Screening &

Assessment of
High Risk Pregnancy
(Prenatal)
Rhealeen V. Vicedo, MAN, RN
 PRENATAL DIAGNOSIS
• Using a wide variety of screening and
diagnostic tests to assess health of a fetus to:
• Manage the pregnancy
• Determine potential outcomes
• Plan for complications at birth
• Decide whether to continue the pregnancy
• Discover conditions that may impact future
pregnancies
 HIGH RISK PREGNANCY
• The condition wherein the maternal and
fetal life is jeopardized by a disorder
coincidental or unique to pregnancy.

RISK FACTORS
• Any finding that suggest the pregnancy may
have a negative outcome, for either the woman
or her unborn child
• Can be identified during the initial assessment;
others may be detected during subsequent
prenatal visits.
 What is screening?
• 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.
What is assessment?

• a process for:
o defining the nature of the problem
o determining a diagnosis, and
o developing specific treatment
recommendations.
CATEGORIES OF

(Assessment Tool)
1. MATERNAL AGE AND PARITY
FACTORS
a. H - high parity (5 or more)
b. I - interval of 8 years or more since last
pregnancy /pregnancy after 3 months or
less after the last delivery
c. M - multipara 40 or over
d. A - age 16 and below
e. N - nullipara 35 and above
 2. Maternal diseases
• 2.1. Pregnancy Induced Hypertension (PIH)
a. P - pre-eclampsia with hospitalization
before
b. E - eclampsia
c. C - chronic hypertension
(160/100 mmHg and over)
a. K - kidney disease (pyelonephritis, end
stage kidney disease)
 2. Maternal diseases

2.2. Anemia
• Physiologic

• Pathologic
 2. Maternal diseases
2.3. Hemorrhage
• History of previous hemorrhage

• Hemorrhage during the present pregnancy

 3. Fetal Factors
a. T - two or more premature deliveries and
consecutive spontaneous
abortions or miscarriages
b. H - history previous defects and LGA
offsprings (over 4000 gms or 9 lbs)
c. O - one or more still birth
d. R - RH incompatibility problems or ABO
immunization
 4. Paternal Factor
• Concerns more about the characteristics
of the sperm and its capacity to fertilize
an ovum.
5. Dystocia (history or anticipated)

a. C - CPD (Cephalo-pelvic disproportion)

b. M - multiple pregnancies
c. P2 - previous operative deliveries and
previous diagnosis of genital tract
anomalies (incompetent cervix)
d. T - two or more breech deliveries
e. H - history of prolonged labor
6. History of concurrent conditions
a. D - diabetes mellitus aka gestational diabetes
b. T4 - (1) thyroid diseases (2) TB and other respiratory
diseases (3) TORCH (4)Tumor
c. M - malnutrition or extreme obesity during
pregnancy
d. A - addiction (drug, alcohol and cigarette)
e. P - psychiatric diseases (mental retardation, tragic
experience of being pregnant, loss of support)
f. H - hyperemesis gravidarum that causes metabolic
alkalosis
POSSIBLE NURSING DIAGNOSIS
• Anxiety related to guarded pregnancy outcome
• Deficient fluid volume related to third-trimester
bleeding
• Risk for infection related to incomplete miscarriage.
• Risk for ineffective tissue perfusion related to
pregnancy induced hypertension
• Deficient knowledge related to signs and symptoms of
possible complication
 What is a diagnostic test?
• a test is to establish the presence (or absence)
of disease
• a basis for treatment decisions in
symptomatic or screen positive individuals
(confirmatory test).
 Diagnostic tests for
high risk pregnancy
NONINVASIVE INVASIVE
• Fetal ultrasound or • Chorionic villus
ultrasonic testing sampling
• Cardiotocography • Amniocentesis
• Non stress test • Embryoscopy
(NST) • Fetoscopy
• Contraction stress • Percutaneous umbilical
cord blood sampling.
test (CST)
 NON INVASIVE
DIAGNOSTIC TESTS
Fetal ultrasound or ultrasonic testing
• 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.
 Ultrasonography
• no known risks to mother or fetus
• 2-D, 3-D, 4-D high resolution and fetal
echocardiograms
• Assess fetal proportions, sex, position, growth;
placenta, amniotic fluid
• Accurately estimate fetal age
• At 6 weeks can see developing embryo
• Between 16-20 weeks gestation is optimal time
to screen for congenital anomalies for prenatal
diagnosis
 Ultrasonography
1st-trimester fetal ultrasound is done to:
• To establish the dates of a pregnancy
• To determine the number of fetuses and
identify placental structures
• To diagnose an ectopic pregnancy or
miscarriage
• To examine the uterus and other pelvic
anatomy
• In some cases to detect fetal abnormalities
 Ultrasonography
2nd-trimester fetal ultrasound is done to:
• To confirm pregnancy dates
• To determine the number of fetuses and examine the
placental structures
• To assist in prenatal tests, such as an amniocentesis
• To examine the fetal anatomy for presence of
abnormalities
• To check the amount of amniotic fluid
• To examine blood flow patterns
• To observe fetal behavior and activity
• To examine the placenta
• To measure the length of the cervix
• To monitor fetal growth
 Ultrasonography
3rd-trimester fetal ultrasound is
done to:
• To monitor fetal growth
• To check the amount of amniotic fluid
• As part of the biophysical profile
• To determine the position of a fetus
• To assess the placenta
Some conditions detected by
ultrasound
• Neural tube defects
• Body wall defects
• Major organ abnormalities
• Oligo- or polyhydramnios
• Major limb abnormalities
• Growth disturbances
 Cardiotocography (CTG)
• a technical means of recording (-graphy)
the fetal heartbeat (cardio-) and the
uterine contractions (-toco-) during
pregnancy
• typically done in the third trimester
• machine used to perform the monitoring
is called a cardiotocograph, more
commonly known as an Electronic Fetal
Monitor (EFM).
Cardiotocography (CTG)
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

• also known as fetal heart rate

monitoring
• a baby's heart rate is monitored to
see how it responds to the baby's
movements.
• recommended for women at
increased risk of fetal death
• usually done after week 26 of
pregnancy.
Contraction Stress Test

• 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
 Genetic Amniocentesis
• obtain fetal cells
• Study chromosomes, DNA, or biochemical
profile of fetus
• Approach via mother’s abdomen under
ultrasound guidance
• Enough fluid after 14 weeks of gestation to
perform safely
• Most often preformed between 15 and 20
weeks gestation
 Genetic Amniocentesis

• Risks:
– fetal loss - < 0.5% higher than normally
expected
– trauma and infection,
– risk of club foot reported when done < 13
weeks
• Later in pregnancy (eg. third trimester),
amniotic fluid can be taken to assess fetal
lung maturity prior to a premature delivery
 Chorionic Villus Sampling
• Invasive technique to obtain fetal cells
• Study chromosomes, DNA, or biochemical profile of
fetus
• Most often approached through the vagina but may
be approached through the abdomen of mother
• Most often performed between 10-13 weeks
gestation, but as early as 9 weeks and any time after
13 weeks
• More genetic material from cells to study right away
 Chorionic Villus Sampling
• Risks:
– fetal loss rate slightly higher than amnio -
about 1%
– Very slight risk of increased limb
abnormalities if done < 10 weeks
– risk of infection
 Percutaneous Umbilical
Blood sampling

• Invasive procedure to obtain fetal blood cells

• Study chromosomes, DNA, blood chemistries,
or biochemical
• Needle under ultrasound guidance to obtain
blood from umbilical vein
 Percutaneous Umbilical
Blood sampling
• Risks:
– Fetal loss rate higher than amnio or CVS (at
least 2% mid-2nd trimester )
• Rarely needed except in special circumstances
where results can not be obtained by
amniocentesis or CVS techniques
 Fetoscopy
• Fetoscopy is the examination of the fetus
after 11 weeks' gestation.
• Insertion of a fiber optic fetoscope though a
small incision in the mother’s abdomen
• Done under local anesthesia

• Confirms ultrasound findings of gross fetal

disorders and DNA analysis
ANEMIA IN PREGNANCY
 Background Information
● Most common medical disorder in pregnancy
● Prevalence in USA is 2-4% Phil. 24.6%
● Nutritional anemia (Fe deficiency) most common type
● It is an important contributor to maternal &
perinatal morbidity & mortality.
 ANEMIA
● A condition where circulating levels of Hgb are
quantitatively or qualitatively lower than normal

● Non pregnant women Hb < 12gm%

● Pregnant women (WHO) Hb < 11 gm%
Haematocrit < 33%
 Anemia
Disorder by which the body is depleted of RBC to
carry adequate oxygen to tissues

NICE Guidelines (for pregnant woman)

• Hb level <11g/dl in the 1 and 3
st rd trimester

• Hb level <10.5g/dl in the 2

nd trimester

• Mild------------ 8 – 10 mg %

• Moderate ---- 5 –< 8 mg %

• Severe---------- < 5 mg %a
 Anemia
Decreased Production Increased Production
Iron Deficiency Anemia Hemolytic Anemia (Thalassemia)

Folate Deficiency Chronic blood loss

Vitamin B12 Deficiency

Bone marrow Failure

Chronic Illness (eg, malignancy)

 PHYSIOLOGIC ANEMIA
• During Pregnancy there is increase in:
o total blood volume (1500 ml = 30 - 40%)
o plasma volume (250 ml = 40-50 %)
o RBC volume (350ml = 20 -30 % )

• But increment in plasma volume is more than the

increased total hemoglobin (15-20 % ).

• Hence there is dilution of blood

 Iron Supplementation in Pregnancy
• By prenatal vitamins:

• The fetus requires a total of about 350 to 400 mg of iron per day
to grow.

• The increases in the mother’s circulatory red blood cell mass

require an additional 400 mg of iron per day, which creates a
total needed increase of about 800 mg.

• Iron absorption may be impaired during pregnancy as a result

of decreased gastric acidity (iron is absorbed best from an acid
medium) (Whitney & Rolfes, 2012).
 NUTRIENTS SOURCES

Iron Haem Iron :Animal blood , flesh , viscera ( live

Kidney , red meat , poultry and fish ( including
muscles )
Non Haem Iron : green leafy vegetables, cereals,
seeds, Vegetable ( peas , blacked beans ) roots
and tubes, japery, Cooking in iron vessels, Dates
etc .
Folic Acid Green Vegetables (Broccoli ) Fruits , Germinate
wheat , Liver and Kidney.
Cyanocobalamin Meat , fish , eggs , milk
( Vit B12 )
Ascorbic Acid Citrus fruits ,
( vit. C )
Other Vit,B Green leafy vegetables and fruits
 IRON
• a critical element in the function of cells.
• major role of iron (ferrous form ) is to carry O2 as part
of hemoglobin . O2 is also bound by myoglobin, an iron
compound present in muscles. → extreme fatigue and
poor exercise tolerance
• excessive iron is highly toxic ,as it generates free
radicals.
• Iron is a critical element of enzymes including
cytochrome system in mitochondria.
IRON DEFICIENCY ANEMIA
● Most common anemia in pregnancy
● Physiological iron requirements are 3x higher in
pregnancy, with increasing demand as pregnancy
advances
● Due to:
o Inadequate dietary supplement
o Ineffective absorption
o Increased iron loss
 IRON DEFICIENCY ANEMIA
• More common in developing countries
• Low Dietary Intake of Iron ,
• Chronic Intestinal Diseases Like Amoebiasis, Diarrhea, Parasitic
Infestation (Hook Worm) Malaria , Schistosomiasis
• Chronic Blood Loss (Menorrhagia),
• Too many and too frequent pregnancies and multiple pregnancy
 Metabolism of Iron
● ↑ erythropoietin production → ↑erythropoiesis
● In pregnancy, ↑ in plasma volume compared to red
cell mass, therefore → HEMODILUTION
● Demand for iron is ↑to meet the needs of the
expanded red cell mass & requirements of developing
fetus and placenta
● Fetus derives iron from maternal serum by active
transport across placenta MAINLY @ the last 4 weeks
of pregnancy
 IRON RICH FOOD
• Dark-green leafy vegetables
• Iron-fortified cereals whole
grains eg. brown rice
• Beans, peas, soya bean
• Nuts, peanut butter
• Meat and fish
• Oatmeals
• Spinach
• Prunes, Raisins
IRON ABSORPTION IMPAIRMENT
● Tea and coffee
● Calcium, found in dairy products
such as milk
● Antacids (medication to help relieve
indigestion)
● Proton pump inhibitors (PPIs),
which affect the production of acid
in your stomach
● Some whole grain cereals
contain phytic acid
 MATERNAL EFFECTS OF
IRON DEFICIENCY ANEMIA

● Feelings of weakness and

exhaustion
● Indigestion and loss of
appetite.
● Palpitation
● Dyspnea
● Pallor
● Edema
FETAL EFFECTS OF IRON
DEFICIENCY ANEMIA
● LBW

● Prematurity

● Stillbirth

● Neonatal death

● Severe IDA
 MANAGEMENT OF IRON
DEFICIENCY ANEMIA
● Total iron requirement 700-1400mg, 4mg/day
● WHO recommends: 30-60mg/day ≈ 1tab Obimin/ 1tab
Ferrous Fumerate (for women with normal iron level)
● Hb levels increase 0.3mg/week
● At least 180 mg /day of elemental iron required for
therapeutic management
● Hb levels need to be checked 2 weeks after commencing
treatment
 FOLATE DEFICIENCY
ANEMIA
• Folic acid is needed in higher doses
• increased cell replication , taking place in fetus ,
uterus and bone marrow.
• 800 ug is required / day , but pre existing
deficiency is common mainly due to inadequate
diet / intestinal malabsorption syndrome .
 FOLATE DEFICIENCY
ANEMIA
• More common in:
• twin pregnancy
• multigravida ,
• hook worm infestation ,
• GIT diseases , bleeding piles
• Haemolytic conditions ,
• malaria and other infections

• Anti-folate medications like anti-epileptics , anti

cancer.
MATERNAL EFFECTS FOLATE
DEFICIENCY ANEMIA
● Asymptomatic
● loss of appetite
● vomiting
● diarrhea
● Pallor
● Bleeding points on skin
● Enlarged spleen and liver and
neuropathy.
● PIH
● Abruptio placenta
 FETAL EFFECTS FOLATE
DEFICIENCY ANEMIA
● Neural Tube Defects:
● Spina bifida
● Anencephaly
 CARDIAC
DISEASES IN
PREGNANCY
 CARDIAC DISEASE
• Hemodynamic changes of pregnancy
increases the workload of the heart
• Cardiac output increases up to 50%
• Plasma volume increases by 50 %
CARDIOVASCULAR DISEASE

Cardiovascular changes of pregnancy

● Plasma volume increases gradually
● Plasma volume peeks at 50% greater than
nonpregnant level, between 28 and 32
weeks gestation
CARDIOVASCULAR DISEASE
▪Increase in erythrocytes also contributes to peek
plasma volume
▪Total erythrocyte count increases
-by about 30% in women who receive iron
-by only about 18% in women who do not
CARDIOVASCULAR DISEASE

● Since plasma volume increase is greater than

erythrocyte
● Hematocrit decreases slightly resulting in
Physiologic Anemia of Pregnancy
CARDIOVASCULAR DISEASE

• Blood flow increases to organ systems

with increased workload (uterus and
kidneys)
• Results in increased cardiac output in
early pregnancy
• Cardiac Output remains elevated
throughout pregnancy
CARDIOVASCULAR DISEASE
• Enlarging uterus puts pressure on pelvic and
femoral vessels
• impedes return blood flow causing stasis of blood in
lower extremities
• stasis predisposes to postural hypotension
• dependant edema
• hemorrhoids
 NYHA (NEW YORK HEART
ASSOCIATION) FUNCTIONAL
GRADING OF HEART DISEASE
● Grade I: No limitation of physical activity-
asymptomatic with normal activity
● Grade II: Mild limitation of physical activity -
Symptoms with normal physical activity
● Grade III: Marked limitation of physical activity
-Symptoms with less than normal activity,
comfortable at rest
● Grade IV: Severe limitation of physical activity-
symptoms at rest
SIGNS AND SYMPTOMS
• H- heart murmurs
• EA- edema or ascites.
• D- decreased cardiac output
• PH- pulmonary edema and hypertension.
• I- increased venous pressure
• C- cyanosis of nail beds
 DIAGNOSTICS
● ECG – cardiac arrhythmias, hypertrophy
● Echocardiography – cardiac status and structural
anomalies
● Chest X-ray – cardiomegaly, vascular prominence
● Cardiac catheterization - rarely
CLASSIFICATION OF HEART DISEASE
ACCORDING TO ETIOLOGY
• Congenital
• non cyanotic ( ASD, VSD, Pulm stenosis, coarctation
of aorta)
• cyanotic (Fallots tetralogy, Eisenmenger’s syndrome)
• Rheumatic heart disease – MS, MR, AS, AR
• Cardiomyopathy
• Ischaemic heart disease
• Others – conduction defects, syphilitic,
thyrotoxic, hypertensive
CONGENITAL
CONGENITAL
CONGENITAL
CONGENITAL
EISENMENGER’S SYNDROME
RHEUMATIC HEART DISEASE
RHEUMATIC HEART DISEASE
ISCHEMIC HEART DISEASE
ADDITIONAL RISK FACTORS
● Anemia ● Caffein , alcohol
● Infections intake
● Hypertension ● Pain
● Physical labor ● Drugs – tocolytic
● Weight gain
● Multiple pregnancy
EFFECT OF PREGNANCY ON
HEART DISEASE
● Worsening of cardiac status
● Bacterial endocarditis, pulmonary edema,
pulmonary embolism, rupture of aneurysm
EFFECT OF HEART DISEASE
ON PREGNANCY
● Abortion
● Preterm labour

● IUGR

● Congenital heart disease in

baby – 5%
● Intrauterine fetal demise
 MANAGEMENT
● High index of suspicion
● Timely diagnosis
● Effective management
● Team Approach
■ Obstetrician
■ Cardiologist
■ Anaesthetist
■ Neonatologist
■ CTV surgeon
■ Nursing Staff
 PRECONCEPTIONAL
COUNSELING
● No pregnancy especially in high risk types
● Maternal mortality varies directly with
functional classification at pregnancy onset
● Optimal Medical/Surgical treatment pre-
pregnancy
● Counselling
○ Maternal & Fetal risks
○ Prognosis
○ Social and cost considerations
○ Hospital delivery- Preferable at tertiary care
centre
Medical Termination of Pregnancy

● Termination advised in early

pregnancy in high risk group only
● Only in 1st trim, better before 8
weeks
● Suction evacuation preferred
● MTP also carries risk for life
Contraceptive advice at time of
discharge:
• Contraception Barrier
• Progesterone – good option
• DMPA, Norplant
• IUD- Less preferred
• COC - contraindicated
• Sterilization- best
• Vasectomy
• Tubal ligation
 NURSING PROCESS
●Nursing Diagnosis
-Decreased cardiac Output
-Excess fluid volume
-Impaired gas exchange
-Activity intolerance
-Anxiety
-Risk for Infection
 NURSING PROCESS
●Intervention / Management
●Rest, avoid undue excitement/strain
●Diet/ Iron and vitamins
●Hygiene, dental care to prevent any infection
●Dietary salt restriction (4-6g/d)
●Avoid smoking, drugs
●Early diagnosis and treatment of PIH, infections
 NURSING PROCESS
●Therapeutic/prophylactic cardiac
interventions as applicable-
○Iron and vitamin supplementation
○Benzathine Penicillin at 3 weeks - to
prevent recurrence of rheumatic fever
○Heparin (Anticoagulants)
○Furosemide (Diuretics)
○Digitalis glycosides (antiarrhytmics)
 NURSING PROCESS
NURSING MANAGEMENT (PRENATAL)
● Promote frequent rest periods, adequate sleep
and decrease stress
● Teach client to recognize and report signs of
infections and the importance of prophylactic
antibiotics
● Compare vital signs to baseline and normal
values expected during pregnancy
 NURSING PROCESS
NURSING MANAGEMENT (INTRAPARTAL)
● Monitor maternal ECG and FHT continuously
● Explain to client that vaginal delivery is preferred over
CS
● Monitor client response to stress of labor and watch for
signs of decompensation
● Position client in side-lying or semi-fowlers position
● Administer oxygen and pain medications as ordered
● Provide a calm atmosphere
● Encourage open-glottal pushing
 NURSING PROCESS
NURSING MANAGEMENT (POSTPARTAL)
● Monitor vital signs, bleeding, strict
I&O, daily weight, rest and diet
● Anti-embolic stockings
● Prevent infections
● Prevent straining (stool softeners)
● Facilitate non stressful mother/baby
interactions
 NURSING PROCESS
●Evaluation
-Client experiences healthy
pregnancy
-Client avoids heart failure
-Client gives birth to healthy
infant