If you can't read please download the document
Upload
truongxuyen
View
226
Download
3
Embed Size (px)
Citation preview
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
th
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¶sympatheticnervoussystemsPresenceofaccelerationsofFHRwithfoetalmovementsorinresponsetofoetalstimulationisreliablesignoffoetalhealthThepresenceofspontaneousseverevariableorlatedecelerationsisworrisome,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
58
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