High risk pregnancy
Definition of high risk pregnancy :
High-risk pregnancy refers to a pregnancy during which a condition puts the mother, developing fetus or both at a higher-than-normal risk for complications. Or any conditions past or present can jeopardize either the mother or the fetus during pregnancy, labor or early puerperium.
Why High Risk pregnancy is important?
In a high-risk (at-risk) pregnancy, the mother, fetus, or neonate is at increased risk of morbidity or mortality before or after delivery. Nearly half of maternal deaths are preventable.
The most common causes of maternal death worldwide are:
- Hemorrhage (27.1 %)
- Preeclampsia (14.0 %)
- Sepsis (10.7 %)
- Abortion (including induced abortion, miscarriage, and ectopic pregnancy)
- Pulmonary embolism
- Obstetric complications e.g., pre eclampsia eclampsia.
- Other disorders (eg, preexisting disorders such as HIV infection)
Perinatal mortality rate :
perinatal deaths are deaths of a fetus at 28 week till the end of first week of neonate. It is divided about equally between those during the late fetal period (gestational age > 28 weeks) and those during the early neonatal period (< 7 days after birth).
The most common causes of perinatal death are:
- Obstetric complications
- Maternal disorders (eg, hypertension, diabetes mellitus, obesity, autoimmune disorders)
- Infection
- Placental abnormalities
- Congenital malformations
- Preterm delivery
High-Risk Pregnancy may be due to
- Condition present before current pregnancy
- Medical eg DM. fits. Hypertension, thyroid problems, autoimmune disease, heart disease…etc
- Surgical e.g., thyroidectomy, previous CS previous myomectomy
- Social e,g,. Poverty, extremity of ages, history of Drug abuse or smoking.
- Pschological factors
- Previous Obstetrics history e.g., history of gestational hypertension or gestational DM, previous twins, neonatal or antenatal fetal death, recurrent pregnancy loss.
- Previous history of infertility
- Previous history of hormonal treatment or blood transfusion
- Have previous health issues including cancer, organ transplant, sexually transmitted infections or weight loss surgery.
- Are over age 35 or younger than 18.
- Body Mass index < 18 or greater than 30
- Smoke. Use drugs or Drink alcohol.
- Bleeding early or late
- Have high blood pressure.
- Have Gestational diabetes.
- Have seizures.
- Have a family history of genetic defects.
- Are expecting multiples (twins, triplets).
- Infection during current pregnanc
2. Psychological Factors
- History of drug dependence
- History of intimate partner abuse
- History of mental illness
- Loss of support person
- Poor acceptance of pregnancy
- Severely frightened by labor and birth experience
- Inability to participate because of anesthesia
3. Illness in newborn ( Social Factors )
- Occupation involving handling of toxic materials
- Environmental contaminants
- Isolated (Single mother)
- Low economic level
- Poor access to transportation
- Poor housing
- Refusal or neglected prenatal care
- Disruptive family incident
- Conception less than one year after last pregnancy
- Lack of support person
- Inadequate home for infant care
- Lack of access to continued health care
- 4. Physical Factors
- Pelvic inadequacy or misshape
- Uterine incompetency, position or structure
- Secondary major illness
- Poor gynecologic or obstetric history
- Obesity
- Underweight
- PID
- Potential of blood incompatibility
- Younger than 18 years old and older than 35 years old
- Cigarette smoker
- Substance abuser
- Subject to trauma
- Bleeding disruption
- Gestational diabetes
- Nutritional deficiency
- Infection
- Hemorrhage
- Cephalo-pelvic disproportion
- Retained placenta
Existing Health Conditions
High blood pressure. Even though high blood pressure can be risky for mother and fetus, many women with high blood pressure have healthy pregnancies and healthy children. Uncontrolled high blood pressure, however, can lead to damage to the mother’s kidneys and increases the risk for low birth weight or preeclampsia.
Diabetes.
It is important for women with diabetes to manage their blood sugar levels before getting pregnant. High blood sugar levels can cause birth defects during the first few weeks of pregnancy, often before women even know they are pregnant. Controlling blood sugar levels and taking a multivitamin with 40 micrograms of folic acid every day can help reduce this risk.
Existing Health Conditions
Kidney disease.
Women with kidney disease often have difficulty getting pregnant, and any pregnancy is at significant risk for miscarriage. Pregnant women with kidney disease require additional treatments, changes in diet and medication, and frequent visits to their health care provider
Autoimmune disease.
Autoimmune diseases include conditions such as lupus and multiple sclerosis. Some autoimmune diseases can increase a women's risk for problems during pregnancy. For example, lupus can increase the risk for preterm birth and stillbirth. Some women may find that their symptoms improve during pregnancy, while others experience flare ups and other challenges. Certain medications to treat autoimmune diseases may be harmful to the fetus as well
Thyroid disease.
Uncontrolled thyroid disease, such as an overactive or underactive thyroid (small gland in the neck that makes hormones that regulate the heart rate and blood pressure) can cause problems for the fetus, such as heart failure, poor weight gain, and birth defects.
Infertility.
Several studies have found that women who take drugs that increase the chances of pregnancy are significantly more likely to have pregnancy complications than those who get pregnant without assistance. These complications often involve the placenta (the organ linking the fetus and the mother) and vaginal bleeding.
Obesity.
Obesity can make a pregnancy more difficult, increasing a woman’s chance of developing diabetes during pregnancy, which can contribute to difficult births.8On the other hand, some women weigh too little for their own health and the health of their growing fetus. In 2009, the Institute of Medicine updated its recommendations on how much weight to gain during pregnancy.9 New recommendations issued by the American College of Obstetricians and Gynecologists suggest that overweight and obese women may be able to gain even less than what is recommended and still have a healthy infant.
HIV/AIDS.
HIV/AIDS damages cells of the immune system, making it difficult to fight infections and certain cancers. Women can pass the virus to their fetus during pregnancy; transmission also can occur during labor and giving birth or through breastfeeding. Fortunately, effective treatments exist to reduce the spread of HIV from the mother to her fetus, newborn, or infant. Women with very low viral loads may be able to have a vaginal delivery with a low risk of transmission. An option for pregnant women with higher viral loads (measurement of the amount of active HIV in the blood) is a cesarean delivery, which reduces the risk of passing HIV to the infant during labor and delivery. Early and regular prenatal care is important. Women who take medication to treat their HIV and have a cesarean delivery can reduce the risk of transmission to 2%.
Age
Teen pregnancy. Pregnant teens are more likely to develop high blood pressure and anemia (lack of healthy red blood cells), and go into labor earlier than women who are older. Teens also may be exposed to a sexually transmitted disease or infection that could affect their pregancy.12 Teens may be less likely to get prenatal care or to make ongoing appointments with health care providers during the pregnancy to evaluate risks, ensure they are staying healthy, and understand what medications and drugs they can use.
First-time pregnancy after age 35. Older first-time mothers may have normal pregnancies, but research indicates that these women are at increased risk of having14:
A cesarean) delivery (when the newborn is delivered through a surgical incision in the mother’s abdomen)
Delivery complications, including excessive bleeding during labor
Prolonged labor (lasting more than 20 hours)
Labor that does not advance
An infant with a genetic disorder, such as Down syndrome.
Lifestyle Factors
Alcohol use.
Alcohol consumed during pregnancy passes directly to the fetus through the umbilical cord. The Centers for Disease Control and Prevention recommend that women avoid alcoholic beverages during pregnancy or when they are trying to get pregnant.15 During pregnancy, women who drink are more likely to have a miscarriage or stillbirth. Other risks to the fetus include a higher chance of having birth defects and fetal alcohol spectrum disorder (FASD). FASD is the technical name for the group of fetal disorders that have been associated with drinking alcohol during pregnancy. It causes abnormal facial features, short stature and low body weight, hyperactivity disorder, intellectual disabilities, and vision or hearing problems.
Cigarette smoking.
Smoking during pregnancy puts the fetus at risk for preterm birth, certain birth defects, and sudden infant death syndrome (SIDS). Secondhand smoke also puts a woman and her developing fetus at increased risk for health problems.
Conditions Complicating Pregnancy
- Bleeding in early pregnancy (abortion, Molar pregnancy, Ectopic pregnancy)
- Hyperemesis gravidarum
- Hypertension with pregnancy (Gestational hypertension, PET, Eclampsia and HELLP syndrome).
- Gestational diabetes
- Bleeding in late pregnancy (placenta previa, abruptio placenta)
- Peri-natal Loss
Conditions of current Pregnancy
It is possible to a pregnant to develop or be diagnosed with problems during pregnancy that can affect her and her fetus. Two of the more common pregnancy-related problems are:
1_ Gestational diabetes.
Gestational diabetes, also known as gestational diabetes mellitus, GDM, or diabetes during pregnancy, is diabetes that first develops when a woman is pregnant. Many women can have healthy pregnancies if they manage their diabetes, following a diet and treatment plan from their health care provider. Uncontrolled gestational diabetes increases the risk for preterm labor and delivery, preeclampsia, and high blood pressure.
2- Preeclampsia and eclampsia.
Preeclampsia is a syndrome marked by a sudden increase in the blood pressure of a pregnant woman after the 20th week of pregnancy. It can affect the mother's kidneys, liver, and brain. When left untreated, the condition can be fatal for the mother and/or the fetus and result in long-term health problems.
Eclampsia is a more severe form of preeclampsia, marked by seizures and coma in the mother.
3-Other pregnancy-related issues.
Often a pregnancy is classified as high risk because of issues that arise from the pregnancy itself and that have little to do with the mother's health. These include:
- Premature labor is labor that begins before 37 weeks of pregnancy. Although there is no way to know which women will experience preterm labor or birth, there are factors that place women at higher risk, such as certain infections, a shortened cervix, or previous preterm birth.
- Multiple births means pregnant women are carrying more than one baby (twins, triplets, quadruplets, etc.). Multiple pregnancies, which are more common as women are using more infertility treatments, increase the risk of premature labor, gestational diabetes, and pregnancy-induced high blood pressure.
- Placenta previa is a condition in which the placenta covers the cervix. The condition can cause bleeding, especially if a woman has contractions. If the placenta still covers the cervix close to delivery, the doctor may schedule a cesarean section to reduce bleeding risks to the mother and baby.
- Problems, which can sometimes be seen on ultrasound. approximately 2% to 3% of all babies have a minor or major structural problem in development. Sometimes there may be a family history of fetal problems, but other times these problems are completely unexpected.
- Perinatal Loss
- Death of the fetus after 28 weeks or death of the baby in the first week of life
- Death of a fetus or newborn no matter when it occurs is devastating to the mother and family.
