High-risk pregnancy refers to a pregnancy complicated by one or more maternal, fetal, or obstetric conditions that increase the likelihood of adverse outcomes for the mother, fetus, or both [1]. Despite advances in obstetric care, high-risk pregnancies continue to pose a major public health challenge, particularly in developing countries. In India, approximately one-fifth to one-third of pregnancies are categorized as high risk and account for nearly three-quarters of perinatal morbidity and mortality [1,2].

The burden of high-risk pregnancy is influenced by multiple biological, socioeconomic, and healthcare-related factors. Maternal age extremes, multiparity, poor nutritional status, low socioeconomic conditions, chronic medical disorders, previous adverse obstetric events, and inadequate antenatal care contribute significantly to adverse pregnancy outcomes [3–6]. Conditions such as anemia, hypertensive disorders of pregnancy, gestational diabetes mellitus, thyroid dysfunction, seizure disorders, placenta previa, and abruptio placentae remain important contributors to maternal and neonatal complications [7–10].

Maternal complications associated with high-risk pregnancies include preeclampsia, eclampsia, postpartum hemorrhage, cesarean delivery, intensive care admission, and maternal mortality. Fetal consequences include preterm birth, low birth weight, intrauterine growth restriction, neonatal intensive care unit (NICU) admission, congenital anomalies, respiratory distress, septicemia, and perinatal death [11–14]. These complications impose substantial clinical and economic burdens on healthcare systems and families.

Several studies have demonstrated that early risk identification and structured antenatal surveillance can significantly improve maternal and neonatal outcomes. Government initiatives such as the Pradhan Mantri Surakshit Matritva Abhiyan emphasize systematic screening and referral of high-risk pregnancies to improve pregnancy outcomes [15]. However, despite these efforts, a considerable proportion of women continue to present late in pregnancy or remain inadequately monitored.

Although studies from different regions have reported varying prevalence and outcomes of high-risk pregnancies, regional data from Telangana remain limited. Understanding the local spectrum of risk factors and associated outcomes is essential for optimizing resource allocation, strengthening referral systems, and improving evidence-based obstetric care.

Therefore, the present study was undertaken to evaluate the maternal and fetal outcomes of high-risk pregnancies managed at a tertiary care teaching hospital in Warangal and to compare outcomes between booked and unbooked/referred pregnancies

Study Design and Setting This prospective observational study was conducted in the Department of Obstetrics and Gynaecology at CKM Government Maternity Hospital, Warangal, Telangana, India. Study Duration The study was carried out over a period of two years from September 2022 to August 2024. Study Population and Sample Size A total of 250 pregnant women with identified high-risk factors were included in the study. Inclusion Criteria 1. Pregnant women with medical or obstetric risk factors. 2. Booked, unbooked, and referred antenatal cases. 3. Women willing to participate and provide informed consent. Exclusion Criteria 1. Postpartum women. 2. Antenatal women without identifiable risk factors. 3. Women who declined participation METHODOLOGY Eligible participants were enrolled consecutively after obtaining informed consent. Detailed demographic information, present obstetric history, previous obstetric history, and relevant medical history were recorded. A comprehensive clinical examination was performed, including assessment of height, weight, anemia, edema, icterus, and vital signs. Obstetric examination included determination of gestational age, fetal presentation, fetal position, and fetal heart rate assessment. Ultrasonography was performed to confirm obstetric findings whenever required. Baseline investigations and specific investigations for medical complications were undertaken according to clinical indications. Outcome Measures Primary outcome measures included maternal outcome, fetal outcome, mode of delivery, NICU admission, APGAR scores, neonatal growth status, and perinatal morbidity and mortality. Statistical Analysis Data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) version 23.0. Continuous variables were summarized as mean and standard deviation, whereas categorical variables were expressed as frequencies and percentages. Chi-square tests were used for categorical variables and unpaired t-tests for continuous variables. A p-value of less than 0.05 was considered statistically significant.

A total of 250 pregnant women with identified high-risk factors were included in the study. Most participants were aged 21–30 years, multiparous, and from rural areas. Multiple obstetric and medical risk factors were identified, with anemia, thyroid disorders, and a history of medical or genetic disorders being the most common. Maternal and fetal outcomes demonstrated substantial morbidity, reflected by high rates of cesarean delivery and neonatal intensive care admission.

Demographic and Obstetric Characteristics

The majority of women belonged to the age group of 21–25 years (48.8%), followed by 26–30 years (38.4%). Multiparous women constituted 64.4% of the study population, while primigravidae accounted for 35.6%. Most participants were from rural areas (60.0%). Previous lower-segment cesarean section was noted in 31.6% of cases, highlighting the significant burden of repeat high-risk pregnancies within the study cohort.

Table 1. Baseline demographic and obstetric characteristics of study participants (n=250)

The findings indicate that high-risk pregnancies were predominantly observed among women in the reproductive age group of 21–30 years and among multiparous women. The predominance of rural residents emphasizes the importance of strengthening antenatal services and referral mechanisms in rural populations.

Distribution of Major Risk Factors

A wide spectrum of medical and obstetric risk factors was identified. The most common factors included a history of medical or genetic disorders (61.6%), anemia (51.6%), thyroid disorders (28.0%), hypothyroidism (24.8%), gestational hypertension (16.0%), seizure disorders (14.0%), structural disorders (14.4%), gestational diabetes mellitus (12.4%), and preeclampsia (11.2%).

Table 2. Major high-risk factors identified among study participants

The study population demonstrated a considerable burden of both medical and obstetric disorders. Nutritional deficiencies, endocrine disorders, and pre-existing medical illnesses represented the most frequent contributors to high-risk pregnancy status.

Mode of Delivery and Malpresentation

Malpresentation was observed in 20.0% of pregnancies. Cesarean delivery was the predominant mode of delivery and was performed in 62.8% of women, whereas 37.2% delivered vaginally.

Table 3. Malpresentation and mode of delivery

The high cesarean section rate observed in this study reflects the complexity of high-risk pregnancies managed at a tertiary referral center. The presence of malpresentation and associated obstetric complications likely contributed to the increased operative delivery rate.

Neonatal Growth and APGAR Status

Assessment of neonatal growth and immediate neonatal condition demonstrated a substantial burden of fetal compromise. The majority of newborns were appropriate for gestational age, although a significant proportion were small for gestational age. APGAR scores improved considerably between the first and fifth minute after birth.

Table 4. Neonatal growth status and APGAR score distribution

A notable proportion of neonates exhibited growth restriction and low initial APGAR scores, reflecting the adverse intrauterine environment associated with high-risk pregnancies. Improvement in APGAR scores at five minutes indicated successful neonatal resuscitative and supportive interventions.

NICU Admission and Fetal Outcome

Neonatal morbidity remained substantial among high-risk pregnancies. NICU admission was required in a large proportion of newborns. Although most neonates survived, adverse fetal outcomes were documented in a significant minority of cases.

Table 5. NICU admission and fetal outcome

More than two-thirds of neonates required intensive neonatal care, highlighting the substantial burden placed on neonatal services by high-risk pregnancies. Despite this, the majority of pregnancies resulted in favorable fetal outcomes following tertiary-level management.

Maternal Outcomes

Maternal morbidity was common among women with high-risk pregnancies. While most women recovered without major complications, significant maternal adverse outcomes were observed.

Table 6. Maternal outcome among study participants

Maternal complications occurred across multiple high-risk categories. Although most women experienced favorable outcomes, the occurrence of severe maternal morbidity and mortality emphasizes the need for early identification, close surveillance, and timely referral of high-risk pregnancies.

Summary of Key Findings

• Women aged 21–30 years constituted 87.2% of the study population.
• Multiparity was present in 64.4% of cases.
• The most common risk factors were history of medical/genetic disorders (61.6%), anemia (51.6%), thyroid disorders (28.0%), and hypothyroidism (24.8%).
• Cesarean delivery was performed in 62.8% of pregnancies.
• NICU admission was required in 71.4% of neonates.
• Poor fetal outcome occurred in approximately one-fifth of pregnancies.
• Significant maternal and neonatal morbidity persisted despite tertiary-level care

The present prospective observational study evaluated maternal and fetal outcomes among 250 women with high-risk pregnancies managed at a tertiary care referral center in Telangana. The study demonstrated a substantial burden of maternal and neonatal morbidity, with anemia, medical/genetic disorders, thyroid dysfunction, gestational hypertension, and gestational diabetes mellitus emerging as the predominant risk factors. The findings emphasize the importance of early identification, regular antenatal surveillance, and timely referral in improving pregnancy outcomes [11-13].

The majority of women in the present study belonged to the age group of 21–30 years (87.2%). Similar observations were reported by Kulshreshtha et al., where the mean maternal age was 24.7 years and most high-risk pregnancies occurred among women in the reproductive age group [1]. Bhandari et al. also reported that high-risk pregnancies were most frequently observed among women aged 20–30 years [2]. This age distribution likely reflects the reproductive demographics of the population rather than age itself being the primary determinant of risk [14,15].

Multiparous women constituted 64.4% of the study population. Increased parity has long been associated with complications such as anemia, hypertensive disorders, placenta previa, postpartum hemorrhage, and cesarean delivery. Similar findings were reported by Kuppusamy et al., who observed that repeated pregnancies and short interpregnancy intervals contributed substantially to the burden of high-risk pregnancies in India [3]. Multiparity may also explain the high prevalence of previous cesarean section observed in the present study.

Rural women accounted for 60% of participants. This observation is consistent with reports by Kulshreshtha et al. and Bagayoko et al., who noted a predominance of rural women among high-risk pregnancy cohorts [1,4]. Rural populations often face barriers including delayed healthcare access, inadequate transportation, lower educational attainment, and reduced awareness regarding antenatal services, which may contribute to adverse pregnancy outcomes [16-18].

One of the most notable findings of the present study was the high prevalence of anemia (51.6%). Maternal anemia remains one of the most important public health challenges in developing countries. Iron deficiency and nutritional inadequacies continue to affect a substantial proportion of pregnant women despite ongoing supplementation programs. Anemia has been associated with preterm birth, low birth weight, intrauterine growth restriction, postpartum hemorrhage, and increased maternal mortality. Similar findings have been reported across multiple Indian studies evaluating high-risk pregnancies [3,5].

The present study also demonstrated a significant burden of thyroid disorders (28%) and hypothyroidism (24.8%). Mogan et al. reported hypothyroidism as the most common risk factor among high-risk pregnancies, accounting for 43.7% of cases [6]. Thyroid dysfunction during pregnancy has been linked to miscarriage, hypertensive disorders, preterm birth, low birth weight, and impaired neurodevelopmental outcomes in offspring. These findings reinforce the importance of routine antenatal screening for thyroid disorders, particularly in populations with a high prevalence of endocrine abnormalities [17-20].

Gestational hypertension (16%), preeclampsia (11.2%), and eclampsia (4.8%) were important contributors to maternal risk in the current study. Hypertensive disorders remain among the leading causes of maternal and perinatal mortality globally. Shrestha et al. demonstrated significantly higher maternal and neonatal complications among women with severe hypertensive disorders of pregnancy [7]. Similarly, Zhu et al. identified pregnancy-related complications, including hypertensive disorders, as major determinants of adverse perinatal outcomes [8]. Early diagnosis and aggressive management remain essential to reducing associated morbidity.

Gestational diabetes mellitus was present in 12.4% of participants. This prevalence is comparable to that reported by Bhandari et al., who identified gestational diabetes among the leading contributors to high-risk pregnancy [2]. Poor glycemic control during pregnancy has been associated with fetal macrosomia, neonatal hypoglycemia, congenital anomalies, operative delivery, and long-term metabolic complications in offspring. The increasing prevalence of gestational diabetes reflects changing lifestyle patterns and rising maternal obesity rates.

A previous cesarean section was observed in 31.6% of participants. This finding mirrors the observations of Kulshreshtha et al. and Bhandari et al., who identified previous cesarean delivery as one of the most common high-risk factors [1,2]. The rising global cesarean section rate has created a growing population of women at risk for complications including placenta previa, placenta accreta spectrum disorders, uterine rupture, and repeat operative deliveries.

The present study demonstrated a cesarean section rate of 62.8%, substantially higher than that expected in the general obstetric population. Similar rates have been reported among high-risk pregnancy cohorts, where operative delivery is often required because of fetal distress, hypertensive disorders, previous cesarean section, malpresentation, or maternal medical complications [1,7]. The high cesarean section rate observed in this study reflects the complexity of cases managed at a tertiary referral institution.

Malpresentation was identified in 20% of pregnancies. Abnormal fetal presentation frequently necessitates operative delivery and contributes to maternal and neonatal complications. Multiple risk factors present in high-risk pregnancies, including prematurity, polyhydramnios, uterine abnormalities, and placenta previa, may contribute to increased rates of malpresentation.

A major finding of the present study was the high NICU admission rate of 71.4%. This observation indicates a substantial burden of neonatal morbidity among infants born to mothers with high-risk pregnancies. Shrestha et al. reported significantly increased neonatal intensive care requirements among high-risk pregnancies, particularly among extremely high-risk groups [7]. Similarly, Vaghela et al. demonstrated poorer neonatal outcomes, including low Apgar scores and increased neonatal complications, among high-risk pregnancies compared with low-risk pregnancies [9].

The study also demonstrated that approximately one-fifth of pregnancies resulted in poor fetal outcomes. Adverse fetal outcomes may arise through multiple mechanisms including placental insufficiency, maternal anemia, hypertensive disorders, endocrine abnormalities, infections, and prematurity. Zhu et al. identified congenital anomalies, multiple pregnancy, low Apgar scores, and obstetric complications as major predictors of adverse perinatal outcomes [8]. These findings highlight the multifactorial nature of fetal compromise in high-risk pregnancies.

Maternal complications were also observed in the present study, including severe morbidity and maternal mortality. Bagayoko et al. demonstrated that women identified as high risk during antenatal care had significantly greater odds of complications during both pregnancy and delivery compared with low-risk women [4]. Early risk stratification and close monitoring therefore remain fundamental components of obstetric care.

The present study has important clinical implications. First, it highlights the substantial prevalence of preventable and manageable conditions such as anemia, thyroid disorders, and gestational hypertension. Second, it demonstrates the critical role of antenatal booking and regular follow-up in reducing adverse outcomes. Third, it reinforces the need for strengthening referral systems to ensure timely access to comprehensive obstetric and neonatal services.

A major strength of this study is its prospective design and inclusion of a broad spectrum of medical and obstetric risk factors encountered in routine clinical practice. However, being a single-center study, the findings may not be generalizable to all populations. Additionally, long-term neonatal follow-up was not performed.

Overall, the findings support the continued expansion of structured antenatal screening programs, early identification of high-risk pregnancies, multidisciplinary management, and timely referral pathways to improve maternal and neonatal outcomes,

High-risk pregnancies continue to represent a major challenge in obstetric practice because of their association with significant maternal and neonatal morbidity. In the present study, anemia, medical and genetic disorders, thyroid dysfunction, gestational hypertension, and gestational diabetes mellitus were the most frequently identified risk factors. A high proportion of women required cesarean delivery, and neonatal intensive care admission was common, indicating substantial fetal compromise.

The findings demonstrate that adverse maternal and fetal outcomes remain prevalent despite management at a tertiary care center. Early risk identification, comprehensive antenatal surveillance, appropriate referral mechanisms, and timely obstetric intervention are essential to improving outcomes. Strengthening antenatal care services, particularly in rural populations, may contribute significantly to reducing maternal and perinatal morbidity and mortality. Focused management of modifiable risk factors such as anemia and endocrine disorders should be prioritized within maternal healthcare programs.

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