high risk pregnancy - identification and management
TRANSCRIPT
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HIGH RISK PREGNANCY
IDENTIFICATION
MANAGEMENT
&
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One which is complicated by factor or factors that adversely affects the pregnancy outcome-maternal / perinatal / both.
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• 25% OF PREGNANCIES BELONG TO THIS CATEGORY
• FORMS 75% OF PERINATAL MORTALITY & MORBIDITY– >50% OF ALL MATERNAL COMPLICATIONS
&• >60% OF ALL PRIMARY CAESAREAN
SECTIONS ARISE FROM HIGH RISK GROUP
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SCREENING -HIGHRISK CASESHISTORY
• $ MATERNAL AGE :RISK- <17 YRS
- >35YRS - PRIMI >30YRS- FOLLOWING LONG
PERIODS OF INFERTILITY- AFTER INDUCTION OF
OVULATIONSAFE- 20 - 29YRS
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REPRODUCTIVE HISTORY
• LOWEST RISK: 2nd & 3nd pregnancy following 1st normal pregnancy.
• HIGHRISK FACTORS:− 2 or more previous / induced abortions− previous stillbirths / neonatal deaths − previous preterm labour / SFD / LFD− grand multiparity− previous c/s− anaemia / preeclampsia / eclampsia− previous infant-Rh isoimmunisation
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MEDICAL & SURGICAL HISTORY
• Pulm dis / TB• Renal dis /
pyelonephritis• DM• Cardiac disease• Thyroid disease• Epilepsy
• Myomectomy• Repair of VVF• Repair of complete
perineal tear • Repair of stress
incontinence
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FAMILY HISTORY
• H/o T.B. / B.A / H.T / D.M / Heart Disease
• SOCIO ECONOMIC STATUSPoor Family - � Anaemia
Pre term labourIUGR
Working Women - � Abortionpremature labour
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EXAMINATION
• GENERAL– HEIGHT : < 150 cm / < 145 cm (India)– WEIGHT : Overweight / underweight
Accepted BMI (Wt/ht 2) 19.8 – 26
– BLOOD PRESSURE– ANAEMIA– CARDIAC / PULMONARY DISEASE – ORTHOPEDIC PROBLEMS
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PELVIC EXAMINATION
• UTERINE SIZE – DISPROPOTIONATE SMALLER OR BIGGER
• GENITAL PROLAPSE• LACERATION / DILATATION OF Cx• ASSOCIATED TUMOURS• PELVIC INADEQUACY
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COURSE OF PRESENT PREGNACY
• REASSESSMENT AT EACH ANTENATAL VISIT
• TO DETECT ANY ABNORMALITIES LIKE - Anaemia - Post maturity- Preeclampsia - twins- Diabetes - Abnormal presentation- IUGR - Acute surgical problem
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DURING LABOUR
• REASSESSMENT ESSENTIAL DURING LATE PREGNANCY & LABOUR
• AT HIGH RISK (MOTHER OR BABY)– Intrapartum fetal distress– Need for delivery under GA– Difficult forceps / breech delivery– PPH or retained placenta
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POST PARTUM COMPLICATIONS
• NOTE : AN UNEVENTFUL LABOURMAY TURN INTO AN ABNORMAL ONE IN THE FORM OF - PPH- Retained placenta- Shock- Inversion- Sepsis
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NEONATE - HIGH RISK
• APGAR SCORE <7• BIRTH WT. <2.5 Kg
or / > 4 kg• MAJOR CONGENITAL
ABNORMALITY• ANAEMIA• FETAL INFECTION• JAUNDICE
• HYPOGLYCEMIA• PERSISTANT
CYANOSIS• CONVULSIONS• HAEMORRAGHIC
DIATHESIS• RDS
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MANAGEMENT OF HIGH RISK CASES
• Medical Officer of health centres should decide what type of cases can be managed at home or health centers
• Cases with significant risk – referred to specialised referral centre
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ORGANISATIONAL ASPECT
• Proper TRAINING of resident, nursing personnel and community health workers.
• Arranging PERIODIC SEMINARS with participation of workers involved in care of these cases.
• CONCENTRATION of cases in specialized centres for management
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• Proper UTILISATION of health care manpower and financial resource where it is mostly needed.
• Availability of perinatal LABORATORYfor necessary investigations
• Availability of good PAEDIATRICservices for neonates
• Lastly, improvement of STANDARD of health of obstetric population and HEALTH EDUCATION of the community.
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INVESTIGATIONS
• IN NON PREGNANT STATE :Complete investigation for
- Hypertension- Kidney diseases- Thyroid disorders
• IN PREVIOUS UNSUCCESSFUL PREGNANCIES:- Transvaginal ultrasound- HSG - Hysteroscopy- Laparoscopy
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TREATMENT
• Prepregnant state - Start on folic acid- Continue throughout pregnancy
• Necessary inv. (routine & special). & examination
• Advice - Rest and activities- diet- medicines
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ASSESSMENT OF MATERNAL AND FETAL WELL BEING
• DONE AT EACH ANTENATAL VISIT
• Patient with H/O previous 1st trimester abortion - Advice rest
- Avoid journey (early pregnancy)- Restrain sexual intercourse- Avoid vaginal examination
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• Patient with cervix incompetence- do bimanual examn. (II trimester)- do Cx encirclage at appropriate time
• Patient with - premature labour requires prolonged
- unexplained still birth BED REST in - IUGR etc., hospital
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DURING LABOUR
• High risk case - Caesarean section- Induction at 37 -3 8 wks• Those with spontaneous labour or after
induction - Requires close monitoring- For assessment of progress or any
evidence of fetal distress.
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ASSESSMENT OF FETAL CONDITION
• Fetal heart rate monitoring
• Passage of meconium in the liquour in presentation other than breech
• Examn. Of fetal scalp blood pH.
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IF EVIDENCE OF FETAL ANOXIA IN FIRST STAGE
(OR)FAILURE TO PROGRESS
CAESAREAN SECTIONASSESS NEONATE IMMEDIATELY
NEEDS EXPERT NEONATAL CARE
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ed;wp