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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
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
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
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
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
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
7Copyright © 2014 Paras Hospitals. All rights reserved. 7
Emergency
Obstetric Care
To Avert Death and Disability…
…We Need to Ensure that Women have
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
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
10Copyright © 2014 Paras Hospitals. All rights reserved.
11Copyright © 2014 Paras Hospitals. All rights reserved.
Obstetric Emergencies
 Maternal
 Fetal
 Both maternal & fetal
High Mortality rate
12Copyright © 2014 Paras Hospitals. All rights reserved.
Maternal Complications of
Pregnancy
First Trimester
Second Trimester
Third Trimester
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
14Copyright © 2014 Paras Hospitals. All rights reserved.
OUR EXPERIENCE
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
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
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
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
19Copyright © 2014 Paras Hospitals. All rights reserved.
Past History
 GDM
 Thrombocytopenia
Family History
 Father-Diabetic
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
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
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
23Copyright © 2014 Paras Hospitals. All rights reserved.
After a long struggle……
24Copyright © 2014 Paras Hospitals. All rights reserved.
Chronic Right Sided Ruptured Tubal Ectopic
Pregnancy (Heterotopic)
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
26Copyright © 2014 Paras Hospitals. All rights reserved.
Investigations
Serum Beta HCG
 Day 1 - 357.31 mIU/ml
 Day 2 - 90.16 mIU/ml
27Copyright © 2014 Paras Hospitals. All rights reserved.
CECT whole abdomen (12.11.14) Day 1
 Heterogenous mass collection in right adnexa
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
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
30Copyright © 2014 Paras Hospitals. All rights reserved.
Large Cervical Fibroid with extension
into broad ligament
Urology Team
supported us by
intraoperative
bilateral ureteric
catheterisation
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
32Copyright © 2014 Paras Hospitals. All rights reserved.
One crore compensation
33Copyright © 2014 Paras Hospitals. All rights reserved. 33
Maternal Death
34Copyright © 2014 Paras Hospitals. All rights reserved.
Doctors suspended for maternal mortality
35Copyright © 2014 Paras Hospitals. All rights reserved.
Controversy continues on rising
Caesarean Rates 24.2.17
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.
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
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
39Copyright © 2014 Paras Hospitals. All rights reserved. 39
Thank you

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High risk pregnancy

  • 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. 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. 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. 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. 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. 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. 7Copyright © 2014 Paras Hospitals. All rights reserved. 7 Emergency Obstetric Care To Avert Death and Disability… …We Need to Ensure that Women have
  • 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. 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. 10Copyright © 2014 Paras Hospitals. All rights reserved.
  • 11. 11Copyright © 2014 Paras Hospitals. All rights reserved. Obstetric Emergencies  Maternal  Fetal  Both maternal & fetal High Mortality rate
  • 12. 12Copyright © 2014 Paras Hospitals. All rights reserved. Maternal Complications of Pregnancy First Trimester Second Trimester Third Trimester
  • 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. 14Copyright © 2014 Paras Hospitals. All rights reserved. OUR EXPERIENCE
  • 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. 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. 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. 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. 19Copyright © 2014 Paras Hospitals. All rights reserved. Past History  GDM  Thrombocytopenia Family History  Father-Diabetic
  • 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. 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. 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. 23Copyright © 2014 Paras Hospitals. All rights reserved. After a long struggle……
  • 24. 24Copyright © 2014 Paras Hospitals. All rights reserved. Chronic Right Sided Ruptured Tubal Ectopic Pregnancy (Heterotopic)
  • 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. 26Copyright © 2014 Paras Hospitals. All rights reserved. Investigations Serum Beta HCG  Day 1 - 357.31 mIU/ml  Day 2 - 90.16 mIU/ml
  • 27. 27Copyright © 2014 Paras Hospitals. All rights reserved. CECT whole abdomen (12.11.14) Day 1  Heterogenous mass collection in right adnexa
  • 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. 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. 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. 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. 32Copyright © 2014 Paras Hospitals. All rights reserved. One crore compensation
  • 33. 33Copyright © 2014 Paras Hospitals. All rights reserved. 33 Maternal Death
  • 34. 34Copyright © 2014 Paras Hospitals. All rights reserved. Doctors suspended for maternal mortality
  • 35. 35Copyright © 2014 Paras Hospitals. All rights reserved. Controversy continues on rising Caesarean Rates 24.2.17
  • 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. 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. 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. 39Copyright © 2014 Paras Hospitals. All rights reserved. 39 Thank you