Identification of High Risk Women

A high-risk pregnancy is one in which the mother or fetus has a significantly increased
chance of death or disability (Hobel, 1979). In order to achieve optimal perinatal outcome, all
factors contributing to mortality and morbidity in a particular pregnancy must be identified and
acted upon early.
The factors may be divided into the categories of socio-economic, demographic,

and medical.

Socioeconomic Factors
 
Socioeconomic Status.
The many social factors that place a fetus at greater risk are interrelated. Such conditions
as-
1    overcrowding
2    poor standards of housing and hygiene, and
3    poor nutrition are closely associated with high rates of infant and child morbidity and
mortality.
 
Poverty and low educational status are at root of these problems, and in countries where
social and economic improvement has occurred, there has also been a decrease in perinatal
mortality (Chea et al, 1977).

Parental Occupation.
Occupation of the father, as a reflection of socioeconomic status, is related to profound
differences in the incidence of prematurity and infant mortality.  Kessner and Colleagus
(1973) have reported that the lowest incidence of perinatal loss occurs in cases in which
the father is in a professional or managerial position, where as the highest rates of loss are
seen in situations in which the father is absent altogether.
 It has further been demonstrated that a correlation exists between the occupation of the
mother’s father and the incidence of perinatal loss; that is, women from a higher
socioeconomic background have a lower incidence of perinatal loss than those from a
less affluent one (Kessner et al, 1973).
 
Social Environment. 
The effects of maternal social environment on the outcome of pregnancy are recognized
to be both multiple and profound. ‘Social environment’ itself is described as the
summation of numerous factors, including the family’s standards of health and hygiene,
housing and financial status, emotional and social support and so on.
The environment itself was grossly unhygienic. Recurrent infections and ‘poor health’
were frequently noted within the family. Educational needs were, for the most part,
unmet and ignored. The adverse influences of this history of social, emotional, nutritional
and financial deprivation on reproductive outcome were numerous.
 

Psychological High-Risk factors. 

When a woman becomes pregnant the entire family prepares for change. The support and
guidance that the family receives during this preparation period will influence the
family’s ability to cope with the stress of this pregnancy and with its changes in family
structure, as well as with other life stresses in the future. Therefore, it is important to
identify psychological maladaptation to pregnancy. Maladaptations may increase anxiety,
and it has been suggested increased anxiety can cause physical complications during
pregnancy, including preterm labour (Crandon, 1979; Creasy, 1981).
 
Demographic Factors
Maternal Age. 
The relationship between maternal age and pregnancy outcome has long been recognized.
Studies have been shown that the optimal age for childbearing is between 20 and 30
years, with a steadily increasing risk of perinatal mortality when the woman is over 30
years of age. Children of mothers 19 years and younger and the first born of mothers 35
 years of age and older are at an increased risk for prematurity and other pregnancy
complications such as pregnancy-induced hypertension (PIH) and congenital anomalies.
Additionally, babies born to women over 35 years of age have an increased risk of
genetic abnormalities (Crandall et al, 1986).
Maternal Education.  
Correlation’s have been indicated between the number of years of schooling completed
by a pregnant woman and perinatal death rate, birth weight, and the rate of neurologic
abnormalities seen in the child at 1 year of age. As the length of the mothers education
increases, perinatal morbidity and mortality rates drop significantly.
Maternal Height.
Short stature of the mother (less than 5 ft) has been associated with increased perinatal
morbidity and mortality in several studies. The primary reason suspected for this
association is that short maternal stature may be a reflection of adverse environmental
conditions and poor nutrition as a child. Because stature relates to pelvic dimensions,
short women have a higher incidence of operative delivery, including cesarean section
because of cephalopelvic disproportion.
Maternal weight and Weight Gain. 
Women who are underweight or overweight for height and age at the beginning of
pregnancy are at risk for poor perinatal outcome (Abrams and Laros, 1986). Both of these
parameters reflect previous nutritional status of the mother.
¨4    Women who are underweight and or fail to gain the recommended 28 to 35 lb during
pregnancy are at risk for having low-birth- weight babies.
¨5    Women who are overweight and or gain more than 35 lb during pregnancy are at risk
for  developing preeclampsia and having large- for - gestational age babies.
¨6    Fetuses weighing more than 4000 g are frequently associated with an increased
likelihood of dystocia during labour, fetal distress, maternal and infant birth trauma, and
consequently, an increased incidence of perinatal morbidity and mortality.
 
Previous Obstetric Problems
 
In women who have had an obstetric complication or a perinatal loss, there is a tendency
for the problem to ‘repeat’ in a subsequent pregnancy. This is true for all of the factors listed in
the high-risk pregnancy classification.

History of Infertility. Conceptions following medical or surgical treatment of

infertility carry a considerable high-risk factor. There is a high prevalence of multiple gestation
and associated preterm labour in women treated for infertility, and, therefore, an increase in the
perinatal morbidity and mortality rates.
Previous Ectopic Pregnancy and Spontaneous Abortion.  The incidence of
infertility in patients who have had an ectopic pregnancy is high, as is the chance of a repeat
ectopic conception (Kadar and Romero, 1990). In women who have had two or more
spontaneous abortion, the risk of a repeat abortion is significantly increased.
Previous Stillbirth or Neonatal Death. A history of a previous perinatal death,
especially if the cause is unknown, is an indication of high-risk status.
Uterine/Cervical Abnormality.  Abnormalities of the uterus/ cervix such as a
bicornuate uterus, uterine septum, and incompetent cervix are frequently associated with
repeated spontaneous abortions and premature labour.
Previous Premature Labour. Premature labour is one of the most challenging
problems facing perinatal health care providers (Mc Cormick, 1985).  A woman who has had a
previous premature labor has a significantly higher chance of delivering prematurely with a
subsequent pregnancy.  Depending on the etiology of the preterm birth, the history of one
previous preterm birth is associated with a risk of recurrence of 25 to 50 percent, and the risk
increases with each subsequent preterm birth (Creasy, 1990). There is also an increased chance
that the patient will have a stillbirth or neonatal death.

Previous Macrocosmic Infant.  A macrocosmic infant is one who, at term, weighs

more than 4000 g or is large for his or her gestational age. A woman who has previously had, or
is suspected of carrying, a large infant is at risk for having or developing diabetes during
pregnancy, with all its concomitant problems. The infants themselves are at increased risk for
morbidity (including low newborn blood sugars) and mortality as a result of unstable maternal
metabolic condition, placental insufficiency, and even if the mother is not diabetic, birth trauma
due to difficult delivery, shoulder dystocia, and other complications.
Grandmultiparity. Increasing parity increases the risk of pregnancy wastage both in
terms of higher mortality rates and an increased risk of neurologic anomaly. In general, the
lowest perinatal mortality rate and incidence of obstetric complication occurs in second and third
pregnancies, and the highest in fifth and subsequent pregnancies.  The frequency of anemia,
hypertensive disease of pregnancy, antepartum and postpartum hemorrhage, as well as the
number of cesarean sections, almost doubles for each of these complications in women of lower
parity.
 
Maternal Medical History/Status.
 
Certain maternal disease diagnosed prior to pregnancy, at the time of initial physical
examination or at any time during the pregnancy, may have a significant for both fetus and
mother. These are:
Maternal Cardiac Disease. The diagnosis of organic heart disease includes:
¨    rheumatic heart disease
¨    hypertensive heart disease and
¨    congenital heart disease.
Fetal death rates are substantially increased in women with any of these diagnosis; in
fact, the stillbirth rate is doubled compared with that in women without organic heart disease.
The presence of organic heart disease also significantly increases the risk of delivery of a
low-birth-weight infant (< 2500 g).
 
Maternal Pulmonary Disease.
 
Bronchial asthma is a rather common respiratory disease; pregnancy does not seem to
have any consistent effect on it.
¨    The effect of pregnancy on asthma generally follows the rule of thirds: one third of
patients improve during pregnancy, one third remain unchanged, and one third deteriorate.
¨    The fetuses may be at increased risk for intrauterine growth retardation, preterm
delivery, stillbirth, or neonatal death (Benedetti, 1990).
 
Diabetes Mellitus.
 
Diabetes is deleterious to pregnancy in a number of ways. The adverse maternal effects
that are likely to be encountered are as follows:
1.    The likelihood of preeclampsia/eclampsia is increased fourfold.
2.    Infection occurs more often and is likely to be more severe.
 3.    The fetus frequently is macrocosmic, and its size may lead to difficult delivery with
injury to the infant and the birth canal.
4.    The tendency for fetal condition to substantially deteriorate prior to the onset of
labor, as well as the possibility of dystocia, increases the frequency of cesarean section
with its incumbent maternal risk.
5.    Postpartum hemorrhage is more common
6.    Polyhydramnios is common

Maternal diabetes also affects the fetus/neonate in a variety of

ways:
7.    Perinatal death rate is considerably higher.
8.    Morbidity as a result of birth trauma or respiratory distress syndrome is common.
9.    Congenital anomalies, including sacral agenesis or anencephaly, open spina-bifida,
and cardiac anomalies, are more frequent.
10.The infant is more likely to inherit diabetes.
11.Persistent maternal hyperglycemia probably contributes to the increased risk of
intrauterine death, respiratory distress syndrome, hypoglycemia, and other morbidity
(Gabbe, 1991)
 
Maternal Thyroid Dysfunction.
 
Thyroid disease appears to have an adverse effect on pregnancy outcome.
¨      Hypothyroidism results primarily in an increase in the stillbirth rate.
¨      Hyperthyroidism shows a slight association with increased neonatal mortality rate, a
significant increase in the frequency of delivery of low-birth-weight infants, and an overall
drop in the mean birth weight.
 
Once the diagnosis of thyroid disease is made in pregnancy, therapy may be complicated
by the presence of the fetus. Drugs that may be beneficial to the mother can be harmful to the
fetus, and this must be taken into account when a therapeutic decision is made (Burrow and
Ferris, 1982). 
Gastrointestinal/Hepatic System Diseases.
With the exception of hepatitis and appendicitis, maternal gastrointestinal diseases does
not generally cause any increased risk in pregnancy.
¨    Hepatitis appears to be associated with an increase in low-birth-weight infants and an
increased incidence of infection of the infant.
¨    Appendicitis appears to increase the rate of premature labor, fetal death, and low-birth-
weight infants most probably as a result of infection, regardless of whether surgery is
performed.
¨    Chronic Hypertension
In most cases of chronic hypertension, high blood pressure is the only demonstrable
finding. Frequently, the babies of mothers with chronic hypertension show evidence of
intrauterine growth retardation. The incidence of abruptio placenta and PIH also has been noted
to be increased.
Renal Disease / Urinary Tract Disease
Renal diseases such as glomerulonephritis, nephrotic syndrome, polycystic disease of the
kidney, and previous nephrectomy/renal transplant vary in their effect on pregnancy outcome,
depending on the severity of the disease.  Most commonly, they are associated with increased
risk for
premature labor,
intrauterine growth retardation, and
placental insufficiency leading to antepartum fetal distress.
Acute urinary tract infection, if undiagnosed or untreated, may lead to premature labor
(Pritchcard et al, 1985).
Current Obstetric Status
 
Late or No Prenatal Care
Prenatal care that is inadequate, late is the single greatest predictor of poor perinatal
outcome, particularly in regard to low-birth-weight infants (Sachs et al, 1987).
 

Antepartum Bleeding.
 
Antepartum Bleeding. Antepartum bleeding is defined as bleeding from the vagina
after the 28th week of gestation and prior to the onset of labor. The etiology includes
1.Placenta previa,
2.abruptio placenta,
3.local causes such as cervical polyps or erosions, and
4.unknown etiology in which a specific cause cannot found.
Placenta previa, and consequent bleeding from a placenta partly or wholly attached to
the lower uterine segment, is a complication frequently associated with multiparity and older
gravidas. Women who gave had a placenta previa tend to repeat this complication in subsequent
pregnancies.
Overall incidence of placenta previa is 1 in 200 pregnancies at term. Incidence
increases significantly with maternal age, parity, previous placenta previa, and most importantly,
previous uterine surgery (Bender, 1987).
Maternal mortality associated with placenta previa has been reduced to less than 1
percent, but maternal morbidity from this complication is still high as 20 percent (Astrash et al,
1990; Cavanagh, 1982).
Prematurity is the prevalent cause of perinatal mortality associated with placenta previa.
Despite the availability of neonatal intensive care, the perinatal mortality rate remains as high as
20 percent, with intrauterine hypoxia and developmental anomalies also complicated the
situation.
Abruptio placenta  is described as the premature separation of normally implanted
placenta from the uterine implantation site.
 Abruption of the placenta is most commonly associated with hypertension of any
origin, including preeclampsia. High parity and history of previous abruption have been
implicated. Other factors implicated as possible causes of abruption are trauma, sudden uterine
decompression (particularly with polyhydramnios), short umbilical cord, and uterine leiomyomas
and anomalies. Recurrence rates of placental abruption range from 1 in 6 to 1 in 18 pregnancies
(Patterson, 1979).
Maternal mortality in abruptio placenta ranges from 2 to 10 percent in severe cases
with associated fetal death.  Perinatal mortality approaches 35 percent, the major determinats
being length of gestation and fetal condition at the time of presentation (Clark, 1990).
In general, antepartum bleeding is associated with significantly increased risks for
premature labor and delivery, intrauterine growth retardation, fetal and maternal anemia, and
perinatal death (Clark, 1990).
Multiple Gestation.
Perinatal mortality in twins is 2 to 3 times higher than in single births. The predominant
cause of perinatal death is prematurity. Other major complications include
¨placenta previa,
¨intrauterine growth retardation,
¨twin to twin transfusion,
¨prolapsed cord,
¨premature separation of the second placenta, and
¨malformations.
Women with a multiple gestation have an increased incidence of
¨preeclampsia,
¨anemia,
¨polyhydramnios, and
¨postpartum hemorrhage.
 
 
Pregnancy-Induced Hypertension (PIH)
PIH is one of the hypertensive disorders of pregnancy, and a major contributor to
maternal, fetal, and neonatal morbidity and mortality and mortality. Complications of PIH are the
second most common cause of maternal deaths (Atrash, 1990).
The incidence of PIH is approximately 6 to 8 percent. PIH seems to be higher in blacks
for each age and parity group, and it runs in families. The incidence is also higher in young,
primiparous women and in women with twins, diabetes, chronic hypertension, polyhydramnios,
and hydatidiform mole. Approximately one third develop it in subsequent pregnancies (Burrow
and Ferris, 1982).
Maternal effects of PIH range from relatively transient to serious morbidity, such as
¨renal damage or
¨cerebral vascular accident, to death of the mother or fetus, or both.
Fetal problems include increased incidence of
¨intrauterine growth retardation,
¨abruptio placenta,
¨preterm birth,
¨stillbirth, and
¨mental retardation in surviving offspring.
At present, it is not possible to prevent PIH. It is possible, however, to identify patients
who are especially prone to develop the disease. Conditions that predispose a woman to develop
PIH include:
1.First pregnancy
2.Multiple pregnancy
3.Chronic hypertension
4.Hydatidiform mole
5.Chronic renal disease
6.Malnutrition
7.Diabetes
8.Hydrops fetalis
9.History of PIH in family or in previous pregnancy
10.Age less than 20 or greater than 30 
Premature Rupture of the Membranes
 
Premature rupture of the membranes, that is, rupture prior to the onset of labor, is a
major perinatal complication and is responsible for at least 30 percent of preterm deliveries
(Garite, 1990; Kaltreider, 1980).
The incidence of premature rupture of the membranes is reported to be 8 to 10 percent of
all pregnancies that extend beyond 20 weeks’ gestation (Garite, 1990; Gunn et al, 1970). It is
associated with a high perinatal mortality rate, attributable primarily to delivery of premature,
low-birth-weight infants.
Depending on management, premature rupture of the membranes can also be associated
with significant perinatal morbidity, including
¨premature delivery,
¨maternal and/or fetal infection, and
¨fetal respiratory distress syndrome.
Other problems, such as
¨breech presentation,
¨prolapsed cord,
¨transverse lie,
¨a plastic lungs, and
¨positional limb deformities of the fetus due to the lack of “cushioning” normally
provided by amniotic fluid, have also been reported. It is felt by several authors that preexisting
infection may contribute significantly to premature rupture of the membranes.
 
Intrauterine Growth Retardation
 
Intrauterine growth retardation (IUGR) complicates approximately 3 to 7 percent of  all
pregnancies.
Babies born at or below the 10th percentile of mean weight for gestation are at greater
risk of antepartum death, perinatal asphyxia, neonatal morbidity, and later developmental
problems. Babies with IUGR have a perinatal mortality rate that is 8 times that of normal
infants(Butler and Alberman, 1969).
  
Two types of fetal growth retardation’s
¨asymmetric and
¨symmetric have been described
In asymmetric IUGR, there is increasing disproportion in head-to-body ratios. This type
of IUGR is the more common and is known as “brain sparing”, because the last organ to be
deprived of essential nutrients is the brain.
Asymmetric IUGR is most commonly caused by adverse effects applied during the later
part of pregnancy. A common example is placental insufficiency resulting from such conditions
as PIH, chronic hypertension, smoking, and alcoholism.
Symmetric IUGR is non-brain sparing, occurs less commonly, and can be the result of an
acute maternal infection, chromosomal abnormalities in the fetus, maternal drug addiction, or
maternal malnutrition.
 
 
 
 
 Preventing and Treating Pregnancy Complications

Even if you don't have an existing health problem, many doctors recommend a preconception
appointment with your health-care provider to ensure you are as healthy as you can be before
you become pregnant. At this appointment your doctor may recommend steps you can take to
reduce the risk of certain problems. These include:

 Getting at least 400 micrograms of folic acid, beginning before and continuing through
pregnancy
 Getting proper immunizations
 Eating a healthy diet and maintaining proper weight
 Getting regular physical activity, unless advised otherwise by your doctor
 Avoiding cigarettes, alcohol, and drugs (except for medications approved by your doctor)
 See your doctor regularly

If your pregnancy is considered high risk, your doctor may refer you to a perinatologist. Also
called a maternal-fetal medicine specialist, a perinatologist is an obstetrician with special training
in high-risk pregnancy care. This specialist will work with your other doctors, nurses, and other
health-care professionals to ensure the best possible outcome for both you and your baby.
Referral and Its Function in District Health Systems
The term referral is used in different ways: For instance, it is used to indicate the advice of a
health worker to attend a higher-level health unit, whether followed or not. Here we use the term
referral for any upwards movement of health care seeking individuals in the health system .There
are many ways to do this with respect to pathway, timing and urgency. Thus, we can categorize
referrals in pregnancy and childbirth as

(1) institutional or self referral, depending on the involvement of first line services;

(2) antenatal, delivery or postnatal referral; and

(3) elective or emergency referral.

 Bibliography
 DC Dutta (2004), Text Book Of Obestretics including perinatology and Contraceptions
(6th ed.), Calcutta;New Central Book agency (P)ltd. Pg. no.145-150.
 Annamma Jacob(2009).Maternal and Neonatal Nursing Care Plan,(1 st ed.), New
Delhi;Jaypee Brothers Medical Publishers(P) ltd. Pg no. 24-28.
 Sadhana Gupta, (2011). A Comprehensive Textbook of Obstetrics & Gynecology, 1 st ed.
Jaypee Brothers Medical Publishers (P) LTD; 239
 Laurie n. Sherwin, Mary Ann Scoloveno, Carol toussie (1999). Maternity Nursing, (3 rd
ed.), Appleton & Lange Stamford, Connecticut, 160
 Reeder, Martin, Konaik-Griffin (1997).Maternity Nursing, (18th ed.), Lippincott Raven
Publishers;177
 Bobak, Jensen, (1993), Maternity & Gynecology Care, (5th ed.), Mosby; 1263
 Annamma Jacob, (2012), Midwifery & Gynaecology Nursing, (3rd ed.), Jaypee;744s

  http://www.geocities.com/wellesley/1483/artificial.html

 http://www.amazingpregnancy.com/pregnancy-articles/324.html

 http://legal-dictionary.thefreedictionary.com/Artificial+Insemination

 http://www.dailykos.com/story/2009/6/29/725/18020

 http://www.geocities.com/wellesley/1483/artificial.html

 http://www.amazingpregnancy.com/pregnancy-articles/323.html

 http://www.vermesh.com/artificial_insemination_california.html

 http://www.ucdmc.ucdavis.edu/fertility/artificial_insemination/

 http://www.5min.com/Video/How-Artificial-Insemination-works-27107259

 http://en.wikipedia.org/wiki/Intracytoplasmic_sperm_injection
http://womens-health.health-cares.net/intracytoplasmic-sperm-injection.php