High-risk pregnancy

Ob&Gy Department ,First Hospital, Xi’an Jiaotong University


General consideration

mother ,fetus,or newborn during,or after delivery

 before,

 at

increased risk of

morbidity or mortality

 Obstetric disorders can impose a higher toll on the mother and/or fetus:  Abruptia placentae  Prematurity  Postterm pregnancy  Preeclampsia-eclampsia  Polyhydramnios  Oligohydramnios  Growth restriction  Chromosomal abnormalities General consideration .

 Leading cause of maternal death  Thromboembolic disease  Hypertensive disease  Hemorrhage  Infection  Ectopic pregnancy General consideration .

pneumonia  Multiple gestation  Anemia  Abnormal fetal presentation  Preterm rupture of membranes  Placental abnormalities  infection General consideration .Risk factors related to specific pregnancy problems  Preterm labor  age below 16 or over 35 years        Low socioecomonic status Maternal weight below 50Kg Poor nutrition Previous preterm birth Incomplete cervix Uterine amonalies Smoking  Drug addiction and alcohol abuse  Pyelonephritis.

Risk factors related to specific pregnancy problems polyhydramnios  diabetes mellitus  Moutiple gestation  Fetal congenital abnormalities  Isoimmunization(Rh or ABO)  Nonimmune hydrops  Abnormal fetal presentation   oligohydramnios  renal agenesis  Rolonged rupture of membranes  Intrauterine growth restriction  Intrauterine fetal demise General consideration .

 In the chapter we will discuss the indications and justifications for  Antepartum care  Intrapartum management  Postpartum follow-up General consideration .

Maternal assessment for potential fetal or perinatal risk  Initial screening History : oMaternal age oModality of conception oPast medical history oFamily history oEthic background oPast obstetric history .

thyroidectomy)  Maternal cancer  Sickle cell trait and disease  Substance use or abuse  Thyroid disorders pulmonary disease(eg. asthma) Gastrointestinal and liver disease Epilepsy Blood disorders(eg.tuberculosis.coagulo pathy) The others Initial screening .sarci odosis.anemia.History Past medical history  Chronic hypertension  Renal disease  Diabetes mellitus  Heart disease  Previous endocrine ablation(eg.

Past obstetric history  Habitual abortion oKaryotype of abortus oParental karyotype oCervical and uterien anomalies oConnective tissue disease oHormonal abnormalities oAcquired and inherited thrombophilias oInfectious disease of the genital tract  Previous stillbirth or neonatal death Initial screening y Previous preterm delivery Rh isoimmunization or ABO incompatibility Previous preeclampsiaeclampsia Previous infant with genetic disorder or congenital aomaly Teratogen exposure o drugs oInfectious agents oradiation .

hematological sources.delivery Vital signs A .even >103 ℉) o Urinary .4℉.pulmonary .adverse effect on fetus and mother o Amniocentesis for microscopy and culture o Antipyretics.Antepartum course  Prenatal visits o Fever(>100.chorioamnionitis o Preterm labor.

glucose.leukocyte.visits Pulse B oTachycardia(>100bpm even <120bpm) oInfection.anemia.et.blood Antepartum course . hemogram . Blood pressue C urinalysis D o Protein. oMild:follow-up. ketonuria o anbiotics o >140/90mmHg ↑>30/15mmHg oPIH.heart disease. Severe: ECG .chronic hypertention.

βhCG.open neural tube defect Antepartum course .malformation Maternal serum analyte testing B o Triple screen(msAFP.Screening Tests A Faster trail oSonography oFirst and trimester oAneuploidy. estriol) o 15-19 weeks o Trisomy 21.

repeat per 4 weeks if necessary o Fetal or newborn hemolysis Antepartum course Isoimmunization D .malformation o RH(-) or/and type-O mother with RH(+) or/and typeA.24-28 weeks again. o First visit.B.AB father.Tests Diabetic screen C oTransvaginal sonography oFirst and trimester oAneuploidy.

fetal viability. physiologic complication 2. Echogenic bowel Antepartum course .Aneuploid screening o sonography marks: .Fetal Assessment 1. Pyelectasis .placental location. Echogenic intracardiac focus .Ultrasound o Basic:fetal numbers. growth. Shorter femur .pesentation.gestational age A Assessment of prenatal diagnosis o Limited:for suspected problem o Comprehensive:fetalanomalies .

Cytogenetic analysis o 15-20 weeks 4.Amniocentesis o Use of this amniotic fluid: . Alpha-fetoprotein for neural tube defect .Chorionic villus sampling(CVS) o Cytogenetic analysis o 10-12 weeks 5.fetal blood sampling (cordocentesis or PUBS) o Chromosomal or metablic analysis o second ans third trimester Antepartum course . Cytology for infection . L/S for fetal lung maturity .Assessment Assessment of prenatal diagnosis A 3.

fetal heart rate interpretation o NST . Baseline:120-160bpm . Fetal monitoring techniques o External fetal monitoring B Assessment of Fetal well-bing o Internal fetal monitoring o sonographic fetal monitoring 2. acceleration of 15bpm for 15s at least o in risk pregnancy of possible fetal demise Antepartum course .Assessment 1.

Assessment 1.fetal scalp stimulation o stimulate fetal vertex o anoxia 3. Vibroacoustic stimulation o burst of sound to stimulate fetus o when NST is nonreactive o anoxia 2.Oxytocin challenge test (OCT) o induce effective uterine contraction artificially o positive results:late deceleration after each of three consecutive contraction C Ancillary tests Antepartum course o fetal distress .

Fetal Maturity Tests Indications for assessing fetal lung maturity:  >37 weeks  according following criteria: oLecithin:Sphingomyelin Ratio(L/S) oPhosphatidylglycerol(PG) oFoam Stability Index(FSI)  risk of respiratory distress syndrome Antepartum course .

Fetal maturity tests Test Positive discriminating value Positive predictive value 95~100% Tests Relative cost Pros and Cons L:S ratio>2.Can use vaginal pooled sample PG “present” 95~100% High FSI Stable ring of foam95% Low affected by blood.meconium. Antepartum course .meconium.0 High Large laboratory variation Not affected by blood.

2 o Serious fetal distress.Intrapartum Fetal Surveillance  Ancillary tests A:fetal scalp blood sampling o PH<7.low Apgar scores B:Fetal lactate levels o A higher value Marker of neurologic disability .

persistent tachyarrythmia . Persistent bradyarrythmia seldom relate to acidosis or hypoxia Normal autonomic nervous system Fetal head compression Well tolerated Fetal heart disease Intrapartum Fetal Surveillance . Fetal heart rate patterns Reassuring fetal heart rate patterns o Baseline:120-160bpm & Periodic changes o Accelerations and variable deceleration o Early decelerations and bradycardia of 100~119bpm o Certain arrhythmia .

No adverse outcome .Moderate fetal hypoxemia . benign Fetal Ph falls Fetal heart rate patterns Intrapartum Fetal Surveillance . No late component . Fall in fetal PH . may result in fetal distress . Mild cord compressin . Nonreassuring fetal heart rate patterns o Late deceleration o sinusoidal heart rate o variable deceleration . Late recovery if continuation or worsening. Potential for perinatal mortality and morbidity .

Late decelerations . Alternating tachycardia and bradycardia . variable decelerations with late recovery Intrapartum Fetal Surveillance . eg. . FHR <100bpm . >10min o undulating baseline o severe bradycardia o tachycardia with diminished variability o tachycardia associated with additional noreassuring periodic patterns. fetal distress patterns Fetal heart rate patterns likely to cause fetal or neonatal death or damage . Wide range .

. preconceptual counseling. optimize outcome both of fetus and mother . recognize the risk beginning as early as possible. early and frequent prenatal care And try our best to: . maximize therapeutic treatment   .conclusion  Aim at: . Just by: .

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