High-risk pregnancy

Ob&Gy Department ,First Hospital,

Xi’an Jiaotong University

WANG SHU
General consideration

 mother ,fetus,or newborn

 before, during,or after delivery
 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
 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
General
consideration
 Drug addiction and
alcohol abuse
 Pyelonephritis,pneumonia
 Multiple gestation
 Anemia
 Abnormal fetal
presentation
 Preterm rupture of
membranes
 Placental abnormalities
 infection
Risk factors related to specific pregnancy problems
 polyhydramnios
 diabetes mellitus
 Moutiple gestation
 Fetal congenital
abnormalities
 Isoimmunization(Rh or ABO)
 Nonimmune hydrops
 Abnormal fetal presentation
General
consideration
 oligohydramnios
 renal agenesis
 Rolonged rupture of
membranes
 Intrauterine growth
restriction
 Intrauterine fetal
demise
  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
oMaternal age
History :
oModality of conception
oPast medical history
oFamily history
oEthic background
oPast obstetric history
 History
Past medical history
 Chronic hypertension pulmonary
disease(eg.tuberculosis,sarci
 Renal disease
odosis, asthma)
 Diabetes mellitus
Gastrointestinal and liver
 Heart disease
disease
 Previous endocrine
Epilepsy
ablation(eg.thyroidectomy)
Blood
 Maternal cancer
disorders(eg,anemia,coagulo
 Sickle cell trait and disease
pathy)
 Substance use or abuse
The others
 Thyroid disorders

Initial screening
 Past obstetric history History
 Habitual abortion
Previous preterm delivery
oKaryotype of abortus
Rh isoimmunization or
oParental karyotype
ABO incompatibility
oCervical and uterien anomalies
Previous preeclampsia-
oConnective tissue disease
eclampsia
oHormonal abnormalities
Previous infant with
oAcquired and inherited
genetic disorder or
thrombophilias
congenital aomaly
oInfectious disease of the genital
Teratogen exposure
tract
o drugs
 Previous stillbirth or neonatal
oInfectious agents
death
oradiation
Initial screening
 Antepartum course
 Prenatal visits
o Fever(>100.4℉,even >103 ℉)
Vital signs
o Urinary ,pulmonary ,hematological
A sources;chorioamnionitis

o Preterm labor;adverse effect on fetus

and mother

o Amniocentesis for microscopy and

culture

o Antipyretics;delivery
 visits
Pulse B Blood
pressue C
oTachycardia(>100bpm
even <120bpm) o >140/90mmHg

oInfection,anemia,heart ↑>30/15mmHg
disease,et. oPIH,chronic hypertention,
oMild:follow-up;
Severe: ECG , urinalysis
D
hemogram
o Protein,glucose,leukocyte,blood
, ketonuria
o anbiotics
Antepartum
course
 Screening
Tests
A oSonography
Faster trail
oFirst and trimester

oAneuploidy,malformation

B o Triple screen(msAFP,β-
Maternal hCG, estriol)
serum
analyte o 15-19 weeks
testing
o Trisomy 21,open neural tube
defect
Antepartum
course
 Tests

oTransvaginal sonography
Diabetic C
oFirst and trimester
screen oAneuploidy,malformation

o RH(-) or/and type-O mother

D with RH(+) or/and type-
Isoimmunization A,B,AB father;
o First visit,24-28 weeks
again,repeat per 4 weeks if
necessary
o Fetal or newborn hemolysis
Antepartum
course
 Fetal
Assessment
1.Ultrasound
o Basic:fetal numbers,pesentation,fetal
viability,placental location,gestational age
A o Limited:for suspected problem

Assessment o Comprehensive:fetalanomalies , growth,

of physiologic complication
prenatal 2.Aneuploid screening
diagnosis
o sonography marks:
. Echogenic intracardiac focus
. Pyelectasis
. Echogenic bowel

Antepartum . Shorter femur

course
 Assessment of prenatal diagnosis Assessment

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

1. Fetal monitoring techniques

o External fetal monitoring
B o Internal fetal monitoring

Assessment o sonographic fetal monitoring

of
Fetal 2.fetal heart rate interpretation
well-bing o NST
. Baseline:120-160bpm
. acceleration of 15bpm for 15s at least
o in risk pregnancy of possible fetal demise

Antepartum
course
 Assessment
1. Vibroacoustic stimulation
o burst of sound to stimulate fetus
o when NST is nonreactive

C o anoxia

Ancillary 2.fetal scalp stimulation

tests o stimulate fetal vertex
o anoxia

3.Oxytocin challenge test (OCT)

o induce effective uterine contraction artificially
o positive results:late deceleration after each of
three consecutive contraction
o fetal distress
Antepartum
course
 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
 Tests
Fetal maturity tests
Positive Positive
Relative
Test discriminating predictive Pros and Cons
cost
value value

L:S Large laboratory

>2.0 95~100% High
ratio variation

Not affected by
blood,meconium.C
PG “present” 95~100% High
an use vaginal
pooled sample

Stable ring of affected by

FSI 95% Low
foam blood,meconium.

Antepartum
course
 Intrapartum Fetal
Surveillance
 Ancillary tests
A:fetal scalp blood sampling
o PH<7.2
o Serious fetal distress;low Apgar scores
B:Fetal lactate levels
o A higher value Marker of neurologic disability
 Fetal heart rate patterns
Reassuring fetal heart rate
patterns seldom relate to acidosis
or hypoxia
o Baseline:120-160bpm & Periodic
changes
o Accelerations and variable
deceleration Normal autonomic
nervous system
o Early decelerations and
bradycardia of 100~119bpm
Fetal head
o Certain arrhythmia compression
. persistent tachyarrythmia
. Persistent bradyarrythmia Well tolerated

Fetal heart disease

Intrapartum Fetal
Surveillance
 Fetal heart rate
patterns
 Nonreassuring fetal heart if continuation or worsening,
rate patterns may result in fetal distress

. Fall in fetal PH
o Late deceleration . Potential for perinatal
mortality and morbidity

o sinusoidal heart rate .Moderate fetal hypoxemia

.No adverse outcome

o variable deceleration . Mild cord compressin

. No late component . benign

. Late recovery Fetal Ph falls

Intrapartum Fetal
Surveillance
 Fetal heart rate
patterns
likely to cause fetal or
 fetal distress patterns
neonatal death or damage

. Alternating tachycardia
o undulating baseline and bradycardia
. Wide range

o severe bradycardia . FHR <100bpm

. >10min

o tachycardia with diminished variability

o tachycardia associated with additional noreassuring periodic
patterns, eg.
. Late decelerations
. variable decelerations with late recovery

Intrapartum Fetal
Surveillance
 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