High risk Obstetrics
Medical Laboratory And Specialists Services
Pre-eclampsia:
Pre-eclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to other organ systems like the Kidneys, Liver, Brain. It typically occurs after the 20th week of pregnancy and can lead to serious complications for both mother and baby
Key Features:
- Hypertension- Blood pressure ≥ 140/90 mmHg
- Proteinuria-Presence of protein in urine (≥ 300 mg in 24 hours).
- Other Symptoms-Swelling (edema), headaches, visual disturbances, abdominal pain, and sudden weight gain.
Management:
- Monitoring: Regular blood pressure checks, Urinalysis for protein, Fetal monitoring to assess growth and well-being.
- Lifestyle Modifications: Encourage rest and stress reduction, Balanced diet, hydration, and adequate salt intake as advised.
- Medications: Antihypertensive- If BP is significantly elevated.
- Delivery: The definitive treatment for pre-eclampsia is delivery of the baby, especially in severe cases or if the condition worsens or if baby is already mature.
- Postpartum Care: Continued monitoring for hypertension and other complications after delivery.
Follow-Up: Patients with a history of pre-eclampsia should be monitored in future pregnancies, as they are at increased risk for recurrence and other cardiovascular issues later in life
Diabetes in Pregnancy:
Diabetes in pregnancy can occur as pre-existing diabetes (Type 1 or Type 2) or gestational diabetes (GDM), which develops during pregnancy. Proper management is essential to
minimize risks for both the mother and the baby.
Types of Diabetes in Pregnancy:
1. Pre-existing Diabetes: Type 1 Diabetes: Autoimmune condition; insulin-dependent.
Type 2 Diabetes: Insulin resistance; may require medication
1. Gestational Diabetes (GDM): Develops during pregnancy, usually resolves after childbirth but increases future diabetes risk.
Management: 1. Screening: Pre-existing Diabetes: Assess before pregnancy or in the first trimester.
GDM Screening: Typically done between 24-28 weeks of pregnancy using the glucose challenge test.
2. Monitoring: Blood Glucose Levels: Regular monitoring of blood sugar levels to maintain targets (usually fasting < 95 mg/dL, 1 hour postprandial < 140 mg/dL). Hemoglobin A1c: Monitor for overall glycemic control.
3. Lifestyle Modifications: Diet: Balanced diet rich in nutrients, focusing on whole grains, fruits,
vegetables, lean proteins, and healthy fats. Limit sugars and refined carbs.
Exercise: Regular physical activity, as approved by a healthcare provider, to help control blood sugar levels.
4. Medications: Insulin Therapy: Often necessary for managing pre-existing diabetes and sometimes for GDM if diet and exercise are insufficient.
Oral Medications: Consider in GDM if insulin is not used.
5. Prenatal Care: Regular Check-ups: Frequent visits to monitor mother and fetus, assess growth, and detect any complications early.
Fetal Monitoring: Ultrasound and non-stress tests to monitor fetal growth and well-being.
6. Labor and Delivery Management: Close monitoring of blood sugar levels during labor. Plan for
delivery based on the mother’s condition and fetal health; often involves a multidisciplinary team.
7. Postpartum Care: Monitor blood sugar levels after delivery, as GDM usually resolves but carries a risk for future diabetes.
Encourage lifestyle changes to prevent the development of Type 2 diabetes.
Thyroid Disorders in Pregnancy:
Thyroid disorders, including hypothyroidism and hyperthyroidism, can significantly impact pregnancy outcomes. Proper management is essential for the health of both the mother and the developing fetus.
Types of Thyroid Disorders:
1. Hypothyroidism: An underactive thyroid leading to insufficient thyroid hormone production.
Risks: Can cause complications like preeclampsia, anemia, and impaired fetal development.
2. Hyperthyroidism: An overactive thyroid producing excess thyroid hormones.
Risks: Can lead to complications such as preterm birth, low birth weight, and heart problems in the baby.
Management:
1. Screening: Preconception Screening: Women with known thyroid disorders or risk factors should be assessed before conception.
Routine Testing: Thyroid function tests (TSH, free T4) are often performed in the first trimester.
2. Hypothyroidism Management: Levothyroxine: The primary treatment; dosage may need to be increased during pregnancy to maintain normal TSH levels (generally 0.1–2.5 mIU/L).
Monitoring: Regular TSH and free T4 levels should be checked every 4–6 weeks during pregnancy.
3. Hyperthyroidism Management: Medications like propylthiouracil (PTU) or methimazole can be used, usually with PTU preferred in the first trimester due to lower fetal risks.
Monitoring: Regular thyroid function tests to adjust medication doses and ensure normal thyroid
function.
4. Multidisciplinary Approach: Collaboration with endocrinologists and obstetricians is vital for optimal management and monitoring of thyroid disorders during pregnancy.
5. Postpartum Care: Hypothyroidism: Women should continue levothyroxine and be monitored postpartum for TSH levels.
Hyperthyroidism: Continued monitoring is necessary as the condition may fluctuate after delivery.
Previous Lower Segment Caesarean Section (LSCS) and Trial of Labor After Caesarean (TOLAC):
Women with a history of lower segment cesarean section may be candidates for TOLAC, which is the attempt to deliver vaginally after a previous cesarean delivery. Proper assessment and management are critical to ensure maternal and fetal safety.
Indications for TOLAC: Previous LSCS with a low transverse incision.
No contraindications for vaginal delivery (e.g., uterine rupture risk factors).
Contraindications for TOLAC:
– Previous classical or T-shaped uterine incision.
– Uterine rupture in previous pregnancies.
– Major obstetric complications (e.g., placenta previa).
– Certain maternal health issues (e.g., active genital herpes).
Management of TOLAC:
1. Pre-Labor Assessment: Counseling: Discuss risks and benefits of TOLAC versus repeat cesarean delivery, History Review: Assess the indication for the previous cesarean and any complications.
2. Intrapartum Management: TOLAC should be attempted in a facility equipped for emergency cesarean delivery, Continuous Monitoring: Fetal heart rate monitoring is essential to detect signs of uterine rupture or fetal distress.
Postpartum Care: Monitor for complications such as uterine atony or infection, Discuss future pregnancy plans and the potential for VBAC (Vaginal Birth After Cesarean) or repeat cesarean.
Placenta Previa:
Placenta previa is a condition during pregnancy where the placenta partially or completely covers the cervix. This can lead to complications during labor and delivery, including severe
bleeding.
Types of Placenta Previa:
1. Complete (Total) Previa: The placenta completely covers the cervical opening.
2. Partial Previa: The placenta partially covers the cervix.
3. Marginal Previa: The placenta is located at the edge of the cervix.
4. Low-lying Placenta: The placenta is close to the cervix but not covering it.
Risk Factors: Previous cesarean sections, Previous uterine surgery, Multiple pregnancies, Maternal age over 35, Smoking and drug use, High parity (multiple pregnancies).
Diagnosis: Ultrasound: Typically diagnosed via transvaginal ultrasound in the second trimester.
Follow-up Imaging: Regular monitoring of the placenta’s position as pregnancy progresses.
Management:
1. Asymptomatic Cases: Regular ultrasounds to track the placenta’s position.
Activity Modification: Advise avoiding strenuous activities, intercourse, and heavy lifting.
2. Symptomatic Cases: Bleeding Management: Hospitalization may be required for heavy bleeding.
Stabilization: IV fluids and blood transfusions if necessary.
3. Delivery Planning: Elective cesarean delivery is often planned around 36-37 weeks to avoid labor onset and bleeding. Ensure delivery in a facility equipped for managing obstetric emergencies.
Preterm Labor:
Preterm labor is defined as the onset of labor before 37 weeks of gestation. It can lead to preterm birth, which is associated with increased risks for neonatal morbidity and mortality.
Risk Factors: Previous preterm birth, Multiple pregnancies (twins, triplets, etc.), Uterine abnormalities, Infections (e.g., urinary tract infections), Chronic conditions (e.g., hypertension, diabetes),Smoking and substance use, Low socioeconomic status, Poor nutrition
Signs and Symptoms: Regular contractions (every 10 minutes or more), Lower back pain, Pelvic pressure, Changes in vaginal discharge, Abdominal cramps
Diagnosis: Cervical Exam: Assess cervical dilation and effacement.
Ultrasound: Check cervical length and fetal status.
Fetal Monitoring: Monitor fetal heart rate.
Management:
1. Immediate Interventions:
Hospitalization: If signs of preterm labor are present, hospitalization may be necessary for monitoring and treatment.
Hydration: Administer IV fluids to prevent dehydration, which can contribute to contractions.
2. Medications:
Tocolytics Medications to temporarily inhibit contractions and delay preterm birth.
Corticosteroids: Administered to accelerate fetal lung maturity if delivery is anticipated within 7 days (usually betamethasone).
Antibiotics: May be given if there is evidence of infection or to prolong latency in certain cases.
3. Planning for Delivery:
– Discuss options and potential outcomes with the patient.
– Prepare for possible neonatal intensive care if preterm birth occurs.
Rh Negative Pregnancy:
Rh negative pregnancy refers to pregnancies involving a mother with Rh-negative blood type and a potential Rh-positive fetus. This can lead to Rh incompatibility, which may result in hemolytic disease of the newborn (HDN).
Rh Factor: A protein on the surface of red blood cells. If the protein is present, the blood type is Rh
positive; if absent, it is Rh negative.
Sensitization: Occurs when an Rh-negative mother is exposed to Rh-positive blood, leading to the development of antibodies.
Risks: Hemolytic disease of the newborn (HDN), which can cause anemia, jaundice, and other
complications in the fetus or newborn.
– Increased risk with subsequent pregnancies if sensitization occurs.
Management:
1. Preconception Counseling:
– Identify Rh-negative women and assess their blood type.
– Discuss potential risks and the importance of monitoring.
2. Routine Screening:
– Blood Typing: At the first prenatal visit, check maternal blood type and Rh status.
– Antibody Screening: Conduct indirect Coombs test to check for existing antibodies.
3. Rh Immunoglobulin (Rho(D) immune globulin) administration to prevent sensitization.
4. Monitoring Fetal Status: Ultrasound: Regular ultrasounds to assess fetal growth and well-being.
Doppler Studies: Evaluate fetal blood flow and anemia.
5. Intrauterine Transfusion (if needed):
– For severely affected fetuses, intrauterine blood transfusions may be performed to manage anemia.
6. Delivery Planning:
– Discuss delivery options and timing based on maternal and fetal conditions.
– Ensure immediate care for the newborn to monitor for any signs of HDN.
Recurrent Pregnancy Loss
Recurrent pregnancy loss (RPL) is defined as the occurrence of three or more consecutive pregnancy losses before 20 weeks of gestation. It can be a distressing condition for affected
individuals and requires thorough evaluation and management.
Causes of Recurrent Pregnancy Loss:
1. Chromosomal Abnormalities: Genetic abnormalities in the fetus.
2. Anatomical Factors: Uterine anomalies (e.g., septate uterus, fibroids), Incompetent cervix.
3. Endocrine Disorders: Thyroid disorders (hypothyroidism, hyperthyroidism), Polycystic ovary syndrome (PCOS), Diabetes mellitus.
4. Immunological Factors: Antiphospholipid syndrome (APS), Autoimmune disorders.
5. Thrombophilias: Conditions leading to increased blood clotting (e.g., Factor V Leiden, prothrombin mutation).
6. Environmental Factors: Smoking, alcohol, and drug use.
Evaluation:
1. Medical History: Detailed obstetric history including the timing and characteristics of previous losses.
2. Physical Examination: Pelvic exam to assess anatomical issues.
3. Laboratory Tests:
– Genetic testing (karyotyping) for both parents.
– Hormonal evaluations (thyroid function, progesterone levels).
– Blood tests for antiphospholipid syndrome and thrombophilia.
4. Imaging Studies: Ultrasound or hysterosalpingography (HSG) to assess uterine anatomy.
Management:
1. Addressing Underlying Causes and manage accordingly.
2. Encourage healthy lifestyle choices (e.g., cessation of smoking, balanced diet, and regular exercise).
3. Preconception Counseling: Discuss the management plan before attempting pregnancy, including any interventions needed.
Multifetal Pregnancy:
Multifetal pregnancy refers to the presence of two or more fetuses in a single pregnancy, commonly seen in twins, triplets, or higher-order multiples. It is associated with higher risks for both maternal and fetal health.
Risks Associated with Multifetal Pregnancy:
Maternal Risks: Increased risk of gestational hypertension and preeclampsia, Greater likelihood of anemia, Higher chance of cesarean delivery.
Fetal Risks: Preterm birth and low birth weight, Twin-to-twin transfusion syndrome (TTTS) in
monochorionic pregnancies, Congenital anomalies.
Management:
1. Early Diagnosis and frequent monitoring for fetal well being
Maternal Assessment: Monitor for signs of complications, including hypertension and gestational
diabetes.
2. Delivery Planning:
Timing: Plan for delivery around 37 weeks for twins and 34-36 weeks for higher-order multiples to
minimize risks associated with prematurity.
Mode of Delivery: Assess the presentation and health of fetuses to determine the need for cesarean delivery. Vaginal delivery may be possible for some twin presentations.
3. Postpartum Care: Close observation for maternal complications such as hemorrhage or infection. Provide information and resources for postpartum care, including potential NICU needs for preterm infants.
Fetal Growth Restriction (FGR): Fetal growth restriction (FGR) is a condition where a fetus is unable to achieve its genetically determined potential size. It can be classified into two types: symmetrical (uniform growth restriction) and asymmetrical (disproportionate growth, typically affecting the abdomen more).
Causes of FGR:
1. Maternal Factors: Chronic hypertension, Diabetes mellitus, Smoking and substance use, Nutritional deficiencies, Infections (e.g., TORCH infections)
2. Placental Factors: Placental insufficiency, Placenta previa, Placental abruption
3. Fetal Factors: Genetic abnormalities, Multiple gestations, Congenital infections
Diagnosis:
1. Ultrasound: Growth Assessment: Regular ultrasounds to measure fetal growth parameters (biparietal diameter, abdominal circumference, femur length), Doppler Studies: Assess blood flow in the umbilical artery and other vessels.
2. Clinical Signs: Fundal height measurements may indicate growth restriction if below expected
percentiles.
Management:
1. Monitoring: Regular Ultrasounds: Frequent monitoring of fetal growth and amniotic fluid levels.
Doppler Ultrasound: Evaluate blood flow to assess placental function and fetal well-being.
2. Maternal Management: Address Underlying Conditions: Control hypertension, manage diabetes, and optimize maternal nutrition.
Lifestyle Modifications: Encourage cessation of smoking and substance use.
3. Timing of Delivery: Delivery Planning: Consider timing of delivery based on gestational age and severity of FGR.
Indications for Delivery: If signs of fetal distress or placental insufficiency are present, earlier delivery may be warranted.
4. Mode of Delivery: Vaginal vs. Cesarean: Decision based on fetal presentation, maternal health, and fetal status. Cesarean delivery may be preferred in cases of severe FGR or compromised fetal condition.
5. Postpartum Care: Monitoring Newborn: Close observation for potential complications such as
hypoglycemia, temperature instability, and feeding difficulties.
Oligohydramnios and Polyhydramnios:
Oligohydramnios is defined as decreased amniotic fluid volume, typically measured as an amniotic fluid index (AFI) of less than 5 cm or a single deepest pocket of fluid measuring less than 2 cm.
Causes: Maternal Factors: Chronic hypertension, diabetes, dehydration, certain medications.
Fetal Factors: Renal anomalies, urinary tract obstructions, fetal growth restriction.
Placental Factors: Placental insufficiency.
Risks: Fetal distress during labor, Preterm birth, Umbilical cord compression, Pulmonary hypoplasia (underdeveloped lungs).
Management of Oligohydramnios:
1. Monitoring: Regular ultrasound assessments to evaluate amniotic fluid levels and fetal well-being.
2. Maternal Hydration: Encourage adequate hydration to potentially improve amniotic fluid levels.
3. Treat Underlying Conditions: Manage maternal conditions (e.g., diabetes, hypertension) that may
contribute to oligohydramnios.
4. Consider Early Delivery: In cases of severe oligohydramnios or signs of fetal distress, plan for early
delivery, often via cesarean section if necessary.
5. Fetal Monitoring: Continuous fetal heart rate monitoring during labor to detect signs of distress.
Polyhydramnios: Polyhydramnios is defined as excessive amniotic fluid, typically with an AFI greater than 18-20 cm or a single deepest pocket measuring more than 8 cm.
Causes: Maternal Factors: Diabetes mellitus (gestational or pre-existing), multiple gestations.
Fetal Factors: Congenital anomalies (e.g., gastrointestinal obstructions), neural tube defects, infections.
Placental Factors: Chorioamnionitis.
Risks: Preterm birth, Maternal discomfort and complications (e.g., hypertension),Umbilical cord
prolapse.
Management of Polyhydramnios:
1. Monitoring: Regular ultrasounds to assess fluid levels and fetal well-being.
2. Treat Underlying Conditions: Manage diabetes and other maternal conditions contributing to polyhydramnios.
3. Amnioreduction: In cases of severe polyhydramnios causing maternal discomfort, consider therapeutic amniocentesis to reduce fluid levels.
4. Delivery Planning: Monitor closely and plan for delivery, considering potential complications and timing based on maternal and fetal status.
5. Fetal Monitoring: Continuous fetal monitoring during labor due to increased risks of fetal distress and complications
Abortions: Abortion refers to the termination of pregnancy before the fetus can sustain independent life. It can be classified into two main types:
1. Spontaneous Abortion (Miscarriage): Unintentional loss of pregnancy.
2. Induced Abortion: Deliberate termination of pregnancy, which can be elective or therapeutic.
Types of Abortion
1. Spontaneous Abortion:
–Threatened Abortion: Presence of vaginal bleeding but the cervix is closed.
– Inevitable Abortion: Vaginal bleeding with cervical dilation.
– Incomplete Abortion: Some products of conception are expelled, but some remain.
– Complete Abortion: All products of conception have been expelled.
– Missed Abortion: Fetus has died, but products of conception are retained.
2. Induced Abortion:
– Medical Abortion: Use of medications (e.g., mifepristone, misoprostol).
– Surgical Abortion: Procedures such as suction curettage or dilation and curettage (D&C).
Causes of Spontaneous Abortion: Chromosomal abnormalities, Maternal age (higher risk in women over 35), Uterine anomalies, Hormonal imbalances, Infections, Chronic conditions (e.g., diabetes, autoimmune disorders)
Management
1. Spontaneous Abortion: Monitoring and Support:
– Assess for bleeding and cramping; provide emotional support.
– Monitor for signs of complications, such as heavy bleeding or infection.
Medical Management: Incomplete or missed abortion may require medication to help expel retained tissue (e.g., misoprostol).
Surgical Management: D&C: If significant retained products are present or if there are signs of infection or heavy bleeding.
2. Induced Abortion: Medical Abortion: Mifepristone and Misoprostol: Effective for pregnancies up to 10 weeks.
– Provide education on the process, potential side effects, and follow-up care.
Surgical Abortion: Suction Curettage or D&C: Preferred for pregnancies over 10 weeks or when medical abortion is contraindicated.
– Ensure informed consent and provide anesthesia options.