High Risk Pregnancy Overview

High Risk Pregnancy

• A high-risk pregnancy is any condition that puts the mother, fetus, or both in problems.
• Factors influencing high-risk pregnancy are categorized as maternal and fetal.
• Maternal factors include past obstetrical history, current obstetrical history, and medical history.

Past Obstetrical History

• Contracted pelvis or cephalopelvic disproportion
• Pregnancy-induced hypertension
• Kidney disease
• Anemia or hemorrhage
• Preterm labor
• History of prolonged, obstructed, or instrumental delivery
• Two or more breech births
• Previous operative births (e.g., Cesarean birth)
• Genital tract infection

Current Obstetrical History

• Nullipara 35 years or older, or less than 14 years
• Multipara 40 years or older
• High parity
• Gestational diabetes
• Hyperemesis gravidarum
• Pregnancy-induced hypertension
• Bleeding in early or late pregnancy

Medical History

• Thyroid disease (hypo- or hyperthyroidism)
• Malnutrition or extreme obesity
• Heart disease
• Diabetes mellitus
• Tuberculosis or other serious pulmonary conditions (asthma)
• Malignant or premalignant tumors
• Psychiatric disease or epilepsy
• Mental retardation

Fetal Factors

• Multifetal pregnancy
• Malposition and/or malpresentation
• History of macrosomia (large infant; over 4kg)
• Previous low birth weight
• Two or more spontaneous preterm births
• One or more stillbirths during term gestation
• One or more gross anomalies
• Rh incompatibility

Bleeding During Pregnancy

• Early bleeding
• Late bleeding
• Causes: Abortion, ectopic pregnancy, vesicular mole, local gynecological lesions (cervical ectopy, polyp, dysplasia, carcinoma, and rupture of varicose veins)

Abortion

• Definition: Termination of pregnancy before fetal viability (i.e., before 28 weeks in Britain, and before 20 weeks or if the fetal weight is less than 500 gm in USA and Australia)
• When occurring spontaneously, it's often called a miscarriage.
• Incidence: 10-20%
• Aetiology: Chromosomal abnormalities (e.g., trisomy), blighted ovum (anembryonic gestational sac), trauma, endocrine causes (progesterone deficiency, diabetes mellitus, hyperthyroidism), over-distension of the uterus (acute hydramnios), and infections (viral - Rubella, cytomegalo, varicella, variola; parasitic - Toxoplasmosis, Malaria; bacterial - Chlamydia, Ureaplasma, Brucella; spirochetes - Treponema pallidum), immunological causes (Systemic lupus erythematosus, antiphospholipid antibodies), uterine defects (septum, Asherman's syndrome), idiopathic

Types of Abortion

• Threatened, inevitable, complete, incomplete, recurrent, missed, septic

Clinical Picture: Threatened Abortion

• Symptoms and signs of pregnancy match its duration.
• Mild, bright red vaginal bleeding.
• Pain is absent or mild.
• Cervix is closed.
• Positive pregnancy test.
• Ultrasound shows a living fetus.

Clinical Picture: Inevitable Abortion

• Symptoms and signs of pregnancy match its duration.
• Excessive vaginal bleeding, possibly with clots.
• Colicky pain in the suprapubic region, radiating to the back.
• Dilated internal os of the cervix and products of conception may be felt through it.
• Rupture of membranes between 12-28 weeks is a sign of inevitability.

Treatment

• Bed rest for a week after bleeding stops.
• Avoid intercourse.
• Sedatives for anxiety.
• Progestogens or Gonadotrophins for some cases.
• (Anti-D for Rh-negative patients)
• Stabilize vitals, suction evacuation/curettage, IV oxytocin drip (for later stage)

Clinical Picture: Incomplete Abortion

• Retention of some products of conception inside the uterus (possibly the whole or part of the placenta).
• Heavy bleeding.
• Open cervix.
• Severe abdominal pain.
• Medical or surgical management (evacuation under anesthesia)

Clinical Picture: Complete Abortion

• All products of conception have been expelled.
• Slight bleeding that gradually diminishes.
• Pain ceases.
• Cervix is closed.
• Uterus is slightly larger than normal (if later stages).
• Ultrasound shows empty uterine cavity.
• No active intervention required.

Clinical Picture: Missed Abortion

• Retention of dead products of conception for 4 weeks or more.
• Regression of pregnancy symptoms (nausea, vomiting, breast changes).
• Abdomincal size may not increase or decrease.
• Fetus movements are absent.
• Brown/prune juice-like vaginal discharge.
• Uterus fails to grow and feels firmer.
• Cervix is closed.
• No fetal heart sounds or fetal movements evident on Ultrasound.
• Pregnancy test becomes negative after 2 weeks from death

Complications

• Disseminated intravascular coagulation (DIC) if retained dead products longer than 4 weeks.
• Superadded infection.
• Evacuation of the uterus required for some cases.

Ectopic Pregnancy

• Definition: Fertilized ovum implants and develops outside the uterine cavity.
• Incidence: >1 in 100 pregnancies
• Recurrence: 15% after 1 ectopic, 25% after 2 ectopics
• Etiology: Factors causing delayed transport through the fallopian tube (congenital or acquired, mechanical or functional). Congenital issues, inflammation, previous surgery.
• Signs and Symptoms: Amenorrhea, infertility history. Severe, colicky abdominal pain (one iliac fossa or entire lower abdomen), dizziness, fainting, blood-stained vaginal discharge, diffuse lower abdominal tenderness, shock signs, and dyspareunia.
• Management: Depends on stage (complicated or uncomplicated). Complicated ectopic pregnancies require surgery (salpingectomy, posterior colpotomy, and/or salpingo-oophorectomy). Uncomplicated pregnancies can consider medical or expectant management. Medical therapy utilizing methotrexate should be considered when the pregnancy’s size is less than 3.5 cm.

Hydatidiform Mole (Vesicular Mole)

• Definition: Abnormal development of chorionic villi with proliferating villi, forming grape-like clusters of small cysts.
• Causes: Unknown.
• Risk factors: Maternal age (above 35 or below 16), malnutrition (protein deficiency), prior hydatidiform mole.
• Signs and Symptoms: Symptoms of early pregnancy (nausea, vomiting), larger-than-expected uterus, possible vaginal bleeding with vesicles, no fetal movements or fetal heartbeats, soft/doughy uterus on palpation, positive pregnancy test in highly diluted urine.
• Investigations: HCG level in urine, ultrasound scanning.
• Complications: Hemorrhage, uterine sepsis, choriocarcinoma.
• Management: Hospital admission, evacuation of uterus under general anesthesia.

Bleeding in Late Pregnancy

• Differential Diagnosis: Placental abruption, placenta previa, uterine rupture, vasa previa.

Placental Abruption

• Definition: Premature separation of a normally implanted placenta.
• Incidence: Approximately 1 in 120 births.
• Risk factors: Idiopathic, maternal hypertension (≥ 140/90), blunt abdominal trauma, chorioamnionitis, previous abruption, smoking.
• Types: Revealed (peripheral detachment, external hemorrhage), concealed (central separation, retroplacental hematoma), mixed.
• Clinical Picture: Concealed type: severe abdominal pain, tenderness/rigid abdomen, fundal height elevated as per period of amenorrhea, vaginal bleeding, signs of shock. Revealed type: vaginal bleeding, mild abdominal pain, signs of shock, no vaginal examination until placenta previa is excluded.
• Investigations: Ultrasound to exclude placenta previa, evaluate viability, and assess for retroplacental hematoma. Urine analysis for proteinuria.
• Complications: Fetal/maternal death, acute renal failure, DIC, postpartum hemorrhage.
• Management: Treatment depends on type (revealed vs. concealed). Correction of shock, termination (induction of labor or cesarean section) is often required, and hospitalization with monitoring of mother and fetus is critical.

Placenta Previa

• Definition: Placenta located in the lower uterine segment after gestational viability.
• Incidence: 1/200 pregnancies
• Etiology: Unknown; possible risk factors include scarred uterus, high parity, and multiple pregnancies.
• Degrees: Differentiated by where the placenta is located in relation to the internal os.
• Clinical Picture: painless vaginal bleeding, not related to other labor symptoms, possible vital signs changes.
• Investigations: Ultrasound to exclude placenta previa, fetal viability.
• Treatment: Depending on degree and fetal maturity; cesarean delivery may be required.

Role of the Nurse

• Immediate referral of patient with possible abruption to hospital.
• Continuous observation of the patient's condition, vitals, bleeding, and signs of shock.
• Continuous observation of fetal status.
• Initiate and monitor IV fluids/transfusions.
• Accurate medication administration.