High risk pregnancy090909090909099999.ppt
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About This Presentation
HRP
Slide Content
THE FETUS AT RISK
Hassan N. Sallam, MD, FRCOG
(England), PhD (London)
Professor in Obstetrics and Gynaecology
The University of Alexandria in Egypt
Hassan N. Sallam, MD, FRCOG
(England), PhD (London)
Professor in Obstetrics and Gynaecology
The University of Alexandria in Egypt
High risk pregnancy
Is a pregnancy where the mother, the
fetus or newborn is or will be at
increased risk for morbidity or
mortality before, during or after
delivery
Is a pregnancy where the mother, the
fetus or newborn is or will be at
increased risk for morbidity or
mortality before, during or after
delivery
Perinatal mortality
is the number of still births (SB) +
the number of neonatal deaths
(deaths during the first week of life)
per 1000 births
[(SB + NND)/total births] x 1000
In USA 10/1000
In Egypt 20-80/1000
is the number of still births (SB) +
the number of neonatal deaths
(deaths during the first week of life)
per 1000 births
[(SB + NND)/total births] x 1000
In USA 10/1000
In Egypt 20-80/1000
Causes of high risk pregnancy
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
Causes of high risk pregnancy
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
Problems in previous pregnancies
1. Habitual abortions
2. Previous preterm delivery
3. Previous SB or IUFD
4. History of IUGR (SFD baby)
5. History of large baby (>4 Kg)
6. Previous pre-eclampsia/eclampsia
7. History of congenital anomalies
8. Previous birth trauma
1. Habitual abortions
2. Previous preterm delivery
3. Previous SB or IUFD
4. History of IUGR (SFD baby)
5. History of large baby (>4 Kg)
6. Previous pre-eclampsia/eclampsia
7. History of congenital anomalies
8. Previous birth trauma
Syphilis
Hydrops foetalis and neonatal jaundice
Uterine rupture
Causes of high risk pregnancy
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
Problems in current pregnancy
1. Age (<20 and >35 years)
2. Grand multiparity
3. Rh incompatibility
4. Pre-eclampsia/eclampsia
5. Systemic disease
(DM, heart, kidneys, blood, SLE)
6. Exposure to teratogens
(viruses, drugs, X-rays)
7. Reproductive tract disorders
(fibroids, ovarian mass, etc…)
1. Age (<20 and >35 years)
2. Grand multiparity
3. Rh incompatibility
4. Pre-eclampsia/eclampsia
5. Systemic disease
(DM, heart, kidneys, blood, SLE)
6. Exposure to teratogens
(viruses, drugs, X-rays)
7. Reproductive tract disorders
(fibroids, ovarian mass, etc…)
Preeclampsia, eclampsia
Placental infarcts
Abruptio placentae
Fibromyomata
Fibromyomata
Fibromyomata
Causes of high risk pregnancy
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
1. Causes in the mother
• Problems in previous pregnancies
• Problems in the current pregnancy
2. Causes in the fetus
Problems in the fetus
1. Multiple gestation
2. Small for dates (SFD)
3. Large for dates (LFD)
4. Polyhydramnios
5. Oligohydramnios
6. Placenta praevia
1. Multiple gestation
2. Small for dates (SFD)
3. Large for dates (LFD)
4. Polyhydramnios
5. Oligohydramnios
6. Placenta praevia
Multiple gestation
Diamniotic,
dichorionic
placentation
Diamniotic,
monochorionic
placentation
Monoamniotic,
monochorionic
placentation
Diamniotic,
dichorionic
placentation
Diamniotic,
monochorionic
placentation
Monoamniotic,
monochorionic
placentation
Twin to twin transfusion syndrome
(TTTS)
(TTTS)
Multiple pregnancy, polyhydramnios
Placenta praevia
Antepartum fetal surveillance
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
Antepartum fetal surveillance
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
Antenatal clinic
1. Blood pressure (<140/90)
2. Weight (0.5 Kg/wk after 12 weeks)
3. Urine analysis (glucose, proteins)
4. Fundal height (clinical, measuring tape)
5. Fetal heart sounds (140/min)
6. Kick count (>10/day after 28 weeks)
1. Blood pressure (<140/90)
2. Weight (0.5 Kg/wk after 12 weeks)
3. Urine analysis (glucose, proteins)
4. Fundal height (clinical, measuring tape)
5. Fetal heart sounds (140/min)
6. Kick count (>10/day after 28 weeks)
Fetal heart sounds
Antepartum fetal surveillance
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
Biochemical tests
1. Alpha-fetoprotein in maternal serum
(for neural tube defects)
2. Triple test (α-FP, β-HCG, E
3
)
(for Down’s syndrome)
3. Urinary oestriol (E
3) in 24 hours urine
(for IUGR)
4. HPL in maternal serum (for IUGR)
1. Alpha-fetoprotein in maternal serum
(for neural tube defects)
2. Triple test (α-FP, β-HCG, E
3
)
(for Down’s syndrome)
3. Urinary oestriol (E
3) in 24 hours urine
(for IUGR)
4. HPL in maternal serum (for IUGR)
Antepartum fetal surveillance
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
Abdominal ultrasound
Gestational sac at 5 weeks
Fetus at 6 weeks
Vaginal ultrasound
Vaginal sonography: early pregnancy
Ultrasound in pregnancy
• At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
• At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
Ultrasound in pregnancy
• At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
• At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
Early pregnancy
Early pregnancy
Twin pregnancy
Monochorionic Dichorionic
Monochorionic Dichorionic
Nuchal translucency
Nuchal translucency
Ectopic pregnancy
Fetus at 7 weeks
Fetal growth: crown-rump length
Fetus at 10 weeks
Fetus at 11 weeks
Fetus at 12 weeks
Ultrasound in pregnancy
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
Ultrasound in pregnancy
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
Normal anatomy: biparietal diameter
Normal anatomy: fetal brain
Hydrocephalus + spina bifida
Hydrocephalus
Ultrasound: Hydrocephalus
Ultrasound: Anencephaly
Microcephaly
Absent cerebellum
Encephalocoele
Encephalocoele
Normal anatomy: fetal spine
Spina bifida
Spina bifida
Ultrasound: Spina bifida
Fetal face: sagittal view
Fetal face: sagittal view
Fetal face
Facial abnormalities
Normal anatomy: male genitalia
Normal anatomy: male genitalia
Normal anatomy: fetal femur
Fractured femur
Limb deformities
Normal anatomy: fetal hand
Normal anatomy: fetal hand
Fetal hand
Phocomelia
Exomphalus
Gastroschisis
Omphalocoele, gastroschisis
Double bubble sign
Polycystic kidneys
Fetal kidney
Fetal kidneys
Polycystic kidneys
Polycystic kidneys
Bilateral hydronephrosis
Congenital heart disease: cyanosis
Congenital heart disease
Fetal heart: 4 chamber view
Fetal heart and aortic arch
Fetal aorta
Umbilical vessels
Umbilical cord vessels
Voluson: 3-D ultrasonography
3D/4D ultrasound: fetal face
3D/4D ultrasound: fetal back
Ultrasound in pregnancy
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
Closed internal cervical os
Closed internal cervical os
Cervical incompetence: funelling
Funelling of internal cervical os
Ultrasound in pregnancy
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
• At 8 to 12 weeks
• At 20 to 24 weeks
(a) Congenital anomalies
(b) Cervical length
(c) Prediction of PET
• At 28 to 32 weeks
Doppler ultrasonography
Blood flow waveform
Normal uterine blood flow
Abnormal uterine blood flow: notching
Notch
Notch
Ultrasound in pregnancy
•At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
(a) Fetal growth
(b) Fetal blood flow
•At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
(a) Fetal growth
(b) Fetal blood flow
Ultrasound in pregnancy
•At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
(a) Fetal growth
(b) Fetal blood flow
•At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
(a) Fetal growth
(b) Fetal blood flow
Biparietal diameter
Symmetrical IUGR
Asymmetrical IUGR
Estimation of fetal weight from BPD & AC
Head circumference
Abdominal circumference
Ultrasound in pregnancy
•At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
(a) Fetal growth
(b) Fetal blood flow
•At 8 to 12 weeks
• At 20 to 24 weeks
• At 28 to 32 weeks
(a) Fetal growth
(b) Fetal blood flow
Colour Doppler: umbilical cord
Umbilical vessels
Umbilical vessels
Umbilical vessels
Normal fetal blood flow (umbilical)
Abnormal fetal blood flow (umbilical)
Antepartum fetal surveillance
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
Invasive procedures
1. Amniocentesis
2. Chrion villus biopsy
3. Cordocentesis
4. Interventional ultrasonography
1. Amniocentesis
2. Chrion villus biopsy
3. Cordocentesis
4. Interventional ultrasonography
Amniocentesis
Amniocentesis
Karyotyping
Lecithin/sphingomyelin ratio
L
S
L
S
L
S
L
S
Optical density of amniotic fluid
Chorion villus sampling (CVS)
Fetoscopy: fetal blood sampling
Antepartum fetal surveillance
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
Cardiotocography
Cardiotocography
FHR transducer
CTG: FHR accelerations
CTG: loss of beat to beat variation
Fetal scalp electrode
Fetal scalp electrode
Uterine pressure transducer
Cardiotocography
Fetal heart acceleration (normal)
Early decceleration (head compression)
Late deccelerations (hypoxia)
Variable deccelerations (cord compression)
Antepartum fetal surveillance
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
1. Clinical examination
2. Biochemical tests
3. Ultrasonography
4. Invasive procedures
5. Cardiotocography
6. Biophysical profile
The biophysical profile
Criterion 0 2
AF volumePockets >1cmPockets <1cm
CTG Normal Abnormal
Breathing1 or more per
30 min
Absent
Movements 3 or more
per 30 min
2 or less
per 30 min
Fetal toneNormal Decreased
Criterion 0 2
AF volumePockets >1cmPockets <1cm
CTG Normal Abnormal
Breathing1 or more per
30 min
Absent
Movements 3 or more
per 30 min
2 or less
per 30 min
Fetal toneNormal Decreased
Management of the fetus at risk
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
Management of the fetus at risk
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
Termination of pregnancy (TOP)
(A) Termination of early pregnancy
• Mefipristone
• Misoprostol
• D&C
B) Termination of late pregnancy
• PGE
2
• Amniotomy
• Hysterotomy
(A) Termination of early pregnancy
• Mefipristone
• Misoprostol
• D&C
B) Termination of late pregnancy
• PGE
2
• Amniotomy
• Hysterotomy
Management of the fetus at risk
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
Cervical cerclage
1. Shirodkar’s suture
2. MacDonald’s suture
3. Abdominal cerclage
1. Shirodkar’s suture
2. MacDonald’s suture
3. Abdominal cerclage
Shirodkar’s suture
(Cervical cerclage)
(Cervical cerclage)
Management of the fetus at risk
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
Management of the fetus at risk
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures (e.g. Digitalis,
diuretics, antibiotics, etc…)
5. Surgical treatment
6. Induction of labour
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures (e.g. Digitalis,
diuretics, antibiotics, etc…)
5. Surgical treatment
6. Induction of labour
Intrauterine transfusion
Double pig-tail catheter
Management of the fetus at risk
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
Twin-twin
transfusion
syndrome
transfusion
syndrome
Laser coagulation of the
communicating placental vessels
communicating placental vessels
Intrauterine closure of myelomeningocele
Bilateral nephrostomies
Management of the fetus at risk
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
1. Termination of pregnancy
2. Cervical cerclage
3. Medical therapy
4. Invasive procedures
5. Surgical treatment
6. Induction of labour
Induction of labour
+ intranatal monitoring
1. PGE
2
2. Amniotomy
3. Oxytocin
4. Caesarean section
+ intranatal monitoring
1. PGE
2
2. Amniotomy
3. Oxytocin
4. Caesarean section
THE FETUS AT RISK
Hassan N. Sallam, MD, FRCOG
(England), PhD(London)
Professor in Obstetrics and Gynaecology
The University of Alexandria in Egypt
Hassan N. Sallam, MD, FRCOG
(England), PhD(London)
Professor in Obstetrics and Gynaecology
The University of Alexandria in Egypt
Hydrops fetalis
ALEXANDRIA GYNAECOLOGY AND
FERTILITY FORUM, 28-30 May 2003
The dog Mosaic, Bibliotheca Alexandrina
FERTILITY FORUM, 28-30 May 2003
The dog Mosaic, Bibliotheca Alexandrina
Title
Fetal femur
Biparietal diameter
Fetal femur
Title
Title
Polycystic kidneys
Title
Title
Title
Omphalocoele
Gastroschisis
Spina bifida
Title
Title
Title
Potter’s syndrome
title
title
title
title
title
title
Normal anatomy: fetal face
Blighted ovum
Cervical competence
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