepam and phenytoin may be used as second-line agents for refractory seizures

18. Pre-eclampsia & eclampsia Acute treatment of severe hypertension in pregnancy Antihypertensive treatment is recommended for severe hypertension (>160/110 mmHg) G oal of hypertension treatment: 140/90 mm Hg Medications used for BP control include the following: Hydralazine Labetalol Nifedipine Sodium nitroprusside (in severe hypertensive emergency refractory to other medications)

19. Pre-eclampsia & eclampsia Fluid management Diuretics should be avoided Aggressive volume resuscitation may lead to pulmonary edema Patients should be fluid restricted when possible, at least until the period of postpartum diuresis Central venous pressure (CVP) or pulmonary artery pressure monitoring may be indicated in critical cases A CVP of 5 mm Hg in women with no heart disease indicates sufficient intravascular volume, and maintenance fluids alone are sufficient Total fluids should generally be limited to 80 mL/ hr or 1 mL/kg/ hr

20. Pre-eclampsia & eclampsia Postpartum management Many patients will have a brief (up to 6 hours) period of oliguria following delivery Magnesium sulfate seizure prophylaxis is continued for 24 hours postpartum LFT and platelet counts must document decreasing values prior to hospital discharge Elevated BP may be controlled with nifedipine or labetalol postpartum If discharged with BP medication, reassessment and a BP check should be performed, frequently and followed up with physician for further management In most cases of preeclampsia, the BP returns to baseline by 12 weeks postpartum Patients should be carefully monitored for recurrent preeclampsia, which may develop up to 4 weeks postpartum, and for eclampsia that has occurred up to 6 weeks after delivery

21. Gestational diabetes Defined as glucose intolerance of variable degree with onset or first recognition during pregnancy Infants of mothers with preexisting DM experience double the risk of serious injury at birth triple the likelihood of LSCS quadruple the incidence of NICU admission GDM: 90% of cases of diabetes mellitus in pregnancy Pre- existing type 2 diabetes accounts for 8%

22. Gestational diabetes Screening for GDM: Random blood sugar as a part of routine reports OGTT by 5 th month of pregnancy Diagnosis: Fasting blood glucose Post-prandial blood glucose HbA1c

23. Gestational diabetes Management: Diet care Glyburide & metformin Insulin Prenatal obstetric Mx: Doppler studies Fetal heart rate and movement Mx of Neonate: Frequent blood glucose checks Early oral feeding

24. Abruptio placentae/ placental abruption Separation of placenta, partially or totally, from its implantation site, before delivery Consumptive coagulopathy Very high risk of IUD Fluid replacement with 5% hydroxyethyl starch (plasma volume substitute) LSCS

25. Abruptio placentae/ placental abruption

26. placenta previa Previa: (Latin) ‘before’ the fetus Placental migration

27. Placenta previa Painless bleeding, bouts of frequent bleeding Dx: USG Mx: Tocolytics Progesterone supplementation Tranexa Absolute bed rest Planned CS Emergency delivery if bleeding is not controlled

28. Placent previa Especially in acreta spectrum Incision is placed in the upper segment, above the tentative position of placenta. Baby delivered first Placenta is allowed to separate naturally if possible Uterine artery or internal iliac artery ligation helpful High risk for hysterectomy, ICU outcome, Blood transfusion

29. Cervical incompetence N- wiring/ cervical cerclage 14 to 16 weeks: preventive Or as detected

30. Threatened preterm labor At risk for preterm delivery (<37 weeks) Mx aimed towards stopping labor if possible Or delaying labor till effect of corticosteroids occurs to bring fetal lungs to maturity If labor progresses, to conduct a safe delivery

31. Other conditions in high risk pregnancy Thrombocytopenia or megaloblastic anemia and other bleeding disorders Thalassemia History of thrombosis or thrombophilias History of neurological disease (epilepsy, brain haemorrhage , or tumor) Malignancy (cervical, ovarian or breast) Fibroid uterus Congenital malformations that can survive

32. Complications in childbirth Dystocia Prom Precipitate labor Abnormal presentations umbilical cord prolapse Pph Amniotic fluid embolism

33. dystocia Difficult, prolonged labor Abnormally slow labor progress Non- progression of labor [NPL] Pathology lies with: P- power P- passenger P- passage

34. Prom- premature rupture of membranes Membrane rupture at term without spontaneous uterine contractions Wait for 6 hrs , and if labor still doesn’t start, induction of labor Prostaglandin E2 gel ( Cerviprime ) Oxytocin infusion IV, after labor initiates only Antibiotic coverage Increased risk of: Chorioamnionitis NICU admission

35. Precipitate labor Abnormal extremely rapid labor and delivery Expulsion of fetus in <3 hrs from initiation of labor Less complications if cervix is effaced Otherwise: Cervical/ vaginal/ vulval tears/ lacerations Uterine rupture Amniotic fluid embolism PPH Linked with cocaine abuse Newborn injury risk

36. Abnormal presentations in vaginal delivery Transverse lie External cephalic version

37. Umbilical cord prolapse Can occur during labor, or be a presenting part Eventually causes cord compression Risk factors: High floating head Polyhydramnios Abnormal presentations Very small baby Multifetal gestations Mx: Head up, manual elevation of fetal head, lscs

38. PPH- post partum hemorrhage

39. PPH- post partum hemorrhage Investigation: Labs: Hb, Hematocrit evaluation to watch for blood loss USG: To look for retained placental products Management: Uterine massage Fluid replacement oxytocin Tranexa Methergine Misoprostol etc Surgical management

40. Surgical management: Vaginal and cervical laceration for traumatic PPH Laprotomy Uterine rupture Uterine lacerations Hematoma Uterine artery or internal iliac artery ligation Compression sutures Uterine packing (removed after 24 hrs ) Cath lab: Angiographic embolization of uterine artery

41. B- Lynch sutures

42. Rare complications Uterine inversion Amniotic fluid embolism Uterine rupture Retained placenta Puerperial sepsis