IDENTIFYING HIGH RISK PREGNANCY AND ITS EFFECTIVENESS IN DETERMINING MATERNAL AND PERINATAL OUTCOME

1* 2 2 3 Junu Shrestha , Sangeeta Devi Gurung , Anjali Subedi , Chandani Pandey Introduc on Iden fica on of high risk pregnancy can be done by using various scoring systems which is highly predic ve in determining maternal and perinatal outcome.


INTRODUCTION
High risk pregnancy is defined as the one in which there is presence of maternal or fetal factor that affects the 1 pregnancy outcome -maternal or perinatal or both. High risk pregnancy cons tutes about 15 to 40 % of cases of [2][3][4][5][6][7][8] pregnancy based on different studies. Maternal complica ons have been reported to be increased in pregnancies 4,7,9 complicated by high risk factors. Likewise, perinatal outcome in terms of low birth weight, prematurity, birth asphyxia and perinatal deaths are also more in the high risk 4,5,7,9,10,11 women. Therefore, iden fica on of high risk pregnancy is prudent for improving the maternal and perinatal outcome. This could be made possible only through risk stra fica on of pregnant women during their antenatal care. Screening for risk factors can help in iden fying the vulnerable group of pregnant women at the earliest so that extra care and appropriate interven on be given to improve the maternal 12 and neonatal outcome. This can be especially useful for the antenatal care in the rural setup to make mely referrals of high risk pregnancies to ter ary centres. Objec vely defining high risk pregnancy by using scoring system can be useful for health care workers providing antenatal care especially in centres with limited resources. This can be true in country like ours. There are several systems for scoring of high risk pregnancy proposed by various authors. Nesbi et al, Coopland  are the different scoring system used in the past to score the high risk status of a woman [12][13][14][15] during pregnancy. Many other authors have modified 4,11,16 scoring system based on these systems. Nepal has made great leaps in maternal and perinatal health over two decades. 17,18 Nevertheless, in order to meet the aspiring SDG target of reducing the MMR to 70 per 100,000 live births and preventable deaths of newborns to less than 19 one percent by 2030, mul focal interven ons need to be made, one of which is quality antenatal care and iden fica on of high risk factors in pregnancy. Introducing a scoring system in antenatal care to iden fy high risk pregnancies seems to be a useful means to improve maternal and perinatal health. Hence, this study was conducted with the aim to determine the use of scoring system to iden fy high risk pregnancies and compare the maternal and perinatal outcome of high risk pregnancies with that of low risk pregnancies.

METHODOLOGY
This was a prospec ve cross-sec onal study that was conducted in the department of Obstetrics and Gynaecology, Manipal Teaching Hospital in Pokhara, Nepal. Study was conducted for a period of six months from 1st August 2020 to 31st January 2021a er obtaining ethical approval. Study par cipants were selected using convenient sampling technique. Those who met the inclusion criteria and consented to par cipate were included in the study. Pa ents who were lost to follow up were excluded. This study included the women presen ng at the me of delivery, which included booked as well as unbooked cases.

Inclusion criteria:
All women presen ng for delivery a er 28 weeks of gesta on Booked as well as unbooked pa ents All women willing to par cipate in the study

Exclusion criteria:
Pregnant women admi ed before 28 weeks of gesta on Sample size The sample size was calculated using the following formula for cross-sec onal study. 2 n =Z p (1-p) 2 d Where, n is the sample size, Z is the sta s c corresponding to level of confidence, P is expected prevalence and d is precision (corresponding to effect size). With es mated prevalence of about 25% high risk 3 pregnancy taken from some studies conducted in Nepal, Z = 1.96 at 95% level of confidence and 5% precision, minimum sample size was calculated to be 288. However, a total of 700 cases were enrolled in the study during the study period.

Ethical Considera on:
Informed consent was taken from all par cipants a er informing them about the nature of the study. Only those pregnant women willing to par cipate in the study were included. They were informed that they would have the right to withdraw from the study any me if they wished to do so. Privacy and confiden ality was maintained. Ethical approval was taken from the Ins tu onal Review Commi ee prior to conduc ng the study.

Data Collec on
Women presen ng for delivery a er 28 weeks of gesta on were included in the study. Detailed history was taken. Their state of booking and the level of antenatal supervision were noted. Detailed general, systemic and obstetric examina on was done. The risk scoring was done using modified 4 antenatal scoring system used by Anand B et al. Few other risk factors (mul ple pregnancy, post term pregnancy) that were missing were also added in this scoring system. The modified risk scoring system is given in table1. Pregnant women were grouped as low risk with score of less than 3, high risk if score was 4 to 6 and extremely high risk if score was ≥ 7. All the women were closely followed up during the intrapartum and postnatal period ll discharge. Mode of delivery, intrapartum and postpartum complica ons, amount of blood loss, number of days of hospital stay were the variables that were studied. For perinatal outcomebirth weight, Apgar score and need for neonatal admission and indica on for admission, early perinatal deaths were also studied.

Data analysis
All the data were noted in the proforma. Data entry was done in excel and all analysis were conducted using Stata/IC version 15.1 (StataCorp, College Sta on, Texas 77845 USA). Descrip ve analysis of prevalence of high risk pregnancy, socio demographic characteris cs, maternal outcomes and perinatal outcomes were done using percentage. For examining the associa on of con nuous variables with risk categories, t-test was used, and for examining the associa on of categorical variables with risk categories, either chi-square test or fisher's exact tests were used as required. The p-value less than 0.05 were considered to be sta s cally significant.

RESULTS
Using modified antenatal risk scoring system, amongst 700 women, 471 (67.3%) were low risk , 140 (20%) high risk and 89 (12.7%) were grouped as extremely high risk pregnancy. There was no risk factor in 216 (30.9%) pregnant women and had score zero. However, according to scoring system, they were grouped in low risk group. Common medical risk factors present were elderly gravida (7.4%), urinary tract infec on (3.9%) and hypothyroidism (5.3%). In terms of risk factors in rela on to past obstetric factors, history of previous cesarean sec on (20.6%) and previous abor on especially in first trimester (22%) were very prevalent in pregnant women in this study. The obstetric risk factors of present pregnancy that were common were hypertensive disorders of pregnancy (15.4%), oligohydramnios (9.7%), Preterm labour and preterm prelabour rupture of membranes (8.1%), anemia (5.7%), malpresenta on at term (4.9%) and intrauterine growth restric ons (2.5%).

Table1: Modified High Risk Pregnancy Scoring System
Shrestha J et al

Socio-demographic Variables, Antenatal Care and their Associa on with High Risk Groups
The socio-demographic variables and antenatal care of the par cipants are presented in table 2. Majority of the par cipa ons belonged to Brahmin and Chhetri ethnic group. Educa onal status of most of them was upto secondary level in all three groups. Almost three quarters of the women were housewives in low and high risk group and about two third of them in extremely high risk group. Likewise, most of the women came from urban areas in all three groups of women. The difference in the sociodemographic variables in the different risk groups was not sta s cally significant. While analyzing the antenatal supervision of these pa ents, it was found all the women had antenatal care even though the number of visits was less than four. Most of the women in all groups had been booked outside. Only, about one-third of the par cipants were booked at our centre in all three groups. Considering the number of visits, it was found that more than half of the par cipants had four or more antenatal visits and this was true for all three groups.

Maternal Outcome in Pregnant Women belonging to Different High Risk Groups
The maternal outcome of the pregnant women belonging to different high risk groups are presented in table 3.
Majority of the women in extremely high risk and high risk pregnancy were delivered by cesarean sec on. Nearly 90% of women belonging to extremely high risk group and 78% belonging to high risk group delivered via cesarean sec on compared to 51% of low risk pregnancy being delivered by cesarean sec on. This difference was found to be sta s cally significant.
Overall, 5.3% of all par cipants developed complica ons following delivery. On comparing the maternal complica ons in different groups, it was found to be more in high risk (7.9%) and extremely high risk group (10.1%) compared to low risk group (3.6%). This difference was also found to sta s cally significant.
Blood loss during delivery was also significantly more in the extremely high risk pregnancy and high risk group compared to low risk group. However, the need for blood transfusion though more in the high risk groups; was not sta s cally significant.  Most common complica on developed by pa ents was postpartum haemorrhage (56.8%) followed by urinary complica ons (16.4%). Postpartum haemorrhage was the commonest complica on in all three groups. Other complica ons were puerperal pyrexia, rectus sheath haematoma, postpartum eclampsia etc. One pa ent in extremely high risk group developed postpartum haemorrhage which required peripartum hysterectomy.

Neonatal Outcome in Pregnant Women belonging to Different High Risk Groups
The neonatal outcome of the pregnant women belonging to different high risk groups are presented table 5. Since there were five set of twins, the total number of neonates summed 705. In extremely high risk pa ents, nearly 60% of babies were low birth weight (<2500 gms) with 9% babies weighing less than 1500gms. This was significantly high compared to only 15% and 24% neonates being low birth weight in low risk and high risk groups respec vely. Likewise, higher propor on of neonates in extremely high risk group had Apgar score at 1 and 5 minutes less than 7. This was also found to be sta s cally significant. Larger propor on of neonates(34.8%) in extremely high risk group required admission in the neonatal intensive care unit (NICU) compared to 9.2% in high risk and 4.5% in low risk group. Perinatal deaths (s llbirths and early neonatal deaths) were also significantly more in the extremely high risk group compared to low risk and high risk groups. The neonatal complica ons in different high risk pregnancy groups are presented in table 6.
Data are presented as mean (SD) for con nuous measures, and n (%) for categorical measures.  Data are presented as mean (SD) for con nuous measures, and n (%) for categorical measures.

The most common reason for admission in Neonatal
Intensive Care Unit (NICU) was prematurity followed by neonatal sepsis in the study popula on. Mostly prematurity was the common indica on for NICU admission in extremely high risk group (62.5%). Other indica ons were neonatal jaundice, low birth weight, meconium aspira on syndrome, birth asphyxia etc.

DISCUSSION
Iden fying high risk pregnancy can ensure appropriate and mely care to the women, which in turn ensures op mal maternal and perinatal outcome. This could be made possible using objec vely defined scoring systems. Review of studies done in different se ngs using different scoring systems has found good sensi vity of these systems in 20 predic ng perinatal outcome. many new diseases. Few risk factors like mul ple pregnancies which was not included in this scoring system was incorporated in our scoring. This system seemed the most appropriate in the present day obstetric prac ce and hence has been used in this study. In our study, 67.3% women belonged to low risk, 20% to high risk and 12.7% to extremely high risk group. This was almost same to finding of study conducted by Anand B et al, whose scoring system was used in our study. They have reported 64.3% women in low risk group, 24.2% in high risk and 11.5% 4 in extremely high risk group. Other studies conducted in 2,3,21 Nepal have reported prevalence of 15 to 25%. Studies using Du a and Das scoring system reported prevalence of high risk pregnancy to range from 20 to 30% and that of 9,10,22 moderate risk pregnancy to range from 15 to 33%. Other studies using various other scoring systems have a wide variance in 5,6,7,23,24 prevalence of high risk pregnancy-18 to 33%.
The variance in the prevalence is due to different criteria and tools used for stra fica on of pregnancy into high risk groups and due to different study popula on and study se ng. In our study, in about 30% of the pregnant women, there were no risk factors at all and were scored zero. However, based on the stra fica ons system used in this study, they belonged to low risk group ( score 0 to 3). Study conducted by Jain et al also found that 30% of women had no risk factors 24 at all. However, different studies have reported that 2 to 48% of pregnant women had no risk factors and scored 10,22,25 zero.
The difference could be due to different se ng in which the studies were conducted. On risk stra fica on, there were women, who had only one risk factor while others have mul ple risk factors. The common risk factors in our study were abor on (22%), previous cesarean sec on (20.6%), hypertensive disorders in pregnancy (15.4%), oligohydramnios (9.7%), anemia (5.7%), extreme age at pregnancy (7.4%), malpresenta on at term (4.9%), intrauterine growth restric on (2.5%). Bernard et al also reported abor on, previous cesarean sec on, anemia, hypertensive disorders, malpresenta on as their common risk factors during risk stra fica on of high 22 risk pregnancies. Similar were the risk factors in study 4 conducted by Anand B et al. Maternal age was the 7 commonest risk factor in another study. Previous cesarean sec on is a common obstetric event that can complicate pregnancy outcome. With increasing cesarean sec on rates worldwide, presence of this risk factor was very common in 2,5,22,25 many other studies including ours.
This has been one of many indica ons leading to increased cesarean sec on rate in any ins tute and same held true in ours as well. In terms of ethnicity, place of their residence, educa onal and occupa onal status, distribu on of women in low risk, high risk and extremely high risk appeared to be similar in this study. Bernard also reported no difference in different risk groups in terms of religion and socioeconomic status. 22 There are few other studies which have shown illiteracy and low socioeconomic status to be posi vely associated 6,25 with high risk factors. All women had antenatal care even though the number of visits was less than four. Majority of the women in all three groups had more than four antenatal visits. Most of them had been ge ng antenatal care in ter ary level care either at our centre or outside. A hospital based study similar to ours however reported that 77% in the high risk group were unbooked compared to 20% of the 9 low risk group. In this study, cesarean deliveries were significantly more in high risk (77.9%) and extremely high risk pregnancy ( 89.9%) compared to low risk pregnancy (51%) with p-value <0.001. Opera ve deliveries were significantly common in high risk 4,5,7,9 pregnancy groups in other studies as well.
Cesarean sec on rate in high risk pregnancies ranged from 68% to 4,5,9 82% as shown in our study. High overall cesarean sec on in our study is high because almost 35% women belonged to high risk groups and cesarean sec on in both these high risk groups were very high ( 77.9% and 89.9%). Maternal complica ons were also sta s cally significant in extremely high risk and high risk groups compared to low risk groups in our study. About ten percent of extremely high risk pregnancy and 7.9% of high risk group developed complica ons. Postpartum haemorrhage and urinary complica ons were the common complica ons. Severe complica ons like Postpartum hemorrhage requiring peripartum hysterectomy, morbidly adherent placenta were seen in extremely high risk pregnancy and two cases of rectus sheath haematoma developed in high risk pregnancy. Obstetric haemorrhage requiring blood transfusion was more common in high risk pregnancies in another study as in our was more in extremely high risk pregnancy and high risk pregnancy compared to low risk pregnancy. This was sta s cally significant. Similar finding was reported by 4 Anand B et al. Perinatal outcome in terms of low birth weight, Apgar score less than 7 at 1 and 5 minutes and need for NICU admission and perinatal deaths were analyzed. The perinatal outcome was poor in high risk pregnancies compared to low risk pregnancy. Birth weight of newborns below 2500gm was more on extremely high risk (60%) compared to high risk (26%) and low risk pregnancy (15%). This was sta s cally significant. Other studies on perinatal outcome of the high risk pregnancy also showed significantly higher percentage of neonates with birth weight below 2500 gms in high risk 4,5,7,9,10 pregnancies.
Apgar score below 7 at 1 and 5 minutes was more common in extremely high risk pregnancy compared to high risk and low risk pregnancies in our study; 4,10,23 similar to findings of the other studies.
Prematurity was not analyzed as it was one of the risk factors used in the scoring system. Prematurity was reported to be more 4,7,10,23 common in high risk pregnancy in various studies. One third of the neonates required NICU admission in the extremely high risk group compared to 9.2% and 4.5% neonates in high risk and low risk pregnancy respec vely. Commonest indica on for admission was prematurity especially in extremely high risk and high risk groups-62.5% and 30.8% respec vely compared to 4.8 percent in low risk group. Neonatal sepsis was more common in the low risk and high risk groups. Birth asphyxia was only present in 14.3% of low risk and 7.7% high risk pregnancy in contrary to findings 9 of study done by Kolluru et al. NICU admission was found to be 4 significantly more for high risk pregnancies in another study. Perinatal deaths (s llbirths and early neonatal deaths) were significantly more in extremely high risk pregnancy compared to high risk and low risk groups. Similar results were seen in the other studies with increased perinatal 4,5,7,9,23,24 mortality in the high risk pregnancies.

CONCLUSION
Almost one-third of pregnant women were high risk pregnancies with previous abor ons and previous cesarean sec on, preterm labour being common risk factors during risk stra fica on. Maternal morbidity in terms of opera ve deliveries, maternal complica ons and hospital stay were increased in the high risk pregnancies. Likewise, neonatal outcome -low birth weight, low Apgar score at 1 and 5 minutes, need for NICU admission and perinatal mortality was increased in the high risk pregnancy compared to low risk pregnancy. Hence, antenatal risk scoring system seems to be useful in predic ng the women at risk of developing poor maternal and perinatal outcome.

RECOMMENDATIONS
Antenatal scoring is a risk assessment system that should be used during rou ne antenatal care to stra fy women into different risk groups. This will ensure that high risk women receive mely and appropriate care so that adverse pregnancy outcomes are prevented. U lizing this system, primary health care facili es with limited resources can make mely referrals while ter ary care centres can make different protocols for managing the risk factors to ensure be er outcome for mother and new born.

LIMITATIONS OF THE STUDY
This was a small study limited to ter ary care referral centre. Larger study integra ng both community as well as hospital se ngs will produce more meaningful result so that screening tool like this could be developed and recommended for countrywide use.