Managing A High Risk Pregnancy

Every family looks forward to a healthy pregnancy and birth of a healthy newborn.

The act of giving birth is the only moment when both pain and pleasure converge in a moment if time. It is the manner of the sharp point of a needle, astride upon that point are both pleasure and pain, simultaneously assailing the female that is undergoing the miracle of child birth.

For the vast majority women, pregnancy follows a fairly routine course. But, for some, there may be unexpected difficulties and challenge along the way with a high- risk pregnancy.

High risk pregnancy means that a woman has greater chance of complications because of conditions in her pregnancy, her own medical status or lifestyle or due to external factors, which can lead to fatal consequence either for the mother or the baby.

While many complications are unavoidable, with the help of the obstetrician, the expectant mother can minimize the risks and work towards the healthiest pregnancy possible.

Fortunately advances in technology have helped improve the care of both mothers and unborn babies.

A pregnancy can be considered to be high risk for a variety of reasons. Factors can be divided to be maternal & fetal.

Maternal factors include

1. age (younger than 18 & older than 35),
2. over weight or obese
3. height shorter than 5 feet
4. history of complications during previous pregnancies (including still birth, fetal loss, pre term labour and/ or delivery, small-for-gestational age baby, large baby, pre-eclampsia), more than 5 previous pregnancies, bleeding during the third semester, abnormalities of the reproductive tract, uterine fibroids, hypertension, Rh incompatibility, gestational diabetes, infections of the vagina and/or cervix, kidney infection, cardiac disease & SLE.

Existing chronic illness as asthma, auto immune disease, tuberculosis also affect the normal course of pregnancy.

Fetal factors include

• exposure to infection especially herpes simplex, viral hepatitis, chicken pox,
• exposure to addictive substances as cigarette smoking, alcohol intake and illicit or abused drug intake.
  

Before becoming pregnant, a woman may have a disorder that can increase the risk of problems during pregnancy. These women need to talk to the obstetrician and try to get in the best physical condition possible before they become pregnant.

The common problems as may be faced during pregnancy are:

High Blood Pressure

Women who have high blood pressure or chronic hypertension before they become pregnant are more likely to have potentially serious problems during pregnancy. High blood pressure can decrease blood flow to the placenta, which affects the baby?s supply of oxygen and nutrients. This will slow the baby?s growth and increase the risk of preterm delivery. High blood pressure also increases the risk of placental abruption in which the placenta prematurely separates from the uterus. During the pregnancy period, these women are monitored closely to make sure blood pressure is well controlled, the kidneys are functioning normally and the foetus is growing as it should. Approximately 5 to 8% women develop high blood pressure during pregnancy, leading to preeclampsia, characterized by increased blood pressure and protein in the urine.

Anaemia

Having a hereditary anaemia such as sickle cell disease, haemoglobin S-C disease and some thalassemia, increases the risk of problems during pregnancy. Before delivery, blood tests are routinely performed to check for haemoglobin abnormalities. Women with sickle cell disease are at the risk of developing infections during pregnancy. Pneumonia, urinary tract infections and infections of the uterus are most common.

Jaundice

Jaundice in pregnancy could be dangerous because pregnancy puts extra load on the liver in terms of raising the enzyme level, and this is so even in the normal pregnancy. In case of jaundice, liver damage is more acute and if not treated properly, there could be a risk of bleeding disorder. It can also lead to Hepatic failure and Hepatic coma leading to loss of maternal and foetal life. Hospitalization is advised if the patient is found to be having jaundice and preferably in a set up with high dependency unit.

Asthma

In about half of the women who have asthma and become pregnant, the frequency or the severity of asthma attacks does not change during pregnancy. Pregnant women with asthma should see their doctors very regularly so that the treatment can be adjusted as per the fluctuations in asthma level.

Fibroids & Ovarian Cysts

Fibroids have the effect of increasing preterm labour, abnormal presentation of the foetus, a mislocated placenta (placenta previa) and repeated miscarriages. Rarely fibroids interfere with the movement of the foetus through the vagina during labour. However there could be some situations when ovarian cysts need to be taken out between 14-20 weeks of pregnancy.

Diabetes

In pregnancy two types of diabetes may occur:

• Gestational Diabetes- when a mother who does not have diabetes develop resistance to insulin because of the hormones of pregnancy. Women with gestational diabetes may or may not be insulin dependant. This occurs in about 7% of the pregnancies. It goes away as soon as the baby is born. Screening for gestational diabetes usually takes place between 24 to 28 weeks. However women at high risk are usually screened during the 1st trimester.
• Pre-existing Diabetes-women who already have type I insulin-dependant diabetes and become pregnant.

Women develop gestational diabetes during pregnancy, some factors that may increase the risk are:

• Family history of diabetes
• Obesity
• Age, women who are older than 25 years are at greater risk than younger women
• Giving birth to a baby that weighed more than 9 pounds.

Treatment for gestational diabetes focuses on keeping blood glucose levels in the normal range. Treatment includes exercise, special diet, daily glucose monitoring & insulin injections.

Heart Disease

Most women who have heart disease including heart valve disorders and some birth defect of the heart, can safely give birth to healthy children, without any permanent ill effects on heart function or life span. However women who have heart failure before pregnancy are at considerable risk of problems. Pregnancy requires the heart to work harder. Consequently, this may worsen the heart disease. The same can also affect the foetus. The foetus may be bprn prematurely.

Communicable Diseases

Chicken Pox, Measles, Viral Infections, Malaria, Typhoid are some of the common communicable diseases that an expectant mother can have while pregnant. The doctor needs to be consulted immediately. As a preventive measure, all the requisite vaccinations must be taken in consultation with the doctor so that such risk factors are minimized.

Obesity

Obesity is associated with many pregnancy complications. It is always more difficult for women to get pregnant when they are overweight, and if pregnancy does occur, the risk of complications during pregnancy and problems for the baby after birth increase dramatically. It can lead to diabetes, high blood pressure and delivery problems.

Underweight

The main risk associated with underweight women is IUGR or intra uterine growth retardation. Probability of having the delivery through surgical procedures also increases.

As an obstetrician we advise the following DON?T?s during pregnancy:

1. You should not drink alcohol.
2. You should not smoke or be around people who does
3. You should not take Over The Counter (OTC) drugs without consulting your doctor.
4. You should avoid caffeine intake.
5. You should avoid eating junk food.
6. You should avoid stress.
7. You should not expose yourself to pesticides.
8. You should avoid fumes from paint, paint thinner, household cleaning products and such other harmful substances.
9. You should not use a sauna, hot tub or take long hot baths

A healthy and normal diet must be followed throughout the entire course of pregnancy. It must be remembered that the diet affects the baby?s health.

Recent research shows that folic acid helps prevent neural tube defects from occurring in the early stages of foetal development. So it is important that the expectant mother consumes plenty of folic acid before pregnancy and during the early weeks.

Calcium is another important nutrient for pregnant women. Because the growing baby?s calcium demands are high, the mother should increase her calcium consumption to prevent loss of calcium from bones. Best food sources of calcium are milk and other dairy products.

Some of the most common nutrients that the expectant mother needs and the food that contains them are:

Nutrient	Needed For	Best Sources
Protein	Cell growth and blood production	Lean meat, fish, poultry, egg whites, beans, peanut butter
Carbohydrates	Daily energy production	Breads, Cereals, Rice, Potatoes, Pasta, Fruits, Vegetables
Calcium	Strong bones and teeth, muscle contraction, nerve function	Milk, Cheese, Yoghurt, Spinach
Iron	Red Blood Cell production	Lean red neat, spinach
Vitamin A	Healthy Skin, Good Eyesight, Growing Bones	Citrus fruit, Brocoli, tomatoes, fortified fruit juices
Vitamin B6	Red Blood Cell formation, effective use of protein, fat and carbohydrates	Whole grain cereals and bananas
Vitamin B12	Formation of red blood cells, maintaining nervous system health	Meat, Fish, Poultry, Milk
Vitamin D	Healthy bones and teeth	Fortified milk, dairy products, cereals and breads
Folic Acid	Blood and Protein production, effective enzyme function	Green leafy vegetables, dark yellow fruits and vegetables, beans, peas and fruits
Fat	Body energy stores	Meat, whole-milk dairy products, nuts, butter, margarine, vegetable oils

A woman with high- risk pregnancy will need closer monitoring than the average pregnant woman. Such monitoring include more frequent visits with the doctor, tests to monitor the medical problem, blood tests to check the level of medication, aminocentesis, serial ultrasound examination and fetal monitoring. These tests are done to trace the original condition, survey for complications & verify that the fetus is growing adequately.

As an obstetrician, our advice to the expectant mothers is to visit the doctor at regular intervals for close monitoring, specially so if such high risk factors are present.

Pregnancy is a lifetime experience. Let the journey be a cherishing one for all such mothers who are aspiring to be in the family way.