MID 104

CLINICAL MANAGEMENT-OBSTETRICAL
EMERGENCIES HIGH RISK PREGNANCY
MANAGEMENT
JESSICA A. TORREJA, RM,BSM
 High Risk Pregnancy
A high-risk pregnancy is a pregnancy that
involves increased health risks for the
pregnant person, fetus or both. Certain health
conditions and your age(being over 35 or
under 17 when pregnant) can make a
pregnancy high risk. These pregnancies
require close monitoring to reduce the chance
of complications.
What causes high-risk
pregnancy?
• Preexisting health conditions.
• Pregnancy health conditions.
• Lifestyle factors(including smoking, drug
addiction, alcohol abuse and exposure to
certain toxins.)
• Age (being over 35 or under 17 pregnant).
What are common medical risk factors for a
high-risk pregnancy?
 Autoimmune disease, such as lupus
or multiple sclerosis(MS)  Mental health disorders, such as
 COVID-19 depression.
 Diabetes  Obesity
 Fibroids  PCOS
 HIV/AIDS  Thyroid disease
 Kidney disease  Blood clotting disorders.
 Low body weight(BMI of less than
18.5)
Pregnancy-related health conditions that can
pose risks to the pregnant person and fetus
include.
• Birth defects or genetic conditions in the fetus
• Poor growth in the fetus
• Gestational diabetes
• Multiple gestation
• Preeclampsia and eclampsia
• Previous pre-term labor or birth, or other
complications with previous pregnancies
What are the signs and symptoms of high risk
pregnancy?
• Abdominal pain that doesn’t go
away • Severe headache
• Chest pain • Swelling, redness or pain in your
• Dizziness or fainting face or limbs
• Extreme fatigue • Thoughts about harming self of
• The fetus movement stopping or the fetus
slowing • Trouble breathing
• Fever over 100.4⸰F • Vaginal bleeding or discharge.
• Heart palpitations
• Nausea and vomiting that worse
than normal morning sickness.
 BIOPHYSICAL
MONITORING
BIOPHYSICAL PROFILE(BPP)
is prenatal ultrasound evaluation of current fetal well-being
involving a scoring system. It is performed over 30 minutes and assesses
fetal behavior by observing fetal breathing movement, body movement, tone
and amniotic fluid volume.
The goal of a biophysical profile is to prevent pregnancy
loss and defect fetal hypoxia when the baby is deprived of an adequate
oxygen supply early enough so that the baby can be delivered and not
sustain permanent damage.
5 Components of Biophysical
Profile
1. Fetal Heart Rate
2. Fetal Breathing
3. Fetal Movement
4. Fetal Tone
5. Amniotic Fluid Volume
Parameter Normal (2 points) Abnormal (0 points)

NST/Reactive FHR At least 2 accelerations in 20 Less than 2 accelerations to

minutes satisfy the test in 20 minutes

Fetal Breathing movements At least 1 episode of >30s or None or less than 30s or 20s
>20s in 30 minutes

Fetal activity/ gross body At least 3 or 2 movements of Less than 3 or 2 movements

movements the torso or limbs

Fetal Muscle Tone At least 1 episode of active No movements of

bending and straightening of movements slow and
the limb or trunk incomplete
Quality AFV/AFI At least 1 vertical pocket Largest vertical pocket </= 2
>2cm or more in the vertical cm
axis
 BIOCHEMICAL
MONITORING
Maternal Urine Assessment
is used to assess bladder or kidney
infections, diabetes, dehydration, and
preeclampsia by screening for high levels of
sugars, proteins, ketones, and bacteria
 BIOCHEMICAL
MONITORING
Maternal Serum Assessment
is an screening test is a blood test offered to
pregnant women.
It helps to inform them of chance of their
unborn child having Down Syndrome, Edward syndrome
or a neural tube defect.
The test may be performed at around 10
weeks (combined first trimester screening test) or
between 14 and 20 weeks (second trimester maternal
serum screening test.)
Screening and
Assessment of
High Risk
Pregnancy
 What is Screening?
• Screening is a process of identifying
apparently healthy people who maybe 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.
 What is Assessment?
• Assessment is a process for
defining the nature of that problem,
determining a diagnosis, and
developing specific treatment
recommendations.
 What is a Diagnostic
Test?

• It is a test to establish a presence

(or absence) of disease as a basis
for treatment decisions in
symptomatic or screen positive
individuals (confirmatory test)
DIAGNOSTIC TESTS FOR HIGH RISK
PREGNANCY
NONINVASIVE INVASIVE
 Fetal ultrasound or ultrasonic  Chorionic villus sampling
testing  Amniocentesis
 Cardiotocography  Embryoscopy
 Non stress test (NST)  Fetoscpoy
 Contraction stress test (CST)  Percutaneous umbilical cord
blood sampling
 Non-invasive
diagnostic tests
 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 sonogram, echogram, or
scan, and they may be saved as part
of your baby’s record.
Fetal utrasound camera is done to learn about the health of the fetus. Different
information is gained at different times (trimesters) during your pregnancy.

1st-trimester fetal utrasound is done to:

 Determine how your pregnancy is progressing
 Find out if you are 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 utrasound is done to:

 Estimate the age of the fetus (gestational age)
 Look at the size and the 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 camera.gif or umbilical cord blood sampling.
 Detect major birth defects, such as neural tube defect or heart problems.
3rd -trimester fetal utrasound 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
 Cardiotocography (CTG) 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 cardiotocograph,
more commonly known as Electronic
Fetal Monitor (EFM)
Interpretation
Interpretation of a CTG tracing requires
both qualitative and quantitative description
of:
• Uterine activity (contractions)
• Baseline fetal heart rate (FHR)
• Baseline FHR variability
 Non stress test
 A non stress test is common prenatal test used
to check on 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 result might
indicate that you and your baby need further
monitoring, testing or special care.
Contraction Stress Test
(CST)
 A contraction stress test (CST) 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,
usually with FISH or PCR. 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
 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
doctor’s office or medical center. You do not
need to stay in the hospital.
Amniocentesis is most often offered to women who are at
increeassed risk for bearing a child with birth defects. 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

You may choose genetic counseling befor the procedure. This will allow you to:
 Learn about other prenatal tests
 Make an informed deccision regarding oprions for prenatal diagnosis
 This test:
• Is a diagnostic test, not a screening 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:
o Anencephaly
o Down syndrome
o Rare, metabolic disorders that are passed down
through families
o Other genetic abnormalities like trisomy 18
Embryoscopy
 Embryoscopy is the examination of the
embryo at 9-10 weeks’ gestation during the
intact membranes by introducing an
endoscope into the exocoelomic space
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%.
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 application 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, also sometimes called Percutaneous
Umbilical Cord Blood Sampling (PUBS), is a diagnostic
test that examines blood from the fetus to defect fetal
abnormalities
 An advanced imaging ultrasound determines the location
where the umbilical cord inserts into the placenta. The
ultrasound guide the thin needle through the abdomen and
uterine wall 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 can not be obtained through amniocentesis,
CVS, ultrasound or the results of these tests were
inconclusive. Cordocentesis is performed after 17 weeks
into pregnancy
 Cordocentesis detects chromosomes 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 in the mother
 Fetal anemia
 Isoimmunisation
Thank You!