Know How to Avoid a High-Risk Pregnancy

During the past decade, there has been significant advancement in our understanding of the pathophysiology, diagnosis and management of several maternal and obstetric conditions collectively wrapped up and leading to the term “high-risk pregnancy.” Such conditions can adversely affect maternal and perinatal outcomes.

What Is a High-Risk Pregnancy?

While all pregnancy carries a certain risk to both mother and her baby, some pregnancies have more than the average risk for complications. It is important to understand that there are factors that can be present before a woman becomes pregnant that can result in high-risk pregnancy. And there are some preexisting heath conditions that can predispose a pregnant woman to be high risk.

Therefore, before a woman becomes pregnant, it is crucial for her to have good nutrition, to live within the parameters of a healthy lifestyle, and to undergo good prenatal care—all of which will help identify women in the high-risk category, so that proper counseling and preventive treatment strategy by the obstetrician can help prevent complications during the period of pregnancy.

Some of the conditions that can predispose a pregnant woman to the high-risk category are:

• Young or old maternal age.
• Being overweight or underweight.
• Having problems in previous pregnancies such as:
  • Repeated pregnancy loss.
  • Gestational diabetes.
  • Pregnancy-induced hypertension.
  • Placental problems.
  • Preeclampsia or eclampsia.
  • Previous history of preterm births.
• Having preexisting health conditions, such as:
  • Chronic hypertension.
  • Heart disease.
  • Kidney problems.
  • Autoimmune problems.
  • Sexually transmitted diseases.
  • Type 1 diabetes.
  • Cancer.
• Having problems in the current pregnancy, such as:
  • Multiple gestation (twin or higher order pregnancies).
  • Current bout of preterm labor.
  • Pregnancy-induced hypertension.
  • Gestational diabetes.

Conditions Contributing to a High-Risk Pregnancy

High blood pressure in pregnancy. Hypertension complicates 5-8 percent of pregnancies and constitutes a major cause of maternal and perinatal morbidity and mortality. Although many pregnant women with high blood pressure have healthy babies without serious problems, high blood pressure can be dangerous for both the mother and the fetus.

Some women develop high blood pressure when they are pregnant, in what is often called as gestational hypertension or pregnancy-induced hypertension. Some women with preexisting or chronic high blood pressure are at greater risk for complications during pregnancy than those with normal blood pressure.

Potential fetal and neonatal complications associated with chronic hypertension include prematurity, intrauterine growth restriction and fetal death. Maternal complications include superimposed preeclampsia, placental abruption, cesarean delivery and potentially life threatening complications such as pulmonary edema, hypertensive encephalopathy, retinopathy, cerebral hemorrhage and acute renal failure.

Preeclampsia and eclampsia. Preeclampsia is a condition that typically starts after the 20th week of pregnancy. It includes high blood pressure, urinary protein and changes in blood levels of liver enzymes. The woman can have symptoms such as swelling in the face and hands, headache, blurred vision and abdominal pain. It can affect the mother’s kidneys, liver and brain.

When preeclampsia causes seizures, the condition is known as eclampsia. With treatment, many women will have healthy babies. If left untreated, this condition can be fatal for the mother and the baby and can lead to long-term health problems.

Some of the risk factors which can predispose pregnant women to have preeclampsia are:

• Women who have high blood pressure before becoming pregnant.
• Women who have had high blood pressure and preeclampsia in previous pregnancies.
• Women who are obese.
• Women younger than age 20 and older than 40 years of age.
• Women who are pregnant with more than one baby.
• Women with health conditions such as diabetes and kidney diseases.

Gestational diabetes (GDM). The incidence of GDM is about 5 percent of all pregnancies, which translates to about 200,000 cases a year in the U.S. The diagnosis will be made by the healthcare provider by testing most women who have average risk for GDM when they are between 24-28 weeks pregnant. In women with past history of GDM in previous pregnancies, a family history of diabetes or a history of pregestational DM, the provider may test (using an oral glucose challenge test) such women much earlier or as soon as they become pregnant.

Most women who have GDM will give birth to healthy babies, especially when they control their blood sugar well, eat a healthy diet, exercise and keep a healthy weight. Some of the potential risks to the newborn baby include macrosomia, where the baby’s body is larger than normal, potentially requiring a delivery by cesarean section. These newborns are at a higher risk for birth trauma. They are also at risk for developing hypoglycemia, hypocalcaemia (low levels of serum calcium levels leading to muscle twitching), hyperbilirubinemia (jaundice) and respiratory distress syndrome (difficulty in breathing because of lung surfactant deficiency). Mothers with poorly controlled diabetes, especially those with pregestational diabetes, have a higher risk of having fetal malformations and still births than do patients with mild GDM.

Preterm labor (PTL). PTL is the labor that begins before 37 weeks of pregnancy. Despite intense research efforts and technological advances, data demonstrate a steady rise in the preterm delivery rate in the U.S., from a preterm birthrate of 10.6 percent in 1990 to 13 percent in 2010.
Healthcare providers currently have no way of knowing which women will experience PTL or deliver their babies preterm. There are certain screening tools in place to help identify the pregnancy at risk for preterm delivery. These include a cervical examination, home uterine monitoring, screening for genital tract colonization or infection and vaginal secretions containing fetal fibronectin.

Approximately 70 percent of preterm births may be associated with clinical evidence of ruptured membranes or underlying maternal, obstetric or fetal conditions. These newborns who are born preterm face a number of health challenges such as: low birth weight, breathing problems such as respiratory distress syndrome because of underdeveloped lungs, greater risk for life-threatening infections, feeding problems, and developmental disabilities including cerebral palsy.

Perinatal infections. Any infection occurring during pregnancy has the potential to cause complications in the mother and the fetus. The two important routes for fetal infection are hematogenous—via the placenta—and ascending, via the vagina and cervix, the latter usually occurring intrapartum.

The effect of an infectious agent on fetal growth and development depends on, among other things, the type of organism, the infectious load, timing in gestation, and potential organ systems affected. Many different organisms have been implicated in causing fetal infection, such as cytomegalovirus, rubella, herpes simplex virus, varicella zoster, parvovirus, HIV, hepatitis B virus, group B streptococcus, Neisseria gonorrhea, Treponema pallidum, Toxoplasma gondii, bacterial vaginosis and trichomoniasis.

Autoimmune disorders. A number of disorders that involve circulating auto antibodies or deposition of immune complexes may have direct effects on pregnancy. These include the rheumatologic or connective tissue diseases and conditions associated with circulating antiphospholipid antibodies, the most important of these being systemic lupus ertyhematosus (SLE) and antiphospholipid syndrome (APS).

SLE is the most common connective tissue disorder seen among reproductive age women and clinically presents as joint involvement, skin manifestations and nephritis. Patients with SLE have a high incidence of fetal wastage such as spontaneous abortion, IUGR, preterm deliveries, still birth and perinatal deaths. Infants of mothers with SLE are at risk for the neonatal lupus syndrome. This constellation of findings consists of abnormalities in the heart and skin and occurs from transplacental passage of maternal antibodies. Circulating antiphospholipid and the APS are associated with clinical complications such as adverse pregnancy outcomes, autoimmune thrombocytopenia and thrombosis.

Maternal renal and cardiac disorders. Mild renal dysfunction has little, if any, effect on pregnancy outcome. However, adverse pregnancy events are well described in women with moderate to severe renal insufficiency. Maternal complications include anemia, vascular accidents, placental abruption, chronic hypertension, preeclampsia and perinatal complications such as IUGR, still birth, prematurity and midtrimester pregnancy loss.

Maternal cardiac disease may be accompanied by significant maternal and perinatal morbidity and mortality. Preconception counseling is critical in this group of patients. The added cardiovascular demands of pregnancy may be associated with cardiac deterioration in women with underlying cardiac diseases, putting them at high-risk for maternal mortality. Fetal risks include premature delivery, IUGR and still births.

How To Enhance a Healthy Pregnancy

It is highly recommended that a woman who is thinking about becoming pregnant see a healthcare provider to ensure that she is in good preconception health. There are certain important health related steps a woman can take to reduce the risk of certain problems during pregnancy.

Folic acid supplementation. The U.S. public health service recommends that woman of child bearing age get at least 400 micrograms of folic acid every day, through food or supplements. It is recommended by many healthcare providers to supplement the diet with folic acid for three months before getting pregnant and at least three months of pregnancy.

Immunizations. Women who are thinking about getting pregnant should be properly vaccinated for certain diseases that could harm a developing fetus, such as chicken pox and rubella.

Healthy behaviors. Maintaining a healthy weight and diet, getting regular physical activity and avoiding smoking, alcohol or drug use.
Starting prenatal care appointments early in pregnancy is important for both the mother and the baby. Prenatal care includes healthcare, along with education and counseling about how to handle different aspects of pregnancy. A healthcare provider may discuss many issues such as nutrition, physical activity, understanding the underlying maternal disease that one may have, including its effects on maternal health, fetal health and treatment strategies.

Managing Specific Maternal Diseases in Pregnancy

Hypertension in pregnancy. Even before becoming pregnant women should try to keep their blood pressure under control. Lifestyle changes such as limiting your salt intake, participating in regular exercise, losing weight and avoiding alcohol and drugs can be helpful. If one is on hypertensive medications, ask your doctor whether you should change the dose or keep it the same during pregnancy.

If preeclampsia develops, the healthcare provider may develop a plan to prolong the pregnancy to give the fetus more time to grow and mature. Conservative management may be attempted for women with eclampsia, and delivery, which remains the only definitive treatment, ultimately may be required. In cases managed conservatively, patients are hospitalized at bed rest with frequent clinical and lab assessments. Magnesium sulfate, an agent long recognized for its anticonvulsant effects, is often administered. Blood pressure control is achieved with use of agents such as labetalol, hydralizine or nifedipine.

Diabetes in pregnancy. Many women with gestational diabetes have healthy pregnancies and healthy babies. Each woman should have a specific plan designed just for her needs, but there are some general ways to stay healthy with gestational diabetes:

• Know your blood sugar and keep it under control. Have a plan worked with your provider and have the blood sugar tested at home.
• Eat a healthy diet, control carbohydrate intake and coordinate with your doctor to have the best diet for you. Have a basic understanding of the disease, which will help you to manage the disease effectively at home.
• Get regular, moderate physical activity, which can help to control the blood sugars better.
• Keep a healthy weight. It is important to track both your overall weight gain and weekly rate of gain.

In summary, it is important to keep daily records of your diet, physical activity and glucose level. This will help the healthcare provider plan a treatment strategy and make appropriate changes in the management regime. In spite of these measures, if glucose levels exceed standard recommendations, insulin or oral antiglycemic medication is administered with close monitoring.

Infection. Routine screening for various infections is recommended early in pregnancy. Additional testing for other sexually transmitted diseases, however, is left to the discretion of the practioner based on the patient’s history and physical examination. If a woman is sexually active, she can reduce the risk of acquiring STDs by practicing “safe sex,” which means using a condom for any type of sexual intercourse, knowing one’s partner and his STD status and health and having regular medical checkups, especially if a woman has more than one sexual partner.

In Summary

Many maternal conditions have relevance for a developing pregnancy. Counseling pregnant women with underlying medical disorders must encompass the effects of the illness on the pregnancy, the effects of the pregnancy on the condition, as well as potential complications of therapeutic interventions. There is much to be accomplished in perinatology in order to impact on the high rate of premature delivery and to improve the health of women before and during delivery.