This document discusses screening methods for high-risk pregnancies. It defines screening as identifying apparently healthy individuals at increased disease risk. High-risk pregnancies are those with increased maternal, fetal, or newborn morbidity/mortality risks due to complicating factors. Screening assessments evaluate medical histories and examine for risk factors like young/elderly primigravidas, medical conditions, obstetric histories, and other maternal conditions. Newer screening modalities include biochemical tests, cytogenetic tests, non-invasive methods like ultrasound and NSTs, and invasive methods like CVS and amniocentesis.

1. SCREENING OF HIGH RISK
PREGNANCY , NEW
MODALITIES OF DIAGNOSIS
PRESENTED BY:
BEDANI YUMLEMBAM
M.Sc .Nursing 2nd year

2. INTRODUCTION :

3. DEFINITIONS :
1) SCREENING:
Screening is defined as a process of identifying
apparently healthy people who may be at increased risk
of a disease or condition.

4. 2) HIGH RISK PREGNANCY :
High risk pregnancy is defined as a pregnancy in which
mother , fetus or newborn are at increased risk of morbidity
or mortality during pregnancy , labor or puerperium due to
some complicating factors

5. INCIDENCE :
 According to National Health Portal ,GOI ,2019 ,in
India about 20-30% pregnancies belong to high risk
category, which is responsible for 75% of perinatal
morbidity and mortality.

6. RISK FACTORS OF HIGH RISK
PREGNANCY :
1) Young
Primi mother
2) Elderly
Primi mother
3)Multigravida
Mother
4) Having too close
pregnancies

7. 5) Associated
Medical conditions
6) Previous Abnormal
Obstetrical History
7) Other
maternal conditions

8. WARNING SIGNS THAT REQUIRE
IMMEDIATE VISIT TO THE DOCTOR/
HEALTH FACILITY
Following warning signs require immediate visit to the
doctor/ health facility
 Fever >38.5ºC/for more than 24 hours
 Headache, blurring of vision
 Generalized swelling of the body and puffiness of
face
 Palpitations, easy fatigability and breathlessness at
rest
 Pain in abdomen
 Vaginal bleeding / watery discharge
 Reduced fetal movements

9. SCREENING OF HIGH RISK CASES :
 The cases are assessed at the initial antenatal
examination, preferably in the first trimester of
pregnancy.
 This examination may be performed in a big institution
(teaching or non-teaching) or in a peripheral health
center.
 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 factor

10. SCREENING OF HIGH RISK PREGNANCY
:
A) DURING PREGNANCY :
1) INITIAL SCREENING :
i) History taking
 Maternal age
 Reproductive history
 Pre-eclampsia, eclampsia
 Anemia
 Third stage abnormality
 Medical or surgical disorders
 Previous infant with Rh-isoimmunization or ABO incompatibility
 Psychiatric illness
 Cardiac disease

11. CONTD.
 Viral hepatitis
 Family history :
• Socioeconomic status
• Family history of diabetes ,hypertension
• Multiple pregnancy
• Congenital malformation
 Previous operations
• Myomectomy
• Repair of complete perineal tear
• Repair of vesico-vaginal fistula

12. ii)Examination :
a)General physical examination
 Height ,weight
 BMI
 Medical conditions
b) Pelvic examination :
 Uterine size
 Genital prolapse
 Laceration or dilatation of cervix
 Tumour
 Pelvic inadequacy

13. iii) Course of the present pregnancy-
 The cases should be reassessed at each antenatal visit to
detect any abnormality that might have arisen later.
 Example: pre-eclampsia, anemia, Rh- isoimmunisation,
high-fever, pyelonephritis, haemorrhage, diabetes mellitus,
large uterus, lack of uterine growth, post maturity,
abnormal presentation, twins and history of exposure to
drugs or radiation, acute surgical problems.

14. B) DURING LABOUR :
 Premature ruptured of membrane
 Prolonged labour
 Hand ,feet or cord prolapse
 Retained placenta more than half an hour
 PPH
 Puerperal fever and sepsis
 Abnormal presentation, position
 Obstructed labour

15. C) CERTAIN COMPLICATIONS MAY ARISE DURING
LABOUR AND PLACE THE MOTHER OR BABY AT A HIGH
RISK-
 Intrapartum fetal distress
 Difficult forceps or breech delivery
 Prolonged interval from the diagnosis of fetal distress to
delivery.
 PPH or retained placenta
 Postpartum complications

16. D) AN UNEVENTFUL LABOUR MAY SUDDENLY
TURN INTO AN ABNORMAL ONE IN THE FORM OF
–
 PPH
 Retained placenta
 Shock
 Inversion
 Sepsis may develop later on

17. E)HIGH RISK NEWBORN –
 APGAR score below 7
 Birth weight less than 2500gm or more than 4 kg
 Convulsions
 Respiratory distress syndrome
 Hypo glycaemia
 Fetal infection
 Persistent cyanosis
 Anemia
 Major congenital abnormalities
 Jaundice

18. NEWER MODALITIES OF DIAGNOSIS :
 Objective :
a) To check fetal growth and development.
b) To ensure satisfactory growth and wellbeing of the foetus
throughout pregnancy.
c) To screen out the high risk factors that affect the growth of
the foetus.
d) To check maternal and fetal mortality rate
e) To enable timely medical or surgical treatment of a
condition before or after birth .
f) To give parents the chance to prepare psychologically ,
socially , financially and medically for a baby with health
problem or disability or for the likelihood of a stillbirth.

19. 1)BIOCHEMICAL
2) CYTOGENIC
3) NON – INVASIVE
METHODS
4) INVASIVE
METHODS

20. BIOCHEMICAL
1) Maternal serum alpha feto protein:
 Rise 14-32 weeks, ten decline
 10-150ng/ml
 Test- 15-21 weeks , ideal- 17 weeks
 Elevate- IUFD, neural tube defect, multiple
pregnancy, wrong GA, ant. Abdominal wall defect,
renal anomalies
 Decrease- Trisomies down syndrome

21. 2) TRIPLE TEST:
 MSAFP+ Hcg+ UE3
 15-18 weeks
 Risk ratio result is positive if ratio greater than or equal
to 1:250
3) coomb’s test:
 For RH incompatibility
 28-34 weeks
 Presence of maternal antibodies on fetal cells
 Ratio greater than 1:8 to 1:16, then amniocenthesis

22. 4) Acetyl choline esterase:
 Increase – down syndrome
5) Inhibin A:
 Produce from corpus leutum and placenta
 Increase – down syndrome
6) First trimester screening:
 Low MSAFP + low pregnancy associated plaental
protein A+ elevated hCG = down syndrome

23. CYTOGENIC:
A) PERI-IMPLANTATION GENETIC DIAGNOSIS (PGD):
 Polar biopsy
 Blastomere biopsy
 Trophectoderm biopsy

24. B) FETAL CELLS ISOLATED FROM THE
MATERNAL BLOOD:
 FISH ( Fluorecence In Situ Hybridization) : for trisomy
13,18 and 21
 PCR (Polymerase chain reaction)

25. NON INVASIVE METHODS :
1) Ultrasonography
2) Cardiotocography
3) Non- stress test
4) Contraction stress test

26. INVASIVE METHODS :
1) Chorionic villus sampling
2) Amniocentesis
3) Embryoscopy
4) Fetoscopy
5) Cordocentesis

27. 1) FETAL ULTRASOUND
/ULTRASONIC TESTING :
 Fetal ultrasound is a test done
during pregnancy that uses
reflected sound waves to produce
a picture of a fetus , the organ that
nourishes the fetus (placenta),
and the liquid that surrounds the
fetus (amniotic fluid).
 The picture is displayed on a TV
screen and may be in black and
white or in color.
 The pictures are also called a
sonogram echogram, or scan, and
they may be saved as part of
baby's record.

29.  Fetal ultrasound camera is done to
learn about the health of the fetus.
 Different information is gained at
different times (trimesters) during
pregnancy.
 This exam is typically done
between weeks 18 and 20 of
pregnancy.
 incision at the scanning site, which
could limit visualization of the
foetus.
 Most women get an ultrasound in
their second trimester at 16 to 20
weeks of pregnancy. Some also get
a first-trimester ultrasound (also
called an early ultrasound) before
14 weeks of pregnancy.

30. 1st-trimester fetal ultrasound is done to:
 Determine how pregnancy is progressing.
 Find out if female is pregnant with more than 1 fetus.
 Estimate the age of the fetus (gestational age).
 Estimate the risk of a chromosome defect, such as Down
syndrome.
 Check for birth defects that affect the brain or spinal cord.

32. 2nd-trimester fetal ultrasound is
done to:
 Estimate the age of the fetus
(gestational age).
 Look at the size and position of
the fetus, placenta, and amniotic
fluid.
 Determine the position of the
fetus, umbilical cord, and the
placenta during a procedure,
such as an amniocentesis or
umbilical cord blood sampling.
 Detect major birth defects, such
as a neural tube defect or heart
problems.

33. 3rd-trimester fetal ultrasound is done to:
 Make sure that a fetus is alive and moving.
 Look at the size and position of the fetus, placenta, and
amniotic fluid.

34. 2)CARDIOTOCOGRAPHY(CTG)
 It is a technical means of
recording(-graphy), the fetal
heartbeat (cardio-) and the
uterine contractions (toco)
during pregnancy, typically in
the third trimester. The
machine used to perform the
monitoring is called a
cardiotocograph, more
commonly known as an
electronic fetal monitor
(EFM).

35. INTERPRETATION OF A CTG TRACING REQUIRES BOTH
QUALITATIVE AND QUANTITATIVE DESCRIPTION OF:
 Uterine activity (contractions)
 Baseline fetal heart rate (FHR)
 Baseline FHR variability
 Acceleration
 Periodic/ episodic deceleration

37. 3) Non-stress test(NST)
 A non-stress test is a common
prenatal test used to check on a
baby's health.
 During a non-stress test, also
known as fetal heart rate
monitoring, a baby's heart rate is
monitored to see how it responds
to the baby's movements.
 Typically, a non-stress test is
recommended for women at
increased risk of fetal death.
 A non-stress test is usually done
after week 26 of pregnancy.
Certain non-stress test results
might indicate that client and baby
need further monitoring, testing or
special care.

39. 4) Contraction stress
test(CST)
 It is performed near the end
of pregnancy to determine
how well the fetus will cope
with the contractions of
childbirth.
 The aim is to induce
contractions and monitor the
fetus to check for heart rate
abnormalities using a
cardiotocograph.

40.  Measures the response of the fetus to contractions.
 Required 3 contractions in 10 mins.
 a positive test or abnormal test result in
deceleration in more than half of the contraction
 A negative test means no decelerations with
contractions.

42. II) INVASIVE DIAGNOSTIC TESTS
A) Chorionic villus sampling
 Chorionic villi are small
structures in the placenta that
act like blood vessels.
 These structures contain cells
from the developing fetus. A
test that removes a sample of
these cells through a needle is
called chorionic villus sampling
(CVS).
 CVS is a form of prenatal
diagnosis to determine
chromosomal or genetic
disorders in the fetus.

43.  It entails sampling of the
chorionic villus (placental
tissue) and testing it for
chromosomal abnormalities.
 CVS usually takes place at
10–12 weeks' gestation,
earlier than amniocentesis or
percutaneous umbilical cord
blood sampling.
 It is the preferred technique
before 15 weeks.

44. B) AMNIOCENTESIS
 Amniocentesis is a test that can be
done during pregnancy to look for
birth defects and genetic problems in
the developing baby.
 Amniocentesis removes a small
amount of fluid from the sac around
the baby in the womb (uterus).
 It is most often done in a medical
centre.
 Do not need to stay in the hospital.
 Amniocentesis is most often offered to
women who are at increased risk for
bearing a child with birth defects.

45. This includes women who:
 Will be 35 or older when they give birth
 Had a screening test result that shows there may be a birth
defect or other problem.
 Have had babies with birth defects in other pregnancies
 Have a family history of genetic disorders
 It may choose genetic counselling before the procedure.
This will allow to:
 Learn about other prenatal tests
 Make an informed decision regarding options for prenatal
diagnosis

46. This test:
 Is a diagnostic test.
 Is 99% accurate for diagnosing Down syndrome
 Is usually done between 14 and 20 weeks.
 Amniocentesis can be used to diagnose many different
gene and chromosome problems in the baby, including:
 Anencephaly
 Down syndrome

47. C) EMBRYOSCOPY
 It is the examination of the
embryo at 9-10 weeks' gestation
through the intact membranes by
introducing an endoscope into
the exocoelomic space/cavity
transcervically or trans
abdominally.
 This is likely to remain confined
to the management of early
pregnancy in selected families
affected by recurrent genetic
syndromes with recognizable
external fetal abnormalities.
 The procedure-related risk of
fetal loss is around 12 per cent.

48. D) FETOSCOPY
 Fetoscopy is the examination
of the fetus after 11 weeks'
gestation.
 This is performed
transabdominally in the
amniotic fluid.
 The technique has evolved
with the miniaturization of the
optical device by using fibre-
optics technology.
 This procedure is likely to find
new with the development of
ultrasound examination at 10-
14 weeks' gestation in order
to, either confirm, or rule out
suspected external fetal
abnormalities.

49. E) PERCUTANEOUS UMBILICAL CORD
BLOOD SAMPLING/ CORDOCENTESIS
 Cordocentesis, also sometimes called
Percutaneous Umbilical Cord Blood
Sampling (PUBS), is a diagnostic test
that examines blood from the fetus to
detect fetal abnormalities.
 An advanced imaging ultrasound
determines the location where the
umbilical cord inserts into the
placenta.
 The ultrasound guides a thin needle
through the abdomen and uterine
walls to the umbilical cord.
 The needle is inserted into the
umbilical cord to retrieve a small
sample of fetal blood.
 The sample is sent to the laboratory
for analysis, and results are usually
available within 72 hours.

50.  The procedure is similar to amniocentesis except
the objective is to retrieve blood from the fetus
versus amniotic fluid.
 Cordocentesis is usually done when diagnostic
information cannot be obtained through
amniocentesis, CVS ultrasound or the results of
these tests were inconclusive.
 Cordocentesis is performed after 17 weeks of
pregnancy.
 Cordocentesis detects chromosome abnormalities
(i.e.Down syndrome) and blood disorders (i.e. fetal
hemolytic disease.).

51.  Cordocentesis may be
preformed to help diagnose
any of the following
concerns :
a) Malformation of the foetus
b) Fetal infection( eg
toxoplasmosis or rubella )
c) Fetal platelet count
d) Fetal anemia
e) Rh-isoimmunization

52. PREVENTION :
 High risk pregnancy can not be always prevented. Staying
healthy before and during pregnancy is a way to reduce the
chances of high risk pregnancy.
 Intake of folic acid 4mg/day before and during
pregnancy, eating a healthy diet and maintaining proper
weight, getting regular physical activity, avoiding tobacco,
alcohol and substance abuse are some important factors
that should be followed.
 If there is any medical condition it is important to consult the
health care provider before getting pregnant.
 Women with high-risk pregnancies should receive care from
a special team of health care providers to ensure the best
possible outcomes.

53. MANAGEMENT OF HIGH RISK CASES
 The high-risk cases should be identified and give
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
centers and their care can be left to properly trained
midwives and medical officers in health centers, or
general practitioners.
 It is necessary that all expectant mothers are covered
by the obstetric service of a particular area.

54.  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 and urban and semi-urban pockets.
 Cases with a significantly higher risk should be referred to
specialized referral centers. Cases from rural areas may
be kept at maternity waiting homes close to the referral
centers.
 Cases having a previous unsuccessful pregnancy should
be seen and investigated before another conception
occurs.
 Complete investigations for hypertension, diabetes, kidney
disease or thyroid disorders should be undertaken and
proper treatment instituted in the non pregnant state.

55.  Sexually transmitted disease should be treated before
embarking on another pregnancy.
 Cervical tears should also be repaired in the non
pregnant state.
 Serology for toxoplasma IgG, IgM and anti-phospholipid
antibodies should be done and corrected appropriately
when found positive.
 Folic acid (4mg/day) therapy should be started in the pre
pregnant state and is continued throughout the
pregnancy
 Early in pregnancy after the initial clinical examination,
routine and special laboratory investigations should be
undertaken.

56.  Client with history of previous first trimester abortion
should be advised rest and to refrain from sexual
intercourse. Vaginal examination should be avoided in
first trimester in these cases.
 Clients suspected to have cervical incompetence should
have sonographic evaluation early in second trimester so
that cervical encirclage, if necessary may be performed
at appropriate time.
 Clients having premature labour, unexplained stillbirth,
intrauterine growth restriction and may other
abnormalities benefited by prolonged rest in hospital with
close supervision.

57. MANAGEMENT OF LABOUR:
 Elective caesarean section
 Induction of labour after 37-38 completed weeks of gestation
 Need close monitoring during labour for the assessment of
progress of labour or for any evidence of the fetal hypoxia.
 The condition of the fetus can be assessed by
 FHR monitoring (by stetoscope , fetoscope or doppler)
 Passage of meconium in the liquor
 Examination of fetal scalp blood for pH values
 Delivery should be conducted in an institution
 Close observation after IOL
 Neonate need expert neonatal care

58. ORGANIZATIONAL ASPECT OF MANAGEMENT
 Strengthen midwifery skills, community participation
and referral system.
 Proper training of resident, nursing personnel and
community health workers.
 Arranging periodic seminars, refresher courses with
participation of workers involved in the care of these
cases.

59.  Community participation, 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 pediatrics service for
the neonates.
 Lastly, improvement of economic status, literary and
health awareness of the community.

60. RESEARCH ARTICLE:
 Kumudini Pradhan, Lina Baru; et.al. conducted a prospective
hospital-based study on “Pregnancy outcome in elderly
primigravida”; 2019. The study was conducted from October 2016
to November 2018. Women of reproductive age group with first
pregnancy admitted to department of obstetrics and gynaecology,
Veer Surendra Sai Institute of Medical Science and
Research,Odhisa, India were taken. The incidence of elderly
primigravida was 2.51%. But majority (84.76%) though married
early, conceived late. Most of them are belongs to high
socioeconomic group (62.86%). Anaemia was commonest
complication (28.57%), fibroid in 5.71% cases. Pre-eclampsia
(18.09%), eclampsia (3.81%), IUGR (12.38%) and twin
pregnancies (5.72%) were seen more frequently than young
primigravida. 55.24% were developed complications during
labour like foetal distress (33.33%), PPH (3.81%) and retained
placenta (2.86%). Gestational diabetes mellitus in (0.95%),
caesarean section rate 29.52%, normal delivery 51.42%, and
congenital anomaly 8.15%.

61. CONCLUSION

62. THANK YOU