High-risk pregnancies are complicated by factors that threaten the health of the mother, fetus, or neonate. About 20-30% of pregnancies are considered high-risk. Early identification of risk factors through preconception counseling and specialized antenatal care can help implement effective intervention strategies to address complications. Common high-risk conditions include anemia, diabetes, hypertension, pre-eclampsia, multiple gestation, and cardiac disease.

1. HIGH RISK PREGNANCY
DR. MONICA AGRAWAL
ASSOCIATE PROFESSOR
DEPT OF OBS &GYNAE
KGMU, LUCKNOW

2. High-risk (at-risk) pregnancy, is defined as one which
is complicated by factor or factors that adversely
affects and threatens the health or life of the
mother, fetus or neonate before or after delivery
It often requires specialized care from specially
trained providers.
High Risk Pregnancy

3. Some pregnancies become high risk as they progress, while some
women are at increased risk for complications even before they
get pregnant
A pregnancy at risk needs to be identified at an earlier state,
often in the antenatal period in order to have an effective
intervention strategy to deal with its complications.
High Risk Pregnancy

4. Leading Causes Of Maternal Mortality
Hemorrhage Sepsis/infections
Pre-
eclampsia/eclampsia
Unsafe abortions

5. About 20-30% of all pregnancies are high risk.
The Centers for Disease Control and Prevention reported that 65,000
women in the US are affected annually by high risk pregnancies with
severe complications.
High risk pregnancies are responsible for 50% of all maternal
complications, 60% of all primary cesarean deliveries and 70-80% of
perinatal mortality and morbidity.
Incidence

6. HOW TO
IDENTIFY ??
A WOMEN
AT RISK
HIGH RISK
PREGNANCY

7. Preconception Counselling and Antenatal care
Access to good health care delivery system, trained health
care personnel and appropriate infrastructure.
Early and regular antenatal care helps women have healthy
pregnancies and deliveries without complications.
High Risk Pregnancy

8. Preconception care
Prenatal care begin before conception.
Health during pregnancy depends on a woman’s general health,
nutrition and other factors before conception
Optimize the woman’s health
Minimize risks to mother and the fetus and improve pregnancy
outcome

9. Preconception Counselling
• Identifying medical and surgical high risk
• Identify how each risk factor would alter
pregnancy outcome
• Identify how pregnancy would alter the course of
each medical/surgical disorder
Preconceptional counselling is important to
diagnose high risk factors from history , investigate
before pregnancy so that they conceive when their
medical conditions are under control.

10. Low Risk Category

11. High Risk Category

12. Current
approach
for Antenatal
care
Antenatal
care

13. The high concentration of visits
in the third trimester implies -
• That most complications
occur at late stage of
pregnancy
• That most adverse outcomes
are unpredictable during the
first or even second trimester.

14. Early
identification of
risk factors and
detection of
complications at
11-13 weeks of
pregnancy by
history,
biochemical tests
and high
resolution
ultrasound .
Enables
effective
treatment
or even
prevention
of a
disease.
Prof. Kypros
Nicolaides
(Fetal
Medicine
Foundation,
UK) focused
on the very
early weeks
of
pregnancy
to identify
high risks.
High risk
cases can be
monitored
very closely
and can
receive
special
medical
care during
the whole
course of
the
pregnancy.
Women at
low risk in
the
beginning
of
pregnancy,
on the
other hand,
do not
need such
frequent
and speciali
sed
antenatal
care.
Enables much
more
individualised
patient and
disease-
specific
approach of
antenatal
care.
Inverted Pyramid

15. Inverted Pyramid

17. Antenatal Visits In High Risk Patients
• High risk patients are issued
HIGH RISK or PINK CARD
• They should be seen every 2
weeks after first trimester and
weekly in last trimester
• They should be admitted in a
well equipped tertiary Cre
hospital 2 weeks prior to EDD

18. Screening Of Pregnancies For High Risk
Maternal age (below 16yrs or above 35 yrs of age )
Past obstetric history (previous congenital malformation, repeated abortion,
preterm labour, stillbirth, ceasarean)
Grand multiparity
Medical disorders (anemia, hypertension, diabetes, cardiac, renal)
History of surgery or trauma (myomectomy, repair of third degree perineal
tear, VVF repair)
HISTORY TAKING

20. EXAMINATION

21. EXAMINATION

22. First Trimester
1. Ectopic pregnancy
2. Abortion
3. Molar Pregnancy
4. Uterine rupture
Second Trimester
1. Abortion
2. Cervical Incompetence
Third Trimester
1. Placenta Praevia
2. Placenta Accreta
3. PPH
4. Uterine rupture
5. Inversion
6. Hypertension
High Risk Pregnancy

23. Identifying High Risk Factors
MEDICAL RISK FACTORS
• Anaemia
• Chronic hypertension
• Diabetes type 1or 2
• Cardiac disorder
• Renal disorder
• Obesity
• Autoimmune disorder
• Thrombophilia
• Connective tissue disorder
• COPD

24. Obstetrics High Risk Factors
Extremes of maternal age of conception
High parity status
h/o recurrent abortions
h/o previous preterm deliveries
h/o PPH
Prior cesarean delivery
h/o frequent conceptions (less time gap)
h/o prior stillbirth
h/o uterine rupture of perforation
h/o previous pelvic operative surgery (myomectomy)
h/o previous pregnancy with pre-eclampsia or gestational diabetes

25. High Risk Pregnancy Conditions
Anemia
Diabetes
Hypertension or pre-eclampsia
Multiple pregnancy
Preterm birth
Hypothyroidism
Antepartum and Post partum hemorrhage
Heart disease
Hematological disorders (thrombocytopenia, thalassemia)

26. High Risk Labour
Preterm labour
Previous cesarean
Cephalopelvic disproportion
Malpresentations
Shoulder dystocia
Obstructed labour
Retained placenta
Inversion of uterus
Rupture of uterus
Perineal tear

27. ANEMIA -Global Burden of disease

28. ICMR-
Severity
Classification
Haemoglobin(g/dl)
• Mild 10.0-10.9
• Moderate 7-9.9
• Severe <7
• Very Severe <4

29. Consequences of IDA in pregnancy
Antepartum
complications
• Increased risk of preterm
delivery
• Premature rupture of
memebrane
• Preecclampsia intrauterine
death
• Intercurrent infection
• Antepartum hemorrhage
• Congestive heart failure
Intrapartum
complications
• Prolonged labor
• Incresed rates of
operative delivery and
induced labor
• Fetal distress
• Abruption
Postpartum
complications
• Postpartum hemorrhage
• Purperal sepsis
• Lactation failure
• Pulmonary
thromboembolism
• Subinvolution of uterus
• Postpartum depression
Fetal outcome
• Low birth weight
• Prematurity
• Infections
• Congenital malformation
• Neonatal anemia
• Abnormal cognitive
development
• Increased risk of
schizophrenia

30. Interventions to prevent and correct iron deficiency and IDA

31. Iron supplementation
• GI side effects include diarrhea, constipation, abdominal pain,
flatulence, nausea, black or tarry stools and heartburn.
Prophylaxis Treatment
WHO 60 mg Iron + 400ug FA
till term
120 mg Iron+400 ug
FA
MoHFW 100 mg Iron + 500 ug
FA for 100 days
(starting from 14-16
week)
Mild anemia-200 mg
Iron +500 ug FA for
100 days.
Mod anemia- IM Iron
+ oral folic acid
Severe Anemia IV iron
Iron
Supplementation

32. Intravenous Iron • Immediate replineshment
• Rapid intake by bone marrow & RE
system
• Given in divided dose
• m/c used iron sucrose, 200 mg in 100 ml
normal saline in 15 -20 minutes (for first
5 minutes slowly)
• Not require test dose
• More efficacy and safety than im iron
• Ferric carboxymaltose superior to all
parenteral iron (dextran free, fewer side
effects, dose 1000 mg in 15 min)

33. Pre-eclampsia/Eclampsia

35. Mgso4 In Pre-eclampsia/Eclampsia

36. Diabetes In Pregnancy
Prevalence of gestational diabetes is around 18%.
Women with GDM are at an increased risk of future diabetes
predominantly type 2 DM.
Treatment of GDM reduces perinatal morbidity and improves
neonatal outcome.

37. Screening Of GDM
1) Single step method- 75gm glucose is given and 2 hours post prandial
blood sugar is checked. Value of more than 140 mg/dl is positive.
2)Two step method-
a) Glucose Challenge Test- 50 g glucose
b) Glucose Tolerance Test- 100 g glucose

38. Antepartum Hemorrhage
Bleeding from the genital tract in the second half of pregnancy.
Causes-
• Placenta previa
• Placental abruption
• Placenta accreta
• Other causes- APH of indeterminate origin
-vasa previa
-bleeding from lower genital tract
-blood stained cervical mucus (show)

41. Cardiac Disease In Pregnancy
Cardiac disease complicates 0.2-4% of all pregnancies.
Women with cardiac conditions who desire or anticipate
pregnancy should be offered preconceptional counselling.

43. Take Home Message