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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.PreEclampsia
Eclampsia
4.Grand multi
parity

3. Previous
preterm
labour or
birth of SFD
baby or
weight of
3.5kg or
more.

2. Previous
still birth,
neonatal
death or birth
of babies with
congenital
abnormalities
.

6. Anaemia

Risk
Factors In
Reproducti
ve History

1. Two or
more
previous
abortions or
previous
induced
abortion

7.Previous
Caesarean
section

8.Previous
infant with
Rh- iso
immunisation
or also
incompatibilit
y

1.
Pulmona
ry
disease
6. Viral
hepatitis

5.
Cardiac
disease

Medic
al
Surgic
al
Disord
ers

4. Renal
disease

2.
Thyroid
disorder

3.
Epilepsy

1.
Myomecto
my

4. Repair
of stress
incontinen
ce

Previou
s
Operati
on

3. Repair
of
complete
perineal
tear

2. Repair
of vesicovaginal
fistula

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,

pregnancy, congenital malformation.

or

multiple

Examination
General Physical
Examination
Height: Below 150 cm

Pelvic Examination
Uterine size Disproportionate

particularly below 145 cm in smaller or bigger


our country
Weight: Overweight or

Genital prolapse

Under weight
High BP

Laceration or dilatation of the

Anaemia
Cardiac or pulmonary
disease

cervix
Pelvic inadequacy

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

deoxygenations.

know

the

oxygenations

and

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 Previous still birth, IUD
cm)
Threatened

abortion

APH
Malpresentations
Anaemia

and Prolonged pregnancy


Pregnancy associated with
medical diseases
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,

Gonorrhoea

Chlamydial

infection

and

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 50008000 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,
Sonologist,

Anaesthetist,

Microbiologist,

Radiologist,
Geneticist,

and

Paediatric

Surgeons and well equipped laboratory and blood


transfusion service.
There are FW and MTP centres.