High Risk Pregnancy: Causes, Complications & Management

High risk pregnancy is defined as one which is complicated by factor that adversely affects the pregnancy outcome maternal or perinatal or both.

All pregnancies and deliveries are potentially at risk. However, there are certain categories of pregnancies where the mother, the fetus or the neonate is in a state of increased jeopardy. About 20 to 30 per cent pregnancies belong to this category. If we desire to improve obstetric results, this group must be identified and given extra care. Even with adequate antenatal and intranatal care, this small group is responsible for 70 to 80 percent of perinatal mortality and morbidity.

High Risk Pregnancy Causes, Complications & Management

SCREENING OF HIGH RISK CASES:

The cases are assessed at the 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.The cases are also reassessed near term and again in labour for any new risk factors. The neonates are also assessed very soon after delivery for any high risk factor. It is obvious that all abnormalities do not carry the same risk ; some have a lower risk as compared to others carrying a very high risk for the mother or the fetus.

Initial Screening :

History :

A. Maternal age : Pregnancy below the age of 17 or above the age of 35 years. Primigravidae above the age of 30 years. Pregnancy is safest between the ages of 20-29 years. Pregnancy following a long period of infertility and after induction of ovulation.

B. Reproductive history : Second and third pregnancies after a normal first delivery carry the lowest risk.

The high risk factors in reproductive history are :

  1. Two or more previous abortions ; previous induced abortion. In these cases there is further risk of abortion or preterm delivery. Previous stillbirth, neonatal death or birth of babies with congenital abnormality.
  2. Previous preterm labour or birth of a small for date baby or, weight of baby or, weight of baby 3.5 kg or more.
  3. Grand multiparity.
  4. Previous Caesarean section or hysterotomy.
  5. Pre-eclampsia, eclampsia
  6. Anaemia
  7. Third stage abnormalities- this has a particular tendency or recur.
  8. Previous infant with Rh-isoimmunisation or ABO incompatibility

C. Medical diseases or previous operations.
Diseases :
 Pulmonary disease; tuberculosis
 Renal disease (Pyelonephritis)
 Diabetes mellitus
 Cardiac disease
 Thyroid disorders
 Epilepsy
 Psychiatric illness
 Viral hepatitis
Previous operations :
 Myomectomy
 Repair of vesico-vaginal fistula
 Repair of complete perineal tear
 Repair of stress incontinence

In all these conditions, fetal maternal outcome or both may be affected.
According to WHO (1978), risk approach MCH care is to identify the high risk cases from a large group of antenatal mothers. These cases are :
During pregnancy : (1) Elderly primi (>30 years). (2) Short statured primi (<140 cm). (3) Threatened abortion and APH. (4) Malpresentations. (5) Pre-eclampsia and eclampsia. (6) Anaemia. (7) Elderly grand multiparas. (8) Twins and Hydramnios. (9) Previous stillbirth, IUD, manual removal of placenta. (10) Prolonged pregnancy. (11) History of previous caesarean section and instrumental delivery. (12) Pregnancy associated with medical diseases.

During labour : (1) PROM. (2) Prolonged labour. (3) Hand, feet or cord prolapse. (4) Placenta retained more than half an hour. (5) P.P.H. 6. Pus.

D. Family history :
 Socioeconomic status – Patients 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 labour.
 Family history of diabetes, Hypertension or multiple pregnancy (maternal side), congenital malformation.

Examination :

General Physical Examination
 Height : Below 150 cm particularly below 145 cm in our country
 Weight : Overweight or underweight body Mass Index (BMI) : Weight / (height)2 BMI : 19.8 – 26 is accepted as normal.
 High 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

Course of the present pregnancy :

After the initial visit, the cases should be reassessed at each antenatal visit to detect any abnormality that might have arisen later. few examples are – pre-eclampsia, anaemia, Rh-isoimmunisation, high fever, pyelonephritis, haemorrhage, diabetes mellitus, large uterus ; lack of uterine growth, postmaturity ( both the conditions may be associated with poor placental function) ; abnormal presentation, with and history or exposure to drugs or radiation, acute surgical problems.

Complications of labour :

The cases should be reassessed during the pregnancy and labour. Attention is turned to detect the risks that may develop during labour. Some important points to be considered are :

 Patients having no antenatal care
 Anaemia, pre-eclampsia or eclampsia
 Premature or prolonged rupture of membranes
 Amnionitis
 Meconium stained liquor
 Abnormal presentation and position
 Disproportion, floating head in labour
 Multiple pregnancy
 Premature labour
 Abnormal fetal heart labour
 Patients admitted with prolonged or obstructed labour
 Rupture uterus
 Patients having induction or
 Acceleration of labour

Certain complications may arise during labour and place the mother or baby at a high risk : Examples are–
 Intrapartum fetal distress
 Need for delivery under general anaesthesia
 Difficult forceps for breech delivery
 Failed forceps
 Prolonged interval from the diagnosis of fetal distress to delivery. If more than 30 minutes elapse from the recognition of fetal distress to delivery, the mortality increases three folds.
 Post-partum haemorrhage or retained placenta

Postpartum Complications :

An uneventful labour may suddenly turn into an abnormal one in from of PPH retained placenta, shock or inversion or sepsis may develop later on.
The condition of the neonate should be assessed after delivery. The following categories of neonate are at high risk :

 Apgar score below 7
 Birth weight less than 2500 gm or more than 4 kg
 Major congenital abnormalities
 Anaemia
 Fetal infection
 Jaundice
 Hypoglycemia
 Persistent cyanosis
 Convulsions
 Haemorrhagic diathesis
 Respiratory distress syndrome
 Central nervous system depression for more than 24 hours

Some workers have introduced a scoring system for screening of high risk cases , such a scoring system is not essential. However, if one wants to introduced a scoring system, local factors and experience of previous management should be taken into consideration before attaching a particular score to any abnormality.

Management of High Risk Cases

If we desire to improve our obstetric results, the high risk cases should be identified and given proper antenatal, internatal and neonatal care.it is necessary that all expectant mothers are covered by the obstetric service of a particular area. A simple check list should be prepared for them to fill up; arrangement should be made for early examination of the high risk cases by medical officers of health centres. Higher risk should be referred to specialized referral centres. The organizational aspect may be summarised as follows :

 Proper training of resident, nursing personnel and community health workers
 Arranging periodic seminars with participation of workers involved in the care of these cases
 Concentration of cases in specialized centres for management
 Proper utilisation of health care manpower and financial resources where it is mostly needed
 Availability of perinatal laboratory for necessary investigations; availability of a good paediatric service for the neonates.
 Lastly, improvement of the standard of health of obstetric population and health education of the community.

Assessment of maternal and fetal wellbeing:

This should be done at each antenatal visit according to the guidelines given in the appropriate chapter; maternal complications should be looked for and treated, if necessary.

Management of labour :

It is evident that elective Caesarean section is necessary in a high-risk case. Some cases may need induction of labour after 37-38 completed weeks of gestation. Those cases who go into labour spontaneously or after induction, need close monitoring during labour for the assessment of progress of labour or for any evidence of the fetal hypoxia.

The condition of the fetus can be assessed by :
 Fetal heart rate monitoring
 By stethoscope, fetoscope or Doppler
 Continuous monitoring by electronic device
 Passage of meconium in the liquor in presentations other than breech.
 Examination of fetal scalp blood for pH values

If there is any evidence of fetal anoxia in the first stage or there is future to progress, Caesarean section is necessary. The condition of the neonate is assessed immediately after delivery. many of these babies need expert neonatal care.

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    Dr. Sujon Paul

    Hello! I am Dr. Sujon Paul. I am professionally a doctor, but love to write blogs and update SUJONHERA.COM regularly with fresh contents. Thank you for visiting SUJONHERA.COM. Contact me on Facebook, Twitter & Google Plus. Don't forget to subscribe SUJONHERA.COM on Facebook, Twitter & Google Plus.

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