High Risk Pregnancy
Introduction to risk
A dictionary definition of the word “risk” is
hazard, danger, exposure to mischance or peril”.
It implies that the probability of adverse
consequences is increased by the presence of
some characteristics or factor.
Though all mothers and children are vulnerable
to disease or disability, there are certain
mothers and infants who are at increased or
special risk of complications of pregnancy/labor
or both.
definition
High-risk pregnancy is defined as one where
pregnancy is complicated by factor or factors
that adversely affects the outcome—maternal or
perinatal or both.
The risk factors may be pre-existing prior to or at
the time of first antenatal visit or may develop
subsequently in the ongoing pregnancy labour
or puerperium.
Over 50 percent of all maternal complications
and 60 percent of all primary caesarean sections
arise from the high risk group of cases.
The cases are assessed at the initial antenatal
examination, preferably in the first trimester of pregnancy.
This examination may be performed in a big institution
(teaching or non-teaching) or in a peripheral health centre.
SCREENING OF HIGH-RISK CASES
INITIAL SCREENING(HISTORY)
Maternal age: Pregnancy is safest between the
ages of 20-29 years. Age < 16/> 30 years and
pregnancy following a long period of infertility,
after induction of ovulation is of high risks.
Reproductive history:
Two or more previous miscarriage or previous
induced abortion.
Previous stillbirth, neonatal death or birth of
babies with congenital abnormality
Previous preterm labor or birth of a IUGR or,
macrosomic baby
Grand multiparity
Previous cesarean section or hysterotomy
Third stage abnormalities (PPH)
Previous infant with Rh-isoimmunization or
ABO incompatibility
Medical Disorders in Pregnancy
Pulmonary disease
tuberculosis
Renal disease (Pyelonephritis)
Thyroid disorders
Psychiatric illness
Cardiac disease
Epilepsy
Viral hepatitis
Preeclampsia, eclampsia
Anemia
Infections in pregnancy
Malaria, HIV
Previous Surgery
• Myomectomy
• Repair of complete perineal tear
• Repair of vesico-vaginal fistula
• Repair of stress incontinence
Family History
• Socioeconomic status — Patients belonging to
low socio economic status have a higher
incidence of anemia, preterm labor, growth
retarded babies
• Family history of diabetes, hypertension or
multiple pregnancy and congenital
malformation.
According to WHO,cases are:
During pregnancy:
Elderly primi (>30 years)
Short statured primi (<140 cm)
Threatened abortion and APH
Malpresentations
Preeclampsia and eclampsia
Anemia
Elderly grand multiparas
Twins and hydramnios
• Previous still birth, IUD, manual removal of
placenta
• Prolonged pregnancy
• History of previous cesarean section and
instrumental delivery
• Pregnancy associated with medical diseases
During labor:
PROM
Prologned labor
Hand, feet or cord prolapse
Placenta retained more than half an hour
PPH
Puerperal fever and sepsis
Patients having no antenatal care
Anemia, preeclampsia or eclampsia
Premature or prolonged rupture of
membranes
Amnionitis
Meconium-stained liquor
Abnormal presentation and position
Disproportion, floating head in labor
Multiple pregnancy, premature labor
Abnormal fetal heart rate
Patients admitted with prolonged or
obstructed labor
Rupture uterus
Patients having induction or acceleration of
labor
Certain complications may arise during labor
and place the mother or baby at a high risk.
Examples are
Intrapartum fetal distress
Delivery under general anesthesia
Difficult forceps or breech delivery
Failed forceps
Postpartum hemorrhage or retained placenta
Prolonged interval from the diagnosis of fetal
distress to delivery.
POSTPARTUM COMPLICATIONS:
Apgar score below 7
Hypoglycemia
Anemia
Birth weight less than 2500 gm or more than
4 kg
Major congenital abnormalities
Convulsions
Fetal infection
Jaundice
Respiratory distress syndrome
Persistent cyanosis
Hemorrhagic disorder.
EXAMINATION:
• Examination General physical examination
• Height
• Weight
• Blood pressure
• Anaemia
• Cardiac or pulmonary disease
• Orthopaedic problems
• Pelvic examination
• Uterine size- disproportionately smaller or
bigger
• Genital prolapse
• Lacerations or dilatation of the cervix
• Associated tumours
• Pelvic inadequacy
MANAGEMENT OF HIGH RISK CASES
• Strengthen midwifery skills, community
participation and referral (transport) system
• Proper training of resident, nursing personnel
and community health workers
• Arranging periodic seminars, refresher
courses with participation of workers involved
in the care of these cases
• Concentration of cases in specialized centers
for management
• Community participation, proper utilization of
health care manpower and financial resources
where it is mostly needed
• Availability of perinatal laboratory for
necessary investigations; availability of a good
pediatric service for the neonates
• Lastly, improvement of literary rate, health
awareness of the community and economic
status.
Other management
• Referral services for unhandled cases
• A simple checklist should be prepared for
them to fill up for high risk assessment.
• Cases with a significantly higher risk should be
referred to specialized referral centers.
Pre-conceptional counselling
• Folic acid (4 mg/day) therapy should be
started in the prepregnant state and is
continued throughout the pregnancy.
• Ensure healthy concept
Antenatal care:
Supplemental therapy
Advice good nutritious food
Immunization
Antenatal visits
MANAGEMENT OF LABOR
• Early detection of complication during labour.
• Fetal heart rate monitoring: By stethoscope,
fetoscope or Doppler—Continuous electronic
monitoring
Post partum care:
Provide good postnatal assessment
Levels of care
Primary
Secondary
Tertiary
subcenter
Primary
Village health
center
Community
District
health
hospital
center
Responsibility of health profession
• Essential obstetrical care for all pregnant
women
• Early detection of pregnancy complication
• Emergency services whenever needed
Thank you
