high risk pregnancy and foetal evaluation risk-14-10-2015.pdf · high risk pregnancy and foetal...
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HIGHRISKPREGNANCYANDFOETALEVALUATION
DrSunitaMishraAssociateProfessor
Dept.ofOBGKIMS,Narketpally
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HIGHRISKPREGNANCYANYPREGNANCYWITHASIGNIFICANTPROBABILITYFORAPOORMATERNALORFOETALOUTCOMESomerecognizedearlyinthefirstantenatalvisitPoorobsterichistoryThosewithwellrecognizedmedicalcomplicationsSomebecomebydevelopingunexpectedcomplicationsinthecourseofotherwisenormalpregnancies
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HIGHRISKPREGNANCYTOOPTIMIZETHEOUTCOMESophisticatedmaternalandfetalsurveillanceDifficultmanagementdecisions
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HIGHRISKPREGNANCYMANAGEMENTIdentificationofwomenathighriskforabnormalpregnancyoutcomesAppropriateAntenatalcareinpreventionofmorbidoutcomesFoetalsurveillance
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IDENTIFICATIONOFHIGHRISKPREGNANCYACCESSTOANTENATALCAREPoverty,animportantlimitingfactorforlimitingaccesstohealthcaresystemQUALITYOFANTENATALCAREServicesprovidedaremanyatimesofmarginalquality,thusrenderingmanyhighriskpregnanciesunidentifiableHIGHRISKPREGNANCIESBELONGTOASMALLSEGMENTOFTHEOBSTETRICALPOULATIONTHATPRODUCESTHEMAJORITYOFTHEMATERNALANDINFANTMORTALITYANDMORBIDITY
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IDENTIFICATIONOFHIGHRISKPREGNANCY
ALISTOFHIGHRISKFACTORSSHOULDBESYSTEMATICALLYCHECKEDDURINGTHEFIRSTANTENATALVISITTOFINDWOMENATRISK
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MEDICALCONDITIONSPLACINGPREGNANCYATHIGHRISKMalnutritionAnaemiaChronichypertensionDiabetesAsthmaThrombophilia(historyofDVTorPE)CardiacdisorderSeizuredisorderFamilyhistoryofgeneticdiseaseHemoglobinopathy
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MEDICALCONDITIONSPLACINGPREGNANCYATHIGHRISKRenaldiseasePsychiatricillnessLupuserythematosusandotherconnectivetissuedisordersDrugandalcoholabuseSmokingRhalloimmunizationHepatitisBcarrierHumanimmunodeficiencyvirusSyphilsGonorrheaandChlamydialinfectionAsymptomaticbacteriuria
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OBSTETRICALHIGHRISKFACTORSH/OpreviousprolongedlabourinstrumentalassisteddeliveryH/Opreviousobstructedlabour/ruptureuterus/traumaticdeliveryH/OPPH(highparitystatus)/obstetricshockH/OpuerperalsepsisPriorpretermbirth(
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OBSTETRICALHIGHRISKFACTORS
PriorneonataldeathPriorinfantwithcerebralpalsyPriorcaesareandeliveryDiagnosisofincompetentcervixinpriorpregnancyH/Opreeclampsiabefore32weeksinpriorpregnancyPriorfoetuswithchromosomaldisorderorcongenitalanatomicabnormalitiesAnatomicabnormalityoftheuterusH/Ocervicaltrauma
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HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE
1. Womenwithconditionsrequiringinvasiveproceduresforfoetaldiagnosisortreatment
RhalloimunizationNonimmunologicfoetalhydropsFoetalurinarytractobstructionNeedforCVS
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HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE2.Womenwithseveremedicalcomplicationsaffectingpregnancy:InsulindependentdiabetesArtificialheartvalvesCardiomyopathySystemiclupuserythematosusSicklecelldisease/thalassemiaThromboembolicphenomenaSeizuredisorder
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HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE3. Womenwithrecurrentpoorobstetricaloutcome:RepetitivesecondtrimesterpregnancylossesRecurrentstillbirthsRecurrentearlypretermlabourRecurrentearlyruptureofmembranes
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HIGHRISKPATIENTSBENEFITTINGBYREFERRAL/CONSULTATIONWITHMATERNAL&FOETALMEDICINE4.Womenwithsevereobstetricalcomplications:Preeclampsia/eclampsiawithrenalfailure,pulmonaryoedemaSevereHELLPsyndromeSuspectedcervicalincompetenceafter20weeksgestationSuspectedtwintotwintransfusionMultiplegestationofhighorder(3andabove)
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PRECONCEPTIONALCOUNSELING
ThebesttimetoassessthepotentialimpactofmedicalorobstetricalcomplicationsontheoutcomeofpregnancyisBEFOREPREGNANCYOCCURSThefollowingpointsshouldbemethodicallyreviewedbytheobstetrician:1. Relativeimportanceofeachofthehighriskfactors
identifiedthroughhistory&examinationofthepatient
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PRECONCEPTIONALCOUNSELING
2.Thepotentialeffectsthateachriskfactormayhaveonthepregnancy
3.Thechangesoreffectsthatpregnancymaycauseuponeachriskfactor
4.Thepotentialdisabilityforthemotherduringpregnancy&thelengthofsuchdisability
5.Thetestsrequiredtomonitormaternal&foetalwellbeingduringpregnancy
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PRECONCEPTIONALCOUNSELING
6.Theprognosisfortheoutcomeofthepregnancy7.Thecostofpregnancy,thelossofrevenueasaresultofprolongedhospitalization&frequenttesting,needforhelpathomewithotherchildrenandthemonetaryandemotionalcostsofdealingwitheffectsofprematurity
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PRECONCEPTIONALCOUNSELING
Conditionsbenefiting:MaternaldiabetesRhalloimmunizationHistoryofrecurrentstillbirthsPatientsathighriskforhavingfoetuseswithaneuploidy
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PRECONCEPTIONALCOUNSELING
WomenwithaH/Obirthofababywithneuraltubedefectshouldbeprescribedfolicacidsupplementsfor3monthspriortoattemptingsubsequentpregnancyRoutinetestingforrubellaIgGantibodiespriortoplanningpregnancyisrecommendedUsingiodizedsaltandpracticeofscreeningallpatientsforthyroiddisordersarerecommended
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ANTENATALCARE
PRIMARYOBJECTIVE:Preventionandtreatmentofabnormalmaternalandfoetaloutcomes
DETERMINATIONOFGESTATIONALAGE:Anaccuratedeterminationofthegestationalageandtheexpecteddateofdelivery(EDD)Isfundamentaltothemanagementofhighriskpregnancies
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DETERMINATIONOFGESTATIONALAGEBestmethodisthroughneonatalevaluation.Althoughgoldstandard,itsnotofmuchusetoobstetriciansClinicaldatingDatingbyultrasound
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DETERMINATIONOFGESTATIONALAGECLINICALDATINGTiming&characteristicsoftheLMPThefindingsontheinitialpelvicexaminationThedateonwhichfoetalhearttonesarefirstheardRelationbetweenthedateoffirstpositivepregnancytestandthemenstrualhistory
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CLINICALDATING
MENSTRUALHISTORYADEQUATEFOREDDONLYIF
LMPnormalinduration&amountofflowpriormenstrualperiodscameatregularintervalspatienthasnotusedoralcontraceptiveswithinthreemonthsofherlastperiod30%patientsdonotfulfillthesecriteria,makingestimationofEDDbasedontheirLMPsunreliable
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CLINICALDATINGEVALUATIONOFUTERINESIZELIMITEDVALUEmaternalobesityobserverexperiencepositionoftheuterusamountofamnioticfluidmultiplegestationpresenceofuterinemyomasfoetalgrowthdisordersStudieshavedemonstratedthatphysiciansmeasurementstendtounderestimatethegestationalage&haveapreferenceforevennumbers
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CLINICALDATING
DATEONWHICHFOETALHEARTTONESAREFIRSTAUDIBLE
withDopplerultrasounddevices(10weeks)withobstetricalstethoscopes(20weeks)Butthisisofvalueonlywhenitagreeswithotherclinicalindicators&withtheultrasoundmeasurements
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CLINICALDATINGDATEOFTHEFIRSTPOSITIVEPREGNANCYTESThighlysensitiveallowsdiagnosisofpregnancyat45postmenstrualweeksAssuchdatesfirmlyestablishedifpatienthasapositivepregnancytest45weeksafterherLMP
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DATINGBYULTRASOUNDFOETALBIOMETRY:Theabilitytovisualizewithultrasound,differentfoetalanatomicallandmarksandtofollowtheirgrowthduringgestationAccuratelydeterminesthegestationalageofthefoetusandtheadequacyofthefoetalgrowthUsesCRLinthefirsttrimesterandtheBPD,HC,FL,HL&ACinthesecondtrimester
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DATINGBYULTRASOUND
Similaraccuracywhenperformedbetween1114weeksofgestationand1822weeksofgestation
After22weeksthemarginoferrorincreasesandthenitisnecessarytoobtainserialmeasurements34weeksaparttoavoidasignificanterror
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RELIABILITYOFEDD
EXCELLENTDATES:Patientswithadequateclinicalinformationplusultrasoundexaminationbetweenbetween1624weeksPatientswithinadequateorincompleteclinicalinformationbutwithtwoultrasoundexaminationsbetween16and24weeks
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RELIABILITYOFEDDGOODDATES:Patientswithadequateclinicalinformationandoneconfirmingultrasoundexaminationobtainedafter24weeksofgestationPatientswithinadequateorincompleteclinicalinformationandtwoormoreultrasoundexaminationsshowingadequategrowthandsimilarEDD
POORDATES:Anyclinicalsituationdifferentfromthoselistedabove
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DATINGBYULTRASOUND
CRLMeasurementofCRLinthefirsttrimesterofpregnancyisthemostaccuratemethodtodetermineGAPredictsthemenstrualagewithavariationof+3dayswhenobtainedbetween710weeksPossiblesourceoferrorinpresenceofanembryowithchromosomalabnormalities
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DATINGBYULTRASOUND
BPD:MostaccuratemeasurementtodetermineGAinthesecondtrimesterofpregnancyCephalicIndex,ratiooftheBPDtoOFD,measuredwhenfoetalheadlooksflattened&elongated
HC:NotalteredbydolichocephalyorbrachycephalyoffoetalheadUsuallymeasuredbyelectroniccalipers,butcanalsobecalculatedusingtheequationHC=BPD+OFD/2
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DATINGBYULTRASOUND
FL:Excellentparameter,asitisnotsignificantlyaffectedbyalterationsinthefoetalgrowth.
HL:RelativelyeasytoobtainAC:LessreliableparameterforGAestimationbecauseitisverysensitivetoalterationsinfoetalgrowthMostimportantparameterintheestimationoffoetalweight
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DATINGBYULTRASOUND
DETERMINATIONOFGESTATIONALAGEMostUSGmachineshaveincorporatedintotheirsoftware,NOMOGRAMStocalculateGAusingtheBPD,HC,AC,FL,CRL,andHL
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESFUNDAMENTALOBJECTIVEOFANTENATALCARETheworseoutcomesarematernalandfetaldeathMATERNALDEATHMMR(Maternalmortalityrate)inIndiacontinuestobeunacceptablyhighatabout162per100,000livebirths
TheInternationalClassificationofDiseasesdefinesmaternaldeathasthedeathofawomanwhilepregnantorwithin42days(or1yearforlatematernaldeaths)ofdelivery,irrespectiveofthedurationorsiteofthepregnancy,fromanycauserelatedtooraggravatedbypregnancy,butnotfromaccidentalorincidentalcauses
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES
AccordingtoWHO,inIndiatheleadingdirectcausesofmaternalmortalityarehaemorrhage,sepsis,preeclampsia&eclampsia,unsafeabortion,andobstructedlabour.
Necessarytoincreaseaccesstoprenatalcaretodecreasematernaldeathssecondarytopreeclampsia/eclampsia/HELLPsyndromeindevelopingcountries.
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES
Maternaldeathsecondarytoinfectionexhibitedasignificantdecreasewithavailabilityoflegalabortionbutisontheriseagain
Maternaldeathsecondarytoabortionisstillasignificantproblemindevelopingandindustrializedcountries,explainedpartiallybylackofavailabilityoflegalabortions.
Directobstetriccausesrelatetomaternaldeathsresultingfromcomplicationsofpregnancy,labour,puerperiumduetointerventions,omissions,orincorrecttreatments,orfromchainofeventsresultingfromanyoftheabove.
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES
Mostmaternaldeathsarepreventable:PovertyalleviationHumanrightsassertionIndividualeffortsfromhealthcareprovidersProperantenatalcareIdentifyingwomenatriskToaggressivelytreatcomplications
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESHEALTHSECTORACTIONSTOPREVENTORREDUCE
MATERNALMORTALITYBasicantenatal,intranatal&postnatalcareAskilledattendant&afunctioningreferralsystemEmergencyobstetriccare(EmOC)GoodqualityobstetricservicesFamilyplanningservicesFrequentjointconsultationamongspecialistsinmanaging
medicaldisordersinpregnancyMaternalmortalityconferencesPeriodicrefreshercoursesforeducationoftheskilled
personnelsCOMMUNITY,SOCIETYANDFAMILYACTIONS:Widerangeofgroups(womensgroups),healthcare
professionals,religiousleadersandsafemotherhoodcommiteescanhelpthewomanobtaintheessentialobstetriccare.
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES
HEALTHPLANNERS/POLICYMAKERSACTION:Communityeducation,motivation&formationofsafemotherhoodcommitteeatthelocallevelStrengtheningreferralsystemsforobstetricemergenciesWrittenmanagementprotocolsforobstetricemergenciesinthehospitalImprovingstandard&qualityofcarebyorganizingrefreshercoursesforhealthcarepersonnelsPeriodicauditofexistinghealthcaredeliverysystem&toimplementchangesasneeded
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES
LEGISLATIVEANDPOLICYACTIONS:Girlchildren&adolescentsshouldhavegoodnutrition,educationandeconomicopportunitiesBarrierstotheaccessofhealthcarefacilitiesshouldberemovedDecentralizationofservicesSafeabortionservicesandpostabortioncareSocialinequalities&discriminationongroundsofgender,age&maritalstatus,aretoberemoved
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMES
NEONATALDEATH:Deathoftheinfantwithin28daysafterbirthThemaincausesofneonatalmortalityindevelopingcountriesare Prematurity Infection Birthasphyxia
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESSTILLBIRTH:Birthofanewbornafter28thcompleted
week,weighing1000gmormore,whenthebabydoesnotbreatheorshowanysignoflifeafterdelivery,bothantepartum(macerated)andintrapartum(freshstillbirths)deathsincluded
PREVENTIONOFSTILLBIRTHANDNEONATALDEATHS: Skillledattendantatbirth,effectivemanagementofobstetric
complications Prepregancycare,effectivemanagementofpregnancy
complications Preconceptionalgeneticcounselling,prenataldiagnosis Effectivecareduringpregnancyandlabour.Cleandelivery
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESPERINATALMORTALITY:Deathamongfoetusesweighing1000gmsormoreatbirth(28wksgestation)whodiebeforeorduringdeliveryorwithinfirst7daysofdelivery
PNMRofIndiaisabout60per1000totalbirthstobereducedto3035/1000births
CAUSES:PrematurityLowbirthweightBirthasphyxiaInfectionsCongenitalmalformationsBirthtraumaRespiratorydistresssyndrome
th
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PREVENTIONOFABNORMALMATERNALANDFOETALOUTCOMESPREVENTIONOFPERINATALMORTALITY: Prepregnancyhealthcareandcounseling Geneticcounseling RegularANCDetection&managementofmedicaldisordersinpregnancy Screeningofhighriskpatients Carefulmonitoringinlabour Skilledbirthattendant ProvisionofreferralneonatalserviceHealthcareeducationofthemotheraboutthecareofthe
newborn Educatingthecommunitytoutilizefamilyplanningservices Autopsystudiesofallperinataldeaths Continuedstudyofperinatalmortalityproblems
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ANTEPARTUMFOETALSURVEILLANCEMETHODSUSEDTODETECT&EVALUATETHESEVERITYOFACUTEORCHRONICFOETALHYPOXIAAREBIOPHYSICALINNATUREFoetalmovementcountThenonstresstest(NST)Thecontractionstresstest(CST)Thefoetalbiophysicalprofile(BPP)Themodifiedbiophysicalprofile(MBPP)Umbilical,cerebral,uterine,andvenousDopplerPercutaneousumbilicalbloodsampling
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ANTEPARTUMFOETALSURVEILLANCEFOETALMOVEMENTCOUNT: Simplestandleastcostlymethodfortheevaluationoffoetal
wellbeinginthesecondhalfofpregnancy Cardif`count10formula:Patientcountsfoetalmovements
startingat9amandcountendsassoonas10movementsperceived.Sheisinstructedtoreportiflessthan10movementsoccurduring12hourson2successivedaysorifnomovementsperceivedevenafter12hoursinasingleday.
Dailyfoetalmovementcount(DFMC):3countseachof1hourduration(morning,noon,evening)arerecommended.Totalcountmultipliedby4givesDFMC.If
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ANTEPARTUMFOETALSURVEILLANCENONSTRESSTEST(NST):ACONTINUOUSELECTRONICMONITORINGOFTHEFOETALHEARTRATEALONGWITHRECORDINGOFFOETALMOVEMENTS
ThetestlooksforthepresenceoftemporaryaccelerationsofFHRassociatedwithfoetalmovement.
Foetalsleep&foetalhypoxiaarethemostcommonphysiologic&pathologicconditionsrespectivelyforabsenceofaccelerationsduringaNST.
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ANTEPARTUMFOETALSURVEILLANCEREACTIVENST(normal):TwoormoreFHRaccelerationsofatleast15beatsperminute&lastingatleast15secondsfrombaselinetobaselinewithina20minuteperiodwithorwithoutassociationwithfoetalmovementsasperceivedbythewoman
NONREACTIVENST:Lackofaccelerationsforaperiodof40minutes
VariablesevaluatedinNST:BaselineFHRVariabilityofFHRPresenceorabsenceofaccelerationsPresenceorabsenceofdecelerations
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REACTIVENST
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ANTEPARTUMFOETALSURVEILLANCENSTVARIABLES:AnormalbaselineFHRisbetween110&160bpmFHRvariabilityisofutmostimportance&dependsontheinteractionofthefoetalsympathetic¶sympatheticnervoussystemsPresenceofaccelerationsofFHRwithfoetalmovementsorinresponsetofoetalstimulationisreliablesignoffoetalhealthThepresenceofspontaneousseverevariableorlatedecelerationsisworrisome,indicatingfoetalcompromise
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ANTEPARTUMFOETALSURVEILLANCECONTRACTIONSTRESSTEST:TestbasedonexperimentalevidencesthattheuteroplacentalbloodflowdecreasesmarkedlyorceasesduringuterinecontractionsTheendpointoftheCSTisthepresenceorabsenceoflatedecelerationsoftheFHRfollowinguterinecontractionsLatedecelerationsareoneoftheearliestindicatorsoffoetalcompromiseCSTusedinfrequently,rathermostcommonlyusedtofollowanonreactiveNST
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ANTEPARTUMFOETALSURVEILLANCETHEBIOPHYSICALPROFILE:CombinestheNSTwiththeobservationbyultrasoundoffourvariables:
foetalbreathingmovementsfoetalbodymovementsfoetaltoneamnioticfluidvolume
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ANTEPARTUMFOETALSURVEILLANCE(BPP)Foetalbreathingmovement:thirtysecondsofsustainedbreathingmovementduringa30
minuteobservationperiodFoetalmovement:threeormoregrossbodymovementsina30minute
observationperiodFoetaltone:oneormoreepisodesoflimbmotionfromapositionofflexion
toextension&arapidreturntoflexionFoetalheartratereactivity:Twoormorefoetalheartrateaccelerationsassociatedwith
foetalmovementofatleast15bpm&lastingatleast15secondsin10minutes(reactiveNST)
Fluidvolume:Presenceofapocketofamnioticfluidthatmeasuresatleast2
cmintwoperpendicularplanes
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ANTEPARTUMFOETALSURVEILLANCE(BPP)EachofthefivecomponentsoftheBPPassignedanumericalvalueof2(ifpresentornormal)or0(ifabsentorabnormal)Avalueof8or10indicatesanormalorreassuringfoetalstatusAscoreof6isequivocal,requiresfurthertesttoverifyfoetalwellbeingAscoreof4orlessissuggestiveoffoetalcompromise
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ANTEPARTUMFOETALSURVEILLANCE(MODIFIEDBPP)
COMBINESTHEOBSERVATIONOFANINDEXOFACUTEFOETALHYPOXIA,
THENSTWITHVAST,WITHASECONDINDEXINDICATIVEOFCHRONICFOETALPROBLEMS,THEAMNIOTICFLUIDVOLUME
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ANTEPARTUMFOETALSURVEILLANCE(DOPPLERULTRASOUNDVELOCIMETRY)
EVALUATIONOFFOETALCIRCULATIONBASEDONTHEPHYSICALPRINCIPLEOFCHANGEINFREQUENCYOFSOUNDWAVEWHENITISREFLECTEDBYAMOVINGOBJECT
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ANTEPARTUMFOETALSURVEILLANCE(DOPPLERULTRASOUNDVELOCIMETRY)
ARTERIALDOPPLER:Waveformshelpfultoassessthedownstreamvascularresistance Usedtomeasurepeaksystolic(S),peakdiastolic(D)&mean(M)
volumesfromwhichS/DratioPulsatalityindex(PI)[PI=(SD/M]Resistanceindex(RI)[RI=(SD/S] InanormalpregnancytheS/Dratio,PI&RIdecreasesasthe
gestationalageadvancesHighervaluesgreaterthan2SDsabovethegestationalage
meanindicatesreduceddiastolicvelocities&increasedplacentalvascularresistanceindicatingadversepregnancyoutcome.
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THREESTUDIESOFFOETALUMBILICALARTERYVELOCIMETRY
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ANTEPARTUMFOETALSURVEILLANCE(DOPPLERULTRASOUNDVELOCIMETRY)
VENOUSDOPPLER:Provideinformationaboutcardiacforwardfunction(cardiaccompliance,contractility&afterload)FoetuseswithabnormalcardiacfunctionshowpulasatileflowintheumbilicalveinNormalUVflowismonophasic
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ANTEPARTUMFOETALSURVEILLANCEFOETALBLOODSAMPLING(CORDOCENTESIS)PercutaneousUmbilicalBloodSamplingorCordocentesisEasilyperformedafter24weeks,butcanbedoneasearlyas18weekstooPlacentalinsertionsitepreferredRequireshighresolutionultrasoundequipmentMainrisksarebleedingfrompuncturesiteandvagalreflexcausingseverefoetalbradycardiaUsedeclinedwithdevelopmentoflessinvasivetechnologyforfoetaldiagnosis
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GOI,SAFEMOTHERHOODPROGRAMME(CSSM)ESSENTIALOBSTETRICCAREFORALLINCLUDES:Registrationbetween1216weeksAntenatalvisits(minimumthree)at16,28,and38weeksgestationDocumentBP,Wt,&obstetricexaminationfindingsateachvisitMandatoryinvestigationsincludeHb%,ABO&Rhtype,urineprotein&sugar,stools,postprandialsugarMedications:oraliron,folicacid,anddewormingagentsafter16weeksgestation
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GOI,SAFEMOTHERHOODPROGRAMME(CSSM)Tetanustoxoidinjection,twodoses/46weeksapartTimelyreferenceforemergencyobstetriccareUseofcleanpregnancykitforconductingdeliveryTheaimwastoprovidetheANMs/skilledbirthattendantstoconductsafedeliveryunderhygienicsurroundingstominimizematernaldeathsinruralsettings.
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THANKYOU