Pregnancy Complications (C FW 06)

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Pregnancy Complications…:

Pregnancy Complications…

Hydatidiform Mole:

Hydatidiform Mole Moore LE, Ware D. Hydatidiform Mole. eMedicine. Retrieved 31 January 2006, from www.emedicine.com/med/topic1047.htm Viera AJ, Clenney TL, Shenenberger DW. Vaginal Bleeding at 16 Weeks. [Electronic version] J Am Fam Phys 1999;59(3), Retrieved 16 November 2005, from www.aafp.org/afp/990201ap/photo.html

Hydatidiform Mole:

Hydatidiform Mole Complete/Classic Mole No identifiable fetal tissue Partial Mole Some recognizable fetal or embryonic tissue http://www-medlib.med.utah.edu/WebPath/jpeg2/PLAC062.jpg

Hydatidiform Moles:

Hydatidiform Moles 1/1000-1500 pregnancies Risk factors Teenagers Women over 35 (35+: 2x risk, 40+: 7x risk) Previous miscarriage *Only 1% of subsequent conceptions result in another molar pregnancy

Complete Hydatidiform Mole:

Complete Hydatidiform Mole Signs & Symptoms Vaginal bleeding (97%) *most common presenting symptom Hyperemesis due to elevated HCG Hyperthyroidism (7%) may present with tachycardia, tremor, warm skin Preeclampsia (27%) Large for date uterus

Incomplete Hydatidiform Mole:

Incomplete Hydatidiform Mole Signs & Symptoms (similar to incomplete or missed abortion) Vaginal bleeding Absence of fetal heart tones Uterine enlargement and preeclampsia only 3% of patients Hyperemesis and hyperthyroidism are rare

Hydatidiform Mole:

Hydatidiform Mole Diagnosis Ultrasound vesicular / “snowstorm” pattern HCG levels Elevated compared to a normal pregnancy of similar gestational age www.obgyn.net/us/ _uploads/hmole2.jpg

Hydatidiform Mole:

Hydatidiform Mole Differential Diagnosis Painless vaginal bleeding: Placenta previa Missed abortion Key differential? Absence of identifiable fetal parts on ultrasound

Hydatidiform Mole:

Hydatidiform Mole Treatment Evacuation and curettage OR Hysterectomy Must consider: Age of the patient Desire to preserve fertility

Hydatidiform Mole:

Hydatidiform Mole Potential precursor to gestational trophoblastic disease and choriocarcinoma 20% develop a malignancy metastasis occurs in 4% of complete moles Choriocarcinoma may metastasize to: Lungs Vagina Brain Liver Kidney

Hydatidiform Mole:

Hydatidiform Mole Follow-up bHCG* tested regularly monthly for 6-12 months *any rise in levels should prompt a chest radiograph and pelvic examination Contraception must be used during the entire follow-up period at least 1 year

Ectopic Pregnancy:

Ectopic Pregnancy Lozeau A, Potter B. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician 2005;72(9):1707-1714.

Ectopic Pregnancy:

Ectopic Pregnancy Any pregnancy that occurs outside of the uterine cavity Tubal Ampulla (55%) Isthmus (25%) Fimbria (17%) Cervical Ovarian Abdominal 3% 97%

Ectopic Pregnancy:

Ectopic Pregnancy http://connection.lww.com/Products/smeltzer10e/documents/Ch46/jpg/46_009.jpg

Ectopic Pregnacy:

Ectopic Pregnacy 1.9% of reported pregnancies Leading cause of pregnancy-related death in the first trimester Ruptured ectopic pregnancy accounts for 10-15% of all maternal deaths

Ectopic Pregnancy:

Ectopic Pregnancy Risk Factors Previous tubal surgery Previous ectopic pregnancy In utero DES exposure diethylstilbestrol (used until 1971; miscarriage & premature delivery) Previous genital infections Infertility Current smoking Previous IUD use HIGH

Ectopic Pregnancy:

Ectopic Pregnancy Most common presentation: Woman of reproductive age Abdominal pain Vaginal bleeding Approx 7 weeks after amenorrhea *Nonspecific… dDx is important

Ectopic Pregnancy :

Ectopic Pregnancy Differential Diagnosis Acute appendicitis Miscarriage Ovarian torsion Pelvic inflammatory disease Ruptured corpus luteum cyst or follicle Tubo-ovarian abcess Urinary calculi

Ectopic Pregnancy:

Ectopic Pregnancy Exam Findings Normal or slightly enlarged uterus Vaginal bleeding Pelvic pain with manipulation of the cervix Palpable adnexal mass (fallopian tube)

Ectopic Pregnancy:

Ectopic Pregnancy Suspect Rupture… Significant abdominal tenderness *Especially if accompanied by: Hypotension Abdominal guarding Rebound tenderness

Ectopic Pregnancy:

Ectopic Pregnancy Diagnositc Tests Ultrasound (*test of choice) No intrauterine gestational sac bHCG Do not increase appropriately Urine pregnancy test Pregnant / not pregnant Progesterone level (less reliable)

Ectopic Pregnancy:

Ectopic Pregnancy Treatment Expectant management Monitor progress Medical treatment Methotrexate – folic acid antagonist Disrupts rapidly dividing trophoblastic cells Surgery Laparoscopy with salpingostomy, without fallopian tube removal

Ectopic Pregnancy:

Ectopic Pregnancy ~30% have later difficulty conceiving No difference between treatment options 5-20% rate of recurrence 32% risk of recurrence if she’s had 2 consecutive ectopic pregnancies

Spontaneous Abortion:

Spontaneous Abortion Griebel CP, Halvorsen J, Golemon, TB. Management of Spontaneous Abortion. Am Fam Physician 2005; 72(7):1243-50.

Spontaneous Abortion:

Spontaneous Abortion aka “miscarriage”, “spontaneous pregnacy loss”, “early pregnancy failure” Pregnancy loss at less than 20 weeks’ gestation

Definitions:

Definitions Threatened abortion A pregnancy complicated by bleeding before 20 weeks’ gestation Inevitable abortion The cervix has dilated, but the products of conception have not been expelled

Definitions:

Definitions Complete abortion All products of conception have been passed without need for surgical or medical intervention Incomplete abortion Some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes Missed abortion A pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception

Definitions:

Definitions Septic abortion A spontaneous abortion that is complicated by intrauterine infection Recurrent spontaneous abortion Three (3) or more consecutive pregnancy losses

Spontaneous Abortion:

Spontaneous Abortion Etiology and Risk Factors Chromosomal abnormality 49% of spontaneous abortions *most are random events NOTE: Stress Marijuana use Sexual activity Do NOT increase risk

Spontaneous Abortion:

Spontaneous Abortion Advanced maternal age Alcohol use Anesthetic gas use (nitrous oxide) Caffeine use (heavy) Chronic maternal diseases poorly controlled diabetes celiac disease autoimmune diseases Cigarette smoking Cocaine use Conception within 3-6 months after delivery IUD use Maternal infections Bacterial vaginosis TORCH STD’s Medications Multiple previous elective abortions Previous spontaneaous abortions Toxins Uterine abnormalities Risk Factors

Spontaneous Abortion:

Spontaneous Abortion Up to 20% of recognized pregnancies ~30% actual miscarriage rate Often mistaken for late onset of menses ~50% of pregnancies complicated by bleeding before 20 weeks’ gestation will end in spontaneous abortion dDx?

Differential Diagnosis: First Trimester Vaginal Bleeding:

Differential Diagnosis: First Trimester Vaginal Bleeding Idiopathic bleeding in a viable pregnancy Ectopic pregnancy Molar pregnancy Spontaneous abortion Subchorionic hemorrhage Infection of the vagina or cervix Cervical abnormalities Malignancy, polyps, trauma Vaginal trauma

Spontaneous Abortion:

Spontaneous Abortion Diagnosis HCG levels Progesterone levels Ultrasound Status of the pregnancy Intrauterine? Ectopic? Exam: dilated cervix ~> inevitable abortion *the risk for spontaneous abortion decreases from 50% to 3% when a fetal heartbeat is identified on ultrasound labs

Abortion? or not?:

Abortion? or not? Progesterone HCG Ultrasound Abortion? >25 ng per mL Increases (48 hours) Normal No <5 ng per mL Plateau or decrease Nonviable pregnancy Yes

Spontaneous Abortion:

Spontaneous Abortion Management Surgical evacuation (D&C) Patient is unstable Heavy bleeding Septic abortion Patient choice Medical therapy Missed spontaneous abortion Expectant management Completed spontaneous abortion Incomplete spontaneous abortion No need for surgical intervention 80-95% of the time

Spontaneous Abortion:

Spontaneous Abortion Considerations… Feelings of guilt Grieving process Anxiety & depression counseling www.compassionatefriends.org www.nationalshareoffice.com

Spontaneous Abortion - Tips:

Spontaneous Abortion - Tips Acknowledge and attempt to dispel guilt Acknowledge and legitimize grief Assess level of grief and adjust counseling accordingly Counsel how to tell family and friends of the miscarriage Include the patient’s partner in psychologic care Provide comfort, empathy, and ongoing support Reassure about the future Warn about the “anniversary phenomenon”

Placenta Previa:

Placenta Previa Ko P, Yoon Y. Placenta Previa. eMedicine. Retrieved 5 February 2006 from www.emedicine.com/emerg/topic427.htm

Placenta Previa:

Placenta Previa Implantation of the placenta over or near the internal os of the cervix Vaginal bleeding in the 2nd and 3rd trimesters 5/1,000 deliveries Maternal mortality rate of 0.03%

Placenta Previa:

Placenta Previa Total placenta previa internal os is completely covered by the placenta Partial placenta previa internal os is partially covered by the placenta self-correct? uterus enlarges, placental site moves cephalad Marginal placenta previa placenta is at the margin of the internal os Low-lying placenta previa placenta is implanted in the lower uterine segment edge of the placenta is near the internal os but does not reach it

Placenta Previa:

Placenta Previa Risk Factors Prior previa Multiparity Multiple gestations Advanced maternal age Previous cesarean delivery Prior induced abortion Smoking

Placenta Previa:

Placenta Previa History Vaginal bleeding Bright red and painless (recurrent) Occurs on average at 27-32 weeks' gestation Contractions may or may not occur simultaneously with the bleeding Exam Findings Profuse hemorrhage Hypotension Tachycardia Soft and nontender uterus Normal fetal heart tones (usually)

Placenta Previa:

Placenta Previa Differentials Abruptio Placenta Disseminated Intravascular Coagulation Pregnancy, Delivery Vasa previa Infection Vaginal bleeding Lower genital tract lesions Bloody show

Placenta Previa:

Placenta Previa Diagnosis Ultrasound Management <37 weeks without hemorrhage expectant management Hemorrhage or >37 weeks and in labor delivery C-section trial of labor may be considered for anterior marginal previa

Abruptio Placentae:

Abruptio Placentae Gaufberg SV. Abruptio Placentae. eMedicine. Retrieved 5 February 2006 from www.emedicine.com/emerg/topic12.htm

Abruptio Placentae:

Abruptio Placentae Separation of the normally located placenta after the 20th week of gestation (prior to birth) 1% of all pregnancies Compromised blood supply to the fetus Severity of fetal distress correlates with the degree of placental separation

Abruptio Placentae:

Abruptio Placentae Clinical presentation Vaginal bleeding (80%) Abdominal or back pain and uterine tenderness (70%) Fetal distress (60%) Abnormal uterine contractions (35%) Idiopathic premature labor (25%) Fetal death (15%)

Abruptio Placentae:

Abruptio Placentae Diagnosis Severe uterine pain and tenderness with mild vaginal bleeding in a patient with hypertension (HTN) indicates placental abruption Difficult to identify on ultrasound Can help differentiate from other causes of bleeding (i.e placenta previa)

Abruptio Placentae (Class 0-3):

Abruptio Placentae (Class 0-3) Class 0 Asymptomatic Diagnosis is made retrospectively organized blood clot or a depressed area on a delivered placenta

Abruptio Placentae (Class 0-3):

Abruptio Placentae (Class 0-3) Class 1 Mild ~48% of all cases Characteristics : No vaginal bleeding to mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress

Abruptio Placentae (Class 0-3):

Abruptio Placentae (Class 0-3) Class 2 Moderate ~27% of all cases Characteristics: Vaginal bleeding: none to moderate Moderate-to-severe uterine tenderness with possible tetanic contractions Maternal tachycardia with orthostatic changes in BP and heart rate Fetal distress Hypofibrinogenemia (ie, 50-250 mg/dL)

Abruptio Placentae (Class 0-3):

Abruptio Placentae (Class 0-3) Class 3 Severe ~24% of all cases Characteristics: vaginal bleeding: none to heavy Very painful tetanic uterus Maternal shock Hypofibrinogenemia (ie, <150 mg/dL) Coagulopathy Fetal death

Abruptio Placentae:

Abruptio Placentae Causes Maternal hypertension (44%) Maternal trauma (1.5-9.4%) MVA, assaults, falls Cigarette smoking Alcohol consumption Cocaine use Short umbilical cord Advanced maternal age Retroplacental fibromyoma Sudden decompression of the uterus premature rupture of membranes, delivery of first twin Retroplacental bleeding from needle puncture postamniocentesis Idiopathic probable abnormalities of uterine blood vessels and decidua

Abruptio Placentae:

Abruptio Placentae Maternal complications Hemorrhagic shock Coagulopathy/DIC Uterine rupture Renal failure Ischemic necrosis of distal organs (eg, hepatic, adrenal, pituitary) Fetal complications Hypoxia Anemia Growth retardation CNS anomalies Fetal death

Polyhydramnios:

Polyhydramnios Boyd RL, Carter BS. Polyhydramnios and Oligohydramnios. EMedicine. Retrieved 5 February 2006 from http://www.emedicine.com/ped/topic1854.htm

Polyhydramnios:

Polyhydramnios Abnormally high level of amniotic fluid >2000 mL of fluid Normal: peaks at 800-1000mL at 36-37 weeks' gestation 1% of pregnancies 20% are born with congenital anomalies

Polyhydramnios:

Polyhydramnios Risk Factors Multiple gestations twin to twin transfusion Maternal diabetes Fetal anomolies Gastrointestinal system (40%) Central nervous system (26%) swallowing dysfunction Cardiovascular system (22%) Genitourinary system (13%) Chromosomal abnormalities

Polyhydramnios:

Polyhydramnios Examination Rapidly enlarging uterus Difficulty identifying fetal parts (Leopold’s) Fetal ballottement is easier

Polyhydramnios:

Polyhydramnios Complications Preterm labor and delivery (26%) Premature rupture of the membranes (PROM) Abruptio placenta Malpresentation Cesarean delivery Postpartum hemorrhage

Polyhydramnios:

Polyhydramnios Considerations Management of diabetes Steroid therapy enhance fetal lung maturity if preterm labor is expected Genetic counseling

Oligohydramnios:

Oligohydramnios Boyd RL, Carter BS. Polyhydramnios and Oligohydramnios. EMedicine. Retrieved 5 February 2006 from http://www.emedicine.com/ped/topic1854.htm

Oligohydramnios:

Oligohydramnios Inadequate levels of amniotic fluid results in poor development of the lung tissue and can lead to fetal death Affects ~4% of pregnancies

Oligohydramnios:

Oligohydramnios Causes Fetal urinary tract anomalies Renal agenesis Polycystic kidneys Obstructive urinary lesion Postmaturity syndrome Possibly caused by a decline in placental function Maternal problems Placental insufficiency Premature rupture of membranes Chronic leakage of the amniotic fluid

Oligohydramnios:

Oligohydramnios Mortality rate is high (5-6%) Increased risk of Pulmonary hypoplasia Meconium staining of the amniotic fluid Fetal heart conduction abnormalities Poor tolerance of labor Lower Apgar scores Fetal acidosis Intrauterine growth restriction (IUGR)

Oligohydramnios:

Oligohydramnios Complications Fetal distress before or during labor Meconium potential for aspiration Fetal infection (prolonged rupture of the membranes)

Oligohydramnios:

Oligohydramnios Management Maternal bed rest and hydration promote the production of amniotic fluid

Oligohydramnios:

Oligohydramnios Considerations Fetal anomaly counseling Postmaturity review pregnancy dating deliver the fetus (induction or cesarean)

Preeclampsia - Eclampsia:

Preeclampsia - Eclampsia Morrison EH. Common Peripartum Emergencies. Am Fam Physician 1998; 58(7). Retrieved 16 November 2005 from www.aafp.org/afp/981101ap/morrison.html . Wagner LK. Diagnosis and Management of Preeclampsia. Am Fam Physician 2004; 70(12):2317-24.

Preeclampsia:

Preeclampsia Defined as a “ pregnancy-specific multisystem disorder of unknown etiology. ” New onset of elevated blood pressure and proteinuria after 20 weeks’ gestation

Preeclampsia:

Preeclampsia Affects 5-7% of pregnancies Increased risk of: Placental abruption Acute renal failure Cerebrovascular/cardiovascular complications Disseminated intravascular coagulation Maternal death

Preeclampsia:

Preeclampsia 3 rd leading cause of pregnancy-related deaths Maternal death due to: Cerebrovascular events Renal or hepatic failure HELLP syndrome Complications of hypertension

Preeclampsia:

Preeclampsia Risk Factors Pregnancy-associated Maternal-specific Paternal-specific

Preeclampsia Risk Factors:

Preeclampsia Risk Factors 1. Pregnancy-associated Chromosomal abnormalities Hydatidiform mole Hydrops fetalis Multifetal pregnancy Structural congenital anomalies Urinary tract infection

Preeclampsia Risk Factors:

Preeclampsia Risk Factors 2. Maternal-specific Age >35 years Age <20 years Black Family history of preeclampsia Nulliparity Preeclampsia in a previous pregnancy Medical conditions: Gestational diabetes Type I diabetes Obesity Chronic hypertension Renal disease Stress

Preeclampsia Risk Factors:

Preeclampsia Risk Factors 3. Paternal-specific First-time father Previously fathered a preeclamptic pregnancy (in another woman)

Preeclampsia:

Preeclampsia Diagnosis Blood pressure: 140 mmHg or higher systolic or 90 mmHg or higher diastolic *Previously normal blood pressure Proteinuria: 0.3 g or more of protein in a 24 hr urine collection

Severe Preeclampsia:

Severe Preeclampsia Diagnosis Blood pressure: 160 mmHg or higher systolic or 110 mmHg or higher diastolic Proteinuria: 5g or more of protein in a 24 hr urine collection Other: Oliguria Cerebral or visual disturbances Pulmonary edema or cyanosis Epigastric or R upper quadrant pain Impaired liver function Thrombocytopenia Intrauterine growth restriction

Hypertensive Disorders of Pregnancy:

Hypertensive Disorders of Pregnancy

Preeclampsia:

Preeclampsia Clinical Presentation Asymptomatic Severe Preeclampsia Visual disturbances Severe headache Upper abdominal pain HELLP

Preeclampsia – HELLP Syndrome :

Preeclampsia – HELLP Syndrome H emolysis E levated L iver enzymes L ow P latelet count 4-14% of women with preeclampsia Mortality or serious morbidity: 25%

Preeclampsia:

Preeclampsia History “Pregnant women should be asked about specific symptoms , including visual disturbances, persistent headaches, epigastric or R upper quadrant pain, and increased edema.”

Preeclampsia:

Preeclampsia Examination Blood pressure Fundal height Growth retardation? Oligohydramnios? NOTE Increasing maternal facial edema Rapid weight gain Fluid retention is often associated with preeclampsia

Preeclampsia:

Preeclampsia Medical Management Antihypertensive drug therapy* 160-180/105-110 or higher *many are contraindicated for use during pregnancy… Magnesium sulfate During labor to prevent seizures

Preeclampsia:

Preeclampsia Treatment If preterm… Observed on an outpatient basis Hospitalized Delivery Vaginal delivery is preferred Avoid added physiological stress of C-section

Indications for Delivery:

Indications for Delivery Fetus Severe intrauterine growth retardation Nonreassuring fetal surveillance Oligohydramnios Mother Gestational age 38 weeks or greater Low platelet count Mother (cont’d) Deterioration of hepatic or renal function Suspected placental abruption Persistent severe HA, visual changes Persistent severe epigastric pain, nausea, or vomiting Eclamspia

Preeclampsia:

Preeclampsia Risk of recurrence Nulliparous may be as high as 40% Multiparous even higher

Eclampsia:

Eclampsia Severe complication of preeclampsia New onset of seizures in a woman with preeclampsia Affects .05 to .3% of pregnancies (developed countries) Mortality rate: 2% Serious complications: up to 35%

Eclampsia:

Eclampsia Clinical course is usually gradual BUT… 20% do not have classic preeclamptic triad (or only mild)

Eclampsia:

Eclampsia Treatment Magnesium sulfate Controls seizures Antihypertensive agents Decrease risk of maternal intracranial hemorrhage without jeopardizing uterine blood flow As soon as the mother is stable… deliver the baby

Preterm Labor:

Preterm Labor Von Der Pool BA. Preterm labor: diagnosis and treatment. Am Fam Physician. 1998 May 15;57(10):2457-64. Weismiller DG. Preterm Labor. Am Fam Physician. 1999 Feb 1;59(3):593-602.

Preterm Labor:

Preterm Labor Cervical effacement and/or dilatation and increased uterine irritability before 37 weeks of gestation Affects 8-10% of births in the US Rate may be worsening but survival rates have increased and morbidity has decreased Still remains a leading cause of perinatal morbidity and mortality in the US

Risk Factors:

Risk Factors Previous preterm delivery (greatest risk) Low socioeconomic status Non-white race Maternal age <18 years or >40 years Preterm premature rupture of the membranes (PPROM) Multiple gestation Maternal history of one or more spontaneous second-trimester abortions

Risk Factors (cont’d):

Risk Factors (cont’d) Maternal complications Smoking Illicit drug use Alcohol use Lack of prenatal care Uterine causes Myomata Uterine septum Bicornuate uterus Cervical incompetence Exposure to diethylstilbestrol Infectious causes Chorioamnionitis Bacterial vaginosis Acute pyelonephritis Fetal causes Intrauterine fetal death Intrauterine growth retardation Congenital anomalies Abnormal placentation Presence of a retained intrauterine device

Preterm Labor:

Preterm Labor Predicting preterm labor… Monitor cervical change, uterine contractions, bleeding, and changes in fetal behavioral states ? High false positive rate Unnecessary and potentially hazardous treatment

Preterm Labor:

Preterm Labor Management Tocolytic therapy Inhibit labor, slow down or halt the contractions of the uterus Delay delivery; time to administer corticosteroid therapy Corticosteroid therapy Enhance pulmonary maturity Reduce severity of fetal RDS and intraventricular hemorrhage Antibiotic Therapy Women with PPROM sustain the pregnancy longer Bed rest(?) No conclusive studies documenting its benefit

Post-term Pregnancy:

Post-term Pregnancy Briscoe D, Nguyen H, Mencer M, Gautam N, Kalb DB. Management of pregnancy beyond 40 weeks' gestation. Am Fam Physician. 2005; 71(10): 1935-41.

Post-term Pregnancy:

Post-term Pregnancy Pregnancy that reaches 42+ weeks’ gestation (5-10% of pregnancies) Increased risk to the mother and fetus Perinatal mortality rate doubles by 42 weeks and is 4-6x greater at 44 weeks

Risks Associated with Post-term Pregnancy:

Risks Associated with Post-term Pregnancy Maternal risks Acute cesarean delivery Cephalopelvic disproportion Cervical rupture Dystocia Fetal death during delivery Large fetus Postpartum hemorrhage Puerperal infection Neonatal risks Asphyxia Aspiration Bone fracture Perinatal death Peripheral nerve paralysis Pneumonia Septicemia Briscoe D, Nguyen H, Mencer M, Gautam N, Kalb DB. Management of pregnancy beyond 40 weeks' gestation. Am Fam Physician. 2005 May 15;71(10):1935-41.

Pregnancy Beyond 40 Weeks:

Pregnancy Beyond 40 Weeks Challenge Accurate assessment of gestational age (?) Ultrasound dating at 13-24 weeks is more accurate than estimates based on LMP

Management?:

Management? Labor induction proposed to reduce rates of adverse fetal and maternal complications Decrease C-section(?) Decrease perinatal mortality (?) vs. expectant management (fetal monitoring)

Management?:

Management? Expectant Management With fetal monitoring Up to 42 weeks’ gestation Indication for labor induction Nonreassuring test results Oligohydramnios 42+ weeks’ gestation

Contraindications to Cervical Ripening and Labor Induction:

Contraindications to Cervical Ripening and Labor Induction Absolute contraindications Complete placenta previa Previous transfundal uterine surgery Transverse fetal lie Umbilical cord prolapse Vasa previa Caution required Abnormal fetal heart rate patterns not requiring emergent delivery Breech presentation Maternal heart disease or severe hypertension Multifetal pregnancy Polyhydramnios Presenting part above the pelvic inlet One or more previous low-transverse cesarean deliveries

Higher-risk Pregnancies*:

Higher-risk Pregnancies* Gestational diabetes Hypertension *Cannot be managed the same way as low-risk post-term pregnancies

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