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
Drug addiction and
age below 16 or over 35 alcohol abuse
years Pyelonephritis,pneumonia
Low socioecomonic status Multiple gestation
Maternal weight below Anemia
50Kg Abnormal fetal
Poor nutrition presentation
Previous preterm birth Preterm rupture of
membranes
Incomplete cervix
Placental abnormalities
Uterine amonalies infection
Smoking
General
consideration
Risk factors related to specific pregnancy problems
polyhydramnios oligohydramnios
diabetes mellitus renal agenesis
Moutiple gestation Rolonged rupture of
Fetal congenital membranes
abnormalities Intrauterine growth
Isoimmunization(Rh or ABO) restriction
Nonimmune hydrops Intrauterine fetal
Abnormal fetal presentation demise
General
consideration
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
