High Risk Pregnancy

A high-risk pregnancy is a pregnancy that poses a threat to a woman before or during pregnancy, or after delivery.

A high-risk pregnancy demands regular monitoring and special care of both the baby and mother throughout the pregnancy.

Recognizing the cause of high-risk pregnancy and taking care of the baby and yourself is considered the best strategy to prevent complications.

A pregnancy is said to be a high-risk pregnancy, if the mother has certain medical conditions or other factors that threaten the development of the foetus and/or increases the risk of complications for the mother.

Factors Considered for High Risk Pregnancy

The factors that may put the mother at a high risk of complications during or after the pregnancy include:

• Age – less than 15 or more than 38 years
• Weight – weight under 100 lb before pregnancy or overweight
• Height – under five feet
• Difficult pregnancies in the past
• Chronic medical conditions such as diabetes, high blood pressure
• Family history of genetic conditions
• Rh incompatibility
• Multiple pregnancy
• More than five previous pregnancies
• Quick labour in the previous pregnancies
• Prenatal tests indicating that the baby has a serious health problem
• Medical or surgical conditions that may arise during the pregnancy particularly and most commonly gestational diabetes and pregnancy induced hypertension and preeclampsia.

In addition to the above factors, women who have had difficult pregnancies in the past may have similar problems in future pregnancies.

If you have any of these risk factors, a pre-pregnancy visit to Dr Alexander is essential. Women with a high-risk pregnancy should be under the care of a perinatologist, an obstetrician specialized in the care of high-risk pregnancies.

Dr Alexander may refer you to a perinatal care centre in which a woman with a high-risk pregnancy is managed with specialized attention. In these centres, obstetricians and a newborn intensive care unit work together to render best care for you and your baby.

Causes of High Risk Pregnancy

A high-risk pregnancy may occur due to a pre-existing medical condition or problems that can develop during the course of pregnancy. Factors that can cause high-risk pregnancies may include:

• Lifestyle: Alcohol consumption, smoking and use of illegal drugs
• Maternal age: Pregnancy at 38 years or above
• Underlying condition: Diabetes, high blood pressure, anaemia (low oxygen carrying haemoglobin levels in blood), epilepsy (neurological disorder), etc.
• Medical history: genetic conditions, prior pregnancy loss (death of baby), history of C-section or preterm birth (early birth of the baby i.e., before 37 weeks of gestational period)
• Pregnancy complications: Problems in uterus, placenta or cervix, too much or too little amniotic fluid (fluid surrounding and protecting the baby in the womb), suppressed foetal growth, when your baby’s blood group is Rh positive and yours is Rh negative, and severe morning sickness.

Diagnosis of High Risk Pregnancy

Dr Alexander may recommend various diagnostic tests including:

• Amniocentesis: A sample of the amniotic fluid is collected after 15 weeks of pregnancy to examine genetic conditions such as neural tube defects (brain and spinal cord abnormalities).
• Ultrasound scan: An ultrasound produces images of the foetus to check for abnormal development.
• Chorionic villus sampling: A sample of cells removed from the placenta between weeks 10 and 12 of pregnancy is examined for genetic abnormalities.
• Lab tests: Vaginal secretion is analysed for the presence of foetal fibronectin (glue-like substance between the lining of the uterus and foetal sac), which can indicate preterm labour.
• Cordocentesis: Foetal blood sample is collected from the umbilical cord after week 18 of pregnancy to detect chromosomal variations, infections and any blood disorders.
• Biophysical profile: Foetal heart rate and foetal ultrasound are performed to examine your baby’s wellbeing.
• Cervical length measurement: An ultrasound technique that measures the length of your cervix can identify preterm labour.

High-Risk Pregnancy Management

We take care of many high-risk pregnancies at “My OBGYN”. There are a variety of different conditions that qualify as a high-risk pregnancy.

Most pregnancy complications can easily be detected and prevented during regular prenatal visits.

The most common complications that arise during pregnancy are

• Twin Pregnancy,
• High blood pressure in pregnancy,
• Diabetes in pregnancy (gestational diabetes)
• Poor fetal growth and
• Anaemia
• Thyroid disease in pregnancy.

Our practice is unique in that we have different protocols to guide management of high risk pregnancies. A protocol is a list of

• Specific blood tests,
• Ultrasounds,
• Frequency of visits,
• etc.

that we follow for each high risk condition. Each protocol is evidence based, which means that they are derived from the best available medical research.

Managing High Risk Pregnancy

Things you need to know about high-risk pregnancies:

• It is generally agreed that high risk pregnancies are best managed in a well equipped maternity hospital. Dr Alexander only delivers at The Mater Mothers Hospital for that particular reason. A tertiary hospital like the Mater hospital can cater for both low risk and high risk pregnancies.
• You are advised to report to Dr Alexander if you have vaginal bleeding, pain or cramps in the lower abdomen, watery vaginal discharge or decreased foetal movements.

High-risk pregnancies may instil fear in many, but it is important to stay positive and follow Dr Alexander’s instructions for a healthy and successful pregnancy.

Twin Pregnancy

A twin pregnancy is more likely to occur in women with late pregnancies because more than one egg might get released at a time as a result of hormonal disturbances. Sometimes, a twin pregnancy may be expected when assistive reproductive techniques such as in vitro fertilisation have been used. Regardless of the cause for twin pregnancy, you need special care..

Dr Alexander may diagnose twin pregnancy at your first visit by ultrasound. If unexpected, the findings could give the couple mixed feelings of joy and anxiety.

During a twin pregnancy, you need to take extra care of yourself and the babies and you should have:

• Frequent checkups: Frequent visits to the doctor are often recommended to monitor your babies’ growth, your health and to check signs of preterm labour
• Healthy nutritious diet: You should have more amounts of folic acid, calcium, iron and proteins in your diet. You may take vitamin and iron supplements as per Dr Alexander’s recommendation.
• Appropriate weight gain:  It is recommended to gain about 12 to 16 kilograms throughout your pregnancy if you have a twin pregnancy and it is important to gain appropriate weight to support your babies’ health.
• Precautions: You should refrain from certain activities that may cause strain such as work, travel or strenuous exercise as pregnancy progresses.

It is important that you remain aware of possible complications in a twin pregnancy. High blood pressure is more likely and when it occurs in combination with proteinuria (protein in the urine), it is called preeclampsia, which is a serious complication. There is also an increased risk of preterm labour that may lead to complications such as low birth weight, breathing difficulty, underdeveloped organs, learning and developmental problems in the newborn. Most women having twins may need C-section delivery. Therefore, discuss with Dr Alexander and get prepared mentally as well as physically for C-section.

Have regular medical visits, proper diet and follow the instructions of your obstetrician to have a safe and successful delivery of twins or multiple babies.

High Blood Pressure During Pregnancy

Pregnancy Induced Hypertension (PIH), or preeclampsia (PET) if the rise in blood pressure is accompanied by more systemic symptoms and organ abnormalities including liver kidneys placenta and brain. It is a pregnancy complication that usually starts after the 20th week of pregnancy. It is one of the main causes of concern in pregnant women, as a severe form of PET may necessitate early premature induction of labour.

It is important to remember that hypertension during pregnancy is a serious condition and should be addressed in order to prevent further complications.

Signs of Preeclampsia

You should watch for signs such as

• rapid weight gain of 4-5 lbs in a week,
• severe headaches,
• blurred vision,
• severe pain in the stomach under the ribs

Pregnancy induced hypertension might also be accompanied with other conditions such as

• protein in the urine,
• swelling and
• convulsions as end stage

The condition can be detected during antenatal visits and should be treated appropriately. If you have any concerns between appointments you should consult Dr Alexander immediately.

The condition can be detected during antenatal visits and should be treated appropriately. If left untreated, this condition can cause serious problems for both the mother and the baby. In the mother.

Causes High Blood Pressure During Pregnancy (pre-Eclampsia)

If PIH is left untreated, this condition can cause serious problems for both the mother and the baby.

For the mother, Pregnancy induced hypertension can cause 

• placental abruption (premature detachment of the placenta from the uterus)
• Cerebro-vascular accident ( like strock )
• liver inflammation, liver and kidney failure
• seizures.

For the baby, Pregnancy induced hypertension can cause 

• less blood flow to the placenta.
• premature birth,
• low birth weight,
• stillbirth, or
• growth restriction.

Routine Checkups and Tests

During a routine check-up, Dr Alexander will check your

• blood pressure,
• urine levels, and
• may order blood tests which may show if you have preeclampsia.

Treatments for Preeclampsia

Pregnancy induced hypertension (PIH) is a condition that should be taken care of in order to prevent further complications. Treatment options which include

• medications,
• dietary modifications,
• minimal stress and activity
• sufficient rest.

In severe cases Dr Alexander may want your baby to be delivered.

High Blood Sugar During Pregnancy

Gestational Diabetes

Gestational diabetes is a condition in which the level of sugar in your blood becomes higher than normal. This condition can develop in the second trimester and most often returns to normal soon after delivery.

Risks of Pregnancy Induced High Blood Sugar

High blood sugar levels can affect both the mother as well as the development and growth of the baby.

Poorly controlled or uncontrolled gestational diabetes

• Increases the risk of preeclampsia,
• Preterm delivery,
• Large-sized baby,
• Caesarean section,
• Newborn with low blood sugar,
• Breathing difficulties and
• Jaundice.

Signs of Pregnancy Induced High Blood Sugar 

Normally there are few symptoms except sometimes patients can show

• Extreme thirst,
• Hunger or
• Tiredness

Routine Checkups and Tests Pregnancy Induced High Blood Sugar

The tests for diabetes are done in the 28th week of pregnancy. Dr Alexander may check your blood glucose level using a number of tests such as:

• Fasting blood glucose test.
• Screening glucose challenge test
• Oral glucose tolerance test

Treatments for Pregnancy Induced High Blood Sugar 

Pregnancy induced diabetes can usually be controlled by

• Certain dietary changes,
• Regular exercise, and
• Frequent blood tests as suggested by Dr Alexander.

Some cases might also require use of a hormone to keep the blood sugar levels under control.

Even if the gestational diabetes goes away after your baby is born, it increases your risk for diabetes later in your life.

Therefore, it is important to exercise, eat a healthy diet and maintain a healthy weight after pregnancy.

Anaemia During Pregnancy

Anaemia, characterised by low oxygen-carrying capacity of the blood, can occur during pregnancy.

During pregnancy the blood production in the body increases in order to support your baby's growth, but sometimes, insufficient iron or other nutrient intake hampers the body's ability to produce sufficient red blood cells, which carry oxygen to the tissues.

Types of Anaemia

The three major types of anaemia that develop during pregnancy are

• Iron-deficiency anaemia (most common),
• Vitamin B12 deficiency and
• Folate deficiency anaemia.

In its early stages, anaemia may not show any symptoms or the symptoms may be common to those experienced during pregnancy without anaemia.

During Pregnancy Induced Anaemia

Anaemia during pregnancy can make you

• Feel tired and weak,
• Dizzy and may cause shortness of breath,
• Increased heartbeat,
• Problems in concentration, and
• Paleness of the lips, skin and nails.

Risks of Anaemia During Pregnancy

If left untreated, it may increase the risk of preterm (premature) delivery.

Routine Checkups and Tests for Anaemia During Pregnancy

Routine blood tests are important to detect anaemia in its early stages. Dr Alexander will suggest a blood test during the first prenatal appointment.

Lower levels of haemoglobin and red blood cells in the haematocrit test may indicate anaemia. Tests are repeated during the second or third trimester.

Treatments for Pregnancy Induced Anaemia

Anaemia during pregnancy can be treated with iron and folic acid supplements. Dr Alexander will advise you to include foods rich in iron and folic acid in your diet.

You can prevent anaemia by including

• Eggs,
• Poultry,
• Fish,
• Lean red meat,
• Dark green and leafy vegetables,
• Iron-rich cereals, and
• Nuts in your diet.

To improve iron absorption in your body, you can also include vitamin C rich foods like

• Citrus fruits,
• Tomatoes,
• Capsaicin and
• Strawberries,

Vegetarians and vegans should consult their doctor regarding taking vitamin B12 supplements during pregnancy and breastfeeding.

Recurrent Miscarriage

Miscarriage is the spontaneous loss of pregnancy before the 20th week and is one of the most common complications of pregnancy. Two or more consecutive pregnancy losses is termed as recurrent miscarriage.

Causes

The following may cause pregnancy losses:

• Genetic abnormality
• Abnormalities in egg, sperm or early embryo
• Abnormalities in the uterus or womb, such as fibroids (lumps)
• Antiphospholipid syndrome (APS): production of antibodies by the immune system that attack fat cells in blood, leading to clot formation
• Hormonal abnormalities: Polycystic ovarian syndrome, uncontrolled diabetes
• Immune system problems
• Bacterial infections in the vagina

The following are factors that could increase your risk for recurrent miscarriages:

• You and your partner are above the age of 35
• You are overweight or underweight
• Previous pregnancy loss

Diagnosis

Your physician initially performs a detailed medical and physical examination and reviews your family and genetic history. Several different tests are used for the diagnosis of recurrent miscarriage:

• Karyotype testing (testing of the genetic makeup) of both partners to find abnormalities that can pass on to the offspring, which could result in repeated miscarriage
• Uterus is evaluated using ultrasound scans and imaging techniques to detect the presence of fibroids
• Anti-phospholipid antibodies are evaluated to check for APS
• Hormone function tests and thyroid function tests to check for abnormalities in hormonal levels
• Ovarian reserve tests to check the functioning of the ovaries

Treatment

Treatment for patients with recurrent pregnancy loss is based on the cause of the miscarriage. If you have a genetic cause, you will be recommended genetic counselling, where you are counselled about the genetic abnormality and the possibility of having a normal pregnancy in the future.

Older Women and Pregnancy

Women who become pregnant late in their lives can experience other problems during their pregnancy and after childbirth. However, some women may experience safe and successful pregnancies even if they have late pregnancy.

Planning a pregnancy much later in your life, in your late thirties or early forties poses a greater risk of pregnancy-related complications and other health problems to both you and your baby.

Knowledge of the genetic disorders and chromosomal defects that may occur and the tests that can detect these problems during pregnancy can help decrease the incidences of complications.

Discuss with Dr Alexander and ensure that any existing medical conditions such as

• high blood pressure,
• diabetes and
• Thyroid diseases are under control before you plan a pregnancy. 

You may be advised to take vitamin supplements with folic acid that helps prevent neural tube defects.

Risks for Older Pregnant Women

As you become older, your chances of becoming a mother decrease, and also the risk of miscarriage increases.

Infertility may be attributed to uterine conditions such as endometriosis, fibroids and blocked fallopian tubes. 

With advancing age, there is greater occurrence of chromosomal aberrations and a higher risk of giving birth to a child with genetic disorders such as Down’s syndrome.

Down’s Syndrome is caused by the presence of an extra chromosome. However, detection of these chromosomal abnormalities early in the pregnancy is possible through screening tests performed in the first trimester.

Maternal blood tests, ultrasound, chorionic villus sampling and amniocentesis are the screening tests.

Labour for Older Women

Problems during labour do occur and it is found that the second stage of labour is more prolonged in older women. This is likely to increase the possibility of a forceps or vacuum assisted vaginal delivery or a Caesarean section.

Stillbirth or delivery of a baby that has died in the womb is more common in older women. Also, women getting pregnant late in their lives have more chances of delivering twins or triplets, which is usually considered a risk.

Preparation for Birth

Therefore, women who have late pregnancies must maintain good health both before conceiving and during pregnancy to reduce complications and have a safe as well as successful pregnancy.

Eat a healthy, well-balanced diet with green leafy vegetables, beans, citrus fruits that are natural sources rich in folic acid. Avoid consuming alcohol and smoking during pregnancy. Regular antenatal care throughout your pregnancy is needed to monitor your health and prevent developing complications.

Discuss with Dr Alexander before planning pregnancy and follow the instructions carefully.

Hyperthyroidism During Pregnancy

The thyroid gland is located in front of your neck just below the voice box (larynx). It makes two hormones thyroxine (T4) and triiodothyronine (T3) that regulate body metabolism.

Thyroid hormone production is controlled by another hormone called thyroid-stimulating hormone (TSH), which is released by the pituitary gland, a pea-sized gland located in the brain.

Thyroid disease is a condition that affects the function of the thyroid gland. Thyroid disease results in production of too much or too little of the thyroid hormone. Hyperthyroidism is the disorder that occurs if the thyroid gland produces too much thyroid hormone and may cause the body's functions to speed up. Hypothyroidism is the disorder that occurs if the thyroid gland produces too little thyroid hormone and may cause the body functions to slow down. Some women have a thyroid disorder that may begin before or during pregnancy or soon after delivery.

Risks from Thyroid Disorders

Thyroid disorders during pregnancy may affect both mother and baby. But with proper treatment, most women with thyroid disorders can have a healthy baby.

Human chorionic gonadotropin (hCG) and estrogen are the hormones produced during pregnancy that cause increased thyroid hormone levels in your blood. Estrogen increases the amount of thyroid-binding globulin, a protein that is responsible for carrying thyroid hormone. Sometimes, the interpretation of tests for thyroid disease is difficult because of the normal changes in the thyroid activity that occurs during pregnancy.

Thyroid hormone is very essential for the normal development of the fetal brain and nervous system. During the first trimester of pregnancy, the fetus is completely dependent on the mother for supply of thyroid hormone. At 10 to 12 weeks, the baby’s thyroid gland begins to produce thyroid hormone on its own. The baby, however, remains dependent on the mother for supply of iodine, which is essential to make the thyroid hormones. During pregnancy, women need about 250 micrograms (µg) of iodine per day, which can be ensured by use of iodized salt, salt supplemented with iodine.

During pregnancy, the thyroid can slightly increase in size but is not apparent on physical examination by the physician. However, a significantly enlarged gland can be a sign of thyroid disease and should be assessed. Symptoms such as fatigue, higher level of thyroid hormone in the blood, and enlarged thyroid size are common to both pregnancy and thyroid disease that can make the diagnosis difficult.

Graves’ Disease in Pregnancy

The most common cause of hyperthyroidism during pregnancy is Graves’ disease.

Graves' disease is a condition in which the thyroid gland produces excessive hormones (hyperthyroidism). With Graves' disease, the immune system makes antibodies that attack the thyroid cells and stimulate the thyroid gland to make more thyroid hormones than your body actually needs.

Graves’ disease may be present initially during the first trimester, and in women with pre-existing Graves’ disease. The condition may often improve during the second and third trimester of pregnancy but may worsen during the postpartum period. In addition to other causes, very high levels of hCG, seen in severe forms of morning sickness (hyperemesis gravidarum), may cause transient hyperthyroidism that usually resolves by the second half of pregnancy.

Causes of Hypothyroidism in Pregnancy

The most common cause of hypothyroidism during pregnancy is the autoimmune disorder known as Hashimoto’s thyroiditis.

Hashimoto's disease is a condition caused by chronic inflammation of the thyroid gland. The resulting inflammation often leads to hypothyroidism, an underactive thyroid gland.

With Hashimoto’s disease, the immune system makes antibodies that attack the thyroid cells and damage your thyroid gland making the gland unable to produce the thyroid hormones that the body needs. This results in hypothyroidism.

During pregnancy hypothyroidism can occur due to inadequate treatment of pre-existing hypothyroidism or from prior destruction or removal of the thyroid as a treatment for hyperthyroidism.

Uncontrolled hypothyroidism during pregnancy, particularly during the first trimester, can result in cognitive and developmental abnormalities in the baby.

Hypothyroidism during pregnancy is treated with synthetic thyroxine, which is same as the T4 made by the thyroid gland. In women with known hypothyroidism, the dose is adjusted as needed to maintain normal thyroid function throughout the pregnancy.

Postpartum Thyroiditis

Postpartum thyroiditis is inflammation of the thyroid gland that occurs after childbirth. It occurs within the first year after delivery, usually from one to eight months postpartum.

Thyroiditis can cause both hyperthyroidism and hypothyroidism. In postpartum thyroiditis, mild hyperthyroidism occurs first followed by hypothyroidism. For some women, hypothyroidism becomes permanent and requires lifelong treatment with synthetic thyroid hormones.

There can be some difficulty in correctly diagnosing postpartum thyroiditis, because the symptoms such as exhaustion and moodiness that sometimes develops after delivery may be mistaken for postpartum blues.

Discuss with Dr Alexander if you have symptoms such as fatigue, lethargy, or postpartum depression that remain for a long period of time. In such a case, you may have developed a permanent thyroid condition and may require treatment.