High Risk Pregnancy

High risk mothers require constant observation during the AN period especially during the last few weeks of pregnancy. These High risk mothers should be admitted at the PHC prior to the expected date of delivery for constant observation and to continue the treatment. AN mothers with following high risk factors should be admitted in the PHC and they should be transferred to the CEmONC centers well before the EDD to plan the strategy for the individual case management and to provide quality EmONC services. In case if the mother develops complication during admission they should be immediately referred to the CEmONC center . On admission the mother should be examined and individual case sheet should be maintained. During the stay at PHC all the high risk mothers should be observed for the following vital indicators at the specified periodicity both by the Medical Officer and Staff Nurse/ANM.


Goals of prenatal care
The major goal of prenatal care is to help ensure the birth of a healthy baby while minimizing risk to the mother.
The components involved in achieving this objective: 1. Early, accurate estimation of gestational age 2. Identification of pregnancies at increased risk for maternal or fetal morbidity and mortality 3. Ongoing evaluation of maternal and fetal health status 4. Anticipation of problems with intervention, if possible, to prevent or minimize morbidity 5. Health promotion, education, support, and shared decision making www.uptodate.com

Risk Assessment During Pregnancy
• Risk assessment is part of routine prenatal care.
• Risk factors are assessed systematically because each risk factor present increases overall risk. • High-risk pregnancies require close monitoring and sometimes referral to a perinatal center, especially if women have complex high-risk conditions.
• These centers offer many specialty and subspecialty services, provided by maternal, fetal, and neonatal specialists https://www.msdmanuals.com/professional/gynecology-and-obstetrics/high-risk-pregnancy/overview-of-high-risk-pregnancy A high-risk pregnancy involves at least one of the following: 1. The woman or baby is more likely to become ill or die than usual. 2. Complications before or after delivery are more likely to occur than usual. • High risk patients require sophisticated maternal and fetal surveillance and in many occasions, difficult management decisions in order to optimize their outcomes • A pregnancy is defined as high risk 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 of more ascertainable risk factors or indicators. • Some conditions may require the involvement of a maternalfetal medicine subspecialist, geneticist, pediatrician, anesthesiologist, or other medical specialist in the evaluation, counseling, and care of the woman and her fetus. •

Existing maternal health conditions
Existing health conditions • Hypertension: may proceed to develop into CH with superimposed preeclampsia; may cause fetal growth and amniotic fluid disorders; high risk for preterm delivery and cesarean delivery • Diabetes: high risk for pregnancy-induced hypertensive disease, fetal growth disorders, amniotic fluid disorders, cesarean delivery • Kidney disease: High risk for preterm delivery, low birth weight, and preeclampsia.
• Autoimmune disease: Highrisk for preeclampsia, miscarriage, preterm birth and stillbirth; Certain medicines to treat autoimmune diseases may be harmful to the fetus.
• Thyroid disease: can cause problems for the fetus, such as heart failure, poor weight gain, and brain development problems; • Malnutrition/Obesity: high risk for fetal growth disorders; obesity is a risk factor for development of GDM, pregnancy-induced hypertension, cesarean delivery • Of the estimated 5.6 million abortions that occur each year among adolescent girls aged 15-19 years, 3.9 million are unsafe, contributing to maternal mortality, morbidity and lasting health problems.
• Adolescent mothers (ages 10-19 years) face higher risks of eclampsia, puerperal endometritis, and systemic infections than women aged 20 to 24 years, and babies of adolescent mothers face higher risks of low birth weight, preterm delivery and severe neonatal conditions https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy

Teenage (adolescent) pregnancy
• Usually associated with history of risky behaviors: smoking, alcohol consumption, drug abuse, sexual promiscuity, mental health problems, or a history of adverse childhood experiences • Associated medical complications include: preterm birth, low birth weight, perinatal mortality, short interval to next pregnancy, and sudden infant death syndrome • Pregnant adolescents are high risk for nutritional deficiencies, anemia, HIV infection, and other STIs • High incidence of pregnancy-induced hypertension • "Competition for nutrients" between the fetus and the mother could affect pregnancy outcome in adolescents by interrupting the normal growth process.
• Higher incidence of cesarean delivery (secondary to CPD) https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy Advanced Maternal Age (AMA) • Maternal age 35 years old and above (at time of first pregnancy) • High risk for spontaneous miscarriage, ectopic pregnancy, stillbirth, chromosomal abnormalities, multiple gestation, hypertensive disorders, gestational diabetes, operative deliveries, placenta previa, low birth weight, • an increase in congenital anomalies with advancing maternal age has been attributed to the recognized increase of aneuploidy with advancing maternal age and the association of aneuploid fetuses with structural anomalies. • Cardiac anomalies seem to increase with maternal age independent of aneuploidy. www.uptodate.com

Lifestyle factors
Lifestyle factors • Alcohol use: high risk for fetal alcohol spectrum disorders (FASDs), sudden infant death syndrome, and other problems. FASDs may lead to intellectual and developmental disabilities, behavior problems, abnormal facial features, and disorders of the heart, kidneys, bones, and hearing • Tobacco use: high risk for preterm labor and delivery, birth defects, and sudden infant death syndrome (SIDS); Secondhand smoke also puts a woman and her developing fetus at increased risk for health problems. • Drug use: high risk of stillbirth; smoking marijuana during pregnancy can interfere with normal brain development in the fetus, possibly causing long-term developmental problems.

Pregnancy conditions
• Multiple gestation: high risk of preterm labor and delivery, postpartum hemorrhage, preeclampsia, fetal congenital malformations cesarean • Gestational diabetes: high risk for preterm labor and delivery, fetal growth and amniotic fluid disorders and preeclampsia. It also increases the risk that a woman and her baby will develop type 2 diabetes later in life. • Previous preterm birth: high risk for preterm labor and delivery.
• Birth defects or genetic conditions in the fetus. Knowing a fetus may have birth defects before birth can help healthcare providers and parents be prepared to give treatment right away after delivery.
• Preconception evaluation and counseling of women of reproductive age • Referral to perinatologist (maternal fetal medicine) • Screening tests identify fetuses at high risk of aneuploidy • Genetic counseling • Lifestyle modification • Nutrition counseling • Antenatal surveillance tests: The appropriate initiation and frequency of testing is determined by the indication for the test as well as gestational age. Typically, testing is begun at 32 weeks and is performed on a weekly to twice weekly basis.