a brief and to the point ppt about high risk pregnancies and the complications of child birth or delivery

1. HIGH RISK PREGNANCY
COMPLICATIONS OF CHILDBIRTH
DR. MITALI SRIVASTAVA, MBBS, MD,
SEXUAL MEDICINE CONSULTANT,
SHITAL WOMENS HOSPITAL, AHMEDABAD,
the.besharam.doctor

2. HIGH RISK PREGNANCY [HRP]
 Refers to pregnancies in which the mother or the fetus
has an increased risk of complications compared to
uncomplicated pregnancies
 Maternal and medical risks increase pregnancy risk and
complications during pregnancy and childbirth

3. BAD OBSTETRIC HISTORY
 1st or 2nd trimester miscarriages
 Still birth
 Small weight baby
 Fetal anomalies
 IUGR- intrauterine growth restriction
 Prolonged labor
 Massive PPH
 IUD- intrauterine death
 Recurrent pregnancy loss

4. HEART DISEASE

5. SEVERE ANEMIA
Who is at risk?
• Have two closely spaced pregnancies
• Are pregnant with more than one baby
• Are vomiting frequently due to morning sickness
• Don't consume enough iron-rich foods
• Have a heavy pre-pregnancy menstrual flow
• Have a history of anemia before your pregnancy

6. SEVERE ANEMIA
What are the signs and symptoms?
 Anemia:
• Fatigue
• Weakness
• Dizziness or lightheadedness
• Headache
• Pale or yellowish skin
• Shortness of breath
• Craving or chewing ice (pica)
 Severe anemia:
• A rapid heartbeat
• Low blood pressure
• Difficulty concentrating

7. SEVERE ANEMIA
Prevention:
 Iron RDA (required daily allowance): 30mg/day
 Iron rich diet
 Iron supplements:
 Should be taken with vit C (helps absorption)
 Should not be taken with calcium (reduces absorption)
 Can cause constipation, gastric disturbances, dark stools

8. SEVERE ANEMIA
Treatment:
 Iron injections (eg. Revofer, IV iron bolus)
 Blood transfusions, Packed cell volume transfusions

9. MULTIPLE PREGNANCY
Why is it high risk?
 Preterm labor and birth
 Gestational hypertension
 Anemia
 Birth defects
 Miscarriage
 Postpartum hemorrhage
 Twin to twin transfusion syndrome
 Lower backache/ disc prolapse

10. PRE-ECLAMPSIA & ECLAMPSIA
 Preeclampsia is a pregnancy-specific disorder involving
 Widespread endothelial dysfunction and vasospasm
 Occurs after 20 weeks of gestation and can present as late as 4-6
weeks postpartum
 Clinically defined by new-onset hypertension and proteinuria, with
or without severe features
 In a previously normotensive patient: >140/90 mmHg, measured atleast
twice, 4 hrs apart
 Or a one time reading >160/110 mmHg

11. PRE-ECLAMPSIA & ECLAMPSIA
 Severe features:
• Impaired hepatic function (elevated LFT)
• Severe persistent upper quadrant or epigastric pain that does not respond to
pharmacotherapy and is not accounted for by alternative diagnoses
• Progressive renal insufficiency
• (serum creatinine concentration >1.1 mg/dL or a doubling of the serum
creatinine concentration in the absence of other renal disease)
• New-onset cerebral or visual disturbances
• Pulmonary edema
• Thrombocytopenia

12. PRE-ECLAMPSIA & ECLAMPSIA
Who is at risk?
• Nulliparity
• Multifetal gestations
• Preeclampsia in a previous pregnancy
• Chronic hypertension
• Pregestational diabetes
• Gestational diabetes
• Thrombophilia
• Systemic Lupus Erythematoses [SLE]
• Pre-pregnancy BMI >30
• Antiphospholipid antibody syndrome
• Maternal age 35 years or older
• Kidney disease
• ART: IVF etc

13. PRE-ECLAMPSIA & ECLAMPSIA
What are the clinical features?
• Headache
• Visual disturbances: Blurred, scintillating scotomata
• Altered mental status
• Blindness: May be cortical [3] or retinal
• Dyspnea
• Edema: Sudden increase in edema or facial edema
• Epigastric or right upper quadrant abdominal pain
• Weakness or malaise: May be evidence of hemolytic anemia
• Clonus: May indicate an increased risk of convulsions

14. PRE-ECLAMPSIA & ECLAMPSIA
 HELLP syndrome
 Hemolysis
 Elevated liver enzymes
 Low platelets

15. PRE-ECLAMPSIA & ECLAMPSIA
 Management of Pre-eclampsia & eclampsia:
 Delivery is the only cure for preeclampsia
 Patients with preeclampsia without severe features induced after 37 weeks
 <37 weeks Hospitalized and monitored for development of worsening
preeclampsia or complications of preeclampsia
 Immature fetus is treated with corticosteroids to accelerate lung maturity in
preparation for early delivery

16. PRE-ECLAMPSIA & ECLAMPSIA
Management of active seizures:
 The basic principles of airway, breathing, and circulation (ABC) should always be
followed
 Magnesium sulfate is the first-line treatment for primary and recurrent
eclamptic seizures
 A loading dose of 4-6g is given by infusion pump over 5-10 minutes
 Followed by maintenance dose: infusion of 1g/hr maintained for 24 hours after
the last seizure

17. PRE-ECLAMPSIA & ECLAMPSIA
 Recurrent seizures: Treated with an additional bolus of 2 g or an
increase in the infusion rate to 1.5 or 2 g/hr
 Prophylactic treatment with magnesium sulfate is indicated for all
patients with preeclampsia with severe features
 Magnesium sulfate is discontinued 24 hrs after delivery
 Lorazepam and phenytoin may be used as second-line agents for
refractory seizures

18. PRE-ECLAMPSIA & ECLAMPSIA
Acute treatment of severe hypertension in pregnancy
 Antihypertensive treatment is recommended for severe hypertension (>160/110 mmHg)
 Goal of hypertension treatment: 140/90 mm Hg
 Medications used for BP control include the following:
• Hydralazine
• Labetalol
• Nifedipine
• Sodium nitroprusside (in severe hypertensive emergency refractory to other
medications)

19. PRE-ECLAMPSIA & ECLAMPSIA
Fluid management
• Diuretics should be avoided
• Aggressive volume resuscitation may lead to pulmonary edema
• Patients should be fluid restricted when possible, at least until the period of
postpartum diuresis
• Central venous pressure (CVP) or pulmonary artery pressure monitoring may be
indicated in critical cases
• A CVP of 5 mm Hg in women with no heart disease indicates sufficient
intravascular volume, and maintenance fluids alone are sufficient
• Total fluids should generally be limited to 80 mL/hr or 1 mL/kg/hr

20. PRE-ECLAMPSIA & ECLAMPSIA
Postpartum management
• Many patients will have a brief (up to 6 hours) period of oliguria following delivery
• Magnesium sulfate seizure prophylaxis is continued for 24 hours postpartum
• LFT and platelet counts must document decreasing values prior to hospital discharge
• Elevated BP may be controlled with nifedipine or labetalol postpartum
• If discharged with BP medication, reassessment and a BP check should be performed,
frequently and followed up with physician for further management
• In most cases of preeclampsia, the BP returns to baseline by 12 weeks postpartum
• Patients should be carefully monitored for recurrent preeclampsia, which may develop up
to 4 weeks postpartum, and for eclampsia that has occurred up to 6 weeks after delivery

21. GESTATIONAL DIABETES
 Defined as glucose intolerance of variable degree with onset or first
recognition during pregnancy
 Infants of mothers with preexisting DM experience
 double the risk of serious injury at birth
 triple the likelihood of LSCS
 quadruple the incidence of NICU admission
 GDM: 90% of cases of diabetes mellitus in pregnancy
 Pre- existing type 2 diabetes accounts for 8%

22. GESTATIONAL DIABETES
 Screening for GDM:
 Random blood sugar as a part of routine reports
 OGTT by 5th month of pregnancy
 Diagnosis:
 Fasting blood glucose
 Post-prandial blood glucose
 HbA1c

23. GESTATIONAL DIABETES
 Management:
 Diet care
 Glyburide & metformin
 Insulin
 Prenatal obstetric Mx:
 Doppler studies
 Fetal heart rate and movement
 Mx of Neonate:
 Frequent blood glucose checks
 Early oral feeding

24. ABRUPTIO PLACENTAE/ PLACENTAL ABRUPTION
Separation of placenta,
partially or totally,
from its implantation site,
before delivery
 Consumptive
coagulopathy
 Very high risk of IUD
 Fluid replacement with
5% hydroxyethyl
starch (plasma volume
substitute)
 LSCS

25. ABRUPTIO PLACENTAE/ PLACENTAL ABRUPTION

26. PLACENTA PREVIA Previa: (Latin) ‘before’ the fetus
Placental migration

27. PLACENTA PREVIA
 Painless bleeding, bouts of
frequent bleeding
 Dx: USG
 Mx:
 Tocolytics
 Progesterone
supplementation
 Tranexa
 Absolute bed rest
 Planned CS
 Emergency delivery if
bleeding is not
controlled

28. PLACENT PREVIA
 Especially in acreta spectrum
 Incision is placed in the upper segment, above the tentative position of
placenta.
 Baby delivered first
 Placenta is allowed to separate naturally if possible
 Uterine artery or internal iliac artery ligation helpful
 High risk for hysterectomy, ICU outcome, Blood transfusion

29. CERVICAL INCOMPETENCE
 N- wiring/ cervical
cerclage
 14 to 16 weeks: preventive
 Or as detected

30. THREATENED PRETERM LABOR
 At risk for preterm delivery (<37 weeks)
 Mx aimed towards stopping labor if possible
 Or delaying labor till effect of corticosteroids occurs to bring fetal lungs to
maturity
 If labor progresses, to conduct a safe delivery

31. OTHER CONDITIONS IN HIGH RISK PREGNANCY
 Thrombocytopenia or megaloblastic anemia and other bleeding disorders
 Thalassemia
 History of thrombosis or thrombophilias
 History of neurological disease (epilepsy, brain haemorrhage, or tumor)
 Malignancy (cervical, ovarian or breast)
 Fibroid uterus
 Congenital malformations that can survive

33. COMPLICATIONS IN CHILDBIRTH
 DYSTOCIA
 PROM
 PRECIPITATE LABOR
 ABNORMAL PRESENTATIONS
 UMBILICAL CORD PROLAPSE
 PPH
 AMNIOTIC FLUID EMBOLISM

34. DYSTOCIA
• Difficult, prolonged labor
• Abnormally slow labor
progress
• Non- progression of labor
[NPL]
• Pathology lies with:
• P- power
• P- passenger
• P- passage

35. PROM- PREMATURE RUPTURE OF MEMBRANES
 Membrane rupture at term without spontaneous uterine contractions
 Wait for 6 hrs, and if labor still doesn’t start, induction of labor
 Prostaglandin E2 gel (Cerviprime)
 Oxytocin infusion IV, after labor initiates only
 Antibiotic coverage
 Increased risk of:
 Chorioamnionitis
 NICU admission

36. PRECIPITATE LABOR
 Abnormal extremely rapid labor and delivery
 Expulsion of fetus in <3 hrs from initiation of labor
 Less complications if cervix is effaced
 Otherwise:
 Cervical/ vaginal/ vulval tears/ lacerations
 Uterine rupture
 Amniotic fluid embolism
 PPH
 Linked with cocaine abuse
 Newborn injury risk

37. ABNORMAL PRESENTATIONS IN VAGINAL
DELIVERY
Transverse lie
External cephalic version

41. UMBILICAL CORD PROLAPSE
 Can occur during labor, or be a presenting part
 Eventually causes cord compression
 Risk factors:
 High floating head
 Polyhydramnios
 Abnormal presentations
 Very small baby
 Multifetal gestations
 Mx: Head up, manual elevation of fetal head, lscs

42. PPH- POST PARTUM HEMORRHAGE

43. PPH- POST PARTUM HEMORRHAGE
 Investigation:
 Labs: Hb, Hematocrit evaluation to watch for blood loss
 USG: To look for retained placental products
 Management:
 Uterine massage
 Fluid replacement
 oxytocin
 Tranexa
 Methergine
 Misoprostol etc
 Surgical management

45.  Surgical management:
 Vaginal and cervical laceration for traumatic PPH
 Laprotomy
 Uterine rupture
 Uterine lacerations
 Hematoma
 Uterine artery or internal iliac artery ligation
 Compression sutures
 Uterine packing (removed after 24 hrs)
 Cath lab: Angiographic embolization of uterine artery

46. B- Lynch sutures

47. RARE COMPLICATIONS
 Uterine inversion
 Amniotic fluid embolism
 Uterine rupture
 Retained placenta
 Puerperial sepsis