H

IGH

(T

HE

P

ARITY

G

RANDE

P

REGNANCY

M

ULTIPARA

)

T

HE

E

FFECT OF

M

ATERNAL

M P

ARITY ON ORTALITY

R EASONS FOR R ISK WITH I R ISING M NCREASING ORTALITY 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 A GE M ATERNAL 

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 M ULTIPARA G RANDE   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!

A NY Q UESTIONS OR C OMMENTS ?