What is High Risk Pregnancy?

A High-Risk Pregnancy is a pregnancy which has a significant chance of developing serious health issues for mother or baby or both. Sometimes these cases are identified in early visits of antenatal care, but in other cases complications may arise lately in a smooth going pregnancy.  15% of all pregnancies could be High Risk Pregnancy. Some factors contributing  to high-risk pregnancy can’t be changed. But you can make some changes which can increase your chances of having a healthy pregnancy

Risk factors for High-risk pregnancy:

There are many factors that can make a pregnancy high-risk.. However, there are factors that may be present before you become pregnant that can cause a high-risk pregnancy. Even if you are healthy when you become pregnant, it is possible to develop or be diagnosed with problems during pregnancy that can affect mother and baby.

Risk factors related to mother

• Anemia (mostly severe anemia)
• Pregnancy at Younger age (<20yrs), Elderly (>35yrs)
• Hypertensive disorder
• Thyroid disorders
• Diabetes Mellitus
• Gestational Diabetes Mellitus (increased sugar levels first time detected during pregnancy)
• Rh Incompatibility (mother’s Blood group Negative and father’s positive)
• Heart diseases
• Asthma
• HIV positive, Hepatitis B Carrier
• Family history of Genetic diseases
• Smoking and Alcohol
• Psychiatric illness
• Sexually Transmitted Diseases
• Prior Caesarean delivery
• Infections and medical conditions developed during pregnancy

Risk factors related to baby

• Genetic/Chromosomal abnormalities
• Congenital anomaly
• Growth restricted baby (Small baby)
• Previous history of fetal death/still birth/neonatal death
• Twins or Multiple pregnancies
• Malpresentation (abnormal baby position)

Other risk factors

• Malnutrition
• Low lying placenta / placenta previa
• Bleeding in pregnancy
• Premature rupture of membranes/ Preterm deliveries
• Fibroid in pregnancy

Alarming Signs for High-Risk Pregnancy

• Severe Vomiting
• Vaginal Bleeding at any time of pregnancy
• Pain in lower abdomen
• Severe swelling of face, limbs and vulva (Genital area)
• Severe headache
• Blurring of vision
• Pain on epigastric area (just below chest)
• Fever
• Less fetal movement
• Severe itching of sole and palm

Management of High-Risk Pregnancy

Before you become pregnant, it is important for you to practice good nutrition and a healthy lifestyle. Good prenatal care and medical treatment during pregnancy can also help prevent complications

Management for a high-risk pregnancy will depend on your risk factors, past and present health conditions. A customized care plan is needed for effective management of the pregnancy

A: Preventing Pregnancy Complications

To start with, one need to register with an Obstetrician or Hospital at the earliest to identify possible risks before planning for pregnancy.

Preconceptional Counselling need to be done by Visiting an specialist Obstetrician before planning a pregnancy. Getting proper knowledge regarding pregnancy, its course and outcome, getting essential treatment for pre-existing diseases and to optimise health before pregnancy are the part of preconceptional counselling. Below are some key procedures done during the counselling:

• Elaborate history taking of patient and Family
• Examination and Laboratory tests as needed
• Vaccination in nonimmunized women (Rubella and Hepatitis)
• Pre-existing medical diseases are evaluated, stabilised
• Optimisation of health status
• Folic acid supplementation
• Screening of Genetic diseases like Sickling and Thalassemia

Mother who has history of previous fetal loss (death of baby before delivery) are counselled appropriately, necessary investigations done and all required treatment given accordingly.

B: Treatment

PRENATAL OR ANTENATAL CARE

Objective of Prenatal care is prevention and treatment of the abnormal maternal and fetal outcome (mother and baby care). A proper regular Prenatal care can detect any abnormality in early phase and treatment can be done to get positive outcome.

 As soon as pregnancy is diagnosed (urine card test positive), mother need to visit obstetrician. In some part of our country, it is believed that pregnant women should visit a doctor after 2-3 months of pregnancy. It’s a MYTH and by doing so one may miss the essential part of treatment.

• Regular visit to Obstetrician: Early referral to specialist and Specialized centre ensures treatment of health conditions in time. Complications can be minimized by regular check-up and following advice properly.
  Investigations/ laboratory tests: other than normal pregnancy tests, mothers are advised for some more specific specialised tests according to their health conditions.
• Prenatal Genetic screening: Prenatal genetic testing is offered to women during pregnancy to determine if the baby has a possibility to be born with a genetic condition or birth defect. Previously it was thought the risks of having such foetal problem is associated with elderly pregnancy or with those who have significant family history. But it has been found that in any age group or any pregnancy such genetic problems could be found. Hence all pregnant women should be offered for such tests in 1st and 2nd

Genetic screening tests gives the probability of Genetic diseases like Down syndrome.  Results showing increased risk are further advised for Diagnostic tests to be performed in special centres. Diagnostic tests to be carried out include Chorionic villous sampling (11-14 weeks) and Genetic Amniocentesis (around 16 weeks).

• NIPT: Cell free DNA testing: This is a non-invasive procedure. Maternal blood sample is collected to examine the Fetal DNA for certain Chromosomal problems (around 10th week)
  ULTRASONOGRAPHY

Ultrasonography is a very useful investigation technique to know the baby’s wellbeing and should be done in all Trimesters of pregnancy as per doctor’s advice.

USG gives complete picture of pregnancy including  

• Age and position of the baby
• Chromosomal/genetic screening any tumour like fibroid or ovarian cyst associated with the pregnancy no of fetus and types of Twin pregnancy
• Anomaly scan (Detailed study of Baby’s anatomic structure)
• Fetal Echo
• Placental location
• Growth of baby
• Doppler tests of arteries to know blood circulation, oxygen supply and
• Wellbeing of baby
• Amount of liquor/fluid inside womb

Serial USG growth and doppler is the best test to diagnose IUGR (small babies) and further monitor their conditions till delivery.

SPECIALISED TESTS or SURVILLENCE/MONITORING FOR FETAL WELLBEING

• Fetal movement /kick count: It’s a traditional and age-old simple practice but very promising and informative test that mother can do by herself.

A mother can perceive the baby’s kick from second half of the pregnancy (18/20 weeks). Proper regular movements are felt from 28 weeks onwards. So, the kick count should be performed daily from 28 weeks onwards.

• A count of 10 or more movements in 12 hours is normal. If the count is less than 10, mother should inform her doctor.
• One other method is to count for 3 sessions (morning, afternoon and evening) for 1 hour each. If the count is less than 3 in an hour, it is said to be less fetal movement.
• Not only count, also the intensity of movement is important, A mother is the best judge to tell how the baby is moving/kicking every day.
• Less fetal movement or less intense/slow movement may be the indicators that the baby is not well and need immediate check up by the obstetrician.

NON-STRESS TEST: These are non-invasive monitoring methods to know the fetal wellbeing done in hospitals.

Fetal Cardiotocography: This is a foetal heart rate monitoring done in hospital. A transducer is placed on mother’s abdomen and a continuous tracing of fetal heart rate with the fetal movement is obtained on a paper. The doctor will read the result and asses the baby’s health. In High-risk pregnancy, this test is done at a frequent interval like once or twice in a week starting from 32 weeks onward.

Biophysical Profile: It is an USG based study in which baby’s different parameters like gross body movement, breathing movement, muscle tone, amount of liquor/ fluid inside womb are evaluated.
SPECIAL LABORATORY BLOOD TESTS

Special blood tests as below may be required along with regular investigations as per the risk conditions.

• Blood sugar levels in each trimester to diagnose and monitor Diabetes mellitus/ Gestational Diabetes
• Urine for protein(albumin) for monitoring Hypertension
• Coomb’s test for Rh negative mothers
• HPLC/ Hb Electrophoresis (to detect Thalassemia or Sickling)
• Thyroid profile (Hypothyroidism)
• LFT/ Bile acids (Obstetric cholestasis)

MULTIDISCIPLINARY APPROACH

Based on the associated risks, pregnant women may need to undergo a multidisciplinary approach for herself or her baby’s condition

• Endocrinologist (Diabetes, Thyroid diseases)
• Medicine specialist (Hypertension, Infective diseases)
• Pulmonologist (Asthma)
• Cardiologist (Hypertension, Cardiac disease, Thromboembolic disorders)
• Haematologist (Severe anaemia, low platelet disorders, Thalassemia, Sickling)
• Pediatrician (counselling before delivery and preparation for the unborn baby)

Living with High-Risk Pregnancy

The outcomes of High-Risk Pregnancy can be minor or life-threatening in severity for both the mother and the baby, requiring extra care and monitoring from your Obstetrician. Mothers often undergo Emotional stress (feeling of distressed ” why my pregnancy is not normal”).  Pregnancies with high risk may not always lead to major problems and you can have a healthy delivery despite high risks if proper care taken as advised.

Though High-Risk Pregnancy seems to be very dangerous and complicated, the outcomes could be positive by preconceptional counselling, optimization of mother’s health, regular prenatal care by an expert, laboratory tests, prenatal surveillance/ monitoring of mother and baby, timely delivery in a tertiary care hospital with multidisciplinary approach.