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.
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 :
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 :
- 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.
- Previous preterm labour or birth of a small for date baby or, weight of baby or, weight of baby 3.5 kg or more.
- Grand multiparity.
- Previous Caesarean section or hysterotomy.
- Pre-eclampsia, eclampsia
- Third stage abnormalities- this has a particular tendency or recur.
- Previous infant with Rh-isoimmunisation or ABO incompatibility
C. Medical diseases or previous operations.
Pulmonary disease; tuberculosis
Renal disease (Pyelonephritis)
Previous operations :
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.
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
Cardiac or pulmonary disease
Pelvic Examination :
Uterine size – disproportionately smaller or bigger
Lacerations or dilatation of the cervix
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
Meconium stained liquor
Abnormal presentation and position
Disproportion, floating head in labour
Abnormal fetal heart labour
Patients admitted with prolonged or obstructed labour
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
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
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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