High Risk Pregnancy - Identification And Management

HIGH RISK PREGNANCY IDENTIFICATION

& MANAGEMENT

????????? One which is complicated by factor or factors that adversely affects the pregnancy outcomematernal / perinatal / both.

!!!!!!!!!!! • 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 CASES HISTORY • $ MATERNAL AGE : RISK- <17 YRS - >35YRS - PRIMI >30YRS - FOLLOWING LONG PERIODS OF INFERTILITY - AFTER INDUCTION OF OVULATION SAFE- 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 STATUS Poor Family Anaemia Pre term labour IUGR Working Women - Abortion premature labour

EXAMINATION • GENERAL – HEIGHT – WEIGHT

– – – –

: :

< 150 cm / < 145 cm (India) 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 LABOUR MAY 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 LABORATORY for necessary investigations • Availability of good PAEDIATRIC services 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 - unexplained still birth - IUGR etc.,

requires prolonged

BED REST in 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 SECTION ASSESS NEONATE IMMEDIATELY NEEDS EXPERT NEONATAL CARE

ed;wp