UPDATED 6/2024
There has been a lot of buzz recently on social media regarding having a high-risk pregnancy. Some people lament over the fact that they have been told they are high-risk, others simply accept it and move along, and still others will share the complications they are having with friends, family and even on social media. Each person has a different response and approach to their 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 individuals with high-risk pregnancies. I try my best to explain exactly what makes a certain pregnancy high-risk, so each patient will have a good understanding about their condition{s}. At the same time it is my job to make sure they have an appropriate level of worry and concern. 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 person may enter a pregnancy already high risk or the pregnancy may start off as umcomplicated 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
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 the comfort level of the OCP in managing your pregnancy. Oftentimes your OCP will remain the primary OCP, with the MFM will also be involved with your care and delivery planning. Depending on what makes your pregnancy high-risk, your OCP may ask the MFM to take over your care as the primary OCP and manage your pregnancy and delivery exclusively. If an MFM becomes onvolved in your are for any reason, it is important to as if your OCP will retain the role as your primary OCP.
If your primary OCP feels comfortable delivering you they will do so as your primary OCP. Whether or not your primary OCP is the actual 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, their 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 person over age 35 is first considered high-risk based on age alone because we know that people over age 35 are at increased risk for having a child with chromosomal abnormalities or differences, like Down syndrome (DS). The reasons why we focus so much on DS is that there is a small percentage of babies with DS who have completely normal ultrasounds, and the risk of a person having a baby with Down syndrome at 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 those over 35, prenatal genetic screening testing to assess their risk for having baby with DS and other more common chromosomal differences {i.e. Trisomy 18 and 13}, a detailed fetal anatomy ultrasound to asses for fetal birth defects, and genetic counseling.
I want to take a moment to address whether or not prenatal genetic screening testing (ie NIPT, NIPS, cell-free DNA, quad screen, etc) should be done in pregnancy. Many people decline for various reasons, but I want to explain why, as an MFM, I feel it is important accept the screening test offered to you. When we look at a fetus on a routine anatomy ultrasound at 18-22 weeks, we look for two types of abnormalities: 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 fetus ones they are born. Minor markers {i.e. echogenic intracardiac focus, choroid plexus cysts} are not birth defects nor do they cause any problems with the fetus once they are born. We look for minor markers because they can be associated with an increased risk of having a baby with a chromosomal difference. If we see a minor marker{s} and we do not have the results of a prenatal genetic screening test, it is much more difficult for us to explain to you what your actual risk is of having a fetus with a chromosomal difference. The prenatal genetic screening test can give us a numerical risk that many patients find more easy to understand. As a result, we may offer additional testing. However, if you had a prenatal genetic screening test and it was negative or low risk, we may not need to offer anything else. Having this information in the event of a minor marker allows us to both assess risk and counsel you more precisely.
There are other reasons that people over age 35 are considered high-risk. First, you have pre-existing medical condition(s) like renal disease, high blood pressure, diabetes, cardiovascular disease, and lupus, just to name a few, your pregnancy may have an increased risk for additional complications. If you have a pre-existing medical condition{s} or that is suboptimally 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 if at all possible. Finally, people over age 35 are at increased risk for developing certain complications during the pregnancy based on age alone. This may place you into the high-risk category as well and co-management or management by a high-risk specialist may be indicated.
At baseline, people 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 I am over 35, but healthy, am I automatically considered a high-risk pregnancy?
Although many over age 35 people find exception with this rule, the answer is yes. Again, even if the prenatal genetic screening testing and ultrasound are completely normal, a healthy person 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
-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 seem, try your best to enjoy your pregnancy and bond with your fetus. This is very important for your mental well-being and for the growth and health of the fetus. As I always say, "Even though your pregnancy is high-risk, it doesn't mean your risk is high."
To learn more about having a high-risk pregnancy, visit my Instagram page and peruse the highlights!