HIGH RISK PREGNANCY

IDENTIFICATION

MANAGEMENT

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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 CASESHISTORY

• $ MATERNAL AGE :RISK- <17 YRS

- >35YRS - PRIMI >30YRS- FOLLOWING LONG

PERIODS OF INFERTILITY- AFTER INDUCTION OF

OVULATIONSAFE- 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• Renal dis /

pyelonephritis• DM• Cardiac disease• Thyroid disease• Epilepsy

• Myomectomy• Repair of VVF• Repair of complete

perineal tear • Repair of stress

incontinence

FAMILY HISTORY

• H/o T.B. / B.A / H.T / D.M / Heart Disease

• SOCIO ECONOMIC STATUSPoor Family - � Anaemia

Pre term labourIUGR

Working Women - � Abortionpremature 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 LABOURMAY TURN INTO AN ABNORMAL ONE IN THE FORM OF - PPH- Retained placenta- Shock- Inversion- Sepsis

NEONATE - HIGH RISK

• APGAR SCORE <7• BIRTH WT. <2.5 Kg

or / > 4 kg• MAJOR CONGENITAL

ABNORMALITY• ANAEMIA• FETAL INFECTION• JAUNDICE

• HYPOGLYCEMIA• PERSISTANT

CYANOSIS• CONVULSIONS• HAEMORRAGHIC

DIATHESIS• 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 LABORATORYfor necessary investigations

• Availability of good PAEDIATRICservices 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 SECTIONASSESS NEONATE IMMEDIATELY

NEEDS EXPERT NEONATAL CARE

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