Tuesday, September 21, 2021
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Understanding High-Risk Pregnancies

This is an INFORMATION page, authored by physician

Pregnancy usually goes smoothly for many women, but a small number of women experience serious complications that can impact the health of the mother, baby or both. In the Cayman Islands and elsewhere, medical professionals refer to these pregnancies as high-risk, because specialist care is needed to ensure optimal health and safety for both mother and baby.

Some women will know from the start that they are likely to be higher risk due to the presence of certain risk factors (see below), which helps them make sensible choices about whether they might need a dedicated high-risk pregnancy service. However, for some, risk is not apparent at the start and so understanding what a high-risk pregnancy is and what to do if issues emerge is part of ensuring yours and your baby’s safety.

Is a high-risk pregnancy preventable?

Many high-risk pregnancies are due to pre-existing medical conditions, although some risk factors can be managed with regular pre-natal care and living a healthy lifestyle. Good OBGYNs will assess your risk factors at your first ‘booking’ antenatal appointment, so you will have an early opportunity to discuss any concerns with your doctor, as well as make informed choices about the type of pregnancy service you may feel most comfortable with.

As it is possible to begin a normal pregnancy and develop conditions that put you into the high-risk category, each antenatal visit is in effect a repeat assessment of risk factors. Regardless of what causes your pregnancy to become high-risk, it is likely that problems may persist with both you and/or the baby during the pregnancy, birth process, or even after the delivery.

The problems can range from minor to life-threatening in severity for both the mother and the baby, with most requiring extra care and monitoring from your OBGYN, and many benefiting from closer monitoring and management by a qualified maternal-fetal medicine specialist, which we do have here in the Cayman Islands.

What are some risk factors for a high-risk pregnancy?

Here is a list of possible reasons that might lead to a high-risk pregnancy:

  • The age of the mother. Women who are younger than the age of 17 and older than the age of 35 are more likely to experience pregnancy complications than women between the ages of 17 and 35. Women who are over 40 years of age also have a higher risk of experiencing miscarriage and delivering a baby with genetic disorders. In Cayman, we have our fair share (or more) of pregnancies in women over 35 years of age.
  • Pre-existing medical conditions. Women living with health problems like high blood pressure, anaemia, blood problems like thalassemia and sickle cell disease or trait, asthma epilepsy, diabetes, heart or blood disorders, obesity, autoimmune disease like lupus or rheumatoid arthritis, kidney disease, thyroid disease, or chronic infections like HIV, Hepatitis B or C are at higher risk. Some sexually transmitted infections and mental health concerns like depression can also pose a risk to pregnancy.
  • Pregnancy complications. These medical conditions take place during pregnancy, even when a woman is healthy before becoming pregnant.

Pre-eclampsia is a condition unique to pregnancy where you have high blood pressure in conjunction with protein in your urine and edema (swelling of the skin). In some women with pre-eclampsia, liver or platelet abnormalities are present. Referral to a Maternal-Fetal Medicine Specialist may be important, depending on the severity of your disease or if you are preterm. The treatment of pre-eclampsia is delivery of the baby, so this is a condition that requires very close monitoring to balance maternal complications against the risks of delivering your baby early.

Gestational diabetes is another complication that develops during pregnancy, usually resolving after the delivery of the baby. If you have developed Gestational diabetes, your Maternal-Fetal Medicine Specialist will follow your baby’s growth and well-being, and manage your health with nutrition counseling, glucose monitoring and, possibly, medications.

  • Placental complications. Placenta previa is a condition in which the placenta covers the cervix. The condition can cause bleeding, especially if a woman has contractions. If the placenta still covers the cervix close to delivery, your doctor will schedule a cesarean section to reduce bleeding risks to the mother and baby.
  • Fetal problems.  These can be seen on ultrasound. Approximately 2% to 3% of all babies have a minor or major structural problem in development. Sometimes there may be a family history of fetal problems, but other times these problems are completely unexpected. If you are under the care of a Maternal-Fetal Medicine Specialist, they will monitor and test for these problems and discuss them with you, advising on the implications and care options.
  • Pregnancy history. Previous issues with miscarriage and/or a complicated genetic family history are also risk factors for a high-risk pregnancy. If a woman has had pre-eclampsia in the past or pregnancy-related hypertension, her pregnancy might also be considered high-risk. Past preterm births may also predict future early deliveries, and so coordination with a neonatologist may be important.
  • Multiple pregnancy. Pregnancies with twins or higher-order multiples have a greater risk of complications. Women with multiple pregnancies are more likely to develop pre-eclampsia or gestational diabetes or go into preterm labor. Twin pregnancies have a higher risk of fetal anomalies and growth problems, especially if they share a placenta. If you have a multiple pregnancy, your Maternal-Fetal Medicine specialist will closely monitor the pregnancy by performing additional ultrasounds. The maternal-fetal medicine specialist will recommend how and when your babies should be delivered and work closely with a qualified neonatologist due to the likelihood of a preterm delivery.
  • Lifestyle. Certain lifestyle choices are dangerous for pregnancy. For example, women who smoke, drink alcohol, and use illegal drugs are putting their pregnancies at risk.

The presence of some of these risk factors should inform your choices and approach to pregnancy to ensure a successful and safe pregnancy journey for you and your baby. We will discuss specialist maternal-fetal medicine support, neonatal care and more as we progress through this guide.

Role of Maternal-Fetal Medicine Specialist

After evaluating the circumstances of a high-risk pregnancy, in the presence of risk factors or concerns, you will likely be referred to a Specialist in Maternal-Fetal Medicine. This type of doctor has received special training in how to care for women with a high-risk pregnancy. It is a higher training than normal obstetric training and carries formal accreditation in modern health systems, as well as experience of working in high-risk specialist centers.

In addition, the Maternal-Fetal Medicine Specialist has extensive training in assessment and treatment of fetal problems.  In this case, the Maternal-Fetal Medicine Specialist will coordinate your care, as well as your baby’s care during pregnancy, with other doctors, nurses and other healthcare professionals, and at delivery with the help of a Neonatal care team to ensure the best possible outcome for both you and your baby. The goal is to improve the outcome of the patient’s current pregnancy, as well as lower her risks for complications in future pregnancies. Safe care typically involves a multidisciplinary approach and seamless coordination.

Should I see a Maternal-Fetal Medicine Specialist before pregnancy?

It can be beneficial to consult with a Maternal-Fetal Medicine specialist before pregnancy if you have one (or more) of the following:

Pre-existing medical condition: There are many pre-existing medical conditions that may need to be monitored in relation to pregnancy, e.g., Diabetes, lupus, Renal disease, Thyroid problems and Hypertension (high blood pressure). In some instances, a Maternal-Fetal Medicine Specialist may alter the type of medication you’re taking to maintain your health and prevent any adverse effects to your baby. If you have diabetes, the Maternal-Fetal Medicine Specialist can help you optimize your blood sugar control prior to conception to help reduce the risk of fetal anomalies. If you struggle with obesity, the Maternal-Fetal Medicine Specialist can review the benefits of weight loss before pregnancy.

Genetic risks: Preconception genetic screening has become more common in recent years as technology has advanced and testing has become more accessible. If you have family members with a certain disease or if you belong to an ethnicity that has a greater risk of developing specific conditions (such as sickle cell disease or Thalassemia), genetic screening can be used to assess your and your partner’s risk of being a carrier.

Additionally, if you have a child affected by a genetic disorder or syndrome, a Maternal-Fetal Medicine Specialist can provide counseling and management to consider how the condition may impact your future pregnancies. Always speak with your healthcare provider to determine what’s best for you and your pregnancy.

Preventing and Treating Pregnancy Complications

Even if you don’t have an existing health problem, many doctors recommend a preconception appointment with your health care provider or OBGYN to ensure you are as healthy as you can be before you become pregnant. At this appointment your doctor may recommend steps you can take to reduce the risk of certain problems. These include:

  • Getting at least 400 micrograms of folic acid daily, starting before and continuing through pregnancy, occasionally you may be advised to take bigger doses like 5 mg of folic acid.
  • Getting recommended immunizations
  • Eating a healthy diet and maintaining proper weight
  • Getting regular physical activity, unless advised otherwise by your doctor
  • Avoiding cigarettes, alcohol, and drugs (except for medications approved by your doctor)
  • Taking only the over the counter and prescription medicines that your doctor or midwife has OK’d for you
  • Seeing your doctor regularly
  • Working with them to manage problems such as diabetes, depression, high blood pressure, or infection

Do I need special tests?

There are a great many tests available to help in the diagnosis and monitoring of problems in pregnancy and a Maternal Fetal Medicine specialist will help you make sensible choices about what’s necessary, what’s advisable and what’s optional. They might recommend:

  • NIPT (Non-Invasive Prenatal Testing). During this procedure, DNA from the mother and fetus is extracted from a maternal blood sample and the fetal DNA is screened for the increased chance of specific chromosome problems. The options available in Cayman include the Panorama and the QNatal tests. Some clinics offer either and some just one, and these tests are slightly different in their sensitivities and the abnormalities that they detect.  It’s important to ensure you are properly informed about this.
  • Specialized or targeted ultrasound. This type of fetal ultrasound – an imaging technique that uses high-frequency sound waves to produce images of a baby in the uterus – targets a suspected problem, such as abnormal growth. Most OBGYNs conduct basic ultrasound as part of normal monitoring but more advanced ultrasound may well be necessary in high-risk pregnancies. Your Maternal-Fetal Medicine Specialist will advise.
  • Invasive genetic screening. Your Specialist might recommend amniocentesis or chorionic villus sampling (CVS). During amniocentesis, a sample of the fluid that surrounds and protects a baby during pregnancy (amniotic fluid) is withdrawn from the uterus. Typically done after week 15 of pregnancy, amniocentesis can identify certain genetic conditions as well as serious abnormalities of the brain or spinal cord (neural tube defects). During CVS, a sample of cells is removed from the placenta. Typically done between weeks 10 and 12 of pregnancy, CVS can identify certain genetic conditions. These tests carry a small risk of pregnancy loss. The decision to pursue these tests is up to you and your partner. Please discuss the risks and benefits with your Specialist.
  • Ultrasound for cervical length. Your specialist might use an ultrasound to measure the length of your cervix at prenatal appointments to determine if you’re at risk of preterm labor.
  • Biophysical profile. This prenatal ultrasound is used to check on a baby’s well-being. It might involve only an ultrasound to evaluate fetal well-being or, depending on the results of the ultrasound, also fetal heart rate monitoring (NST nonstress test).

What else do I need to know about high-risk pregnancy?

Talk to your health care provider about how to manage any medical conditions you experience during pregnancy and how your health might affect labor and delivery. It is important to monitor your health and any signs of an emerging problem. Contact your health care provider if you have:

  • Vaginal bleeding or watery vaginal discharge
  • Severe headaches
  • Pain or cramping in the lower abdomen
  • Decreased fetal activity
  • Pain or burning with urination
  • Changes in vision, including blurred vision
  • Sudden or severe swelling in the face, hands or fingers
  • Fever or chills
  • Vomiting or persistent nausea
  • Dizziness
  • Thoughts of harming yourself or your baby

Will My Prenatal Care Be Different with a High-Risk Pregnancy?

While any pregnancy can be challenging, high risk pregnancies may potentially threaten the health of both the mother and the fetus. High risk pregnancies need a greater level of attention and monitoring since they carry an elevated risk of complications and increase a baby’s chances for health and developmental problems at birth and beyond. High risk pregnancies usually require a greater number of prenatal office visits, in order to closely monitor the progression of the pregnancy. Women with high-risk pregnancies are counseled to be especially attentive to their health, eat a nutritious diet, gain a proper amount of weight and avoid any risky substances or medications. Doctors will often prescribe vitamins, iron supplements or medicines to enhance the health of the mother and baby.

As you have probably gathered, there are many dimensions to a high-risk pregnancy, and it is easy to see just why being managed by an experienced high-risk pregnancy team can be important, given the multi-professional – OBGYN, Maternal-Fetal Medicine, Neonatal – nature of that care.

Where will I deliver my baby if I have a high-risk pregnancy?

In the Cayman Islands, all deliveries take place in a hospital, but in a high-risk pregnancy it is vital because of the need for the proper equipment and personnel to closely monitor the birth process and step in if something goes wrong. There are two hospitals handling deliveries in Cayman but only Cayman Islands Hospital (HSA) has a NICU (Neonatal Intensive Care Unit). If there is a greater than normal risk of preterm birth or complications, this is the appropriate choice.

If you’re having multiple pregnancy, you’re more likely to go into labour early, although preterm labour is more common in high-risk pregnancies generally. Early labour may be caused by having too much amniotic fluid around the baby or having other medical conditions that cause early labour. Your OBGYN may even have your labour induced to prevent or reduce the likelihood of other health problems arising for you and your baby. In this case, they will discuss this with you. Again, coordination between your OBGYN (or Maternal-Fetal Medicine Specialist) and Neonatologist is critically important.

There may also be situations that make a vaginal birth too risky, and you may need to have a caesarean section as a result. Therefore, it’s a good idea to talk to your OBGYN/Specialist regarding what you may need to prepare for during labour so that you will be mentally prepared and know what to expect.

Emotional Support for a High-Risk Pregnancy Diagnosis

A high-risk pregnancy can create many different feelings. In fact, you’re likely to feel a mix of emotions. These emotions may make it hard to enjoy your pregnancy because of all the stress and worry these emotions may create. You may worry about your health as well as the health of your baby, but your doctor should be able to help you manage these feelings.

Ask your Specialist for information and resources that you can use to help manage your emotions. You should also start building a support network to help manage these emotions. Your support can come from family, friends, and even other women in a similar situation. Sharing your thoughts feelings and concerns will give you an outlet and help to keep you informed and more in control of your feelings.

Some practices in Cayman Islands have a dedicated midwife providing prenatal support, including emotional support and advice. If this is the case, it may be a good idea to speak to them. They can also help you monitor your pregnancy and ensure any warning signs are picked up early.

You may hear and read about many issues and complications that could happen as a result of your high-risk pregnancy, but it doesn’t necessarily mean that you won’t have a healthy baby. Manage your emotions by using your support system to help you through those moments when fear and worry set in.

Is my Baby going to be, okay?

It’s natural for a high-risk pregnancy to cause anxiety over the health and wellness of the baby. Good prenatal care, with the right support, from an experienced, multidisciplinary high-risk pregnancy team, makes it possible to still have a healthy baby even if the pregnancy is high-risk.

Keep the lines of communication open with your Specialist or midwife and talk to them about your concerns and anything you can do to keep yourself and your baby as healthy as possible. This means discussing any drugs you may be taking and allowing your doctor to change your medications if they are not safe for the baby.

If complications occur, the results could be early childbirth /preterm birth, which could result in difficulty breathing and feeding. If this happens, the baby may have to spend more time in the hospital to stabilize and get well, in addition to requiring more care and attention. When this happens, newborn babies are often placed in the neonatal intensive care unit (NICU). If your OBGYN thinks you may be at risk, they will likely advise a qualified neonatologist with whom they’ll coordinate care and arrange for you to meet to discuss what might happen or be necessary.

Will all my future pregnancies be high risk?

Having one high-risk pregnancy does not mean that all your future pregnancies will be deemed high risk as well. You may have a fetal complication occur in one pregnancy that wouldn’t in another, and certain health conditions may change over time.

However, if you have had a pregnancy that ended in preterm delivery, you are at greater risk of having preterm labor during your next pregnancy. If this occurs, your obstetric provider will manage your pregnancy using medication, and a maternal-fetal medicine specialist will monitor your cervical length with ultrasound surveillance.

Ultimately, the most important thing to remember about having a high-risk pregnancy is that your Maternal-Fetal Medicine Specialist has the knowledge and experience required to keep you and your baby as healthy as possible.

Further Information:

https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/high-risk-pregnancy/art-20047012

https://www.webmd.com/baby/managing-a-high-risk-pregnancy#1

https://www.nichd.nih.gov/health/topics/high-risk/conditioninfo/factors

https://www.hopkinsmedicine.org/health/conditions-and-diseases/staying-healthy-during-pregnancy/high-risk-pregnancy-what-you-need-to-know

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about the author

Dr Madhavi Manoharan

MBBS, MD, FRCOG

OBSTETRICIAN & GYNAECOLOGIST

Dr Manoharan has 23 years’ experience in obstetrics and gynaecology, including more than a decade at tertiary level, 7 years as consultant at the prestigious Royal Free London NHS Foundation Trust and a number of years as Assistant Professor at the world-renowned Weil Cornell Medicine, located in their Qatar campus, part of Cornell University.



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