High risk pregnancy

Management of high risk cases in pregnancy with a team approach

1. High Risk Pregnancy Care Dr Nupur Gupta Department of Obstetrics & Gynecology Paras Hospitals, Gurgaon At Bournhall Clinic Gurgaon 8 March 2017

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

3. High Risk Pregnancy Bad obstetrics history (previous recurrent miscarriages or preterm deliveries) Heart disease Hypertension or preeclampsia (essential, renal or pregnancy induced) Diabetes (IDDM/NIDDM) Severe anemia Twins or triplets

4. High Risk Pregnancy Placental abruption Threatened preterm labour Haemolytic anemia Thrombocytopenia or megaloblastic anemia Bleeding disorders Thalassemia History of thrombosis or thrombophilias

5. High Risk Pregnancy History of neurological disease (epilepsy, brain haemorrhage , or tumor) Malignancy (cervical, ovarian or breast) Antiphospholipid syndrome Cervical incompetence (elective or emergency) Fibroid uterus Congenital malformations that can survive

6. High Risk Labour Preterm labour Previous Caesarean CPD Prolonged labour Obstructed labour Shoulder dystocia Retained placenta Inversion of uterus Rupture uterus Perineal tear

7. Emergency Obstetric Care To Avert Death and Disability … … We Need to Ensure that Women have

8. What is an Obstetric emergency? A suddenly developing pathologic condition in a patient, due to accident or disease, which requires urgent medical or surgical therapeutic intervention There are 2 patients; fetus is very vulnerable to maternal hypoxia

9. But we do know that of any population of pregnant women at least 15% will experience an obstetric complication … How Do We Know Which Women Will Experience Complications? WE DON’T

10. Obstetric Emergencies Maternal Fetal Both maternal & fetal High Mortality rate

11. Maternal Complications of Pregnancy First Trimester Second Trimester Third Trimester

12. First Trimester Ectopic pregnancy Abortion Molar Pregnancy Uterine rupture Second Trimester Abortion Cervical Incompetence Third Trimester Placenta Praevia Placenta Accreta PPH Uterine rupture Inversion Hypertensive crisis

13. OUR EXPERIENCE

14. SAVING LIVES in Life Threatening Emergencies Intractable PPH Rudimentary Horn Rupture – 2 cases Uncontrolled diabetes with pregnancy Inevitable abortion, ectopic, Heterotopic pregnancy – 2 cases Retained placenta accreta Uterine AVM – UAE, 2 cases

15. SOLVING DIFFICULT CASES Second trimester twin with malformed foetus at 20 wks PUPPP in third trimester of pregnancy Brain tumor with pregnancy Subarachnoid haemorrhage with pregnancy Twisted ovarian cyst with acute abdomen Torsion of ovarian tumor with acute abdomen

16. G2A1 with 25 weeks+4 days POG with thrombocytopenia with GDM with pre-eclampsia with amegakaryocytic anemia with HELLP Syndrome

17. Admitting Complaints Amenorrhea 25 weeks 3 days Pain lower abdomen since 30 days Increased frequency of micturition 15-20 days Loose stool since 1 day Abdominal distension Obstetric History – G2A1 G1-Spontaneous Abortion - D&C, 2013 G2- Present Pregnancy

18. Past History GDM Thrombocytopenia Family History Father-Diabetic

19. Course In the Hospital LFT, KFT were deranged Platelet Count-14000, Uric acid-7.1, hb-7.7. BP was persistently high. Patient shifted to ICU on 14/9/2014. Labetolol & MgSo4 infusion was given. Patient reviewed with hematologist, Neurologist, Endocrinologist, opthalmologist , nephrologist , Physician

20. Course in Hospital….. Steroid given in view of Thrombocytopenia. Decision taken for termination of pregnancy in view of kidney deterioration, HELLP Syndrome & uncontrolled blood pressure. Emergency LSCS done under GA on 20.9.14 Per-op findings 100-200cc ascitis Bilateral tubes & ovaries normal Baby shifted to NICU

21. POST OP PERIOD She was given Inj Mgso4, labetalol , monocef in post op period She was discharged on day 5 th of post-op period with following medication advised on discharge Tab Dapsone 1 tab od Tab R evolade 50 mg once daily Tab T exid , tab Amlodipine , tab dexamethasone 12 mg od , tab ultracet tds

22. After a long struggle ……

23. Chronic Right Sided Ruptured Tubal Ectopic Pregnancy ( Heterotopic )

24. Admitting Complaints 24 year old P2L2 Spasmodic Pain in Right sided lower abdomen associated with spotting per vaginum since one month Irregular bleeding off and on

25. I nvestigations Serum Beta HCG Day 1 - 357.31 mIU /ml Day 2 - 90.16 mIU /ml

26. CECT whole abdomen (12.11.14) Day 1 Heterogenous mass collection in right adnexa

27. Management Patient was taken up for diagnostic laparoscopy followed by right sided salpingectomy + peritoneal lavage + D&C under GA

28. Intra-op findings Right sided tubal mass S/o ruptured ectopic pregnancy Salpingectomy done & sent for HPE Organised Blood in POD Small bowel adherent to posterior wall of uterus, adhesiolysis done Left tube & ovary normal, RO normal Endometrial curettings sent for HPE

29. Large Cervical Fibroid with extension into broad ligament Urology Team supported us by intraoperative bilateral ureteric catheterisation

30. Managed by laparoscopy & hysteroscopy - GI surgeons as there was perforation peritonitis and dense bowel adhesions Misplaced & Lost IUCD thread after postplacental insertion 3 years back during LSCS

31. One crore compensation

32. Maternal Death

33. Doctors suspended for maternal mortality

34. Controversy continues on rising Caesarean Rates 24.2.17

35. High Risk Obstetric Care There are no absolute rules of management Lay public - that modern reproductive research eliminates all the risks & hazards associated with childbirths Therefore only 100% healthy babies are accepted Pregnancy is regarded as a 'success story' and if the baby is born with neurological defects (cerebral palsy) the parents & their advisors feel, that someone responsible for the defect should be found in the chain of management EJOGRB 1997 Feb;71(2):181-5. High-risk obstetrics, medicolegal problems.

36. This attitude starts a legal battle focusing on the events of labor and delivery But in most cases it is very difficult to determine if a peripartal neonatal encephalopathy originated from the time period of labor and delivery, or started weeks earlier during pregnancy as an unnoticed event. Perinatal morbidity indicators are best based on neonatal clinical signs, which are predictive of later morbidity of the child. Neonatal seizures within 48 h of delivery of the baby could be a good index of later morbidity. High Risk Obstetric Care

37. Our Team (Senior Residents & Labour room staff) Facility of blood transfusion Multispeciality backup ICU – Medical, Surgical, Neurological, Neurosurgical, Cardiac, CTVS Neonatal ICU {NICU}, Paediatric ICU {PICU} OUR USP

38. Thank you