WEBVTT 1 00:00:10.000 --> 00:00:15.900 Thank you, thank you Dr. Srishti for that warm welcome. Okay, 2 00:00:16.100 --> 00:00:21.600 so hello everyone. I'm Dr. Seeru Garg. She is already introduced 3 00:00:21.600 --> 00:00:26.600 me enough. So I'll be discussing about high risk pregnancy 4 00:00:26.600 --> 00:00:31.800 because that is what I specialize in as an obstetrician and gynecologist 5 00:00:32.000 --> 00:00:37.000 and I'm attached to it. I'm running Well Woman Gynecology Clinic and 6 00:00:37.000 --> 00:00:41.200 I am attached with Dr. L. H. Hiranandani Hospital, Surya Hospitals and 7 00:00:41.200 --> 00:00:45.800 Fortis Hospitals and we do run a high risk pregnancy clinic especially 8 00:00:45.800 --> 00:00:50.900 at Hiranandani Hospital in Mumbai. So and 9 00:00:51.200 --> 00:00:55.500 I have already been running the high risk pregnancy clinic for the 10 00:00:55.500 --> 00:01:00.900 last eight to nine years and that's where the expertise 11 00:01:00.900 --> 00:01:05.900 comes from and I'm a member of Foxy, MOGS, ICOGP, CSS 12 00:01:05.900 --> 00:01:10.900 Society of India, IMC with 19 plus years of experience. So 13 00:01:11.700 --> 00:01:17.000 as Nora Robert said, nothing worthwhile is ever without complications. 14 00:01:17.600 --> 00:01:22.700 That's why a pregnancy complicated with various factors is a high risk 15 00:01:22.700 --> 00:01:26.200 pregnancy. That why we are here to discuss today about high risk 16 00:01:26.200 --> 00:01:31.200 pregnancy and overview. Now a high risk pregnancy is a condition that 17 00:01:31.200 --> 00:01:36.200 threatens the health and life of the mother and offspring. And 18 00:01:36.200 --> 00:01:40.700 a high risk pregnancy needs special care, follow up and management. We 19 00:01:40.700 --> 00:01:44.700 all know that and that's what how we should manage these high 20 00:01:44.700 --> 00:01:48.500 risk pregnancy cases and which patients fall into the high risk pregnancy 21 00:01:48.500 --> 00:01:51.500 group is what is important for us to understand. If you see 22 00:01:51.500 --> 00:01:56.400 this picture, there are few of the pictures of high risk cases 23 00:01:56.400 --> 00:02:00.200 which I have put here. This is a woman who's 100 kg 24 00:02:00.200 --> 00:02:04.900 on a cesarean section operation theater table. So obesity is the risk 25 00:02:04.900 --> 00:02:08.700 factor here. If you can see this baby is a macrosomic baby 26 00:02:08.700 --> 00:02:13.700 with 4.44 kg of birth weight born to 27 00:02:13.700 --> 00:02:19.800 a obese woman who also had gestational diabetes. This 28 00:02:19.800 --> 00:02:24.400 is a case of severe preeclampsia where you can see the puffiness 29 00:02:24.400 --> 00:02:28.200 of face and obviously there was edema feet and the other associated 30 00:02:28.200 --> 00:02:33.900 complications, a case of fibroid uterus with pregnancy. 31 00:02:34.000 --> 00:02:39.300 So this is what is again fibroid complicating the pregnancy. This 32 00:02:39.300 --> 00:02:43.500 is a very interesting case of a twin pregnancy complicated with twin 33 00:02:43.500 --> 00:02:48.600 reverse arterial perfusion syndrome and I'll be discussing this later on. You 34 00:02:48.600 --> 00:02:52.000 can have a look at the slide now. Now which patients fall 35 00:02:52.000 --> 00:02:56.100 in the category of high risk pregnancy? If I can tell you, 36 00:02:56.100 --> 00:03:00.500 now there are various categories, how we categorize high risk pregnancy is 37 00:03:00.500 --> 00:03:06.500 one is medical diseases complicating pregnancy like high blood pressure, chronic 38 00:03:07.500 --> 00:03:12.500 high blood pressure could be chronic hypertension or essential hypertension, 39 00:03:12.700 --> 00:03:18.100 preeclampsia, gestational hypertension, chronic hypertension with superimposed 40 00:03:18.100 --> 00:03:22.700 preeclampsia. So all these come under the category of high blood pressure 41 00:03:22.700 --> 00:03:28.100 during pregnancy or hypertension during pregnancy. Now diabetes complicating pregnancy 42 00:03:28.100 --> 00:03:34.100 could be gestational diabetes mellitus or overt diabetes mellitus, hypothyroidism. 43 00:03:34.100 --> 00:03:39.900 So we see a lot of cases of subclinical hypothyroidism during pregnancy 44 00:03:40.000 --> 00:03:44.100 which means that thyroid needs to be well controlled when the patient 45 00:03:44.100 --> 00:03:49.200 conceives and during throughout the pregnancy. So even if the 46 00:03:49.200 --> 00:03:54.800 values which are normal for other normal individuals 47 00:03:54.800 --> 00:03:59.400 may not stay hold true for the pregnant woman as the requirement 48 00:03:59.500 --> 00:04:03.800 of thyroid increases. That is why we have to control it and 49 00:04:03.800 --> 00:04:09.300 those kind of patients are called put under subclinical hypothyroidism 50 00:04:09.300 --> 00:04:13.200 category and that also needs treatment. So this is what we need 51 00:04:13.200 --> 00:04:18.200 to understand. Hyperthyroidism of course, heart disease in pregnancy, liver 52 00:04:18.200 --> 00:04:23.300 disorders in pregnancy, kidney diseases like nephrotic syndrome, glomerular nephritis, 53 00:04:23.900 --> 00:04:28.900 all these are could be complicating the pregnancy and that 54 00:04:28.900 --> 00:04:33.000 pregnancy becomes a high risk pregnancy. Then anemia in pregnancy, obesity. I 55 00:04:33.000 --> 00:04:38.000 all just now showed you a picture, thrombophilias, systemic lupus 56 00:04:38.000 --> 00:04:43.400 erythematosus and other collagen vascular diseases complicating pregnancy, rheumatoid 57 00:04:43.400 --> 00:04:48.700 arthritis and more. Now there could be certain events 58 00:04:48.700 --> 00:04:52.300 occurring during the present pregnancy which can put the pregnancy at risk 59 00:04:52.400 --> 00:04:57.500 like fetal fetal growth restriction, threatened preterm labor, preterm 60 00:04:57.700 --> 00:05:04.200 premature rupture of membranes, antepartum 61 00:05:04.200 --> 00:05:09.200 hemorrhage like placenta previa or abruptio placentae or vasa previa, 62 00:05:09.400 --> 00:05:14.700 utero placental insufficiency. It could be due to pregnancy induced 63 00:05:14.700 --> 00:05:19.900 hypertension. It could be due to diabetes with vasculitis. So 64 00:05:19.900 --> 00:05:25.500 there could be many many reasons. It could be a nutritional deficiency 65 00:05:25.500 --> 00:05:31.000 which which can cause utero placental insufficiency, oligohydramnios, 66 00:05:31.200 --> 00:05:36.400 polyhydramnios. These are the other risk factors. Now the surgical disorders 67 00:05:36.400 --> 00:05:40.300 can complicate pregnancy like fibroid uterus. I just showed you a picture. 68 00:05:40.800 --> 00:05:46.100 Previous history of myo so fibroid, how can that complicate pregnancy? Fibroid 69 00:05:46.100 --> 00:05:51.300 uterus can cause you know preterm 70 00:05:51.300 --> 00:05:55.700 labors, red degeneration of fibroid can complicate pregnancy in the second and 71 00:05:55.700 --> 00:06:00.000 third trimester. So we have to be extremely vigilant with these kind 72 00:06:00.000 --> 00:06:05.000 of women and monitor these pregnancies more closely. Previous history of 73 00:06:05.000 --> 00:06:10.300 myomectomy puts the patient at risk because a previous 74 00:06:10.300 --> 00:06:15.400 myomectomy scar if present in case so there could be 75 00:06:15.400 --> 00:06:20.400 chances of rupture of that previous scar if the cavity was 76 00:06:20.400 --> 00:06:25.600 open during myomectomy, the uterine cavity was open. then this patient needs 77 00:06:25.600 --> 00:06:29.000 to go for an elective cesarean section in the next pregnancy at 78 00:06:29.000 --> 00:06:34.300 37 weeks of gestation. Previous classical cesarean section again is a high 79 00:06:34.300 --> 00:06:38.500 risk pregnancy because of chances of rupture of the previous scar and 80 00:06:38.500 --> 00:06:44.100 ovarian cysts can complicate pregnancy. We've seen cases of cyst with torsion 81 00:06:44.100 --> 00:06:49.200 during pregnancy. A recent bariatric surgery again puts the woman 82 00:06:49.300 --> 00:06:54.500 at risk because of nutritional deficiencies and a ketosis which 83 00:06:54.500 --> 00:07:00.000 happens post bariatric surgery. That that that 84 00:07:00.000 --> 00:07:05.200 is why we suggest patients to plan pregnancy at least one 85 00:07:05.200 --> 00:07:11.400 year after the bariatric surgery and not earlier. Now 86 00:07:11.400 --> 00:07:16.400 what is the challenge in these high risk pregnancies in today's day 87 00:07:16.400 --> 00:07:20.200 and age and why are we encountering so many high risk pregnancies 88 00:07:20.200 --> 00:07:24.600 today's day and age? The challenges are obesity a very big because 89 00:07:24.600 --> 00:07:29.600 we all know obesity is a pandemic today and we've 90 00:07:29.600 --> 00:07:34.300 got that prevalence is increasing because of our lifestyle changes, because of 91 00:07:34.300 --> 00:07:39.500 the sedentary lifestyle, because of the stress associated with our day-to-day life 92 00:07:39.700 --> 00:07:44.900 and because of the eating patterns and the emotional 93 00:07:44.900 --> 00:07:49.700 eating which people go through. So again that puts the woman at 94 00:07:49.700 --> 00:07:55.100 different challenges which I'm going to discuss further. PCOS very rampant 95 00:07:55.100 --> 00:08:00.100 and today one in five women are are facing 96 00:08:00.100 --> 00:08:05.300 PCOS in India today. That's how the incidence of PCOS 97 00:08:05.300 --> 00:08:10.900 is and what obstetric complications again miscarriages can be preterm labor, 98 00:08:10.900 --> 00:08:16.800 gestational diabetes, hypertension can all complicate a woman who's 99 00:08:16.800 --> 00:08:21.800 pregnant and had has a history of PCOS. Advanced maternal age again 100 00:08:21.800 --> 00:08:27.400 puts the woman at risk of a chromosomal abnormalities in the baby, 101 00:08:28.000 --> 00:08:33.200 high blood pressure, diabetes and other complications. 102 00:08:33.300 --> 00:08:38.100 Now pregnancies with artificial reproductive techniques now today's day and age we 103 00:08:38.100 --> 00:08:42.400 are seeing every day in my practice I am seeing women planning 104 00:08:42.400 --> 00:08:47.400 pregnancies at 39 38 39 40 years of age where they 105 00:08:47.400 --> 00:08:51.700 fall into the advanced maternal age category and these women many a 106 00:08:51.700 --> 00:08:57.200 times because of challenges with fertility or subfertility 107 00:08:57.200 --> 00:09:02.300 or infertility, they need artificial reproductive techniques to conceive and then obviously 108 00:09:02.500 --> 00:09:07.800 there are complications maybe associated with that because of age 109 00:09:07.800 --> 00:09:11.900 of the mother and also the other incidence is higher incidence of 110 00:09:11.900 --> 00:09:17.000 again diabetes and blood pressure. Again high incidence of multiple pregnancies. 111 00:09:17.300 --> 00:09:22.000 Why are we encountering that? Again another risk risk factor again comes 112 00:09:22.000 --> 00:09:27.000 as women with subfertility or infertility or 113 00:09:27.000 --> 00:09:32.000 planning pregnancy and an advanced gestational age where ovulation induction drugs have 114 00:09:32.000 --> 00:09:35.700 been used or artificial reproductive techniques have been used. That is why 115 00:09:35.700 --> 00:09:40.000 the incidence of multiple pregnancies which is twins or triplets has also 116 00:09:40.000 --> 00:09:45.200 increased and putting the woman for upward challenges 117 00:09:45.300 --> 00:09:50.300 like anemia, diabetes, hypertension, preterm labors and other 118 00:09:50.300 --> 00:09:55.400 complications which I'm going to discuss further. Now some past obstetric outcomes 119 00:09:55.400 --> 00:09:59.300 can put the pregnant present pregnancy at risk which are recurrent pregnancy 120 00:09:59.300 --> 00:10:04.600 loss, past obstetric history, previous preterm delivery, previous stillbirth, previous 121 00:10:04.600 --> 00:10:09.800 Down syndrome child or a previous neonatal death. So the next pregnancy 122 00:10:09.800 --> 00:10:14.900 has to be monitored extremely vigilantly so that the outcome 123 00:10:14.900 --> 00:10:19.300 is not the same and much better in this pregnancy. Now what 124 00:10:19.300 --> 00:10:23.800 is recurrent pregnancy loss? Different pregnancy loss can be because of anatomical 125 00:10:23.800 --> 00:10:29.000 problems in uterus or cervix, any thrombophilias like protein 126 00:10:29.000 --> 00:10:34.300 C, protein S, antithrombin three deficiencies or factor five Leiden. 127 00:10:34.400 --> 00:10:39.400 There can be beta glyco protein deficiencies or apply 128 00:10:39.400 --> 00:10:44.500 anti-phospholipid antibody syndrome or due to hormonal imbalances or 129 00:10:44.500 --> 00:10:50.900 recurrent chromosomal abnormalities due to certain inherent 130 00:10:50.900 --> 00:10:56.500 properties in both partners or anyone of the partners. Now such patients 131 00:10:56.500 --> 00:11:01.700 require special screening and diagnostic tests and treatment right from the beginning 132 00:11:01.700 --> 00:11:06.100 of first trimester or rather before planning pregnancy. Before planning the next 133 00:11:06.100 --> 00:11:11.300 pregnancy, it's extremely important. Now preterm previous 134 00:11:11.300 --> 00:11:16.400 preterm delivery may be caused due to infections, incompetent cervix or cervical 135 00:11:16.400 --> 00:11:21.400 insufficiency, multiple pregnancies or any other medical illnesses. These patients 136 00:11:21.400 --> 00:11:25.800 again need increased care for early diagnosis and management of certain preterm 137 00:11:25.800 --> 00:11:30.600 labor. Now we've got beautiful drugs which are available to manage the 138 00:11:31.000 --> 00:11:35.900 threatened preterm labor and as long as we are vigilant and we 139 00:11:35.900 --> 00:11:39.600 know what we are dealing with. Like we say the eyes will 140 00:11:39.600 --> 00:11:42.900 only see what the mind knows. That is how it's important to 141 00:11:42.900 --> 00:11:47.000 understand all these factors. Go back into these three of the patient, 142 00:11:47.000 --> 00:11:51.700 understand what was what were the factors responsible for the preterm delivery 143 00:11:51.900 --> 00:11:57.000 and then manage the next pregnancy accordingly. And now you you've already 144 00:11:57.000 --> 00:12:03.000 seen this picture with severe preeclampsia and puffiness of face. That 145 00:12:03.000 --> 00:12:08.500 that's the hypertension in pregnancy. Now gestational hypertension is one entity 146 00:12:08.600 --> 00:12:13.300 or it can progress to preeclampsia. That is hypertension with proteinuria or 147 00:12:13.300 --> 00:12:18.300 eclampsia, hypertension with seizures. So hypertension 148 00:12:18.300 --> 00:12:23.500 in pregnancy puts the pregnant woman at risk and the fetus 149 00:12:23.500 --> 00:12:27.100 at risk. So that is why it's extremely important to manage this 150 00:12:27.100 --> 00:12:32.700 condition very efficiently. Hence at every visit weight 151 00:12:34.300 --> 00:12:38.000 weight gain in pregnancy has to be monitored. Just now I was 152 00:12:38.000 --> 00:12:42.000 just before this session I was discussing this with one of my 153 00:12:42.000 --> 00:12:46.200 antenatal patients where she's put on seven kg of the weight in 154 00:12:46.200 --> 00:12:50.400 the last one and a half months. Again we have to go 155 00:12:50.400 --> 00:12:54.300 back why this is happening or is it only nutritional? Is it 156 00:12:54.300 --> 00:12:58.600 that she's taking too much of a high carb diet? So all 157 00:12:58.600 --> 00:13:02.900 this and sometimes hypertension could be the risk factor because of excessive 158 00:13:02.900 --> 00:13:07.500 weight gain in the mother. So weight gain in pregnancy, blood pressure 159 00:13:07.500 --> 00:13:12.900 monitoring and if the woman has a high blood pressure that monitoring 160 00:13:12.900 --> 00:13:19.000 the urine albumin levels for her and the other profile 161 00:13:19.000 --> 00:13:23.200 which we call as the PIH profile or the pregnancy in hypertension 162 00:13:23.500 --> 00:13:28.900 profile. So all these parameters have to be monitored. Put the patient 163 00:13:28.900 --> 00:13:34.400 on a low salt diet, keep her on antihypertensive management, 164 00:13:34.400 --> 00:13:39.800 keep her on a high protein diet and keep monitoring the pregnancy 165 00:13:39.800 --> 00:13:44.100 more vigilantly. Call them for frequent antenatal visits and that's how we 166 00:13:44.100 --> 00:13:49.200 will be able to manage the hypertension in pregnancy correctly and 167 00:13:49.200 --> 00:13:54.400 our outcome is much better. It can cause fetal growth restriction 168 00:13:54.400 --> 00:13:59.500 in the baby. So again there are certain medications or protein supplements 169 00:13:59.500 --> 00:14:03.400 may be required to be given to the mother sometimes you know 170 00:14:03.800 --> 00:14:07.500 a low dose of aspirin may be required, L-arginine for the growth 171 00:14:07.500 --> 00:14:12.800 of the baby or in cases of oligohydramnios. All these measures 172 00:14:12.900 --> 00:14:18.000 are extremely important in managing the hypertension in pregnancy. Now we come 173 00:14:18.000 --> 00:14:21.800 to the second entity which is diabetes mellitus. Now as we can 174 00:14:21.800 --> 00:14:25.200 see I already showed you this picture. This is risk for the 175 00:14:25.200 --> 00:14:30.200 fetus or infant of a diabetic mother. What are the 176 00:14:31.800 --> 00:14:35.000 risk for fetus which or the babies delivered to diabetic mothers could 177 00:14:35.000 --> 00:14:39.200 be macrosomic baby like you can see in the picture, neural tube 178 00:14:39.200 --> 00:14:44.200 defects in the baby, sudden intrauterine fetal death, birth trauma due to 179 00:14:44.200 --> 00:14:49.200 high incidence of instrumental deliveries or shoulder 180 00:14:49.200 --> 00:14:54.200 dystocia encountered at at delivery, respiratory 181 00:14:54.200 --> 00:14:59.300 distress syndrome for the baby, hypocalcemia in baby, hyperbilirubinemia 182 00:14:59.500 --> 00:15:04.500 and subsequent childhood and adolescent obesity. Hence again it's extremely important to 183 00:15:04.500 --> 00:15:09.600 manage manage the diabetes well with oral with diet 184 00:15:09.600 --> 00:15:14.800 first. Multidisciplinary team approach with the dietitian, gynecologist, 185 00:15:14.800 --> 00:15:19.900 dietitian, endocrinologist is extremely important. Counsel the patient about 186 00:15:19.900 --> 00:15:25.000 the diet, low glycemic index food, oral hypoglycemic agents 187 00:15:25.000 --> 00:15:30.100 when indicated or insulin therapy when indicated. That's how we will 188 00:15:30.100 --> 00:15:33.900 be able to control the diabetes and we will have less complications 189 00:15:34.100 --> 00:15:39.400 in the fetus or the newborn. Now heart disease complicated in pregnancy 190 00:15:39.400 --> 00:15:43.000 is still one of the leading causes of maternal mortality. As heart 191 00:15:43.000 --> 00:15:47.700 disease can cause heart failure at any time during the pregnancy, delivery 192 00:15:47.900 --> 00:15:52.900 and even post delivery, it needs asthma supervision. 193 00:15:53.000 --> 00:15:58.000 Now complications vary from abortions to intrauterine growth restriction, prematurity 194 00:15:58.000 --> 00:16:03.000 and stillbirth. Again a supervision of an expert obstetrician trained with high 195 00:16:03.000 --> 00:16:08.100 risk pregnancy, cardiologist and neonatologist is required. So hence emphasizing 196 00:16:08.100 --> 00:16:13.700 that every step of the way it is a multidisciplinary team approach 197 00:16:13.800 --> 00:16:17.200 which is extremely important and this is what we need to understand. 198 00:16:17.300 --> 00:16:21.800 Now I already discussed some about obesity. It's a rapid socioeconomic growth 199 00:16:21.800 --> 00:16:26.800 with increase is there is an increasing prevalence of obesity. 200 00:16:27.000 --> 00:16:31.600 Hypertension, diabetes come as a package along with it. Large for date 201 00:16:31.600 --> 00:16:36.500 babies, increased risk of thromboembolism and associated risk with obese patients. Now 202 00:16:36.500 --> 00:16:41.700 again we need to involvement of dietitian, physiotherapist in the antenatal 203 00:16:41.700 --> 00:16:46.800 care. Now again complications of obesity as you can see this woman 204 00:16:46.900 --> 00:16:47.500 it's difficult even to fit onto the OT table and there are 205 00:16:51.300 --> 00:16:53.300 complications associated about anesthesia during the surgery which I'm going to discuss. 206 00:16:56.400 --> 00:16:57.700 Now a very important aspect which I want to discuss is the 207 00:16:59.400 --> 00:17:02.500 PMI or body mass index calculation which is WHO versus Asian. 208 00:17:05.000 --> 00:17:07.400 It's an extremely important chart. Please remember this contrary to popular belief 209 00:17:10.000 --> 00:17:11.800 where everyone thinks that the normal PMI 210 00:17:16.100 --> 00:17:21.100 for Indian women is 18.5 to 25 noon. This is the 211 00:17:21.100 --> 00:17:26.100 WHO classification, not for us. We have a separate Asian classification. 212 00:17:26.200 --> 00:17:31.400 So us Indians fall into this category where the normal range of 213 00:17:31.400 --> 00:17:36.400 BMI is 18.5 to 22.9 which is can 214 00:17:36.400 --> 00:17:39.400 you see which is the normal for us and an Indian woman 215 00:17:39.400 --> 00:17:44.800 should have the abdominal circumference measured should be less than 80 cm. 216 00:17:44.800 --> 00:17:48.900 That is what we call as a normal BMI and normal base 217 00:17:48.900 --> 00:17:53.400 circumference. If you know remember this, then it will be easier to 218 00:17:53.400 --> 00:17:58.600 counsel your patients about their weight gain and excessive weight 219 00:17:58.600 --> 00:18:02.700 gain during pregnancy which is not good. Now appropriate weight gain during 220 00:18:02.700 --> 00:18:08.000 pregnancy, what exactly is appropriate? Now there's no evidence-based guideline or recommendation 221 00:18:08.000 --> 00:18:12.100 about the weight ranges during pregnancy, but US Institute of Medicine guidelines 222 00:18:12.100 --> 00:18:17.100 2009 have given us this data where the healthy women again mind 223 00:18:17.100 --> 00:18:22.200 you this is according calculated according to the BMI normal 24 224 00:18:22.200 --> 00:18:25.800 for nine, but we are not into that category. But considering a 225 00:18:25.800 --> 00:18:29.900 healthy woman with a normal weight that is BMI up to 22.9 226 00:18:30.100 --> 00:18:35.400 before planning pregnancy or before pregnancy, they can gain weight. So our 227 00:18:35.400 --> 00:18:40.800 categories will be towards the lower side and not this. So approximate 228 00:18:40.800 --> 00:18:45.400 normal weight gain could be approximately about 10 to 11 kg during 229 00:18:45.400 --> 00:18:50.600 the entire pregnancy. Now overweight women should gain about seven to 230 00:18:50.600 --> 00:18:54.400 eight kg and not more than that during the pregnancy and obese 231 00:18:54.400 --> 00:18:58.500 women with BMI greater than 30 should only put on around five 232 00:18:58.500 --> 00:19:03.400 to six kg during the pregnancy which means only the baby grows 233 00:19:03.400 --> 00:19:07.300 well and the woman does not put on too much of the 234 00:19:07.300 --> 00:19:11.900 weight. That's how we'll be able to get the positive outcome during 235 00:19:11.900 --> 00:19:16.800 pregnancy. So I've had patients where patients have lost some weight during 236 00:19:16.800 --> 00:19:21.200 pregnancy with a low carb and high protein diet, but still have 237 00:19:21.200 --> 00:19:26.300 had a positive outcome and a good three kg baby outcome. 238 00:19:26.700 --> 00:19:30.600 So it's not important to put on excess amounts of weight rather 239 00:19:30.600 --> 00:19:35.900 than that is harmful for the pregnancy and our outcome is not 240 00:19:35.900 --> 00:19:40.800 good. Now what are the risk and complications associated or maternal risks 241 00:19:41.200 --> 00:19:49.100 with obesity are miscarriage, thromboembolism, gestational 242 00:19:49.100 --> 00:19:54.700 diabetes, preeclampsia, dysfunctional labors, increase cesarean section rates by 243 00:19:54.700 --> 00:20:00.300 2.1 fold wound infections which can be encountered, anesthesia complications and 244 00:20:00.400 --> 00:20:05.400 so most studies demonstrate a linear relationship between risk and BMI. Now 245 00:20:05.400 --> 00:20:10.800 increased fetal risk of congenital malformation, fetal macrosomia, shoulder dystocia 246 00:20:10.800 --> 00:20:15.900 like I discussed could stillbirth, neonatal death, neonatal morbidity and NICU 247 00:20:15.900 --> 00:20:20.900 admissions which is increased in obese women. Now obese women 248 00:20:20.900 --> 00:20:25.700 have twice the normal cesarean section rates. A common indications for cesarean 249 00:20:25.700 --> 00:20:29.900 section in these cases are dysfunctional labor, increase rates of preeclampsia, gestational 250 00:20:29.900 --> 00:20:34.700 diabetes, large for gestational age babies and all contribute to the likelihood 251 00:20:34.700 --> 00:20:39.900 of a cesarean section. Now if you can see here it's again 252 00:20:40.000 --> 00:20:44.600 there are challenges during cesarean section in an obese women. So this 253 00:20:44.600 --> 00:20:49.600 is a woman with honesty. This is 254 00:20:49.600 --> 00:20:54.600 a case of 153 kg woman where we had the cesarean 255 00:20:54.600 --> 00:20:57.800 section for her. You can see the pannus and you can see 256 00:20:57.800 --> 00:21:03.000 the fat accumulated. So we need multiple you know more assistance 257 00:21:03.000 --> 00:21:07.300 to retract the abdominal wall or the pannus to be able to 258 00:21:07.300 --> 00:21:10.800 do the cesarean section. Sometimes it's challenging to deliver the baby and 259 00:21:10.800 --> 00:21:15.600 we have to reduce obstetric forceps to deliver the fetal head and 260 00:21:15.600 --> 00:21:20.700 it's important to close the subcutaneous layer or 261 00:21:21.000 --> 00:21:26.000 the fat layer appropriately and properly. It may be required to 262 00:21:26.000 --> 00:21:29.800 put a subcutaneous vein in some cases so that we don't encounter 263 00:21:29.800 --> 00:21:34.200 any wound infections. So that's how challenging the cesarean section can become. 264 00:21:34.400 --> 00:21:38.700 A maternal surveillance and screening in these cases requires an appropriate size 265 00:21:38.700 --> 00:21:43.200 of arm cuff should be Why am I discussing obesity so much? 266 00:21:43.200 --> 00:21:47.500 Because you will encounter a lot of these cases during your practice 267 00:21:47.500 --> 00:21:51.400 and all your outcomes will depend upon how good you are with 268 00:21:51.400 --> 00:21:55.100 the antenatal care and look how good you are with counseling the 269 00:21:55.100 --> 00:22:00.500 patients and we can reduce the other complications associated as well. Now 270 00:22:00.500 --> 00:22:04.400 appropriate size of arm cuff should be used for blood pressure monitoring 271 00:22:04.500 --> 00:22:09.600 taken at the booking visit and subsequent antenatal visits. Women's if 272 00:22:09.600 --> 00:22:14.000 the booking BMI is more than 30 have an increased risk of 273 00:22:14.000 --> 00:22:18.600 preeclampsia and blood pressure should be frequently monitored. All pregnant women with 274 00:22:18.600 --> 00:22:21.600 the booking BMI of more than 30 should be screened for gestational 275 00:22:21.600 --> 00:22:26.600 diabetes with a two hour 75 oral 75 grams oral glucose 276 00:22:26.600 --> 00:22:30.400 tolerance test at 24 to 28 weeks is mandatory for all women. 277 00:22:30.700 --> 00:22:35.200 For them we may require to do this at the first booking 278 00:22:35.200 --> 00:22:40.400 visit itself to rule out gestational diabetes. 279 00:22:40.900 --> 00:22:46.000 And the ACOG recommendations are pre-conceptual assessment and counseling, monitoring and 280 00:22:46.000 --> 00:22:51.000 guidance regarding appropriate weight gain during pregnancy, nutrition and exercise counseling. 281 00:22:51.000 --> 00:22:56.100 Women who have undergone bariatric surgery should be evaluated for nutritional deficiencies 282 00:22:56.100 --> 00:23:01.100 and supplementation should be done during pregnancy. Now individual risk 283 00:23:01.100 --> 00:23:06.100 assessment and thromboprophylaxis in the form of pneumatic compression pumps or DVT 284 00:23:06.100 --> 00:23:11.000 pumps and low molecular weight heparin is extremely important which which should 285 00:23:11.000 --> 00:23:16.100 be started at least six to eight hours post delivery or post 286 00:23:16.100 --> 00:23:22.300 cesarean section because the the because of the higher chances of thromboembolism. 287 00:23:22.400 --> 00:23:27.600 Now consider using high appropriate doses of preoperative and postoperative 288 00:23:27.600 --> 00:23:32.600 antibiotic coverage, suturing subcutaneous layer prevents any disruption of wound like I 289 00:23:32.600 --> 00:23:36.500 discussed. We may require to keep a subcutaneous drain at times and 290 00:23:36.600 --> 00:23:41.700 anesthesiological consultation early in labor is mandatory. And now 291 00:23:41.700 --> 00:23:46.900 renal diseases. Pregnancy complicated with renal diseases cause acute or chronic 292 00:23:46.900 --> 00:23:52.100 renal hypertension, pyelonephritis and lower urinary tract infections. The fetus may suffer 293 00:23:52.100 --> 00:23:57.200 from intrauterine growth restriction and of fetal growth restriction and 294 00:23:57.200 --> 00:24:01.600 infections can may lead to preterm labors or predisposed to preterm labor. 295 00:24:02.100 --> 00:24:07.200 Now infections during pregnancy can be toxoplasmosis, rubella, CMV, herpes, 296 00:24:07.200 --> 00:24:12.400 chickenpox, tuberculosis, HIV which need to be managed appropriately and with 297 00:24:12.400 --> 00:24:17.400 appropriate management. Now there are I already mentioned that surgical 298 00:24:17.400 --> 00:24:21.500 disorders complicated pregnancy could be fibroid uterus which here you can see 299 00:24:21.500 --> 00:24:25.100 in the picture. This is a cesarean section done and then the 300 00:24:25.100 --> 00:24:30.400 fibroid is being removed. Now with fibroid uterus now this 301 00:24:30.400 --> 00:24:34.400 coil should be taken by the obstetrician whether at the time of 302 00:24:34.400 --> 00:24:38.400 cesarean section the fibroid can be removed or no. It has the 303 00:24:38.400 --> 00:24:41.800 coil has to be taken by the obstetrician and I already mentioned 304 00:24:41.800 --> 00:24:46.900 to you that preterm labors may be are common. Renal 305 00:24:46.900 --> 00:24:51.500 degeneration of fibroid can complicate the pregnancy, previous history of myomectomy, previous 306 00:24:51.500 --> 00:24:56.100 cesarean section, classical cesarean section. We already discussed that ovarian cyst and 307 00:24:56.100 --> 00:25:01.300 recent bariatric surgery are all high risk pregnancies. Now extremes of 308 00:25:01.300 --> 00:25:04.600 age can put the woman in the high risk category like an 309 00:25:04.600 --> 00:25:09.700 elderly gravida, pregnant planning pregnancy or having being pregnant after 35 years 310 00:25:09.700 --> 00:25:14.600 of age or adolescent pregnancy. Now advanced maternal age after 35 years 311 00:25:14.900 --> 00:25:20.300 I already discussed some that it requires extra care because of significant 312 00:25:20.300 --> 00:25:26.000 high risk involved like hypertension, diabetes, obesity, spontaneous abortions, chromosomal abnormalities 313 00:25:26.000 --> 00:25:29.700 in the fetus. Fetal because of advanced maternal age and aging of 314 00:25:29.700 --> 00:25:35.400 the ovum and fetal growth restriction, other medical illnesses complicating the pregnancy. 315 00:25:35.600 --> 00:25:40.700 So hence to be managed extremely vigilantly. Now 316 00:25:40.800 --> 00:25:45.800 high risk pregnancy, adolescent pregnancy is always high risk. Obviously these 317 00:25:45.800 --> 00:25:50.000 are unintended and unplanned pregnancies which have profound negative impact on the 318 00:25:50.000 --> 00:25:55.200 girl's health. Here risk factors associated could be anemia, malnutrition, 319 00:25:55.900 --> 00:26:00.900 sexually transmitted diseases, standard abortion, hypertension, psychological disturbances 320 00:26:00.900 --> 00:26:06.100 with suicidal infanticidal tendencies. Obviously such patients need 321 00:26:06.100 --> 00:26:11.100 a multidisciplinary team approach with the psychologist involved. Now very 322 00:26:11.100 --> 00:26:16.000 important high risk pregnancy factor is multifetal gestations which I told you 323 00:26:16.100 --> 00:26:21.500 about could be twins, triplets, quadruple, quadruplets with or without associated 324 00:26:21.500 --> 00:26:26.700 complications. Now multiple pregnancies, the complications associated 325 00:26:26.700 --> 00:26:31.800 can be abortions, anemia, preeclampsia, preterm labor, 326 00:26:31.800 --> 00:26:36.800 placenta previa, malpresentations and complications like twin to twin 327 00:26:36.800 --> 00:26:42.400 transfusion syndrome and twin reverse arterial perfusion syndrome of very interesting 328 00:26:44.200 --> 00:26:48.500 topic. Now here I want you to see this this is what 329 00:26:48.500 --> 00:26:53.100 we encountered a few years ago. It's a twin reverse arterial perfusion 330 00:26:53.100 --> 00:26:58.100 syndrome. So twin pregnancy complicated with truck. Now this is the 331 00:26:58.200 --> 00:27:02.200 acardiac twin. One twin is the dependent twin or the acardiac twin. 332 00:27:02.200 --> 00:27:05.600 Here you can see only the lower body is developed and there 333 00:27:05.600 --> 00:27:09.600 is no upper body developed. It's only a tuft of hair. Okay 334 00:27:09.700 --> 00:27:14.100 and this is an acardiac twin. Hence it is completely dependent on 335 00:27:14.100 --> 00:27:19.200 the other twin for blood blood supply. So that is what 336 00:27:19.200 --> 00:27:23.000 is called as a twin reverse arterial perfusion. That is how the 337 00:27:23.200 --> 00:27:28.300 the blood supply is going to this acardiac twin. 338 00:27:28.300 --> 00:27:32.600 That's how the growth of one twin can get affected. They can 339 00:27:32.800 --> 00:27:37.900 go into high output failure. So this is after the delivery and 340 00:27:38.100 --> 00:27:42.000 this pregnancy we encountered a few years ago was referred to us 341 00:27:43.800 --> 00:27:49.200 some other came to us from some other state and she had 342 00:27:50.600 --> 00:27:55.400 we managed the pregnancy here. She had a premature rupture of membranes 343 00:27:55.400 --> 00:27:59.400 at 32 weeks of gestation and a cesarean section was done. Baby 344 00:27:59.400 --> 00:28:04.700 was 1.8 kg, remained in the NICU for about 12 to 345 00:28:04.700 --> 00:28:09.900 13 days and was discharged and doing is doing perfectly well. This 346 00:28:09.900 --> 00:28:15.400 is the acardiac twin and the placenta. So this and 347 00:28:15.400 --> 00:28:20.200 these are the kind of complications which can which rare complication which 348 00:28:20.200 --> 00:28:25.500 can we can encountered in a twin pregnancy. Now situations special 349 00:28:25.500 --> 00:28:30.000 situations like pregnancy after after renal transplant obviously a high risk pregnancy 350 00:28:30.200 --> 00:28:35.400 needs a multidisciplinary team approach. Now how do we manage this 351 00:28:35.400 --> 00:28:39.900 these high risk pregnancies? So for that what we have is a 352 00:28:39.900 --> 00:28:43.100 high risk pregnancy clinic. So we run this high risk pregnancy clinic 353 00:28:43.100 --> 00:28:46.900 in all these hospitals especially at Dr. L. H. Hiranandani Hospital. We 354 00:28:46.900 --> 00:28:50.000 have a high risk pregnancy clinic and I was a clinic coordinator 355 00:28:50.000 --> 00:28:54.300 for a very long time and it aims to provide education, surveillance 356 00:28:54.300 --> 00:28:58.900 and management of pregnancies at risk and provide a multidisciplinary team approach 357 00:28:58.900 --> 00:29:02.800 in managing the high risk pregnancies and to provide advanced facilities for 358 00:29:02.800 --> 00:29:07.100 managing and delivering the high risk pregnancies. The scope of high risk 359 00:29:07.100 --> 00:29:12.800 pregnancy clinic is complete antenatal, intranatal and postpartum management 360 00:29:12.900 --> 00:29:16.800 of high risk pregnancies with management of the neonate. Now what are 361 00:29:16.800 --> 00:29:21.800 the services offered in the high risk pregnancy clinic is genetic counseling 362 00:29:21.800 --> 00:29:27.200 when required, pre-conceptual counseling for all the couples planning pregnancy, 363 00:29:27.800 --> 00:29:32.800 prenatal screening and diagnosis with facilities which include biochemical marker screening, 364 00:29:32.800 --> 00:29:37.700 double marker, quadruple marker test, integrated test, advanced ultrasound for the detection 365 00:29:37.700 --> 00:29:43.100 of fetal abnormalities like nuchal translucency scan and a detailed malformation 366 00:29:43.100 --> 00:29:48.300 scan, fetal 2D echo whenever required, advanced procedures like chorionic villus sampling, 367 00:29:48.300 --> 00:29:53.300 selective fetal reduction, amniocentesis, fetal cord blood sampling, intrauterine 368 00:29:53.300 --> 00:29:58.700 transfusion in cases of Rh isoimmunization in Rh negative pregnancy, 369 00:29:58.900 --> 00:30:04.000 fetal therapy, molecular karyotype etc. So all these 370 00:30:04.000 --> 00:30:08.000 obstetric ultrasounds with Doppler are done by the fetal medicine specialist. So 371 00:30:08.000 --> 00:30:18.000 we have fetal medicine consultants, all the high risk pregnancies regular 372 00:30:21.000 --> 00:30:24.800 and frequent follow up with the obstetrician in OPD which is extremely 373 00:30:24.800 --> 00:30:29.800 important vis-a-vis a uncomplicated or 374 00:30:29.800 --> 00:30:35.300 low risk pregnancy. Now extensive antenatal, intrapartum fetal surveillance. We 375 00:30:35.300 --> 00:30:38.700 have something called as the state of the art LDRP sweet rooms 376 00:30:38.700 --> 00:30:43.700 which is labor, delivery, recovery and postpartum everything happening in one 377 00:30:43.700 --> 00:30:48.800 room with complete privacy and also sometimes we can offer the patients 378 00:30:48.800 --> 00:30:55.000 hydrotherapy during labor which helps in pain relief and also a 379 00:30:55.000 --> 00:31:00.200 labor room and operation well equipped operation theater facilities, labor analgesia given 380 00:31:00.200 --> 00:31:04.400 to the patients when required so that patient is at least you 381 00:31:04.400 --> 00:31:08.300 know has less pain during labor. It's never pain free, but yes 382 00:31:08.300 --> 00:31:12.300 less pain which is done by the anesthetist, a blood bank facility 383 00:31:12.300 --> 00:31:17.300 which is required for obstetric emergencies, NICU with advanced neonatal care 384 00:31:17.700 --> 00:31:22.400 which is managed by the neonatologist. So all these are a part 385 00:31:22.400 --> 00:31:27.500 of the high risk pregnancy clinic. Now what is extremely important 386 00:31:27.500 --> 00:31:32.300 which I have been harping through my presentation is a multidisciplinary team 387 00:31:32.300 --> 00:31:37.700 approach and calling consultants, you know involving the consultant 388 00:31:37.700 --> 00:31:43.000 obstetrician, the primary consultant and associate consultant obstetrician, pediatrician, neonatologist, 389 00:31:43.000 --> 00:31:48.000 radiologist, medic and consultants and other specialists like 390 00:31:48.000 --> 00:31:53.500 physician, endocrinologist, cardiologist, hematologist, nephrologist, neurologist, 391 00:31:53.500 --> 00:31:59.000 psychiatrist, psychologist, rheumatologist, gastroenterologist, dietitian etc. 392 00:31:59.200 --> 00:32:03.200 according to the individual case scenario and we've had cases like this 393 00:32:03.200 --> 00:32:07.600 where we have conducted multidisciplinary team meets and we've been able to 394 00:32:07.600 --> 00:32:13.100 manage these pregnancies very beautifully with successful 395 00:32:13.300 --> 00:32:18.000 outcomes and all these specialists are under one roof. So the patient 396 00:32:18.200 --> 00:32:21.500 doesn't have to go hunting for the specialist and we all sit 397 00:32:21.500 --> 00:32:26.500 together and consult together to give you know the counsel 398 00:32:26.500 --> 00:32:31.600 the patient and draft a proper management for the patient. 399 00:32:31.700 --> 00:32:35.300 So that's what is called as a multidisciplinary team meetings or MDT 400 00:32:35.300 --> 00:32:39.900 meetings which are conducted for high risk pregnancy cases. Now monitoring includes 401 00:32:39.900 --> 00:32:43.600 more frequent visits to the doctor, tests to monitor the medical problems 402 00:32:43.600 --> 00:32:48.100 like blood tests, several ultrasound examinations which are routine and special examinations 403 00:32:48.400 --> 00:32:54.000 when required and fetal monitoring with regular anesthesias if required 404 00:32:54.800 --> 00:33:00.000 and and Doppler studies. Now these tests and investigations are designed 405 00:33:00.000 --> 00:33:03.600 to track the condition of the mother and the fetus. Now how 406 00:33:03.600 --> 00:33:07.700 does the high risk pregnancy differ from the normal pregnancy? So obviously 407 00:33:07.700 --> 00:33:12.800 like I said before frequent antenatal visits, close monitoring of maternal fetal 408 00:33:12.800 --> 00:33:17.800 well-being, special investigations other than the routine when required and management 409 00:33:17.800 --> 00:33:19.800 of the underlying causes like if you have hypertension, you have the 410 00:16:41.800 --> 00:16:41.800 diabetes, you have a renal disease. So special investigations may be required 411 00:16:47.500 --> 00:16:51.300 and a multidisciplinary team approach. Thank you so 412 00:16:53.300 --> 00:16:56.400 much. So this is what is important when we are managing a 413 00:16:57.700 --> 00:16:59.400 high risk pregnancy and we'll be able to give a successful outcome 414 00:17:02.500 --> 00:17:05.000 to our patients. Thank you so much. I hope that helped you. 415 00:17:07.400 --> 00:17:10.000 We can you know manage these patients and give them a successful 416 00:17:11.800 --> 00:17:16.100 outcome. Thank 417 00:33:53.300 --> 00:33:56.800 you so much ma'am. The session was very insightful throughout and I'm 418 00:33:56.800 --> 00:33:59.800 sure our viewers will get to learn a lot. Ma'am, we have 419 00:33:59.800 --> 00:34:02.300 a few questions. So with your permission, shall we move ahead with 420 00:34:02.300 --> 00:34:07.300 those? Yes, yes we can. All right, ma'am. So to begin with 421 00:34:07.500 --> 00:34:11.800 the first question is ma'am, how frequently should high risk pregnancies be 422 00:34:11.800 --> 00:34:17.100 monitored compared to that of a low risk pregnancies? Yeah. 423 00:34:17.300 --> 00:34:21.000 So when I say frequent monitoring, see we all know that in 424 00:34:21.000 --> 00:34:26.300 a low risk pregnancy we monitor we call the patients monthly up 425 00:34:26.300 --> 00:34:31.500 to 28 weeks of pregnancy. After that every 15 days up to 426 00:34:31.500 --> 00:34:36.700 say 36 weeks and after that weekly. Okay. So that's how 427 00:34:36.700 --> 00:34:41.200 our usual antenatal visits are. Okay, but in a high risk pregnancy 428 00:34:41.200 --> 00:34:46.000 I might want to see the patient instead of one monthly interval. 429 00:34:46.100 --> 00:34:50.700 I would call the patient at every two weeks. Okay, when required. 430 00:34:50.800 --> 00:34:55.900 Initially it may not be required because obviously when I say pregnancy 431 00:34:55.900 --> 00:35:01.100 associated hypertension which is developing during after 20 weeks of pregnancy, before 432 00:35:01.100 --> 00:35:04.500 that possibly the patient does not have a risk factor. So patient 433 00:35:04.500 --> 00:35:09.500 continues to visit me as or visit the obstetrician as the regular 434 00:35:09.500 --> 00:35:13.500 visits. But eventually when there is a high risk condition, instead of 435 00:35:13.700 --> 00:35:18.700 calling them on monthly intervals, we call them every two weeks. That's 436 00:35:18.700 --> 00:35:22.900 how that's how we will be able to monitor them more vigilantly. 437 00:35:23.300 --> 00:35:28.300 Again now when in case say say the blood pressure 438 00:35:28.300 --> 00:35:30.800 is high and you know I might have to call the patient 439 00:35:30.800 --> 00:35:35.100 every week also. So it all depends upon the individual case scenario. 440 00:35:35.100 --> 00:35:39.000 Okay, but yeah a 15 days visit should be good enough and 441 00:35:39.000 --> 00:35:44.000 when we are talking about multiple pregnancies say twins so in that 442 00:35:44.000 --> 00:35:49.100 case every month the patient has to do an ultrasound which 443 00:35:49.100 --> 00:35:52.000 is again very important. It should be it should be emphasized to 444 00:35:52.000 --> 00:35:55.400 the patient right in the beginning of the pregnancy. Otherwise they'll say 445 00:35:56.800 --> 00:36:01.200 Dr. keeps asking for ultrasounds because it's extremely difficult in a twin 446 00:36:01.200 --> 00:36:05.900 pregnancy to know clinically which fetus is you know getting. Suppose there 447 00:36:05.900 --> 00:36:08.900 is a fetal growth restriction in one of the fetuses which is 448 00:36:08.900 --> 00:36:13.200 very common. We clinically do not get to know. So that is 449 00:36:13.200 --> 00:36:16.300 why we do not get to know enough. So that's why it's 450 00:36:16.300 --> 00:36:20.400 extremely important plus the other factors like I like I showed a 451 00:36:20.400 --> 00:36:25.800 case of trapped reverse arterial perfusion syndrome or twin to twin transfusion 452 00:36:25.800 --> 00:36:30.600 syndrome. All these will be picked up on an ultrasound done by 453 00:36:30.600 --> 00:36:35.700 a specialist. So it's important that they do frequent ultrasounds and obviously 454 00:36:35.700 --> 00:36:41.200 they come for frequent visits. All right, ma'am. We 455 00:36:41.200 --> 00:36:45.400 have one question here in the comment box that is Harika is 456 00:36:45.400 --> 00:36:49.900 asking any test to know how the organs are formed and check 457 00:36:50.000 --> 00:36:52.300 the function of the organs when the baby is in the womb? 458 00:36:54.000 --> 00:36:58.900 Yeah. So basically when I was explaining to you about the services 459 00:36:59.100 --> 00:37:03.300 offered in the high risk pregnancy clinic, it is so all see 460 00:37:03.300 --> 00:37:07.900 all what we are doing is a universal protocol. It's nothing that 461 00:37:07.900 --> 00:37:11.300 we have designed it. Okay. So NT scan which is a nuchal 462 00:37:11.300 --> 00:37:16.600 translucency scan is mandatory for all women which is done for at 463 00:37:16.600 --> 00:37:21.600 11 to 13.6 weeks of gestation. Okay, that's the right time 464 00:37:21.600 --> 00:37:25.900 to do it. That will rule out any kind of chromosomal abnormality 465 00:37:25.900 --> 00:37:29.900 in the fetus. Along with that we do a double marker test 466 00:37:29.900 --> 00:37:33.200 which is a blood test which is done. So these two tests 467 00:37:33.200 --> 00:37:38.400 combined together will give us a great idea about any chromosomal 468 00:37:38.400 --> 00:37:42.100 abnormalities in the fetus. And if it shows any kind of abnormality, 469 00:37:42.100 --> 00:37:47.400 we go for further investigations you know like NIPT or 470 00:37:47.500 --> 00:37:53.800 an amniocentesis when required. Okay and the next step is malformation 471 00:37:53.800 --> 00:37:57.500 scan or an anomaly scan which is done at 18 to 20 472 00:37:57.500 --> 00:38:01.800 between 18 and 20 weeks of gestation. The reason is that in 473 00:38:01.800 --> 00:38:06.100 case there's any abnormality and in case the you know the pregnancy 474 00:38:06.100 --> 00:38:09.900 needs to be terminated with at 20 weeks within 20 weeks of 475 00:38:09.900 --> 00:38:14.800 gestation it's very well can be decided. Now obviously the age has 476 00:38:14.800 --> 00:38:19.900 been advanced to 24 weeks with special recommendations, but yes 477 00:38:19.900 --> 00:38:23.900 between 18 and 20 weeks we need to do a malformation scan 478 00:38:24.100 --> 00:38:28.200 which tells us that yes the baby is completely formed. That is 479 00:38:28.200 --> 00:38:32.800 when we see the baby from head to toe completely and then 480 00:38:32.900 --> 00:38:38.000 at 24 weeks again because the cardiac or the heart is 481 00:38:38.000 --> 00:38:43.100 not completely formed at 20 weeks. At 23 to 24 482 00:38:43.100 --> 00:38:46.400 weeks it's a good idea to go for a repeat anomaly scan 483 00:38:46.600 --> 00:38:50.800 and fetal to the echo if required like in cases of diabetes 484 00:38:50.800 --> 00:38:55.800 or if their woman has had adverse pregnancy outcome 485 00:38:55.800 --> 00:38:58.800 in the previous pregnancies, then we can go for a fetal to 486 00:38:58.800 --> 00:39:02.700 the echo at 24 weeks of gestation. So all this will tell 487 00:39:02.700 --> 00:39:05.700 us that the baby is completely well formed and there is no 488 00:39:05.700 --> 00:39:10.800 abnormality. Very rightly mentioned ma'am and with 489 00:39:10.800 --> 00:39:13.300 this I would like to conclude today's session. Thank you so much 490 00:39:13.300 --> 00:39:16.000 for your time ma'am. Even in your busy schedule you managed to 491 00:39:16.000 --> 00:39:18.800 take out time and you have delivered such a wonderful session for 492 00:39:18.800 --> 00:39:21.900 all of us. I'm sure our doctors will get to learn and 493 00:39:21.900 --> 00:39:25.200 extract a lot of information from this session and I'm really looking 494 00:39:25.200 --> 00:39:30.300 forward to have you again on our platform. Thank you. Thank 495 00:39:30.300 --> 00:39:33.500 you ma'am. Dear doctors, you can join, you can watch all the 496 00:39:33.500 --> 00:39:37.200 sessions on our website assimilate.one there you'll find all the other sessions 497 00:39:37.200 --> 00:39:41.300 according to your we have your session lined up this week. So 498 00:39:41.300 --> 00:39:43.900 I'll see you all there. Till then happy learning and good evening. 499 00:39:44.500 --> 00:39:47.200 Thank you ma'am. Thank you.