High-risk pregnancy lecture

2021-03-21 12:00 AM

The effect of occasional drinking during pregnancy is unknown, but doctors advise pregnant women not to drink alcohol.

Question

Perinatal care aims to ensure a healthy mother and a normal baby, so the need to orient the risk factor for the mother needs to be emphasized. Early identification and management of risk factors will improve adverse events in the future. Pregnancy is a dynamic condition that requires constant monitoring and an adjusted management plan at all times.

Medical history

Through medical history helps physicians detect risk factors and manage them early. Continuously exploiting medical history helps physicians to detect new, advanced pregnancy conditions.

Socio-economic status

Socio-economic status is defined as the combination of a set of complex, interrelated factors: education, marital status, income, and occupation. All of these factors play an important role in both maternal and infant mortality and morbidity. The low socioeconomic status will increase mortality and perinatal morbidity.

Age

Pregnant women who are too young or old are considered risk factors.

Pregnant women under the age of 20 are at risk of:

Premature birth

Stillbirth.

Infant mortality.

Pre-eclampsia / eclampsia.

Uterine contraction disorders.

Antenatal care and monitoring are not good.

Pregnant women over 35 are at risk of:

Increase perinatal mortality for both mother and fetus.

Placental presentation.

Preterm if giving birth after 35 years old.

Addiction

Tobacco addiction. There is a strong correlation between maternal heavy smokers and fetal morbidity and mortality. Although the mechanism of this association is clear, smokers are at risk of:

Abruptio placentae.

Placental presentation.

Bleeding during pregnancy.

Broken amniotic fluid.

Premature birth

Miscarriage.

Syndrome of the sudden death of newborns.

Stillbirth.

Low birth weight.

Reduce the amount of milk to breastfeed.

Lung disease.

Drug addiction:

The consequences for the mother and child depend on the type and dose of the mother's drug. The harmful effects of drugs include:

Increase the number of drugs used when necessary, when using drugs with therapeutic properties of the same origin as narcotic drugs, the dosage of drugs must be increased higher than the average person to work.

Drug withdrawal syndrome.

Pregnancy development delay.

Birth defects.

Infections related to drug injection do not guarantee sterility.

Malnutrition.

Premature birth

Alcoholism:

The extent to which alcohol affects pregnancy depends on the amount of alcohol used and the length of time it is used during pregnancy.

When pregnant women sometimes drink alcohol, this effect is not known, but physicians advise pregnant women not to drink alcohol.

Job

This issue is still being discussed. In general, occupations that require hard work and stress are more likely to cause preterm labor.

Obstetric history

The exploitation of obstetric history is very important in the prognosis of future pregnancy progression.

The number of births:

First childbirth:

Women who give first childbirth are at high risk as follows:

Pre-eclampsia / eclampsia.

New physiological changes, stresses, and underlying diseases may emerge.

There is no understanding of the state of pregnancy and its complications.

The womb gives birth many times:

When a woman has more than 5 children the risk of:

Vegetable forwards.

Bleeding secondary to postpartum due to uterine phlegmon.

Increase the rate of twins.

Abortion:

The cervix can be damaged by dilatation of the cervix during an abortion and increases the risk of:

Miscarriage.

Waist-cervical opening.

Premature birth

A low-birth-weight baby is born.

Premature birth:

The frequency of preterm labor is related to the genitalia, two possibilities in the following births:

Decreased in subsequent births.

Increased in subsequent births.

Large fetus (> 4000g):

It may be due to not being able to detect diabetes or control blood sugar and there may be complications during delivery such as:

The bottom lane birth is difficult.

Cesarean section due to head-pelvic mismatch.

Complications after childbirth.

Pregnancy in the perinatal period can be linked to:

Diabetes.

Systemic disease.

Birth defects.

Premature birth

Obstetric trauma.

Hemolytic disease.

Unusual labor.

Birth defects:

If there has been a time when the baby has been born with a congenital malformation, the rate of birth defects increases in the following pregnancies, so it is necessary to evaluate early by amniocentesis if there is chromosomal abnormality need to end an early pregnancy.

Ectopic pregnancy:

In patients with a history of ectopic pregnancy, the following pregnancies increase the risk of ectopic pregnancy, so during pregnancy, it is necessary to assess whether an egg has been implanted in the uterus.

Old cesarean section:

Women should have indications for cesarean section in the following pregnancies:

Acute herpes infection at full term.

The top-pot mismatch is absolute.

Open the body of the uterus to get pregnant.

Dissociate the fibrous nucleus into the endometrium.

Most physicians recommend that if you have had two cesarean sections, your next pregnancies need a cesarean section.

Bleeding:

Patients with a history of bleeding have an increased risk of bleeding in the next pregnancies (placenta, premature peeling, bleeding after giving birth).

Pregnancy causes hypertension (pre-eclampsia / eclampsia):

Increased risk of high blood pressure in subsequent pregnancies.

Complicated in subsequent pregnancies due to increased blood pressure.

History of medical disease

Chronic hypertension (> 149/90)

This condition can be detected right from the first antenatal care visits, the prognosis depends on how well blood pressure is controlled during pregnancy, but it still has the following risks:

Preeclampsia.

Abruptio placentae.

Perinatal death

Mother's death.

Heart attack.

Reduce the circulation of the placenta.

Heart disease affects both mother and fetus

For mothers: The disease can be aggravated, because during pregnancy, the hemodynamic status changes, some heart damage especially becomes dangerous such as mitral stenosis, pulmonary hypertension, syndrome Marfan, Eisenmenger syndrome.

Fetal development is dependent on oxygen supply. If due to heart damage, inadequate oxygen supply makes the fetus grow abnormally and even die.

The next generation of people with heart disease is at risk of wearing heart disease.

Some of the medications used to treat heart disease have the potential to cause complications in the fetus.

Lung disease

Respiratory function and gas exchange in the lungs affects the amount of oxygen supplied to the fetus.

Kidney disease

When a woman becomes pregnant, she causes physiological and anatomic changes to the urinary system, thus exacerbating the pre-existing latent kidney disease.

Under close medical supervision especially for blood pressure, the underlying kidney disease during pregnancy has a good prognosis.

The fetal mortality rate increases in patients with kidney disease, so it is necessary to go to regular antenatal care and to do prenatal screening tests. Patients should be advised about possible complications of antihypertensive drugs in the fetus.

Diabetes

Increased maternal mortality.

Increased fetal mortality.

Poly amniotic fluid.

Birth defects.

Chronic blood pressure.

Preeclampsia.

Whew.

Glomerulonephritis in the mother.

Stillbirth (the main cause is malformations).

Increased rates of neonatal disease include:

Respiratory failure syndrome.

Babies are overweight.

Lower blood sugar.

Increased blood bilirubin.

Reduces blood calcium.

Thyroid disease

During pregnancy, a woman has hormonal and metabolic changes in her body, making it complicated to evaluate the function of the thyroid gland. No treatment of weakness, as well as hyperthyroidism, will greatly affect the fetus during pregnancy. Treatment of thyroid disease during pregnancy is also complicated because the thyroid gland is the same as it reacts to the endocrine and pharmacological properties of the drug as it is for the mother.

Systemic vascular collagen disease (rheumatism)

The effects of pregnancy on this disease are difficult to predict: it may make the disease progress more rapidly, worsen, it may also make the disease milder. It also has an impact on pregnancy (for example, systemic lupus erythematosus increases the risk of miscarriage, premature delivery, stillbirth), and especially the adverse effects of medications on the fetus.

Hematological diseases

During pregnancy, there will be changes in physiology as well as metabolic requirements, thus often causing secondary anemia due to lack of iron and folic acid.

Hemoglobin diseases (such as sickle cell anemia) can get worse during pregnancy and cause serious complications for both mother and baby.

Platelet diseases and blood clotting disorders not only affect the mother and fetus during pregnancy but also during childbirth, especially when the bleeding occurs.

Some types of blood pathology are inherited and therefore need counseling before becoming pregnant and at the beginning of pregnancy.

Genetic pathology

Maternal genetic pathology should be assessed before becoming pregnant or at the beginning of pregnancy. During pregnancy, genetic problems can be more severe that affect the development of the fetus in the uterus.

History factors that may help identify a couple's risk factors include:

Cognition. Getting together between people who are closely related increases the risk of developing the same genetic mutations.

Increased risk of miscarriage.

Progeny is susceptible to rare genetic recessive diseases.

Race: Some races are susceptible to genetic diseases such as sickle cell disease.

When a mother's age (> 35) is born, she has an increased risk of developing the Down syndrome.

At the high age of parents (> 55) the offspring are susceptible to genetic mutations.

Pituitary disease

Women with pituitary disease often find it difficult to get pregnant, making it worse.

Adrenal gland disease

When pregnant, the function of the adrenal glands is also changed, and cases of acute adrenal insufficiency during pregnancy can be life-threatening.

Parathyroid disease

A normally stable parathyroid gland is the basis for ensuring the health of both mother and child, and blood calcium concentration is the key to assess the activity of the parathyroid glands. Calcium demand increases during pregnancy, so it is necessary to ensure nutrition as well as medications to provide adequate calcium needed.

Liver failure

Like most internal organs, the liver has anatomical, physiological, and functional changes during pregnancy. Most of the liver diseases in pregnancy worsen and therefore need to be closely monitored. Liver disease can adversely affect the fetus (viral hepatitis).

Nervous system disease

The effects of pregnancy on pre-existing or newly acquired nervous system diseases are quite different, and the medications used to treat the disease can harm both mother and baby.

Thrombophlebitis caused by thrombosis

The disease can occur during pregnancy or immediately postpartum in patients with a history of thrombosis, it is important to identify those who are at high risk of pregnancy for prevention.

Infections

Certain viruses, bacteria, and parasites can cross the placental barrier, causing serious effects to the fetus and newborn. Common tests to detect syphilis, gonorrhea, and rubella should be performed. Some of the following infections can cause morbidity and mortality for mother and baby to increase.

Cytomegalovirus:

Pregnant women with primary cytomegalovirus have an increased risk of birth defects, especially on the nervous system.

When the disease progresses, it will cause the death of the baby.

Postpartum infection can occur but usually does not cause sequelae.

Herpes virus:

It is a sexually transmitted disease.

Infection during pregnancy increases the risk of stillbirth and preterm delivery.

Most babies become infected through the genital tract or the virus spreads through the cervix when the amniotic fluid ruptures.

Infected babies may not detect sequelae. The fetuses are infected entirely, if they survive they can have sequelae in the eye or nervous system.

It is important to identify patients with old or recently infected herpes so that appropriate management can be instituted.

Hepatitis B virus:

(1) If the infection is in the first or second trimester, there is usually no effect. Infections occurring during the last trimester are often associated with an increased risk of preterm birth resulting in increased morbidity and mortality, and the infant may become infected with the virus:

(a) Asymptomatic.

(b) Fatal hepatitis and cirrhosis of the liver.

(c) Becoming a chronic carrier.

(2) The mother is a chronic carrier, HBsAg, passing the disease on to her baby.

(3) Medical efforts to prevent neonatal infections of mothers with chronic pathogens. For mothers with acute hepatitis in the last trimester of pregnancy, it is necessary to manage immediately at birth including nasopharyngeal aspiration, serum injection with immune globulin.

(4) The attitude of handling towards the mother includes resting, ensuring the nutrition as well as the amount of fluid supplied to the body.

Toxoplasma:

(1) Toxoplasma is a parasite, when an infected mother may have unclear symptoms, but the fetus can become infected in the uterus.

(2) The risk to the fetus depends on the gestational age when infected, reflecting the immune status of the fetus, for example, the fetus is at increased risk of infection when the mother is infected in the last trimester but in general, there are no significant sequelae, the fetus is less likely to be infected with the virus when the mother is sick in the first trimester, but when sick, it often leaves serious sequelae.

(3) Patients who are infected are often at high risk:

(a) Miscarriage.

(b) Stillbirth.

(c) Severe congenital malformation.

(4) Cats are a serious source of infection, and physicians should advise patients:

(a) The risk of toxoplasma infection from cats during pregnancy.

(b) Serum test for toxoplasma infection in pregnant women with cats.

(c) Advise the patient to limit contact with cats during pregnancy.

Family history

Family history tends to be for the following risk factors:

Mom

High blood pressure.

Laying a lot.

Diabetes.

Haemoglobin disease.

Mom or Dad

Intellectual retardation.

Birth defects.

Born deaf.

Allergy.

Clinical examination

For obstetric patients need a comprehensive clinical examination.

Full body examination

Examination of height and weight reflects the socio-economic status and nutrition of the mother, which is one of the important prognostic indicators.

Mothers who are short, the under-normal weight will increase the mortality rate and perinatal pathology rate for babies, low birth weight babies, and premature babies.

Mothers who report obesity pose a risk to both mother and child. The risks to mothers include:

High blood pressure.

Diabetes.

Inhalation of gastric juice during anesthesia.

Complications of the wound.

Thromboembolism is caused by thrombosis.

Sub-frame examination

Primary frame, vulva, vagina, cervix, and appendages.

Clinically measure pelvic size.

Pregnancy.

Uterine size

The size of the uterus needs to be continually assessed throughout pregnancy. An assessment of the relationship between uterine size and gestational age should be carried out from the first antenatal visit. The proportionality between gestational age and uterine height is significant from the 20th week of pregnancy.

If the uterus is smaller than the estimated gestational age, the physician needs to reassess:

The correct gestational age, especially for women with irregular menstrual cycles.

The pregnancy is smaller than the gestational age.

Late pregnancy in the uterus.

If the uterus is larger than the gestational age, it is necessary to reassess:

Recalculate gestational age.

Uterine deformity.

Poly amniotic fluid.

Multiple pregnancies.

Abnormal genital tract

Abnormal structure:

If there are only minor abnormalities, the prognosis is good.

If the abnormalities are large, there is an increased risk of:

Caesareans.

Perinatal death.

Low birth weight.

Miscarriage.

Abruptio placentae.

Endometriosis in the uterine muscle (adenomyosis):

That is, there are endometrial glands in the uterine lining and muscle, which increase the risk of:

Broken uterus.

Postpartum bleeding.

Chipped difficult.

Cancer lesions and precancerous:

The prognosis depends on how widespread the lesion is.

Fibroids:

The prognosis depends on the location of the fibroids during pregnancy, for example, for fibroids with stalks that can cause torsion complications, fibroids under the mucosa can cause necrotic complications. In general, fibroids affect pregnancy:

Miscarriage.

Placenta clings abnormality.

Misjudging the correlation between gestational age and uterine size.

Retained placenta.

Disorders of uterine contractions during labor.

Postpartum bleeding.

A forward tumor for cases of nasal fibroids and cervical fibroids.

Unusual throne.

Waist-cervical opening

Patients with a history of mid-trimester miscarriage with mild uterine contractions, possible rupture of membranes, history of cervical trauma.

Patients exposed to Diethylstilbestrol:

These patients should be carefully monitored because there is a potential for cervical and uterine abnormalities that may cause:

Miscarriage, ectopic pregnancy (in the first trimester).

Waist-cervical dilation (in the middle trimester)

Premature birth ruptured amniotic fluid (in the last three months).

Test for blood type and Rh

VDRL test

Syphilis of different stages has the risk of pregnancy such as:

Babies born do not have syphilis.

Late miscarriage (after 4 months).

Stillbirth.

Children with congenital syphilis.

Test for gonorrhea

Pregnant women with gonorrhea may or may not have clinical symptoms. Gonorrhea increases the following complications:

Major issues need to be assessed during the perinatal period

Combination prenatal problems

 

Historical factors

New elements form

Premature (<37 weeks)

Mother's qualifications

History of stillbirth

History of preterm labor

History of newborn death

Spawning (> 5)

The uterus is deformed

Weighs less than 45 kg

History of urinary tract infections

Pregnancy-induced hypertension ranges from moderate to severe

Waist-cervical opening

Irregular Rh

Smoke

Radiculitis turns the kidneys

Drug addiction

The fetus develops slowly in the uterus

History of stillbirth

History of newborn death

Spawning (> 5)

Pregnancy-induced hypertension ranges from moderate to severe

 

Pre-eclampsia, eclampsia

Chronic high blood pressure

History of kidney disease

Diabetes

Under 17 years old

Weight increased more than 900 g / week

The fetus develops slowly in the uterus

Roll-up test positive

Multiple pregnancies

Diabetes

Over 35 years old

History of childbirth over 4000g

Family history of someone with diabetes

History of birth defects

Poly amniotic fluid

High blood pressure due to pregnancy

Urinary tract infections

 

Birth defects

Over 35 years old

Diabetes

Recurrent miscarriages

History of birth defects

 

Premature birth

Broken amniotic fluid.

Postpartum fever.

Amniocentesis.

Infection of the newborn.

Pregnancy development delay.

Rubella test

Clinically: Pregnant women with rubella are no different than non-pregnant women who have the disease, but with an acute infection the risks to pregnancy include:

Miscarriage in the first trimester.

Infection of the fetus: Causes birth defects.

Mothers infected in the first trimester: There is a high risk to the fetus.

Patients with a serum rating of <1: 8 for Rubella may already have immunity to the disease.

General analysis of whole blood

Anemia: If so, it should be assessed and treated.

Leukocytosis: When pregnant, the leukocytes increase slightly, if the increase is much, it is necessary to test further.

Urine test

Although the mechanism is not clear yet, during pregnancy, the anatomical and physiological changes will make a woman more susceptible to an asymptomatic or symptomatic urinary tract infection and lead to pyelonephritis.

Approximately 20-40% of pregnant women with asymptomatic urinary tract infections due to bacteria will develop pyelonephritis, causing serious complications in both mother and baby, possibly leading to preterm delivery.

Very few women with asymptomatic urinary tract infections without bacteria, in this group usually have no complications of pyelonephritis and no complications for the fetus.

Asymptomatic urinary tract infections account for 3-5% of pregnant women, especially women with low socio-economic conditions due to multiple births and old age.

It is important for early detection, prompt treatment, and close monitoring.

Cervical vaginal map of the cervix

If an abnormality is found, it should be assessed and treated.

Blood sugar

Pregnancy is the cause of blood sugar worsening, early detection of gestational diabetes will prevent its complications. All pregnant women with a family history of diabetes should be assessed.

Risk assessment

Before giving birth

Pregnancy is a dynamic condition so continuous monitoring and evaluation in the prenatal period to detect abnormal problems early to promptly intervene.

BOARD. PURPOSE OF PRE-BIRTH ASSESSMENT.

Premature birth

Perinatal morbidity and mortality increase in preterm labor cases.

BOARD. ASSESSMENT OF CHILD RISK.

Point

Socio-economic factors

Medical history

Work and daily routine

Current pregnancy status

1

2 children, stay at home

Low socioeconomic status

Miscarriage x 1

Pregnant again after giving birth less than 1 year

Labor outside society

Tired often

2

Mother's age under 20 years old or over 40 years old

No husband

Miscarriage x 2

Smoke more than 10 cigarettes a day

Weight gain less than 4.5 kg from 32 weeks

3

The socioeconomic status is very low

Height below 150 cm

Weighs less than 45 kg

 

Miscarriage x 3

Hard labor, much stress

Going away, tired

Back in the 32nd week.

Weight loss about 2.5 kg

First passed at 32 weeks

Fever

4

Mother under 18 years old

Pyelonephritis

 

Bleeding after 12 weeks

The cervix has been removed, opened

5

 

The uterus is deformed

Miscarriage between the third trimester

Mother used diethylstilbestrol

Cut the tip of the cervix

 

Placental presentation.

Poly amniotic fluid

10

 

premature birth

First and second trimester consecutive miscarriages

 

twin

Abdominal surgery

Scores should be evaluated at the first antenatal visit and re-evaluated at week 22 to week 26. If the score is 10 or above then the patient is at risk of preterm delivery.

Late fetal development in the uterus:

Evaluate systematically by regularly measuring uterine weight and height. Examining fetal measurements on ultrasound and fetal blood flow will more accurately confirm the diagnosis of fetal delay in the uterus and its cause.

Pre-eclampsia and eclampsia:

Many risk factors are associated with developing preeclampsia and eclampsia (Table 1). Tilt test: if the patient lies on his left side and then turns himself on his back with a minimum increase in blood pressure of more than 20 mmHg, the test is considered positive. A positive roll-up test should be closely monitored for early detection of proteinuria, edema, and high blood pressure for people with high-risk factors.

Diabetes:

It is important to diagnose diabetes as soon as possible to develop an early and timely treatment to reduce morbidity and mortality for both mother and child.

Birth defects:

There are a number of risk factors for birth defects in a mother during pregnancy (Table 1). The diagnosis is accurate thanks to ultrasound and amniotic fluid chromatography test as well as some other biochemical tests such as maternal alpha-fetoprotein to determine the malformation of the child's nervous system.

During labor

Maternal risk assessment should be conducted continuously during labor. Several antenatal risk factors are associated with risks during labor and delivery. To reduce perinatal morbidity and mortality it is necessary to clearly define the perinatal risks (Table 3) and the implications of complications during labor and the infant.

Abnormal labor:

Three types of abnormal labor (a-c) are associated with the pathological outcome of the newborn. However, prenatal factors have been associated with other forms of abnormal labor (a, c - e).

Primary contraction disorder.

The second stage of labor is prolonged (> 2.5 hours).

Prolonged labor (total labor> 20 hours)

The potential stage of labor is prolonged.

Labor is very fast.

The cervix does not progress secondary.

Low Apgar index:

Many of the risk factors for low Apgar values ​​can be identified early in labor and it is important to propose timely neonatal resuscitation.

Respiratory failure:

Respiratory failure syndrome is often associated with preterm infants.

Transient rapid breathing. Several risk factors for prenatal and labor should be identified in order to avoid and prevent respiratory failure at birth.

Inhalation of amniotic fluid. It is important to actively manage labor during labor and immediately after birth to avoid inhaling amniotic fluid with meconium.

BOARD.

 

Big problems need prevention

Related issues

 

Before birth

Newborn and in labor

Unusual labor.

The latent period is long

Primary contraction disorder

 

The second stage of labor is prolonged (> 2.5 hours)

Fast labor

 

Prolonged labor (> 20 hours)

 

Mother's age over 35

Recurrent miscarriages

 

Is not

 

History of stillbirth

History of preterm labor

Mother smokes

 

Is not

Neonatal malformation, Apgar index low at 1 minute, inhalation of amniotic fluid

Increased blood bilirubin.

 

Is not

 

Resuscitation at birth

Newborn deformity

Apgar scores are low.

1 minute under 5 points.

 

 

 

 

 

 

 

 

 

5 minutes under 5 points

 

Moderate to severe pre-eclampsia

Mother has heart disease

Mother has diabetes

History of stillbirth

History of newborn death

Abnormal pregnancy

Multiple pregnancies

 

 

Moderate to severe pre-eclampsia

Mother has diabetes

History of stillbirth

Rh (-)

Abnormal pregnancy

 

Preterm baby

Premature rupture of the amniotic fluid

Unusual throne

Multiple pregnancies

Amniotic fluid has plenty of mecon

Primary disorder contraction

Abruptio placentae

Inverse throne.

Deafness due to shoulder

Laying with forceps, suction cups

Abruptio placentae

Amniotic fluid has plenty of mecon

Unusual throne

Preterm baby

Inverse throne

Laying with forceps, suction cups

Respiratory failure

Respiratory failure syndrome

 

 

 

 

 

 

 

 

 

Another respiratory failure

(transient rapid breathing)

 

 

 

Inhalation of amniotic fluid

 

 

 

Moderate to severe kidney disease

Mother has diabetes

History of stillbirth

History of preterm labor

History of newborn death

Mother gives birth more.

The uterus is deformed

Rh (-)

The pre-production is medium to heavy

Renal pelvic calyx

Mother has diabetes

History of newborn death

History of cesarean section

Children weighing more than 9 lbs

Mother's age over 35

Mother has diabetes

History of stillbirth

Mother giving birth more (> 5 children)

Multiple pregnancies

Moderate to severe pre-eclampsia

 

Preterm labor

Moderate to severe pre-eclampsia

Inverse throne

Abruptio placentae

 

 

 

 

 

 

Đẻ not

Broken amniotic fluid

Caesareans

Amniotic fluid has plenty of mecon

 

Moderate to severe pre-eclampsia

Amniotic fluid has plenty of mecon

Multiple pregnancies

Primary contraction disorder

Abruptio placentae

Inverse throne

Deafness due to shoulder