Max Brinsmead MB BS PhD May 2015 H IGH P ARITY P REGNANCY (T HE G RANDE M ULTIPARA )

T HE E FFECT OF P ARITY ON M ATERNAL M ORTALITY

R EASONS FOR R ISING M ORTALITY R ISK WITH I NCREASING P ARITY  “Wear and Tear” from prior pregnancies  Increasing Maternal Age  Associated socio-economic factors

P REGNANCY W EAR AND T EAR  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

P REGNANCY W EAR AND T EAR (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

T HE E FFECTS OF I NCREASING M ATERNAL A GE  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

A SSOCIATED S OCIO -E CONOMIC F ACTORS  Poverty  Illiteracy  Smoking, alcohol & drug abuse  Poor Access to Health Care  War and Famine  Domestic abuse etc.

C OMMON P ROBLEMS OF H IGH P ARITY  Unstable lie and malpresentation  Dysfunctional Labour  Precipitate delivery  Uterine atony  Obstetric Haemorrhage  Placenta previa  PPH  Uterine Rupture

M ANAGEMENT OF THE G RANDE M ULTIPARA  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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