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H IGH PARITY P REGNANCY (T HE G RANDE M ULTIPARA ) T HE E FFECT OF PARITY ON M ATERNAL M ORTALITY R EASONS FOR R ISING M ORTALITY R ISK WITH I NCREASING PARITY “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 FACTORS Poverty Illiteracy Smoking, alcohol & drug abuse Poor Access to Health Care War and Famine Domestic abuse etc. C OMMON P ROBLEMS OF H IGH PARITY 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 3rd stage of labour Prevention of High Parity Family Planning Starts with the first pregnancy! A NY Q UESTIONS OR C OMMENTS ?