HIGH RISK PREGNANCY

IDENTIFICATION

&
MANAGEMENT
 ?????????
One which is complicated by factor or factors
that adversely affects the pregnancy outcome-
maternal / perinatal / both.
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• 25% OF PREGNANCIES BELONG TO THIS
CATEGORY
• FORMS 75% OF PERINATAL MORTALITY &
MORBIDITY
– >50% OF ALL MATERNAL COMPLICATIONS
&
• >60% OF ALL PRIMARY CAESAREAN
SECTIONS ARISE FROM HIGH RISK GROUP
SCREENING -HIGHRISK CASES
HISTORY
• $ MATERNAL AGE :
RISK- <17 YRS
- >35YRS
- PRIMI >30YRS
- FOLLOWING LONG
PERIODS OF INFERTILITY
- AFTER INDUCTION OF
OVULATION
SAFE- 20 - 29YRS
 REPRODUCTIVE HISTORY
• LOWEST RISK: 2nd & 3nd pregnancy
following 1st normal pregnancy.
• HIGHRISK FACTORS:
− 2 or more previous / induced abortions
− previous stillbirths / neonatal deaths
− previous preterm labour / SFD / LFD
− grand multiparity
− previous c/s
− anaemia / preeclampsia / eclampsia
− previous infant-Rh isoimmunisation
MEDICAL & SURGICAL HISTORY

• Pulm dis / TB • Myomectomy

• Renal dis / • Repair of VVF
pyelonephritis • Repair of complete
• DM perineal tear
• Cardiac disease • Repair of stress
• Thyroid disease incontinence
• Epilepsy
 FAMILY HISTORY
• H/o T.B. / B.A / H.T / D.M / Heart
Disease
• SOCIO ECONOMIC STATUS
Poor Family - Anaemia
Pre term labour
IUGR
Working Women - Abortion
premature labour
 EXAMINATION
• GENERAL
– HEIGHT : < 150 cm / < 145 cm (India)
– WEIGHT : Overweight / underweight
Accepted BMI (Wt/ht 2)
19.8 – 26
– BLOOD PRESSURE
– ANAEMIA
– CARDIAC / PULMONARY DISEASE
– ORTHOPEDIC PROBLEMS
 PELVIC EXAMINATION
• UTERINE SIZE – DISPROPOTIONATE
SMALLER OR BIGGER
• GENITAL PROLAPSE
• LACERATION / DILATATION OF Cx
• ASSOCIATED TUMOURS
• PELVIC INADEQUACY
 COURSE OF PRESENT
PREGNACY
• REASSESSMENT AT EACH
ANTENATAL VISIT
• TO DETECT ANY ABNORMALITIES LIKE
- Anaemia - Post maturity
- Preeclampsia - twins
- Diabetes - Abnormal presentation
- IUGR - Acute surgical problem
 DURING LABOUR
• REASSESSMENT ESSENTIAL DURING
LATE PREGNANCY & LABOUR
• AT HIGH RISK (MOTHER OR BABY)
– Intrapartum fetal distress
– Need for delivery under GA
– Difficult forceps / breech delivery
– PPH or retained placenta
 POST PARTUM COMPLICATIONS

• NOTE : AN UNEVENTFUL LABOUR

MAY TURN INTO AN ABNORMAL
ONE IN THE FORM OF
- PPH
- Retained placenta
- Shock
- Inversion
- Sepsis
 NEONATE - HIGH RISK
• APGAR SCORE <7 • HYPOGLYCEMIA
• BIRTH WT. <2.5 Kg • PERSISTANT
or / > 4 kg CYANOSIS
• MAJOR CONGENITAL • CONVULSIONS
ABNORMALITY
• HAEMORRAGHIC
• ANAEMIA
DIATHESIS
• FETAL INFECTION
• JAUNDICE
• RDS
MANAGEMENT OF HIGH RISK
CASES
• Medical Officer of health centres should
decide what type of cases can be
managed at home or health centers

• Cases with significant risk – referred to

specialised referral centre
 ORGANISATIONAL ASPECT
• Proper TRAINING of resident, nursing
personnel and community health workers.

• Arranging PERIODIC SEMINARS with

participation of workers involved in care of
these cases.

• CONCENTRATION of cases in
specialized centres for management
• Proper UTILISATION of health care
manpower and financial resource where it
is mostly needed.
• Availability of perinatal LABORATORY
for necessary investigations
• Availability of good PAEDIATRIC
services for neonates
• Lastly, improvement of STANDARD of
health of obstetric population and
HEALTH EDUCATION of the
community.
 INVESTIGATIONS
• IN NON PREGNANT STATE :
Complete investigation for
- Hypertension
- Kidney diseases
- Thyroid disorders
• IN PREVIOUS UNSUCCESSFUL PREGNANCIES:
- Transvaginal ultrasound
- HSG
- Hysteroscopy
- Laparoscopy
 TREATMENT
• Prepregnant state
- Start on folic acid
- Continue throughout pregnancy
• Necessary inv. (routine & special). &
examination
• Advice - Rest and activities
- diet
- medicines
 ASSESSMENT OF MATERNAL AND
FETAL WELL BEING

• DONE AT EACH ANTENATAL VISIT

• Patient with H/O previous 1st trimester

abortion - Advice rest
- Avoid journey (early pregnancy)
- Restrain sexual intercourse
- Avoid vaginal examination
• Patient with cervix incompetence
- do bimanual examn. (II trimester)
- do Cx encirclage at appropriate time

• Patient with
- premature labour requires prolonged
- unexplained still birth BED REST in
- IUGR etc., hospital
 DURING LABOUR
• High risk case
- Caesarean section
- Induction at 37 -3 8 wks
• Those with spontaneous labour or after
induction
- Requires close monitoring
- For assessment of progress or any
evidence of fetal distress.
 ASSESSMENT OF FETAL CONDITION

• Fetal heart rate monitoring

• Passage of meconium in the liquour in

presentation other than breech

• Examn. Of fetal scalp blood pH.

IF EVIDENCE OF FETAL ANOXIA IN
FIRST STAGE
(OR)
FAILURE TO PROGRESS

CAESAREAN SECTION
ASSESS NEONATE IMMEDIATELY
NEEDS EXPERT NEONATAL CARE
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