MATERNITY NURSING:-

SEMINAR ON
ASSESSMENT AND DIAGNOSIS OF HIGH RISK PREGNANCY
ASSESSMENT AND DIAGNOSIS OF HIGH RISK MOTHERS

INTRODUCTION
Most of the time having a baby is a natural process. After a full-term pregnancy, a woman goes into labor on or near her due date and gives birth to a healthy baby. A day or two later she leaves the hospital to begin day-to-day life with her growing family. But not all pregnancies go smoothly. Some women experience what doctors refer to as a high-risk pregnancy. A pregnancy is considered high-risk when there are potential complications that could affect the mother, the baby, or both. High-risk pregnancies require management by a specialist to help ensure the best outcome for the mother and baby.
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WHAT IS A HIGH RISK PREGNANCY:DEFINITION: -High risk pregnancy is defined as one which is complicated by factor or factors that adversely affects the pregnancy outcome- maternal, perinatal or both. RISK: - Is defined as the probability of an adverse outcome or a factor that increases this probability.

HIGH RISK PREGNANCY: When the probability of an adverse outcome for the mother or child is increased over and above the baseline risk of that outcome among the general pregnant population by the presence of one or more ascertainable risk factors, or indicators. All pregnancies and deliveries are potentially at risk . Hoowever there are certain categories of pregnancies where the mother , the fetus or the neonate is in a state of increased jeopardy. About 20-30% pregnancies belongs to this category. If we desire to improve obstetric result, this group must be identified and given extra care. Even with adequate antenatal and intranatal care, this small group is responsible for 70-80% of perinatal mortality and morbidity. In the developed countries the maternal deaths has been brought down to irreducible minimum and as such it may be prudent to consider only perinatal mortality and morbidity in identifying high risk cases. But in the developing countries with a high maternal and perinatal mortality, the maternal factors also should be considered. 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. It must be remembered that over 505 of all maternal complications and 60% of all primary caesarean sections arise from the high risk group of cases.
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Risk factors in pregnancy are those findings discovered during prenatal assessment that are known to have a potentially negative effect on the outcome of the pregnancy, either for the woman or the fetus. This evaluation determines whether or not the mother has characteristics or conditions that make her or her baby more likely to become sick or die during the pregnancy.

Causes and symptoms

All risk factors do not threaten pregnancy to the same extent. The risk of complications is increased by smoking, poor nutritional habits, drug and alcohol abuse, domestic violence, prepregnancy maternal health status, psychosocial factors, prior health care, the presence of chronic medical problems in the mother, past history of repeated preterm delivery, multiple gestation, and abnormalities of the fetus or placenta. A woman with a highrisk pregnancy may have an earlier labor and delivery depending upon the fetal or maternal complication present and, likewise, present with symptoms dependent upon the condition. Since the placenta supplies the baby with its nutrients and oxygen, any condition that threatens the blood supply to it threatens fetal development. The threat of a preterm delivery is the most common reason for a referral to a perinatal center, which is linked to obstetric and newborn services that provide the highest level of care for a pregnant woman and her baby. A preterm delivery may occur because of a premature rupture of membranes (the bag of water surrounding the baby breaks) or preterm labor. There is a strong correlation of vaginal or uterine infection with the pregnant woman's water breaking, and there are lab tests that can be predictive of a woman's risk of experiencing preterm labor. According to a 2001 report from the U.S. Centers for Disease Control and Prevention, there were 29.6 deaths per 100,000 births among AfricanAmerican women between 1991 and 1997. The rate for women of Hispanic origin was 10.3, and for white women it was 7.3. The rate for Asian women was unavailable. The second most common causes of death in women are problems related to pregnancy and delivery, including blood clots that
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travel to the lungs, anesthesia complications, bleeding, infection, and high blood pressure complications. A baby dies before, during, or after birth in 16 out of 1,000 deliveries in the United States. Almost 50% of these deaths are stillbirths, which are sometimes unexplained. The rest of the deaths occur in babies up to 28 days old, and the leading cause of these is birth defects, followed by prematurity. Risk factors can be present before pregnancy occurs and others develop during pregnancy.

SCREENING OF HIGH RISK CASES:_ The cases are screened at the initial antenatal examinations preferably in the first trimester of pregnancy. This examination may be performed in a big institution or in a peripheral health centres in rural areas, the initial screening may be done by properly trained paramedical personnel. From the peripheral areas the high risk cases are sent to referral hospitals in subdivisions, districts or cities for management by specialists. Some risk factors may later appear and are detected at subsequent visits. 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 when compared to others carrying a very high risk for the mother or the fetus. Initial screening History :
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.

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. 2. Previous still birth, neonatal death or birth of babies with congenital abnormality. Previous preterm labour or birth of a small for date baby or weight of baby 3.5 kg or more.
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4. 5. 6. 7. 8.
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Grand multiparity Previous caesarean section or hysterotomy. Pre- eclampsia, eclampsia. Anaemia. Third stage abnormalities this has a particular tendency to recur. Previous infant with Rh-isoimmunization or ABO incompatibility.

Medical diseases or previous operations:-

Diseases:

Pulmonary diseases; tuberculosis. Renal disease. 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 or maternal outcome or both may be affected.

Family history:-

Socio economic status:- Patients belonging to poor families have a higher incidence of anemia, preterm labour, growth retarded babies and so on. Working woman 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:GENERALPHYSICAL EXAMINATION PELVIC EXAMINATION

1. Height: below150cm 1. Uterine sizeparticularly, below 145cm in India. disproportionately smaller or bigger. 2. Weight: overweight or under 2. weight.
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Genital prolapse.

BMI 19.8-26 is normal 3. High blood pressure. 4.Anaemia. 5. Cardiac or pulmonary disease. 6. Orthopaedic problems 3. Lacerations or dialatation of cervix. 4. Associated tumours.

According to WHO (1978), risk approach for MCH care is to identify the high risk cases from a large group of antenatal mothers. These cases are: During pregnancy:
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Elderly primi (more than or equal to 30 years) Short statured primi(less than or equal to 140 cm.) Threatened abortion and APH. Malpresentations. Pre- eclampsia and eclampsia. Anaemia. Elderly grand multiparas. Twins and hydramnios. Previous still birth, IUD, manual removal of placenta. Prolonged pregnancy. History of previous caesarean section and instrumental delivery. Pregnancy associated with medical diseases.

During labour:

PROM. Prolonged labour. Hnad , feet or cord prolapse. Placenta retained more than half an hour. PPH Puerperal fever and sepsis. 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 iso immunization, high fever, pyelonephritis, haemorrhage, diabetes mellitus, large uterus, lack of uterine growth, post maturity, abnormal presentation, twin and history of exposure to drugs or radiation, acute surgical problems. COMPLICATIONS OF LABOUR:The cases should be reassessed during late pregnancy and labour. Attention is turned to detect the risk 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. Multiplt pregnancy Premature labour. Abnormal fetal heart rate. 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 or 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 threefold. POST PARTUM COMPLICATIONS:An uneventful labour may suddenly turn in to an abnormal one in the form of PPH, retained placenta, shock or inversion or sepsis may develop later on. The condition of the neonate should be assessed after delivery.
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The following categories of neonates are at high risk; Apgar score below 7 Birth weight less than 2500 gmsor more than 4kg. Major congenital abnormalities. Anaemia Fetal infection Jaundice Hypoglycemia Persistent cyanosis Convulsions Haemorrhagic diathesis

Respiratory distress syndrome

Central nervous system depression more than 24 hours. Some workers have introduced scoring system for screening of high risk cases; such a scoring system is not essential. However if one wants to introduce a scoring system, local factors and experience of previous management should be taken in to consideration before attaching a particular score to any abnormality. COMMON REASONS FOR ASSESSMENT: To date pregnancy and to check for fetal cardiac activity.
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To determine the number of fetuses. Unexplained bleeding in early pregnancy.

Severe nausea and vomiting in early pregnancy. Lower abdominal pain in early pregnancy. Possible miscarriage or ectopic pregnancy following previous miscarriage or

Reassurance ectopic pregnancy.

A pregnancy test followed by a transvaginal ultrasound can be performed if not done earlier, if the situation is still unclear. Beta HCG level is monitored. The patient is either call back after few days or one week to repeat either the scan or a blood test or both.

DIAGNOSTIC TESTS:-

Ultrasound

An ultrasound scan is a diagnostic technique which uses highfrequency sound waves to create an image of the internal organs. A screening ultrasound is sometimes done during the course of a pregnancy to monitor normal fetal growth and verify the due date. Ultrasounds may be performed at various times throughout pregnancy for different reasons:
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PRENATAL SCREENING OF FETAL DEFECTS:(CHROMOSOMAL AND STRUCTURAL) Screening through ultrasound and biochemical markers can be carried out much earlier in pregnancy. Screening includes: Maternal age

Measurement of free beta HCG and PAPP-A (pregnancy associated plasma protein A) An ultrasound scan at 11-13_+6 weeks.

This method of screening reduces the number of invasive procedure required and increase the detection rate from less than 50% to more than 90%. ROLE OF GENETIC INVESTIGATIONS AND COUNSELING:Physicians engaged in prenatal care are increasingly aware of the need to evaluate pregnancies with risk of genetic disorder or birth defects in the fetuses. This is because 2% of new borns have major malformations and about 1% has single gene disorders and 1% will have mental subnormality. It is observed that 60% of abortuses have chromosomal anomalies.

TYPES OF PRENATAL GENETIC INVESTIGATIONS:1. SCREENING TESTS:-

MATERNAL SERUM SCREEENING: - Screening test has to be done for a woman more than age 35 years. These are noninvasive and no harm for mother or baby. Disorders that can be screened by tests are;
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trisomy 21(down syndrome), trisomy 18 (Edward syndrome) and neural tube defects.

First trimester maternal screening tests

Free Beeta HCG Pregnancy associated plasma protein A In pregnancies with Down syndrome, beta HCG is raised and PAPPA is decreased.

Second trimester maternal serum screening:In the second trimester, the test is performed between 15-20 weeks and mostly measures three substances. Alpha feto protein, Beta HCG , and Serum estriol. COMBINED SCREENING TESTS:Any woman who has undergone first trimester screening must be offered serum alpha protein in the second trimester for screening of neural tube defects. Three approaches to Down syndrome screening: Integrated screening testing. Stepwise sequential screening test Contigent screening test.

SERUM ALPHA PROTEINS:Alpha-fetoprotein (AFP, -fetoprotein; also sometimes called alpha-1-fetoprotein or alpha-fetoglobulin) is a protein that in humans is encoded by the AFP gene. AFP is a major plasma protein produced by the yolk sac and the liver during fetal development that is thought to be the fetal form of serum
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albumin. The AFP gene is located on the q arm of chromosome 4 (4q25). AFP binds to copper, nickel, fatty acids and bilirubin[4] and is found in monomeric, dimeric and trimeric forms. POPULATION SCREENING:Also known as carrier testing. This is offered to the couple who are at risk for genetic disorder due to ethnic background. Carrier testing can be done before during or after a pregnancy.

DIAGNOSTIC METHODS OF FETAL DIAGNOSIS:These are diagnostic tests with a higher degree of reliability. Diagnostic tests are done by fetal tissue sampling. The major sources of fetal tissues are, Amniotic fluid Chorionic villi Fetal blood cells Placental villi The tissues can be analyzed for used for chromosomal studies, enzymes assay and DNA analysis. The ideal time, specificity and sensitivity of the tests has been described below. AMNIOCENTESIS: - This is the earliest method used in prenatal diagnosis. Steele and Berg reported the first prenatal detection of chromosomal abnormality on culture amniotic cells.(1966). The cells are obtained for culture by amniocentesis at 16-18 weeks gestation. CHORIONIC VILLUS SAMPLING:- Chorionic villus sampling is a well-established technique of fetal tissue sampling in the first trimester. The ideal time is between 10 and 12 weeks of gestation. CORDOCENTESIS: Under ultra sound guidance a fine needle can be passed Trans abdominally in to the fatal umbilical cord where it enters the placenta in order to take a fetal blood sample or to perform an in utero transfusion. The procedure is possible from 18 weeks of gestation onwards and procedure related fetal loss rate is about 1-2%.
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There is also a risk of feto maternal hemorrhage with the development or enhancement of Rhesus isoimmunization. Indications for fetal blood sampling are hemophilia A and B fragile X mental retardation, beta thalassemia, sickle cell anemia, alpha 1antitrypsin deficiency, severe combined immunodeficiency, suspected mosaicism, in utero transfusion for isoimmunization, unexplained hydrops, failed CVS, or amniotic culture or late booking, potentially treatable congenital malformations, unexplained severe fetal growth retardation. FETOSCOPY, FETAL SKIN BIOPSY AND FETAL LIVER BIOPSY:Fetoscopy is the endoscopic visualization of the fetus. The optimal timer for this procedure is 18-20weeks of gestation. The procedure carries a fetal loss rate of 3%. Some serious skin disorders can be diagnosed in a fetal skin biopsy taken via the fetoscope and occasionally fetal liver biopsy is necessary for diagnosing metabolic disorders. COLOR DOPPLER: - Plays a vital role in the diagnosis of fetal, cardiac and non-cardiac malformations and hemodynamic responses to hypoxia and anemia. LABORATORY METHODS OF FETAL TISSUE ANALYSIS:Fetal karyotyping:- Fetal Karyotyping is a laboratory method of fetal tissue analysis. Is indicated in case of an increased risk of aneuploidy on the basis of maternal age and prenatal screening tests, a previous child with chromosomal anomaly, pregnancies where one parent has a balanced structural chromosomal rearrangement and to confirm the fetal sex in X-linked conditions FETAL ENZYME ASSAY: - The amniotic fluid cells need to be cultured for 4-6 weeks in order to provide sufficient cells for the assay of the appropriate enzymes. Now it is possible to use chorionic villi directly for the enzyme assay and reports are available within weeks.
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FETAL DNA DIAGNOSIS: The DNA can be extracted for chorionic villi or amniotic cells after culturing them for 3-4 weeks. The diagnosis may be by direct demonstration of the molecular defector or may be established with a linked restriction fragment length polymorphism. These days it is possible to get a sufficient amount of DNA from chorionic villi without prior culture and the test can be performed earlier(9-11 weeks gestation.). Chorionic villus sampling is the preferred technique to obtain fetal tissue for DNA analysis.

Preimplantation Genetic Diagnosis;Identification of the genes responsible for certain severe hereditary diseases and in vitro fertilization techniques allow diagnosis of a few such disorders prior to implantation. TRANS VAGINAL OBSTETRIC ULTRASOUND:Ultrasound plays an important role in obstetrics from conception until delivery. The introduction of ultrasound probe in to the body cavities has the added benefit of better view due to improvement in resolution. Kratochwil was the first to introduce vaginal sonography, higher frequency transducers of 5-7.5 MHz are better used to get the resolution in comparison to the Trans abdominal; probes (3-5 MHz)

COLOR DOPPLER IN FETAL ANOMALIES:

Color Doppler plays a vital role in the diagnosis of fetal cardiac defects and in the assessment of the hemodynamic responses to fetal hypoxia and anemia. In the future, color Doppler may also be used in the three16

dimensional reconstruction and visualization of fetal and placental vessels.

Bio physical methods for assessing fetal well being:Tests for assessing biophysical activity includes, o o o o o o o o o Daily fetal kick count Non stress test Contraction stress test Fetal bio physical profile Modified biophysical profile Acoustic stimulation test Visual acoustic stimulation tests Umbilical, cerebral, uterine , venous Doppler Percutaneous umbilical blood sampling

MANAGEMENT OF HIGH RISK CASES:If we desire to improve our obstetric results, the high risk cases should be identified and given proper antenatal, intranatal and neonatal care. This is not to say that healthy uncomplicated cases should not get proper attention. But in general they need not be admitted to specialized centres and their care can be left to properly trained midwives and medical officers in health centres or general practitioners. It is necessary that all expectant mothers are covered by the obstetric service of a particular area. The services of trained community health workers and assistant nurse cum midwife of health centers should be utilized to provide the primary care and screening in rural areas, urban and semiurban pockets.

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A simple checklist should be prepared for them to fill up; arrangement should be made for early examination of the high risk cases by medical officers of the health centers. The general practitioner or medical officer of health centers, in collaboration with the specialists will decide what type of cases can be managed at home or health centers. Cases with significantly higher risk should be referred to specialized referral centres. The organizational aspect may be summarized 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 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 sevice for the neonates.

Lastly, improvement of the standard of health of obstetric population and health education of the community. Cases having a previous unsuccessful pregnancy should be seen and investigated before another conception occurs. investigations like hysterogram, hysteroscopy, laproscopy or trans vaginal ultrasonography should be performed to rule out Mullarian abnormality. Complete investigation for hypertension, kidney disease or thyroid disorder should undertaken and proper treatment instituted in the nonpregnant state. Sexually transmitted diseases should be treated before embarking on another pregnancy. Cervical tears should also be repaired in the nonpregnant state. Serology for toxoplasma IgG, IgM and antiphospholipid antibodies should be done and corrected appropriately when found positive.
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Folic acid (4mg/day) therapy should be started in the pregnant state and is continued throught the pregnancy. Early in pregnancy after the initial clinical examination, routine and special laboratory investigation should be undertaken. Necessary advice should be given regarding diet, activities, rest and medicines. Minimum medicines should be taken during pregnancy, particularly in the early months. Assessment of maternal and fetal well being:This should be done at each antenatal visit according to the guidelines given; maternal complications should be looked for and treated, if necessary. Patient with history of previous first trimester abortion should be advised rest and avoidance of journey in the early pregnancy. They should also retain from sexual intercourse. Vaginal examination should be avoided in the first trimester in these cases. Patients suspected to have cervical incompetence should have a bimanual examination early in the second trimester so that cervical encirclage if necessary may be performed at appropriate time. Patients having premature labour, unexplained still birth, intrauterine growth restriction and many other abnormalities are benefited by prolonged rest in hospitals; this particularly applies to women of lower socio economic group who cannot have adequate rest and nutrition at home. 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 in to labour spontaneously or after induction , need close monitoring during labour for the assessment of progress of labour or fro any evidence of the fetal hypoxia. The condition of the fetus can be assessed by :
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 Fetal heart rate monitoring by fetoscope or stethoscope or Doppler or by electronic devices. 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 failure to progress, caesarean section is necessary. The condition of the neonate is assessed immediately after delivery. Many of these babies need expert neonatal care.

CONCLUSION:The main objective of the obstetrical practice was the prevention of maternal mortality. In the recent times the improvement in the overall health condition of the women, obstetrical anesthesia,. Laboratory diagnosis, availability of blood transfusion, and improvement in surgical techniques have led to a drastic reduction in maternal mortality. The significant improvement achieved in maternal outcome was quickly followed by the adoption of a second paradigm of obstetrical care which was to obtain the best possible fetal outcome. Prenatal care offers to a unique opportunity to timely detect morbid changes in the fetal status and implement interventions to avoid death or disability.
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