PREGNANCY RISKS: Assessing for pregnancy

risks
• High-risk pregnancy is one in which the
mother, fetus, or newborn is or may be at
increased risk of morbidity & mortality before,
during & after delivery
 Assessing pregnancy risks
• All pregnancies are at risk
To assess for risks:
• A careful history to reveal specific risks factors
• A maternal physical exam. to identify/exclude risk
factors
• Routine maternal lab. screening for common disorders
• Special maternal lab. evaluations for disorders
suggested from any evaluative process
• Comprehensive fetal assessment over entire course of
pregnancy
Factors that lead to increased risks
• Maternal health
• Obstetric abnormalities
• Fetal disease
 Risk factors related to specific pregnancy
problems
Causes of maternal death Causes of infant mortality
• Thromboembolic disease • Congenital malformations
• Hypertensive disease • Prematurity related
• Haemorrhage conditions
• Infection
• Ectopic pregnancy
 Risk factors related to specific pregnancy
problems
Preterm labor Preterm labour
• Age below 16 or over 35 yrs • Alcohol use & alcohol abuse
• Low social economic status • Abnormal fetal presentation
• Maternal weight below 50 • Pyelonephritis
kgs • Multiple pregnancy
• Poor nutrition • Anaemia
• Previous preterm birth • Preterm rupture of
• Incompetent cervix membranes
• Uterine anomalies • Placental abnormalities
• smoking • infection
 Risk factors related to specific pregnancy
problems
Intrauterine fetal growth restriction Intrauterine fetal growth restriction
(IUGR) (IUGR)
• Multiple gestation • Maternal diabetes with
• Poor nutrition coagulopathy
• Maternal cyanotic heart • Fetal infections
disease • Fetal cardiovascular
• Chronic hypertension anomalies
• Gestation hypertension • Drug addiction & alcohol
• Recurrent APH abuse
• Smoking • Fetal congenital anomalies
• haemoglobinopathies
 Risk factors related to specific pregnancy
problems
Polyhydramnios oligohydramnios
• Diabetes mellitus • Renal agenesis (potter’s
• Multiple gestation syndrome)
• Fetal congenital • Prolonged rupture of
abnormalities membranes
• Isoimmunization (Rh or • Intrauterine growth
ABO) restriction
• Intrauterine fetal demise
 Risk factors related to specific pregnancy
problems
Post-term pregnancy Chromosomal abnormalities
• Anencephaly • Maternal age 35 yrs or more
• Placental sulfatase at delivery
deficiency • Balanced translocation
• Perinatal hypoxia, accidosis (maternal & paternal)
• Placental insufficiency
 Methods of assessment for pregnancy at
risk
• Preconception care- maximize maternal & fetal
benefits before conception
Prenatal period: Risks
• Maternal age- extremes of maternal age increase
risks
• Modality of conception- use of ART increases risks of
multiple gestation, preterm delivery, low birth
weight
• Past medical history- medical conditions can
complicate pregnancy course for mother & fetus
 Methods of assessment for pregnancy at
risk
Prenatal period
• Family history- determine risks for heritable
states(diabetes, hypertension, twins)
• Ethnic background- many genetic disorders
affect certain communities (sickle cell)
 Methods of assessment for pregnancy at
risk
Past obstetric history- Past obstetric history-
• recurrent abortions • Previous preeclampsia,
• previous stillbirth or eclampsia
neonatal death, • Teratogen exposure
• previous preterm delivery • Drugs
• Rh isoimmunization or ABO • Infectious agents- CMV,
incompatibility Rubella, toxoplasmosis
• Previous infant with genetic • Radiation < 0.05 Gy (5rad)
disorder or congenital no teratogenicity
abnormality- cytogenic test
 Methods of assessment for pregnancy at
risk
• Physical examination
• Vital signs- temp., pulse, BP
• Urinalysis- c/s initial, dipstick for protein,
glucose, ketones, leukocytes, blood
• Screening tests: blood type, Rh factor, HIV,
VDRL, Gonorrhoea, rubella, hepatitis,
 Antepaturm management
• First trimester screening- nuchal translucency at
11-13 wks combined with Beta-hCG & plasma
protein A levels or detection of Trisomy 21
• Maternal serum analyte testing- detects neural
tube defects & chromosomal anomalies(trisomy
21) at 15-22 wks
• Syndromic testing- haemoglobin electrophoresis
determines carrier status for sickle cell
 Antepaturm management
• Preterm labour detection- cervical length
>30mm 34-35wks(labour unlikely); fetal
fibronectin is negative
• Diabetes screening- glucose challenge test at
24 & 28 wks (50g glucose. plasma 1hr after. >
140g/dl GTT)
• Group B streptococcus- rectovaginal culture
screening at 35-37 wks, intrapartum
antibiotics
 FETAL SCREENING

• Performed during all trimesters. Techniques

used diverse. Information obtained varies
according to the quality of imaging, depth of
investigation & gestation age of the pregnancy
 FETAL SCREENING: Methods
• Ultrasound
• Aneuploid screening
• Amniocentensis
• Chorionic villus sampling
• Fetal blood sampling
 Fetal screening: Ultrasound
• Ultrasound demonstrates:
– fetal anatomy
– number
– wt
– movement
– vol. of amniotic fluid
– structural anomalies(myomas, placenta previa)
– fetal presentation
– state of viability
– gestational age
– placenta location
– fetal biometry
 Fetal screening: Aneuploidy screening
• Identifies markers for defects:
– Echogenic intracardial focus
– Choroid plexus cysts
– Pyelectasis
– Echogenic bowel
– Short femur
– Hypermineralization of the 5th digit of the fetal
hand
Fetal screening- invasive: Amniocentencis

Guided by ultrasonography: Indications

• Amniotic fluid evaluated for Alpha Feto
proteins (AFP) for NTD in early 2nd trim (15-22
wks)
• Intra-amniotic inflammation/infection
• Fetal lung maturity
 Fetal screening- invasive: chorionic villus
sampling (CVS)
• An alternative to amniocentensis
• Performed 10-12 wks, transcervically,
transabdominally
• Chorionic villi undergo cytogenic analysis
• NB: high risk of abortions; does not allow dx of
NTD
 Fetal screening- invasive: Fetal blood
sampling
• Cordocentensis/ percutaneous umbilical blood
sampling. (blood from umbilical cord or
intrahepatic vein- less risky)
• An option for chromosomal or metabolic
analysis of the fetus; ambiguous findings from
placental tissue. Results are rapid
• Indication: assessment fetal & RX of Rh
sensitization & alloimmune thrombocytopenia
 Antepartum Fetal Testing

• Fetal movement assessment- perception of

10 fetal movements in 1hr reassuring
• Nonstress test(NST)- a reactive & reassuring
NST is 2or >2 FHR accelerations at least 15
bpm above the baseline & lasting at least 15s
within a 20 minute period. A non-reassuring
NST warrants further evaluation or delivery
 Biophysical profile (BPP)
• U/s measure of fetal wellbeing
• Determines signs of fetal hypoxia or compromise placental
function or both
• BPP- comprises:
– NST,
– fetal breathing movements(30s or more in 30 mins),
– fetal movement(3 or more gross body mvts. in 30 mins),
– fetal tone ( 1 mvt. of extension/flexion of an extremity & rapid
return to flexion)
– amniotic fluid vol.(vertical pocket of 2cm or more).
• Each component worthy 2 points. A score of 8-10 is normal, 6-
fair, 4 or less is abnormal
 Modified biophysical profile

• Combines NST, a short term indicator of fetal

acid- base status with amniotic fluid index (AFI) a
long term indicator of placental function
• AFI is measured by dividing the uterus into 4
equal quadrants & measuring the largest vertical
pocket in each quadrant. Results summed &
expressed in mls. A nonreactive NST or an AFI
<50mls (oligohydramnios) requires evaluation
 Contraction stress test (CST)

• Based on response of FHR to contractions-

expecting fetal oxygenation worsens
• Test requires 3 contractions in 10 mins, a +ve
or abnormal test when late decelerations
occur with more than ½ of the contractions
suspicious with any late decelerations, & -ve
with no late decelerations
 Growth ultrasound

• Performed every 3-4 wks, useful for assessing

fetuses that may be at risk of growth restrictions
due to medical conditions of pregnancy or fetal
abnormalities eg diabetes mellitus

• Doppler status – placental blood flow assessed to

determine a compromised fetus, & a diagnostic
tool to alert midwives of the need for
intervention(BPP, continuous fetal monitoring,
delivery)
 Fetal maturity tests

• Indications for assessing fetal lung maturity

– Elective c/s
– Premature labour
– Medical conditions like diabetes
• Lecithin/sphingomyelin ratio : reaches 2:0 at
35 wks
 Fetal maturity
• Phosphatidylglycerol (PG)- constituent of
surfactant. Increases after lecithin begins to
rise. More indicative of lung maturity.
Enhances spread of phospholipids on the
alveoli (has a high false –ve rate)
• Florescent polorization- a direct
measurement of surfactant concentration.
Reflects the ratio of surfactant to albumin
(55mg/g of albumin)
 Intrapartum Management
Fetal heart rate monitoring
• Intermittent auscultation using fetoscope
• Electronic fetal monitoring (EFM)
• Fetal Heart Rate (FHR)
• Normal baseline is 110-160 bpm
• Baseline FHR <110bpm- bradycardia, >160bpm tarchycardia
• Bradycardia (new baseline <80bpm) or tachycardia
(associated with decrease in variability or repetitive late or
severe variable decelerations)suggests non-reassuring fetal
status
• The interpretation of the fetal heart rate
tracing should follow a systematic
approach with a full qualitative and
quantitative description of the following:
1. Baseline rate.
2. Baseline fetal heart rate (FHR) variability.
3. Presence of accelerations.
4. Periodic or episodic decelerations.
5. Changes or trends of FHR patterns over time.
 Interpreting FHR Patterns

• A systematic approach is recommended when reading

FHR recordings to avoid misinterpretation
• The FHR recordings may be interpreted as reassuring,
nonreassuring or ominous, according to the pattern of
the tracing.
• Reassuring patterns correlate well with a good fetal
outcome, while nonreassuring patterns do not.
• Evaluation of fetal well-being using fetal scalp
stimulation, pH measurement, or both, is
recommended for use in patients with nonreassuring
patterns.
• Evaluation for immediate delivery is recommended for
patients with ominous patterns
 A
Systematic Approach to Reading Fetal Heart Rate Recordings

• Evaluate recording—is it continuous and adequate for interpretation?

• Identify type of monitor used—external versus internal, first-generation

versus second-generation.

• Identify baseline fetal heart rate and presence of variability, both long-
term and beat-to-beat (short-term).

• Determine whether accelerations or decelerations from the baseline

occur.

• Identify pattern of uterine contractions, including regularity, rate,

intensity, duration and baseline tone between contractions.
• correlate accelerations and decelerations with uterine contractions and
identify the pattern.

• Identify changes in the FHR recording over time, if possible.

• Conclude whether the FHR recording is reassuring, nonreassuring or

ominous.

• Develop a plan, in the context of the clinical scenario, according to

interpretation of the FHR.

• Document in detail interpretation of FHR, clinical conclusion and plan

of management.
Fetal Heart Rate
• Accelerations (at 32wks or greater) are defined as elevations
above the baseline of 15bpm lasting 15s or longer; <32 wks
is defined as elevations of 10bpm lasting at least in 10s.
• 2 or more accelerations in 20-min interval are reassuring
(reactivity in NST);
• Variability is defined by fluctuations in FHR of 2 cycles/min or
greater, can range from absent to marked
• Decelerations are categorized as early, late & variable
• Early decelerations reflect contractions (head compression -
not bad)
Fetal Heart Rate
• Late decelerations are smooth falls in FHR
beginning after the contraction has started and
ending after the contraction has ended- associated
with fetal hypoxeamia
• Variable decelerations are abrupt in decline &
return to baseline vary in timing with the
contraction (reflect cord compression)
• Prolonged deceleration is a decrease of 15bpm
below the baseline lasting 2 & 10 mins
 New & emerging technologies
• Magnetic Resonance Imaging (MRI)
• Indications: examining the brain; alternative to
postmortem; serial brain images following
asphyxia in the newborn to understand
evolution of brain injury
• Fetal cells in the maternal circulation- for
genetic diagnosis. Abnormal pregnancies are
likely to have leaky placentas which allow fetal
cells into maternal circulation
 New & emerging technologies
• Fetal therapy- therapaeutic amniocentensis -
interventions to improve fetal prognosis(eg to
drain excessive liqour); may reduce preterm
labour when uterus is large for dates; equalize
pressure in twin-to twin transfusion allowing both
fetuses to grow
• Laser treatment to reduce pathological placental
flow between twins. Shunts can also be inserted
into the fetus to drain fluid collections (ascites,
renal obstruction)
 Other tests
• Vibroacoustic stimulation/scalp stimulation-
acceleration after vaginal exam confirms
absence of acidosis- non invasive
• Fetal pulse oximetry- measure of fetal
oxygenation during labour