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High Risk Pregnancy
Chapter 26
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Learning Objectives (1 of 2)
 Explore biophysical, psychosocial,
sociodemographic, and environmental influences on
high-risk pregnancy.
 Examine risk factors identified through history,
physical examination, and diagnostic techniques.
 Differentiate among screening and diagnostic
techniques, including when they are used in
pregnancy and for what purposes.
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Learning Objectives (2 of 2)
 Discuss psychologic considerations for the woman
and her family experiencing a high-risk pregnancy.
 Develop a teaching plan to explain screening and
diagnostic techniques and implications of findings to
women and their families.
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Assessment of Risk Factors
(1 of 4)
 A comprehensive approach to high-risk pregnancy
is used now
 Requires the efforts of an interprofessional health
care team
 The factors associated with high-risk childbearing
are grouped into broad categories based on threats
to health and pregnancy outcomes
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Assessment of Risk Factors
(2 of 4)
 Biophysical
 Originates with the mother or the fetus
 May affect development and functioning of both
 Genetic disorders, nutritional and general health status,
and medical or obstetric-related illnesses
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Assessment of Risk Factors
(3 of 4)
 Psychosocial
 Maternal behaviors and adverse lifestyles that have a
negative effect on health of mother or fetus
 May include emotional distress and disturbed
interpersonal relationships
 Inadequate social support
 Unsafe cultural practices
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Assessment of Risk Factors
(4 of 4)
 Sociodemographic
 Arise from mother and her family
 Lack of prenatal care, low income, marital status, and
ethnicity
 Environmental

Hazards in workplace and woman’s general
environment
 May include chemicals, anesthetic gases, and
radiation
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Antepartum Testing:
Biophysical Assessment (1 of 5)
 Daily fetal movement
count (DFMC)

Used to monitor fetus in
pregnancies complicated by
conditions that may affect
oxygenation

Also called kick counts

Several different protocols
are used for counting

A count of fewer than three
kicks in 1 hour warrants
further evaluation by a
nonstress test (NST)

Fetal alarm signal
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Antepartum Testing:
Biophysical Assessment (2 of 5)

Ultrasonography

Considered by many to be the
most valuable diagnostic tool
used in obstetrics

Abdominal versus Transvaginal
Ultrasounds

Levels of Ultrasonography


Standard (basic)

Limited

Specialized (targeted)
Indications for use

Fetal heart activity

Gestational age

Fetal growth

Fetal anatomy
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Antepartum Testing:
Biophysical Assessment (3 of 5)
 Ultrasonography: Indications for use

Fetal genetic disorders and physical anomalies

Nuchal translucency (NT) screening

Placental position and function

Adjunct to other invasive tests

Amniocentesis risks are reduced with use of ultrasound
 Fetal well-being

Doppler blood flow analysis

Amniotic fluid volume

Biophysical profile (BPP)

Modified biophysical profile
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Antepartum Testing:
Biophysical Assessment (4 of 5)
 Ultrasonography
 Nursing role

Primarily counseling and educating women about
procedure
 Nonmedical ultrasounds

3-D and 4-D increasingly popular with pregnant women
and their families

American Institute of Ultrasound in Medicine (AIUM) and
the American College of Obstetricians and Gynecologists
(ACOG) have published statements that strongly
discourage this practice

Exposure of the fetus to high-frequency soundwaves
without a clear medical indication

Often performed by people who are not qualified health
care professionals
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Antepartum Testing:
Biophysical Assessment (5 of 5)
 Magnetic resonance imaging (MRI)
 Noninvasive radiologic technique
 Examiner can evaluate the following:

Fetal structure, overall growth

Placenta

Quantity of amniotic fluid

Maternal structures

Biochemical status of tissues and organs

Soft-tissue, metabolic, or functional anomalies
 MRI has little effect on the fetus
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Antepartum Testing:
Biochemical Assessment (1 of 6)
 Biochemical assessment involves biologic examination
and chemical determinations

Procedures used to obtain the needed specimens include
amniocentesis, percutaneous umbilical blood sampling,
chorionic villus sampling, and maternal sampling
 Amniocentesis: obtains amniotic fluid

Potential complications

Indications for use

Genetic concerns

Fetal maturity

Fetal hemolytic disease
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Antepartum Testing:
Biochemical Assessment (2 of 6)
 Chorionic villus sampling (CVS)
 Technique for genetic studies in 1st trimester
 Earlier diagnosis, rapid results
 Performed between 10 and 13 weeks of gestation
 Involves removal of small tissue specimen from fetal portion of
placenta
 Transcervically or transabdominally
 CVS is a relatively safe procedure
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Antepartum Testing:
Biochemical Assessment (3 of 6)
 Percutaneous umbilical blood sampling (PUBS)
(also
called cordocentesis or funipuncture)

Direct access to the fetal circulation during the second
and third trimesters

Most widely used method for fetal blood sampling and
transfusion

Insertion of needle directly into fetal umbilical vessel under
ultrasound guidance

Bleeding from the cord puncture site is the most common
complication of the procedure.

Transient fetal bradycardia can also occur
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Antepartum Testing:
Biochemical Assessment (4 of 6)
 Maternal assays
 Maternal serum alpha-fetoprotein (MSAFP)

Maternal serum levels used as screening tool for neural
tube defects (NTDs) in pregnancy

Detects 80% to 85% of all open NTDs and open
abdominal wall defects early in pregnancy

Screening recommended for all pregnant women

Triple- and quad-screening to detect autosomal trisomies
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Antepartum Testing:
Biochemical Assessment (5 of 6)
 Maternal assays
 Multiple marker screens

Screening to detect fetal chromosomal abnormalities,
particularly trisomy 21

Quad test: the only widely used multiple marker test in the
United States, to screen for fetuses with trisomy 21 and
trisomy 18

Measures the levels of four maternal serum markers: MSAFP,
unconjugated estriol, hCG, and inhibin
 Coombs’ test

Screening tool for Rh incompatibility

Detects other antibodies that may place fetus at risk for
incompatibility with maternal antigens
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Antepartum Testing:
Biochemical Assessment (6 of 6)
 Maternal assays
 Cell-free DNA screening in maternal blood

Example of Noninvasive prenatal testing (NIPT)

Provides definitive diagnosis noninvasively for fetal Rh
status, fetal gender, and certain paternally transmitted
single gene disorders

Optimally performed at 10 to 12 weeks of gestation

The test is less sensitive in women who are obese
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Fetal Care Centers
 Fetal care centers have evolved in response to the
need to provide diagnostic and therapeutic options
as well as support services for families with a fetal
anomaly diagnosis
 Access to support services such as genetic
counseling, social work, chaplain services, a
palliative care team, and ethics consultation
because of the complex emotional stressors they
face
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Antepartum Assessment Using Electronic
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Fetal Monitoring (1 of 4)
 Indications
 The goal is to determine whether the intrauterine environment continues
to support the fetus
 Nonstress Test (NST)
 Procedure
 Interpretation: Reactive (normal) or nonreactive (requires further
evaluation)
 Vibroacoustic Stimulation (VAS)
 Contraction Stress Test (CST)
 Procedure

Nipple-stimulated contraction test

Oxytocin-stimulated contraction test
Negative (desired result) or Positive (late FHR
decelerations are present)
 Interpretation:
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Psychologic Considerations
Related to High-Risk Pregnancy
 Label of high risk often increases the patient’s
sense of vulnerability
 May exhibit anxiety, low self-esteem, guilt,
frustration, and inability to function
 May affect parental attachment, accomplishment of
the tasks of pregnancy, and family adaptation to the
pregnancy
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The Nurse’s Role in
Assessment and Management of the
High Risk Pregnancy
 Provide education
 Anticipatory planning
 Counseling for family adaptation
 Support person
 In many settings nurses perform the following:
 Nonstress Tests (NST’s)
 Contraction Stress Tests (CST’s)
 Biophysical Profiles (BPP’s)
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Key Points (1 of 3)
 A high-risk pregnancy is one in which the life or
well-being of the mother or infant is jeopardized by
a biophysical or psychosocial disorder coincidental
with or unique to pregnancy.
 Biophysical, sociodemographic, psychosocial, and
environmental factors place the pregnancy and
fetus or neonate at risk.
 Biophysical assessment techniques include DFMCs,
ultrasonography, and MRI.
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Key Points (2 of 3)
 Biochemical monitoring techniques include
amniocentesis, PUBS, CVS, MSAFP, multiple
marker screens, and cell-free DNA screening in
maternal blood.
 Fetal care centers have evolved in response to the
need to provide diagnostic and therapeutic options
as well as care coordination and other support
services for families with a fetal anomaly diagnosis.
 Reactive NSTs and negative CSTs suggest fetal
well-being.
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Key Points (3 of 3)
 Most assessment tests have some degree of risk
for the mother and fetus and usually cause some
anxiety for the woman and her family.
 The nurse’s roles in assessment and management
of the high-risk pregnancy are primarily those of
educator and support person.
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Question
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A prenatal screening technique called nuchal translucency (NT) uses
ultrasound measurement of fluid at the nape of the neck between 14
and 16 weeks to identify possible fetal abnormalities. An elevated NT
of greater than 3 mm indicates an increased risk of which of the
following?
a. Trisomy 13
b. Fetal cardiac disease
c. Trisomy 18
d. Trisomy 21
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Answer
B. Fetal cardiac disease
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