High-Risk Pregnancy Management

HRP Intro & Screening - Spotting Trouble Early

• High-Risk Pregnancy (HRP): Condition where mother, fetus, or neonate faces ↑ risk of morbidity/mortality pre, intra, or postpartum.
• **Key Risk Factors (Indian Context):
  • Age: <18 yrs or >35 yrs
  • Parity: Nullipara, Grand multipara (≥5 births)
  • Bad Obstetric Hx: Recurrent loss, stillbirth, preterm, IUGR, previous LSCS, PIH
  • Medical Illness: Anemia (Hb <10 g/dl), HTN, DM, Heart/Kidney disease, HIV, TB
  • Socio-demographic: Low SES, malnutrition, <4 ANC visits
• Screening & Early Detection:
  • Thorough history & physical exam at each ANC visit.
  • Essential Labs: Hb, Blood group & Rh, Urine (albumin, sugar), VDRL, HIV, HBsAg, RBS.
  • GDM screen: DIPSI (75g OGTT, plasma glucose ≥140 mg/dl at 2 hrs).

⭐ Booking visit (1st ANC) is crucial for risk assessment; ideally within 1st trimester (by 12 weeks).

HRP: Hypertensive Disorders - Pressure Cooker Situations

• Classification:
  • Chronic HTN: BP ≥140/90 mmHg <20 wks.
  • Gestational HTN (GHTN): BP ≥140/90 mmHg >20 wks, no proteinuria.
  • Preeclampsia (PE): GHTN + Proteinuria (≥300mg/24h / PCR ≥0.3).
    • Severe Features: BP ≥160/110 mmHg OR end-organ dysfunction (platelets <100k/µL, LFTs ↑↑, Creat >1.1mg/dL, pulm edema, CNS sx).
  • Eclampsia: PE + Seizures.
  • HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets.
• Management:
  • Antihypertensives: Hydralazine, Methyldopa, Labetalol, Nifedipine (📌 HMLN). Avoid ACEi/ARBs.
  • MgSO₄: Seizure prophylaxis/Rx (Sev PE/Eclampsia). Load 4-6g IV, Maint 1-2g/hr. Antidote: Ca Gluconate 1g.
  • Delivery: Definitive Rx.

⭐ MgSO₄ is DOC for seizure prophylaxis in severe PE & seizure control in eclampsia.

HRP: GDM & Anemia - Sweet & Low Battles

Gestational Diabetes Mellitus (GDM):

• Screening (India): DIPSI - 75g OGTT (anytime, non-fasting).
  • Diagnosis: 2-hr plasma glucose ≥ 140 mg/dL.
• Targets: FBS < 95; 1-hr PP < 140; 2-hr PP < 120 mg/dL.
• Management: MNT first; then Insulin. Metformin is an option.

Anemia in Pregnancy (India):

• Cut-off: Hb < 11 g/dL. Severe: Hb < 7 g/dL.
• Prophylaxis (National): 100 mg elemental Fe + 500 µg Folic Acid daily.
• Treatment: 100-200 mg elemental Fe daily. Parenteral Fe for severe/intolerant cases.

⭐ In India, GDM screening uses DIPSI: 75g OGTT (non-fasting), with a single 2-hr plasma glucose ≥ 140 mg/dL being diagnostic.

HRP: Obstetric Alarms - Early Birds & Small Wonders

• Preterm Labor (PTL): Labor < 37 weeks.
  • Tocolysis (e.g., Nifedipine): If < 34 weeks, to delay for Antenatal Corticosteroids (ACS).
  • ACS (Betamethasone 12mg IM x 2 doses, 24h apart): 24-34 weeks (up to 36+6 if high risk) for fetal lung maturity. 📌 BAM for Lungs.
  • $MgSO_4$: Neuroprotection if < 32 weeks.
• Intrauterine Growth Restriction (IUGR)/SGA: Estimated Fetal Weight (EFW) < 10th percentile.
  • Monitor: Serial USG, Doppler (Umbilical Artery - UA, Middle Cerebral Artery - MCA).
  • Delivery: Timed by Doppler severity (e.g., UA absent/reversed end-diastolic flow).

⭐ $MgSO_4$ for fetal neuroprotection in preterm birth < 32 weeks significantly reduces cerebral palsy risk.

High‑Yield Points - ⚡ Biggest Takeaways

• Antenatal corticosteroids (e.g., Betamethasone) for fetal lung maturity (24-34 weeks) in threatened preterm labor.
• Magnesium sulfate (MgSO4) for fetal neuroprotection (<32 weeks) and eclampsia seizure control/prophylaxis.
• DIPSI criteria (single 75g OGTT) for GDM screening is widely used in India.
• Safe pregnancy antihypertensives: Labetalol, Nifedipine, Methyldopa.
• AMTSL with Oxytocin prevents PPH; manage active PPH with multiple uterotonics.
• Anti-D immunoglobulin at 28 weeks & post-delivery for Rh-negative mothers with Rh-positive infants.