High Risk Pregnancies

Objectives
 Discuss PIH, pre-eclampsia & eclampsia

 Review the management of PIH, pre-eclampsia & eclampsia

 Discuss GDM & its management

 Discuss abortion ,its type and management

 Discuss the role of community health care providers

Introduction
 Chronic hypertension: hypertension present
at the booking visit or before 20 weeks.

 Gestational hypertension/PIH: hypertension

presenting after 20 weeks of gestation
without significant proteinuria.

 Pre-eclampsia: hypertension presenting after 20

weeks of gestation with significant proteinuria.

 Eclampsia: is a convulsive condition

associated with pre-eclampsia.
(NICE, 2011)
Classification of Hypertension
 Mild hypertension: diastolic blood pressure 90–99 mmHg,
systolic blood pressure140–149 mmHg.

 Moderate hypertension: diastolic blood pressure 100–109

mmHg, systolic blood pressure150–159 mmHg.

 Severe hypertension: diastolic blood pressure 110 mmHg or

greater, systolic blood pressure 160 mmHg or greater.

(NICE, 2011)
Classification of Protein urea
Mild Pre-eclampsia:
 Protein up to 2+
 An excretion of 0.3 g (300mg) protein/24
hours

Severe Pre-eclampsia: protein 3+ or more

 Risk Factors
• First pregnancy
• Age ≥ 40 years
• Previous pre-eclampsia
• Body mass index ≥ 35
• Family history of pre-eclampsia
• Booking diastolic blood pressure ≥ 80 mm Hg
• Proteinuria at booking (≥ 300 mg/24 h)
• Multiple pregnancy
• Underlying medical conditions:
– Pre-existing hypertension, renal disease, diabetes,
presence of anti-phospholipid antibodies
Clinical features
• History
– Usually asymptomatic
– Headache
– Drowsiness
– Visual disturbance
– Nausea & vomiting
– Epigastric pain
– Decrease urinary output
– Decreased fetal movement

• Examination
– Oedema (hands and face)
– Proteinuria on dipstick
– Epigastric tenderness (liver
involvement)
 Management of PIH
Aim of care is to have safe delivery at term
• Rest, lying left side to ensure ample fetal blood supply
• Ensure regular pre-natal visits
• Progress of gestation:
• Any abdominal discomfort
• PV bleeding (placenta abruptio--- separation of
placenta before term; painless bleeding occur)
• BP monitoring
• Fetal assessment
• Fluid intake
• Urine test for creatinine and protein
Medical Management of PIH 9

 Anti hypertensive therapy

 Steroids, to reduce the risk of neonatal respiratory distress

by increasing production of surfactant

 Aspirin, to inhibit the production of thromboxane

(Platelet Aggregating Agent)
Pre-Eclampsia Toxemia (PET) Profile
• Liver Function Test (LFTs)
• Platelets
• PT/APTT
• Uric Acid
• Creatinine

Fetal:
– Ultrasound
• FHS, Fetal size/growth, amniotic fluid volume, doppler scan ---umbilical cord
blood flow
– CTG
Management
**Remember: No cure except delivery

• Anti-hypertensives:
– Methyldopa (Aldomat, Adalat)
– Labetalol **(Avoid beta blocker in asthmatics)
– Nifedipine

• In case of eclampsia:
– Magnesium sulphate --- Anti-convulsant
**Calcium gluconate --- antidote

• Induction of labour:
– Ensure to administer antenatal steroids (inj.
Dexamethasone)
Management; Mild Preeclampsia (PET)
 Bed Rest, only bathroom privilege
 Rest in left lateral ( ↓pressure to venacava--↑cadiac return--↑ perfusion to
vital organs ↑ blood to kidneys --↓ angiotensin – diuresis-- low BP)
 Keep calm and quite
 Restrict visitors

 Diet
 Protein diet (1.5g / kg ) to replace loss in urine
 High fiber to avoid constipation

 Monitor Fetal Activity

 Kick chart --- note fetal movement every hour (approx. ten kicks in any
twelve hour period)
Management; Severe Preeclampsia

 Anti-hypertensive (hydralazine)

 Sedative
 Diazepam (fetal addiction)

 Anticonvulsants
 MgSO4: blocks the neuromuscular transmission by reducing
acetylcholine and causing the Smooth Muscle relaxation (Safe
for fetus)
Eclampsia 1
4

Characterized by: grand mal seizures & coma

 Tonic clonic form of convulsion

 Tonic stage: (10-20 seconds) muscle spasms and rigid teeth,

clenched, eye staring

 Clonic stage: (1 minute) violent contraction

and intermittent, relaxation, salivation increase and foaming,
tongue bite

 Stage of coma: noisy breathing with unconsciousness

Signs of MgSO4 Toxicity
• Respiratory Rate ≤ 12

• Decreased deep tendon reflexes, sluggish patellar

reflex

• Urine output < 30ml/hour

**Immediately stop MgSO4, administer

“calcium gluconate”
 Maternal Complications
• Head/brain
– Eclampsia, Stroke/ cerebrovascular haemorrhage
• Heart
– Heart failure
• Lung
– Pulmonary oedema, bronchial aspiration, ARDS
• Liver
– Hepatocellular injury, liver failure, liver rupture
• Kidneys
– Renal failure, oliguria
• Vascular
– Uncontrolled hypertension, DIC
– HELLP syndrome (haemolysis, elevated liver enzymes and low platelets)
(RCOG, 2010)
 Fetal Complications
 IUGR

 Oligo-hydramnios

 Placental infarction

 Placental abruption --- painless bleeding, often fetal parts

non-palpable

 Utero-placental insufficiency

 Prematurity
GESTATIONAL DIABETES
MELLITUS

• This is defined as carbohydrate intolerance resulting

in hyperglycemia

• Among all pregnancies 65% cases are involved in

gestational diabetes

• Onset during pregnancy, usually in second and third trimester

(Fraser & Cooper, 2014)

Cause
Hormones from the placenta (HPL, progesterone, cortisol) block
the action of the mother's insulin in her body (insulin
resistance)

Insulin resistance makes it hard for the mother's body to use

insulin

GDM starts when body is not able to make & use all the insulin

Without enough insulin, glucose cannot leave the blood and be

changed to energy

hyperglycemia
Diagnosis
 Monitor for cardinal signs of diabetes, increased thirst
(polydipsia), increased urine volume (polyuria),
increased hunger (polyphagia), unexplained weight
loss

 OGTT should always be used to diagnose GDM at 28

weeks of gestation, but if the client is at a greater risk then
can be done at 20 – 24 weeks
Risk factors for GDM
 Increased maternal age and weight

 Previous GDM

 Previous macrosomic infant

 Family history of diabetes

Maternal complications
 Obstetric complications
– Polyhydramnios (increased volume of amniotic fluid)
– Pre-eclampsia
 Diabetic emergency
– Hypoglycemia
– Ketoacidosis
– Diabetic coma
 Vascular and organ involvement (cardiac,
renal, ophthalmic, and peripheral vascular)
 Neurologic (peripheral neuropathy)
 Infection (antepartum and postpartum)
Fetal complications
 Spontaneous abortion

 Premature labor and delivery (premature preterm rupture of

the membrane, PPROM)

 Unexplained intrauterine fetal demise and stillbirth

 Macrosomia with traumatic delivery such as cesarean section

and shoulder dystocia

 Delayed organ maturity (lung)

 Congenital anomalies

 IUGR
Pre-pregnancy Care
 History

 Contraceptive advice

 Risks of pregnancy (maternal and

fetal/neonatal)

 Importance of maintaining blood glucose levels

 FBS, RBS, HbA1c levels

 Nutritional and dietary advice

Antenatal Care
• Blood glucose level should be monitored;
(glycosylated hemoglobin) HbA1c, OGTT, FBS, RBS
levels

• Obtain follow up history & perform examination

• Ultrasound: fetal growth

• Encourage 30 minutes exercise every day

• Dietary advice
Dietary Management
 Determine weight
 Eat small frequent meals
 Take high fiber diet
 Avoid concentrated sweets
Cookies, cakes, pies, soft drinks, chocolate, table sugar, fruit
juice, jams or jellies.
 Avoid convenient foods
Instant noodles, canned soups, instant potatoes, frozen meals
or packaged stuffing
Intrapartum Care
• Birth of baby should be recommended with neonatal
intensive

care facilities

• Monitor & maintain blood sugars: 80-120 mg/dl

• Administer insulin if sugar more than 120 mg/dl

• Maintain partograph; assess progress of labor, maternal & fetal

condition
Postpartum Care
 After third stage of labor (delivery of placenta) the insulin
requirement will rapidly fall; carbohydrate metabolism returns to
normal very quickly

 Reduce the insulin infusion rate at least 50%

 Monitor blood glucose level

 Encourage breastfeeding

 Women with diabetes will prone to infection and delayed wound

healing, the administration of antibiotics is useful after operative
birth

 Advice for contraceptive

Abortion
 Abortion is defined as, “the expulsion of fetus before it reaches viability.”

 The interruption in pregnancy before it is viable.

29
 WHO has recommended that the fetus is viable when the gestation
period has reached 22 or more weeks, or when the fetus weights
500 grams.
 FETAL MATERNAL CAUSES
1. Chromosomal
CAUSES abnormalities 1. Maternal age
2. Structural abnormalities 2. Structural abnormalities of the
genital tract, reproductive organs
3. Genetic causes (e.g. Cousin marriage
4. Uterine causes
5. Maternal Disease
6. Dietary causes

30
7. Environmental factors
8. Maternal Immune response
9.Endocrine abnormalities
10.Stress
11. Hormonal deficiency
12.In Vitro Fertilization (21% abort
spontaneously)
13. Incompetent cervix, cervical
trauma
Reasons for Pregnancy Termination
 In adequate finances
 Lack of readiness for
responsibility
 Change of roles and responsibilities
 Problems in relationships

31
 Unmarried (socio cultural reasons)
 Too young
 Possible health problems with fetus
 Maternal health problems
 Rape, incest, etc.
Types of Abortion
Spontaneous
Abortion

32
Threatened Inevitable

Pregnancy
Missed Incomplete Complete

Progresses
Birth of a
Birth Mole Septic
viable Baby
Cont...

Induced

33
Therapeutic Criminal/Unsafe

Septic
Threatened Abortion
It means there is only threat of abortion, the process has started but
it
may be arrested and pregnancy may continue.

Symptoms

34
Blood loss may be scanty, with or without low backache and
cramping pains. The pain may resemble dysmenorrhea. Cervical
os remains closed.

Outcomes of Threatened Miscarriage

 IUGR
 Pre-term labour
 Inevitable miscarriage
Care

Limit enemas and vaginal examinations

Allow bed rest until bleeding ceases
Hospital admission:

35
 Ultrasounds for monitoring of fetal growth

Bleeding

Serum progesterone levels

Inevitable Abortion

 The key feature of inevitable abortion is

cervical dilatation.
 It means the process has become
irreversible; the expulsion of products of

36
conception has not occurred but bound to
happen.
 Moreover, nothing can be done to stop this
process and will proceed to incomplete /complete
abortion.
 There is often severe vaginal bleeding along
with labour contractions.
Signs & Symptoms

 The size of uterus will be smaller than expected

 The membranes can rupture, & amniotic fluid will be seen
 The cervix dilates and heavy bleeding occurs
 Clots may be seen in the vagina or protruding through the
os

37
 Severe rhythmical abdominal pain
 Gestational sac containing embryo or fetus may be expelled

Care

 Clean the vulva using aseptic technique

 Provide sterile pad
 Save pads to examine the products of conception
 Monitor for the signs of shock
Incomplete Abortion

Incomplete abortion means abortion has taken place, but some

retained products of conception (RPOCs), are inside the uterine.
This is more likely to occur in second trimester of pregnancy.

Symptoms

38
Part or all of placenta remains within the uterine cavity contributing to
bleeding that may be heavy and profuse, leading to shock.
Complete Abortion

In complete abortion, all the products of conception embryo/ fetus,

placenta and membranes are expelled completely and nothing is
left behind in the uterine cavity. It is more likely to occur in the first
eight weeks of pregnancy.

39
Symptoms
 Severe pain
 Heavy profuse bleeding initially, but after expulsion there is
light bleeding
Recurrent Abortion
 When a woman has had three or more
consecutive pregnancies ending in spontaneous
abortion
 Mostly, cause is unknown

40
 Examine karyotype & autoimmune factors
 U/S: to assess ovarian morphology (PCOs) &
uterine cavity
 Cervical cerclage, at 14 - 16 weeks in cases
with cervical incompetence
 Administer low dose aspirin during
pregnancy; BUT stop it at 36 weeks
Missed Abortion
Features Treatment
- Gradual disappearance of - Wait 4 weeks for spontaneous
pregnancy signs & expulsion
symptoms - Evacuate if:
- Brownish vaginal discharge  Spontaneous expulsion does
- Pregnancy test: negative not occur after 4 weeks

41
but it may be + ve for 3-4  Infection
weeks after the death of the  DIC
fetus.
- U/S: absent fetal Manage according to size of
heart pulsation uterus
-If uterus size is < 12 weeks:
Complications dilatation and evacuation
- Infection (Septic - If uterus size is > 12 weeks:
abortion) try oxytocin or PGEs.
- DIC
 Induced Abortion

 It is an intentional termination of a pregnancy

 Induced abortion occurs as a result of interference in the

natural process which may be medical, surgical or result from the
use of herbal preparations or other traditional practices which cause

42
the uterus to completely or partly expel the contents

 Induced abortion may be legal or illegal according to the law

in the country

 In Pakistan, it is illegal unless required to save a woman’s life

Methods of Therapeutic
Abortion
 Misoprostol
 Suction evacuation
 Manual Vacuum Aspiration (MVA)

43
Therapeutic Abortion

An abortion is considered legal in

conditions where termination is the

44
only way to save the life of a woman
or to provide necessary treatment to the
woman during pregnancy
Criminal
Abortion
Any abortion which is performed by a person
who lacks necessary skills; & is not permitted
under the country law to carry out such a

45
procedure.
There is a very high risk of sepsis and/or
haemorrhage as well as other injuries, like
fistula.
Septic Abortion
Uterine infection occurring after any abortion or invasive
procedures

Signs & Symptoms

46
Fever, tachycardia, headache, nausea , general malaise,
uterine tenderness, offensive vaginal loss

Care
 Shock management
 Isolation
 Microscopy and blood cultures
 Antibiotics
 Uterine evacuation
Complications

 Septicemia
 Shock
 DIC
 Liver and renal damage (Jaundice,
Oligouria)
 Adhesion formation, salphingitis, infertility
Management of Abortions
First Trimester:
The first trimester involves less pain and complications. The main
procedure involved are as follows:
 Manual Vacuum Aspiration (MVA) (up to 6th- 9th week after conception)
 Dilation & Curettage (D & C) (up to 9th and 14th week)

48
 Abortion inducing pills (Misoprostol)

• Second Trimester: beyond the 14 th week of gestation

 Dilatation & Evacuation (D & E)

• Third Trimester:
 Involve surgical procedure
 Summary
Signs & Threatened Inevitable Incomplete Complete Missed Septic
symptoms Abortion Abortion Abortion Abortion Abortion Abortion

lower Variable Some times sometimes Diminishing None Severe /

abdominal Severe severe /none
pain /rhythmical variable

Bleeding * Slight to ** Heavy/ Heavy Light Light Variable

49
clots profuse bleeding smell may
moderate offensive
Cervical OS Closed Open Open Closed Closed Open

Uterus (if Soft no corresponds Tender/ Softer than Smaller than Bulky/tender
Palpable) tenderness to date painful normal expected /painful
uterus Smaller than
corres- dates
ponds to
date

Additional Tissue Nausea & Maternal

Signs & present in vomiting pyrexia
symptoms cervix,
shock
References
• RCOG Green top guidelines The management of severe pre-
eclampsia/eclampsia http://www.rcog.org.uk/files/rcog-
corp/GTG10a230611.pdf
• NICE (2010, reviewed 2011 ) High blood pressure in pregnancy,
Understanding NICE guidance, National Institute for Health and Clinical
Excellence, p7
• Fraser, D.M., & Cooper, M.A., (2014). Myles Text Book For Midwives. (16th
ed.). Churchill Living Stone Elsevier.
• Royal College of Obstetricians and Gynecologists (2007) Pre-eclampsia:
what you need to know, p3, http://www.rcog.org.uk/womens-
health/clinicalguidance/pre-eclampsia-what-you-need-know,
• Royal College of Obstetricians and Gynecologists (2006, reviewed 2010)
The Management of Severe Pre-eclampsia/Eclampsia, p1,
http://www.rcog.org.uk/files/rcog-corp/GTG10a230611.pdf
• NHS Choices (accessed 2012) Health A-Z, Pre-eclampsia, Overview,
http://www.nhs.uk/Conditions/Pre-eclampsia/Pages/Introduction.aspx
Thank You