HIGH PARITY PREGNANCY THE GRANDE MULTIPARA Max Brinsmead

HIGH PARITY PREGNANCY (THE GRANDE MULTIPARA) Max Brinsmead MB BS Ph. D May 2015

THE EFFECT OF PARITY ON MATERNAL MORTALITY

REASONS FOR RISING MORTALITY RISK WITH INCREASING PARITY “Wear and Tear” from prior pregnancies Increasing Maternal Age Associated socio-economic factors

PREGNANCY WEAR AND TEAR Nutrient depletion Iron drain from pregnancy and lactation Calcium and others Uterine Damage Myometrial thinning and fibrosis → Dysfunctional labour Both hypertonic and hypotonic uterine activity Unpredictable response to oxytocic agents Risk of uterine rupture Endometrial thinning and morbid adherence of the placenta → Placenta previa and also Retained placenta and PPH

PREGNANCY WEAR AND TEAR (2) Abdominal Wall, Genital Tract and Pelvic Floor Spherical uterus → unstable lie and malpresentation Precipitate deliveries and genital tract injury Uterovaginal prolapse and urinary incontinence Other Sites Problems with pelvic stability Back problems Varicose veins and Haemorrhoids Metabolic Increasing birthweight due to a variety of causes Sometimes increasing maternal weight

THE EFFECTS OF INCREASING MATERNAL AGE Increased risk miscarriage and aneuploidy Increasing age of eggs Risk of miscarriage is 1: 10 at 20 but 1: 3 at 40 Increased rates of multiple pregnancy An effect of increasing FSH which ripens >1 follicle Many Diseases Diabetes Hypertension Coronary artery disease

ASSOCIATED SOCIO-ECONOMIC FACTORS Poverty Illiteracy Smoking, alcohol & drug abuse Poor Access to Health Care War and Famine Domestic abuse etc.

COMMON PROBLEMS OF HIGH PARITY Unstable lie and malpresentation Dysfunctional Labour Precipitate delivery Uterine atony Obstetric Haemorrhage Placenta previa PPH Uterine Rupture

MANAGEMENT OF THE GRANDE MULTIPARA Take a careful history – past obstetric history Optimise HB and iron stores Increased surveillance and screening in pregnancy Check carefully presentation at each visit >36 weeks “Watch and wait” in labour Use oxytocics with caution Active management of the 3 rd stage of labour Prevention of High Parity Family Planning Starts with the first pregnancy!

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