High Risk Pregnancies

Anna Mae Smith, MPAS, PA-C

DEFINITION
A pregnancy in which the mother, fetus, or
newborn is or will be in a state of increased
jeopardy
75% of obstetric deaths are preventable &
most are a result of

HEMORRHAGE
INFECTION
HYPERTENSIVE states

Perinatal death

Those not caused by congenital anomalies

Breech
Placental separation
Pre-eclampsia/eclampsia
Twinning
Pyelonephritis
Placenta previa/abruptio
Hydramnios

INITIAL SCREENING
HISTORY
Maternal Age - young or old
Reproductive history
Medical complications
Physical Exam

TWINS

Dyzogotic twins - (fraternal)

originate from two zygotes!

Account for about 2/3 of twins
rate increases with age
same or different sex
hereditary tendency
genotype

of the mom
one set of dyzotic twins twice as likely as general
population of doing it again!!

TWINS

Monozygotic - (identical)

form from one zygote

If the division of the inner cell mass occurs
after the amniotic cavity occurs (8days) the
identical twins will be in the same amniotic &
chorionic sac
this

accounts for only 1% of monozygotic twins

Monozygotic twins cond

70% of monozygotic twins will have a
separate amniotic sac, single chorion, & a
common placenta
29% develop from early separation of the
blastomeres (first 3 days)

each embryo has its own amnionic & chorionic

sac
The placentas may be separate or fused

Maternal Complications

The physiologic changes occurring in the

mother with a twin gestation are an
exaggeration of what occurs in a singleton
pregnancy.

She has a greater increase in blood volume,

pulse, cardiac output, and weight gain.

Increased Risk for...

Preterm labor

Hypertension

Abruption

Anemia

Hydramnios

Urinary tract infection

Postpartum hemorrhage

Cesarean section

INFANT Complications
Prematurity
small infants weighing less than 2500 g
from a twin pregnancy fare better in the
nursery and have lower mortality rates than
comparable-weight infants from singleton
pregnancies.

INFANT Complications

congenital anomalies is increased two to

three times in twins, and this increase is
mostly confined monozygotic infants

Discordance - unequal weights

altered surface area of placenta

twin to twin transfusion

Twin complications
Vanishing fetus
Locking Twins
Dead fetus syndrome
Delayed delivery of one twin
Cord clamping
Abruption

Epilepsy

Seizure Activity
Maternal injury
miscarriage
fetal hypoxia
Status epilepticus increases the mortality
rate for both mom & fetus!!

Seizures
May be related to hormone levels in some
women
90% will have a good outcome with
adequate planning
25%will have fewer seizures when pregnant
25%will have more
50% no change in seizure activity

Increased risk of
Pre-eclampsia
anemia
vaginal bleeding
C-section
abruption
hyperemesis gravidarum

AED anticonvulsant drugs

Many are anti-folate, therefore critical to
begin folate replacement prior to conception
Most are secreted in breast milk
High teratogenicity (neural tube defects)
seen with

phenobarbital
valproic acid
carbamazepine

Risk of Congenital Problems

MAJOR: 4-6% ( general population - 2-4%)
MINOR: 6-20%

Most common abnormality - Cleft Lip&

palate & congenital heart disease
Vit K deficiency in the newborn from
AEDs

THROMBOEMBOLIC
DISEASE

More estrogen
May occur at any stage but more common later
DVT!!!
VIRDOWs TRIAD

hypercoagulable state
venous stasis
endothelial injury

Hypercoagulation
Protective for delivery
Liver produces more clotting factors!