HIGH RISK PREGNANCY

ASSESSMENT AND MANAGEMENT

 High Risk Pregnancy

Definition: High risk pregnancy is defined as one which is complicate

by factor or factors that adversely affects the pregnancy outcomes

maternal or perinatal or both.

 SCREENING AND ASSESSMENT

 Initial antenatal examination - in the first trimester of pregnancy.

 Some risk factors may later appear and are detected at subsequent visit.

 The cases are also reassessed near term and again in labour for any new
risk factors.

 The neonate are also assessed very soon after delivery for any high risk
factors.
 SCREENING AND ASSESSMENT

A. INITIAL SCREENING – HISTORY

B. NON-INVASIVE SCREENING

C. INVASIVE SCREENING
 A. INITIAL SCREENING - HISTORY

1. Maternal age - Pregnancy below the age of 17 above the age of

35 years. Primi gravida above the age of 30 years. Pregnancy safest
between the ages of 20-29 years.

2. Reproductive history: Second and third pregnancies after a

normal first delivery carry the low risk.
 5.Pre-Eclampsia
– Eclampsia

4.Grand multi
6. Anaemia
parity

3. Previous Risk Factors

preterm labour In 7.Previous
or birth of SFD Caesarean
baby or weight of Reproductive section
3.5kg or more. History

2. Previous still
8.Previous infant
birth, neonatal
with Rh- iso
death or birth of
immunisation or
babies with
also
congenital
incompatibility
abnormalities. 1. Two or more
previous
abortions or
previous induced
abortion
 1.
Pulmonary
disease

6. Viral 2. Thyroid
hepatitis disorder

Medical
Surgical
Disorders

5. Cardiac
3. Epilepsy
disease

4. Renal
disease
 1.
Myomectomy

4. Repair of Previous 2. Repair of

stress vesico-vaginal
incontinence Operation fistula

3. Repair of
complete
perineal tear
 Family History

Socio-economic Status: Patient belonging to poor families have a higher

incidence of anaemia, preterm labour, growth retarded babies and so on.
Working women who have to undertake long road journeys, have a higher
incidence of recurrent abortion or premature labor.

Family history of diabetes, hypertension, or multiple pregnancy, congenital

malformation.
 Examination
General Physical Examination Pelvic Examination

Height: Below 150 cm particularly Uterine size – Disproportionate smaller

below 145 cm in our country or bigger

Weight: Overweight or Under weight Genital prolapse

High BP Laceration or dilatation of the cervix
Anaemia Pelvic inadequacy
Cardiac or pulmonary disease
Orthopaedic problems
 B. NON INVASIVE MONITORING

1. Radio Diagnostic Examination

2. Radiation Therapy
3. Magnetic Resonance Imaging
4. Ultrasound (Doppler)
5. Doppler For Fetal HR Monitoring
6. Transvaginal Ultrasonography
 1. Radio Diagnostic Examination
 Every women child bearing potential – Ask orally or in writing,
whether pregnant or have missed a period. If any uncertainty about
pregnancy - Postponed examination.

 If pregnant special attention - Justification and urgency of the

radio diagnostic examination.

 In pregnant women alternative diagnostic method can be

considered – US or MRI.
 1. Radio Diagnostic Examination
 Reduction to the radiation dosage by the fetus may be achieved by
lead-shielding the abdomen where feasible and fewer images.

 In woman undergoing nuclear medicine examination - asked,

orally or in writing, is she breast feeding?

 When pregnant women undergoing a nuclear medical

examination, the dose of radio nuclear is kept as low as possible
without sacrificing radiographic information
 2. Radiation Therapy
 Evaluate the presence of pregnancy (women of reproductive age)
when radiation therapy is considered for.

 Appropriate lead shield to protect gonads of patient undergoing

radiation therapy.

 If the patient is pregnant, she must be involved in discussion and

decision about radiation therapy.
 2. Radiation Therapy
 Termination of pregnancy should be considered if the radiation
dose would lead to severe effects.

 Patients who have radiation therapy should not be discouraged

from having children.
 3. MRI
 MRI is a powerful imaging tool.

 Does not expose patient to ionizing radiation.

 MRI requires powerful magnetic field and a radio frequency pulse

to produces a diagnostic imaging.
 3. MRI
 MRI has some maternal safety issues - Metallic biomedical
implants or other metallic foreign bodies.

 Foreign metallic materials embedded within patient can have

ferromagnetic properties that presents a potential hazards.
 4. Ultrasound (Doppler)

 It is widely accepted and valuable diagnostic tool in standard

clinical practice.

 No potential harmful effects in the offspring.

 Recent trend – colour flow imaging, power Doppler, pulsed

Doppler.
 5. Doppler for fetal HR monitoring

o It can be used for extended periods and not contraindicated on

safety grounds.
 6. Transvaginal Ultrasonography

 It should be performed in first trimester with valid medical reasons

that benefit the mother and embryo.
 7. Kick Chart

I. Cardiff ‘count 10 formula’

 The patient count fetal movement starting at 9 am.

 The counting comes to an end as soon as 10 movements are perceived.

 7. Kick Chart

I. Cardiff ‘count 10 formula’

She is instructed to report the physician if

◦ Less than 10 movements occur during 12 hours on 2 successive days.

◦ No movement is perceived even after 12 hrs in a single day.

 7. Kick Chart

II. Daily Fetal Movement Count (DFMC)

 Three counts each of one hour duration (morning, noon and

evening) are recommended.

 The total counts multiplied by four is given daily (12 hours) fetal
movement count.
 7. Kick Chart
II. Daily Fetal Movement Count (DFMC)

 If there is diminution of the number of kicks to less than 10 in 12

hrs (or less than 3 in each hour) is indicates fetal compromise.

The count must be started in the beginning of 28 week of

pregnancy.
 C. INVASIVE MONITORING

1. CVP and Pulmonary Artery Monitoring

2. Oxygen saturation Monitoring

3. Hemodynamic Monitoring of Cardiac Output

4. Capnometry
 1. CVP and Pulmonary Artery Monitoring

 CVP catheter is placed to give a greater understanding of the

mechanical phases of the cardiac cycle.

 Management of oliguria, unresponsiveness to a fluid challenge,

pulmonary oedema, and refractory hypertension are clinical
situation in which some clinical desire of CVP monitoring.
 1. CVP and Pulmonary Artery Monitoring

 Pulmonary Artery Monitoring

Assist in determining the etiology of pulmonary oedema, oliguria
with a normal CVP or cardiac vascular failure.
 2. Oxygen Saturation Monitoring

Oximetry is the detection of oxygenated and deoxygenated blood.

The oxygenated Hb reflects more light of 60mm whereas at 940mm

deoxy Hb reflects infrared light more strongly.
 2. Oxygen Saturation Monitoring

 This allows the simultaneous acquisition of peripheral signal from

which are ratio of oxyhemoglobin to deoxyhaemoglobin can be
calculated and expressed as a percentage of oxyhemoglobin
saturators.
 2. Oxygen Saturation Monitoring

 Oximetry may be based on transcutaneal measurement or can be

derived from mixed venous blood and a probe located in a
pulmonary artery catheter.

 Purpose to know the oxygenations and deoxygenations.

 3. Hemodynamic Monitoring of Cardiac
Output
 Hb monitoring is an integral part of ICU management

 Important in case of severe haemorrhage, severe preeclampsia and

septic shock.

 An adequate cardiac output is important in delivering oxygenated

blood to the peripheral tissues.
 3. Hemodynamic Monitoring of Cardiac
Output
 Low output will reflect either hypovolemia or ventricular failure

 Knowledge of the cardiac output will determine more and will

calculate the Hb value.
 4. Capnometry

 Exhaled gas can be evaluated using an infrared probe and a photo

detector set to detect CO2.

 Purpose is to detect level of co2.

 HIGH RISK APPROACH
 According to WHO (1978),

 Risk approach for MCH is to identify the high risk cases from a
large group of antenatal mothers.

 These cases are

HIGH RISK APPROACH - DURING PREGNANCY
 Elderly primi (> 30 yrs)  Twins and Hydramnios

 Short statured primi (< 140 cm)  Previous still birth, IUD

 Threatened abortion and APH  Prolonged pregnancy

 Malpresentations  Pregnancy associated with medical

diseases
 Anaemia Elderly Grand multipara
 HIGH RISK APPROACH - DURING LABOUR

 PROM  Placenta retained more than half

an hour

 Prolonged labour  Puerperal fever and sepsis

 Hand, feet or cord prolapse  PPH

 Categories Of High Risk Pregnancy
 Pregnancy during hypertension

 Rh incompatibility

 Ectopic pregnancy

 ABO incompatibility

 Gestational DM

 Abruptio placenta
 Categories Of High Risk Pregnancy

 Other medical disorders like

◦ Cardiac diseases, DM, Hepatic disorder and jaundice

◦ UTI, TB, Anaemia

◦ Viral infection, HIV disease

◦ Syphilis in pregnancy

◦ Renal disorders, Chlamydial infection and Gonorrhoea

LEVELS OF OBSTETRIC CARE

Level I or Primary Care

Level II or Secondary Care

Level III or Tertiary Care

 Level I or Primary Care
 This is for low risk pregnant woman and low risk neonate (Perinatal
care).

 This constitutes 75% of all births in a community.

 Level I or Primary Care
1. Village: (Average 1000 population) - 6, 00,000 villages in India.

 Trained Dai and trained female health workers from subcenters

give low risk maternity and neonatal care at villages.

 High risk cases are referred to PHC or CHC or District hospital.

 Level I or Primary Care
2. Subcenters working for 8-10 villages one for 5000-8000
population. Total 1, 32,000 subcenters in India.

 A female health worker provides low risk maternity and neonatal

services with referral of high risk cases to CHC and higher centre.
 Level I or Primary Care
3. Primary Health Centre at block level catering 1, 00, 000 - 3, 00,000
rural population

 Staff: Medical Officers (MBBS), Public Health Nurse, Female Health

Worker (Previously ANM)
 Level I or Primary Care
3. Primary Health Centre

 Total number of PHCs 22000 in India.

PHC caters low risk maternity and neonatal service in labour room,
maternity beds and refers high risk cases to CHC and higher centre hospitals.

 Family Welfare program in all PHCs and MTP in some centres are
available.
 Level II or Secondary Care
It is provided by rural hospitals, sub divisional district hospital at
towns with obstetrician, anaesthetist, paediatrician, blood
transfusion, laboratory, family welfare and MTP centres.

There are 2500 CHC and over 500 district hospitals and around
3000 sub divisional hospitals.
 Level II or Secondary Care
 Municipal, ESI, Central GOVT. and private maternity hospitals are
included at level II.

 Level II hospitals cater 20% of all births both low and high risk
cases.
 Level III or Tertiary Care

 It is provided by medical collages and teaching hospitals and

corporation and big private hospitals.

 They cater high risk cases which are referred from periphery.

 Level III caters 5% of obstetric cases.

 Level III or Tertiary Care

 Level III hospital are well equipped with Obstetrician,

Neonatologist, Anaesthetist, Radiologist, and Sonologist,
Microbiologist, Geneticist, Paediatric Surgeons and well equipped
laboratory and blood transfusion service.

 There are FW and MTP centres.