High-risk approach with screening and assessment

High-risk approach with screening and assessment

1. HIGH RISK APPROACH WITH SCREENING AND ASSESSMENT ANAMIKA RAMAWAT M.Sc. Nursing Prev. Batch 2017-18 GCON, Jodhpur

2. Introduction All pregnancies and deliveries are potentially at risk. However, there are certain categories of pregnancies where the mother, the fetus or the neonate is in a state of increased jeopardy.

3. About 20 to 30 percent pregnancies belong to this category.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.,-

10. High risk cases (According to WHO) i ) During pregnancy- 1. Elderly primigravida (≥30 years) 7. Elderly grand multiparas 2. Short statured primi (≤ 140 cm) 8. Twins and hydramnios 3. Threatened abortion and APH 9. Previous still birth, IUD, manual removal of placenta 4. Malpresentations & Malposition's 10. Prolonged pregnancy 5. Pre-eclampsia and eclampsia 11. History of previous caesarean section and instrumental delivery 6. Anemia 12. Pregnancy associated with medical diseases.

11. ii) During labour- PROM Prolonged labour Hand, feet or cord prolapse Placenta retained more than half an hour PPH Puerperal fever and sepsis.

12. iii) 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.

13. iv) Complications of labour – 1. Anemia, pre- eclampsia or eclampsia 7. Premature labour 2. PROM 8. Abnormal FHR 3. Amnionitis 9. Clients admitted with prolonged labour 4. Abnormal presentation and position 10. Obstructed labour 5. Disproportion, floating head in labour 11. Rupture uterus 6. Multiple pregnancy 12. Clients having induction or acceleration of labour

14.   v) 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  

15. vi) An uneventful labour may suddenly turn into an abnormal one in the form of – PPH Retained placenta Shock Inversion Sepsis may develop later on

16. vii) 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

17. Screening/ Assessment-   Initial screening History Maternal age Reproductive history Pre-eclampsia, eclampsia Anemia Third stage abnormality Previous infant with Rh-isoimmunization or ABO incompatibility Medical or surgical disorders Psychiatric illness Cardiac disease Viral hepatitis Previous operations Myomectomy Repair of complete perineal tear Repair of vesico -vaginal fistula

18. Family history - Socio-economic status Family history of diabetes, hypertension multiple pregnancy (maternal side), congenital malformation .

19. 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).  

20. Diagnostic tests for high risk pregnancy Noninvasive diagnostic tests   Fetal ultrasound or ultrasonic testing Cardiotocography(CTG) Non-stress test (NST) Contraction stress test (CST)  

21. Invasive diagnostic tests Chorionic villus sampling Amniocentesis Embryoscopy Fetoscopy Percutaneous umbilical cord blood sampling.

22. I ) Noninvasive diagnostic tests   A) Fetal ultrasound or ultrasonic testing

23. 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.

24. 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 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.

25. 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.    

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

27. 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.

28. B) 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).  

29. Interpretation of a CTG tracing requires both qualitative and quantitative description of: • Uterine activity (contractions) • Baseline fetal heart rate (FHR) • Baseline FHR variability

30. C) 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.

31. D) 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 .

32. 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.

33. 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.

34. 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 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.

35. 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 counseling before the procedure.   This will allow to: Learn about other prenatal tests Make an informed decision regarding options for prenatal diagnosis

36. 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 • Rare, metabolic disorders that are passed down through families • Other genetic abnormalities, like trisomy 18.

37. 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 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.

38. 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 applications with the development of ultrasound examination at 10-14 weeks' gestation in order to, either confirm, or rule out suspected external fetal abnormalities.

39. 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.

40. 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.).

41. 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

42. 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.

43. 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.

44. 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

45. 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 .

46. 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.

47. 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.

48. SUMMARY…