High Risk Pregnancy

What is a High Risk Pregnancy?

A high risk pregnancy is defined as a pregnancy in which there is a significant risk to the health and life of the mother, the fetus within the womb, or both during pregnancy or immediately after delivery.

Is High Risk Pregnancy a medical emergency?

This can turn into a medical emergency if not adequately diagnosed and managed.

Causes

Several factors can result in a high risk pregnancy, and they include the following:

• Physical conditions of the mother
• Medical conditions affecting the mother
• Pregnancy-related conditions and complications
• Lifestyle factors of the mother

Risk factors

The following are the risk factors associated with this:

• Physical conditions of the mother
  • Age at the time of first pregnancy and delivery: Less than 19 years or more than 35 years (elderly primi)
  • Weight: Underweight or obesity
  • Short stature
• Medical conditions affecting the mother
  • Uncontrolled High Blood Pressure: This can result in damage to the kidneys and may manifest as:
    • Preeclampsia
    • Eclampsia
  • Diabetes mellitus
  • Polycystic ovarian syndrome
  • Renal disease
  • Autoimmune disease
    • The systemic lupus erythematosus (SLE)
    • Multiple sclerosis
  • Thyroid disease
  • Sexually transmitted diseases: Syphilis, HIV, Hepatitis B
  • Untreated severe urinary tract infections
  • Cardiac disease: Such as Atrial septal defect, heart rhythm disorders, etc.
• Pregnancy-related conditions and complications
  • Preeclampsia and Eclampsia: Extremely high blood pressure
  • Hyperemesis gravidarum: Persistent vomiting beyond the 1sttrimester
  • Disorders of the placenta
    • Placenta previa: Implantation of the placenta very near to the cervix
    • Abruptio placenta: Separation of the placenta from the uterine wall, leading to severe bleeding
  • Abnormal amniotic fluid levels
    • polyhydramnios: High levels of amniotic fluid
    • oligohydramnios: Low levels of amniotic fluid
  • Ectopic pregnancy: The growth of the fetus outside the uterus
  • Rh incompatibility
  • Multiple gestations: Pregnancy with twins, triplets, or more
  • Uncontrolled gestational diabetes: Development of diabetes in a previously non-diabetic mother
  • Fetal malformations
  • History of premature births
  • Cervical incompetence
  • Disseminated intravascular coagulation (DIC)
  • Peripartum cardiomyopathy
• Lifestyle factors
  • Smoking
  • Alcohol consumption
  • Recreational and illicit drug use
• High-risk labor may be seen in the following conditions
  • Preterm labor
  • Obstructed labor
  • Post-term labor
  • History of lower section cesarean section surgery
  • Abnormal position of the fetus inside the uterus
  • Shoulder dystocia
  • Retained placenta
  • Inversion of the uterus
  • Rupture of the uterus

Signs & symptoms

The symptoms and signs of this vary based on the underlying condition that puts the pregnancy at risk and may include the following:

• Hyperemesis
  • Dry mouth and thirst
  • Loss of weight
  • Dehydration and loss of skin elasticity
• Placenta previa
  • Intermittent painless bleeding, which is bright red after the 20thweek
• Abruptio placenta
  • Tenderness of the abdomen or severe pain
  • Moderate to severe bleeding, which is usually dark
• Ectopic pregnancy
  • Severe cramping pain on one side of the abdomen or pelvis
  • Pain may radiate to the shoulder or the rectum
  • Dizziness or weakness
  • Symptoms of shock if the bleeding is severe
• Preeclampsia
  • Vomiting
  • Headache
  • Reduced urinary output
  • Dizziness
  • Confusion/seizures
  • Abdominal pain
  • Blood in vomit or urine

Investigations

Some investigations that may be done for the identification of this type of pregnancy include:

• Thorough physical and medical evaluation, including for Diabetes, Hypertension, cardiac disease, etc., after confirmation of pregnancy
• Thorough gynecological and obstetric evaluation before/after confirmation of pregnancy

Some investigations that may be done before/immediately after pregnancy may include:

• Rubella vaccine testing
• Bacterial and viral serology tests for syphilis, HIV, Hepatitis B & C
• Genetic Screening
• Liver and renal function tests
• Coagulation profile and blood type
• Blood glucose/HbA1c
• Ultrasound: Abdomen and pelvis
• Echocardiogram
• Electrocardiography (ECG)

Some investigations that may be done as a part of prenatal evaluation may include:

• Urine examination: At each prenatal visit
• Ultrasound examination: At frequent intervals during prenatal visits
• First-trimester screening: Before 12 weeks of pregnancy
• Nuchal translucency screening: Between 11-14 weeks of pregnancy
• Chorionic villus sampling: Between 10-14 weeks of pregnancy
• Quad screen or maternal serum screening: Between 15-20 weeks of pregnancy
• Amniocentesis: Between 15-20 weeks of pregnancy
• Glucose challenge screening: To assess the risk of gestational diabetes
• Group B streptococcus screening: Done at 35-37 weeks of pregnancy
• Biophysical profile: In the third trimester of pregnancy

Diagnosis

Diagnosis is established based on medical history, clinical evaluation, and investigation results.

Treatment options

The treatment of a High Risk Pregnancy depends on the underlying risk factor, and treatment aims to reduce the risk factors, keep a close watch, and take immediate necessary action in case of a medical emergency.

Role of Diet/ Exercise/ Lifestyle changes/ Preventive measures

Some measures that may be taken to reduce the risk factors for a High Risk Pregnancy include:

• Taking folic acid supplementation
• Avoid smoking, alcohol, and recreational drugs
• Avoid exposure to radiation, chemical fumes, and toxic chemicals like pesticides.
• Eat a healthy and safe diet
• Participate in physical activity as advised by the physician
• Maintain a healthy weight
• Take steps to prevent infections
• Getting required vaccinations before pregnancy
• Get periodic medical and dental check-ups
• Get periodic gynecological and obstetric check-ups

Complications

Complications of this type of pregnancy depend on the underlying condition and may include both maternal and fetal complications, such as:

• Premature births
• Birth defects
• Fetal death
• Severe bleeding
• Renal failure
• Liver failure
• Cardiac failure
• Respiratory failure
• Maternal Death

Prognosis

The prognosis of this type of pregnancy depends on the underlying cause and how early it is diagnosed and managed.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if symptoms and signs are noticed.

Indications for hospitalization if required

Hospitalization may be required for the management of this pregnancy.

Screening methods

Several screening tests are available for routine prenatal check-ups to identify and diagnose common causes.

Suggested clinical specialist/ Departments to consult for this condition

Specialists from the Department of Maternal and fetal medicine, gynaecology & obstetrics treat a High Risk Pregnancy.