You’re High-Risk, Now What?
Many women hear these terms at the beginning of their pregnancy, but in reality “high risk” needs explaining. Any pregnancy can be considered high risk for maternal reasons or fetal reasons, and any condition that impacts a woman’s health or the future newborn’s health makes a pregnancy high risk. Although the information below seems extensive, it is not exclusive and for more information you should consult a specialist such as a Maternal-Fetal Medicine OB provider.
Maternal age over 40 and pre-existing conditions such as infertility, diabetes, thyroid disease or arthritis, are just some of the conditions that can influence a pregnancy. Today more than 20 percent of pregnant woman are over age 35. Age alone does not make a pregnancy high risk, but age plus a pre-existing condition creates more of an issue. Many women today delay pregnancy to fulfill career choices, and more women now conceive thanks to assisted reproductive service such as In Vitro, donor egg or donor sperm. Once pregnant these women may not realize how their conditions may change the course of the pregnancy.
To simplify maternal conditions we can separate the issues into pre-existing medical conditions complicating pregnancy (e.g. diabetes), pre-existing surgical conditions (gall bladder disease), prior infertility (IVF), and complications typical of pregnancy caused by the pregnancy itself such as hypertension and pre-eclampsia (a hypertensive disorder only seen in pregnancy also called toxemia), or Gestational Diabetes.
Pregnancy also heralds other conditions such as chronic hypertension, and more importantly, conditions such as Lupus (a form of arthritis), ITP (idiopathic thrombocytopenia or low platelets) and other autoimmune diseases may show up for the first time during pregnancy.
Although cancer is rare in pregnancy, abnormal bleeding, unusual symptoms, tumors and pain can sometimes be symptoms of a cancer. The most common cancers during pregnancy are lymphoma, leukemia, malignant melanoma, cervical and breast cancers. In some instance the cancer will be stimulated by the pregnancy (e.g. breast cancer), but in other cases it is a coincidence and does not progress secondarily to the pregnancy (e.g. cervical cancer).
Infectious diseases are pure complications of pregnancy; the best example is HIV. A primary infection during pregnancy is very high risk for transmission to the fetus, but as in pre-existing conditions, the risk to the fetus is almost nil if the patient is under treatment and has a negative viral load. More common than HIV is Hepatitis C. There is no treatment or prevention of transmission for Hep C, contrarily to HIV.
Chicken Pox, Herpes Zoster and Genital Herpes can be treated. Patient should be tested for these viruses and, if available, should use treatment in the third trimester prior to delivery. The list of viral diseases causing pregnancy complications must include CMV (cytomegalovirus), Parvovirus B19 and influenza. If there is a safe vaccine (influenza) it should be given. However, live attenuated vaccines cannot be used (German measles). Some viral diseases can be fatal during pregnancy (Chicken Pox pneumonia, Influenza) and treatment should be sought immediately to prevent complication.
Psychiatric and social ills are particularly important in pregnancy. Since approximately one percent of society suffers psychiatric disease, pregnancy is no exception. Many women have a diagnosis of depression, bi-polar disease or substance abuse. Alcohol is the number one cause of non-genetic mental retardation. Substance abuse and alcohol go hand-in-hand with depression and these three conditions linked with pregnancy are very dangerous times for women, specifically in the post-partum. Detection of these conditions is key to prevention of morbidity and mortality.
True pregnancy complications such as toxemia (or pre-eclampsia), premature labor, premature rupture of membranes, is a combination of pregnancy and fetal complications, bringing us to the fetus. Genetic disorders, chromosomal disorders, multiple pregnancies (twins, triplets and more) and fetal anomalies are a huge category in and of themselves.
Many studies have shown that maternal age of 40 or greater has very specific risks such as intra-uterine growth restriction and even fetal death. Certainly the health of the mother influences the quality of the pregnancy, but a common misconception about maternal age is that the risk of trisomy 21 or Downs syndrome occurs only in older women. While it does increase with age, any woman could have a child with Downs (trisomy 21). Chromosomal defects are “accidents” that occur after conception. Rarely one of the parents is a carrier of a balanced translocation, but only 1 to 3 percent of chromosomal defects are caused by such a condition. In general one has to assume that trisomy 21 is not an inheritable disease.
Genetic diseases, on the other hand, are caused by either new mutations of specific genes, or by parents being carriers of these mutations. The best example is cystic fibrosis or sickle cell disease. Diagnosis is made by taking a good history and then offering the mother an amniocentesis to check the fetal chromosomes for a specific genetic disease.
Ultrasound is the mainstay of obstetrical care today and is a window into the privacy of the developing fetus. We can detect high-risk pregnancies, such as incorrect dates, multiple pregnancies, uterine anomalies, and placental anomalies. The genetic ultrasound attempts to predict the status of the fetus with the help of serum screening (commonly known as the AFP test). Ultrasound with amniocentesis allows for correct detection of multiple fetal conditions.
Pregnancy is not a disease, but you should seek prenatal care as early as possible to assure a successful and happy pregnancy. Certainly, you cannot always choose how a pregnancy develops, but a team approach to pregnancy care will help the high-risk patient achieve the best success possible.