Our Daily Bread: It is not the healthy who

need a doctor, but the sick

Two thousand years ago, Jesus came to call the spiritually
unfit to follow Him. Levi was one such person. Jesus saw him
sitting in his tax collector’s booth and said, “Follow me.” His
words captured Levi’s heart, and he followed Jesus.
Tax collectors were often greedy and dishonest in their
dealings and were considered religiously unclean. When the
religious leaders saw Jesus having dinner at Levi’s house with
other tax collectors, they asked, “Why does he eat with tax
collectors and sinners?” Jesus replied, “I have not come to
call the righteous, but sinners.”
 High-Risk
Pregnancies
and
The Fetus Part 1
 Objectives
 To give an overview on high-risk pregnancies and their
effect on fetal growth and development
 To discuss fetal growth and maturity

 To discuss markers of fetal well-being and distress

 High-Risk
Pregnancies
 Definition
 Pregnanciesthat increase the likelihood of abortion, fetal
death, preterm delivery, IUGR, poor cardiopulmonary or
metabolic transitioning at birth, fetal or neonatal disease,
congenital malformations, mental retardation and other
handicaps
 High-Risk Pregnancies
 10-20% - identified based on history

 ~50%of perinatal morbidity and mortality are associated

with high-risk pregnancies
 Prenatal check-ups  determine antepartum risk
 Some pregnancies become high risk during intrapartum course
 Factors Associated with High-Risk
Pregnancies Poverty
Low educational
Previous
Diabetes LBW
mellitus,
or status
preterm
Hypertension
infant
Previous
UnemploymentCS
Poor
Low
CHD healthcare
Uterine bleeding,
weight for attitudes
uterine or
height
Previous infertility,
Underinsured/uninsured
cervical anomalies use of ART
Inadequate
Poor
Autoimmune
pregnancyprenatal
disease
weight caregain
Economic Prolonged
Poor
Parityaccess
0 or gestation
> to
5 prenatalandcare
labor
Genetic Medical Cigarette,
Short
Sickle alcohol,
stature
cell anemia illicit drug use
Previous
Fetal infantabnormal
disease, w/ CP, MR, birth
fetal
Age
Poor <20 or
Intercurrent
trauma, >40
nutrition surgery/trauma
congenital anomalies
growth
Unmarried, lack of support group
Cultural- Consanguinity
STIs
Abnormal lie, multiple gestations
Idiopathic
Short premature labor
inter-pregnancy interval
Behavioral Reproductive Intergenerational
Maternal
Premature hypercoagulable
rupture effects
of state
membranes
Iatrogenic
Stress prematurity
Low
TORCH maternal BW
Infection
Abnormal
Black race maternal serum a-FP
Hereditary
Exposure
Preeclampsia,todiseases
prescription
eclampsia drugs
 Maternal Factors
 Lowest neonatal mortality: Mothers 20-30 yrs of age
with adequate prenatal care
 Increased risk of IUGR, fetal distress, intrauterine
death in teenagers and women older than 40,
especially in primiparas
 Maternal Factors
 Maternal illnesses, infections, and drug intake
 Multiple gestations (monochorionic twinning)
 Use of assisted reproductive technologies
 Increased perinatal morbidity and mortality, LBW, CP
 Increased risk for birth defects
 Preterm birth: Biologic markers
 Cervical shortening
 Genital infection
 Fetal fibronectin in cervicovaginal secretions
 serum α-fetoprotein
 Preterm premature rupture of membranes
 Amniotic Fluid Volume
 Amniotic fluid gradually increases at a rate of
< 10 ml/day
until 34th wk AOG and thereafter slowly diminishes
 Volume at term: 500 – 2000 ml
 Polyhydramnios: > 2000 ml; AFI > 24cm
 Oligohydramnios: < 500 ml; AFI < 5 cm
 Polyhydramnios
 Acute vs Chronic
 Associated with preterm labor, abruptio placentae, multiple
congenital anomalies, and fetal neuromuscular dysfunction or
obstruction of the gastrointestinal tract (impaired reabsorption)
 Increased fetal urination or edema formation  also associated
with excessive amniotic fluid volume (excessive formation)
 Tx: Serial amniocenteses or short-course maternal indomethacin (if
the problem is caused by excessive fetal urination)
 Oligohydramnios
 Associated with congenital anomalies, IUGR, severe renal,
bladder, or urethral anomalies, drugs that interfere w/ fetal
urination
 Causes fetal compression abnormalities such as fetal distress,
clubfoot, spadelike hands, and a flattened nasal bridge.
 Most serious complication: pulmonary hypoplasia
 Intrapartum risk of umbilical cord compression
 TX: Prophylactic intrapartum amnioinfusion reduces the need for
cesarean section and improves Apgar scores.
 Screening
Antenatal screening
 Maternal blood tests, UTZ, and
diagnostic amniocentesis,
chorionic villus sampling, fetal
blood or tissue sampling
 Down syndrome, chromosomal
abnormalities, neural tube
defects, structural anomalies,
metabolic genetic diseases,
hemoglobinopathies
Second-trimester screening
 15-18 wks sampling of maternal
serum α-fetoprotein (MSAFP)
 High MSAFP: Open neural tube
defects, gastroschisis,
omphalocele, congenital
nephrosis, twins,
 Low MSAFP: incorrect aging,
trisomy 18 or 21, IUGR
 Uterine Size
 Large for AOG:
 Multiple fetuses, hydramnios, excessively large
infant
 Small for AOG:
 Inappropriately small infant  oligohydramnios or
poor intrauterine growth
 Premature Rupture of Membranes
 >24hr before delivery: increased risk of fetal infection
and premature birth
 At term: increased risk of chorioamnionitis and umbilical
cord compression.
 Before 37 wks: increased risk of cord prolapse,
oligohydramnios, abruptio placentae, fetal malposition
 2nd
trimester: PROM > 7 days: pulmonary hypoplasia,
uterine-induced deformations, extremity contractures
 Labor
 Prolonged and difficult labor: increases the risk for mechanical
and hypoxic damage
 Tumultuous short labor with a precipitous delivery: increases
the risk of birth asphyxia and intracranial hemorrhage
 Placental separation at any time before delivery and abnormal
implantation or compression of the cord increase the
possibility of brain damage from fetal hypoxia
 Manner of Delivery
 Vacuum extraction or forceps delivery: inc risk of intracranial
hemorrhage and traumatic intracranial injury
 Cesearean section – risk is related to indication for CS
 MC problem: TTNB
 May also develop RDS and PPHN
 Anesthesia and analgesia: severe maternal hypoxemia secondary
to hypoventilation or hypotension resulting from epidural
anesthesia -> severe fetal hypoxia and shock
 Factors Associated with High-Risk
Pregnancies
Economic Genetic Medical

Cultural-
Behavioral Reproductive
The Fetus
 Fetal Medicine
Involves assessment and evaluation of:
 Fetal growth and maturity
 Fetal well-being or distress
 Effects of maternal disease on the fetus
 Effects of drugs administered to the mother on the fetus
 Identification and treatment of fetal disease or anomalies
 Ultrasound
 Indications:
 Estimation of gestational age
 Assessment of amniotic fluid volume
 Estimation of fetal weight
 Determination of the location of the placenta, the number and
position of fetuses
 Identification of congenital anomalies
 Fetal Growth
 Fetal growth can be assessed by UTZ as early as 6-8 wks
 1st-trimester crown-rump length by ultrasound – most accurate
estimate of gestational age
 Biparietal diameter - used to assess gestational age beginning in
the 2nd trimester
 Abdominal circumference, femoral length – Estimates gestation
when close to term
 Fetal Growth and Maturity
 Single UTZ: best performed at18-20 wks when both AOG
and fetal anomaly can both be evaluated
 Patterns of IUGR
 Symmetric: continuous IUGR 2 SD below the mean
 Asymmetric: Normal growth w/ abrupt slowing and
flattening later in gestation
 Fetal Maturity and Dating
 History (LMP)

 Physical examination

 Auscultation of fetal hearts sounds – 16-18 wks

 Maternal perception of fetal movements at 18 -20 wks
 Fundal height measurement

 Lung maturation  surfactant content of amniotic fluid

 Fetal Distress
 May occur both ante- and intrapartum

 Antepartum surveillance – warranted for women with high-risk pregnancies

 Major cause: uteroplacental insufficiency

 Goals of antepartum and intrapartum surveillance

 prevent IUFD
 prevent hypoxic brain injury
 prolong gestation in women at risk for preterm delivery when such
prolongation is safe or deliver a fetus when it is in jeopardy
 Tests for Fetal Well-being
 Ultrasound

 Nonstress test

 Biophysical profile (BPP)

 Contraction stress test

 Nonstress Test
 Monitors presence of FHR accelerations following fetal
movement
 Normal: Reactive  2 fetal HR accelerations of at least 15
bpm lasting 15 sec
 Nonreactive: suggests fetal compromise
 Contraction Stress Test
 Observes FHR response to uterine contractions

 Fetalcompromise: majority of contractions in 10 min are

followed by late decelerations
 C/I:
PPROM, Previous classic CS, multiple gestation,
incompetent cervix, placenta previa
 Biophysical Profile
 Fetal breathing
 Fetal movement
 Fetal tone
 Heart rate
 Amniotic fluid volume
8-10 reassuring
6-7 equivocal repeat in 12-24 hrs
4 or less – immediate evaluation and possible delivery
 Doppler UTZ
 Reduced, absent, or reversed end-diastolic wave form
velocity  progressive compromise
 Intrapartum Fetal Surveillance
 Compromise during labor is detected by
monitoring:
 FHR
 Uterine pressure
 Fetal scalp blood pH
 Fetal Heart Rate
 Continuous FHR monitoring
 Baseline fetal HR: Normal at term  110 -160 bpm
 Tachycardia (>160)  Early fetal hypoxia, maternal fever and
hyperthyroidism, B-sympathomimetic drug, atropine, fetal anemia,
infection
 Bradycardia (<110)  fetal hypoxia, placental transfer of certain
drugs, heart block
 Fetal Heart Rate
 Variability – change in amplitude of fetal heart rate
 Absent
 Minimal: < 5 bpm
 Moderate: 6-25 bpm
 Marked: > 25 bpm

 Minimal or absent variability  fetal hypoxemia and

placental transfer of sedating drugs
 Fetal Heart Rate
 Acceleration – abrupt increase in FHR of > 15 bpm in > 15
sec

 *Accelerations+ moderate variability  predicts absence

of fetal metabolic academia
 l e r a t ions
Dec e
 Decelerations
 Reflex late decelerations with N beat-to-beat variability  Chronic
compensated fetal hypoxia
 Nonreflex late decelerations  severe hypoxic depression of
myocardial function
 10-15% of fetuses have terminal decelerations
 Benign if < 10 mins prior
 Persistent bradycardia/Longer terminal deceleration without recovery
 fetal acidosis
 Decelerations
 Categories  Management
 Category I – normal  O2 supplementation
 Category II – not  D/c labor stimulation
predictive of abnormal  Position changes
fetal status
 Prompt delivery
 Category III – abnormal
 further eval,
surveillance, and
re=evaluation needed
 Fetal Scalp Blood pH Sampling
 Confirms fetal distress

 pH < 7.25 – fetal suggests distress

 pH < 7.20 – need for further
assessment ad intervention
Thank you!