Correct Answer: A. Previous manual removal of placenta
Manual removal of placenta (MRP) is an obstetric procedure performed when the placenta does not separate spontaneously within 30 minutes of delivery of the baby. While MRP itself carries maternal morbidity (infection, uterine perforation, hemorrhage), it is a management intervention for retained placenta, not a risk factor for future pregnancies. The procedure does not inherently increase the risk of adverse outcomes in subsequent pregnancies unless it resulted in significant uterine damage (perforation, curettage-related Asherman's syndrome). In contrast, obesity, polyhydramnios, and anemia are well-established antepartum risk factors that increase maternal and fetal morbidity/mortality in the current pregnancy. Per Indian guidelines (ICMR, FOGSI) and Harrison's Obstetrics, high-risk pregnancy classification includes maternal factors (obesity, anemia), fetal factors (polyhydramnios), and placental factors—but not prior procedural history unless it caused permanent structural damage. MRP is a management outcome, not a risk factor for future pregnancy classification.
Why the other options are wrong
B. Obesity — Obesity (BMI ≥30 kg/m²) is a major modifiable risk factor for high-risk pregnancy in India. It increases gestational diabetes, preeclampsia, thromboembolism, and operative delivery risk. FOGSI and ICMR guidelines explicitly classify obesity as a high-risk factor requiring intensive antenatal monitoring and lifestyle intervention. C. Polyhydramnios — Polyhydramnios (AFI >25 cm or deepest pocket >10 cm) is a fetal/placental factor causing high-risk pregnancy. It increases preterm labor, cord prolapse, fetal anomalies, and maternal respiratory compromise. Per DC Dutta and Harrison, it mandates increased surveillance and delivery planning. D. Anaemia — Anemia in pregnancy (Hb <11 g/dL in 2nd/3rd trimester) is a maternal risk factor increasing preterm labor, IUGR, and peripartum hemorrhage complications. Indian prevalence is high (>50% in rural areas); RNTCP guidelines recommend iron supplementation and monitoring as standard high-risk care.
High-Yield Facts
- Manual removal of placenta is a management procedure for retained placenta, not a risk factor for future pregnancy classification.
- Obesity (BMI ≥30) increases gestational diabetes, preeclampsia, and operative delivery—classified as high-risk in FOGSI guidelines.
- Polyhydramnios (AFI >25 cm) increases preterm labor, cord prolapse, and fetal anomalies—a fetal/placental high-risk factor.
- Anemia (Hb <11 g/dL) increases preterm labor, IUGR, and hemorrhage risk—high-risk factor in Indian obstetrics.
- High-risk pregnancy classification includes maternal factors (age, obesity, anemia), fetal factors (polyhydramnios, IUGR), and placental factors—not prior procedures unless they caused permanent damage.
Mnemonics
HIGH-RISK PREGNANCY (Maternal/Fetal/Placental factors) Maternal (obesity, anemia, age, HTN) | Fetal (polyhydramnios, IUGR, anomalies) | Placental (preeclampsia, abruption, previa). MRP is a procedure, not a risk factor. REMEMBER: Procedure ≠ Risk Factor MRP, forceps delivery, episiotomy are management interventions. Risk factors are pre-existing conditions or current pregnancy findings (obesity, anemia, polyhydramnios). This distinction is NBE's favorite trap.
NBE Trap
NBE pairs "manual removal of placenta" with other genuine risk factors to test whether students confuse management procedures (outcomes of complications) with risk factors (pre-existing or current pregnancy conditions). Students who have seen MRP complications may incorrectly classify it as a risk factor.
Clinical Pearl
In Indian antenatal clinics, the high-risk card (used in RNTCP and state programs) lists obesity, anemia, and polyhydramnios as screening criteria for referral to tertiary centers. Manual removal of placenta is documented as a complication managed in the previous delivery, not as a criterion for high-risk classification in the current pregnancy—unless it caused uterine perforation or scarring.
_Reference: DC Dutta's Textbook of Obstetrics (7th ed.) Ch. 3 "High-Risk Pregnancy"; Harrison's Obstetrics & Gynecology Ch. 1; FOGSI Guidelines on High-Risk Pregnancy Management_