HIGHRISKPREGNANCYANDFOETALEVALUATION

DrSunitaMishraAssociateProfessor

Dept.ofOBGKIMS,Narketpally

HIGHRISKPREGNANCYANYPREGNANCYWITHASIGNIFICANTPROBABILITYFORAPOORMATERNALORFOETALOUTCOMESomerecognizedearlyinthefirstantenatalvisitPoorobsterichistoryThosewithwellrecognizedmedicalcomplicationsSomebecomebydevelopingunexpectedcomplicationsinthecourseofotherwisenormalpregnancies

HIGHRISKPREGNANCYTOOPTIMIZETHEOUTCOMESophisticatedmaternalandfetalsurveillanceDifficultmanagementdecisions

HIGHRISKPREGNANCYMANAGEMENTIdentificationofwomenathighriskforabnormalpregnancyoutcomesAppropriateAntenatalcareinpreventionofmorbidoutcomesFoetalsurveillance

IDENTIFICATIONOFHIGHRISKPREGNANCYACCESSTOANTENATALCAREPoverty,animportantlimitingfactorforlimitingaccesstohealthcaresystemQUALITYOFANTENATALCAREServicesprovidedaremanyatimesofmarginalquality,thusrenderingmanyhighriskpregnanciesunidentifiableHIGHRISKPREGNANCIESBELONGTOASMALLSEGMENTOFTHEOBSTETRICALPOULATIONTHATPRODUCESTHEMAJORITYOFTHEMATERNALANDINFANTMORTALITYANDMORBIDITY

IDENTIFICATIONOFHIGHRISKPREGNANCY

ALISTOFHIGHRISKFACTORSSHOULDBESYSTEMATICALLYCHECKEDDURINGTHEFIRSTANTENATALVISITTOFINDWOMENATRISK

MEDICALCONDITIONSPLACINGPREGNANCYATHIGHRISKMalnutritionAnaemiaChronichypertensionDiabetesAsthmaThrombophilia(historyofDVTorPE)CardiacdisorderSeizuredisorderFamilyhistoryofgeneticdiseaseHemoglobinopathy

MEDICALCONDITIONSPLACINGPREGNANCYATHIGHRISKRenaldiseasePsychiatricillnessLupuserythematosusandotherconnectivetissuedisordersDrugandalcoholabuseSmokingRhalloimmunizationHepatitisBcarrierHumanimmunodeficiencyvirusSyphilsGonorrheaandChlamydialinfectionAsymptomaticbacteriuria

OBSTETRICALHIGHRISKFACTORSH/OpreviousprolongedlabourinstrumentalassisteddeliveryH/Opreviousobstructedlabour/ruptureuterus/traumaticdeliveryH/OPPH(highparitystatus)/obstetricshockH/OpuerperalsepsisPriorpretermbirth(

OBSTETRICALHIGHRISKFACTORS

PriorneonataldeathPriorinfantwithcerebralpalsyPriorcaesareandeliveryDiagnosisofincompetentcervixinpriorpregnancyH/Opreeclampsiabefore32weeksinpriorpregnancyPriorfoetuswithchromosomaldisorderorcongenitalanatomicabnormalitiesAnatomicabnormalityoftheuterusH/Ocervicaltrauma

HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE

1. Womenwithconditionsrequiringinvasiveproceduresforfoetaldiagnosisortreatment

RhalloimunizationNonimmunologicfoetalhydropsFoetalurinarytractobstructionNeedforCVS

HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE2.Womenwithseveremedicalcomplicationsaffectingpregnancy:InsulindependentdiabetesArtificialheartvalvesCardiomyopathySystemiclupuserythematosusSicklecelldisease/thalassemiaThromboembolicphenomenaSeizuredisorder

HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE3. Womenwithrecurrentpoorobstetricaloutcome:RepetitivesecondtrimesterpregnancylossesRecurrentstillbirthsRecurrentearlypretermlabourRecurrentearlyruptureofmembranes

HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE4.Womenwithsevereobstetricalcomplications:Preeclampsia/eclampsiawithrenalfailure,pulmonaryoedemaSevereHELLPsyndromeSuspectedcervicalincompetenceafter20weeksgestationSuspectedtwintotwintransfusionMultiplegestationofhighorder(3andabove)

PRECONCEPTIONALCOUNSELING

ThebesttimetoassessthepotentialimpactofmedicalorobstetricalcomplicationsontheoutcomeofpregnancyisBEFOREPREGNANCYOCCURSThefollowingpointsshouldbemethodicallyreviewedbytheobstetrician:1. Relativeimportanceofeachofthehighriskfactors

identifiedthroughhistory&examinationofthepatient

PRECONCEPTIONALCOUNSELING

2.Thepotentialeffectsthateachriskfactormayhaveonthepregnancy

3.Thechangesoreffectsthatpregnancymaycauseuponeachriskfactor

4.Thepotentialdisabilityforthemotherduringpregnancy&thelengthofsuchdisability

5.Thetestsrequiredtomonitormaternal&foetalwellbeingduringpregnancy

PRECONCEPTIONALCOUNSELING

6.Theprognosisfortheoutcomeofthepregnancy7.Thecostofpregnancy,thelossofrevenueasaresultofprolongedhospitalization&frequenttesting,needforhelpathomewithotherchildrenandthemonetaryandemotionalcostsofdealingwitheffectsofprematurity

PRECONCEPTIONALCOUNSELING

Conditionsbenefiting:MaternaldiabetesRhalloimmunizationHistoryofrecurrentstillbirthsPatientsathighriskforhavingfoetuseswithaneuploidy

PRECONCEPTIONALCOUNSELING

WomenwithaH/Obirthofababywithneuraltubedefectshouldbeprescribedfolicacidsupplementsfor3monthspriortoattemptingsubsequentpregnancyRoutinetestingforrubellaIgGantibodiespriortoplanningpregnancyisrecommendedUsingiodizedsaltandpracticeofscreeningallpatientsforthyroiddisordersarerecommended

ANTENATALCARE

PRIMARYOBJECTIVE:Preventionandtreatmentofabnormalmaternalandfoetaloutcomes

DETERMINATIONOFGESTATIONALAGE:Anaccuratedeterminationofthegestationalageandtheexpecteddateofdelivery(EDD)Isfundamentaltothemanagementofhighriskpregnancies

DETERMINATIONOFGESTATIONALAGEBestmethodisthroughneonatalevaluation.Althoughgoldstandard,itsnotofmuchusetoobstetriciansClinicaldatingDatingbyultrasound

DETERMINATIONOFGESTATIONALAGECLINICALDATINGTiming&characteristicsoftheLMPThefindingsontheinitialpelvicexaminationThedateonwhichfoetalhearttonesarefirstheardRelationbetweenthedateoffirstpositivepregnancytestandthemenstrualhistory

CLINICALDATING

MENSTRUALHISTORYADEQUATEFOREDDONLYIF

LMPnormalinduration&amountofflowpriormenstrualperiodscameatregularintervalspatienthasnotusedoralcontraceptiveswithinthreemonthsofherlastperiod30%patientsdonotfulfillthesecriteria,makingestimationofEDDbasedontheirLMPsunreliable

CLINICALDATINGEVALUATIONOFUTERINESIZELIMITEDVALUEmaternalobesityobserverexperiencepositionoftheuterusamountofamnioticfluidmultiplegestationpresenceofuterinemyomasfoetalgrowthdisordersStudieshavedemonstratedthatphysiciansmeasurementstendtounderestimatethegestationalage&haveapreferenceforevennumbers

CLINICALDATING

DATEONWHICHFOETALHEARTTONESAREFIRSTAUDIBLE

withDopplerultrasounddevices(10weeks)withobstetricalstethoscopes(20weeks)Butthisisofvalueonlywhenitagreeswithotherclinicalindicators&withtheultrasoundmeasurements

CLINICALDATINGDATEOFTHEFIRSTPOSITIVEPREGNANCYTESThighlysensitiveallowsdiagnosisofpregnancyat45postmenstrualweeksAssuchdatesfirmlyestablishedifpatienthasapositivepregnancytest45weeksafterherLMP

DATINGBYULTRASOUNDFOETALBIOMETRY:Theabilitytovisualizewithultrasound,differentfoetalanatomicallandmarksandtofollowtheirgrowthduringgestationAccuratelydeterminesthegestationalageofthefoetusandtheadequacyofthefoetalgrowthUsesCRLinthefirsttrimesterandtheBPD,HC,FL,HL&ACinthesecondtrimester

DATINGBYULTRASOUND

Similaraccuracywhenperformedbetween1114weeksofgestationand1822weeksofgestation

After22weeksthemarginoferrorincreasesandthenitisnecessarytoobtainserialmeasurements34weeksaparttoavoidasignificanterror

RELIABILITYOFEDD

EXCELLENTDATES:Patientswithadequateclinicalinformationplusultrasoundexaminationbetweenbetween1624weeksPatientswithinadequateorincompleteclinicalinformationbutwithtwoultrasoundexaminationsbetween16and24weeks

RELIABILITYOFEDDGOODDATES:Patientswithadequateclinicalinformationandoneconfirmingultrasoundexaminationobtainedafter24weeksofgestationPatientswithinadequateorincompleteclinicalinformationandtwoormoreultrasoundexaminationsshowingadequategrowthandsimilarEDD

POORDATES:Anyclinicalsituationdifferentfromthoselistedabove

DATINGBYULTRASOUND

CRLMeasurementofCRLinthefirsttrimesterofpregnancyisthemostaccuratemethodtodetermineGAPredictsthemenstrualagewithavariationof+3dayswhenobtainedbetween710weeksPossiblesourceoferrorinpresenceofanembryowithchromosomalabnormalities

DATINGBYULTRASOUND

BPD:MostaccuratemeasurementtodetermineGAinthesecondtrimesterofpregnancyCephalicIndex,ratiooftheBPDtoOFD,measuredwhenfoetalheadlooksflattened&elongated

HC:NotalteredbydolichocephalyorbrachycephalyoffoetalheadUsuallymeasuredbyelectroniccalipers,butcanalsobecalculatedusingtheequationHC=BPD+OFD/2

DATINGBYULTRASOUND

FL:Excellentparameter,asitisnotsignificantlyaffectedbyalterationsinthefoetalgrowth.

HL:RelativelyeasytoobtainAC:LessreliableparameterforGAestimationbecauseitisverysensitivetoalterationsinfoetalgrowthMostimportantparameterintheestimationoffoetalweight

DATINGBYULTRASOUND

DETERMINATIONOFGESTATIONALAGEMostUSGmachineshaveincorporatedintotheirsoftware,NOMOGRAMStocalculateGAusingtheBPD,HC,AC,FL,CRL,andHL

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESFUNDAMENTALOBJECTIVEOFANTENATALCARETheworseoutcomesarematernalandfetaldeathMATERNALDEATHMMR(Maternalmortalityrate)inIndiacontinuestobeunacceptablyhighatabout162per100,000livebirths

TheInternationalClassificationofDiseasesdefinesmaternaldeathasthedeathofawomanwhilepregnantorwithin42days(or1yearforlatematernaldeaths)ofdelivery,irrespectiveofthedurationorsiteofthepregnancy,fromanycauserelatedtooraggravatedbypregnancy,butnotfromaccidentalorincidentalcauses

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES

AccordingtoWHO,inIndiatheleadingdirectcausesofmaternalmortalityarehaemorrhage,sepsis,preeclampsia&eclampsia,unsafeabortion,andobstructedlabour.

Necessarytoincreaseaccesstoprenatalcaretodecreasematernaldeathssecondarytopreeclampsia/eclampsia/HELLPsyndromeindevelopingcountries.

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES

Maternaldeathsecondarytoinfectionexhibitedasignificantdecreasewithavailabilityoflegalabortionbutisontheriseagain

Maternaldeathsecondarytoabortionisstillasignificantproblemindevelopingandindustrializedcountries,explainedpartiallybylackofavailabilityoflegalabortions.

Directobstetriccausesrelatetomaternaldeathsresultingfromcomplicationsofpregnancy,labour,puerperiumduetointerventions,omissions,orincorrecttreatments,orfromchainofeventsresultingfromanyoftheabove.

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES

Mostmaternaldeathsarepreventable:PovertyalleviationHumanrightsassertionIndividualeffortsfromhealthcareprovidersProperantenatalcareIdentifyingwomenatriskToaggressivelytreatcomplications

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESHEALTHSECTORACTIONSTOPREVENTORREDUCE

MATERNALMORTALITYBasicantenatal,intranatal&postnatalcareAskilledattendant&afunctioningreferralsystemEmergencyobstetriccare(EmOC)GoodqualityobstetricservicesFamilyplanningservicesFrequentjointconsultationamongspecialistsinmanaging

medicaldisordersinpregnancyMaternalmortalityconferencesPeriodicrefreshercoursesforeducationoftheskilled

personnelsCOMMUNITY,SOCIETYANDFAMILYACTIONS:Widerangeofgroups(womensgroups),healthcare

professionals,religiousleadersandsafemotherhoodcommiteescanhelpthewomanobtaintheessentialobstetriccare.

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES

HEALTHPLANNERS/POLICYMAKERSACTION:Communityeducation,motivation&formationofsafemotherhoodcommitteeatthelocallevelStrengtheningreferralsystemsforobstetricemergenciesWrittenmanagementprotocolsforobstetricemergenciesinthehospitalImprovingstandard&qualityofcarebyorganizingrefreshercoursesforhealthcarepersonnelsPeriodicauditofexistinghealthcaredeliverysystem&toimplementchangesasneeded

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES

LEGISLATIVEANDPOLICYACTIONS:Girlchildren&adolescentsshouldhavegoodnutrition,educationandeconomicopportunitiesBarrierstotheaccessofhealthcarefacilitiesshouldberemovedDecentralizationofservicesSafeabortionservicesandpostabortioncareSocialinequalities&discriminationongroundsofgender,age&maritalstatus,aretoberemoved

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES

NEONATALDEATH:Deathoftheinfantwithin28daysafterbirthThemaincausesofneonatalmortalityindevelopingcountriesare Prematurity Infection Birthasphyxia

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESSTILLBIRTH:Birthofanewbornafter28thcompleted

week,weighing1000gmormore,whenthebabydoesnotbreatheorshowanysignoflifeafterdelivery,bothantepartum(macerated)andintrapartum(freshstillbirths)deathsincluded

PREVENTIONOFSTILLBIRTHANDNEONATALDEATHS: Skillledattendantatbirth,effectivemanagementofobstetric

complications Prepregancycare,effectivemanagementofpregnancy

complications Preconceptionalgeneticcounselling,prenataldiagnosis Effectivecareduringpregnancyandlabour.Cleandelivery

PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESPERINATALMORTALITY:Deathamongfoetusesweighing1000gmsormoreatbirth(28wksgestation)whodiebeforeorduringdeliveryorwithinfirst7daysofdelivery

PNMRofIndiaisabout60per1000totalbirthstobereducedto3035/1000births

CAUSES:PrematurityLowbirthweightBirthasphyxiaInfectionsCongenitalmalformationsBirthtraumaRespiratorydistresssyndrome

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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESPREVENTIONOFPERINATALMORTALITY: Prepregnancyhealthcareandcounseling Geneticcounseling RegularANCDetection&managementofmedicaldisordersinpregnancy Screeningofhighriskpatients Carefulmonitoringinlabour Skilledbirthattendant ProvisionofreferralneonatalserviceHealthcareeducationofthemotheraboutthecareofthe

newborn Educatingthecommunitytoutilizefamilyplanningservices Autopsystudiesofallperinataldeaths Continuedstudyofperinatalmortalityproblems

ANTEPARTUMFOETALSURVEILLANCEMETHODSUSEDTODETECT&EVALUATETHESEVERITYOFACUTEORCHRONICFOETALHYPOXIAAREBIOPHYSICALINNATUREFoetalmovementcountThenonstresstest(NST)Thecontractionstresstest(CST)Thefoetalbiophysicalprofile(BPP)Themodifiedbiophysicalprofile(MBPP)Umbilical,cerebral,uterine,andvenousDopplerPercutaneousumbilicalbloodsampling

ANTEPARTUMFOETALSURVEILLANCEFOETALMOVEMENTCOUNT: Simplestandleastcostlymethodfortheevaluationoffoetal

wellbeinginthesecondhalfofpregnancy Cardif`count10formula:Patientcountsfoetalmovements

startingat9amandcountendsassoonas10movementsperceived.Sheisinstructedtoreportiflessthan10movementsoccurduring12hourson2successivedaysorifnomovementsperceivedevenafter12hoursinasingleday.

Dailyfoetalmovementcount(DFMC):3countseachof1hourduration(morning,noon,evening)arerecommended.Totalcountmultipliedby4givesDFMC.If

ANTEPARTUMFOETALSURVEILLANCENONSTRESSTEST(NST):ACONTINUOUSELECTRONICMONITORINGOFTHEFOETALHEARTRATEALONGWITHRECORDINGOFFOETALMOVEMENTS

ThetestlooksforthepresenceoftemporaryaccelerationsofFHRassociatedwithfoetalmovement.

Foetalsleep&foetalhypoxiaarethemostcommonphysiologic&pathologicconditionsrespectivelyforabsenceofaccelerationsduringaNST.

ANTEPARTUMFOETALSURVEILLANCEREACTIVENST(normal):TwoormoreFHRaccelerationsofatleast15beatsperminute&lastingatleast15secondsfrombaselinetobaselinewithina20minuteperiodwithorwithoutassociationwithfoetalmovementsasperceivedbythewoman

NONREACTIVENST:Lackofaccelerationsforaperiodof40minutes

VariablesevaluatedinNST:BaselineFHRVariabilityofFHRPresenceorabsenceofaccelerationsPresenceorabsenceofdecelerations

REACTIVENST

ANTEPARTUMFOETALSURVEILLANCENSTVARIABLES:AnormalbaselineFHRisbetween110&160bpmFHRvariabilityisofutmostimportance&dependsontheinteractionofthefoetalsympathetic&parasympatheticnervoussystemsPresenceofaccelerationsofFHRwithfoetalmovementsorinresponsetofoetalstimulationisreliablesignoffoetalhealthThepresenceofspontaneousseverevariableorlatedecelerationsisworrisome,indicatingfoetalcompromise

ANTEPARTUMFOETALSURVEILLANCECONTRACTIONSTRESSTEST:TestbasedonexperimentalevidencesthattheuteroplacentalbloodflowdecreasesmarkedlyorceasesduringuterinecontractionsTheendpointoftheCSTisthepresenceorabsenceoflatedecelerationsoftheFHRfollowinguterinecontractionsLatedecelerationsareoneoftheearliestindicatorsoffoetalcompromiseCSTusedinfrequently,rathermostcommonlyusedtofollowanonreactiveNST

ANTEPARTUMFOETALSURVEILLANCETHEBIOPHYSICALPROFILE:CombinestheNSTwiththeobservationbyultrasoundoffourvariables:

foetalbreathingmovementsfoetalbodymovementsfoetaltoneamnioticfluidvolume

ANTEPARTUMFOETALSURVEILLANCE(BPP)Foetalbreathingmovement:thirtysecondsofsustainedbreathingmovementduringa30

minuteobservationperiodFoetalmovement:threeormoregrossbodymovementsina30minute

observationperiodFoetaltone:oneormoreepisodesoflimbmotionfromapositionofflexion

toextension&arapidreturntoflexionFoetalheartratereactivity:Twoormorefoetalheartrateaccelerationsassociatedwith

foetalmovementofatleast15bpm&lastingatleast15secondsin10minutes(reactiveNST)

Fluidvolume:Presenceofapocketofamnioticfluidthatmeasuresatleast2

cmintwoperpendicularplanes

ANTEPARTUMFOETALSURVEILLANCE(BPP)EachofthefivecomponentsoftheBPPassignedanumericalvalueof2(ifpresentornormal)or0(ifabsentorabnormal)Avalueof8or10indicatesanormalorreassuringfoetalstatusAscoreof6isequivocal,requiresfurthertesttoverifyfoetalwellbeingAscoreof4orlessissuggestiveoffoetalcompromise

ANTEPARTUMFOETALSURVEILLANCE(MODIFIEDBPP)

COMBINESTHEOBSERVATIONOFANINDEXOFACUTEFOETALHYPOXIA,

THENSTWITHVAST,WITHASECONDINDEXINDICATIVEOFCHRONICFOETALPROBLEMS,THEAMNIOTICFLUIDVOLUME

ANTEPARTUMFOETALSURVEILLANCE(DOPPLERULTRASOUNDVELOCIMETRY)

EVALUATIONOFFOETALCIRCULATIONBASEDONTHEPHYSICALPRINCIPLEOFCHANGEINFREQUENCYOFSOUNDWAVEWHENITISREFLECTEDBYAMOVINGOBJECT

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ANTEPARTUMFOETALSURVEILLANCE(DOPPLERULTRASOUNDVELOCIMETRY)

ARTERIALDOPPLER:Waveformshelpfultoassessthedownstreamvascularresistance Usedtomeasurepeaksystolic(S),peakdiastolic(D)&mean(M)

volumesfromwhichS/DratioPulsatalityindex(PI)[PI=(SD/M]Resistanceindex(RI)[RI=(SD/S] InanormalpregnancytheS/Dratio,PI&RIdecreasesasthe

gestationalageadvancesHighervaluesgreaterthan2SDsabovethegestationalage

meanindicatesreduceddiastolicvelocities&increasedplacentalvascularresistanceindicatingadversepregnancyoutcome.

THREESTUDIESOFFOETALUMBILICALARTERYVELOCIMETRY

ANTEPARTUMFOETALSURVEILLANCE(DOPPLERULTRASOUNDVELOCIMETRY)

VENOUSDOPPLER:Provideinformationaboutcardiacforwardfunction(cardiaccompliance,contractility&afterload)FoetuseswithabnormalcardiacfunctionshowpulasatileflowintheumbilicalveinNormalUVflowismonophasic

ANTEPARTUMFOETALSURVEILLANCEFOETALBLOODSAMPLING(CORDOCENTESIS)PercutaneousUmbilicalBloodSamplingorCordocentesisEasilyperformedafter24weeks,butcanbedoneasearlyas18weekstooPlacentalinsertionsitepreferredRequireshighresolutionultrasoundequipmentMainrisksarebleedingfrompuncturesiteandvagalreflexcausingseverefoetalbradycardiaUsedeclinedwithdevelopmentoflessinvasivetechnologyforfoetaldiagnosis

GOI,SAFEMOTHERHOODPROGRAMME(CSSM)ESSENTIALOBSTETRICCAREFORALLINCLUDES:Registrationbetween1216weeksAntenatalvisits(minimumthree)at16,28,and38weeksgestationDocumentBP,Wt,&obstetricexaminationfindingsateachvisitMandatoryinvestigationsincludeHb%,ABO&Rhtype,urineprotein&sugar,stools,postprandialsugarMedications:oraliron,folicacid,anddewormingagentsafter16weeksgestation

GOI,SAFEMOTHERHOODPROGRAMME(CSSM)Tetanustoxoidinjection,twodoses/46weeksapartTimelyreferenceforemergencyobstetriccareUseofcleanpregnancykitforconductingdeliveryTheaimwastoprovidetheANMs/skilledbirthattendantstoconductsafedeliveryunderhygienicsurroundingstominimizematernaldeathsinruralsettings.

THANKYOU