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High risk pregnancy

  1. 1. 1Copyright © 2014 Paras Hospitals. All rights reserved. High Risk Pregnancy Care Dr Nupur Gupta Department of Obstetrics & Gynecology Paras Hospitals, Gurgaon At Bournhall Clinic Gurgaon 8 March 2017
  2. 2. 2Copyright © 2014 Paras Hospitals. All rights reserved. High Risk Pregnancy  Is a pregnancy complicated by a disease or disorder that may endanger the life, or affect the health of the mother, the fetus or newborn
  3. 3. 3Copyright © 2014 Paras Hospitals. All rights reserved. High Risk Pregnancy  Bad obstetrics history (previous recurrent miscarriages or preterm deliveries)  Heart disease  Hypertension or preeclampsia (essential, renal or pregnancy induced)  Diabetes (IDDM/NIDDM)  Severe anemia  Twins or triplets
  4. 4. 4Copyright © 2014 Paras Hospitals. All rights reserved. High Risk Pregnancy  Placental abruption  Threatened preterm labour  Haemolytic anemia  Thrombocytopenia or megaloblastic anemia  Bleeding disorders  Thalassemia  History of thrombosis or thrombophilias
  5. 5. 5Copyright © 2014 Paras Hospitals. All rights reserved. High Risk Pregnancy  History of neurological disease (epilepsy, brain haemorrhage, or tumor)  Malignancy (cervical, ovarian or breast)  Antiphospholipid syndrome  Cervical incompetence (elective or emergency)  Fibroid uterus  Congenital malformations that can survive
  6. 6. 6Copyright © 2014 Paras Hospitals. All rights reserved. High Risk Labour  Preterm labour  Previous Caesarean  CPD  Prolonged labour  Obstructed labour  Shoulder dystocia  Retained placenta  Inversion of uterus  Rupture uterus  Perineal tear
  7. 7. 7Copyright © 2014 Paras Hospitals. All rights reserved. 7 Emergency Obstetric Care To Avert Death and Disability… …We Need to Ensure that Women have
  8. 8. 8Copyright © 2014 Paras Hospitals. All rights reserved. What is an Obstetric emergency?  A suddenly developing pathologic condition in a patient, due to accident or disease, which requires urgent medical or surgical therapeutic intervention There are 2 patients; fetus is very vulnerable to maternal hypoxia
  9. 9. 9Copyright © 2014 Paras Hospitals. All rights reserved. But we do know that of any population of pregnant women at least 15% will experience an obstetric complication … How Do We Know Which Women Will Experience Complications? WE DON’T
  10. 10. 10Copyright © 2014 Paras Hospitals. All rights reserved.
  11. 11. 11Copyright © 2014 Paras Hospitals. All rights reserved. Obstetric Emergencies  Maternal  Fetal  Both maternal & fetal High Mortality rate
  12. 12. 12Copyright © 2014 Paras Hospitals. All rights reserved. Maternal Complications of Pregnancy First Trimester Second Trimester Third Trimester
  13. 13. 13Copyright © 2014 Paras Hospitals. All rights reserved. First Trimester 1. Ectopic pregnancy 2. Abortion 3. Molar Pregnancy 4. Uterine rupture Second Trimester 1. Abortion 2. Cervical Incompetence Third Trimester 1. Placenta Praevia 2. Placenta Accreta 3. PPH 4. Uterine rupture 5. Inversion 6. Hypertensive crisis
  14. 14. 14Copyright © 2014 Paras Hospitals. All rights reserved. OUR EXPERIENCE
  15. 15. 15Copyright © 2014 Paras Hospitals. All rights reserved. SAVING LIVES in Life Threatening Emergencies  Intractable PPH  Rudimentary Horn Rupture – 2 cases  Uncontrolled diabetes with pregnancy  Inevitable abortion, ectopic,  Heterotopic pregnancy – 2 cases  Retained placenta accreta  Uterine AVM – UAE, 2 cases
  16. 16. 16Copyright © 2014 Paras Hospitals. All rights reserved. SOLVING DIFFICULT CASES  Second trimester twin with malformed foetus at 20 wks  PUPPP in third trimester of pregnancy  Brain tumor with pregnancy  Subarachnoid haemorrhage with pregnancy  Twisted ovarian cyst with acute abdomen  Torsion of ovarian tumor with acute abdomen
  17. 17. 17Copyright © 2014 Paras Hospitals. All rights reserved. G2A1 with 25 weeks+4 days POG with thrombocytopenia with GDM with pre-eclampsia with amegakaryocytic anemia with HELLP Syndrome
  18. 18. 18Copyright © 2014 Paras Hospitals. All rights reserved. Admitting Complaints  Amenorrhea 25 weeks 3 days  Pain lower abdomen since 30 days  Increased frequency of micturition 15-20 days  Loose stool since 1 day  Abdominal distension Obstetric History – G2A1  G1-Spontaneous Abortion - D&C, 2013  G2- Present Pregnancy
  19. 19. 19Copyright © 2014 Paras Hospitals. All rights reserved. Past History  GDM  Thrombocytopenia Family History  Father-Diabetic
  20. 20. 20Copyright © 2014 Paras Hospitals. All rights reserved. Course In the Hospital  LFT, KFT were deranged  Platelet Count-14000, Uric acid-7.1, hb-7.7.  BP was persistently high.  Patient shifted to ICU on 14/9/2014.  Labetolol & MgSo4 infusion was given.  Patient reviewed with hematologist, Neurologist, Endocrinologist, opthalmologist, nephrologist, Physician
  21. 21. 21Copyright © 2014 Paras Hospitals. All rights reserved. Course in Hospital…..  Steroid given in view of Thrombocytopenia.  Decision taken for termination of pregnancy in view of kidney deterioration, HELLP Syndrome & uncontrolled blood pressure.  Emergency LSCS done under GA on 20.9.14 Per-op findings  100-200cc ascitis  Bilateral tubes & ovaries normal  Baby shifted to NICU
  22. 22. 22Copyright © 2014 Paras Hospitals. All rights reserved. POST OP PERIOD  She was given Inj Mgso4, labetalol, monocef in post op period  She was discharged on day 5th of post-op period with following medication advised on discharge  Tab Dapsone 1 tab od  Tab Revolade 50 mg once daily  Tab Texid, tab Amlodipine, tab dexamethasone 12 mg od, tab ultracet tds
  23. 23. 23Copyright © 2014 Paras Hospitals. All rights reserved. After a long struggle……
  24. 24. 24Copyright © 2014 Paras Hospitals. All rights reserved. Chronic Right Sided Ruptured Tubal Ectopic Pregnancy (Heterotopic)
  25. 25. 25Copyright © 2014 Paras Hospitals. All rights reserved. Admitting Complaints  24 year old P2L2  Spasmodic Pain in Right sided lower abdomen associated with spotting per vaginum since one month  Irregular bleeding off and on
  26. 26. 26Copyright © 2014 Paras Hospitals. All rights reserved. Investigations Serum Beta HCG  Day 1 - 357.31 mIU/ml  Day 2 - 90.16 mIU/ml
  27. 27. 27Copyright © 2014 Paras Hospitals. All rights reserved. CECT whole abdomen (12.11.14) Day 1  Heterogenous mass collection in right adnexa
  28. 28. 28Copyright © 2014 Paras Hospitals. All rights reserved. Management  Patient was taken up for diagnostic laparoscopy followed by right sided salpingectomy + peritoneal lavage + D&C under GA
  29. 29. 29Copyright © 2014 Paras Hospitals. All rights reserved. Intra-op findings  Right sided tubal mass S/o ruptured ectopic pregnancy  Salpingectomy done & sent for HPE  Organised Blood in POD  Small bowel adherent to posterior wall of uterus, adhesiolysis done  Left tube & ovary normal, RO normal  Endometrial curettings sent for HPE
  30. 30. 30Copyright © 2014 Paras Hospitals. All rights reserved. Large Cervical Fibroid with extension into broad ligament Urology Team supported us by intraoperative bilateral ureteric catheterisation
  31. 31. 31Copyright © 2014 Paras Hospitals. All rights reserved.  Managed by laparoscopy & hysteroscopy - GI surgeons as there was perforation peritonitis and dense bowel adhesions Misplaced & Lost IUCD thread after postplacental insertion 3 years back during LSCS
  32. 32. 32Copyright © 2014 Paras Hospitals. All rights reserved. One crore compensation
  33. 33. 33Copyright © 2014 Paras Hospitals. All rights reserved. 33 Maternal Death
  34. 34. 34Copyright © 2014 Paras Hospitals. All rights reserved. Doctors suspended for maternal mortality
  35. 35. 35Copyright © 2014 Paras Hospitals. All rights reserved. Controversy continues on rising Caesarean Rates 24.2.17
  36. 36. 36Copyright © 2014 Paras Hospitals. All rights reserved. High Risk Obstetric Care  There are no absolute rules of management  Lay public - that modern reproductive research eliminates all the risks & hazards associated with childbirths  Therefore only 100% healthy babies are accepted  Pregnancy is regarded as a 'success story' and if the baby is born with neurological defects (cerebral palsy) the parents & their advisors feel, that someone responsible for the defect should be found in the chain of management EJOGRB 1997 Feb;71(2):181-5. High-risk obstetrics, medicolegal problems.
  37. 37. 37Copyright © 2014 Paras Hospitals. All rights reserved.  This attitude starts a legal battle focusing on the events of labor and delivery  But in most cases it is very difficult to determine if a peripartal neonatal encephalopathy originated from the time period of labor and delivery, or started weeks earlier during pregnancy as an unnoticed event.  Perinatal morbidity indicators are best based on neonatal clinical signs, which are predictive of later morbidity of the child. Neonatal seizures within 48 h of delivery of the baby could be a good index of later morbidity. High Risk Obstetric Care
  38. 38. 38Copyright © 2014 Paras Hospitals. All rights reserved.  Our Team (Senior Residents & Labour room staff)  Facility of blood transfusion  Multispeciality backup  ICU – Medical, Surgical, Neurological, Neurosurgical, Cardiac, CTVS  Neonatal ICU {NICU}, Paediatric ICU {PICU} OUR USP
  39. 39. 39Copyright © 2014 Paras Hospitals. All rights reserved. 39 Thank you

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