High risk pregnancy

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

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

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

High Risk Pregnancy
 Placental abruption
 Threatened preterm labour
 Haemolytic anemia
 Thrombocytopenia or megaloblastic anemia
 Bleeding disorders
 Thalassemia
 History of thrombosis or thrombophilias

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

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

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

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

Obstetric Emergencies
 Maternal
 Fetal
 Both maternal & fetal
High Mortality rate

Maternal Complications of
Pregnancy
First Trimester
Second Trimester
Third Trimester

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

OUR EXPERIENCE

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

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

G2A1 with 25 weeks+4 days POG with
thrombocytopenia with GDM with pre-eclampsia
with amegakaryocytic anemia with HELLP
Syndrome

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

Past History
 GDM
 Thrombocytopenia
Family History
 Father-Diabetic

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

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

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

After a long struggle……

Chronic Right Sided Ruptured Tubal Ectopic
Pregnancy (Heterotopic)

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

Investigations
Serum Beta HCG
 Day 1 - 357.31 mIU/ml
 Day 2 - 90.16 mIU/ml

CECT whole abdomen (12.11.14) Day 1
 Heterogenous mass collection in right adnexa

Management
 Patient was taken up for diagnostic laparoscopy
followed by right sided salpingectomy + peritoneal
lavage + D&C under GA

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

Large Cervical Fibroid with extension
into broad ligament
Urology Team
supported us by
intraoperative
bilateral ureteric
catheterisation

 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

One crore compensation

Maternal Death

Doctors suspended for maternal mortality

Controversy continues on rising
Caesarean Rates 24.2.17

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.

 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

 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

Thank you

High risk pregnancy

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