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Complications and High-Risk Pregnancies

Every pregnancy has its risks. When certain medical conditions arise before or during pregnancy, more careful monitoring is needed. Pregnancies are labeled “high risk” when there are complications with either the mother or the baby that need careful monitoring and observation.  All of our providers have the expertise and resources available to manage high risk pregnancies.

 A high risk pregnancy requires a team approach. If you are a “high risk” patient, you are the most important person on the team.  Here are steps you can take to manage your high risk pregnancy:

  • Learn all you can about why your pregnancy is considered high risk.  Some of the more common high risk conditions are listed below.
  • Know what activity restrictions are required; ask if you may work, travel, exercise, have sex, or if there other limits on your activity.
  • Keep specialist appointments.  Depending on your condition you may be referred to a specialist such as a perinatologist, endocrinologist, or nurse specialist. These providers help to manage your high risk condition. 
  • Take all prescription medications, as ordered and carry a small supply of your medications with you to avoid missing any doses. Discuss with your provider what to do if you do miss a dose. 
  • Keep a copy of your prenatal medical records and directions to the hospital readily assessable in case of an emergency. 

See topics relating to common high-risk conditions and typical treatments for each below. As always, if you have any questions about your own pregnancy, make sure to talk to your Women's Health CT high risk pregnancy Ob/Gyn.

  • Intra Uterine Growth Restriction (IUGR)

    Intrauterine growth retardation (IUGR) means that your baby is growing slower than the expected rate. This usually is identified by an ultrasound examination done between the 6th and 8th months. With early identification, monitoring and treatment, most small babies grow up to be healthy children.

    Risk factors associated with slower than normal growth include:


    In the mom

    • Smoking
    • Excessive drinking of alcohol
    • High blood pressure
    • Diabetes mellitus (which can effect blood vessels)
    • Abnormal blood supply to the fetus
    • Infection during pregnancy
    • Abnormally shaped uterus
    • Certain drug use during pregnancy (like blood thinners, seizure medications or recreational drugs like cocaine)
    • Small-framed mother (< 5 feet tall and weighing < 110 pounds)

    In the baby

    • Multiple gestations (twins or more)
    • Certain genetic abnormalities
    • Placental problems that restrict oxygen and nutrients from mother to fetus
    • Umbilical cord defects – decreased blood supply from placenta to fetus

    Treatment includes managing risk factors like poor diet, infection, smoking and alcohol abuse. Bedrest or reduced activity is often recommended so the baby obtains maximum benefits of the mother’s blood supply. Regular ultrasounds and fetal monitoring are done to evaluate fetal growth.

    If the fetus shows continued signs of growth, things are going well. When slow growth continues — further evaluation is needed.  If you are diagnosed with IUGR, your provider will discuss a plan of care for you  considering the number of completed weeks in the pregnancy, the likelihood of early delivery, a monitoring regimen and a delivery plan.  Specialists such as a perinatologist (obstetrician who specializes in care of the mother and fetus) and a neonatologist (pediatrician with a specialty in newborn care), will be involved to help manage your care.

  • Pre-existing medical conditions requiring closer observation
    Diabetes Mellitus

    This condition requires closer monitoring before and during pregnancy. The closer blood sugar levels are to the normal range, the better the health of both mom and baby. This also reduces the possibility of giving birth to a large baby – which can be a problem with vaginal delivery. Tests of fetal well being including fetal movement counts are especially important for diabetic mothers through the final trimester of pregnancy. Specialist physicians may assist your obstetrician in closely monitoring your health.

    Hypertension

    Pre-existing high blood pressure requires close follow up in pregnancy. It brings about a 20% risk of developing pre-eclampsia, as well as possibilities of an early separation of the placenta from the uterine lining (placental abruption) or slowed growth (Intra Uterine Growth Restriction). A specialist physician in hypertension or cardiology may help your obstetrician manage your care. More frequent office visits and evaluation of fetal well may be recommended.

    Asthma

    In pregnancy, the severity of asthma does not change for the majority of women. With good control of asthma, there is no more risk for asthmatic women who are pregnant than for a non-asthmatic.

    Epilepsy and Pregnancy

    According to the Epilepsy Foundation, having epilepsy should not prevent a woman from planning a family. The vast majority of babies born to women with epilepsy are normal and healthy. Key strategies for pregnant women who have epilepsy include:

    • Taking your anti-epileptic medication(s) as prescribed
    • Reducing factors that trigger seizures
    • Reporting all seizures to your neurologist

    The shift in your hormones can cause a change in the frequency of seizures. A small percentage of women have an increase in the number of seizures while others have no change. Preconception planning, followed by early and on-going prenatal care, is very helpful in ensuring a safe and healthy pregnancy.

    Eating disorders

    Being pregnant when you have an eating disorder may be especially difficult. Eating a balanced diet and tolerating weight gain are vital components of your pregnancy. Your baby’s vital organs and nervous system develop during the first 3 months of pregnancy, so nutrition is especially important during this time.

    Speak openly with your health care provider about your eating disorder. There may be medication and emotional support that may help during your pregnancy. Your baby’s growth and well being will be monitored closely. Counseling is recommended to help you adjust to feelings about your changing body.

    Depression, anxiety, and other mental illnesses

    This may require treatment while you are pregnant. Your health care provider will evaluate any medication you are taking for possible risks it poses to your baby. If you have a history of depression or anxiety you should continue care with your mental health provider to help reduce your risk for postpartum depression. Do not discontinue psychiatric medication without consulting a health care professional.

    Teen Pregnancy

    Teenagers typically do not have the best diets and may be at risk for nutritional deficiencies – teens need to be monitored for adequate weight gain. Many times, teens do not seek prenatal care until the pregnancy is pretty far along. Smoking, alcohol and drug use may contribute to risks of preterm labor, premature rupture of the membranes, and/or pre-eclampsia. Any high-risk behaviors must be avoided – this includes drug, tobacco and alcohol use, multiple sexual exposures, and unprotected sex. Health care providers will work with school social workers to be sure that the teenager’s appointments are met and her schoolwork maintained. Tutors will be offered if conditions require bed rest.

    Substance Abuse

    Any drug you are taking should be discussed with your doctor; recreational drugs are particularly concerning. If you are struggling with addiction, here are some good reasons to seek help:

    Drug abuse or addiction can contribute to premature birth, underweight babies, increased need for resuscitation at birth, tremors and addiction in your newborn. Cocaine addicted newborns can be extremely sensitive to light, noise and other types of stimulation, and can often be irritable and difficult to calm.

    Even occasional recreational drug use, particularly cocaine, can be disastrous for your baby. Babies have a difficult time going through withdrawal symptoms, just as adults do. Be sure that you are honest with your clinician, so s/he will be able to support you and care more effectively for you and your baby. Your clinician will help you obtain confidential help.

  • Trauma in Pregnancy

    Trauma, like an injury from a car accident or fall, may cause maternal bleeding, miscarriage, preterm labor, placenta abruption and stillbirth. It is important to note that domestic violence is another very real source of trauma for pregnant women. The incidence of violence in abusive relationships tends to increase in pregnancy.

    Treatment includes hospitalization, treatment of injuries and evaluation of fetal well being by monitoring for signs of vaginal bleeding, contractions and uterine muscle tone.

  • Premature Rupture of Membranes

    When the bag of water (membranes) breaks before natural labor begins, it is called premature rupture of membranes (PROM). If this happens well before it is safe for the baby to be born, it is called preterm premature rupture of membranes (PPROM). The incidence of premature rupture of membranes is less than 1% of all pregnancies.

    Risks associated with preterm premature rupture of membranes
    • Infection of the mother and baby
    • Fetal stress from having too little amniotic fluid
    • Potential for decreased oxygen to the fetus
    • With early rupture of membranes (between 26 – 28 weeks of pregnancy), the fetus is at increased risk for problems with prematurity, specifically, bone and lung development.

    If you suspect that fluid is leaking from the vagina, consult your physician without delay. There is a simple test to determine whether or not it is amniotic fluid.

    If you are diagnosed with premature rupture of membranes, your physician will carefully monitor both your and your baby’s health. Your clinician will consult with a perinatologist (obstetrician who specializes in care of the mother and fetus) and a neonatologist (pediatrician with a specialty in newborn care), to determine the optimal time for delivery. Treatment for preterm premature rupture of membranes includes fetal monitoring to determine if preterm labor also is present, checking for signs of infection or fever, and prescribing antibiotics as needed.  Steroid injections may be given to help speed up the baby’s lung maturity if premature delivery is anticipated.

  • Multiple Pregnancies

    The natural incidence of multiple babies in one pregnancy is:

    • Twins - 1 in 83
    • Triplets - 1 in 7000
    • Quadruplets - 1 in 571,000
    • Quintuplets - 1 in 47,000,000

    With more than one fetus growing, careful monitoring is required. This includes more frequent office visits, ultrasoundsfetal non-stress testing, and sometimes, bed rest for the mom. Possible problems include preterm labor, premature birth and pre-eclampsia.

    Your physician will be careful to monitor both your and your babies’ health. S/he also will consult with a perinatologist (obstetrician who specializes in care of the mother and fetus) and a neonatologist (pediatrician with a specialty in newborn care), to determine the optimal time for delivery.

  • Vaginal Bleeding Later in Pregnancy

    The placenta is the link to the mother’s blood supply; it is important in providing nourishment to the fetus. Problems with the placenta occur in less than 1% of all pregnancies. In late pregnancy, vaginal bleeding may be a sign that something is wrong with the way the placenta is attached to the lining of the uterus.

    Placental abruption

    This means the placenta has torn away or separated from the lining of the uterus.

    Symptoms of abruption include dark red vaginal bleeding, cramping, and uterine tenderness (tender belly). With small tears, the mother is at risk for anemia and infection. Risks with larger tears include severe bleeding and related problems of loss of oxygen to the brain and heart. The baby will similarly be affected by loss of oxygen that may lead to slow growth (intrauterine growth retardation), premature birth, and cerebral palsy.

    Placenta Previa

    This means the placenta has attached to the uterine lining in a lower portion of the uterus, sometimes right over the cervix. Normally, the placenta attaches at the top of the uterus (uterine fundus). Often by mid-pregnancy, a lower attached placenta moves up the uterine wall, away from the cervix. When the placenta remains very low in the uterus, it can fully or partially cover the cervix, or lie very near it.

    Risk factors for placenta previa
    • Previous pelvic surgery such as cesarean section
    • History of miscarriage, abortion and/or ectopic pregnancy
    • Multiple births
    • Pregnancy with multiples
    • Closely spaced pregnancies
    • Conditions such as high blood pressure, diabetes, uterine tumors (e.g. fibroids) drug addiction, smoking and advanced maternal age.

    For the mother, problems that occur with placenta previa are bleeding, anemia and infection. For the baby, potential complications are premature birth, slowed growth, and anemia. There are risks of excessive bleeding associated with this condition so delivery by cesarean delivery is necessary.

    Treatment often includes observation or hospitalization, bedrest, abstaining from intercourse, fetal monitoring, kick countsultrasounds to observe baby’s growth and for cervical dilation, as well as non-stress tests to check for fetal well being. Medications such as steroid injections may be used to help speed up the baby’s lung maturity if premature delivery is anticipated.

    Your clinician will consult with a perinatologist (obstetrician who specializes in care of the mother and fetus) and a neonatologist (pediatrician with a specialty in newborn care), to determine the optimal time for delivery.

  • Pre-eclampsia

    Pre-eclampsia can develop during the second half of pregnancy, most cases usually occur at or near the end of pregnancy or just after birth. Other terms used to describe pre-eclampsia are toxemia, or pregnancy induced hypertension. Pre-eclampsia causes blood vessels to constrict (get smaller) which makes it harder for the mother’s blood flow to support the fetus. Pre-eclampsia occurs in about 5-8% of pregnancies in the United States. The only cure is delivery of the baby. 

    Women most at risk for pre-eclampsia
    • First time mothers
    • A woman whose mother or sister had pre-eclampsia
    • History of high blood pressure, diabetes, kidney disease and/or migraines
    • Age greater than 35 years
    • Carrying twins or more

    In most cases, blood pressure increases are mild. When the blood pressure gets high and stays high, it may affect the growth and weight of the fetus. Sometimes the baby is born prematurely.

    Left untreated, or if symptoms do not respond to therapy, the mother’s kidneys, liver, brain, heart and eyes may be damaged. Seizures indicate pre-eclampsia has worsened and become eclampsia. Eclampsia is a medical emergency - a potentially life-threatening situation (for mom and baby) that needs intensive treatment, support and monitoring.

    Symptoms you should NEVER overlook
    • Bad to severe headaches
    • Blurred vision, flashes in your eyes and/or double vision
    • Pain just below the ribs
    • Vomiting
    • Decreased urination
    • Swelling of your face, hands or feet that does not go away after resting
    • Dizziness or lightheadedness
    Management of pre-eclampsia

    If you are diagnosed with pre-eclampsia, your provider will discuss a plan of care for you that considers the number of completed weeks of pregnancy, the likelihood of early delivery, a monitoring regimen, and a delivery plan. The plan of care may include bedrest, more frequent visits (and home recording) to monitor blood pressure, urine protein and weight, blood tests to check for kidney, liver and clotting function, kick countsultrasounds to observe growth and non-stress tests to check fetal well being.

    If symptoms worsen, hospitalization and medications to decrease blood pressure and prevent seizures may be required. Since delivery of the baby is the only cure for pre-eclampsia, your clinician will consult with a perinatologist (obstetrician who specializes in care of mother and fetus) and a neonatologist (pediatrician with a specialty in newborn care), to determine the optimal time for delivery.

  • Gestational Diabetes

    Some pregnant women have trouble controlling their blood sugar, often due to gestational diabetes. Blood sugar (glucose) provides energy for the body. The amount of “sugar” in your blood is kept in a normal range by insulin. Normally, your body makes enough insulin to maintain a normal blood sugar level. With gestational diabetes, insulin cannot keep up with demand, resulting in a higher than normal blood sugar level. Gestational diabetes usually starts in the later half of the second trimester.

    Risk factors for gestational diabetes include:
    • Women over age 25
    • A family history of adult onset diabetes
    • Previous delivery of a large baby
    • Obesity

    Routine screening for gestational diabetes (with a glucose tolerance test) is suggested around 24 - 28 weeks. If your clinician feels that you are at increased risk for gestational diabetes, earlier screening may be recommended.

    Gestational diabetes rarely causes problems in the mother though mothers may experience similar problems in future pregnancies and are more likely to develop adult-onset diabetes later in life. Since 50% of women with gestational diabetes develop adult onset diabetes, your health care provider may monitor your blood sugars during the postpartum period (after you deliver) and regularly thereafter.

    The effects to the baby are more of a concern. The higher sugar levels in the mother excite insulin production in the fetus. The fetus becomes accustomed to making extra insulin which may cause the baby’s blood sugar to be lower than normal after birth. In addition, a baby receiving too much sugar from its mother during pregnancy may grow large for its age, and this can make vaginal delivery difficult.

    Specialists such as a perinatologist (obstetrician who specializes in care of the mother and fetus) and a neonatologist (pediatrician with a specialty in newborn care), will be involved to help manage your care

    How is gestational diabetes managed?
    • Dietary management
      You may need to see a dietician or nutritionist for a healthy diet plan during pregnancy.

    • Finger stick blood sugars
      You will need to check your blood sugars regularly, often 4 to 5 times per day.  A nurse will teach you on how to test your blood and keep a log of your blood sugar levels.  You may need to call your provider in between prenatal visits to discuss your blood sugar levels.  You should always bring your blood sugar log to all your prenatal appointments. The only way to effectively manage gestational diabetes is to eat properly, test blood sugars regularly and work with your clinician to assure that your blood sugar is in the proper range.

    • Medications
      When diet alone does not keep the blood sugar in control, medications may be required.
       
    • Growth and development
      Your health care provider will monitor the baby’s growth and development more closely. You may undergo regular ultrasoundsnon-stress tests and biophysical profiles.
    • Fetal movements
      A fetal movement chart also may be recommended so that you can keep track of “kick counts” – a sign of fetal well being.
  • Premature Labor

    Premature or pre-term labor is defined as labor occurring before the 37th week of pregnancy. This happens in about 10% of all births. Not all women who develop preterm labor go on to have a premature birth. 

    Women at risk for a pregnancy with preterm labor and early delivery include those who:
    • are younger than 18, and older than 40 years
    • have poor nutrition
    • smoke
    • have had a previous pre-term delivery
    • have had a previous abortion
    • have had a previous surgical procedure of the cervix such as cone biopsy
    • have a defect of the uterus such as fibroids
    • have infections like urinary tract infections, sexually transmitted infections, etc.
    • have multiple gestations (twins or more)
    • have early rupture of membranes (water bag break or leak)
    The signs of pre-term labor include:
    • Abdominal cramps (like menstrual cramps)
    • Pressure in the pelvis
    • Regular contractions or tightening, more than four contractions in an hour, either with OR without pain
    • Vaginal discharge, an increase in the amount, or a change in the type - watery to bloody
    • Change in the dilation of the cervix or thinning of the cervix
    • Loose stool or diarrhea

    Evaluation of pre-term labor typically includes admission to the labor and delivery unit for assessment to include tests for infection, ultrasound with measurements of cervical length, fetal monitoring, plus a test of vaginal discharge to determine is a substance called fetal fibronectin is present and whether or not the amniotic membranes have ruptured. If fetal fibronectin is not found in high concentrations, risk of premature delivery is lower.

    Typical medications used to manage preterm labor include those to treat infections (if present), slow or stop labor, steriod injections to help speed the infant’s lung maturity and progesterone supplements.  The supplements are given if a previous pregnancy resulted in pre-term birth.

    If you are diagnosed with preterm labor, your provider will discuss a plan of care for you considering the number of completed weeks in the pregnancy, likelihood of early delivery, a monitoring regimen and a delivery plan.  Specialists such as a perinatologist (obstetrician who specializes in care of the mother and fetus) and a neonatologist (pediatrician with a specialty in newborn care) may be involved to help manage your care.

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