High Risk Pregnancy
Pregnancy is a unique but normal physiological episode in a woman’s life. However, sometimes pre-existing or unexpected illness of the mother or the foetus may result in a complicated pregnancy.
While all pregnancies have some level of risk associated with them, not all risks are equal. A pregnancy is considered high risk only when there are potential complications that could hamper the health of the mother, the baby or both. These require management by specialists to ensure that both the mother and the baby have the best outcome.
NEST, backed by specialists from multiple disciplines, specialises in handling high risk pregnancies. An adult intensive care unit along with the Neonatal Intensive Care Unit (NICU) ensures that both the mother and the child are equally taken care of.
It is important to note that women, who are diagnosed with high-risk issues, mostly go on to have a normal pregnancy and a healthy delivery.
1. Conditions that put you or your baby at higher risk
- ADVANCED MATERNAL AGE: PREGNANCY AT AND AFTER 35 YEARS:
In the last few decades, there has been a trend toward deferred childbearing, especially among healthy, well educated women with career opportunities. Earlier, pregnant women aged 35 and older tended to have several unplanned children whereas today the proportion of first births to such women is growing.
- LIFESTYLE CHOICES: SMOKING, DRINKING ALCOHOL AND USE OF ILLEGAL DRUGS
- OBESITY OR PREVIOUS HISTORY OF BARIATRIC SURGERY:
Ideally an obese woman should be encouraged to lose weight before or after pregnancy. Obese women face difficulties in getting accurate scanning done, and also have a higher chance of developing gestational diabetes, hypertension, big babies and poor progress in labour. However, dieting to lose weight is not advisable during pregnancy because it is difficult to achieve and offers no benefit to the mother. It may, in fact, have ill effects on foetal weight and health after birth.
- FAMILY HISTORY OF GENETIC DISORDERS
- HISTORY OF PREVIOUS BABY AFFECTED BY CONGENITAL ANOMALY
- HISTORY OF RECURRENT MISCARRIAGES:
Recurrent miscarriage affects 1% of the population and is defined as three or more consecutive pregnancy losses. The majority of miscarriages occur early in pregnancy before 12 completed weeks of gestation. The incidence of late miscarriage in the second trimester between 13 to 23 completed weeks is estimated at 2%.There are several causes of recurrent miscarriages. Historically they have been grouped into genetic, anatomic, infective, endocrine, immune, environmental, thrombophillic disorders and unexplained categories.
PREGNANCY RELATED ISSUES
- PREMATURE LABOUR:
Labour that begins before the 37th week of pregnancy, the point at which the baby is deemed full-term is premature labour. Although there is no sure shot way to know who will experience premature labour or birth, there are factors that place women at a higher risk for developing certain infections and complications.
- MULTIPLE PREGNANCIES:
The incidence of multiple births has increased remarkably over the past few decades. Multiplets have a more complicated intra uterine environment than that of singletons. It is essential to evaluate multiple pregnancies well to identify congenital anomalies and pick up early signs of intrauterine growth restriction. Monochorionic twin pregnancies share identical genetic constitution and share a single placenta with their circulations connected through vascular communications in the placenta. Such pregnancies have to be monitored well in a tertiary care centre with good foetal surveillance.
- PLACENTA PREVIA:
- This 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, the doctor may schedule a Caesarean section to reduce risks to the mother and baby.
- If the bleeding gets very heavy and does not respond to the surgical measures, specialists at The Nest perform what is called as ‘Uterine Artery Embolisation’. This procedure involves using a foreign material that temporarily blocks the blood supply to the uterine body, preventing excessive bleeding.
- FOETAL PROBLEMS:
These problems can be detected during an Ultrasound. Studies suggest that 2-3% of all babies have minor or major structural problems in development. A family history of foetal problems may be the cause, but these problems often surface unexpectedly.
- AMNIOTIC FLUID ABNORMALITIES:
Amniotic fluid surrounds the foetus after the first few weeks of gestation. This has antibacterial properties which protect the foetus and umbilical cord from compression, and serves as a reservoir of water and nutrients.Oligohydramnios is a decreased amount of amniotic fluid affecting 3 to 5% of pregnancies. Its causes include foetal growth restriction, premature rupture of membranes, foetal anomalies and maternal dehydration. Women who develop this in the second trimester have a poor prognosis with 90% perinatal mortality while women who develop this condition in the third trimester have a better prognosis with 85% perinatal survival. Such cases need to be managed in a tertiary care centre with frequent foetal surveillance.Polyhydramnios or excessive accumulation of amniotic fluid around the foetus occurs in 1 to 3% of pregnancies. The causes may be due to maternal diabetes, foetal anomalies, foetal anaemia or placental tumours. If all these causes are ruled out, there may be no underlying problem detected. Such women may face a risk of premature delivery or abnormal foetal presentation in labour.
- VAGINAL BIRTH AFTER C-SECTION (VBAC):
- Most often, women undergoing labour want to have a Caesarean delivery fearing the pain. After a Caesarean delivery for the first pregnancy, vaginal birth for the second is often suggested by doctors.
- Risk of having a uterine rupture during VBAC is less than 1% (0.2 – 0.5%). Risks of Caesarean section are bladder and bowel adhesions, trauma to adjacent organs and excessive blood loss.
- At The Nest, certain pre-requisite measures are followed during VBAC. The availability of 24/7 neonatologists, anaesthesiologists, gynaecologists, blood bank, operation theatres, and much more, helps prepare and tackle last minute challenges.
- PRE-EXISTING CONDITIONS LIKE:
- Preganancy induced hypertension: Preeclampsia, or pregnancy induced hypertension, occurs in 3 to 8% of pregnancies and is a major cause of maternal mortality, preterm birth and intrauterine growth restriction. This requires close maternal and foetal evaluation.
- Diabetes mellitus
- Cardiac disease: This affects about 1% of the pregnant population. Despite the potential for significant maternal morbidity, most patients with cardiac disease can expect a satisfactory outcome with careful antenatal, intrapartum and postpartum management in a multidisciplinary setting.
- Anaemia, blood dyscrasia, haemoglobinopathy and platelet disorders
- Liver problems with history of previous pregnancy affected by liver disorders such as obstetric cholestasis and acute fatty liver of pregnancy
- Neurological disorders like epilepsy, multiple sclerosis, brain tumours, past history of cerebral venous thrombosis
- Psychiatric illness
- Solid organ transplantation
- Previous history of thromboembolism, strokes, myocardial infarction
- Autoimmune diseases like systemic lupus erythematosus, antiphospolipid syndrome, rheumatoid arthritis, systemic sclerosis
- Thyroid and other endocrine disorders
- Renal disorders like recurrent urinary tract infections, conception after renal transplantation
- Rh incompatibility
- Previous history of preterm labour
- Previous history of third trimester foetal losses
- Previous history of postpartum haemorrhage
2. What steps can I make take to promote a healthy pregnancy?
Whether you know ahead of time that you’ll have a high-risk pregnancy or you simply want to do whatever you can to prevent a high-risk pregnancy, it’s best to stick to the basics.
- Schedule a preconception appointment: If you’re thinking about becoming pregnant, consult your doctor. He or she might counsel you to start taking a daily prenatal vitamin and reach a healthy weight before you become pregnant. If you have a medical condition, your treatment might need to be adjusted to prepare for pregnancy. Your health care provider might also discuss your risk of having a baby with a genetic condition.
- Be cautious when using Assisted Reproductive Technology (ART): If you’re planning to use ART to get pregnant, consider how many embryos will be implanted. Multiple pregnancies carry a higher risk of preterm labour.
- Seek regular prenatal care. Prenatal visits can help your health care provider monitor your health and your baby’s health. Depending on the circumstances, you might be referred to a specialist in maternal-foetal medicine, genetics, paediatrics or other areas.
- Eat a healthy diet: During pregnancy, you’ll need more folic acid, calcium, iron and other essential nutrients. A daily prenatal vitamin can help fill any gaps. Consult your health care provider if you have special nutrition needs due to a health condition, such as diabetes.
- Gain weight wisely: Gaining the right amount of weight can support your baby’s health – and make it easier to shed the extra pounds after delivery. Work with your health care provider to determine what’s right for you.
- Avoid risky substances: If you smoke, quit. Alcohol and illegal drugs are off-limits, too. Get your doctor’s OK before you start – or stop – taking any medications or supplements.
3. Do I need special tests?
If you have a high-risk pregnancy, you might consider various tests or procedures in addition to routine prenatal screening tests. Depending on the circumstances, your health care provider might recommend:
- Specialized or targeted ultrasound: This type of foetal 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 development.
- Amniocentesis: During this procedure, 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 neural tube defects – serious abnormalities of the brain or spinal cord.
- Chorionic Villus Sampling (CVS): During this procedure, a sample of cells is removed from the placenta. Typically done between weeks 10 and 12 of pregnancy, CVS can identify certain genetic conditions.
- Cordocentesis: This test, also known as percutaneous umbilical blood sampling, is a highly specialised prenatal test in which a foetal blood sample is removed from the umbilical cord. Typically done after week 18 of pregnancy, the test can identify chromosomal conditions, blood disorders and infections.
- Cervical length measurement: Your health care provider might use an ultrasound to measure the length of your cervix at prenatal appointments to determine if you’re at risk of preterm labour.
- Lab tests: Your health care provider might take a swab of your vaginal secretions to check for foetal fibronectin – a substance that acts like a glue between the foetal sac and the lining of the uterus. The presence of foetal fibronectin might be a sign of preterm labour.
- Biophysical profile: This prenatal test is used to check on a baby’s well-being. The test combines foetal heart rate monitoring (nonstress test) and foetal ultrasound.
Some prenatal diagnostic tests – such as amniocentesis and chorionic villus sampling – carry a small risk of pregnancy loss. Ultimately, the decision to pursue prenatal testing is up to you and your partner. Discuss the risks and benefits with your doctor.
4. What can I do to ease my anxiety?
If you have a high-risk pregnancy, you might feel scared or anxious which might result in you being nervous about prenatal visits – for fear that you’ll hear bad news.
Unfortunately, anxiety can affect both your health as well as your baby’s. Consult your doctor on healthy ways to relax and stay calm.
5. What else do I need to know about high-risk pregnancy?
Consult your doctor about how to manage any medical conditions that might come up during your pregnancy, and how your health might affect labour and delivery. The specific signs or symptoms to look out for are:
- Vaginal bleeding
- Persistent headaches
- Pain or cramping in the lower abdomen
- Watery vaginal discharge – in a gush or a trickle
- Regular or frequent contractions – a tightening sensation in the abdomen
- Decreased foetal activity
- Pain or burning with urination
- Changes in vision, including blurred vision
A high-risk pregnancy might have ups and downs. Do your best to stay positive as we at NEST, along with you, take the necessary steps to ensure a healthy pregnancy for you.