SCREENING OF HIGH-RISK PREGNANCY,

NEWER MODALITIES OF DIAGNOSIS

Mrs. Shwetha Rani C.M. Associate Professor, H.O.D. Obstetrical & Gynecological Nursing
SCPM COLLEGE OF NURSING GONDA
SCREENING OF HIGH-RISK PREGNANCY, NEWER MODALITIES OF DIAGNOSIS

Though all mothers and children are vulnerable to disease or disability, there are certain

mothers and infants who are at increased or special risk of complications of pregnancy/labor or

both. If we desire to improve obstetric results, this group must be identified and given extra care.

Definition:

“A risk factor is defined as any ascertainable characteristic or circumstance of a person (or

group of such persons) known to be associated with an abnormal risk of developing or being

adversely affected by a morbid process” -(WHO, 1973).

High risk pregnancy is defined as one which is complicated by factor or factors that

adversely affects the pregnancy outcome –maternal or perinatal or both.

Introduction to Assessment, Screening & Risk Approach

i) Assessment- Assessment is a process for defining the nature of that problem,

determining a diagnosis, and developing specific treatment recommendations.

ii) Screening- • Screening is a process of identifying apparently healthy people who may

be at increased risk of a disease or condition. • They can then be offered information,

further tests and appropriate treatment to reduce their risk and/or any complications

arising from the disease or condition.

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 factors.

Risk approach (according to WHO)-

The main objective of the risk approach is the optimal use of existing resources for the

benefit of the majority. It attempts to ensure a minimum of care for all while providing guidelines

for the diversion of limited resources to those who most need them. Inherent in this approach is

maximum utilization of all resources, including some human resources, that are not conventionally

involved in such care e.g.,- TBA, women’s group. WHO)- approach is the for the benefit of ensure

a minimum of guidelines for the those who most maximum utilization of human resources, that in

such care e.g.,-

High risk cases (According to WHO)

i) During pregnancy-
1. Elderly primigravida (≥30 years)
2. Short statured primi (≤ 140 cm) .
3.Twins and hydramnios .
4. Threatened abortion and APH
5. Previous still birth, IUD, manual removal of placenta
6. Malpresentations & Malposition's
7. Prolonged pregnancy .
8. Pre-eclampsia and eclampsia .
9. History of previous caesarean section and instrumental delivery
11. Anemia
12. Pregnancy associated with medical diseases
ii) During labour-

• PROM
• Prolonged labour
• Hand, feet or cord prolapse
• Placenta retained more than half an hour
• PPH
• Puerperal fever and sepsis.

Course of the present pregnancy-

The cases should be reassessed at each antenatal visit to detect any abnormality that might

have arisen later.  Few examples are- pre-eclampsia, anemias, Rh- isoimmunization, high fever,

pyelonephritis, hemorrhage, diabetes mellitus, large uterus, lack of uterine growth, post maturity,

abnormal presentation, twins and history of exposure to drugs or radiation, acute surgical

problems.

Complications of labour are

o Anemia,
o Pre- eclampsia or eclampsia,
o Premature labour,
o PROM,
o Abnormal FHR,
o Amnionitis,
o Clients admitted with prolonged labour,
o Abnormal presentation and position,
o Obstructed labour,
o Disproportion,
o floating head in labour,
o Rupture uterus,
o Multiple pregnancy,
o Clients having induction or acceleration of labour
Modalities commonly used to screen/assess high risk cases are

Diagnostic test-

It is a test is to establish the presence (or absence) of disease as a basis for treatment

decisions in symptomatic or screen positive individuals (confirmatory test).

Diagnostic tests for high risk pregnancies are

- Noninvasive diagnostic tests like:-

◦Fetal ultrasound or ultrasonic testing

◦Cardiotocography(CTG)

◦Non-stress test (NST)

◦Contraction stress test (CST)

- Invasive diagnostic tests

◦Chorionic villus sampling

◦Amniocentesis

◦Embryoscopy

◦Fetoscopy

◦Percutaneous umbilical cord blood sampling.

 - Noninvasive diagnostic tests

A) Fetal ultrasound or ultrasonic testing:

Fetal ultrasound is a test done during pregnancy that uses reflected sound waves to produce

a picture of a fetus camera.gif, 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. 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. However, the timing of this ultrasound

might be altered for reasons such as obesity or prior surgical incision at the scanning site, which

could limit visualization of the fetus. 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.

* 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.

* 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 amniocentesi or umbilical

cord blood sampling. Detect major birth defects, such as a neural tube defect or heart problems.

*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.
 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). Interpretation of a CTG tracing requires both qualitative and quantitative

description of: • Uterine activity (contractions) • Baseline fetal heart rate (FHR) • Baseline FHR

variability

B) Non-stress test(NST) • A nonstress test is a common prenatal test used to check on a baby's health.

During a nonstress 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 nonstress test is recommended for

women at increased risk of fetal death. A nonstress test is usually done after week 26 of pregnancy.

Certain nonstress test results might indicate that client and baby need further monitoring, testing

or special care.

C) 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.

- Invasive diagnostic tests

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.

• 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.

Amniocentesis

• It 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 doctor's office or medical center.

• 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.

• This includes women who:

o 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.

o Have had babies with birth defects in other pregnancies

o Have a family history of genetic disorders

 o It may choose genetic counseling before the procedure. This will allow to: Learn about other

prenatal tests.

o Make an informed decision regarding options for prenatal diagnosis

o This test: Is a diagnostic test.

o Is 99% accurate for diagnosing Down syndrome

o 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 • Rare, metabolic disorders that are

passed down through families • Other genetic abnormalities, like trisomy 18.

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 transabdominally.

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.

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 applications with the development of ultrasound

examination at 10-14 weeks' gestation in order to, either confirm, or rule out suspected external

fetal abnormalities.

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.

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 into pregnancy.

Cordocentesis detects chromosome abnormalities (i.e. Down syndrome) and blood disorders

(i.e. fetal hemolytic disease.).

 Cordocentesis may be performed to help diagnose any of the following concerns:

◦Malformations of the fetus ◦Fetal infection (i.e. toxoplasmosis or rubella) ◦Fetal platelet count

◦Fetal anemia ◦Rh-Isoimmunization

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.
• 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 nonpregnant state.
• Sexually transmitted disease should be treated before embarking on another pregnancy.
Cervical tears should also be repaired in the nonpregnant state.
• Serology for toxoplasma IgG, IgM and antiphospholipid antibodies should be done and
corrected appropriately when found positive.
• Folic acid (4mg/day) therapy should be started in the prepregnant state and is continued
throughout the pregnancy
• Early in pregnancy after the initial clinical examination, routine and special laboratory
investigations should be undertaken. 
• 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.
• 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.
• Concentration of cases in specialized centers for management
• 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.