High-risk pregnancy

1. High-risk pregnancy Ob&Gy Department ,First Hospital, Xi’an Jiaotong University WANG SHU

2. General consideration • mother ,fetus,or newborn • before, during,or after delivery • at increased risk of morbidity or mortality

3. 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

4. Leading cause of maternal death • Thromboembolic disease • Hypertensive disease • Hemorrhage • Infection • Ectopic pregnancy General consideration

5. Risk factors related to specific pregnancy problems • Drug addiction and alcohol abuse • Pyelonephritis,pneumonia • Multiple gestation • Anemia • Abnormal fetal presentation • Preterm rupture of membranes • Placental abnormalities • infection • 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 General consideration

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

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

8. Maternal assessment for potential fetal or perinatal risk • Initial screening History: • Maternal age • Modality of conception • Past medical history • Family history • Ethic background • Past obstetric history

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

10. Past obstetric history • Habitual abortion • Karyotype of abortus • Parental karyotype • Cervical and uterien anomalies • Connective tissue disease • Hormonal abnormalities • Acquired and inherited thrombophilias • Infectious disease of the genital tract • Previous stillbirth or neonatal death History • Previous preterm delivery • Rh isoimmunization or ABO incompatibility • Previous preeclampsia-eclampsia • Previous infant with genetic disorder or congenital aomaly • Teratogen exposure • drugs • Infectious agents • radiation Initial screening

11. Antepartum course • Prenatal visits • Fever(>100.4℉,even >103 ℉) • Urinary ,pulmonary ,hematological sources;chorioamnionitis • Preterm labor;adverse effect on fetus and mother • Amniocentesis for microscopy and culture • Antipyretics;delivery Vital signs A

12. Prenatal visits B Blood pressue C • Tachycardia(>100bpmeven <120bpm) • Infection,anemia,heart disease,et. • Mild:follow-up; • Severe: ECG , hemogram • >140/90mmHg • ↑>30/15mmHg • PIH,chronic hypertention, Pulse urinalysis D • Protein,glucose,leukocyte,blood, ketonuria • anbiotics Antepartum course

13. Screening Tests A • Sonography • First and trimester • Aneuploidy,malformation Faster trail • Triple screen(msAFP,β-hCG, estriol) • 15-19 weeks • Trisomy 21,open neural tube defect B Maternal serum analyte testing Antepartum course

14. Screening Tests • Transvaginal sonography • First and trimester • Aneuploidy,malformation C Diabetic screen • RH(-) or/and type-O mother with RH(+) or/and type-A,B,AB father; • First visit,24-28 weeks again,repeat per 4 weeks if necessary • Fetal or newborn hemolysis D Isoimmunization Antepartum course

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

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

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

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

19. Fetal Maturity Tests • Indications for assessing fetal lung maturity: • >37 weeks • according following criteria: • Lecithin:Sphingomyelin Ratio(L/S) • Phosphatidylglycerol(PG) • Foam Stability Index(FSI) • risk of respiratory distress syndrome Antepartum course

20. Fetal Maturity Tests Fetal maturity tests Antepartum course

21. Intrapartum Fetal Surveillance • Ancillary tests A:fetal scalp blood sampling • PH<7.2 • Serious fetal distress;low Apgar scores B:Fetal lactate levels • A higher value Marker of neurologic disability

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

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

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

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