There has been a lot of buzz recently on social media regarding high-risk pregnancy. Some women lament over the fact that they have been told they are high-risk, some women simply accept it and react appropriately, and some shout it from the mountain tops sharing every detail of what complications they are having with anyone who will listen. Each woman has a different response and approach to her high-risk pregnancy.
As a Maternal-Fetal Medicine Specialist {MFM}, i.e. Perinatologist, High-Risk Pregnancy Specialist or High-Risk Obstetrician, it is my job to care for the women with high-risk pregnancies. I try my best to explain exactly what makes a certain pregnancy high-risk, so each woman will have a good understanding about her condition{s}. At the same time it is my job to make sure she has an appropriate level of worry and concern about her pregnancy. Having a high level of anxiety or not taking a complicated pregnancy seriously is not conducive to a healthy and successful pregnancy. Maintaining a healthy and realistic perspective is key.
Below, I answer some common questions about having a high-risk pregnancy.
What is a high-risk pregnancy?
A high-risk pregnancy is a pregnancy with maternal and/or fetal complications that requires additional testing, surveillance, or medical or surgical interventions to either treat or assess the progressing pregnancy. A woman may enter a pregnancy already high risk or the pregnancy may start off as normal and become high risk as the pregnancy progresses.
Some common reasons that a pregnancy is considered high-risk include, but are not limited to, the following:
Maternal medical conditions
Advanced maternal age, diabetes, hypertension, asthma, blood clotting disorders, fibroids, cardiovascular disease, renal disease, autoimmune disease {i.e. lupus}, thyroid disease, obesity, infectious disease {i.e. Zika virus, HIV, hepatitis, cytomegalovirus, syphilis, rubella virus, parvovirus}, isoimmunization, chronic kidney disease, depression or other mental health disorders
Pregnancy-related medical conditions
Preterm labor, preeclampsia, short or incompetent cervix, placenta previa and accreta, gestational diabetes or hypertension
Surgical complications
Multiple Cesarean sections, prior uterine surgery, prior complex abdominal surgery
Fetal abnormalities
Growth abnormalities, hereditary or genetic defects that may affect the fetus in utero, complex birth defects
Multiple gestations
Twins and higher order multiples, twin-twin transfusion syndrome
Drug or alcohol use/abuse and smoking
History of {recurrent} pregnancy loss or intrauterine fetal demise after 20 weeks
Obesity
A BMI of 35 or more
What does it mean to have a high-risk pregnancy?
A high-risk pregnancy may require more frequent visits, increased fetal surveillance {nonstress tests, ultrasounds, biophysical profiles}, a planned delivery {via Cesarean section or induction of labor}, early delivery, prolonged hospitalization, and/or treatment of maternal medical conditions. Also, management by an MFM like myself, may be necessary.
Overall, having a high-risk pregnancy means your pregnancy needs more attention, individualized management, and planning.
If my pregnancy is considered high-risk, who will take care of me and who will deliver me?
If you have a high-risk pregnancy your general obstetrical care provider {OCP} may refer you to an MFM for a consultation and/or co-management depending on the severity of the complication and/or the comfort level of the OCP in managing your pregnancy. Oftentimes your OCP will remain the primary OCP, but the MFM will also be involved with your care. Depending on what makes your pregnancy high-risk, your OCP may ask the MFM take over your care, become the primary OCP, and manage your pregnancy and delivery exclusively.
If your primary OCP feels comfortable delivering you, he/she will do so. But whether or not your primary OCP is the person delivering you depends on the practice. Some OCPs still deliver all their own patients, but this is becoming more rare. Many are in practices with numerous OCPs who share in the call/delivery schedule. This means that depending on when you deliver, another OCP in the practice may be delivering you. This is a discussion that you should have with your primary OCP.
If the primary OCP determines that you require a higher level of care, he/she may ask the MFM to plan and manage your delivery. Again, depending on how the practice is arranged, the MFM, his/her partner, or a resident {if the MFM works at an academic institution} may deliver you. For example, I do not have my own patients, but I manage high-risk patients on labor and delivery and deliver them with the residents at my institution. Again, this should be discussed with your MFM.
Why is a maternal age of 35 and over considered a high-risk pregnancy?
A woman over age 35 is first considered high-risk based on age alone because we know that women over age 35 are at increased risk for having a child with chromosomal abnormalities, like Down syndrome. The reasons why we focus so much on Down Syndrome is that there is a small percentage of babies with DS who have completely normal ultrasounds, and the risk of a woman having a baby with Down syndrome a age 35 is roughly equal to the risks of an amniocentesis {the only definitive way to know for sure that the chromosomes of a baby are normal prior to delivery}. For this reason, we offer all patients, not just women over 35, antenatal screening to assess her risk for having baby with Down Syndrome and other more common chromosomal abnormalities {i.e. Trisomy 18 and 13}, a detailed fetal anatomy ultrasound to asses for fetal defects, and genetic counseling. There are many other chromosomal abnormalities that can occur, but they are more likely to have abnormal ultrasounds.
I want to take a moment to address whether or not antenatal screening should be done in any pregnancy. Many women decline for various reasons, but I want to explain why, as an MFM, I feel it is important. When we look at a baby on a routine anatomy ultrasound at 18-22 weeks, we look for two types of abnormalities called minor markers and major defects. Major defects are considered birth defects {i.e. heart deject, cleft lip/palate, brain abnormality} and may cause a problem with the baby ones he/she is born. Minor markers {i.e. echogenic intracardiac focus, choroid plexus cysts} are not birth defects nor do they cause any problems with the baby once he/she is born. We look for minor markers because they can be associated with an increased risk of having a baby with a chromosomal abnormality. If we see a minor marker{s} and we do not have the results of an antenatal screening test, it is much more difficult for us to explain to you what your actual risk is of having a baby with a chromosomal abnormality. As a result, we may offer additional testing, but if you had a screening test and it was negative, we may not need to offer anything else. Having this information in the event of a minor marker or major defect allows us to both assess risk and counsel you more precisely.
There are other reasons that women over age 35 are considered high-risk. First, if a mother has pre-existing medical conditions like renal disease, high blood pressure, diabetes, cardiovascular disease, and lupus, to name a few, her pregnancy may have additional complications. If she has a pre-existing medical condition{s} or that is sub-optimally controlled, this could complicate the pregnancy even further. Trying to play catch-up after a pregnancy is established is not ideal. These conditions should be closely monitored and well-controlled well before conception. Finally, women over age 35 are at increased risk for developing certain complications during the pregnancy based on age alone. This may place her into the high-risk category as well and co-management or management by a high-risk specialist may be indicated.
At baseline, women over age 35 are at increased risk for the following:
-Diabetes and/or high blood pressure
-Having a multiple gestation
-Delivering prematurely
-Having a large for gestational age or low birth-weight baby
-Requiring a cesarean section
-Having placenta previa
-Experiencing pregnancy loss
If the antenatal screening is negative, the fetal ultrasound is normal, and you are an otherwise healthy woman, you should expect to have a normal pregnancy and may no longer be considered “high-risk”. Your pregnancy would simply be monitored more closely for the above complications.
To learn more about fertility, pregnancy and motherhood after age 35 go to my website Babies After 35.
If I am over 35, but healthy, am I automatically considered a high-risk pregnancy?
Although many over age 35 women find exception with this rule, the answer is yes. Again, even if the antenatal screening and ultrasound are completely normal, a healthy woman over age 35 is still at increased risk for additional complications based on age alone. Being considered high-risk because of your age doesn’t have to be a bad thing, though. Worst case scenario is that you will be watched more closely. But if you feel that you are having too many interventions or testing, ask your OCP if they are warranted and why. You do have the right to question or ask for more information on anything that is done to you during your pregnancy.
What are the precautions I should take if I have a high-risk pregnancy?
The most important things you can do are the following:
-Optimally manage any pre-existing medical conditions, ideally prior to conception
-Establish early onset and routine prenatal care
-Start taking a prenatal vitamin at least 3 months before conception if possible
-Control weight gain during pregnancy
-Comply with medical management
-Deliver at an institution that is equipped to handle maternal and neonatal complications
-Know your medical history and obtain relevant medical records from other physicians for your OCP
Is there any piece of advice you would give to me during my high-risk pregnancy?
The one thing I say is that no matter what makes your pregnancy high-risk or how complicated your pregnancy might be, try your best to enjoy your pregnancy and bond with your baby. This is very important for your mental well-being and for the growth and health of the baby.